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A 
 
A MANUAL OF SURGERY 
 
 gov Stu^ellts aiiD ipractitioncre. 
 
MA] 
 
 WIL 
 
 Professor of 
 
 ALl 
 
 Surgeon tc 
 
MANUAL OF SURGERY 
 
 3For Stut)cnt9 an& IPractitioucvs. 
 
 UY 
 
 WILLIAM ROSE, M.B., B.S., Lond., F.R.C.S., 
 
 Pkofkssor of Clinical Surgery in King's College, London, and Sbnior Surgeon 
 TO King's College Hospital, Etc. 
 
 AND 
 
 ALBERT CARLESS, M.S., Lond., F.R.C.S., 
 
 Surgeon to King's College Hospital, and Teacher ov Operative Surgery 
 IN King's College, London, Etc. 
 
 THIRD EDITION 
 
 TORONTO: 
 
 J. A. CARVETH & CO. 
 
 1900 
 

 yo 
 
 i^O-o 
 
 208615 
 
 THE 
 
 IN GRATEFUI 
 
 WHIL! 
 
TO 
 
 LORD LISTER, ll.d., f.k.s., 
 
 President of the Royal Society, 
 
 THE FATHER OF ANTISEPTIC S U K G i: K Y, 
 
 THIS WORK IS, WITH PERMISSION, 
 
 ^cliicjtteli bj) the ^iithors, 
 
 IM GRATEFUL ACKNOWLEDGMENT OF THE MANY AIHANTAGES 
 
 THEY HAVE DERIVED 
 WHILST ASSOCIATED WITH HIM IN HIS WORK 
 
 AT KING S COLLEGE HOSPITAL. 
 
PRE! 
 
 As only twelve i 
 second edition oi 
 to revise the tex 
 will add to its vs 
 so as to avoid tl 
 diseases of cert 
 number of new i 
 sl<iagraphic plate 
 to the courtesy 
 Street, W. Drs 
 read through the 
 and have made s( 
 
 September, rgoo. 
 
PREFACE TO THIRD EDITION. 
 
 As only twelve niontlis ha\e ehipsed since the publication of the 
 second edition of this book, we have merely thought it desirable 
 to revise the text and to make sundry changes which, we trust, 
 will add to its value. The order of the chapters has been altered 
 so as to avoid the awkward separation of the injuries from the 
 diseases of certain of the organs which formerly existed. A 
 number of new illustrations have been added, and a fresh set of 
 skiagraphic plates has been introduced, for which we are indebted 
 to the courtesy of Messrs. Allen and Hanbury, of 48, Wigmore 
 Street, W. Drs. St. Clair Thomson and Silk have also kindly 
 read through the sections in which they are respectively interested, 
 and have made several valuable alterations and suggestions. 
 
 September, rgoo. 
 
PR 
 
 In preparing 
 
 have endeavo 
 
 a genuine ne( 
 
 works of refer 
 
 ordinary stude 
 
 has therefore 1 
 
 in a concise ar 
 
 student, even ( 
 
 tions. At the 
 
 titioner have i 
 
 discuss in deta 
 
 with in ordinar 
 
 press into a sm 
 
 available, so t 
 
 line much that 
 
 size of the hoc 
 
 bibhographical 
 
 whilst diseases ( 
 
 f,^enital organs— 
 
 they encroach o: 
 
 of bacteriology a 
 
 the characters ai 
 
 of the traditions 
 
PREFACE TO FIRST EDITION. 
 
 In preparinpf this Manual of Surj^ery for the profession, we 
 have endeavoured to meet what we think is at the present time 
 a genuine need. The many large and valuable text-books and 
 works of reference already in existence are almost more than the 
 ordinary student can master during the time at his disposal. It 
 has therefore been our aim to present the facts of surgical science 
 in a concise and succinct form, so as to satisfy ^he needs of ..^e 
 student, even of those who ar. preparing for the higher examina- 
 tions. At the same time, the requireiiients of the ge:ieral prac- 
 titioner have not been overlooked, for we have taken care to 
 discuss in detail those conditions which are most likely to be met 
 with in ordinary practice. The main difficulty has been to com- 
 press into a small space the ever-increasing amount of material 
 available, so that we have only been able to sketch in out- 
 line much that could have been elaborately described did the 
 size of the book permit. For the same reason, historical and 
 bibliographical references have to a large extent been omitted, 
 whilst diseases of special regions — such as the eye, ear, and female 
 <,^enital organs — are also practically excluded, except in so far as 
 they encroach on the domains of general surgery. The progress 
 of bacteriology and the influence of antisepsis have so transformed 
 the characters and extended the scope of surgical work that many 
 of the traditions and theories of the past have had to be discarded. 
 

 PREFACE TO FIRST EDITION 
 
 although at the same time we have endeavoured to preserve and 
 respect that which has been shown to be good and useful in the 
 laborious researches and accumulated experiences of bygone 
 generations. 
 
 In conclusion, our best thanks are due to Dr. St. Clair Thom- 
 son, who has kindly looked through the proofs of the sections 
 devoted to the nose and ear ; to Dr. Silk, who has fulfilled a 
 similar office in reference to the chapter on anaesthetics ; to Mr. 
 William Turner for preparing the index ; and to Dr. Arthur 
 Griffiths, late of the Bristol General Hospital, who has drawn 
 several of the pictures, and given other valuable assistance. 
 
 Many of the illustrations have been specially prepared for this 
 work, but we have also to acknowledge the loan of blocks from 
 Messrs. Veit and Co., of Leipzig ; from Messrs. Cassell and Co., 
 J. and A. Churchill, Longmans and Co. ; and from the editors of the 
 Lancet for the loan of Fig. 287 [296]. The various sources from 
 which these are derived are acknowledged throughout the book. 
 Illustrations of instruments are mainly derived from Messrs. 
 Down Brothers, who have kindly placed them at our disposal. 
 
 W. ROSE, 
 
 17, Harlev Street, W. 
 
 A. CARLESS, 
 
 10, Welbeck Street, W. 
 London, 
 
 May I, 1898. 
 
 CHAI'TER 
 
 I. INFLAMMi 
 
 11. SUPPUKA1 
 
 HI. ULCERATI 
 
 IV. GANGREN 
 
 V. SEPSIS, 11 
 
 VI. TUMOURS 
 
 VII. WOUNDS 
 
 VIII. H^MORRH 
 
 IX. INJURIES 
 
 LIGATU 
 
 X. SURGERY 
 XI. DISEASES 
 
 XII. AFFECTION 
 
 XIII. SURGICAL 
 
 CUTANE 
 
 XIV. AFFECTION 
 XV. DEFORMITI 
 
 XVI. INJURIES C 
 
 XVII. DISEASES ( 
 
 XVIII. INJURIES C 
 
 XIX. DISEASES C 
 
 XX. INJURIES O 
 
 XXI. DISEASES C 
 
 XXII. HEAD INJUi 
 
CONTENTS 
 
 I. INFLAMMATION ..... i 
 
 II. SUPPURATION AND ABSCESS - - - - 26 
 
 III. ULCERATION - - - - - "43 
 
 IV. GANGRENE - - - - - "53 
 V. SEPSIS, INFECTION, AND INFECTIVE DISEASES - 75 
 
 VI. TUMOURS AND CYSTS - - - - " "5 
 
 VII. WOUNDS ...... 1^4 
 
 VIII. h.«;morrhage ------ igo 
 
 IX. INJURIES AND DISEASES OF ARTERIES ANEURISM 
 
 LIGATURE OF ARTERIES - - - - 214 
 
 X. SURGERY OF THE VEINS .... 269 
 
 XI. DISEASES OF THE LYMPHATICS - - - 284 
 
 XII. AFFECTIONS OF NERVES .... 297 
 
 XIII. SURGICAL DISEASES OF THE SKIN AND OF THE 
 
 CUTANEOUS APPENDAGES - - - - 322 
 
 XIV. AFFECTIONS OF MUSCLES, TENDONS, AND BURS^. - 334 
 XV. DEFORMITIES ------ 348 
 
 XVI. INJURIES OF BONES — FRACTURES - - - 386 
 
 XVII. DISEASES OF BONE .... - 462 
 
 XVIII. INJURIES OF JOINTS— DISLOCATIONS - - - 502 
 
 XIX. DISEASES OF JOINTS ----- 536 
 
 XX. INJURIES OF i'HE SPINE - . - - 389 
 
 XXI. DISEASES OF THE SPINE - - . . 607 
 
 XXII. HEAD INJURIES ..... 628 
 
Xll 
 
 CONTENTS 
 
 CFIAl'TF.N 
 
 XXIII. 
 
 XXIV. 
 
 XXV. 
 
 XXVI. 
 
 XXVII. 
 
 XXVIII. 
 
 XXIX. 
 
 XXX. 
 
 XXXI. 
 
 XXXII. 
 
 XXXIII. 
 
 XXXIV. 
 
 XXXV. 
 
 XXXVI. 
 
 XXXVI 1. 
 
 XXXVIII. 
 
 XXXIX. 
 
 XL. 
 
 XLI. 
 
 DISEASES OF THE SCALP, CRANIUM, AND CRANIAL 
 CONTENTS . - - - - 
 
 AFFECTIONS OF THE LIPS AND JAWS 
 AFFECTIONS OF THE NOSE AND NASO-PHARYNX 
 AFFECTIONS OF THE MOUTH, THROAT, AND OESO- 
 PHAGUS ------ 
 
 AFFECTIONS OF THE EAR - - " - 
 
 SURGERY OF THE NECK - - - - 
 
 SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 
 DISEASES OF THE BREAST - - - - 
 
 ABDOMINAL SURGERY - - 
 
 HERNIA .-..-- 
 
 INTESTINAL OBSTRUCTION - - - - 
 
 AFFECTIONS OF THE RECTUM AND ANUS 
 SURGICAL AFFECTIONS OF THE KIDNEYS 
 SURGERY OF THE BLADDER AND PROSTATE 
 AFFECTIONS OF THE URETHRA AND PENIS - 
 AFFECTIONS OF THE TESTIS, CORD, SCROTUM, AND 
 SEMINAL VESICLES . - - - 
 
 VENER EAL DISEASES . . - - 
 
 AMPUTATIONS . . - - - 
 
 ANESTHESIA . . . - - 
 
 INDEX ------ 
 
 PAGE 
 
 667 
 682 
 
 770 
 780 
 796 
 824 
 848 
 921 
 960 
 976 
 
 lOOI 
 
 1023 
 1068 
 
 I09I 
 
 1 1 39 
 
 1157 
 1165 
 
 I'LATE 
 
 I. Fig. I. —I 
 
 Fig. 2.— S 
 
 II. Fig. 1.— j 
 
 Magnif 
 
 Fig. 2.— T 
 
 PHATIC ( 
 
 III. Exostosis 
 
 IV. Fig. I.— h 
 
 firm Fib 
 
 Fig. 2.— Gf 
 
 V. Skiagram ( 
 
 CLOSE T( 
 
 VI. Splinter 
 
 OF THE ] 
 
 VII. Fig. I.— Se 
 
 Ten Da\ 
 
 Fig. 2.~Sca 
 
 (Low Po' 
 
 VIII. Skiagram o 
 
 IX. Oblique Fi 
 
 Fragmen' 
 
 X. Impacted F 
 
 ifi' 
 
 XI. Fracture 01 
 
 XII. Separation 
 WITH Dis 
 LITTLE OV 
 
 XIII. Fracture 01 
 
LIST OF PLATES. 
 
 ILATE I'AGK 
 
 I. Fig. I. — Early Stage of Abscess Formation - To face 30 
 
 Fig. 2. — Section of Abscess Wall Eight Days Old ,, 30 
 
 II. Fig. I. — Miliary Tubercle with Giant Cell (Highly 
 
 Magnified) - - - - - -To face 107 
 
 Fig. 2. — Tuberculous Abscess kkom a Suppurating Lym- 
 phatic Gland (I.o\v Power) - - - -To face 107 
 
 III. Exostosis of the Radius - - - - ,, 129 
 
 IV. Fig. I. — Hard Glandular Carcinoma, with abundance of 
 
 FIRM FiBRO-ClCATKICIAL STROMA (SCIRRHOUS MaMM^) To foCC I44 
 
 Fig. 2. — Granulation Tissue from a Healing Wound ,, 144 
 
 V. Skiagram of Hand, with Needle embedded in the Palm, 
 
 close to the Carpus To face Plate VI., between 164, 165 
 
 VI. Splinter of Glass in Hand, close to Metacarpal Bone, 
 
 OF THE Index Finger To face Plate V., bettceen 164, 1G5 
 
 VII. Fig. I. — Section of a Wound Healed by First Intention 
 
 Ten Days after its Infliction - - -To face 176 
 
 Fig. 2. — Scar from a Recently Healed Superficial Wound 
 
 (Low Power) - - - - - -To face 176 
 
 VIII. Skiagram of Double Coxa Vara - - - ,, 362 
 IX. Oblique Fracture of Tibia, showing the Ends of the 
 
 Fragments shaped en bee de flute - - -To face 389 
 
 X. Impacted Fracture of Anatomical Neck of Humerus 
 
 To face Plate XL, between 420, 421 
 XI. Fracture of Surgical Neck of Humerus 
 
 To face Plate X., betiveen 420, 421 
 
 XII. Separation of the Lower Epiphysis of the Humerus, 
 
 with Displacement Outwards, in a Younc; Person, a 
 
 LITTLE OVER THE AgE OF PUBERTY - - - To faCC 427 
 
 XIII. Fracture of Olecranon before Operation 
 
 To face Plate XIV., between 428, 429 
 
XIV 
 
 LIST OF PLATES 
 
 il-i 
 
 I'l.ATK I'AGK 
 
 XIV. Fracture of Olecranon after Operation 
 
 To face Plate XIIL, between 428, 429 
 XV. CoLLEs's Fracture : a Simple Case, without much Lateral 
 
 Displacement of Hand To face Plate XVL, between 432, 433 
 
 XVI. Colles's Fracture : a Bad Case, with the Styloid Process 
 OF THE Ulna torn off and much Outward Displace- 
 ment OF Hand - - - To face Plate XV., between 432, 433 
 XVII. Fracture of both Bones of the forearm, with Displace- 
 ment OUTWARDS - - - - - - 435 
 
 XVIII. Fracture of both Bones of the Leg, seen from in Front 
 
 To face Plate XIX., between 456, 457 
 XIX. The same Fracture as in Plate XVIII., seen from the 
 
 Inner Side - - To face Plate XVIII., between 456, 457 
 
 XX. Dupuytren's Fracture, with well-marked Displacement 
 outwards of the foot, as well as of the lower 
 Fragment of the Fibula and the Internal Malleolus. 
 (Skiagram taken from in Front) - - -To face 458 
 
 XXI. Tuberculous Disease of Radius - - - ,, 479 
 
 XXII. Double Congenital Dislocation of the Hip - ,, 505 
 
 XXIII. Dislocation of Radius forwards, and Fracture of Upper 
 
 Third of Ulna - - - - -To face 520 
 
 XXIV. Tuberculous Disease of Knee-joint, showing Invasion of 
 
 Patella - - - - - -To face 556 
 
 XXV. Skiagram of Pelvis, showin(; Tuberculous Disease of 
 
 Right Hip-joint - - - -To face 576 
 
 A Ml 
 
 ' Inflammation 
 
 living2fisS'ulfe'"Wh6 
 
 IT'cIegree'aT to -a 
 
 was tlie 'd'efliliti 
 
 it is sufficiently 
 
 itrchide' liacfertal 
 
 repair. .Former 
 
 as always of a de 
 
 time bacteriologii 
 
 rather of a prote( 
 
 means of limiting 
 
 of finally eliminal 
 
 to the exact natur 
 
 and even at the j 
 
 divided. It is, h 
 
 primary lesion is 
 
 turbance of the < 
 
 vessel walls and 
 
 enabled to escape 
 
 the clinical effects 
 
 The actual p/iciio 
 
 the web of a fro^ 
 
 under the microscc 
 
 io^acal activity m^ 
 
 vessels, as indicate 
 
 ones, each separate 
 
 current, the leucoc^ 
 
 iiiid there one maj 
 
 rarpuscle-free perij 
 
A MANUAL OF SURGERY. 
 
 CHAPTER I. 
 
 INFLAMMATION. 
 
 ' Inflammation is the succession of changes which occur in a 
 living'fisSu^e* WhSil'tf i'S li^fufecl,' {5'rbviciirig tTie injury Ts'n'ot'of^ucTi""^ 
 Ti"^gree' aT tO' 'at tJU'Ce -destroy it'ss'tfucture" andfviFaliTy?''' 'Such 
 was tlie'deflilition given in 1870 by Burdon San3erson, and 
 it is sufficiently accura^tfe if One ampHfies' 'the' term ' injury ' to 
 inrhide" 1'Ja'(itei'i'al""inyasion , , arid excludes ' the" fihaT~processes of 
 repair. . Formerly inflammation was looked on loy pathologists 
 as always of a destructive and harmful nature, hut at the present 
 time bacteriological research has demonstrated that it is often 
 rather of a protective or conservative character, being Nature's 
 means of limiting the advance of noxious micro-organisms, and 
 of Anally eliminating them from the system. Many theories as 
 to the exact nature of the process have arisen from time to time, 
 and even at the present day opinions on the subject are much 
 divided. It is, however, admitted by most authorities that the 
 primary lesion is one of the vascular walls, resulting in a dis- 
 turbance of the equilibrium normally maintained between the 
 vessel walls and the vessel contents, whereby the latter are 
 enabled to escape into the perivascular tissues, and there produce 
 the clinical effects so commonly observed. 
 
 The actual phenomena of inflammation are perhaps best studied in 
 the web of a frog's foot. If this is spread out and examined 
 under the microscope, the following evidences of normal physio- 
 loi^ical activity may be seen : {a) the flow of blood through the 
 vessels, as indicated by the movement of the corpuscles, the red 
 ones, each separate from the other, flowing in the central or axial 
 current, the leucocytes occasionally seen amongst the red, or here 
 and there one may be noticed rolling lazily along in the inert 
 corpuscle-free peripheral portion of the tube ; {h) the constant 
 
 I 
 
A MANUAL OF SURGERY 
 
 rhythmical changes in calibre of the arterioles independent of 
 the heart's action, and influencinjif in a marked degree the flow 
 through the capillaries ; and (c) the changes which occur in the 
 pigment-cells, which represent the connective tissues of the part, 
 and which are mainly due to the influence of light, the cells con- 
 tracting or expanding as the light is increased or diminished. 
 
 If now a crystal of common salt, or some such irritant, is 
 applied to the web, the early vascular phenomena contributing to 
 inflammation may be readily observed. 
 
 I.— The Vascular Changes in Acute Inflammation. 
 
 A momentary contraction may perhaps be noticed in the 
 arterioles of the part, but this is only apparent in inflammations 
 produced artificially, and is of no known significance. It is 
 followed by a condition of Hypersemia of the inflamed area, as 
 manifested by a rapid and lasting dilatation of the \'essels, accom- 
 panied by an increase in the rapidity of the blood-flow {accelci'a- 
 tion). This is a peculiarly vital phenomenon, and oppc)sed to the 
 hydrostatic law that when fluid is flowing through a tube or 
 channel at a fixed pressure, if the lumen is suddenly widened, tlie 
 rate of the blood-flow is diminished. It is probably brought aboui 
 by some change in the local vasomotor mechanism present in tiie 
 smaller arterioles. This increased rapidity of the flow lasts for a 
 while, and then the current gradually becomes slower and slower 
 [retardation), as if an ever-growing obstruction existed to tlu' 
 passage of the blood ; then a period of oscillation will be noticed, 
 the blood-current swaying forwards and backwards, and finally a 
 condition of stasis or still-stand is arrived at, which may or may 
 not end in actual thrombosis or intravascular coagulation. I)urin<^ 
 this period changes have occurred in the behaviour of the blood 
 contained in tlie vessel, due in all probability to certain invisible 
 changes in the vessel walls and not to any alteration in the blood. 
 Thus, almost as soon as dilatation occurs, the leucocytes collect 
 along the walls in the peri-axial inert layer, seeming, as it were, 
 to fall out of rank ; this process first commences in the veins, 
 but can be observed in all the vessels. The red corpuscles also, 
 which formerly had flowed along separately, now tend to adhere 
 to the vessel walls and to each other, running into rouleaux. 
 
 The second factor in the vascular clianges must now be con- 
 sidered, viz.. Exudation, a proceeding which becomes evident at 
 a very early stage. Every element in the constitution of the 
 blood participates in this process. It has been already mentioned 
 that the leucocytes collect in the peri-axial layer, a phenomenon due 
 partly to the retardation of the blood-stream, whereby the relatively 
 heavier bodies separate from the lighter, and in part due to a 
 process we shall describe later on under the title ' chemiotaxis' 
 (p. 17). The next change consists in the passage of the leucocytes I 
 
 through the ve 
 less often of tl 
 brought about 
 of the leucocyt 
 cells lining th( 
 fared with by 
 protoplasm of 
 endothelial elei 
 into the conne- 
 
 ICi. r— DiAGRAMM 
 OF InI 
 
 I Two thin-walled veni 
 are still occupyi 
 crowded with lei 
 tion into the sun 
 
 [the leucocytes on 
 
 actually circulatir 
 
 I ceases. When tl 
 
 vascular tissues, i 
 
 place, it may die a 
 
 Iferment, and thus 
 
 Icoatrulum to be 
 
 Ipahulum for the L 
 
 [appearance, arisin 
 
 connective -tissue 
 
INFLAMMATION 
 
 through the vessel walls, especially those of the smaller veins and 
 less often of the capillaries. The process is a strictly vital one, 
 l)rought about by am(i}boid movement ; a small arm or outgrowth 
 of the leucocyte (pscudopodium) is inserted between the endothelial 
 cells lining the vessel, whose cohesion has been probably inter- 
 fered with by the inflammatory process. Into this arm the 
 protoplasm of the leucocyte flows, still further separating the 
 endothelial elements, and thus the cell passes through the wall 
 into the connective tissues without (Fig. i). The migration of 
 
 I'lG. I. — Diagrammatic Representation of the Vascular Phenomena 
 OF Inflammation. (After Keen and White.) 
 
 Two thin-walled venules are seen, and several capillaries. The red corpuscles 
 are still occupying the axial portion of the tubes, whilst the periphery is 
 crowded with leucocytes, which in several places are in process of migra- 
 tion into the surrounding cellular tissue. 
 
 the leucocytes only lasts as long as the blood in the vessel is 
 actually circulating ; as soon as thrombosis occurs, migration 
 ceases. When the white corpuscle has escaped into the peri- 
 Ivascular tissues, it may undergo various changes. In the first 
 Iplace, it may die and be at once disintegrated, setting free fibrin 
 Iferment, and thus assist in the production of the inflammatory 
 Icoagulum to be shortly described ; or, again, it may serve as 
 jpabulum for the larger fibroblastic cells which soon make their 
 lappearance, arising apparently from the multiplication of the 
 jconnective - tissue corpuscles in the neighbourhood ; or, once 
 
 I — 2 
 
A MANUAL OF SURGERY 
 
 i 
 
 
 more, it may find its way back into the circulation through the 
 lymphatics, or be transformed into a pus corpuscle ; moreover, 
 prior either to disintegration or transformation into a pus cor- 
 puscle, it may attack and assist to remove any dead tissue which 
 exists in the neighbourhood of the inflammatory focus, whilst a 
 phagocytic function {i.e., microbe-destroying, vide p. i6) is also 
 subserved. In fact, the leucocytes may be looked on as the 
 scavengers of the body, or as advanced guards, which, at the 
 onset of mischief, are thrown out from the vessels as Nature's 
 first line of defence against the invading forces, their chief duty 
 being to remove all damaged and noxious material, and then, 
 having limited the spread of the destructive process, they in turn 
 give place to the larger and more useful fibroblastic cells which 
 are the active agents in the process of repair. 
 
 The red corpuscles pass through the walls of the capillaries by a 
 process of diapedesis, the result of simple mechanical pressure ; 
 this usually occurs only in very acute attacks. When once 
 external to the vessels they are broken up and their colouring 
 matter diffused through the tissues. 
 
 The liquor sanguinis is also extravasated. This is merely an 
 exaggeration of a normal process, although in health the lym- 
 phatics are capable of removing all the fluid exuded. In patho- 
 logical conditions the amount of plasma which passes through 
 the walls is excessive, and although for a time the lymphatics of 
 an inflamed region do increased v/ork, yet the transudation is 
 soon greater than they can deal with. If tlie fluid escapes into 
 the tissues, it undergoes coagulation by meeting the necessary 
 coagulating media developed from the breaking-down leucocytes ; 
 inflammatory lymph forms locally, whilst the scrum collects in the 
 meshes of the tissues, constituting an inflammatory form of 
 cedema ; if there is a sufficient breach of surface, the serum 
 drains away. If the exudation takes place from a serous surface 
 — e.g., pleura, peritoneum, synovial membrane, etc. — the fluid 
 distends the cavity ; it is at first spontaneously coagulable [i.c.^ 
 consists of plasma) ; if coagulation occurs, the clot or lymph 
 either forms an adherent plastic mass on the surface or floats 
 free in the fluid. 
 
 Looked at, therefore, simply froni a vascular point of yiew^ 
 
 Inflammation = Hyperamia + Exudation. 
 
 In addition, however, to these vascular phenomena, which can 
 be readily seen in a frog's web, there are others which cannot be 
 so easily observed, and which may be described as 
 
 II.— The Tissue Changes in Inflammation. 
 
 Great differences of opinion have been in existence as to the 
 part played by the tissues in inflammation ; but although there 
 
 may still be pc 
 pathologists is i 
 in accord with " 
 tissues were th 
 number of cell; 
 due to the pre 
 Lister, as far t 
 the tissues ; anc 
 of the leucocyte 
 attributed to the 
 have worked at 
 fresh light has b 
 sisting in the ins 
 and by others ( 
 functions of leuc 
 of the difficulty 
 ^^JE^L^onfusTG 
 repair. KT^ue] 
 riiafofy nature; 
 the body can occi 
 reaction, yet th( 
 Again, it is impo 
 occur in acute a 
 those met with ii 
 origin or not of tl 
 In acute paren( 
 that the primary ( 
 due to bacterial ai 
 trated with leucoc 
 inicrobic multiplic 
 ing and refusing 
 condition known & 
 in time entirely at 
 activity of bacteri 
 small round cells, s 
 ing to the relative 
 bacteria, this mass 
 cells derived from 
 which most of the 
 about ; or the who 
 Piis. In non-bac 
 amounT-Sf^^^roff 
 ■^^iveasto separate 
 BdT(JSt3 maybe n 
 ^ffef a burn: On( 
 '!'raries "may be assc 
 epithelium, as in ca 
 In chronic inflar 
 
INFLAMMATION 
 
 may still be points to be elucidated, yet the general opinion of 
 pathologists is at the present day tolerably well defined. Formerly, 
 in accord with Virchow's cellular pathology, it was held that the 
 tissues were the all-important element, and that the immense 
 number of cells which collect. in an inflamed area was entirely 
 due to the proliferation of the connective -tissue corpuscles. 
 Lister, as far back as 1858, maintained the passive condition of 
 the tissues ; and when Cohnheim, in 1867, described the migration 
 of the leucocytes, everything in the process of inflammation was 
 attributed to them. Since that date Senftleben and many others 
 have worked at the same problem, and a considerable amount of 
 fresh light has been thrown on the subject by experiments con- 
 sisting in the insertion of foreign bodies into the peritoneal cavity, 
 and by others directed towards demonstrating the phagocytic 
 functions of leucocytes and the influence of chemiotaxis. Much 
 of the difficulty which has enshrouded the question has arisen 
 1rom a confusion between tiie processes 01 mnammation and 
 repair. At one time repair was always looked on as 01 an I'fmatft- 
 ■ rii'atory nature ; but it is now admitted that although no lesion in 
 the body can occur without a certain amount of local inflammatory 
 reaction, yet the true process of repair is not of that nature. 
 Again, it is important to differentiate between the changes which 
 occur in acute and chronic forms of inflammation, and between 
 those met with in superficial and deep parts, whilst the bacterial 
 origin or not of the process must also be taken into account. 
 
 In acute parenchymatous inflammation there is now no question 
 that the primary effect on the tissues, at any rate in inflammations 
 due to bacterial activity, is to paralyze them ; they become infil- 
 trated with leucocytes and with the products of exudation and of 
 microbic multiplication, the protoplasm within the cells coagulat- 
 ing and refusing to take up the ordinary stains, constituting a 
 condition known as Coagulation Necrosis. This necrotic tissue is 
 in time entirely absorbed by the leucocytes, or is liquefied by the 
 activity of bacterial toxins, so that it is replaced by a mass of 
 small round cells, sometimes known as Embryonic Tissue. Accord- 
 ing to the relative vitality and vigour of the individual and the 
 bacteria, this mass may in turn either be replaced by larger round 
 cells derived from the connective tissues {fibroblasts), by means of 
 I which most of the leucocytes are absorbed, and repair is brought 
 about ; or the whole mass may be liquefied and break down into 
 pus. In non-bacterial inflammations of superficial parts the 
 I aiiiounTTJf ^^flfusroTi-bW^V^eetnhe'M'dividua cells' may be;^o-6Xces- 
 [sive as to separate arid disintegrate them, and th\is tj^olllquative 
 J^CTUStS may be i-nduced; as-occil'Ts' in" the rorriiatTori'Tjnjrisfers 
 hitter 'a burn.' Once rhdre, acute iriflamriiEition of tntiCOns-TTtrem- 
 [braries rftay be associated with active proliferation of the surface 
 I epithelium, as in catarrhal and gonorrhoeal affections. 
 
 In chronic inflarhmations, on the other hand, active cell pro- 
 
 ' * 
 
A MANUAL OF SURGERY 
 
 i \ 
 
 liferation is a most important element in the process, resulting in 
 sclerosis and induration of the parts. This, however, jj^jmily 
 affects the interstitial tissues, and thereby tlie true striiciurfi.pit the 
 organ may be TmpaiTecl. 
 
 Terminations of Acute Inflammation. 
 
 These vary according to the cause of the mischief, the intensity 
 of the process, and the powers of resistance possessed by the 
 individual attacked. The causes described at p. ii naturally fall 
 into two main classes, according to whether or not they are asso- 
 ciated with bacterial activity. Speaking generally, lesions not 
 caused by bacteria, such as those following a blow or a burn, are 
 characterized by much exudation of fluid and a comparatively 
 slight amount of cell infiltration, whilst the results are usually 
 localized ; bacterial irritants, on the other hand, produce more 
 infiltration than exudation, and the inflammation is more likely to 
 be of a spreading nature. The intensity of the irritant also 
 modifies the process, since, if slight, it has a somewhat stimulating 
 effect, whilst severe lesions may result in tissue destruction, even 
 amounting to gangrene. Then, too, the type of tissue affected is 
 important, since the same cause may lead to very different results. 
 The more highly organized and important parts are always more 
 vulnerable than the simpler forms of connective tissue, and this 
 in spite of the fact that the former are usually better supplied with 
 blood. Thus, the growing end of the diaphysis in a child is a 
 most delicately organized region, and hence is peculiarly liable to 
 serious destructive inflammation from bacterial agents, which 
 would do little harm if developing under similar circumstances in 
 the subcutaneous connective tissues. 
 
 The actual terminations of acute inflammation may be described 
 under five distinct headings : 
 
 I. Resolution, or the restoration of the part to its natural condi- 
 tion and function. This can only occur when the injury has not 
 been so severe as to destroy the vitality of the affected tissues, 
 and when the vascular changes have not gone further than stasis. 
 When once thrombosis has taken place in a vessel, the parts can 
 never be restored to the siatns quo ante. The phenomena of reso- 
 lution are merely those of inflammation in a retrograde order — 
 viz., an oscillatory movement first manifests itself amongst the 
 corpuscles, and then the blood-stream is gradually restored, slowly 
 at first, and more and more rapidly afterwards. The adhesiveness 
 of the corpuscles disappears by degrees, but it will be some time 
 before the peripheral inert layer can be seen. The exuded leuco- 
 cytes find their way back into the circulation either through thel 
 vessel walls, or to a greater extent via the lymphatics, or else they 
 are disintegrated in the tissues and absorbed. The fluid exuda-l 
 tion is removed by the lymphatics. For some time after an acute 
 
 attack the vesst 
 
 hut this also gn 
 
 2. Organizatic 
 
 (lainmatory pro( 
 of thrombosis, I 
 are then not re 
 take place in th 
 tissue around, w 
 tissue, and henc 
 tliose described 
 (Chapter VII.). 
 (lammatory proc 
 case. 
 
 3- Suppuration 
 
 tfie tissues involv 
 
 4- UTceration 'i 
 mucous membra; 
 and intensity as 
 sloughing (Chapt 
 
 5- Cfangrene is 
 clue either to the i 
 tissues attacked i 
 i'one, constituting; 
 Jue mainly to th 
 lumen of the Ha 
 i"5laf7v%-srnan'm 
 
 These may for f 
 'jeadings given by 
 ''^^■'^'LtLe a/cIifTon ( 
 .^^5j^|t^^"n'mffai 
 perature,'if taken 
 aliove that of the 
 increased amount 
 shown that nearly 
 pa\v of a dog as fr 
 Istrated that the ten 
 lian that of the 
 |iiie heart. Necess; 
 changes are occurri 
 pf heat is produced 
 iliat it may be neglt 
 |of the blood is notec 
 Redness is due to 
 md its mtensity an 
 
INFLAMMATION 
 
 attack tlie vessels of the part are dilated from simple loss of tone, 
 but this also ^^radually disappears. 
 
 2. Organization, or Fibroid Thickening, occurs when the in- 
 llammatory process is not arrested until after tlie supervention 
 ()[ thrombosis, hut has stopped short of suppuration. The parts 
 ,ne then not restored to their original condition, but changes 
 take place in the cellulo-plastic exudation and in the connective 
 tissue around, which result in its transformation into cicatricial 
 tissue, and hence the details of the process will be similar to 
 those described under the heading of ' Repair of Wounds ' 
 (Chapter VII.). Very similar conditions follow when the in- 
 llammatory process becomes chronic, as is not uncommonly the 
 case. 
 
 3. Suppuration is always due to invasion of the affected region 
 by_£yqgenic_pj^amsins, winch disintegrate and liqueiy not only 
 the tissues invoK'ed, but also in pjirt Jthe exudation '^ChapYeKTl.). 
 
 4". XTIceraiion^is produced on the surface of eitKer skin or 
 mucous membrane by the action of an irritant of such nature 
 ;ind intensity as to destroy its vitality, though without evident 
 sloughing (Chapter III.). 
 
 5. Gangrene is a less common result of inflammation, and is 
 due either to the intensity of the virus or to the weakness of the 
 tissues attacked (Chapter IV.). It occurs not unfrequently in 
 lione, constituting the condition known as necrosis, and is then 
 due mainly to the strangulation of vessels within the narrow 
 lumen of the Haversian canals by .^n exudation which is often 
 r5lalTveTy*sman in aiiibunt. """" ' 
 
 Clinical Signs of Inflammation. 
 
 » tMBHiF»JIV<«>«V)k •*>■«*•» (/T'C--' 
 
 These may for practical purposes be described under the four 
 headings given by Celsus, viz., heat, fedness, swelliiig, and ^ain, 
 with t h e_ adJit Ion of a fifth, viz., impairment of "furjQ,t;onr " 
 --^SiSiJiZ"'^^'^ "'"^^^^^ the touch, and the tem- 
 
 perature,' if taken by a surface thermometer, is definitely raised 
 above that of the surrounding skin. The cause of this is the 
 increased amount of blood flowing through it. Cohnheim has 
 shown that nearly twice as much blood returns from an inflamed 
 paw of a dog as from a healthy one ; whilst others have demon- 
 strated that the temperature of an inflamed area is never higher 
 than that of the blood at the centre of the circulation, i.e., in 
 the heart. Necessarily, where active chemical and pathological 
 hanges are occurring, as in an inflamed tissue, a certain amount 
 of heat is produced ; but it is relatively so infinitesimal in quantity 
 ihat it may be neglected. The cause of the increased temperature 
 iof the blood is noted elsewhere (p. 10). 
 
 Redness is due to the hyperaemic condition of the inflamed part, 
 nd its intensity and characters vary considerably. In the early 
 
8 
 
 A MANUAL OF SURGERY 
 
 active hyperncmia the colour is a bright rosy-red, fading quickly 
 on pressure, and returning with eciual rapidity. In the stage of 
 retardation the redness is more dusky, since the blood is longer in 
 passing through the capillaries, and so loses more of its oxygen ; 
 the colour does not disappear or return so rapidly, and a slight 
 yellowish tinge often remains from extravasated haemoglobin. 
 When stasis is reached, and a fovtiovi when thrombosis, pressure 
 does not remove the red colour, and, should such a state persist 
 for long, permanent pigmentation may remain. 
 
 The redness is not always most marked at the focus of tho 
 disturbance, since the portion inflamed may be non-vascular, 
 r.^^, the cornea or articular cartilage ; in the former of these, the 
 redness is most marked in the ciliary region as a zone of deep 
 pink injection. The same absence of redness is observed in iritis, 
 owing to the excess of pigment hiding the dilated vessels ; but in 
 both cornea and iris, the inflammation may in rare cases be so 
 prolonged or acute as to cause these structures to become 
 evidently vascular — in the one case from the formation of new- 
 vessels, and in the latter by the total removal and absorption of 
 the pigment. 
 
 Swelling arises from the same two causes, viz., hyperaemia 
 of,"ancr'Txudation into, the part. Necessarily the amount of 
 tumefaction depends upon the acuteness of the disturbance, and 
 the distensibility of the tissue, and in measure varies inversely 
 with tiie amount of pain. In some cases where the inflamed area 
 is covered by a thick and firm fascia, not only is the tensi\e 
 pain very considerable, but swelling may occur away from the 
 inflamed area, e.g., over the back of the hand in palmar abscess; 
 where the inflammatory products escape into lax tissues, the 
 subjective phenomena are minimised. Similar illustrations of the 
 occurrence of oedema at a distance are to be seen in inflammations 
 of the sole of the foot, in the swelling of the eyelids when the 
 scalp is inflamed, and of the cheek in inflammation of the dental 
 periosteum. Swelling due to inflammation, though diminishing' 
 post mortem, does not entirely disappear. 
 
 Pa ^L — This results from the mechanical irritation of the peri- 
 pheral nerve terminals, both by the increased arterial tension and 
 by the pressure of the exudation, so that it is much greater if, 
 from the density of fascial or fibrous investments, swelling cannot 
 readily occur, e.g., in the palm of the hand, or in the eye or testicle. 
 Possibly the exudation may also have some direct chemical action 
 on the nerve terminals. 
 
 The special feature of inflammatory pain is that it is always 
 aggravated by pressure, whether intrinsic — i.e., by increasing the 
 blood-pressure — or extrinsic, from outside agencies. Thus, if an 
 inflamed finger or hand is allowed to hang down, the pain is much 
 increased, whereas elevation causes speedy relief. 
 
 The pain of suppuration is throbbing in character ; of an inflamed 
 
 mcous memhvane, « 
 
 ■tromwemhrane, sta 
 
 )fteri worse at nijj 
 
 [he organs of speci 
 
 lain, but much ex 
 
 i^dit in retinitis an^ 
 
 The pain is not oi 
 
 xperienced in dista 
 
 ;iipply or from the 
 
 ly a patient to the 
 
 np disease the chief 
 
 nints have a simi 
 
 applied by the gre 
 
 moris, by the ante 
 
 md by a twig of 
 
 iotcli. The knee 
 
 hree articular brai 
 
 rough the nerves 
 
 ibturator entering 
 
 n renal calculus or c 
 
 [enito-crural nerve 
 
 iften accompanied i 
 
 ide affected. This 
 
 he sympathetics w 
 
 lerve. In spinal a 
 
 erniinal branches c 
 
 ■i'. the so-called ' b( 
 
 Impairment or Los 
 
 ff"ect"jrtTreTHTTatWm 
 
 v.elling, and, in me 
 
 nempting to use it. 
 
 luscle, when infla: 
 
 ri,'ans, e.g., the liv< 
 
 )st, at least much 
 
 light be added. 
 
 Genera 
 
 These may be of a 
 iiportant one, such 
 iscuss such conditio 
 ical inflammation ( 
 ritten in one wor 
 laracteristics of th( 
 
 vation of temper 
 iceleration in the rt 
 
 it continues for 
 iaciated, and loses 
 
INFLAMMATION 
 
 incoHS memhyauc, scaldinj;, hurninj,', or gritty ; of an intlanied 
 tri'H-s-memhraiic, stabbinfjj ; of intlamcd /w;/^, achinfjf or liorinj;, and 
 ftL-n worse at night ; of an inllamcd testicle, sickening. W'liun 
 he organs of special sense are inflamed, lli'ere may be little real 
 ain, but much exaggeration of the special sense, c.f,'., flashes of 
 ;'ht in retinitis and noises in the ears in otitis interna. 
 
 The pain is not only limited to the inflamed part, Init is sometimes 
 experienced in distant regions, either througli a similarity of nerve- 
 mpply or from the fact that a sensory stimulus is always yefen'cd 
 \s a patient to the end of the afTected nerve. Vox example, in 
 f^i disease the chief pain is often felt in the knee, because the two"' 
 nints have a similar nervous supply. Thus, the hip-joint is 
 :ilpplied by the great sciatic tlirough the nerve to the (juadratus 
 moris, by the anterior crural through the nerve to the pectineus, 
 md by a twig of the obturator entering through the cotyloid 
 lotcli. The knee is supplied by the great sciatic through the 
 hree articular branches of the popliteal, by the anterior crural 
 hrough the nerves to the vasti, and by the deep branch of the 
 ibturator entering through the posterior ligament of Winslow. 
 n renal calculus or colic, pain is referred along the course of the 
 ;enito-crural nerve into the groin and front of the thigh, and is 
 iften accompanied in the male by r- 'raction of the testicle on the 
 ide affected. This is due to the pi ;ence of connections between 
 he sympathetics which supply the ureter and the genito-crural 
 lerve. In spinal caries pain is frecjuently experienced in the 
 erininal branches of the nerves issuing from the part affected, 
 
 '. the so-called ' belly-ache ' of dorsi-lumbar disease. 
 
 Impairment or Loss of Function is due not only to the paralyzing 
 ffect'oTtTre 1 nTTaWmaTof y"process upon the part, but also to the 
 
 elling, and, in measure, to the pain which is often elicited on 
 tiempting to use it. Thus, an inflamed eye can see but little ; a 
 
 uscle, when inflamed, is naturally kept at rest ; glandular 
 ri,';uis, e.g., the liver and kidneys, have their functions, if not 
 )st, at least much diminished ; and many similar illustrations 
 
 «ht be added. 
 
 General or Constitutional Symptoms. 
 
 These may be of a serious character, if the organ affected is an 
 iiportant one, such as the kidney or heart ; but we cannot here 
 sciiss such conditions. Sufifice it that the general symptoms of 
 al inflammation of parts, not of vital importance, may be 
 ritten in one word, viz.. Fever, or pyrexia. The general 
 laracteristics of the febrile state consist in a greater or less 
 evation of temperature, accompanied with a corresponding 
 :celeration in the rate of the heart-beat and of the respirations. 
 it continues for any time, the patient becomes thin and 
 naciated, and loses muscular power. The mouth is dry, and 
 
 I 
 
10 
 
 A MANUAL OF SURGERY 
 
 1:1. 
 
 i 
 
 ccompanying syr 
 oung healthy adu 
 young man is su 
 n acute abscess is 
 aBevos, without 
 
 the tongue furred ; and in the later stages, where a fatal issue is 
 apprehended, the lips and teeth are usually covered with sordes 
 (or accumulations consisting of inspissated mucus and food debris), 
 The appetite is impaired, digestion is imperfect, and the bowels 
 constipated; any motion passed is very offensive. The urine isL^v^^w,, wuiiour 
 scanty and high-coloured, and owing to the excessive trssue cKangelxliaustion and 
 colitainsan ui^^^^ urea' aftd urates. The excess oMebilitated subject' 
 
 urea Is demonstrated clinically by addiiig an equal part of coldliay also occur at tl 
 nitric acid in a test-tube to some urine, when crystals of nitrate oilie third week of t 
 urea will form on the top of the fluid, giving rise to a mass someljon of products 
 what resembling sugar-candy in appearance. The skin of ; ifective blood-nois 
 febrile patient is often dry. ^ ^ 
 
 Caiisis of Fever. — The temperature of the body, it is well known, is controllec 
 by a principal heat-governing centre in the medulla, assisted possibly b] 
 accessory centres in the cord, and is maintained by the establishment o 
 equilibrium between the amount of heat lost from the skin, by the breath, hik instituti'om'j" 
 in other directions, and the amount of heat produced by the tissue metabolisn 'iM / ? 
 occurring in the viscera generalh', and especially in the voluntary muscle '^^ocal causes inc 
 Pyrexia is necessarily due to one of two causes, viz., a decreased loss of heat ^- JJefective circii 
 or an,mcreased production. The former is a scarcelyT€natne"proposrtlo'n'*\\lre 
 vvtTl'ootc at "tfte"patTeh't's""1:bndition. and hence we are driven to conclude th; 
 fever is due to increased activity in the heat-forming tissues, especially th 
 muscles, a fact which explains the rapid emaciation and loss of strength und( 
 such circumstances, and the presence of a large amount of extractives in tt 
 urine. In all probability this increased activity is due to the excitement 
 the heat-produring centre by some pyrogenous body developed in connectio 
 with the local inflammatory process. Experiments have shown that the fibr 
 ferment, as well as many of the toxins produced by the action of micr 
 organisms, if injected into the circulation in a pure state, possesses such 
 power. 
 
 In regard to the symptoms of fever, it may be stated briefly that they a 
 in large part due to the effect produced by the increased temperature or tl 
 toxic products circulating in the blood upon the constituent cells of glandiilf 
 and other organs. The phenomena in question are termed by different patl 
 ologists ' acutt^ or cloudy swelling,' 'granular degeneration,' ' albuminol 
 infiltration,' etc , and are characterized by the organs becoming soft, friabi 
 and more or less swollen. The secreting cells of glands are increased in sif 
 and the protoplasm becomes markedly granular, so that the nucleus can oJ 
 
 be distinguished with difficulty. The granules are albuminous in charactP'-^'^y? Or phosphori 
 clearing up completely on the addition of acetic acid. A similar changer' 
 also evident in the fibres of the cardiac muscle, which lose their striatioii a[ 
 become granular, a condition which must considerably interfere with thj 
 contractility. The effect produced upon the glands of the digestive systf 
 explains many of the febrile manifestations, inasmuch as their function 
 largely impaired. The salivary and buccal glands are unable to excrete 
 normal amount of saliva, and hence the mouth becomes dry. Gastric dij; 
 tion is interfered with in the same way. The bile is not efficiently produc 
 and hence its fat-emulsifying properties are diminished, as also its cathaj 
 powers, whilst the patient cannot properly digest fats, and is constipated. 
 
 Predisposing Caus 
 
 anunation may be 
 
 nib with rigid ca 
 a leg with varicos. 
 Loss or impairr 
 It less resistant 
 '1^'ition, diminishec 
 dilatory changes. 
 J- One attack of i 
 :re liable to recurre 
 The gcneyal or consi 
 i to depress the ge 
 
 • Old age, when tl 
 
 • Weak action of 
 organs and memb( 
 
 An unhealthy coi 
 ^ome abnormal co: 
 
 Various terms have been applied to different types of snVf 
 
 the insufficient elir 
 
 out ; {c) the absenc 
 
 ^ina or anaemia. 
 
 The presence of 
 
 hesis, as syphilis, ti 
 
 citing Causes— Tl 
 
 mmation is the ex 
 
 ter or longer period 
 
 tats are infinite in 
 
 fcvcy, e.g., sthenic and asthenic, which sometimes depend as mil Mechan' l' ^"^^ 
 
 upon the constitution of the patient as upon the nature or c-'iBolirTen'sTofr"'*"'^'*--"- 
 
 of the affection. By Sthenic inflammatory fever (Greek, o-^fMf>v^v,--jc«.™4,ii:EI^^^H' 
 
 strength) is meant tBafcondTfioii'm'wKicli pyrexia and ^WMnr nr^iX" 
 
 -"-■••»..»,,, 
 
 *'^W*s*%* 
 
INFLAMMATION 
 
 1 1 
 
 iccompanying symptoms are well marked. It occurs mainly in 
 oung healthy adults of soimd constitution, as, for example, when 
 1 young man is suddenly attacked by acute pneumonia, or when 
 n acute abscess is forming. Asthenic inflammatory fever (Greek, 
 Sevos, without strength) iTTt!rra'':TefIzed"''t)y'fhe*'fefidency to 
 xhaustion and collapse associated therewith. It is met with in 
 ebilitated subjects and those exhausted by vicious habits, but 
 nay also occur at the close of a long period of pyrexia, e.g., in 
 he third week of typhoid fever ( = the typhoid state). The absorp- 
 ion of products of putrefaction and the occurrence of acute 
 ifective blood-poisoning also induce fever of this type. 
 
 Causes of Inflammation. 
 
 Predisposing Causes. — The conditions which predispose to in- 
 immation may be conveniently divided into the local and the 
 institutional. 
 
 The local causes include the following more important conditions : 
 
 I. Defective circulation, whether due to chronic anaemia, as in 
 
 llinib with rigid calcareous arteries, or to passive congestion, as 
 
 I a leg with varicose veins. 
 |2. Loss or impairment of the nervous supply to a part, render- 
 k' it less resistant to external irritation either from loss of 
 nsation, diminished trophic control of the nervous centres, or 
 
 br 
 cri 
 
 :ti#culatory changes. 
 
 ]. One attack of inflammation often leaves a part weaker and 
 
 )ie liable to recucrence. 
 
 [The general or constitutional predisposing causes are those which 
 
 ;d to depress the general vitality, e.g. : 
 
 I. Old age, when the body as a whole suffers in its nutrition. 
 
 , Weak action of the heart, disturbing the vascular supply of 
 
 organs and members of the body. 
 
 , An unhealthy condition of the blocd, as from [a) the addition 
 pome abnormal constituent, as in alcohohsm, plethora, lead, 
 [rcury, or phosphorus poisoning, septic diseases, diabetes, etc. ; 
 
 the insufficient elimination of excreta, as in Bright's disease 
 
 ;out ; (f) the absence of some normal 'onstituents, as in albu- 
 
 mria or anaemia. 
 
 |, The presence of some constitutional disease, dyscrasia or 
 
 diesis, as syphilis, tubercle, rheumatism, etc. 
 
 :citing Causes. — The active agent in the production of any 
 
 immation is the existence of some irritant v.hich acts for a 
 
 :ter or longer period upon the tissues. The diflferent forms of 
 
 [ants are infinite in number, but may be grouped under the 
 
 jwing four headings : 
 Mec hanical or traumatic causesj_^,uch as direct violence, 
 
 ion, tension, pressure, etc. 
 CaQ"g6"g"'WhiC'h " act tlirough changes of temperature, either 
 
 ''«t.4.,WNm,fr*n», 
 
 *\'M V1*'*»*V.' 
 
12 
 
 A MANUAL OF SURGERY 
 
 
 ;i:i 
 
 
 l\\ 
 
 \i 
 
 I ', 
 
 3. Electricity, either as applied by the surgeon in the form c|ej/are°ffrou'"^d 'l^ ^^^ 
 the faradic or galvanic current, or through the agency of ^^g^tn'mmRmmations^ stleM ^ 
 or the strong currents used for lighting purposes. lains, the characterist'i 
 
 4. Toxic irritants, under which may be included : 
 
 {a) Chemical ageiitsV such as StrdHg" acids or alkalies 
 
 Ihen they occur in pai 
 morrhcea and pneumoi 
 
 (b) Veggra*te:irfitants,V:^.,cf^ et|caS)Sl5^any"of1h 
 
 (6')"Ariimal irrftants, such as cantharides, and insect Jlatinous in character - 
 
 ■"■ reptile bites. '" "*""" ■?■ ^^.cilli or rod-shape 
 
 (d) The development of micro-organisms within or witlj"."^ or short filaments 
 ^ ^ • ^. i*^i- ° — ■---.rr->v^.^<.k* — W to end ; or the v ma,, 
 
 ^ll^t .^°'^y • l'\f i"V the slSlfe 
 
 Micro-organisms play such an important part in the development of diseal ^'^ ^^*- ^s iso 
 
 that special attention must be given to this cause of inflammation. Four ch 
 classes of micro-organisms exist, and a short notice of each is required. 
 
 I. The Fungi or Ascomycetes (Fig, 2, I.) are characterized by the grow 
 of a mycelium or mass of interlacing fibres or threads, arising from which 
 the spore-bearing conidia, whence multiplication of the growth ensues, 
 great variety of fungi is found in Nature, but the more important pathologi 
 conditions due to their development in the body are as follows : 
 
 Thrush, due to the Oidiiim nlbiauis. 
 
 Ringworm, due either to the Microsporon Audoini (the common type), or 
 the Tricophytoii mc^alosporon cndothrix or cctothrix. 
 
 Favus, arising from the AcJion'oii Schdnlciiiii. 
 
 Pityriasis versicolor, due to the Microsporon furfur. 
 
 Kerato-mycosis, or parasitic ulcer of the cornea, is due to fungi of 
 aspergillus or mucor type (common moulds), which may also be fo 
 developing in the bronchi (pneumo-mycosis), or in the external auditi 
 meatus (otomycosis). 
 
 Actinomycosis (p. 112) is dependent on the growth in the tissues of the 
 fungus, or Actinomyces, although there is some question as to whether t! 
 organisms should not be classed as bacteria. 
 
 II. The Yeasts or Blastomycetes (Fig. 2, II.) multiply by a procts 
 gemmation or budding. They are responsible for many forms of fermentat 
 e.g., the alcoholic or acetous, but play no recognised part in human patho' 
 
 III. The Protozoa constitute a group which can be classed either as ani 
 or vegetable, and consist in their earlier stages of masses of naked nucle 
 protoplasm, which may later on become covered with membranous envelo; 
 through openings in which pseudopodia, are protruded. They form a 1 
 and varied class, the simplest type being the amoeba ; but their influenq 
 pathology is not yet fully worked out. It is supposed that the folio 
 varieties are of pathological importance : 
 
 Aiiia'bce are known to occur in certain forms of colitis, and also in 
 varieties of hepatic abscess. 
 
 Malaria is due to the development of a protozoon, the Plasmodium malan 
 
 The Psorospcrmia, which occur not unfrequently in animals, are men 
 of this group, and it is still a moot question whether the coccidia-like b 
 found in Paget's disease of the nipple, and in some cases of carcinom 
 really living parasites, and if so, whether they have any causative efle 
 the origin of the disease (p. 138). MoUuscum contagiosum is another con 
 which has been attributed to these organisms. 
 
 IV. The Bacteria or Schizomycetes form a very important and num 
 class, and are in the present day looked upon as the essential cause of 
 [action, suppuration, and most of the inflammatory diseases. The 
 classified under the following headings : 
 
 I. Micrococci or Cocci (Fig. 2, 111.) are roundish or oval cells, multi 
 rapidly by a process of fission [i.e., division into equal parts). They 
 remain isolated, but as a rule are collected into certam definite form 
 
 Fig. 2.-D1AGRAM c 
 
 Ifycelium and spore-bea 
 eas organism, undergo 
 solated cocci; IV dir 
 'aphylococci or cluster^ 
 arcmas; IX., cocci arran 
 orpuscles. 
 
 multiply by fission, oi 
 iatter are much more re 
 rhe spore may develop 
 Rn--?,""^;^.''" the so. call 
 'pmlla (Fig. 2, XI.) form 
 vement. They pribabT 
 logy only occur in a few \ 
 
 V general facts must be 
 I °; these vegetable orga 
 *tat.-~Bacteria are aim' 
 
INFLAMMATION 
 
 »3 
 
 (id in consequence are termed staphylococci or cluster cocci (Fig. 2, VI.; when 
 |iey are grouped like a bunch of grapes, usually occurring thus in localized 
 flammations ; streptococci or chain cocci (Fig. 2, V.) when they develop in 
 lains, the characteristic of spreading inflammations ; diplococci (Fig. 2, IV.) 
 hen they occur in pairs, e.g., the gonococcus or pneumococcus met with in 
 inorrhcea and pneumonia respectively. When they are grouped into packets 
 
 bur or eight individuals, they are usually termed sarcince (Fig. 2, VIII.). 
 xasionally any of the above may occur in masses or colonies, slimy or 
 latinous in character, and known as a zooglcea (Fig. 2, VII.). 
 
 Bacilli or rod-shaped bacteria (Fig. 2, X.) are found in the form either 
 
 ong or short filaments made up of an aggregation of individual rods united 
 to end ; or they may become curved and so form spiral rods, which may 
 
 ;ak up into the so-called comma-shaped bacilli ; or they may persist in the 
 
 Jy of their host as isolated rods within the substance of the cells invaded. 
 
 FiG. 2. — Diagram of various forms of Micko-organisms 
 (After Tillmanns.) 
 
 Ilycelium and spore-bearing conidia of fungus {PeniciUium glaucum); II., 
 least organism, undergoing multiplication by gemmation ; III., single or 
 Isolated cocci; IV., diplococci; V., streptococci or chain cocci; VI., 
 staphylococci or cluster cocci ; VII., zoogloea mass of organisms ; VIII., 
 larcinae ; IX., cocci arranged in fours ; X., bacilli; XL, spirilla, with blood 
 prpuscles. 
 
 multiply by fission, or by the formation of spores in their interior, 
 latter are much more resistant and less easily destroyed than the parent 
 The spore may develop in the centre of the bacillus, as in the B. antlimcis, 
 lt)ne end, as in the so-called drumstick-shaped B. teiaiii (Fig. 13). 
 ppirilla (Fig. 2, XI.) form corkscrew-like threads, possessing active power 
 I'vement. They probably multiply by spore formation, and in human 
 liogy only occur in a few conditions, such as remittent fever. 
 
 tw general facts must be added here as to the life history and mode of 
 
 ly of these vegetable organisms. 
 
 kitat. — Bacteria are almost universal in their distribution. Earth, air, 
 
14 
 
 / MANUAL OF SURGERY 
 
 
 and water are full of them, and especially so in populous neighbourhoods. The] 
 greater the number of the inhabitants, the larger the number of organisms ir, 
 the air. On the high Alps, and in isolated, especially mountainous, districts 
 there are comparatively few, whilst in the air of a crowded hospital war;j 
 swarms of them are present, and these often of a most dangerous type. The] 
 surface of our bodies and the intestinal canal, moreover, teem with them 
 although in a healthy individual the solid organs, the blood and lymph, art 
 practically free. Any condition of general weakness facilitates their entranc; 
 into the system or, perhaps one should say, diminishes the resistance of tht 
 body to their presence and activity, and hence lays the individual open to tht 
 occurrence of diverse infective diseases. 
 
 Mobility. — The cocci are as a group incapable of active locomotion, althoiini] 
 they manifest, in common with all minute non-living particles, ' Brownian 
 movements. Most bacilli and spirilla have in addition the power of movin; 
 from place to place, accomplished by means of cilia, which develop either a; 
 one or both ends as single filaments or in bunches. These can be readil 
 demonstrated in the Bac. typliosiis. 
 
 Multiplication. — The power of multiplying possessed by bacteria is enormous 
 Two method.s iiave been mentioned above, viz., fission and the formation cl 
 endospores. Spore formation is not known to occur in the cocci or sarcinae, an 
 although common amongst the bacilli, is not invariable ; thus the Bac. typhosii 
 and Bac. diphthcyiic are asporogenous. Only one spore forms in each bacilld 
 and, as already stated, its position varies in different species. The condition] 
 favourable to the development of spores have not yet been fully ascertained 
 but in most varieties a free supply of oxygen is required ; it is also a fact tha 
 spores never form amongst the living tissues of the body. 
 
 Results of Growth. — The activity and development o' bacteria are physi 
 logical plienomena, carried out in accordance with the general laws governini 
 animal and vegetable life, and requiring certain definite conditions to 
 present. The pabulum or food-stuff differs somewhat with the particul, 
 species, but they all recjuire water, oxygen, hydrogen, nitrogen, carbon, 
 certain inorganic salts ; they usually grow better on highly complies 
 substances than on more simple materials. As to their environment in patlii 
 logical conditions, one divides them into two great classes, according to whetb 
 or not they can develop in the living tissues. The pathogenic or parasiti 
 bacteria can do so, producing what are known as ' infective ' diseases ; but whi 
 an organism can only develop in dead tissues, such as masses of slough, or 
 exudations of blood, serum, or pus, or in some non-living nutrient material, 
 is called a non-patiioi^cnic, saprophytic, or carrion microbe, and any intla 
 matory reaction, local or general, thereby induced is due to the irritating effi 
 of the toxic bodies produced in this way, and not directly to the action of t 
 bacteria. Some of the pathogenic organisms are capable of continuing tin 
 development in dead tissues as ' facultative saprophytes,' and this property 
 one of great danger, in that it permits of extensive diffusion of the virus ; 
 tetanus, anthrax, and malignant cedema bacilli, as also the pyogenic cocci, 
 characterized by this property. 
 
 The necessity or not for atmospheric air in their development constitutes! 
 basis of the division of microbes into aerobic and anaerobic. When they c 
 grow in, and, indeed, require for their development, the actual presence 
 free air, they are termed obligate aerobes. If, however, they have the power 
 acquiring the oxy.gen they need from the tissues surrounding them, they are thi 
 known as facultative anaerobes ; their development is then rather less rapid th 
 when aerobic conditions are present. Obligate anaerobic organisms are thi 
 which require an atmosphere around them, from which oxygen is rigidly 
 eluded, and such usually flourish best in nitrogen or hydrogen, e.g., the bacii 
 of tetanus. It must be remembered, however, that although their power 
 development is arrested by the presence of oxygen, it is not destroyed ; 
 restoration of anaerobic conditions will at once restore their vital activities. 
 
 Many different substances result from bacterial growth, both in cult 
 
 ai!l 
 atel 
 
 ve 
 
 or . 
 
 ore 
 
 le 
 
 neiiia and in the bi 
 
 fe.\tent the symptoms 
 
 the chemical comt 
 
 ather by their effeci 
 
 toxins, which are pe 
 
 lany of them are all 
 
 ferment-like action 
 
 leptonising proteids. 
 
 iomaines) are more or 
 
 iiilt up in the liken 
 
 ids, and can be cry^ 
 
 -important cause c 
 
 [anous inflammatory 
 
 tiler pyrexia alone, c 
 
 tanus and diphtheria 
 
 Other results of bac 
 
 Ibvious. I, Acid sub 
 
 instant cause of the s 
 
 e Diplococcits urea: tra 
 
 Gases, often of a 
 
 'ill'. ("')// communis, 
 
 nerated, but thi' 
 
 *hosphoresceu-_ ,s 
 
 Methods of Examinal 
 
 I. Microscopic Examih 
 
 mersion) are needed i 
 
 terniine the charactei 
 
 mute differences in th 
 
 nt in chains, cluster; 
 
 rhaps the most impn 
 
 monstrating and stain 
 
 Cultivation in or on 
 
 ermining the exact n; 
 
 purpose the cut sur 
 
 ts excellently in manx 
 
 ocl serum, are not ver 
 
 ition of gelatine or aj 
 
 the most suitable nut 
 
 IS important to note w 
 
 ' may be accomplis 
 
 s, some of which are 
 
 slant. The former „ 
 
 h an infected platinur 
 
 oblique surface (strea 
 
 Inoculation experime 
 
 the relations of micrd 
 
 learly recognised that 
 
 lan. Koch has insist( 
 
 ''f yo prove the infec 
 
 1) The organism mus 
 
 the blood. 
 i) It must be possibl 
 
 body. 
 
 ) Its inoculation intc 
 
 ance of the spec 
 
 ) The organism mu 
 
 infected in this r 
 
 question of Immui 
 
 ing much attention fi 
 
 
 ..J^Ldir 
 
INFLAMMATION 
 
 »5 
 
 nil 
 ithi 
 •asiti 
 Nvhi 
 or 
 ial 
 \i\x 
 efl'e( 
 )f t 
 th 
 ;rty 
 
 :i, al 
 
 est' 
 ci 
 ice 
 iver 
 eth| 
 
 tlv 
 
 edia and in the body, and upon the characters of these depend to a large 
 
 xtent the symptoms of the special diseases. But little is known at present as 
 
 the chemical composition or nature of these bodies, and ouc recognises them 
 
 ■athcr by their effects than in any other way. Chief amongst these are the 
 
 'oxins, which are perhaps more intensely poisonous than anything else known. 
 
 ilany of them are albuminous bodies (possibly aibumoses) ; most of them have 
 
 , ferment-like action ; and not a few are capable of liquefying gelatine or 
 
 leptonising proteids. The toxins formed by putrefactive organisms (the 
 
 iomiiincs) are more or less peculiar in that they are alkaloidal in nature, i.e., 
 
 milt up in the likeness of ammonium hydrate (NH^HO) ; they unite with 
 
 ids, and can be crystallized. The development of toxins in the body is the 
 
 1-important cause of the symptoms of disease ; locally, they give rise to 
 
 jarious inflammatory phenomena, and by their general absorption produce 
 
 ther pyrexia alone, or peculiar and characteristic groups of symptoms, as in 
 
 tanus and diphtheria. 
 
 Other results of bacterial activity are less important, though some are very 
 vious. I. Acid substances may be formed ; <'.^'., the Buc. acidi lactici is the 
 nstant cause of the souring of milk. 2. Alkaline products may develop ; e.^., 
 e DiplococcHS urea: transforms the ui"ea of urine into carbonate of ammonia. 
 Gases, often of a very pcetrating odour, may be produced by others, e.g., 
 i. coli communis, or Bar. a'l- •itatis maligni. 4. Various colouring bodies are 
 nerated, but thi' property is mainly limited to the non-pathogenic group. 
 Phosphoresceii... is also caused by certain bacteria. 
 Methods of Examination. — These are in the main threefold : 
 I. Microscopic Examination. — High powers of the microscope {e.g., ,V in. oil 
 mersion) are needed for this work, and even with them it is often diiilicult to 
 itermine the characters of any particular form of microbe under examination. 
 inute differences in the size and shape may assist, and the relative arrange- 
 nt in chains, clusters, etc. ; but the effect of different staining reagents is 
 haps the most important fact to ascertain. Into the various methods of 
 imonstrating and staining bacteria it is impossible to enter. 
 
 Cultivation in or on various nutrient media is of the greatest assistance in 
 ermining the exact nature of any special organism under examination. For 
 purpose the cut surface of a raw potato after sterilization of the exterior 
 IS excellently in many cases. Fluids, such as meat infusion, milk or fresh 
 lod serum, are not very satisfactory, but similar materials, solidified by the 
 ition of gelatine or agar-agar, and either placed in test-tubes or on plates, 
 the most suitable nutrient bases. In testing the life-history of any microbe, 
 s important to note whether or not it will develop in contact with the air. 
 s may be accomplished by the use of nutrient gelatine poured into test- 
 is, some of which are allowed to v^^ol in the vertical position, and others on 
 slant. The former are inoculated by puncturing the horizontal surface 
 an infected platinum wire (stab culture), the latter by streaking it along 
 oblique surface (streak culture). 
 
 Inoculation experiments are really the most reliable means of examining 
 
 the relations of micro-organisms to any particular affection ; but it must 
 
 arly recognised that animals are not necessarily affected in the same way 
 
 lan. Koch has insisted that ihe four following essentials must be fulfilled 
 
 der to prove the infective character of any particular disease : 
 
 The organism must be present in every case, either in the tissues or in 
 
 the blood. 
 It must be possible to cultivate it for many generations apart from the 
 
 body. 
 Its inoculation into a suitable animal must be followed by the appear- 
 ance of the specific disease ; and 
 The organism must be found in the tissues or blood of the animal 
 infected in this manner. 
 le question of Immunity from infective diseases has been, and still is, 
 iving much attention from bacteriologists. Three different types exist, viz.: 
 
 icil' 
 Kver 
 
 lulti 
 
i6 
 
 A MANUAL OF SURGERY 
 
 (a) Natural immunity, by which is meant that certain individuals or aniinaj 
 are capable of resisting the action of microbes, which can develop in otheri 
 thus, rats are unharmed by anthrax bacilli, and the dog, the goat and thu 
 are practically immune to tubercle. This condition also obtains in the hum 
 subject ; e.g., negroes are immune against yellow fever, whereas white peo 
 are extremely susceptible. 
 
 (b) Acquired immunity may be active or passive. Active immunity isdevelopi 
 in the following ways: (i.) The individual is free from the danger of contrai 
 ing a specific disease owing to his having already suffered from it. Thus, o 
 attack of any of the ordinary exanthemata or of syphilis protects him, as| 
 rule, from further liability to that special affection. Occasionally, howev 
 this immunity seems to wear itself out, and second attacks may then occi 
 (ii.) Inoculation with repeated doses of the specific organism, beginning w 
 very small ones, hut gradually increasing them in such a way and at such 
 time that the individual is not seriouslv affected. This has been chie "ufiSCytes are ffath 
 
 I attenuated or modifi avp rrimry-.^^ j , 
 
 employed amongst animals, (iii.) Inoculation with an 
 
 virus, which, whilst not giving the patient the disease, has yet such an eftcct up 
 
 e living leucocyt 
 iuggest that it is ( 
 
 ith in this way; 
 iresence of organi 
 hagocytosis, since 
 
 thebacteria, as i 
 iutcome of' this "dc 
 'iE. -introduced t,o 
 Sercised_jjpon the 
 ''C'^lcar.guBifghc^ 
 ctivity. Bypositivi 
 
 ave commenced tc 
 
 VIILIO, Wllil^ll, WliliaL 11 WL ^IVlll^ 1.1 IC Lucille:! iL Hit. V^iU^^^dO^, IICIO J ^^ Clli\.^H CX.IL *^1H.^1^L UIJ nnryi 4-1.. 
 
 his constitution as to protect him from it. This has been utilised by Past; p^-fS tiaye a povve 
 
 with good results in the prevention of anthrax in animals. The attenuation ' P'^Sma, as a result 
 
 organisms can be readily effected in many ways, though, perhaps, one of t more likely tO be 1 
 
 simplest consists in exposure to heat for a variable time, (iv.) Inoculati 
 
 with the sterilized products of bacterial activity is frequently used as 
 
 immunizing agent. A minute dose is at first administered, but as the degi 
 
 of immunity increases, the dose is gradually augmented until finally the ani 
 
 can receive with impunity an injection of many hundred times the dose \vh 
 
 would have sufficed to kill it at first. This method is employed in prepar 
 
 the antidiphtheritic serum. 
 
 Passive immunity is that condition which arises from the injection of 
 blood serum of immunized animals. Most of the serotherapy of the presi 
 day depends on this property, and the serums known as antitetanic, a 
 diphtheritic, antistreptococcic, etc., are all of this nature. They have a t\vof( 
 power, since they are not only immunizing, but also in measure curative, 
 immunity conferred by this means is rapidly acquired, but does not gener, 
 last long. 
 
 (f) Inherited immunity is a condition which undoubtedly occurs, and cani 
 animals be artificially produced, but our knowledge of the subject is at presj 
 very slight. 
 
 Fig. I 
 
 the first figure the rod- 
 the phagocyte ; in th 
 It IS being disintegrat 
 
 otective rather than 
 
 ked on, then, as on 
 
 porous microbic att 
 
 Eesisting or Antiseptic Power of the Tissues. — If we are si 
 
 rornTCteti Witn, Afld ii our nodies even are mvaded by, so greaBough no explanatic 
 swarm of enemies, many of which could under suitable circuBrthcoming. It mus 
 stances produce grave diseases, there must be present within ftdence in favour of 
 some potent natural means of resisting their activity, and sucwe collected, there is 
 termed the antiseptic or germicidal power of the tissues. ThBserum. Negative c 
 can be no manner of doubt that bacteria are destroyed in Mplied to a conditio! 
 body ; some are possibly excreted by the kidneys, but of thislpelled by the organi 
 know very little. There are two main theories as to Natimture, though it is in 
 means of destroying or preventing the action of bacteria in Bsts. Both phenom 
 body, viz. : (i) Metchnikoff's theory of Phagocytosis, which male cornea of r n anim- 
 tams that theJeucoc^tes,.j4id,.aiSD..taeJ^r.g,gr.roim the spot of ir 
 
 ■^^rh flie"connecTive-tissue corpuscles, described elsewhergft development there 
 li5^'T)'MTrstS,*tiflW'f7ie" power'oi'faTanglnfo'TFeiF substance fc caused thpr^^K 
 > ucrobes,jmd destroying them .Iiyjv . pxQcess,jC«iSe£ion. miie which is necrotic 
 ic a i/Tased on'ttlFTesinTs of microscopic examinaTTiI5!T*,' it beftmiotaxis. Outside 
 tolerably t.a.sy to demonstrate the presence of bacteria witBfirst of a whitish-yel 
 
 m 
 
INFLAMMATION 
 
 17 
 
 le living leucocyte (Fig. 3), although opponents to this theory 
 uggest that it is only dead or dying organisms which are dealt 
 ith in this way ; whilst it is also a well-known fact that the 
 iresence of organisms within cells is no absolute evidence of 
 ihagocytosis, since the latter may be invaded and finally destroyed 
 y the bacteria, as in leprosy and gonorrhoea. A^.aii imp.ortaut- 
 u'tcome of this "doctrine has arisen the icTea of Chemiotaxis, a 
 ^frn' intrpduced. to , iodicate an attractive or repulsive power' 
 xefcised upon the leucocytes by foreign ' bodies of vairibus 
 lTfmicar*5UQslahcesi particularly those dependent ofli'ltacteri'al 
 ctivity. By positive chemiotaxis is meant the attraction whereby 
 iucOCytes are gathered towards any tissues in which bacteria 
 ave commenced to develop ; the organisms or their products 
 leiEL-tQ haye a. power of causing active diapedesis and exudation 
 [ plasma, as a result of which the spread of the microbic invasion 
 more likely to be limited, and the inflammation thus caused is 
 
 Fig. 3. — Phagocytosis. (Tillmanns.) 
 
 ithe first figure the rod-shaped organism is being absorbed or swallowed by 
 the phagocyte ; in the second it is incorporated in its body, and in the third 
 it is being disintegrated. 
 
 htective rather than destructive. Positive chemiotax^is ,is tQ,be- 
 
 )ked on, then, as one of Nature's defences against an active and 
 
 j^orous rnicrobic attack. That it occurs cannot be questioned, 
 
 [ough no explanation as to its origin or nature is at present 
 
 fthcoming. It must be noted, however, that its existence is no 
 
 jidence in favour of Metchiiikoff 's theory, since where leucocytes 
 
 |e collected, there is certain to be an increased effusion of plasma 
 
 |i« serum. Negative chemiotaxis, on the other hand, is the term 
 
 Jplied to a condition in which the leucocytes are apparently 
 
 Ipelled by the organisms, probably on account of their virulent 
 
 jture, though it is impossible to prove that any active repulsion 
 
 lists. Both phenomena can be seen very well by inoculating 
 
 cornea of in animal with the Aspergillus niger, as was done by 
 
 |tber ; the spot of inoculation looks opaque and dull, owing to 
 
 development therein of the mycelium of the fungus, and the 
 
 crosis caused thereby ; around this is an area of clear corneal 
 
 sue which is necrotic, but free from leucocytes owing to negative 
 
 emiotaxis. Outside this, again, is a circle of infiltrated tissue^ 
 
 Iftrst of a whitish-yellow colour, and finally breaking down into 
 
'■t 
 
 
 iS 
 
 A MANUAL OF SURGERY 
 
 pus, the result of positive chemiotaxis. (2) More recently thJunctiva or that of 
 theory of phagocytosis has been very vigorously attacked, and iliasses, which can 1 
 has been maintained that the chief germicidal powers of the botljlelow, with merel' 
 reside in the blood serum and its constituents. This idea ilubstance. 
 certainly supported by the well-known fact that fresh blood seruiil A Dyjhtheritic ii 
 
 is a bad medium for the cultivation of bacteria. Its inhibitory 
 germicidal properties can, however, be removed by keeping it 
 
 or by exposing it to a process of dialysis, or by heating it fo lyers of the epithe 
 about half an hour to a temperature of 55° C. Certain specia aving a raw sur 
 albuminous substances, more or less of the nature of ferments iid produce toxins 
 have been isolated, to which the name of Protective Albumens onstitutional symn 
 Alexines has been given. Probably there is truth in both thes "" — 
 
 theories, the two different powers being called into play uncle 
 varying circumstances and in different stages of the disease, th 
 phagocytes only coming in to complete the work which has beei 
 already mainly effected by the blood plasma. 
 
 he Bacillus diptitH'ev 
 lembranous exuda 
 
 I 
 
 Varieties of Inflammation. 
 
 X™-term _ Phlegn 
 )Fmerly~appTied to 
 henomena were wf 
 Parenchymatoug a 
 an inflamed orgar 
 the actual and a 
 rting fibrous tissu 
 The jterm Metasi 
 Many different terms are used to indicate ihe manifestations oli^den'^fransFereh'ce 
 the inflammatory process in the body, and to some of these wft another without 
 nmst now direct attention. ftthology has expla 
 
 A Catarrhal inflammation is one affecting mucous membranealustrations of metas 
 which In the early stages become dry, vividly red, and the seat c|inited to the infla 
 a burning or scalding pain, whilst in the later stages there is fn 
 secretion of mucus, muco-pus, or pus. Pathologically, th 
 process is accompanied, as are all active inflammatory change 
 by hyperaemia and exudation. At first the mucigenous functioi 
 of the membra; ne is abrogated, and any extravascular exudal^,^ is only possibl 
 tion passes into its substance, causing it to become swolle™'"ch guide us in th( 
 Proliferation of the epithelium soon follows, resulting in ajethod of applicatioi 
 increased formation of mucus ; as the membrane becomes mo 
 and more infiltrated with leucocytes, these are added to t 
 discharge, which is thus transformed into muco-pus, or even pu: 
 Small ulcers may develop from the loss of superficial epitheliu: 
 but this is an exception rather than the rule. Microscopi 
 examination of the discharge reveals pus cells, leucocytes, a 
 
 Hows mumps. 
 
 Trea 
 
 described hereafte 
 The Local Treatme 
 
 rr-Rgimrn'me-exat 
 luses 'when feasibh 
 ion is a gross oni 
 reign body embedd( 
 
 lobar pneumonia. On mucous membranes, such as the co m to trust to other 
 
 )in 
 
 epithelial elements in various conditions, some containing globulw^d bone lying at th 
 of mucin, and some of the normal type. This form of inflamm 
 tion may be caused by bacteria, but is often due to the action 
 local irritants, or to what is known as ' taking cold.' 
 
 A Croupous (or plastic) inflammation is one characterized 
 the formatioriof a firm, fibrinous false-membrane. When i 
 volving a serous surface, such as the pleurr,, peritoneum, 
 synovial membrane, it gives rise to a layer of plastic lymph, whi( 
 may organize into adhesions ; it is also seen in open wouni 
 previous to granulation, and occurs in the alveoli of the lungs 
 
 pent-up eflfusioi 
 scess opened. In s 
 
 practicable to totj 
 istule— whilst in otl 
 
 scraping away tl 
 ilkniann's spoon, j 
 rbolic acid or pero 
 iffed with gauze. ] 
 pe, it is usually imp 
 
INFLAMMATION 
 
 19 
 
 K iinctiva or that of tlie pharynx, it occasionally forms white, flaky 
 lasses, which can readily be detached, leaving an injected surface 
 lelow, with merely one or more oozing points, and no loss of 
 ibstance. 
 
 A PJj;)litheritic inflarnm&tion is due to a special organism — 
 he Bacillus diptitticyia — and is characterized by the formation of a 
 jembranous exudation with which are incorporated the superficial 
 b lyers of the epithelium, so that it cannot be removed without 
 aving a raw surface. The bacilli develop in this false membrane 
 ts nd produce toxins, which by their absorption give rise to the 
 onstitutional symptoms of the disease. 
 
 The term Phlegmonous is now but rarely employed. It was 
 le ifmerly applied to any superficial inflammation where the local 
 henomena were well marked. 
 
 Parenchyma^ug a^4 Jateistit^a^il, ar^ terms which indicate that 
 an inffamed organ or gland the process is mainly limited, either 
 the actual and active substance of the organ, or to the sup- 
 rting fibrous tissue. 
 
 The term Metastasis was formerly employed to indicate a 
 
 den'^fransFerence of an inflammatory attack from one place 
 
 another without apparent cause. Increased knowledge of 
 
 thology has explained away almost all the formerly-described 
 
 lustrations of metastasis, and, Indeed, the use of this term is now 
 
 ited to the inflammation of testis, ovary, or breast which 
 
 illows mumps. 
 
 ;ei 
 
 io| 
 da 
 eil 
 
 0I| 
 
 tW 
 )v\ 
 in 
 
 1 1 
 
 IK 
 
 ;ol 
 
 Treatment of Acute Inflammation. 
 
 It is only possible to deal here with the general principles 
 Ihich guide us in the treatment of inflammatory affections. The 
 lethod of application of these to different parts of the body will 
 described hereafter. 
 
 The Local Treatment may be indicated under four headings : 
 
 r:~Reift6W' tiff exciting' cause, if evident, and any contributory 
 
 (uses when feasible. This is not a difficult matter when the 
 
 iion is a gross one, and the exciting cause tangible — e.g., a 
 
 reign body embedded in the conjunctiva or cornea, or a piece of 
 
 id bone lying at the bottom of a sinus. Inflammatory tension 
 
 mi pent-up effusion is readily relieved by an incision, or an 
 
 icess opened. In some cases, due to bacterial invasion, it may 
 
 practicable to totally excise a local focus — e.g., a malignant 
 
 istule — whilst in others, such as a carbuncle, one has to trust 
 
 scraping away the sloughy and infiltrated tissue with a 
 
 olkmann's spoon, and then, after purification with liquefied 
 
 rbolic acid or peroxide of hydrogen, the wound is carefully 
 
 fed with gauze. In bacterial inflammation of a more diffuse 
 
 I, it is usually impossible to remove the cause, and one has 
 
 tn to trust to other measures. 
 
ao 
 
 A MANUAL OF SURGERY 
 
 m 
 
 I Ui'i 
 
 I ! i 
 
 2. AVf/> the iiijlamed part at vest. Wherever inflammation exists,! Heat, especially 
 both physical ami physiological rest should be obtained as far aslnsnrttn treating i 
 possible. Thus, an inflamed joint is immobiUzed by a splint ; anically opposite \\iv 
 inflamed mamma needs both support and the fixation of the arniJthus reducing the 
 whilst if in a condition of physiological activity this must beland vitality of th( 
 checked by suitable treatment ; an inflamed cornea requires thJiacilitatinf lymph^i 
 application of a pad and bandage to prevent the friction of thJing, the applicatio'i 
 eyelid ; an inflamed retina must be given physiological rest bj for subcutaneous 
 exclusion of the light. opium or beiladom 
 
 3. Reduce ^ the local blood -pressure and hyperemia, and thu; simply dry heated 
 dimimsli WtlV exudation and pain. Elevation of an inflaniei abscess is forming 
 limb may secure this end, and is a most essential element in tb( than a linseed-nie; 
 treatment of all inflammatory conditions of the leg, for it is ; allowed to burst ini 
 well-known fact that emptying the veins by gravity in ai )pen wound or abs 
 elevated limb leads to reflex contraction of the arteries. Loon Jition, and then th 
 blood-letting by leeches, punctures, scarification, and wet or dn iiaking them with 
 cupping, is useful in suitable cases, and sometimes gives imnit )oultice or fomenta 
 diate relief. It may be as well to mention that a leech cat natory affections d 
 withdraw about 2 to 4 drachms of blood, and that it should noftonsists in the appli 
 be applied over a large subcutaneous vein, or to parts, like thMvrung out of a hot 
 scrotum or eyelids, where there is much subcutaneous tissue of Miled silk or guttaoe 
 loose texture, in which extravasation readily occurs. The bleedinj 4. Prevent the acce' 
 from a leech-bite usually ceases spontaneously, but may reciuirftose due to piifreTa' 
 the application of slight pressure. Borne of the meth 
 
 In diffuse inflammation of the cellulitic type free incisions arBescribed in Chaptc 
 beneficial, partly on account of the relief of tension and paiMounds, and do not 
 which follows the escape of blood and retained discharges fro™ ihe._ General Tre 
 the tissues, but also because it determines a free flow of bloof" ' " ■ """' 
 
 serum, and as this possesses antitoxic and germicidal propertie 
 it assists in bringing the inflammatory process to an end. 
 
 Cold, wisely utilized is of the greatest service in combati 
 inflammation, causing contraction of the arterioles, and so n 
 ducing the hypera^mia. It should only be used in the early stag(\ 
 and never when suppuration is threatening, as, although it m 
 cause local depletion of the bloodvessels, it at the same ti 
 depresses the vitality of the part, and so may do more harm th 
 good. Again, it should be used with the greatest care in oi 
 people, from fear of causing sloughing of the skin. There a 
 \arious methods of applying it, as by means of an ice-bag ; or 
 
 irrigation from a vessel, suspended over the part, containing icfle freely "employed sc 
 water or lotion, from which strips of lint descend to envelop tftnove irritatino- ma 
 inflamed area ; or a piece of lint wrung out of evaporating loti 
 may be placed directly on the part ; or, better still, the iced wa 
 may be run through a coil of leaden pipes (known as Leitei 
 tubes), fitted carefully to the inflamed region. Under any circii 
 stances the cold must be continuous, and not intermittent, 
 otherwise the alternating periods of anaemia and hyperaemia w 
 have a baneful rather than a beneficial influence. 
 
 th the condition o 
 inci healthy, or wea 
 iho may be expecte 
 It the febrile state, n 
 
 treatment, whilst 
 
 the elimination c 
 liioretics, and diureti 
 E also diffusible s 
 iiimonia, whilst the 
 [exhaustion will ab: 
 tervals of nourishir 
 
 enic type of infla; 
 
 fllowed by low diet 
 kin other instances 
 [a large and full pi 
 prked, it may be 
 ptimony, aconite, fu 
 lecacuanha, to redv 
 ftain diaphoretic ac 
 
INFLAMMATION 
 
 31 
 
 Ilcat, especially when combined with moisture, is very larj^ely 
 sert In treatin;^ inflammatory affections, and acts in a diametri- 
 cally opposite way to cold by relaxinj^ the vessels and tissues, 
 thus reducing the tension and pain ; it also favours the activity 
 and vitality of the part by increasing the vascular supply and 
 tacilitating lymphatic absorption. When suppuration is threaten- 
 ing;, the application of warmth and moisture hastens the process. 
 )y For subcutaneous lesions, fomentations, medicated or not with 
 opium or belladonna, or spongiopiline wrung out of hot water, or 
 us simply dry heated cotton-wool, may be employed. When an 
 ec iibscess is forming, nothing can be more soothing and satisfactory 
 lit than s. linseed-meal poultice, provided that the abscess is not 
 ; allowed to burst into it. Poultices should never be applied to an 
 at open wound or abscess, unless the latter is in a very septic con- 
 :a Jition, and then they can be rendered more or less aseptic by 
 iiaking them with hot carbolic lotion (i in 30). The boracic 
 loultice or fomentation is most useful in many superficial inflam- 
 iiatory affections due to sepsis, dirt, and want of attention. It 
 onsists in the application to the part of a portion of boracic lint 
 vrung out of a hot boric acid solution (i in 20), and covered with 
 iled silk or guttapercha tissue. 
 
 4. Prevent the access of fyesh sources of irritation or infection, such as 
 
 lirliiose due to piitrefaCtive changes Tri'an open discTiai'f^Tfig'wolindr 
 
 jome of the methods and agents for maintaining asepsis are 
 
 ar lescribed in Chapter VII. under the subject of the treatment of 
 
 ail rounds, and do not need to be discussed here. 
 
 or T]^_fi§J&6I!9LJ?reatment of inflammation varies considerably 
 
 30 ,ith the condition of the patient, and as to whether he is strong 
 
 iCi nd healthy, or weakly. Those who are depressed in health, or 
 
 ho may be expected readily to become so from the continuance 
 
 fthe febrile state, need to be carefully supported by a tonic plan 
 
 if treatment, whilst at the same time attention must be directed 
 
 3 the elimination of toxic bodies by suitable purgatives, dia- 
 
 la horetics, and diuretics. Quinine may be given with great benefit, 
 
 also diffusible stimulants, such as ether or carbonate of 
 
 nimonia, whilst the recovery of patients lying in a typhoid state 
 
 exhaustion will absolutely depend on the administration at short 
 
 nervals of nourishing fluids, combined with stimulants. In the 
 
 ihenic type of inflammatory fever, * antiphlogistic ' means may 
 
 cf e freely employed so as to reduce the general blood-pressure and 
 
 move irritating matters from the system, e.g., a smart purge, 
 
 illowed by low diet and abstinence from alcohol for a few days ; 
 
 iit in other instances where the blood-tension is high, as indicated 
 
 I a large and full pulse, and the local signs (pain, etc.) are well 
 
 arked, it may be also necessary to administer such drugs as 
 
 timony, aconite, full doses of acetate of ammonia, colchicum or 
 
 cacuanha, to reduce the general blood-pressure, as also to 
 
 tain diaphoretic action. In a few cases — e.g., acute meningitis 
 
 ?(' 
 
 It 
 
 iti 
 
n 
 
 A MANUAL OF SURGERY 
 
 ii 
 
 — venesection n.ay be needed, and this is an apent too littl 
 employed in tlit' present day. In some forms of inflannnation 
 due to the specific diatheses, suitable drugs must be employed t 
 combat such tendencies — e.g., salicylate of soda or salicin in acut 
 rheimiatism. 
 
 Of late years much attention has been directed to the treatmcn 
 of infective diseases by the injection of antitoxic sera (serotherapy 
 and a number of them have now been introduced into svirf^MCi| 
 practice. They may act in one of two ways : either by pre '-'*<> with the predis 
 ventinjj the further development of the organisms in the syster idicate a few points 
 {inhibitory action), or by counteracting the effects of the toxiij 
 already produced {antitoxic action). Antistreptococcic serum an 
 antitetanic serum are the two most important from the surgic 
 standpoint, and references will be found to the use of these und 
 their appropriate headings. 
 
 aite mischief, l)ut 
 lu! most striking 
 y diathetic conditic 
 e manifestations n 
 ibercle, gout or rh< 
 is nature without i 
 some such taint. 
 The Results vary , 
 
 In Simple chronic 
 larged, mainly frot 
 ;i 11 owed to persist, 
 )one is thickened ai 
 iilst in chronic pe; 
 ay occur. Glands 
 rperplasia of the coi 
 may either beconK 
 ses its characteristii 
 /ibro-cicatricial tis;- 
 
 Chronic Inflammation. 
 
 The phenomena of chronic inflammation are essentially t 
 same as those of the acute process, though the manifestations a 
 somewhat different. Hyperaemia and exudation occur, but t 
 tissue reaction is much more prominent 
 between the two are as follows : 
 
 1. The hypera;mia is less in amount, but longer in duratio 
 owing to the fact that the causative irritant is less intense 
 action, although often applied for a longer time. The loc I'ch are definite tub 
 manifestations therefore are less obvious; pain is not so great a e formation of casea 
 mainly of an aching character, whilst there is icrss heat, the n ppuration or ulcerat 
 ness is more dusky, and the tissues often become pigmeiiK 
 Considerable loss of tone in the vessels, especially the veii 
 results from the prolonged distension, and thus there is a grea 
 difficulty in restoring them to a normal state 
 
 2. The corpuscles do not adhere together or run into roulea 
 to the same extent as in acute inflammation, and migrati 
 though it exists, is on a limited scale. The exudation is m( 
 fluid in character, containing comparatively little albu^nen 
 fibrin ; in fact, in some chronic inflammations of serous mt 
 branes the cavities are distended with fluid of a much lov 
 specific gravity than that of blood serum 
 
 3. The greatest difference in the acute aur^ chronic procesB'^ery-looking slough 
 lies in the reaction of the tissues. In the fi.imer they are il" all these varieties 
 depressed or paralysed condition, but in ihe latter they becow'^tion is always foui 
 infiltrated with round cells, derived rather from the connectB'nflamed area, the n 
 tissue elements than from the leucocytes, and hence organizaljonstitutional sympt( 
 is much more marked than in the acute form. Tissue destilendent on the diathe 
 tion, consequently, is less prominent in the early stage of chrJdue, or to septic cha 
 inflammations, although as a secondary change, especiall)Mhe Treatment of ch 
 tubercular and syphilitic diseases, it is often seen. ■ed and difficult thai 
 
 The Causes are similar in character to those producing litional dyscrasia whi 
 
 The main differencftfTe. Truesuppural 
 
 low virulence occa^ 
 
 n chronic Tubercn 
 
 !d by pulpy cedenic 
 
 tension be limited 
 fuse overgrowth foi 
 lowed by destructioi 
 [animation of the par 
 11 chronic Syphiliti 
 ture is an invasion < 
 ular exudation anc 
 ^Hzed ; if the forme 
 the stony-hard terti 
 eloped, which usu£ 
 sts, giving exit to 
 
 !,;,,!(■ 
 pt 
 
INFLAMMATION 
 
 83 
 
 tV 
 
 iciite mischief, but slighter and more prolonged in their action. 
 
 w most striking point in the aetiology is the large part played 
 
 diathetic conditions or constitutional predisj)ositions. Most of 
 
 le manifestations met with in surgical practice are due to syphilis, 
 
 bercle, gout or rheumatism, and one shoidd never treat cases of 
 
 is nature without carefully incjuiring as to the possible existence 
 
 [some such taint. 
 
 The Results vary according to the part of the body affected, and 
 so with the predisposing diathetic state, and we can here only 
 dicate a few points worthy of notice. 
 
 In Simple chronic inflannuation the part becomes infiltrated and 
 hirged, mainly from proliferation of the connective tissues, and 
 allowed to persist, this will result in fibrosis or sclerosis. Thus, 
 bone is thickened and condensed in chronic osteitis [osteosclerosis), 
 list in chronic periostitis a new subperiosteal deposit of bone 
 ay occur. Glands become enlarged and indurated, mainly by 
 perplasia of the connective tissue, whilst if the skin is involved 
 may either become hypertrophied and thickened, or entirely 
 ses its characteristic structure, being converted into granulation 
 fibro-cicatricial tissue, with or without an intervening ulcerative 
 ige. True suppuration rarely occurs, although certain organisms 
 low virulence occasionally lead to its development. 
 In chronic Tuberculous inflammation the alfected part is occu- 
 ;d by pulpy (edematous granulation tissue, scattered through 
 ich are definite tubercles, which may run together and lead to 
 formation of caseating foci ; these in turn may either result in 
 puration or ulceration, or may undergo calcification, and their 
 [tension be limited by a sclerosing process around them. A 
 use overgrowth forms the earliest stage, and this is often 
 lowed by destruction of the involved tissues, and possibly dis- 
 ani nation of the parts, with or without suppuration. 
 n chronic Syphilitic inflammation (tertiary) the most marked 
 iture is an invasion of any of the connective tissues by a fibro- 
 alar exudation and hyperplasia, which may be diffuse or 
 lized ; if the former, general sclerosis of the part results, e.g., 
 he stony-hard tertiary testicle ; in the latter, a gumma is 
 eloped, which usually undergoes central degeneration and 
 sts, giving exit to a gummy fluid, and perhaps leaving a 
 hery-looking slough behind. 
 
 n all these varieties of chronic inflammation a marked pro- 
 ation is always found in the tunica intima of the arteries of 
 inflamed area, the result of an associated chronic endarteyitis. 
 nstitutional symptoms are but little evident, beyond those 
 ndent on the diathetic condition to which the local phenomena 
 due, or to septic changes developed secondarily. 
 "he Treatment of chronic inflammation is usually more pro- 
 ed and difficult than that of acute cases, because of the con- 
 tional dyscrasia which exists so frequently behind it. 
 
' 
 
 
 ^4 
 
 A MANUAL OF SURGERY 
 
 I . The cause must be removed whenever possible. Dead or disease 
 honB-TTTtrsr'be'T6rilOVeifl^aHT*tub'erc got rid of, b 
 
 the knife or sharp spoon, whilst it is often desirable to supplemeii 
 this by subsequently swabbing the parts over with liquefied car 
 
 bolic acid. A chroni'^ abscess increases the action of the orij^im e tissues are increas 
 irritant tn rough the tension engendered by its presence, and henc iseline, or some stimi 
 it should be dealt with as early as possible (p. 39). 
 
 2j_ Keei) the_J>avt at rest. This is just as much an essential as i 
 
 ht, so as only to affe( 
 
 ^ ,^^ . adually become firm 
 
 the treatment orac'uite' inflammation. Joints should be iminc 'inssage consists in ki 
 
 its in plain up and 
 
 le hand, the up stroli 
 
 assist in the return 
 
 lis way the circulatic 
 
 e finger-tips and the 
 I done across the m\ 
 id is especially valua 
 ins. In Tapotement a 
 rapidly delivered by 
 e circulation in the p 
 •different ways, according to the character of the disease and tl len skilfully done no 
 
 bilized ; the spine must have the weight taken from it by suitab 
 •appliances, or, better still, by maintaining the recumbent position 
 secretory glands are not actively exercised, and the organs 
 sense are protected from irritation. 
 
 3. Counter-irritation is one of the most usgful forms of treatmei 
 for TtiroTrtiy^ffframmMOry* COT is applied in man 
 
 part involved. Thns, friction w'lih. the hand, or with stimulatin 
 
 embrocations, produces a hypergemic condition of the skiUj ai 5 specific diatheses w 
 
 promotes local activity in the superficial parts which may rea 
 beneficially on deeper structures. Scott's dressing may be similar 
 employed ; it consists in wrapping up the part {e.g., a joint) 
 strips of lint covered with ung. hydrarg. co. (containing ov 
 10 per cent, of camphor), and then encircling it firmly with so; 
 plaster, spread preferably on chamois leather. Iodine paint 
 another useful application, whilst blisters are most valuable 
 suitable cases. The moxa, a wound produced by burning 
 spirituous solution of saltpetre on the skin ; the issue, the main 
 nance of a raw surface, however produced, by the constant presen 
 of some irritant, such as the insertion of a bead, or the use 
 savin ointment as a dressing ; and the seton, a double thre 
 knotted at each end, passed for some distance under the skin, a 
 drawn from ei^d to end daily — all these are but little used no 
 although they might be occasionally employed with advantaj 
 The actual cautery is the most severe form of counter-irritant, a 
 is especially useful in some varieties of chronic inflammation 
 bones and joints. 
 
 4. Pm5«r£_js a mps^.. important element in the treatment 
 chr5nic Inflammatory disorders, arid 'prbBably acts by artificia 
 bracing up vessels 'vhich have become relaxed and atonic fn 
 the prolonged distension to which they have been subjected, 
 also favours the absorption of inflammatory exudations. Fi 
 bandaging, and especially the use of an elastic support, are 
 most satisfactory methods of application. 
 
 5. A most valuable means of treating chronic inflammatic 
 and indeed many other affections, consists in Massage. It 
 impossible in a text-book of this size to give a fuiraccount of 
 methods employed, but we may state that the chief of them 
 known as effleurage, petrissage, and tapotement. Effleura^ c 
 
 6. General or constiti 
 
 Jammation, e.g., mer 
 
-iAi:;,',_»«ji,^ ,,.,„ri5, y 
 
 INFLAMMATION 
 
 25 
 
 5ts in plain up and down rubbing of the limb with the flat of 
 le hand, the up stroke being always firmer than the down, so as 
 I assist in the return of the blood and lymph from the part. In 
 lis way the circulation is quickened, and the vital activities of 
 le tissues are increased. The skin should be lubricated with oil, 
 jseline, or some stimulating embrocation, and the rubbing, at first 
 bht, so as only to affect the skin and subcutaneous tissues, §hould 
 adually become firmer so as to influence the deep struchires. 
 Itvissage consists in kneading the muscles or other tissues between 
 e finger-tips and the palm of i\ \e hand ; this necessarily should 
 ; done across the muscle fibres, working from below upwards, 
 id is especially valuable in hastening the absorption of exuda- 
 )ns. In Tapotevient a series of blows perpendicular to the surface 
 rapidly delivered by the ulnar side of the open or clenched hand ; 
 e circulation in the parts thus struck is much quickened, and 
 len skilfully done no pain should be caused. 
 5. General or constitutional treatment must be adopted to meet 
 e specific diatheses which are commonly associated with chronic 
 iammation, e.g. 
 
 mercury or iodide of potash in syphilis. 
 
sun 
 
 fctim occurs, by mea 
 lection from within t 
 [ality of the patient 
 f dition exists favoun 
 lood-clot or inflamm 
 lual, whose germicide' 
 to-mfection, the orgj 
 Jcted area ; an absc 
 'ctive abscess. Occa 
 masse {zoogloea conditi( 
 Wood-clot, as an eml 
 ected wound or inj \ 
 hmbolic infective abscess 
 Jiiar results occur aft 
 When the inflammatory process results from the action of cer*^ers. 
 micro-organisms, known as pyogenic, liquefaction of the inflam) That ordinary irri 
 tissue and of the exudation follows, the liquefied material hmcs (e.g., silver-wire oi 
 known as pus, and the process which leads to its formatioilept in the rarest oi ^ 
 suppuration. Any localized collection of pus is known aslnter of glass, an irr , 
 abscess, and of such two chief varieties are described — the ac f wide, the resi.ic 1 ti 
 
 CHAPTER II. 
 SUPPURATION AND ABSCESS. 
 
 and the chronic. Sometimes the pyogenic infection involves 
 cellular tissue to a considerable extent, and the pus is wi( 
 diffused through the substance of the limb or part ; such a ( ie with sterili.^e'd 
 
 dition is usually known as cellulitis (p. 79). 
 
 Acute Abscess. 
 
 of the neck oi' a .otJ 
 
 ad caused no;^uppara 
 
 crc 
 
 I 
 
 ice 
 dis( 
 
 Etiology. — A large amount of experimental work has 
 undertaken to ascertain the relations of bacteria to acute supp 
 tion, and from the mass of evidence — mainly concordant, 
 occasionally conflicting — the following conclusions may 
 drawn : 
 
 (a) That bacteria are present in all acute abscesses, either in the 
 or in the abscess wall, or in both. Ogston of Aberdeen was 
 first to proclaim this fact, and it is now generally accepted 
 failure to discover organisms in a few cases is quite possibly 
 to imperfect observations, or to the fact that they have died 
 
 owing to their low vitality and the activity of the surroun ped under the' three^l 
 
 ted is possibly in a d 
 
 stance securel r sealed 
 Jngst the spinol nius 
 w the thorough heal 
 ollection of putty '• 
 ation, and much 
 IS to be looked on as 
 iietallic mercury, or 
 cadaverin, putrescin 
 conclusion, therefo 
 juration may be exp 
 nee of micro-organisr 
 tion does not occur apart 
 na. 
 
 lie causes of an acute 
 
 tissues. The liver is one of the commonest sites to find 
 pus ; possibly the bile may play some part in its occurrence 
 
 (b) That such bacteria can reach the inflamed area either 
 without the body or from icithin. The former method is the 
 com non, and is illustrated by the observations of Garre 
 Bockhardt, who rubbed cultures of Staphylococcus pyogenes ci ithout the^bodv' 
 into the skin of their arms, and produced acute suppuration 
 
 mencing in superficial pustules, and finishing as boils or carbur '«*^o'ogy.— As already st 
 1 he suppuration occurring in wounds is most commonly d 
 infection from without, but there can be no question that 
 
 licidal 
 
 properties of I 
 .must exist, which 
 injury, cold or othei 
 ted with pyogenic org 
 
 organisms, the nature of 
 
 suppuration occur« in wc 
 
 or arises idif^.)athic?Il 
 
 al, 
 
SUPPURATION AND ABSCESS 
 
 27 
 
 'Hon occurs, by means of which an abscess can be produced by 
 ction from within the body. This can only happen when the 
 lity of the patient is considerably depressed, and some local 
 dition exists favourable to bacterial development. Thus, given 
 ood-clot or inflammatory serous exudation in an unhealthy indi- 
 lal, whose germicidal power is low, suppuration can ensue from 
 D-infection, the organisms being carried by the blood to the 
 cted area ; an abscess thus produced is termed an idiopathic 
 :tive abscess. Occasionally the microbes are carried eitl.er 
 lasse [zooglcea condition), or in the substance of a small portion 
 (lood-clot, as an embolus, from one part of the body where an 
 cted wound or inj ". v exists to some other part, thus originating 
 mbolic infective abscess. Pyaemic abscesses are of this type, and 
 iiar results occur after gonorrhoea, and after typhoid and other 
 ;rs. 
 
 :) That ordinary irritating chemical products or sterilized foreign 
 es {e.g., silver-wire or glass splinters) do not produce suppuration, 
 ept in the rarest of cases, by auto-infection. Thus, a ragged 
 nter of glass, en ire and a quarter long, and an inch and a 
 f wide, the resi.ic I t'ue bv.'sting of a soda-water bottle, was cut 
 of the neck ol a lOtel jortcr ten months after it had entered ; 
 lad caused no ;-upparat)on. Experiments, moreover, have been 
 le with sterili'-ced croton-oil rnd other irritants, in which the 
 stance securely sealed up in <'i ihin glass capsule is implanted 
 mgst the spiuol muscle^ Oi an anim?l, and after a delay to 
 \v the thorough healin^ of the wound is set free by a blow. 
 oUection of putt) Hke fibrinous material is found at the site of 
 ration, and much discussion has arisen as to whether or not 
 is to be looked on as true pus. On the other hand, injections 
 letallic mercury, or of the ptomaines produced by bacteria 
 cadaverin, putrescin, etc.) certainly result in suppuration, 
 conclusion, therefore, although we have to admit that 
 uration may be experimental 1;. 1 ''Mced in animals in the 
 ince of micro-organisms, in mar jo/ II ordinary conditions sup- 
 ion does not occur apart from tl' yes nee and vital activity of specific 
 \'ia. 
 
 e causes of an acute abscess m .^ Tor nractical purposes be 
 
 ed under the three foil wing heaf^'ngs : (1) The individual 
 
 ed is possibly in a depressed and unhealthy state, and the 
 
 licidal properties of his tissues are defective. (2) A local 
 
 must exist, which is in a condition of lowered vitality, 
 
 injury, cold or otherwise; and (3) this spot must become 
 
 |ed with pyogenic organisms Drought to it either from within 
 
 hout the body. 
 
 sriology. — As already stated, i^Q pu:> ot all bcute abscesses contains 
 
 jrganisms, the nature of whicn, hc<^vf»ver, v^nes \vith circumstances. 
 
 ippuration occur« in wounds r -h-ci >«re is but little putrescible 
 
 d, or arises idi'".)athic?lly, it aii! always results from direct in- 
 
 
 wrr"*% 
 
■■!'■' 
 
 Mi; 
 
 28 
 
 A MANUAL OF SURGERY 
 
 SUPPi 
 
 fection with one or more of the pus-producing pathogenic bacteria. In manifection is not artificial bi 
 so-called septic wounds, however, non-pathogenic bacteria are also present jjury, or from the blood-str 
 leading to putrefacaon of the discharge. The most important PyogeniJ '" 
 Organisms are as follows : 
 
 1. Staphylococcus pyogenes aui'cus is that commonly found in all foci 
 localized suppuration (Fig. 4). It can readily be cultivated on nutrien 
 gelatine, agar-agar, or blood serum. On plate cultures it forms in two day 
 golden-yellow colonies, as also in tube preparations. It is very resistant t 
 chemical and thermal reagents, requiring several minutes' boiling to ensui 
 its destruction. 
 is capable both 
 facultative anaerobe (p. 14). 
 
 2. Staphylococcus pyogenes albiis. 
 
 3. Staphylococcus pyogenes c it reus. 
 These two forms are mainly distinguished from the former by the colour ( 
 
 the colonies formed in their growth ; all their oth^r properties are the samj 
 except that perhaps the citveus is a little slower in rendering gelatine tiuitr 
 
 -vjigP 
 
 ■»i 
 
 •/:. 
 
 k 
 
 
 4. streptococcus pyogenes (Fi 
 kgy, and it is the main ex( 
 i probable that there are se 
 jdeed, it is claimed that ! 
 searches are, however, nee 
 iiltivated on most nutrient i 
 
 . - , ^. , • • 1 "''^ °^ *^^ ^ir, and not ver\ 
 
 It produces no gas and no stinkmg odour m its growth, am elatine nor produce any col 
 of peptonizing albumen and of liquefying gelatine. It is erment. It occurs in cha 
 
 aureate. 
 
 The streptococcus pyogenes ii 
 ithe cellulitic type, whilst ii 
 pticajrnia. It has also be 
 3ipyema, and in some forms 
 iireptococcus of erysipelas si 
 
 5. The Bacillus coll commw 
 ten directed of recent yea 
 Bown as the Bac. pyog. fieticii 
 
 the intestinal canal, extei 
 the duodenum and colon, 
 lormal process of disintegra 
 ■le bowel, it is perfectly innc 
 rough the intestinal wall, a: 
 tabrasion of its surface, it 
 lippurative inflammation of 
 the most common cause ol 
 le infection arises from with 
 formation of abscesses in 
 Ills, acute ischio-rectal sup 
 amres is that— even when 
 foisive and penetrating od 
 :ces ; such is also noticed in 
 le most constant organism 
 power of rendering the urii 
 c The Bacillus pyocyaneus 
 liat is described as blue or 
 cept that in a few cases it h 
 ■ The Pneumococcus and Ba 
 Her pneumonia and typhoid 
 rulent, and the abscesses arc 
 S. The Gonococcus must also 
 
 i 
 
 ^'i?'" '^.'^'is^%:- '^.■•^, 
 
 '^v.. 
 
 V/.N;?.'/. 
 
 
 Si- 
 
 
 i-A. 
 
 Fig. 4. — Staphylococci in Pus. 
 (From Ckookshank's ' Textbook 
 OF Bacteriology.') 
 
 Fig. 5. — Stkeptococci in Pus. (Rij 
 
 DUCED FROM CrOOKSHANK's * Te.\1 
 
 BOOK OF Bacteriology.') 
 
 whilst the albus is apparently not so virulent. The latter organism is verl 
 similar to, if not identical with, the Staph, epidcrmulis albus, which is widel 
 scattered over the skin, and is usually found in the small abscesses developiq 
 in connection with tense stitches. 
 
 The staphylococci are mainly associated with the formation of localizd 
 abscesses. Thus, if a culture is rubbed into th skin of the forearm, a plentifl 
 crop of boils, or perhaps a carbuncle, will result ; if injected beneath the skil 
 a subcutaneous abscess may be formed, or even a typical carbuncle, iff 
 sufficient number has been introduced, and if they are unfiltered so as 
 retain their toxins ; if the peritoneal cavity is infected, suppurative peritonitl 
 follows, provided that a sufficient quantity of the organisms is present ; ifl 
 joint, suppurative arthritis. When injected into the blood-stream, there] 
 but little effect if only a few are introduced ; but when many, multip 
 abscesses in any and every part of the body may occur, as in pyaemia, or moj 
 frequently true septicaemia ; if, soon after the injection of an amount not larl 
 enough to produce general infection, a bone or joint is injured, acute infectii 
 osteomyelitis or arthritis will follow ; whilst if the cardiac valves are arT 
 ficially damaged, a typical ulcerative endocarditis ensues. All these co 
 ditions can be produced artificially in animals, and, from the similarity of tf 
 symptoms and the microscopical appearance of the parts, we concluile th 
 similar affections in man are due to exactly the same causes, except that tl 
 
 Pathological Anatomy 
 
 ited with the formation o 
 a?e of those detailed p 
 on. The vessels of the 
 arious elements of the 
 fganisms develop, the 
 tasis followed by thromb 
 fcn of cells becomes so g 
 'appears, after passing 
 late I., Fig. i). This II 
 n in part to the def( 
 sessure of the exudation 
 
SUPPURATION AND ABSCESS 
 
 29 
 
 :tion is not artificial, but comes either from without, as a result of local 
 ry, or from the blood-stream. 
 
 Streptococcus pyogenes (Fig. 5) is an organism of great importance in path- 
 y, and it is the main exciting cause of many inflammatory conditions. It 
 •obable that there are several distinct species included under this title — 
 led, it is claimed that six different forms have been isolated; further 
 arches are, however, needed to make certain of this fact. It can be readily 
 ivated on most nutrient media, but grows slowly at the ordinary tempera- 
 
 of the air, and not very rapidly even at blood heat. It does not liquefy 
 tine nor produce any colouring reagent, and does not form any proteolytic 
 lent. It occurs in chains of varying length, which may occasionally 
 rcate. 
 
 he Streptococcus pyogenes is mainly associated with spreading inflammations 
 18 cellulitic type, whilst it is a common cause of pyaemia, and even of acute 
 icsemia. It has also been found in many acute localized abscesses, in 
 )yema, and in some forms of suppurative arthritis. It is probable that the 
 ptococcus of erysipelas should be included in this group. 
 
 The Bacillus coli communis is an organism to which m.uch attention has 
 1 directed of recent years. It is identical with the microbes formerly 
 wn as the Bac. pyog. fcetidus and the Bac. lactis aerogencs. It exists normally 
 he intestinal canal, extending from mouth to anus, but most frequently 
 he duodenum and colon, and probably plays a considerable part in the 
 rial process of disintegration of food-stuffs. So long as it iiimains within 
 bowel, it is perfectly innocent ; but as soon as it is able ^ pass into or 
 mgh the intestinal wall, as a result of any loss or diminution in its vitality 
 brasion of its surface, it is liable to become intensely virulent, producing 
 purative inflammation of the most acute type, or even necrosis. Hence it 
 le most common cause of acute suppurative peritonitis in all cases where 
 infection arises from within the bov.'el, whilst it is mainly responsible for 
 formation of abscesses in the neighbourhood of the tube, as in appendi- 
 I, acute ischio-rectal suppuration, etc. One of its most characteristic 
 iires is that — even when cultivated in a test-tube — it produces a most 
 isive and penetrating odour, somewhat similar to that of decomposing 
 such is also noticed in the pus produced by the organism. It is also 
 most constant organism found in the bladder in cases of cystitis, but has 
 lower of rendering the urine alkaline. 
 
 The Bacillus pyocyaneus is occasionally met with in wounds, producing 
 is described as blue or green pus. It is of little clinical importance, 
 
 3t that in a few cases it has been known to give rise to general infection. 
 
 The Pneumococcus and Bacillus typhosus may also give rise to suppuration 
 
 pneumonia and typhoid fever respectively, but they are not specially 
 lent, and the abscesses are usually 01 a subacute type. 
 
 The Gonococcus must also be included in this category. 
 
 athological Anatomy of an Abscess.— The phenomena associ- 
 with the formation of an acute abscess are merely a further 
 
 ;e of those detailed previously as characteristic of inflamma- 
 The vessels of the affected area become distended, and the 
 
 ous elements of the blood pass through the walls. As the 
 
 misms develop, the vascular phenomena of retardation and 
 
 is followed by thrombo.'^'S occur successively, whilst the exuda- 
 of cells becomes so great that the original tissue of the part 
 
 ppears, after passing through a stage of coagulation- necrosis 
 (' I., Fig. i). This r'.!moval of the infiltrated tissues, though 
 in part to the defective blood-supply resulting froni the 
 
 sure of the exudation c>"d the vascular thrombosis, is kirgely 
 
30 
 
 A MANUAL OF SURGERY 
 
 caused by their liquefaction owing to the peptonizing power 
 the bacteria present. In streptococcal infections where a proteo 
 lytic ferment is absent, the solution of the tissues is probabl\ 
 brought about by the direct action of the many phagocyt 
 present in the effusion, a process favoured by the damaged an( 
 degenerative condition of the cells of the part ; this absence of 
 ferment may explain why the onset of suppuration is sometimei 
 slow. The inflamed focus, therefore, consistsmerely of an irregular!' 
 shaped mass of round cells, the central portion of which liquefie 
 and breaks down into pus. When once this has commenced t( 
 form, it depends entirely upon the character of the irritant, and thi 
 nature and behaviour of the surrounding tissues, as to what wil 
 subsequently supervene ; but there is usually a tendency for tb 
 pus to increase steadily in amount. It may then find its way ti 
 the surface and point ; it may. burrow along fascial or muscula 
 planes ; or it may, somewhat less frequently, become circuiii 
 scribed, and more or less chronic. As soon as the acute 
 extending process comes to an end, repair begins to manifea 
 itself in the vascularization of the embryonic tissue, and its trans 
 formation into granulation '.ssue. Should the abscess point, tb 
 normal tissues in the line it travels along are in their turn trans 
 formed into embryonic tissue, which breaks down and liquefie 
 as soon as it is formed, ' hils^ _;: anulations spring up from th 
 floor and sides of the cavity, endeavouring, as it were, to oblitera 
 the track the abscess has taken. Thus, a definite distinction mu 
 be drawn between the structure of its wall in the early and la 
 stages, which, however, we often see co-existing in the sani 
 abscess. In the former or early stage of tissue destruction (Plate 
 Fig. i), the following zones are met with in passing from the cent 
 to the periphery : (i) The central collection of pus ; (2) a layer 
 breaking-down embryonic tissue infiltrated with bacteria; (3) er 
 bryonic tissue showing a trace of the original structure of the p; 
 in a state of coagulation-necrosis, with the vessels thrombosed ai 
 many bacteria present ; (4) tissue of the part infiltrated with leu 
 cytes and organisms, and with the blood-stream either stoppj 
 completely or retarded ; (5) hyperaemic and slightly infiltrat] 
 tissue of the part, gradually shelving off into normal tissue, 
 must be clearly remembered, however, that the inflammat 
 focus is at first diffuse, and that the zones indicated here 
 quite artificial. The early abscess cavity is extremely irregu 
 in outline, and the lining wall very variable in character, 
 part being possibly thick, and another quite thin and yieldi| 
 readily to the extension of the process. In the later stages (Plate 
 Fig. 2), where the inflammation is not spreading, the struct 
 of the abscess may be thus described : (i) The central focus 
 pus ; (2) a layer of granulation tissue to a large extent free fn 
 bacteria ; (3) a layer of fibro-cicatricial tissue gradually merg 
 into (4) the normal tissue, somewhat infiltrated and hyper;emi 
 
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I 
 
 SUPt 
 
 The Clinical Signs i 
 
 bscess may be arrangi 
 I. The local signs con 
 y heat, pain, redness 
 od brawny, but when 
 id fluctuating, whilst 
 le pain throbbing in < 
 m depends entirely u 
 le supply of sensory n 
 isisting membrane, si 
 tensely painful. If 
 )ints and bursts. As 
 1 directions, and natu 
 ast resistance, and so i 
 ay burrow along mus( 
 vities. This is not mei 
 already described. 1 
 le to some injury — it r 
 ted by ulceration of t 
 a large one, by necrosi 
 I Pvessiive effects are in 
 ; swelling upon surrou 
 ;se due to the irritation 
 n may be present, or 
 tant unaffected region. 
 olved, the tissue arour 
 abscess cavity as hi 
 rambosis and the sul 
 jlt, or occasionally t 
 iarteritis), preceded p 
 vessel, owing to its lo! 
 e common in chronic 
 The general effects of 
 e of increased fever, 
 ocytosis, A rigor con; 
 Tresult of some stimula 
 pes of the medulla, ; 
 [ity. It is very simila 
 Ired m by a feeling of ir 
 linched, and the teeth 
 ■pungent, and the temp 
 Ition of cold is partly 
 Id normal temperature 
 [also possibly to the c 
 pent. After this st 
 Pt gradually begins 
 td, the thermometer 
 |ing to act. Finally i 
 
 r*''?'! 
 
 .->;;*■ 
 
SUPPURATION AND ABSCESS 
 
 31 
 
 'he Clinical Signs and Symptoms of an acute subcutaneous 
 cess may be arranged under three lieadings : 
 . The local signs consist of a patch of inflamed tissue, indicated 
 heat, pain, redness and swelling, which latter is at first hard 
 brawny, but when pus forms the centre becomes soft, elastic, 
 1 fluctuating, whilst superficial oedema is more marked, and 
 pain throbbing in character. Naturally, the amount of this 
 a depends entirely upon the density of the tissue affected and 
 supply of sensory nerves to the part, suppuration beneath a 
 isting membrane, such as the palmar fascia, being always 
 msely painful. If left to itself, an abscess sooner or later 
 nts and bursts. As it increases in size, it exerts pressure in 
 directions, and naturally s'^eks to find an exit in the line of 
 5t resistance, and so may eiiuer find its way to the surface, or 
 y burrow along muscular and fascial planes, or into adjacent 
 ities. This is not merely a mechanical, but also a vital process, 
 already described. The actual bursting of an abscess is often 
 ito some injury — it may be a slight one — but is usually pre- 
 led by ulceration of the integument, or perhaps, if the abscess 
 1 large one, by necrosis. 
 
 2. Pressure effects are mainly due to the mechanical influence of 
 
 i swelling upon surrounding structures. The most evident are 
 
 tse due to the irritation of nerves, as a result of which neuralgic 
 
 |n may be present, or the patient may refer the pain to some 
 
 nt unaffected region. In some cases, where bloodvessels are 
 
 ved, the tissue around them disappears, and they are left in 
 
 abscess cavity as bands, surrounded by granulation tissue. 
 
 mbosis and the subsequent obliteration of the vessel may 
 
 t, or occasionally ulceration and haemorrhage (ulcerative 
 
 arteritis), preceded perhaps by an aneurismal dilatation of 
 
 essel, owing to its loss of external support. Such effects are 
 
 common in chronic than in acute abscesses. 
 
 The general effects of the formation of an acute abscess are 
 
 e of increased fever, sometimes amounting to a rigor, and 
 
 Dcytosis. A rigor consists of a definite series of phenomena, 
 
 esult of some stimulating influence reaching the thermogenic 
 
 es of the medulla, and determining a sudden increase of 
 
 ity. It is very similar in nature to an attack of ague, being 
 
 red in by a feeling of intense cold and discomfort ; the features 
 
 inched, and the teeth chatter. The skin, however, feels dry 
 
 jungent, and the temperature of the body rapidly rises. The 
 
 tion of cold is partly due to the contact of air at a main- 
 
 normal temperature with the hot, dry, unperspiring skin, 
 
 so possibly to the condition of superficial anaemia which 
 
 sent. After this stage has lasted a variable period, the 
 
 t gradually begins to feel warmer, the face becoming 
 
 d, the thermometer ceasing to rise, and the skin com- 
 
 ng to act. Finally there is a rapid fall of temperature 
 
32 
 
 A MANUAL OF SURGERY 
 
 SUI 
 
 '!l: 
 
 ■VI 
 
 i. 
 
 I 
 
 [•■■-: 
 
 'ranes. 'I'he occurrei 
 '1^ l>een alrear'y exp 
 
 The Diagnosis of 
 
 '"i^ulties, the sense 
 ■'"1 -irea previously 
 l^f'^tic; hut when 
 '1 fascial planes, ve; 
 irder to determine its \ 
 
 accompanied by profuse perspiration, which leaves the patieii§'*f^^^°®puji) ; when l 
 more or less exhausted. ■iiixed with curdy si 
 
 Leucocytosis is the term employed to indicate an increase in th»"PP'^^''''^f •'>n of a tube 
 number of white corpuscles in the blood. Normally about 8,oo^'"^^'''^' 'insinj.-- from 
 leucocytes are found in each c.mm., although the number is snm 
 what increased immediately after meals. When suppuration 
 occurring, the proportion may be enormously increased, even u| 
 to 100,000 per c.mm. It is best seen in cases of severe infectioi 
 well resisted, and is not a very obvious feature when the infe 
 tion is so acute as to break down all resistance, or so slight as 
 cause little constitutional disturbance. A blood-count may 
 advisably undertaken in some cases of doubtful diagnosis. 
 
 Pus and its Constituents. — Normal, or as it was formerly call .,^ ^ 
 
 healthy, or laudable pus is a thick, creamy fluid, having a speciW^'^^ sense of Huctua 
 
 gravity of about 1030, an alkaline reaction, no smell (unless putrlf"^ '^ noticed, howe) 
 
 tying or under special circumstances), and containing 85 to 90 p«'"'6s. 
 
 cent, of water. If allowed to settle, it separates into two layeil"®**J^ent of Acute 
 
 the upper or fluid part, liqttov piivis, consisting of liquefied tissiB'^'^^'^<^'i"lg to suppural 
 
 and serum, and containing about 6*7 per cent, of proteid matem" """'"• In the earl\ 
 
 {i.e., rather less than in normal blood serum) ; whilst the lowm?'^^''.^'' \\itli the applic 
 
 layer includes the solid elements present, viz., dead and livm^'l*'''^"^''^'^ succeed in ace 
 
 pus corpuscles, fatty and granular debris, perhaps micro-organisiw'.'"" of quinine and ire 
 
 and possibly a few red blood cells. All the pus cells look aliB''^'^Pf'cs — e.g., pure c 
 
 when examined under the microscope on a cold slide ; butB-''oy the pyogenic c 
 
 placed on a warm slide, a difference is soon noticed. Dead p»' ^" acute 
 
 cells are rounded in outline, about o.^V^ inch in diameter, coara 
 
 granular in texture, and show two or three nuclei, which beco: 
 
 more evident on the addition of dilute acetic acid. The liv 
 
 pus corpuscles are fewer in number, and, though spherical 
 
 first, soon manifest amoeboid movements ; their protoplasm 
 
 finely granular, and the single nucleus is not readily observ 
 
 the proliferation of the nucleus is always an evidence of degen 
 
 tion and approaching death. It must be clearly understood t 
 
 both the living and dead cells are derived from the same sour(P^"tations or poultice 
 
 viz., principally from the extravasated leucocytes, but also possi|°^"^ an incision is ni 
 
 from proliferation of the fixed connective-tissue corpuscles of 
 
 part. 
 
 periostit 
 
 I'lies IS permissible. 
 
 '" a few regions of 
 
 "lation, but only whei 
 
 !»ers, such as the ant 
 
 aps some of the sen 
 
 ler the process of ah 
 
 inHuence of local and 
 
 •^s a rule, however, 
 
 rnmg 
 
 m 
 
 As already stated, the pus in an acute abscess contains bacteria, whic 
 best demonstrated in the following way : A drop of pus is placed betv 
 two cover-slips, which are each evenly coated by a thin layer of the fluid 
 sliding one over the other. These are dried by passing them throiighj 
 flame of a spirit-lamp, only sufficient heat being employed to set the albu 
 without destroying the corpuscles. A drop of methyl-violet solution is | 
 placed over the pus film, and allowed to remain for about a minute, ' 
 then washed away by a stream of distilled water. The slip should be 
 dried slowly, and mounted in Canada balsam. The cocci will be found std 
 deeply, whilst albuminous and fatty granules are not coloured at all, o^ 
 slightly (Figs. 4 and 5). 
 
 When pus is mixed with blood, it is termed sanious (shortj 
 
 must be large 
 be placed at" a 
 possible from sources 
 direction that movem 
 i"f,^ with deep absces 
 he advantageously ei 
 skin and superficial st 
 tne abscess cavity : a 
 ^J along the groove, 
 cent opening is made 
 amage-tube. 
 
 ta Ime of the axilla towa 
 
SUPPURATION AND ABSCliSS 
 
 33 
 
 guineoufi) ; when thin and acrid, it is ichorous ; curdy, when 
 <ed with curdy shreds, as is more usually seen in chronic 
 )purati()n of a tuberculous nature ; muco-pus, when mixed with 
 cus, arising.' from inllanunatory conditions of mucous mem- 
 ines. The occurrence of stinking pus apart from {)utrefaction 
 ; been alreac'y explained as due to the activity of the Bacillus 
 iOiiiiiiuiiis. 
 
 riie Diagnosis of an acute superficial abscess presents no 
 iculties, the sense of Ouctuation supervening in the midst 
 ;ui area previously inflamed and brawny beinj; quite char- 
 eristic ; but when the pus is placed deeply under muscular 
 .1 fascial planes, very careful examination may be needed in 
 ler to determine its presence. The surgeon must not be misled 
 the sense of fluctuation obtained across the fibres of a muscle ; 
 ne is noticed, however, by palpating along the course of its 
 res. 
 
 Treatment of Acute Abscess. — When an inflamed area is 
 
 reutening to suppurate, the formation of pus can be but rarely 
 
 Kcntcd. In the early stages, elevation and rest of the part, 
 
 ^ether with the application of cold and evaporating lotions, may 
 
 metimes succeed in accomplishing this, together with the adminis- 
 
 ation of quinine and iron. The hypodermic injection of powerful 
 
 tiseptics — c.<i., pure carbolic acid — has also been employed to 
 
 troy the pyogenic organisms in situ, whilst in some cases 
 
 in acute periostitis) a free incision through the inflamed 
 
 lies is permissible. 
 
 a few regions of the body, pus may be absorbed after its 
 
 ation, but only when situated in a cavity of highly-absorbing 
 
 ers, such as the anterior chamber of the eye (hypopyon), or 
 
 aps some of the serous cavities, e.g., the peritoneal. In the 
 
 nier the process of absorption may certainly be observed under 
 
 influence of local and general treatment. 
 
 a rule, however, one encourages suppuration by applying 
 
 lentations or poultices to the part, and then as soon as pus is 
 
 ent, an incision is made to evacuate the abscess ca\ity. The 
 
 ning must be large enough to prevent re-accumulation ; it 
 
 did be placed at a spot suitable for drainage, but as far 
 
 )ossible from sources of septic contamination, and in such 
 
 irection that movements of the part do not close it. In 
 
 ing with deep abscesses in dangerous regions, Hilton's method 
 
 [be advantageously employed. It consists in merely dividing 
 
 skin and superficial structures, and then thrusting a director 
 
 the abscess cavity : a pair of sinus or dressing forceps is now 
 
 d along the groova, and on forcibly separating the blades a 
 
 icient opening is made to insert the firger, and subsequently 
 
 lainage-tube. 
 
 pods of Opening Various Abscesses. — Axillary Abscess. — Cut in the 
 tn line of the axilla towards the chest from above downwards, and use 
 
 [Q 
 
 \S 
 
34 
 
 A MANUAL OF SURGERY 
 
 Hilton's method, thus escaping,' the three main sources of danger, viz , ihi 
 axillary vessels above, the lonj,' thoracic in front, and the subscapular vessel 
 behind. 
 
 Inguinal bubo. — Make a vertical incision from below upwards, the patien 
 stamlinj,' erect against a wall or lyinj,' down. When he sits the incision gaptsi 
 and so accumulation is preventeil. 
 
 Jiitniiiuiiiiniary Alisci'ss. — ('ut in a direction radiatinj^ from the nipple i] 
 prevent injury to the galactophorous ducts, and pass a finf,'er in so as to ()]« 
 up all the dilated lobules. 
 
 Siibmaiiiiiiaiy .Ibsccss. — Open alonf{ the lower tnarj,'in of the breast, ami, 
 possible, towards the outer side, carefully avoiding the j.;landular tissue. 
 
 Rctyophiuynt:Litl Abscess. — Incise alonj,' the posterior border of the stern 
 mastoid for about an inch ; draw that muscle and the canjtid sheath forwards 
 open by Hilton's method, pushing,' a director inwards to the middle linj 
 immediately in f'-ont of the transverse processes. 
 
 Ischio-n'ctal /J/;siYss.- Place the patient leaning over the back of a chaii 
 or in the lithotomy position if an anaesthetic is employed, and incise vertical! 
 and very freely, as far from the anus as possible ; healing may ensue withoi 
 opening the rectum. la some cases where the skin is undermined, a cruc 
 incision should be made, the resulting corners of skin being removed. 
 
 In opening a I'almar Abscess, care must be taken not to wound the supe| 
 ficial palmar arch or its digital branches. It is best accomplished by enteri 
 the knife immediately in a line with the centre of the metacarpal bones, cutti 
 f'^-wards to the base of the finger ; the upper limit of this incision should ni 
 tri nsgress the centre of the palm. 
 
 A ]['liitlou< should be opened in the middle line of the finger by a knife he] 
 with its back towards the wrist, and it often happens that the patient 
 conscious, unwittingly assists at his own operation by withdrawing his han 
 thus effectually completing the incision ; care must, of course, be taken cj 
 to let the knife travel too far or too deeply. 
 
 SU 
 
 live efficient drainaj^ 
 liisliin;; the fm<rer, a 
 he t is.'- lies, m;ikin<( it 
 pot, and cutting dow 
 
 Chronic Absce 
 
 .V chronic abscess 
 rrias slowly without 
 
 fcu- cases are due 
 jironic pyar'mia, yet I 
 
 ' 'n<Jee .n ac 
 
 f /C'lnte... wiat it is 
 list he clearly und( 
 chronic tubercul 
 irm IS correct, and w 
 ruunly its method c 
 
 those of an acute 
 menient to retain tl 
 
 tion. 
 
 Wherever tubercle i 
 11 ; but it occins it 
 nts, and lymphatic g 
 lections it is unneces; 
 abscess arises fron 
 erculous focus ; 
 
 in 
 
 d ; thj 
 
 pming 
 
 p is no Geuae fascia 
 
 My, there is a great 
 
 lience to become 
 
 inal soUi* 
 
 rculous 
 
 e. Thu!- 
 Ci ease of 
 in many direction 
 
 It is advisable to gently squeeze an abscess after openinf,' fcuall'vlr '^"""^ ' 
 especially if sloughs are present, or when it has burrowed: Jgp-|ipp. . '"^' 
 
 the cavity is large, it should be explored with the finger. All thi 
 is subsequently needed, if there is no complication, such as t 
 presence of dead or diseased bone, is to arrange for drainaj.;e, 
 by inserting a drainage-tube or a slip of protective, and to exclui 
 sepsis by a carefully applied antiseptic dressing ; in other cai 
 it may be desirable to pack the cavity with gauze soaked in 
 iodoform emulsion (lo per cent.). There is often a ronsideral 
 loss of blood during the first twenty-four hours from the yieldi 
 of the capillaries in the abscess wall, owing to the sudden relief 
 tension ; but this usually ceases of itself, or yields to moden 
 pressure. When once the abscess has been evacuated, no move ptn 
 formed if the cavity is kept aseptic, the discharge being merely seroi 
 and the wound rapidly closing and healing. Our colleagi 
 Mr. G. L. Cheatle, has pointed out that, although no more piii 
 formed, the cavity and its lining wall still contain bacteria, 
 perhaps in a state of virulence, but they are evidently unablej 
 develop or do any harm, possibly from the tissues being immuni 
 or protected against them. Pus which stinks on its escape lose 
 smell in a day or two, the wound pursuing a normal course, un 
 the abscess communicates directly with the bowel. In somec; 
 the original opening at the spot where the abscess pointed may 
 
 he side of the spine 
 erficial fibres of the 
 the groin, pointing ^ 
 ■ 6) ; or it may find 
 
 of the rectum. T 
 impossibility of deal 
 ther with the infect 
 cessible position of 
 
 most difficult to i 
 ing them experienc 
 should the cavity of 
 ittJe hope of again p 
 Nr^^e of pus, absorpti 
 aggravation of the 
 I from exhaustion or 
 
SUPPURATION AND AliSCESS 
 
 35 
 
 ive efficient (lr;iin<'i<^e ; n ionntey-openiitf^ should then he made hy 
 [usliin^; the finj^'er, or a prolje, throuffh the abscess wall amongst 
 le tissues, makinj^' it protrude beneath the skin at some dependent 
 )ot, and cutting down upon the finger or probe in this direction. 
 
 Chronic Abscess {:>yn. : Cold or Congestive Abscess). 
 
 \ chronic abscess may be defined as a collection of pus which 
 
 rins slowly without any signs of active indammation. Althougli 
 
 low cases are due to infection with pyogenic microbes or to 
 
 ironic pynr-mia, yet the vast majority are tuberculous in origin ; 
 
 1(1, indee n a chronic abscess is spoken of, it may be taken 
 
 ,Mante>.. uiat it is tuberculous, unless otherwise stated. It 
 
 ;ist be clearly understood that, although we speak clinically 
 
 ;i chronic tuberculous abscess, it is a question whether the 
 
 nil is correct, and whether the fluid contained therein is pus; 
 
 'uiinly its method of origin and characters are very diflerent 
 
 those of an acute abscess, h'or the present, however, it is 
 
 nvenient to retain the terms * pus ' and ' abscess ' in this con- 
 
 ctinn. 
 
 Wherever tubercle can he deposited, a chronic abscess may 
 m ; but it occurs most commonly in connection with bones, 
 ints, and lymphatic glands, lito the details of these causative 
 fections it is unnecessary to enter here ; suffice it to state that 
 abscess arises from the degeneration and licjuefaction of a 
 erculous focus ; that it forms a soft fluctuating swelling, 
 dually ir ising in size, and possibly by its pressure effects 
 oming il ; that it may come directly to the surface if 
 
 re is no Ucnae fascia to prevent it, but that, being often placed 
 ply, there is a great tendency to burrow along fascial planes, 
 lience to become superficial at a spot far removed from its 
 inal sou; e. Thus, an abscess arising in connection with 
 erculous a ease of the dorsi-lumbar region of the spine may 
 el in many directions : it may pass backwards, and be opened 
 he side of the spine as a lumbar abscess ; it may infiltrate the 
 erticial fibres of the psoas muscle, and travel down the sheath 
 the groin, pointing either above or below Poupart's ligament 
 , 6) ; or it may find its way into the pelvis and escape by the 
 of the rectum. The far-reaching extent of these abscesses, 
 impossibility of dealing adequately with the lining membrane, 
 :ther with the infective nature of the disease and the often 
 xessible position of the original focus of the mischief, render 
 most difficult to treat, and fully account for the dread of 
 ing them experienced by surgeons in pre-antiseptic days ; 
 should the cavity of the abscess once become septic, there is 
 little hope of again purifying it, and the result is an increased 
 [liarge of pus, absorption of the chemical products of putrefac- 
 |,affgravation of the original disease, and only too freciuently 
 from exhaustion or blood-poisoning. 
 
 3—2 
 
36 
 
 A MANUAL OF SURGERY 
 
 SU. 
 
 
 > > 
 
 The pus contained in a chronic abscess may be of the ordinarjijead-house one m 
 type, consisting of cells and bacteria ; but if of tuberculoid front of tlie sn' ' 
 origin, there are only a few cells, and those in a condition of fatt\Bf spinal disease T 
 
 degeneration, whilst masses ojliionic abscess the 
 
 me salts. Such deb 
 
 atory mischief wlier 
 
 'ears; suppuration ii 
 
 own as a midital a 
 
 curdy debris of \ariable size aniElid eJementTleft' bel 
 
 consistency are often present. 
 
 the abscess is of long standin 
 
 an abundance of cholesterim 
 
 crystals is often seen, a fact rel 
 
 cognised by the naked eye by thlrine will be' found -iii 
 
 ghstenmg sheen or greasy api)eaiE abscess is rrood • 
 
 ance unparted to the pus ; micnlem entirely by one t 
 
 scopically, they appear in tl.|ResuItsofLong-conti 
 
 shape of rhomboidal plates, ^vitlempn^ZnintiseDti"^ 
 
 r.n. .orn..r r^nfnh^A nnf It ;^g formation of puS 
 
 lonths, but the discha 
 -^iiits will be manifes 
 '!ieral health unimpai 
 icli an abscess beconn 
 i3"?ed; the dischar- 
 iper\enes, and grave' 
 
 , , ,, -"^'■'"''ly lead to the p:^ 
 
 purative process, but the mom^ sitppnmf ion then is 
 
 resistant spores are stdl present,E[rfI5hTSii^ arise '^ 
 
 The mu-roscopic appearance of fcectic Fever uTaybTd 
 
 lod-poisoning, due to 
 pins, and is met with 
 
 one corner notched out. It 
 unusual to find either cocci 
 bacilli in the pus of a chroii 
 tuberculous abscess, and this i| 
 spite of the fact that inoculati 
 of animals with the pus results 
 tuberculosis. Probably the baci 
 have been broken up by the suj 
 
 also 
 
 m any conditi 
 
 Fig. G.^Psoas Abscess due to tuberculous abscess wall is n 
 
 Disease OF THE Upper Lumhar p],^rarteristir /Pl-ite IT Fi<r 
 
 Vertehk.i;. (After Albert.) cliaracteristic (1 late 11., 1 ig. 
 „, .1 1 r . ■ , , 1 he cavity is lined by a layer 
 
 The method oi extension along the ii' • i • i „■ """ — 'J '->jiiuui 
 
 psoas tendon and into the thigh ^"^^Y^ yellowisli-gray, or pinkifcnic suppurative afff 
 
 is well seen. P^lpy granulation tissue, contailease of the lunf>-s \n 
 
 ing miliary tubercles perha|ischaracteri2ed''bVa 
 undergoing caseation. Its colour and vitality are cependent upBjch runs a tol -11 
 the chronicity or not of the process ; the longer the abscess isBnrr thg aftern ' '^i 
 forming, the less vascular the membrane, owing to the associalB cheeks) the ' i 
 
 sclerosis of the surrounding structures leading to compression^ the patient' f 1"^ 
 the bloodvessels, whilst it has been already mentioned that endp ' ^^ 
 
 teritis always accompanies a chronic inflammation, and help.s 
 render the parts non-vascular. This lining membrane, wij 
 necrotic, is but loosely connected with a layer of fibro-cicatriij 
 material, v hich forms the outer part of the wall, and from \vl 
 it can often be readily detached by the finger or a sharp spoBis to the'norm f 
 
 This, in turn, gradually shelves off into the normal tissue \\liBuse nprcr.iVof.- ' 'i^'' ^, 
 J iu 1 T .1 1 ..II- M, ^ '^^P^'^'^'^on brea 
 
 surrounds the abscess. In non-tuberculous cases the lininj-M^' -. - 
 
 consists of granulation tissue passing over into the m 
 
 structure of the part, which is more or less sclerosed, acconi 
 
 to the duration of the mischief. 
 
 Natural Cure. — A tuberculous abscess, if left to itself, does! 
 
 necessarily come to the surface and burst. Occasionally in [ 
 
 'f'.'^ small, compress 
 n It should be ; the tc 
 s condition continue^ 
 iperature may have r 
 "5 to fall as rapidl 
 
 pce^ 
 
 [leaves him in a mucl 
 pnues, the fever and 
 fnution in the patient' 
 iiyloid, Albumenoid, 
 iso present in cases of 
 of this curious cone 
 
SUPPURATION AND ABSCESS 
 
 57 
 
 ad-house one meets with a mass of putty-like consistency lying 
 
 front of tlie spine in the body of a patient who has been cured 
 
 spinal disease. This is evidently the desiccated remains of a 
 
 ionic abscess, the fluid portion having been absorbed, and the 
 
 lid elements left behind, encapsuled and perhaps infdtr-', id with 
 
 lie salts. Such debris can become the seat of recurrent inflam- 
 
 atory mischief when the original disease has been quiescent for 
 
 lars ; suppuration may suddenly occur, giving rise to wliat is 
 
 lown as a residual abscess. Probably a large amount of choles- 
 
 rine will be found amongst its contents. The prognosis of such 
 
 1 abscess is good ; m more than one instance we have cured 
 
 lem entirely by one tapping and free lavage. 
 
 Results of Long-c ontinued Suppuration . — When a chronic abscess 
 
 I emptied antiseptically, and maintained in an aseptic condition, 
 
 le formation of pus ceases ; the wound may remain open for 
 
 ths, but the discharge is merely serous, and no constitutional 
 
 Its will be manifested. The temperature is normal, and the 
 
 aeral health unimpaired, if no other disease is present. Should 
 
 1 an abscess become septic, the condition of affairs is at once 
 
 anged ; the discharge becomes profuse and purulent, fever 
 
 )ervenes, and grave visceral changes occur, which sooner or 
 
 er may lead to the patient's death from exhaustion. Loin^-con - 
 
 l suppHvation . theUf is always an evidence of sepsis , and from it two 
 
 iuITtiohs rnaj aris e, viz.. hectic fever and lardaceous diseas e. 
 
 ectic Fever may be defined as a chronic toxaemia or condition of 
 
 od-poisoning, due to the continual absorption of small doses of 
 
 ins, and is met with not only after opening chronic abscesses, 
 
 also in any condition of chronic sepsis, e.g., after acute or 
 
 onic suppurative affections of bones or joints, in tuberculous 
 
 ease of the lungs, and in septic syphilitic or cancerous disease. 
 
 is characterized by a regular diurnal elevation of temperature, 
 
 ich runs a tolerably typical course. It commences to rise 
 
 ing the afternoon, the face becoming flushed {hectic flush of 
 
 cheeks), the eyes bright and sparkling, the pupils dilated, 
 
 1 the patient feeling better and stronger. The pulse, how- 
 
 :r, is small, compressible, and ten or twenty beats quicker 
 
 it should be ; the tongue becomes red at the edges and tip. 
 
 condition continues till late in the night, by which time the 
 
 iperature may have risen four or five degrees. It then com- 
 
 ces to fall as rapidly as it had formerly risen, and usually 
 
 iS to the normal, or even below it, and in the early morning a 
 
 :use perspiration breaks out which soaks the patient's clothes, 
 
 leaves him in a much-exhausted condition. Day by day this 
 
 ;inues, the fever and sweating together causing a marked 
 
 linution in the patient's strength. 
 
 yloid, Albutnenoid, or Lardaceous Disease of various organs 
 
 b present in cases of long-standing suppuration. As to the 
 
 of this curious condition, but little is known ; either from 
 
38 
 
 A MANUAL OF SURGERY 
 
 SUPi 
 
 the deleterious effects of toxic compounds circulating in the blooff" . "" ^o the umbilic 
 or from the loss of some special substance in the discharg«""'^^^Dber, painless, a 
 e.g., alkaline phosphates, the walls of the smaller arteries anB" capillaries in the 
 the protopljsm of certain of the viscera are converted into M^^^ affected, but the ( 
 infiltrated with a waxy substance, from which lardacein, a»'7^°&^"'c and bile-pr 
 extremely insoluble proteid body, may be obtained. The nan#'^"' ^P that the diges 
 amyloid ' is an entire misnomer, as this material is in no \vi''^°^"'"& fets, is imped 
 akin to starch. It occurs as a waxy homogeneous materiaB„ change commencinj 
 
 T'g- 7), but the capi. 
 Jarly affected. In this 
 ^ nricreased filtration thrc 
 
 ' containing a few 
 
 ihe tubules are i 
 ]l- a higher specific 
 ll'umen. The 5//mMn 
 inextent as the other vi 
 eat of the mischief. 1 
 ecome lardaceous, and 
 luid parts of the blood 
 tutriment is thereby m'l 
 iscretion and diminishe 
 lent IS steadily underr 
 vmyloid changes in th 
 1 to operation, are rati 
 itment is urgently ni 
 patient is such that he 
 aeration, e.g., excision c 
 adicated, the amyloid 
 )pear. 
 
 Treatment of Chronic 
 
 ren was to leave a c 
 d never to interfere „ 
 ctic and increased rapi'c 
 m such interference, 
 lere is no reason to de 
 t the abscess should 
 mation. It is, howev 
 t one slip in the tec 
 refore none should in 
 
 Fig. 7.— Amyloid Kidney in Early Stage. (Ziegler.) 
 
 (Treated with Miiller's fluid and perosmic acid, x 300.) a, Normal capilj 
 loop ; b, amyloid capillary loop ; c, fatty epithelium of glomerulus ; c^. : 
 epithelium of capsule; d, oil-drops on the capillary wall ; e, fatty epithJ 
 cells ill situ ; f, loosened fatty epithelial cells ; g, hyaline coagula (forrf 
 ' c vsts ') ; //, fatty cast in section ; /, amyloid artery ; k, amyloid capiilJ 
 /, infiltration of connective tissue with leucocytes; m, round cells (!ej 
 cytes) within a uriniferous tubule. 
 
 
 un 
 
 
 se 
 
 of 
 
 fi 
 
 becoming a dirty brown on the application of tincture of lodBepared to take the time 
 
 and an inky blue when sulphuric acid id, subsequently adBiain, from the risk of s( 
 
 With methyl-violet the amyloid substance is coloured ruby-Bthe case, those method 
 
 whilst normal tissues are stained blue or indigo. The or^niediate total closure 
 
 mainly affected are the liver, spleen, kidneys, and villi of ■chronic abscess have 
 
 intestines, and the capillaries and muscular coats of the arteme only allude to the mcM 
 
 (Fig. 7, b and i) are the parts first attacked, the change gradiM ^ 
 
 spreading to the parenchyma of the organ. The liver beccBji circumX'/nl'''" ^^^ ^'^^ 
 11 J ^ -J 1 1 J r.. u- r .JM .^''^'^"nistances, viz.. wh 
 
 evenly enlarged to a considerable degree, often reaching tion^when the patient's health 
 
SUPPURATION AND ABSCESS 
 
 39 
 
 rib to the umbilicus, or lower ; it is firm in consistency, like 
 
 arubber, painless, and waxy-looking on section. The arterioles 
 
 capillaries in the intermediate zone of the lobules are those 
 
 affected, but the cells soon participate in the change. The 
 
 logenic and bile-producing functions are naturally interfered 
 
 1, so that the digestive process, and especially the power of 
 
 jrbing fats, is impeded. The kidneys become similarly enlarged, 
 
 change commencing in the arterioles leading to the glomeruli 
 
 f. 7), but the capillaries and the tubal epithelium are also 
 
 y affected. In this stage the urine is very abundant (from the 
 
 eased filtration through the degenerated walls), pale, limpid, 
 
 containing a few hyaline casts and fatty cells ; later on, 
 
 che tubules are more largely involved, there is less urine, 
 
 a higher specific gravity, and a considerable amount of 
 
 imen. The spleen increases in size, but not always to so great 
 
 ixtent as the other viscera ; the Malpighian bodies are the chief 
 
 : of the mischief. The capillaries in the villi of the intestines 
 
 ome lardaceous, and allow of an increased transvidation of the 
 
 d parts of the blood, resulting in diarrhoea ; the absorption of 
 
 riment is thereby much lessened, and thus both by increased 
 
 retion and diminished absorption of food the strength of the 
 
 lent is steadily undermined. 
 
 amyloid changes in the viscera, far from being a contra-indica- 
 
 1 to operation, are rather to be considered as a sign that radical 
 
 [itment is urgently necessary, unless the general condition of 
 
 tient is such that he cannot stand the strain of it. If by an 
 
 ition, e.g., excision or amputation, the local disease can be 
 
 icated, the amyloid changes in the viscera may totally dis- 
 
 ear. 
 
 reatment of Chronic Abscess. — In former days the rule always 
 was to leave a chronic abscess alone as long as possible, 
 never to interfere unless forced to do so ; sepsis, followed by 
 ic and increased rapidity of the disease, almost always resulted 
 such interference. But when asepsis can be maintained, 
 is no reason to depart from the ordinary rule of surgery, 
 the abscess should be evacuated as soon as possible after its 
 lation. It is, however, most important to recognise the fact 
 one slip in the technique may lead to a fatal issue, and 
 efore none should interfere with these cases unless they are 
 ired to take the time and trouble needed to keep them aseptic. 
 in, from the risk of sepsis being admitted during the dressing 
 e case, those methods should be preferred which admit of the 
 ediate total closure of the wound. Many plans of treatment 
 ironic abscess have been suggested and practised ; we can 
 only allude to the more important. 
 
 Simple aspiration has been known to effect a cure, but only in excep- 
 circumstances, viz., where the causative lesion is absolutely passive, 
 vhen the patient's health and constitution are vigorous. It often fails 
 
 1 
 
 M 
 
 '■■ki 
 
1V 
 
 .11 
 
 40 
 
 A MANUAL OF SURGERY 
 
 from the blocking of the aspirator needle by curdy debris, and there is always 
 a fear that much of this material will be left behind, forming a possible source 
 
 the development of the spores remaining in the curdy masses, or of the bacilli 
 within the pyogenic membrane. 
 
 2. Tapping the abscess ivith thorough irrigation is another plan of treatmeni 
 which under favourable circumstances is occasionally successful. We havf 
 seen both psoas abscess and empyema cured by one thorough washing out 
 The modus operandi is as follows : The skin is incised in one or possibly two 
 separate places, and through these openings large trocars and cannuhr are 
 inserted into the abscess cavity, which is emptied as completely as possil)le 
 It is no"' distended through one of the cannulac, with a warm solution of 
 carbolic cid (i in 80), or with a sublimate lotion (i in 5,000), or simply with 
 sterilized water or salt solution (5i. ad Oi), at a temperature of 105^ to no' 1- 
 The abscess is then well kneaded with the fingers, and the fluid with the 
 curdy masses and broken-down pyogenic membrane is allowed to escape 
 The process is repeated again and again imtil the escaping fluid is nearly clear, 
 or only slightb- opalescent. The cannula; are novv withdrawn, the wounds 
 firmly stitched up, and an antiseptic dressing applied, using sufficient pressure 
 to obliterate, if possible, the abscess cavity. The patient must be kept quiet 
 and carefully watched for a time, to ascertain if there is any reaccumulation 
 when the same process maj- be repeated. 
 
 3. Opening the abscess and scraping out the interior with Barker's flushing gouge 
 combines the irrigation of the previous method with the more or less complete 
 removal of the tubercle-containing pyogenic membrane. The instrument 
 employed consists of a gouge or sharp spoon with a long hollow handle 
 which communicates by a tube with a reservoir of fluid placed at some heifihi 
 above the patient. During its application the constant rush of water or lotion 
 through the handle clears the gouge, and removes the debris. It is admirabK 
 adapted for certain cases, but its use needs considerable care, as the sharr 
 edge can readily scrape through an abscess wall, and do much mischief. It 
 is a convenient means of dealing with abscesses of bones and joints in thf 
 more superficial parts of the body. The wounds should be subsequent 
 closed, and an attempt made to gain immediate healing of the denuded cavity 
 
 SUPl 
 
 ith lymphatic glands, it r 
 nd if such is feasible, it i 
 
 of future re-infection. The rapid emptying of the sac, moreover, often leads osterior wall of the cavity 
 to haemorrhage, and the blood thus collecting will form a favourable soil for e thoroughly scraped so a 
 
 ;', with liquefied carboli 
 ounce). An attempt ma 
 rthe cavity may be stuffe< 
 ;, I.aying the cavity free 
 urif}ing with carbolic acic 
 th purified iodoform, ar 
 le open method, may be us 
 urrowed between muscles 
 ;ed instead of iodoform, hi 
 fai ot sloughing of the si 
 Iphurous, and finally intc 
 hich may be employed in 
 
 by l^rofessor Velpeau in France, and has been received with much favour 
 \'arious reagents have been employed, but the majority' contain iodine oithei 
 in the form of the tincture, or as iodoform, which latter may be suspended ii 
 glycerine or olive-oil (10 per cent.), or dissolved in ether (5 percent,). Thi 
 method of introducing these compounds is cpiite simple, the amount varyins:, 
 but as a rule not more than a drachm of iodoform should be used. \Vliei 
 the ethereal solution is injected, the ether immediately volatilizes and full 
 distends the abscess cavity, which becomes tense and tympanitic; it must 
 therefore never be u.sed for abscesses communicating with the interior of tin 
 thorax, death having in one or two recorded cases resulted from heart failure, 
 due to such distension. There is some danger, too, that serious to.NJi 
 symptoms may arise from absorption of the iodoform. This treatment ii 
 most likely to be efficacious when all active bone or joint disease has disj 
 appeared, and is frequently employed as an adjunct to one of the above] 
 described plans. 
 
 5. If the above methods fail, or are for any reason inapplicable, the origin; 
 antiseptic method of simple incision with drainage can always be adopted. Thi: 
 is perfectly safe, so long as asepsis is maintained ; but the great objections t( 
 it are the length of time (months, or even years) often required to bring alwuj 
 healing, especially in cases where, although a free incision is made, the aitui 
 seat of the disease is not reached, and the risk of contamination during one 
 the repeated dressings that are required. 
 
 6. In certain cases of external chronic abscess, especially when connecti 
 
 \\j1en_an_jjj2scess_hj 
 eaXa communication i 
 
 le disea se and tiig~gxt; 
 is anarrow ti 
 
 Sinus 
 
 to tlie tissues, open at 
 large is purulent or r 
 psis is present. A Fi 
 icen two cavities, or b 
 
 hen such conditions 
 
 iscess, the walls cor 
 
 ose of the original a 
 
 iscular layer, merefini 
 
 4, Injection of an antiseptic into the sac after tapping is a method intro(!uce^''lt{ 01 pyogenic men 
 
 ting disease was tub 
 ere is a tendency for 
 th epithelium, and ur 
 :cted to close until th 
 irface again exposed. 
 It is often a matter of 
 
 of a sinus or fistula 
 ly non-closure .• (i) The 
 pths of the wound, s 
 lature, a piece of silv 
 «ased tissue, such a 
 
 the irritation of 
 inormal opening, sucl 
 "cient drainage of a 
 tain amount of tens 
 
 part, due either to ^ 
 involuntary muscular 
 in listula-in-ano ; (5 
 erculous deposit at tl 
 
 c 
 
SUPPURATION AND ABSCESS 
 
 41 
 
 ith lymphatic glands, it may be possible to dissect out the whole cavity en masse, 
 nd if such is feasible, it is the most satisfactory plan to adopt. Should the 
 osterior wall of the cavity be adherent to important deep structures, it should 
 e thoroughly scraped so as to remove all pyogenic material, and disinfected, 
 .', with liquefied carbolic acid or solution of zinc chloride (40 grains to 
 ounce). An attempt may then be made to gain healing by first intention, 
 rthe cavity may be stuffed and allowed to granulate. 
 
 ;. Laying the cavity freely open, scrapmg away the pyogenic tissue, perhaps 
 nrifying with carbolic acid, plugging the wound firmly with gauze infiltrated 
 lith purified iodoform, and allowing it to granulate from the bottom, or 
 te open method, may be used advantageously in cases where abscesses have 
 iirrowed between muscles, and along fascial planes. Sulphur has also been 
 sed instead of iodoform, but has no special advantage, whilst it causes a good 
 Eai ot sloughing of the surrounding tissues owing to its transformation into 
 ilphiirous, and finally into sulphuric, acid. Friar's balsam is another agent 
 hich may be employed in the same way, and is innocuous and useful. 
 
 Sinus a nd Fistula . 
 
 \ Vhen an abscess has been opened, and does not com pletely 
 
 eaTTa com munication ofte n~persists" between Tlie original s eal of 
 
 i rdisease _a nd th e exterior, wh ich is known as a sinus or fist ula. 
 
 Sinus is a narrow track lined with granulations, penetrating 
 
 to the tissues, open at one end and closed at the other ; the dis- 
 
 uf^e is purulent or merely serous according to whether or not 
 
 )sis is present. A Fistula is an abnormal communication be- 
 
 een two cavities, or between a cavity and the external surface. 
 
 len such conditions result from the non-closure of a chronic 
 
 iscess, the walls consist of exactly the same structures as 
 
 ose of the original abscess, viz., an external fibro-cicatricial 
 
 iilar layer, merging into healthy tissues, and an internal 
 
 g of pyogenic membrane containing tubercles, if the origi- 
 
 ww^ disease was tuberculous. If the fistulous track is short, 
 
 e is a tendency for the granulating wall to become covered 
 
 1 epithelium, and under such circumstances it cannot be ex- 
 
 cted to close until the epithelium has been removed, and a raw 
 
 ace again exposed. 
 
 t is often a matter of the greatest difficulty to secure the heal- 
 
 of a sinus or fistula, and the following are the main causes of 
 
 non-closure: (i) The presence of some chronic irritant in the 
 
 )ths of the wound, such as a piece of the clothing, a catgut 
 
 ature, a piece of silver-wire used in an operation, or of some 
 
 eased tissue, such as a fragment of dead or carious bone : 
 
 the irritation of discharges finding an exit through the 
 
 normal opening, such as urine, faeces, or foetid pus ; (3) in- 
 
 iiicient drainage of a deep cavity, so that there is always a 
 
 tain amount of tension in the wound ; (4) want of rest to 
 
 part, due either to voluntary movements, as in the limbs, or 
 
 involuntary muscular action in the immediate neighbourhood, 
 
 in fistula-in-ano ; (5) tuberculous infection of the wall, or a 
 
 )erculous deposit at the bottom of the sinus ; (6) the growth of 
 
 ISC 
 
 i:ii 
 
 It 
 
42 
 
 A MANUAL OF SURGERY 
 
 l\ 
 
 epithelium down the sinus or round the margin of the fistula ; oi 
 (7) constitutional debility. 
 
 The orifice of a sinus is often depressed from the amount o| 
 infiltration around, but in cases where foreign bodies are lodge 
 within, or where diseased bone exists, it is usually surrounded b 
 prominent fungating granulations. 
 
 Treatment. — ^The removal of the cause is the first thinj;- t 
 accomplish in dealing with a sinus or fistula. The passage mu 
 be dilated or slit up to allow of access to the deeper parts of th| 
 wound, to remove any foreign body which may be presen 
 or to allow of the satisfactory drainage of a deep cavity. Th| 
 making of a dependent counter-opening often suffices to cure 
 sinus. A thorough purification of the part by pure carbolic aci 
 or chloride of zinc must also be undertaken, and the wou 
 dresseH^ by "plugging with suitable material and kept at re 
 whilst the general health of the patient is improved by toni 
 Occasionally, the pressure of a roller bandage to immobilize t 
 part is all that is required, or the application of a suitable spli 
 The most complete and certain method is to lay the sinus op 
 and thoroughly destroy the lining granulation tissue by scrapi 
 or cauterising, and then to plug the wound, allowing it to h 
 from the bottom by granulations. 
 
 Should a fistula have become lined with epithelium, the ed 
 will require paring, and some form of plastic operation must 
 undertaken to close the opening. 
 
 The term ' fistula ' is also applied to conditions other than th 
 tracks remaining from the non-closure of an abscess. Th 
 classes may be described : 
 
 I. Congenital fistula:, e.g., branchial, umbilical urinary or fae 
 
 etc. 
 
 2. Traumatic fistula, e.g., aerial, pharyngeal, salivary, rec 
 vesical, recto-vaginal, etc. 
 
 3. Pathological fistula, or those secondary to abscess or disea 
 e.g., biliary, faecal, perineal urinary, fistula-in-ano, etc. 
 
 Each of these will be referred to later on under its appropr^ 
 heading. 
 
 LCERATioN has been 
 eath of a part,' by whi 
 Icial tissues, which lie 
 ny obvious slough. I 
 :rm is used to denot 
 msiderable portion of 
 Iften closely associated- 
 'le former the dead par 
 /e, whereas in the latt( 
 Itt-ays be seen. 
 Three^main classes of 
 
 I. Ulcers due to trauma 
 :e spreading, healing, ( 
 
 II. Ulcers due to spei 
 tberculous, syphilitic, e 
 
 III. Malignant ulcers, 
 id fungaliiig. 
 
 Causation.— Ulceratio] 
 the surface of such a 
 id to local inflammat 
 fsue affected. Any for 
 fchanical, or infective 
 ttors predisposing to i 
 ^us, faulty nutrition, wl 
 Jgestion, is particular! 
 ireover, when any par 
 trophic centres, the cc 
 appreciated, and henc 
 
 lit may be well to note ( 
 ption due to an invasion v 
 N IS due to one special < 
 p are infective in nature, 
 rent types of organisms m 
 
CHAPTER III. 
 ULCERATION. 
 
 LCERATioN has been defined as the ' molecular or particulate 
 ;ath of a part,' by which is meant the disintegration of the super- 
 nal tissues, which liquefy and disappear, and usually without 
 ly obvious slough. It differs from gangrene in that the latter 
 rm is used to denote the simultaneous loss of vitality of a 
 insiderable portion of tissue. The two processes are, however, 
 ten closely associated — in fact, both signify tissue necrosis ; in 
 le former the dead particles are not always visible to the naked 
 le, whereas in the latter the necrotic portions, if superficial, can 
 ways be seen. 
 
 Three main classes of ulcers are met with in surgical practice : 
 Ulcers due to traumatism or to the ovdinayy pyogenic bacteria^ e.g., 
 spreading, healing, chronic, etc. 
 
 Ulcers due to specific* bacteria, e.g., soft chancre, lupoid, 
 erculous, syphilitic, etc. 
 
 I. Malignant ulcers, e.g., rodent, epitheliomatous, scirr hous , 
 fungatiug. 
 
 !ausation. — Ulceration is due to the application of an irritant 
 
 le surface of such an intensity, and for such a period, as to 
 
 to local inflammation resulting in the destruction of the 
 
 e affected. Any form of irritant, whether chemical, thermal, 
 
 lanical, or infective, may accomplish this end, and all the 
 
 tors predisposing to inflammation will hasten its occurrence. 
 
 us, faulty nutrition, whether from anaemia or from long-standing 
 
 gestion, is particularly liable to further the ulcerative process. 
 
 reover, when any part becomes anaesthetic, or is cut off from 
 
 trophic centres, the continued presence of an irritant may not 
 
 appreciated, and hence destructive inflammation occurs, e.g. 
 
 l! 
 
 II 
 
 It may be well to note that whilst the term infective is applied to any 
 ition due to an invasion with bacteria, the word specific denotes that the 
 a is due to one special or specific organism. Nearly all inflammatory 
 s are infective in nature, but only those in Group II. are specific; many 
 :ent types of organisms may give rise to the ulcers in Group I. 
 
4* 
 
 A MANUAL OF SURGERY 
 
 '■ 
 
 corneal ulcer following section of the fifth nerve, or perforatin 
 ulcer of the foot in tabes. In malignant disease the projection of 
 the mass of the growth may expose it xmduly to irritation ; hut 
 the chief cause of ulceration is the replacement of the deeper 
 layers of the skin or mucous membrane by the cells of the 
 neoplasm, so that when the superficial epithelium wears off or is 
 lost, it cannot be reproduced. 
 
 I. Ulcers due to 
 
 Traumatism or to 
 Bacteria. 
 
 the ordinary Pyogenic 
 
 Clinical History. — Every ulcer of this class tends sooner or later 
 to recovery, and so may be said to pass through three stages, viz,, 
 (i) that of ulceration proper, or extension ; (2) a stage of transi 
 tion, or preparation for healing, which may be short or lcn<,' 
 according to whether the ulcer is running a rapid or a slow course, 
 and persists until the surface is covered with granulations ; and 
 (3) the stage of healing or repair. It must be clearly understood 
 that the first stage alone represents the true ulcerative process: 
 when this ceases, the ulcer proper disappears, and merely 
 superficial loss of substance, the result of the preceding ulceration, 
 remains. If every simple ulcer passes through these three stages. 
 then eveyy variety of simple ulcev must necessarily he in one of the ihm 
 stages, and hence may be described as a modification of a typical 
 condition representing the stage to which it belongs. Naturally 
 in a large ulcer the three stages may co-exist, or a healing ulcei 
 may from intrinsic or extrinsic causes relapse again to the stagi 
 of tissue destruction. 
 
 Stage I. : Ulceration proper, or Extension. — The special charac 
 teristic of all ulcers in this stage is that destructive changes an 
 still continuing with greater or less rapidity, and hence, accordiiii 
 to circumstances, they may be described as inflamed, spreading, 01 
 sloughing ulcers. 
 
 Naked-eye Appearances. — Surface, covered with ashy gray 01 
 dirty yellow material, partly slough, partly lymph, partly breaking; 
 down tissue ; no granulations are present ; the tendency to slougl 
 is most marked when the organisms are particularly virulent, 01 
 if the resistance of the tissues is much diminished ; dischay^i, 
 considerable in amount, thin, sanious, and often irritating an 
 offensive, rarely purulent ; margins, thickened and inflamed, ani 
 the surrounding tissues often ci^dematous and infiltrated ; ed^(\ 
 sharply cut and well defined ; the base of the ulcer is thickenei 
 and fixed to the underlying structures. 
 
 Microscopically, all the phenomena of inflammation may 
 observed progressing to thrombosis and tissue necrosis, so tha| 
 in approaching the surface of the ulcer from the healthy tissue] 
 one would pass through zones of active hyperaemia, of retardei 
 blood-flow with infiltration of leucocytes and plasma, of stasii 
 
 nd thrombosis, wl 
 necrosis. 
 Treatment of Fi] 
 c cause, protectir 
 rritation, and pun 
 flamed part must 
 ependent position ( 
 hilst the sore is di 
 ions, such as a bor 
 ive, a charcoal and 
 he state of the boi 
 irohably a mild put 
 ealthy repair is as 
 Stage II. : The Tra 
 cur from the term 
 me when healing 
 nvered with granul 
 t.ii^e of preparation J 
 Naked-eye Appea 
 ased, and the sep 
 the ulcer begins 
 ^er; sloughs and 
 the dressing or ab 
 roblasts. The d 
 rous in character, 
 sy hyperemia. T 
 at the tissues arou 
 the surface becon 
 time, shorter or h 
 ots make their a 
 !crease in number 
 covered by what] 
 ocesses occurrii 
 iighs; (b) the 
 udation ; and (c)\ 
 laterial, and its cor 
 Microscopic Appes 
 
 lased, the migratioj 
 tissue comes to 1 
 vered with a layet 
 ration of the n^ 
 ermixed with fil 
 erstices of the 
 we. The vessels! 
 ome patent, and[ 
 er is thus restoj 
 is next undert 
 apterVII. The 
 
ULCER A TION 
 
 45 
 
 State of coagulation- 
 
 racj 
 ara 
 
 m 
 
 mgl 
 
 t,o 
 
 an( 
 
 am 
 
 cdi:i\ 
 
 enea 
 
 •y , 
 
 thai 
 ssuei 
 irde( 
 ^tasii 
 
 iiul thrombosis, whilst the tissues are in 
 
 lecrosis. 
 
 Treatment of First Stage. — This resohes itself into 
 
 he cavise, protecting,' the surface from all sources of mechanical 
 
 rritation, and purifying it from all septic contamination. The 
 
 flamed part must he kept at rest, and if necessary raised from a 
 
 iependent position [i.e., the leg must not be allowed to hang down), 
 
 ilst the sore is dressed with moist and warm antiseptic applica- 
 
 lons, such as a boracic poultice. \\'hen the parts are very offen- 
 
 ive, a charcoal and linseed-meal poultice may be first employed. 
 
 e state of the bowels and constitution must be attended to, and 
 
 irobably a mild purgative will be needed. Under such a routine 
 
 italthy repair is as a rule soon established. 
 
 Stage II. : The Transition Period comprises all the changes which 
 ccur from the termination of the ulcerative process proper to the 
 me when healing is fully established by the wound becoming 
 dvered with granulations. In short, it may be described as the 
 tai,^e of prepamtion fov healing. 
 
 Naked-eye Appearances. — When the destructive process has 
 ased, and the septic element has been eliminated, the surface 
 the ulcer begins to clean, and becomes, as it were, glazed 
 ;er ; sloughs and portions of dead tissue are either removed 
 the dressing or absorbed by the activity of the leucocytes and 
 nroblasts. The discharge becomes less abundant and more 
 pus in character, and the angry red blush is replaced by a 
 )sy hyperffimia. The infiltration of the base also diminishes, so 
 lat the tissues around are less fixed and more supple. The film 
 lithe surface becomes more and more defined, and in the course 
 time, shorter or longer, according to circumstances, little red 
 3ots make their appearance here and there ; these gradually 
 [crease in number and size, and coalesce, until the whole surface 
 covered by what has now become granulation tissue. The 
 tocesses occurring in this stage are : {a) the removal of the 
 )ughs ; (i) the covering of the surface with a cellulo-plastic 
 [udation ; and {c) the vascularization of this newly-formed 
 jaterial, and its conversion into granulation tissue. 
 IMicroscopic Appearances. — When the action of the irritant has 
 [ased, the migration of the leucocytes lessens, and the destruction 
 tissue comes to an end. The surface of the ulcer is now 
 [vered with a layer of round cells, mainly derived from the pro- 
 ;ration of the neighbouring connective-tissue elements, and 
 (ermixed with fibrin in such a way that the cells lie in the 
 terstices of the fibrillar ; this constitutes the film mentioned 
 juve. The vessels in the area, where merely stasis has occurred, 
 :oine patent, and the circulation in the neighbourhood of the 
 cer is thus restored. The vascularization of this superficial 
 is next undertaken, according to the process described in 
 bpter VII. The wound thus becomes covered with granulation 
 
 il'S I 
 
 vi 
 
46 
 
 A MANUAL OF SURGERY 
 
 period of life. The size vanes I 
 
 so extensive as to involve thej 
 
 It may also follow large burml 
 
 tissue, and with its formation the processes included in the second! 
 stage come to an end. 
 
 All the forms of chyonic ulcer which arc neither spreadinff nor activcl\\ 
 healing way he included in this transitional stage, viz., the indolent or| 
 callous ulcer, the irritable, the varicose, etc. 
 
 The Indolent or Callous Ulcer occurs most frecjuently on the| 
 legs of women about the middle 
 greatly, but they are sometimes 
 whole circumference of the limb. 
 
 on any part of the body ; healing proceeds to a certain extent,! 
 and then stops from the fact that the contraction of the cicatriciall 
 tissue already formed interferes with the vitality of the part stilll 
 unhealed by compressing the vessels, and so cutting off thel 
 granulations from their source of nutriment. The surface isl 
 usually smooth and glistening, and of a dirty yellow colour, withl 
 perhaps a few badly-formed g*'anulations ; the edges are hardi 
 and sharply cut, and elevated considerably above the surface,! 
 whilst the skin around may be heaped up over the edge, andl 
 either covered with sodden cuticle or congested. The skin of thel 
 limb is often deeply pigmented from chronic congestion, the pigl 
 mentation starting in the separate papilla? as maculae, whiclil 
 gradually coalesce. The discharge is purulent or serous, and tnayl 
 be so abundant and irritating as to cause eczema of the partsi 
 around, and thus give rise to one form of eczematous ulcer. Thel 
 base is adherent to the underlying tissues, fasciae, etc. ; and thisl 
 constitutes one of the main difficulties in healing, as contractiori 
 of the sore is thus prevented. If the ulcer extends to thel 
 periosteum, as happens not unfrequently when placed over thel 
 shin, chronic periostitis, or even osteitis, results, and a suhf 
 periosteal node is formed, corresponding exactly to the size andl 
 situation of the ulcer, forming a mushroom-shaped projection, andl 
 possibly going on to necrosis, or to enlargement of the wholel 
 bone. In some very chronic cases the superficial lymphatics andl 
 veins are so much compressed as to cause chronic cedema of thel 
 foot, often of a very solid, brawny type, and the limb may even| 
 pass into a condition of pseud-elephantiasis. 
 
 The so-called Irritable Ulcer is usually met with in this stage,! 
 Its chief peculiarities are the position, generally in the neighJ 
 bourhood of the ankle, and the pain which accompanies it. Thel 
 surface of a healing or chronic ulcer can usually be touched with- 
 out the patient complaining ; but in this variety the pain is e.vl 
 cessive, especially at night. It was pointed out by the latel 
 Mr. Hilton that, if a probe is run lightly over the surface of sucU 
 a sore, one or more spots will be indicated as the chief seats ol 
 the pain, the rest being insensitive. In all probability, nerve filaj 
 ments are there exposed, as the pain has a very marked burning 
 or shooting character. 
 
 The Varicose Ulcer occurs in the leg of a patient who is thj 
 
ULCERATION 
 
 47 
 
 Libjert of aj^gravated varicose veins. The skin becomes passively 
 Conj^'csted, and its nutrition is consecjuently impaired ; any injury 
 pr abrasion, which would readily heal in a sound limb, is likely 
 jiider such circumstances to give rise to a chronic sore. Again, 
 W iiiiiy be preceded by ec/ema resulting from the irritation of dirt 
 br the friction of hard tnuisers, whilst occasionally it may be due 
 lo the yielding of the thinned skin which forms the only covering 
 W a much dilated vein, an accident often leading to severe ha'mor- 
 Hiage. The characters of a varicose ulcer vary considerably, but 
 In the main they correspond to those of the second or transitional 
 beriod. 
 
 The Treatment of ulcers in this stage differs according to the 
 londitions present. If it is merely a passing phase in the progress 
 If an ulcer tending rapidly to repair, all that is needed is to con- 
 linue the same course of treatment as was adopted at an earlier 
 beriod of the case, viz., rest and protection from irritation. It 
 nay be advisable to shield the surface from contact with dressings 
 hy the intervention of a small portion of purified ' protective ' — 
 \c., oiled silk coated with dextrin — so that the reparative material 
 nay not be damaged during their removal. 
 
 The Chronic Ulcer needs much care in its treatment, and some 
 lases require operative interference. Rest in a more or less 
 lievated position is absolutely essential in order to relieve the 
 longested condition of the limb ; whilst if the surface is foul, a 
 lliarcoal poultice may be beneficial, or the sore may be dusted 
 Iver with iodoform, and boracic poultices applied. This may be 
 [receded in some cases by touching the surface with nitrate of 
 Iver, or with a solution of chloride of zinc (40 grains to i ounce). 
 Pressure has been fou. \d of considerable service in the treatment 
 these ulcers ; an ordinary bandage, reaching from the toes to 
 be knee, will suffice in some cases, a suitable dressing of boric 
 dd ointment, with perhaps some resin ointment added to make 
 more stimulating, being applied beneath it. Martin's india- 
 ubber bandage is more useful when the veins are much enlarged. 
 The method of dealing with chronic ulcers suggested by Pro- 
 fessor Unna, of Hamburg, has given excellent results. It con- 
 ists in the use of an adhesive plaster, made up as follows : 
 feelatine, 5 parts; oxide of zinc, 5 parts; boric acid, i part; 
 lycerine, 8 parts ; water, 6 parts ; to this ichthyol (5 per cent.) 
 pay be added with advantage. The limb is first thoroughly 
 lashed with soap and water, and purified with carbolic lotion 
 in 20). It is then wrapped round with a single layer of anti- 
 Jptic gauze, and the paste, liquefied by placing it in a gallipot 
 a saucepan of boiling-water, is applied over it with a paint 
 paste brush. Another layer of gauze is placed over the paste 
 hd a thin bandage over all, and the whole allowed to dry. 
 ihere there is much varicosity of the veins, the paste should 
 itend from the ankle to the knee, the foot being also included 
 
48 
 
 // MANUAL OF SURGERY 
 
 
 in some cases. If there is imicli (lisch:u>,'e, the ulcer should n 
 be coxered, or the dressinj^' should be reapplied in a day or t\v 
 but after it has diminished in amoimt, the paste tiiay be carri 
 right over the sore, and the whole application left in position 
 a week, or even lon},'er. 
 
 When the edges are very indurated and thickened, and 
 action is at a standstill, Syme's suggestion may be followed, v 
 the whole surface, as well as the surrounding skin, is blislcni 
 and then a suitable dressing applied. A more satisfactory meth 
 but requiring an an;esthetic, is to thoroughly scrape the surfa 
 with a sharp s[)oon, and then to rub in a strong solution of chlor 
 of /inc. 'i'his may be accompanied by some means of freeiiii,' i 
 ulcer to allow of its contraction, such as Nussbaum's plan 
 incising the skin around the ulcer at a distance of i, 2, or 3 inch 
 Should it be adherent to a thickened tibia, the base should 
 di\ided, and the exuberant new bone removed, but of course 
 surface must be thoroughly purified before doing this. As soi 
 as healthy action is established, skin-grafting may be undertal 
 if necessary. 
 
 Where varicose veins exist, treatment is of little avail uii 
 these are efficiently dealt with either by operation or by soi 
 suitable support. IJnna's paste often answers this purpose 1 
 admirably. 
 
 The Irritable Ulcer may be treated by discovering the pain 
 spots, and incising the tissues just abo\e them with a knife, so 
 to divide the exposetl nerves; but thorough scraping und* r 
 ana'sthetic is preferable. 
 
 The Eczematous Ulcer must be dealt with differently from t 
 others, or the eczema will be aggravated. Soothing applicatia 
 are needed, such as lead lotion, and when once the acute st; 
 has passed, tarry preparations {\'u\. carbonis detergens, i ouncf 
 I pint of lotio plumbi), or an ichthyol ointment (5-10 per con 
 may be beneficially employed. A mixture of benzoate of 
 and boric acid ointments is a very useful application, or I'nii 
 paste with ichthyol may be utilized. 
 
 Stage III. : Repair having now been fully established, we h 
 merely to deal with, not a healthy ulcer, for such a condit 
 cannot exist, but a healthy granulating wound, the result 
 ulceration, or, as we call it, to avoid confusion, a ' healing ulcei 
 
 A Healing Ulcer is characterized by the following conditio 
 Surface, smooth and even, shelving gradually from the skin 
 co\'ered with healthy granulations ; these present a florii 
 appearance, are painless, and bleed, but not readily, on 
 touched. The discharge varies according to the plan of treai 
 adopted : if the surface is kept at rest and free from all irritj 
 either septic or antiseptic, the discharge is merely serous ; 
 should the wound become septic, or be dressed with irritai 
 antiseptics, ordinary pus is formed. The surrounding ski 
 
 ift. flexible, and fret 
 iiilarly free from f 
 ke. which has be 
 •'K'^: within is a 
 cred by a single 1; 
 [cept in a good ligl 
 le, where the grai 
 iithcliutn, and the 
 citricial developme 
 laping up of sodden 
 Tlic method of rep; 
 je deeper layer of gr, 
 ulually contracts ai 
 I description see CI 
 )ccasionalIy if em( 
 li>'ig, the granulat 
 IS, and the healing [ 
 neral condition of t 
 ins, may also accoi 
 Jplied to it, whilst th 
 ly known as proud Jl 
 riie Treatment of a 
 It is needed is to <n\ 
 "rapidly bring aboi 
 if the leg is the se 
 :i;ingdown. The w( 
 "septic, and perhao 
 protective, the e.xac 
 trposed between tin 
 y he spread on the 1: 
 It, they may be lig 
 K stimulating lotioi 
 /^inci sulphatis, gr 
 I XX. ; acidi borici, 
 Large ulcers require 
 ous healing, otherw 
 cicatricial tissue inte 
 retards the healinjii 
 in adopted to ob\q. 
 lods of skin '/raft, n 
 cin-gr?ftmg the 
 "''=■ jf the skm , 
 y Reverdir in 
 'Uowing me. als 
 'ran^ lantation 
 cHJin' original pi 
 ie is pniched up w 
 of sharp curved sc 
 
 fr 
 
ULCERATION 
 
 49 
 
 IV 
 
 ft. nexil)le, and free from iiill.unniatory conf,'estk)n ; the base is 
 il.irly free from fixity : whilst the imn^iin present a healin;^ 
 c, which lias been describeil as manifesting; three coloured 
 ines : within is a red area consistinj; of ^granulation tissue, 
 ered by a sinj^le layer of epithelial cells which cannot be seen 
 cept in a f^ood li^ht ; next comes a thin dusky purple or blue 
 le, where the {granulations are covered by a few layers of 
 iithi'lium, and the circulation is Ijecoming retarded owing to 
 fiitricial development ; whilst outside is a white /one due to the 
 Mpiufjf up of soclden cuticle upon the healthy or healed part. 
 
 he method of repair in such a wound consists in a chanj^e of 
 e deeper layer of {granulations into fibro-cicatricial tissue, which 
 ulually contracts and is finally covered with epithelium. For 
 11 description see Chapter \'II. 
 
 Occasionally if emollient applications are used too freely and 
 lonf^, the {granulations become pale, protuberant and o-dema- 
 sand the healin{jf process is temporarily checked. A depressed 
 ineral condition of the patient, or a varicose condition of the 
 jins, may also account for this, and the term a ti>eak ulcer is 
 iplied to it, whilst the prominent flabby {granulations are popu- 
 Iv known as proud Jh'sli. 
 
 The Treatment of a healiii{; ulcer is simple in the extreme. All 
 t is needed is to <;uard the surface from irritation, and Nature 
 rapidly bring about a cure. The part must be kept at rest, 
 if the le{; is the seat of the trouble, it should not be allowed 
 hang down. The wound is dressed with any simple unirritating 
 jtiseptic, and perhaps boric acid lint is as good as any ; a piece 
 ■protective, the exact si/.e of the sore, may with advantage be 
 irposed between the lint and the wound, or boric acid ointment 
 A be spread on the lint. If the granulations become too pronii- 
 t, they may be lightly touched with nitrate of silver, and a 
 ire stimulating lotion applied, such as that known as lotio rubra 
 Zinci sulphatis, gr. ii. ; tinct. lavandulaj co., spir. rosmarini, 
 \ XX. ; acidi borici, gr. x. ; aquam. destill. ad 5 i.). 
 arge ulcers require some assistance in order to obtain expe- 
 oiis healing, otherwise a time comes when the contraction of 
 cicatricial tissue interferes with the nutrition of the granulations, 
 retards the healing process. Various plastic operations have 
 ill adopted to ob\aate this difficulty, and also the different 
 hods of skin-eraft.ng. 
 
 Ikin-grr ^ting the transplantation of more or less of the 
 
 if the skin from a healthy to a healing part, was intro- 
 V Keverdii in i86g, and has since been much elaborated, 
 ilowing me, uls are employed : 
 
 "ran^ lantation of small pieces of the cuticle and cutis, 
 
 in' original plan. A small portion of the cutaneous 
 
 e is pinched up with or without forceps, and removed by a 
 
 of sharp curved scissors In thickness it should include the 
 
 4 
 
so 
 
 A MANUAL OF SURGERY 
 
 tr 
 
 I- 
 
 cuticle and a portion of the cutis vera, so that a drop or two o| 
 blood will slowly ooze from the denuded surface. The graft 
 placed cutis downwards on the surface of the granulations anJ 
 covered Avith protective, purified in boric acid. Many of thes] 
 may be applied at the same time, and the whole wound carefull 
 dressed and protected. If there is much discharge, the grafts wi 
 not ' take '; but if the wound is merely discharging serum, Iheri 
 sliould be no difficulty in getting them to grow. Usually tbeJ 
 disappear for a day or two, from the cuticle becoming softened i 
 disintegrated ; but soon the epithelium of the cutis spreads, ani 
 makes itself visible <'.s a distinct centre of repair. The greatcsf 
 
 3. Another plan 
 |he surface of the £ 
 p \igorous scrapir 
 
 II. 1 
 
 The different for 
 jractice_vvillbe de 
 
 
 In n 
 
 fi^^ill£arts_ortF^ 
 Soft Chancre (Ch 
 
 Jpe of all infective I 
 gentleness is needed in handling the graft, as it readily perishes, B(iil)ahbn ul ^ - r 
 
 \^Transplantod(OT of large poiliona of cuticle as suggeakil hl^f^g ^^^ to^g^'^ 
 
 Thiersch. TTTTs^ method consists in removing wide strips oVDn 
 
 cuticle with a r azor , nud implanting the m on th e surface_of t 
 
 wound previously denuded of all granulations. The ulcerati 
 
 surface is first scraped, and the resulting haemorrhage stayed 
 
 pressure with a spong^e, a layer of protective being, howev 
 
 interposed, so that when the sponge is subsequently removed t; 
 
 bleeding shall not recur. The strips of cuticle are then cut, cai 
 
 being taken to make them as thin as possible ; the papilht 
 
 always encroached on, however, and hence some amount of bio 
 
 escapes, in which the grafts are allowed to remain soaking un| 
 
 required for use. When it is thought that sufficient material 
 
 been obtained, the sponge and protective are removed, and t 
 
 grafts gently transferred, being applied in such a way that tin 
 
 . overlap each other and also the margins of the defect. There 
 
 always some tendency for the edges of the grafts to turn in, a 
 
 this must be prevented. They are then covered with protect! 
 
 or thin silver-foil, and the whole dressed antiseptically. Therej 
 
 usually no need to look at the wound for some days. The on 
 
 sides of the thigh or arm are the best places from which 
 
 take the grafts. Exactly the same method may be adopted 
 
 dealing with fresh wounds where the skin covering is deHcie| 
 
 By this method subse(}uent contraction is to a large ext 
 
 prevented. 
 
 3. The whole thickness of the skin is used in some instan 
 Thus, the preputial tissue removed in circumcision is in| 
 valuable for this purpose, being soft and flexible. All reduiuli 
 and fatty tissue must be removed, and only the skin appl 
 The granulations should always be previously scraped away 
 the graft stitched down to the underlying cicatricial tissue 
 fine catgut. It may also be applied to the raw surface ^f 
 operation wound. 
 
 4. The skin of animals, such as frogs and young rats, has \ 
 employed with success in some cases ; but it is just as easy, 
 much more satisfactory, to make use of human skin for 
 purpose. 
 
 Syph 
 
 («) The prims 
 (^■') Secondary 
 sometim 
 down of 
 Intermedia 
 Tertiary u 
 either suj 
 nherited syphili 
 n, except the prime 
 lia^cdcnic ulcevation 
 Ispital wards (p. 68) 
 usually associated v 
 Ifdue to a specific 
 leers due to Tuberc 
 («) The lupoid 
 (Chapter : 
 I'he tuberci 
 bursting o 
 abscess (C 
 Various cthe 
 are descri 
 ' -scrofulode 
 induratum) 
 Iignaut Pustule, di 
 
 II 
 
 e-^e are due, as h^ 
 iiiniatory process, hi 
 ^^ growth, so that 
 ')• re(]uisite to ment 
 « appended later (( 
 
 Kodent ulcer, a c 
 \ or hair follicles. 
 
 (^) 
 
 (0 
 
ULCER A TION 
 
 51 
 
 3. Another plan that has been suggested consists in ' sowing ' 
 he surface of the granulations with the epithelial debris removed 
 )v vigorous scraping of a healthy portion of the skin. 
 
 II. Ulcers due to Specific Bacteria. 
 
 The diffe rent forms of infective ulcers 
 
 rical 
 
 ;ic tice will be described under the appropriate headings in 
 iflere nt parts ot the boo k. It will s pff'''^ hprp tn mpnfinn i-h^rp : 
 Soft Chancre (Chapter XXXIX.) — This may be taken as a 
 Ipe of all infective ulcers, clearly showing the stages of infection, 
 ;ubatibn, ulceration, and repair. ' 
 Ulcers due to Syphilis (Chapter XXXIX.) : 
 
 (a) The primary sore. 
 
 (b) Secondary ulcers, mainly of mucous membranes, but 
 sometimes involving the skin, and due to the breaking 
 down of so-called tubercular syphilides. 
 
 (t) Intermediate, rupial, or ecthymatous sores. 
 (d) Tertiary ulcers from the disintegration of gummata, 
 either superficial and multiple, or deep and single. 
 11 inherited syphilis, any or all of the above \arieties may be 
 n, except the primary sore. 
 
 Whaj^cdenic tilccvation often attacked wounds formerly in crowded 
 pital wards (p. 68), but is now limited to venereal disease. It 
 usually associated with syphilis, but whether the phagedena is 
 !f due to a specific organism is a little doubtful, 
 leers due to Tubercle : 
 
 [a) The lupoid ulcer, due to a cutaneous tubercidosis 
 
 (Chapter XIII.), or 
 {h) The tuberculous ulcer, arising as a rule from the 
 bursting of a subcutaneous or submuc ")us tuberculous 
 abscess (Chapter XI 11.). 
 
 (c) Various other tuberculous ulcerative lesions of the skin 
 are described by dermatologists under the title 
 ' scrofulodermia,' whilst Hazin's disease (or erythema 
 induratum) is possibly tuberculous in origin. 
 
 lignant Pustule, due to the Bacillus anthvacis (p. 104). 
 
 III. Malignant Ulcers. 
 
 Ihese are due, as has already been pointed out, not to any 
 Ininiatory process, but to the actual replacement of the skin 
 pp growth, so that loss of substance necessarily ensues. It 
 liy re(|uisite to mention the varieties here ; a fuller description 
 jlie appended later (Chapter VI.) : 
 Ivodent ulcer, a chronic cancer starting in the sebaceous 
 or hair follicles, and accompanied with very little over- 
 
 4-2 
 
52 
 
 A MANUAL OF SURGERY 
 
 . ( 
 
 (b) Epitheliomatous ulcer, arising froin cancer of the skin oij 
 mucous membranes. 
 
 (c) Scirrhous ulcer, resulting fiom destruction of the skin oveij 
 a scirrhous tumour. 
 
 (d) Fungating ulcer, where a neoplastic growth protrudes fronj 
 the skin. It may be caused by a soft encephaloid cancer, or ; 
 sarcoma, whilst a cysto-adenoma mamma? gives rise to a siniilaj 
 appearance. It constitutes the condition formerly known as 
 
 ' fungus haematodes.'^v/ 
 
 / 
 
 Jv ^^angrene is mear 
 Iderable area of tissi 
 ji the body, it is of 
 lead mass a slough oi 
 y-rosis is said to liav 
 Uaiucstnnii ; while t 
 
 a necrotic process 
 issues of a limb. 
 
 General 
 
 [signs of Death.— D, 
 
 Vocalised prior to 
 I'inges within it by f 
 !• Loss of pulsatioi 
 2. Loss of heat, sin 
 .}■ Loss of sensatio: 
 m death is occun 
 W through irritatior 
 f Loss of functior 
 /''. hes flaccid and r 
 > <^''iange of coloi 
 "'Hint of blood in ch 
 ' »* l^lood, it becon 
 cream colour result 
 ' 'ese five signs m 
 ;"".'ih is seriously t 
 ,'')■ Its embolic obsti 
 jne, death is practi 
 Mered more obvioua 
 Cnanges occurring in 
 »;?es depends main 
 "'I- and whether or 
 
 Klit 
 
 'ons are descril 
 
CHAPTER IV. 
 
 GANOBENE. 
 
 tiv },'angrene is meant the simultaneous loss of vitality of a con- 
 
 ideiable area of tissue. If the process is limited to the soft parts 
 the body, it is often termed sloughing or sphacelation, and the 
 
 lead mass a slough or sphacelus ; if a tangible portion of bone dies, 
 mis is said to have occurred, and the necrosed mass is called 
 iqucstvum ; while the term gangycnc is more especially applied 
 i;i necrotic process affecting simultaneously the hard and soft 
 
 Issues of a limb. 
 
 General History of a Case of Gangrene. 
 
 Signs of Death. — Death of a limited portion of the body can be 
 k)j,aiised prior to the supervention of evident post-mortem 
 jianges within it by five characteristic signs : 
 Loss of pulsation in the vessels. 
 Loss of heat, since no warm blood is brought to it. 
 |j. Loss of sensation, although much pain may be experienced 
 
 1st death is occurring, and such may be referred to the dead 
 b through irritation of the nerves above. 
 
 L Loss of function of the gangrenous mass, which, if it is a 
 fib, lies flaccid and motionless. 
 
 [3. Change of colour, the character of which depends on the 
 fount of blood in tiic part at the time of death ; if the limb is 
 
 of blood, it becomes purple and mottled ; if anajmic, a waxy 
 I cream colour results. 
 
 [These five signs may be in measure present when the vitality 
 |;i limb is seriously depressed, as by ligature of the main vessel 
 
 i y its embolic obstruction ; but if they continue for any length 
 liime, death is practically certain to ensue, and they will then be 
 
 pdcred more obvious by the phenomena about to be described. 
 
 Changes occurring in the Dead Tissues. — The character of these 
 
 pnges depends mainly on the condition of affairs at the time of 
 
 p. and whether or not putrefaction supervenes. The following 
 
 Pilitions are described : 
 
 [■ 
 if, 
 
 1 1 r 
 
!(!■ 
 
 54 
 
 A MANUAL OF SURGERY 
 
 I. Dry Gangrene (= death + mummification). — Such can on 
 occur when the tissue involved is, previous to its death, more 
 less drained of its fluids, so that it readily shrivels up and losI|n the absorndon^of 
 
 its moisture. The usual cause is chronic arterial obstruction, 
 brought about by atheroma or calcification of the terminal arterif 
 
 to which a sudden or gradual complete occlusion of the ma ,ich becomes black 
 
 trunk is often superadded. The dead part becomes hard, d 
 and wrinkled, and is of a dark-brown or black colour from t 
 diffusion of the disintegrated hajmoglobin (Fig. 8). The mc 
 fleshy parts may, however, retain a certain amount of moistu: 
 and the surrounding living tissues are often considerably infJaiiK 
 2. Moist Qangrene arises when a part of the body full of fli 
 dies, and is especially associated with any obstruction on the si 
 of the veins, or with acute arterial thrombosis in a previoui 
 
 m the surrounding 
 turbance, although 
 
 Septic or Putrid M( 
 ted with a rapid b 
 
 : 
 
 im the cutis vera bj 
 bbles of gas, and i\ 
 dermis for some di 
 d lacerable, and on 
 lally noted, 
 he Later History ( 
 asepticity or not, an 
 !/) If the necrotic i 
 &v favourable circu 
 
 Fig. S. — Skmlk Dry Gangrp:ne, affecting both Feet 
 
 sound limb, e.g., in traumatic gangrene due to pressure upon 
 rupture of, the main trunk. The loss of the vis-a-tevgo dei 
 from the heart's impulse causes a negative pressure in the c; 
 laries, which become filled by regurgitation from the \ 
 Obviously, such a condition is well suited for the developn 
 of putrefactive organisms, which always exist in numbers on 
 skin, and unless the most vigorous efforts are made to rende 
 
 aseptic before or immediately after death, moist gangreni ult of sloughinir eel 
 
 certain to be associated with putrefaction. Unhappily, this ] nidations graduallv 
 
 caution is but seldom adopted, or even available, and hena is^ until finally the \\ 
 
 the majority of cases putrefaction occurs ; it must be clei tely a small Hake t 
 
 understood, however, that it is no essential part of the gangren irated. The dead' n 
 
 nrocess. 
 
 lyniphatic spaces c 
 Aseptic Moist Oangrene is characterized by the dead tisi sjr tissues and infi 
 becoming more or less discoloured, either purple or any si x| plasma! By a 
 from black to yellow, green or white. It remains of much"-- " 
 same size and consistency as at the time of death so long as 
 kept from contamination, and is then simply and quietly cas 
 
 Fig. g.— Si 
 
 as is a catgut ligat 
 )f small portions o 
 aseptic, it is gradi 
 npleted, a small da 
 itrix found beneath 
 orbed, if the secmest 
 sin close proximity t 
 Ne to the hospital wit 
 larf,'e as the palm of j 
 
 tioii disappears, and 
 :in of which, see Cha 
 atrix, and covered 
 
GANGRENE 
 
 55 
 
 im the surrounding tissues without any obvious inflammatory 
 turbance, although a certain amount of toxaemia may result 
 m the absorption of various products from the dead tissues. 
 Septic or Putrid Moist Gangrene (Fig. 9) is necessarily asso- 
 ted with a rapid breaking-up and disintegration of the mass, 
 lich becomes black, green, or yellow. The cuticle is raised 
 m the cutis vera by blebs containing stinking serum, or even 
 bbles of gas, and these can be readily pressed along under the 
 dermis for some distance. The tissues of the lir^b are soft 
 d lacerable, and on grasping it emphysematous t-rackling is 
 iially noted. 
 
 The Later History of a gangrenous mass depends, entirely on 
 asepticity or not, and on its bulk. 
 
 (i) If the necrotic area is small in size and aseptic, it may, 
 der favourable circumstances, be entirely absorbed in the same 
 
 Fig. 9. — Septic Moist Gangrene of Leg. 
 
 as is a catgut ligature. Such is often observed after slough - 
 
 )f small portions of amputation flaps ; if the part is kepi dry 
 
 aseptic, it is gradually removed, and when the process is 
 
 npleted, a small dark scab will fall or be picked off, and a 
 
 trix found beneath it. In a similar way dead bone may be 
 
 orhed, if the secjuestrum is not too large or too dense, and if 
 
 sin close proximity to healthy vascular tissue. Thus, a child 
 
 K to the hospital with a portion of the outer table of the skull, 
 
 larpe as the palm of a man's hand, quite bare and dead, as the 
 
 ult of sloughing cellulitis ; it was treated antiseptically, and 
 
 nulations gradually sprang up through the bone in all direc- 
 
 , until finally the whole was absorbed, with the exception of 
 
 ely a small flake, the size of one's little finger nail, tvhich 
 
 irated. The dead portion is first invaded by leucocytes from 
 
 lymphatic spaces or vessels of the immediately contiguous 
 
 K tissues, and infiltrated by them and the accompanying 
 
 k1 plasma. By a process of auto-digestion this infiltrated 
 
 lion disappears, and is replaced by granulation tissue (for the 
 
 in of which, see Chapter VII.), which in turn is converted into 
 
 catrix, and covered with cuticle in the usual way. 
 
 l: 
 
 It 
 
 m 
 
 
 m 
 
56 
 
 A MANUAL OF SURGERY 
 
 Oonsti 
 
 Tliese may be des 
 
 (^0 Those general 
 
 bf gangrene, and whi 
 
 tional results of a v 
 {!>) Those condition 
 iith the body of the 
 tomaine poisoning re 
 type and variable i 
 ominent feature in s 
 metimes liable to 
 
 (b) If the mass, though aseptic, is of such a size, or consists oi 
 such tissues, as to prevent its total absorption, or if the \it;i| 
 activity of the patient is lowered, a modification of the same proj 
 cess results in partial absorption of the dead material, whilst the ;, 
 maindcr is cast off and separated by a simple process of anamic idceratm 
 The dead part immediately contiguous to the living is removed aniL -f-u , i 
 replaced by granulation tissue, and this change continues advanciuM","' , ?^ ^ compo 
 into the mass until the layer of granulations which has penetrateM f' r ^ P^^^^nt mi 
 furthest is at such a distance from its nutritive basis as to *suJts irom precedir 
 unable to derive from it sufficient pabulum, owing to the contract', • . ^'^^^ weaknesi 
 tion of the cicatricial tissue which is forming behind ; and tlienj'^!']",' °^' f'S^'°> ^^i' 
 simple ulcerative process from defective nutrition causes a lineM^fl- • ^, ^'"^romato 
 cleavage to form between the living and dead, by means of whicB" ^'^" ^"PPv of bl 
 the latter is separated from the body. The size of the P^^'inn^ | ^^^ ^'^^' 
 thus cast off is distinctly less than that of the original necrot« , ^ "?^ ' ^^^^ 
 mass. Whilst this is occurring, there is no local inflammator|'^".^ , Y^^ before the 
 reaction, and but little resulting constitutional disturbance, ittf^'^^'^^^^s and albur 
 slow in progress, but there are none of the risks attaching to t 
 more rapid septic proceeding. Of course, the denser and hard 
 the tissues, the longer they take in separating. 
 
 {c) If the gangrenous portion is septic, its separation is accoii 
 plished by a distinctly inffammatovy act taking place in, and at the expai 
 of, the surrounding living tissues. The extent of the gangrene 
 primarily indicated by a line of demarcation, due to the change™ „} ] • 
 colour occurring in the dead part, the living tissues retaining tliM .'^ ^^ '^ protectee 
 normal hue. The irritation of the chemical products form"'^ 
 in the necrosed mass causes in a few days inflammation in tl 
 surrounding structures, resulting in hyperaemia and subsecju 
 exudation of plasma and leucocytes ; the tissue of the part d 
 appears, and is replaced by a cell infiltration, which in turn brea 
 down into pus, whilst a layer of granulation tissue forms at t| 
 limit of the li\ing portion, and thus the final line of separalion 
 produced. Clinically, one notices in this latter stage a bri 
 
 red line of hypera-mia at the extremity of the living tissiiB5""'^"'^'e food, suffi 
 which gradually spreads and deepens until about the eighth ^P'^'ssness must be 
 tenth day, when, if the cuticle is intact, the living and dead paB'^' 'I'^ount of opiun 
 are separated by a narrow white or yellow line, which is provB'''''^tes and albumini 
 on pricking the epidermis, to be due to the presence of a layeij^'"^'' to limit, if pos 
 pus ; as the pus escapes, a shallow groove is seen, running betw 
 a granulating surface on the side of the living tissues and 
 gangrenous mass. This process, gradually extending tliro 
 the whole thickness of the limb, is attended by the local sign«Having thus traced 
 inflammation and by fever, the degree of the latter depending onfcrene — the signs of 
 amount of putrid material absorbed. The inflammatory prownges which may oc 
 moreover, is not always limited to the line of separation, but iBi'ody of such an en 
 spread upwards along the lymphatics or veins, or in the fasB general, the patien 
 and muscular planes, until, perhaps, the whole limb is in\olBilie disease which 
 in an extensive suppurative process. ^twi. The follow] 
 
 his naturally divic 
 lall not discuss the 
 ving it to be dealt wi 
 
 to General treatmei 
 ength of the patien 
 
GANGRENE 
 
 57 
 
 n; 
 
 Constitutional Symptoms of Gai^grene. 
 
 These may be described under two distinct headings : 
 {(j) Those general conditions which predispose to the occurrence 
 gangrene, and which are mainly of a debilitating character, affect- 
 ff either the composition of the blood or the vitality of the limbs. 
 lus, the patient may be suffering from general asthenia, such as 
 esults from preceding fevers ; or his circulation may lack vigour 
 ither from weakness of the heart muscles or from some valvular 
 sion ; or, again, his arteries may be so diseased, or rendered so 
 igid by atheromatous or c.ilcareous changes, that, although a 
 ufficient supply of blood may reach the extremities for all ordinary 
 rcumstances of life, yet any unusual demand upon the circulation 
 annot be met. Many evidences of malnutrition usually manifest 
 lemselves before the onset of gangrene. General diseases, such 
 diabetes and albuminuria, may be present, as also the consti- 
 tional results of a vicious life. 
 
 {!)) Those conditions depending on the presence and connection 
 ith the body of the dead tissue. Various forms of septic or 
 tomaine poisoning result from this, usually causing fever, asthenic 
 :ype and variable in amount. Pain, moreover, is frequently a 
 rominent feature in some forms of gangrene, and the patient is 
 metimes liable to become exhausted from this cause, even 
 ough he is protected by the surgeon's care from the dangers of 
 
 :psis. 
 
 Treatment of Gangrene. 
 
 This naturally divides itself into the local and general. We 
 lall not discuss the question of Local treatment at this place, 
 jiiving it to be dealt with under the appropriate headings hereafter. 
 . to General treatment, but little need be said beyond that the 
 jrength of the patient must be maintained by plenty of easily 
 Isiinih.hle food, sufficient stimulant, and tonics. Pain and 
 leplessness must be combated by the administration of a suit- 
 lie amount of opium or morphia, if the kidneys are healthy. 
 fcahetes and albuminuria need dietetic and therapeutic measures 
 lorder to limit, if possible, the excretion of sugar and albumen. 
 
 l1 
 
 
 Varieties of Gangrene. 
 
 iHaving thus traced in outline the general history of a case of 
 ]ni,Tene — the signs of death in the part, the various post-mortem 
 tinges which may occur in it, the means whereby Nature rids 
 body of such an encumbrance, and the various dangers, local 
 general, the patient runs— we now turn to the different forms 
 [the disease which are met with, and propose to discuss them 
 iitim. The following classification is one which, though 
 
58 
 
 A MANUAL OF SURGERY 
 
 admittedly imperfect, does in a measure group togetiier allied type 
 of the afifection, and will serve as a useful one tor practical purposed 
 
 I. Symptomatic Gangrene, or that predisposed to by precfclinj 
 vascular or general conditions, where a trauma, if present at al 
 is of very slight significance. 
 
 (a) Gangrene from embolus. 
 
 (b) Senile gangrene. 
 
 (c) Gangrene from arterial thrombosis (non-senile). 
 
 (d) Diabetic gangrene. 
 
 (e) Raynaud's disease. 
 (/) Gangrene due to ergot. 
 
 II. Traumatic Gangrene, which may be due to direct or indirej 
 injury, and where the damage done to the vessels or tissues 
 the trauma is the immediate cause of the loss of vitality. T\< 
 varieties of this may be met with, viz. : 
 
 (a) The indirect, where the lesion involves the vessels of ti 
 limb perhaps some distance above the spot where ti 
 gangrene occurs. 
 
 {b) The direct, where the gangrenous process is limited 
 the part injured. 
 
 III. Infective Gangrene, which arises from the activity a^ 
 influence of micro-organisms. 
 
 (a) Acute inflammatory or spreading traumatic gangrenf 
 
 (b) Wound phagedena and hospital gangrene. 
 
 (c) Necrosis of bone (most cases). 
 
 (d) Noma and cancrum oris. 
 {(') Carbuncle and boil. 
 
 IV. Gangrene from Thermal Causes — frost-bite and burns. 
 Each of these varieties must now claim separate and indi\ idi 
 
 attention. 
 
 a young person, i« 
 
 it also follows wl 
 
 main vessel of a lir 
 
 keneration, an occur 
 
 [Emboli are most cor 
 
 main trunks (Fig. 
 
 dnished by the ori^ 
 
 kllmg over the bifu 
 
 the subsequent dej 
 
 ih branches (Fig. lo, 
 
 ision of the femoral 
 
 nhe superior profunda 
 
 The chief early Sym] 
 
 impaction and also 
 
 sel. Pulsation belo^ 
 
 I. Symptomatic Gangrene. 
 
 (a) Embolic Gangrene. (For general details as to emboli, 
 Chapter X.). When the main artery of a limb becomes blocl 
 by a simple embolus, the condition is exactly similar to tl 
 which obtains after ligature — i.e., the vitality of the parti 
 diminished until such a time as the collateral circulation! 
 established. Under ordinary circumstances it should not leai 
 gangrene ; but if either the general or local vitality is nii 
 reduced, the obstruction of the main trunk may be just suffici 
 to determine the death of more or less of the limb. There 
 two chief conditions under which gangrene is likely to followj 
 embolus : (i.) Where the embolus consists of a fibrinous veg( 
 tion detached from one of the cardiac valves in a case of ei 
 carditis following rheumatic or other fevers. The gem 
 nutrition has been depressed by the preceding fever, the he; 
 action is weak, and the circulation possibly impeded by 
 valvular lesion, so that the block of a terminal main trunk, 
 
 !<;. lo. — Diagrams oi 
 
 Jthe embolus is seen, and 
 ■vet obstructing the vesse 
 |y tlie growth of the clot. 
 
 diminish, and the 
 
 Is are healthy, stag] 
 
 Pt, the terminal portic 
 
 ktous, and finally pi 
 
 iowever, the terminal 
 
 fat the limb is in a st 
 
 to follow. The p 
 
 lally upwards until il 
 
 [lation to maintain th 
 
 neighbourhood of a 
 
 foniosis here than in 
 
 in the leg the gangn 
 
 nkle or below the 
 
GANGRENE 
 
 59 
 
 a young person, is often sufficient to determine gangrene. 
 ,) It also follows when a detached atheromatous plate blocks 
 e main vessel of a limb previously rendered anaemic by arterial 
 generation, an occurrence not unusual in elderly people. 
 Emboli are most commonly arrested at the sites of division of 
 e main trunks (Fig. lo. A), or where the calibre is suddenly 
 iiinished by the origin of a large branch, the embolus often 
 Idling over the bifurcation, and thus, as it increases in size 
 the subsequent deposit thereon of fibrin, effectually closing 
 [h branches (Fig. lo, B). In the lower limb it occurs at the 
 ision of the femoral or popliteal ; in the upper, at the origin 
 the superior profunda, or where the brachial divides. 
 The chief early Symptom is pain experienced both at the point 
 impaction and also down the limb along the course of the 
 isel. Pulsation below the block ceases, sensation and tempera- 
 
 lo. — Diagrams oi 
 
 MBOLUS SAODLING THE BIFURCATION OF 
 
 AN Artery. 
 
 Ithe embolus is seen, and the commencement of a thrombus on it, but not 
 let obstructing the vessel ; in H both branches of the trunk are blocked 
 IW the growth of the clot. 
 
 diminish, and the part feels heavy and useless. If the 
 Is are healthy, stagnation of blood in the veins is an early 
 it, the terminal portion of the limb becoming congested and 
 atous, and finally passing into a condition of moist gangrene, 
 lowever, the terminal arteries are calcified or atheromatous, 
 lat the limb is in a state of chronic anaemia, dry gangrene is 
 
 to follow. The process starts peripherally, and spreads 
 
 lily upwards until it reaches a level whers there is sufficient 
 lation to maintain the life of the part. Such usually obtains 
 
 neighbourhood of a joint, since there is always a more free 
 oniosis here than in the inter-articular portions of the limb ; 
 in the leg the gangrene is arrested either immediately above 
 
 kle or below the knee. The subsequent history depends 
 
 i i' 
 
 ! 
 
6o 
 
 A MANUAL OF SURGERY 
 
 upon whether or not the dead tissue is allowed to become septj 
 and recjuires no special notice. 
 
 Treatment. — The all-important re(iuisite in dealing with a cj 
 of this nature is to prevent the advent of sepsis, since it nJ 
 transform what would otherwise be a condition associated \vi| 
 but little danger into one of the gravest moment. As soon 
 possible after the obstruction has taken place, and before aij 
 absolute signs of tleath are manifest, scrupulous care must 
 taken to purify the part. The nails should be cut, and the uhcj 
 limb thoroughly but gently scrubbed with carbolic lotion (i in 2J 
 special attention being directed to the intervals between the to 
 and the folds of skin under and alongside of the nails. It shuiii 
 then be wrapped in a layer or two of moist and purified gaiJ 
 swathed round with salicylic, iodoform, or sterilized wool, aJ 
 lightly, though firmly, bandaged. The limb is kept sli<;lil 
 raised, so as to prevent venous regurgitation without interferiij 
 with the arterial supply, and by this means gangrene may be pil 
 vented. If, however, these precautions are not successful, aa 
 the part dies, the same measures as to the maintenance of asepij 
 must be continued until a natural line of separation forms, 
 old people with dry gangrene similar rules are followed as for 
 senile type ; but in the moist form, occurring in young peopj 
 the natural process of separation may be hastened by severia 
 the dead from the living and sawing through the bone, 
 possibly amputation through the living tissues a little above mJ 
 be considered advisable, a more shapely stump being th| 
 obtained. Where sepsis has occurred it is advisable to amputal 
 through healthy tissue as soon as the gangrenous process 
 finally ceased to extend. If, however, there has been iiiuij 
 spreading septic infiammation, one may be driven much high 
 up the limb than would be otherwise necessary, whilst very acuj 
 septic symptoms may determine amputation before any line I 
 separation has formed. 
 
 (b) Senile Gangrene is a condition which, as the name impliej 
 occurs in elderly people, and is the result of imperfect nutrition] 
 the tissues. The toes are most frecjuently affected, but it is aJ 
 seen in the hand, and may attack the nose, ears, or even til 
 tongue. 
 
 Causes. — These are to be found mainly in the condition of t':| 
 circulatory organs, (a) Calcairoiis dcgcncyation (Chapter IX.) 
 the smaller vessels of the limb or part is always present, as all 
 possibly atheroma of the larger arteries. The vessels in coJ 
 sequence become pipe-like and inelastic, and incapable of acconj 
 modating themselves to the requisite variations in the hloa 
 supply. Hence a fixed minimal amount of blood enters the 
 which passes into a chronic state of anaemia and malnutritioi 
 whilst the tunica intima is often so rough as to predispose i 
 thrombosis with or without injury. (/;) A iveak heart is general! 
 
GANGRENE 
 
 6i 
 
 jesent, leadinf^^ to low pulse tension, and increased difficulty in 
 opelling the blood throufrh the ri<rid and narrowed vessels. 
 Tlie venous viiurii may also be inter fcn'd h'ith by the existence 
 varicose veins, or pulmonary emphysema : whilst {d) the 
 ilition of the blood may be impoverished by albuminuria. When 
 irh predisposing factors are present, anything that results in 
 \tkivnihosis either in the main trunks or in the peripheral arterioles or 
 Miu'ies is likely to determine the onset of grmgrene, Throm- 
 Ls of the main vessels may be due to some injury to the limb 
 |iicli often passes unnoticed, or more frequently arises frotu a 
 (adual deposit of fibrin on the already roughened walls. If the 
 Jstruction originates in the smaller trunks or capillaries, it is 
 Jnerally brought about by some slight injury, such as striking 
 |ehall of the gre.at toe against the table, or even cutting a corn. 
 sposure to cold may also act as an exciting agent. In either 
 Ue the clotting extends for some distance, and the height to 
 Riicli the gangrene spreads will vary accordingly, 
 jSymptoms. — Preliminary evidences of malnutrition of the limb 
 11 probably have been noticed for some time in the form of cramp 
 (1 pain in the muscles, which become fatigued rapidly, whilst 
 liisations of pins and needles or numbness are also complained 
 Tlie circulation in the tibials may be so slight as to be 
 Lucely perceptible, and the whole limb feels cold and heavy. 
 flk' skin is frequently more or less congested, and extremely 
 lone to low forms of ulceration or ec/ema. W hen the gangrene 
 Iminences as a result of some peripheral lesion, an area of painful 
 Llness is first noticed, perhaps running on to ulceration, and in 
 jit centre of this patch a slough is formed, which becomes dry 
 1 black. The process gradually spreads from this focus with 
 lore or less inflammation, so that it is sometimes known as 
 Immatory senile frangrene. If, however, it results from throm- 
 Dsis of the main \essels, death occurs without the supervention 
 local inflammatory phenomena, the toes merely shrivelling up 
 dying {non-injlammatory senile gan<:^rene). The inner side of 
 ne f,'reat toe is perhaps the commonest situation for the com- 
 [lencement of the mischief, and thence it spreads from one toe to 
 cother, and also along the instep and up the ankle to the leg. 
 [ain is always a marked feature, whilst the extent of the gan- 
 Vene is dependent partly on the amount of general and local 
 Itality, and partly on the asepticity or not of the surrounding 
 issues. As the disease spreads, the patient becomes exhausted 
 |y the long-continued pain and want of sleep ; and septic fever, 
 edsores, or the intervention of some cardiac, pulmonary, or renal 
 bmplication, may also hasten a fatal termination.^ 
 The Treatment adopted until within the last few years was 
 Dverned by the observation that any attempt to remove the 
 t;id tissues by amputating through neighbouring living parts is 
 domed to failure, since the gangrenous process is certain to 
 
62 
 
 A MANUAL OF SUUGHKY 
 
 resist bacterial in 
 
 frosinf^endartcriti: 
 
 ct with in the siibjc 
 
 low forty years ol 
 
 aiimatic or infectivr 
 
 li'or at the extreni 
 
 a dusky purple art 
 
 fccntral portion of 
 
 1 1'oni this focus tl 
 
 y t\ ()e accordinj,' to 
 
 In ih»> Treatment a 
 
 crction of suj/ar h 
 
 commence ap^ain in the flaps; if merely cuttinfr a corn suffu 
 
 to orif^Miiate ihi; malady, nuich more does so severe an iiijuri 
 
 as an amputation. The parts were dusted with iodoform 
 
 some similar antiseptic, and wrapped in cotton-wool to l<te| 
 
 them warm ; the surj^'con then waited for a line of separation, a 
 
 even then did not amputate, but merely assisted Nature j 
 
 dividin{j[ tendons or bones. At the same time, the general heal 
 
 w\'is maintained by the judicious adininistration of suital 
 
 nourishment, stiuuilants and tonics, whilst pain was allexiatcd L| 
 
 the use of o{)ium in such doses as the condition of the kiilmni 
 
 allowed. In spite of every care, however, the enfeebled constit 
 
 tion of the patients often proved unecpial to the task of riddii 
 
 the body of the dead mass, so that death from exhaustion c|et, hut too much tin 
 
 blood-poisonin<f was the rule rather than the exception, and c\ 
 
 if the patient did reco\(>r, the prolonfjed and enforced stay in 1 
 
 considerably diminished his vital powers. 
 
 It has now, however, been clearly demonstrated that mi 
 auiputation performed under careful antisepsis, and i^'dl aivay jm 
 the dead mass at a point where the surj^^eon considers the l)lo( 
 supply sufiicicnt to nourisli the flaps, and yet not so near t 
 trunk as to seriously threaten life throu{,di shock, holds out ti 
 best prospects of relief. In order to determine the most favoui 
 able site for the amputation, the pulsation in the main artt 
 should be felt for, and if feasible no operation performed at a sp( 
 where it appears to be occluded. The condition of the linii) w 
 also influence the surj^eon's decision; if thm, attenuated, a 
 
 shrivelled, it will be wise to amputate high; but if the linili Bnal cord, or in some 
 fairly well nourished and with plenty of adipose tissue, Mfonditions of nervoi 
 operation may be performed somewhat lower. In operatin<,', Miilen fright. Three 
 little damage as possible should be inflicted on the parts, Mfope or ana-mia, ari; 
 flaps being nearly ecjual in length and not too flimsy, a circulB ("liaracterized by p.- 
 amputation, or some slight modification of it, being perhaps tiBliyxia or congestion 
 best. In cases where the mischief is limited to the foot, itBnosed from venous i 
 usually advisable to amputate through the lower third of tBoming dry and blaci 
 thigh, or at any rate in the neighbourhood of the knee-joicBend at all deeply 
 though not through the joint itself, as the flaps in that operatiBy last for a variable 
 are always rather flimsy. We have followed this line of practiBervenes, the latter i 
 for some years, and have no reason to be dissatisfied with oHmeans necessarily fo 
 results. Dissection of the portions removed has always siio\» The disease is u 
 that the vascular trouble was fully as advanced as we hMier than the toes, bi 
 anticipated, and that no minor measures would have sufticed. By ; the process 
 
 {c) Gangrene from Arterial Thrombosis (non-senile) is notBoxysmal ha^nioglobi 
 common occurrence. It arises as a result of that curious afTectiB)e due to vaso-nioto 
 cndarteriiis oblitcyans, and also develops in some young people Bhe smaller joints, e 
 scattered patches about the skin without any of the characterisBli'^ed patches of ana 
 phenomena of Raynaud's disease. K are sometimes pr 
 
 {d) Diabetic Gangrene is mainly due to the abnormal conditiB condition somewha 
 of the blood in diabetes, thereby reducing the power of the tissiBis distinguished by 
 
 II ot the condition 
 
 fiahly healthy, rem 
 
 very much a'bove f 
 
 should there be e\ 
 
 leii either tlie separaf 
 
 tiiie, the surgeon m 
 [tferahly, if the patien 
 
 y he undertaken. 
 re is some risk of th 
 ii) Raynaud's Diseas( 
 oiidition usually met 
 ueen the ages of fif 
 
 m, dependent eithe 
 
 
GANG REN i: 
 
 6J 
 
 ct, 
 
 K sist b.ictciial invasion ; but is also in measure the result of a 
 iiosinj,' endarteritis anil peripheral neuritis. It is not commonly 
 1 with in the subjects of acute ilialx.'tes, nor, as a rule, in people 
 ()\\ forty years of af^'e. It results usually from some sli^'ht 
 iiinatic or infecti\e injury, and often commences on the umler 
 eor at the extremity of one of the toes as a bleb, surrounded 
 a dusky purple ar(!ola. When the bleb is opened or bursts, 
 I'Ciiitral portion of liie underlying tissue is found to be necrotic, 
 (1 from this focus the ganj^Mcne spreads, takiufj^ on a moist or a 
 V t\ [)e accordiuf^^ to the amount of vascular disease. 
 In I'le Treatment an attempt should be made to reduce the 
 nelion of suj^ar by administeriuf; codeia and ri'}^'ulatinf^' the 
 hut too much time must not be lost. A careful investifjfa- 
 of the condition of the vessels is necessary, if they are 
 lahly healthy, removal of the dead tissue by an amputation 
 1 viry much above the upper limit of the disease is justifiable; 
 should there be evidence that the main trunks are affected, 
 til either the separation of the necrosed mass must be left to 
 ;iture, the surj^eon merely assistiufj; by the division of bones, or 
 cfiTably, if the patient's general state is good, a high amputation 
 jv he undertaken. Under the latter circumstances, however, 
 tie is some risk of the supervention of diabetic coma. 
 ii) Raynaud's Disease, or Spontaneous Symmetrical Gangrene, is 
 aiiilition usually met with in ana'uuc or neurotic young women 
 jtween the ages of fifteen and thirty. It is due to vaso-motor 
 bin, dependent either on some deep unrecognised lesion of the 
 |n;il cord, or in some cases to a peripheral neuritis. It occurs 
 [conditions of nervous exhaustion, and ha;^ been started by a 
 pden fright. Three stages are usually described : (i.) local 
 [la'pe or anaemia, arising as the direct result of arterial spasm, 
 I characterized by pallor and painfulness of the part ; (ii.) local 
 khvxia or congestion, in which the alTected tissues are blue and 
 jinosed from venous regurgitation ; and (iii.) necrosis, the part 
 Joining dry and black, though it is unusual for the gangrene to 
 leiid at all deeply. The onset is often sudden, and the disease 
 Ivlast for a variable time, from days to months. If gangrene 
 eivenes, the latter is the limit more often reached, but it by 
 [means necessarily follows that tissue necrosis occurs in every 
 The disease is usually symmetrical, and aflfects the fingers 
 her than the toes, but patches may occur on any part of the 
 ly; the process is non-febrile, but often very painful, 
 joxysmal haemoglobinuria has been observed, and is supposed 
 : due to vaso-motor disturbance of the kidneys. Ankylosis 
 |he smaller joints, especially of the terminal phalanges, and 
 lized patches of ana'sthesia, associated with pain of a neuralgic 
 1, are sometimes present, resulting from peripheral neuritis. 
 I condition somewhat resembles the later stages of a chilblain, 
 lis distinguished by its more dusky colour, the greater pain, 
 
64 
 
 A MANUAL OF SURGE-iY 
 
 ill 
 
 the absence of itching, and the fact that the process is not liniited| 
 to exposetl or terminal parts, or to cold weather. 
 
 Tlie Treatment must in the early staj^es be directed to the pre 
 vention cf ganj^rene. The constitution should be built up ' 
 iron, quinine, and if need be by stimulants, whilst menstrui 
 irregularities must be attended to. I'Victions with stimulatiii 
 embrocations, warm ddiches, and protection from cold and injurv 
 may be employed locally, l)ut probably the best results will follow 
 the use of electricity. The constant current is er^oloyed, an 
 preferably in the shape of the electric bath, local or general 
 required, and repeated either once or several times a day. Whti 
 actual gangrene is present, the dead tissue should be kept aseptii 
 when sooner or later it will be absorbed or separated. 
 
 (/) Gangrene from Ergot is a rare phenomenon, but it has heel 
 known to occur when diseased rye has been used in the mani 
 facture '^f bread. The resulting gangrene may vary in extei 
 from the loss of one or two fingers or toes to the sacrifice of t 
 greater portion of one or more limbs. 
 
 II. Traumatic Gangrene. 
 
 By traumatic gangrene is meant the loss of \itality of so: 
 part of the body as the consefiueiice of an injury, whether app!; 
 to the main bloodvessels {indirect traumatic rangrene), or directj 
 to the tissues (direct traumatic gangrene). 
 
 (a) Indirect Traumatic Gangrene arises from a considera 
 variety of lesions, and the course and clinical history are siinihu 
 variable. 
 
 (i.) Ligature of the main artery does not produce gangrene ii 
 healthy limb ; but should it be in a state of chronic malnutii 
 and anaemia from preceding arterial disease, death of a cer 
 portion may ensue, the case running a ^ '"'ilar course to oik 
 gangrene due to embolus. It is usually of the dry type, a 
 limited to one or two toes ; but if it reaches the more lie- 
 portions, the moist \ariety supervenes. 
 
 Where the gangrene is confined to the toes. Treatment coii'^ 
 in waiting for a definite line of separation to form under an ai 
 septic dressing, and then in assisting the natural processes at tj 
 spot by dividing tendons and bones. Where, however, a a 
 siderable area of the lindi loses its vitality, and especially it" 
 dead tissue is moist and septic, an early high, amputationl 
 required. 
 
 (ii.) Arterial thrombosis from injury only causes gangrene iini 
 special circumstances, the course and treatment being similar 
 that for the senile type. 
 
 (iii.) Obstruction to both main artery and vein is an alii 
 certain precursor of gangrene. A few cases are on recorc 
 which both vessels have been ligatured, or even portions of tl 
 
 tmoved without leac 
 eposits in the axilLi 
 th these instances 
 ireviously existed, ■ 
 istomotic branche' 
 erent and efiferent l 
 crosis. It may th( 
 ssels in a ligature 
 thin the body, as 
 when a ligature 
 ndage applied too 
 en occur from the s> 
 s been originally ap] 
 A A-ery similar rei 
 pera^mia and exuda 
 Jistriction around a p 
 'erial blood for som 
 nia,i(ed that they an 
 amount of exudatio 
 '^ the circulation t 
 I after frost-bite, an 
 mfrulated, after remc 
 angrene may also re 
 ipiession of the acco 
 wcurrence perhaps i 
 i/ww ; it is then alv/a 
 to Treatment, tli. 
 a t'me as gangrene 
 ion through the site 
 'maken. It may be 
 'ilenmg from fractui 
 ,1"^' out any clots w 
 Kiwi or lacerated \-es 
 motion in the shap 
 i''lf> surgical measun 
 Direct Traumatic , 
 •iHect of injury to 
 ins. 
 
 Severe crushes jr 
 r*^ne ; thus a Jimb i 
 wcinnery, or by heavi 
 liicles over it. Not| 
 •or even 'pulped,' 
 ■sultujg extravasatiJ 
 
 's of the moist tyl 
 nts^ who.se vitality "iif 
 elderly person is ofj 
 '') a'lult it could be 
 
R 
 
 GANGRENE 
 
 65 
 
 moved without leading to gangrene, as in dealing with cancerous 
 
 iposits in the axilla, or in the extirpation of aneurisms ; but in 
 
 oth these instances obstruction to the circulation must have 
 
 reviouslj' existed, necessitating the opening up of collateral 
 
 nastomotic branches. In a normal limb the occlusion of both 
 
 (ferent and efferent trunks is practically sure to determine tissue 
 
 ecrosis. It may therefore be caused by the inclusion of both 
 
 Bssels in a ligature, or by the styangulation of organs, either 
 
 ithin the body, as in a strangulated hernia, or outside of it, 
 
 when a ligature is tied round the base of the penis, or a 
 
 indage applied too tightly round a fractured limb. It may 
 
 en occur from the swelling up of a limb under a bandage which 
 
 sheen originally applied with no undue tension. 
 
 A very similar result may be produced by the ey.essive 
 
 pei^mia and exudation following the sudden relief of a tight 
 
 nstriction around a part, which has thus been deprived of fresh 
 
 tcrial blood for some time ; the vessel walls are thereby so 
 
 ai^^ed that they are unable to resist the blood-pressure, and 
 
 amount of exudation that follows is so abundant as to rapidly 
 
 Hi,' the circulation to a standstill. Such an occurrence is met 
 
 after frost-bite, and also in a loop of bowel, which has been 
 
 mpulated, after removing the obstruction to the circulation. 
 
 Gangrene may also result from the rupture of a main artery and 
 
 iipression of the accompanying vein by the extravasated blood, 
 
 currence perhaps most frequently seen iiitev fnictiiycs and dis- 
 
 iioiis : it is then always of the moist type. (See Chapter XVI.) 
 
 > to Treatment, the parts are kept warm and aseptic until 
 
 ii a time as gangrene is definitely established, and then ampu- 
 
 011 through the site of obstruction, or just above it, must be 
 
 t'llaken. It may be possible to save a limb when j.,angrene is 
 
 ■ilening from fracture or dislocation by cutting down at once, 
 
 in;,' out any clots whicli may have formed, and securing the 
 
 jded or lacerated vessels, whilst at the saui*. tiuie the cause of 
 
 ruction in the shape of the displaced none is dealt with by 
 
 iilile surgical measures. 
 
 Direct Traumatic Gangrene, or that . a .ilHng from the imme- 
 
 effect of injury to the parts, is similarly due to a variety of 
 
 th 
 
 lins. 
 
 Severe crushes or blows are a common cause of this type of 
 
 creiie ; thus a limb may become mangled between the wheels 
 
 [achinery, or by heavy weights falling on it, or by the passage 
 
 Viicles over it. Not only are the parts crushed, severely con- 
 
 p. or even 'pulped,' but the bloodvessels may be torn, and 
 
 itsulting extravasation contributes to the result. The gan- 
 
 is of the moist type, and is more likely to sup'.Mvene in 
 
 [nts whose vitality is diminished. Thus, a crush oi the foot 
 
 ] elderly person is often followed by it, when in a young and 
 
 Illy adult it could be prevented. 
 
66 
 
 A MANUAL OF SURGERY 
 
 I 
 
 Treatment. — If the part is hopelessly damaged, there is not t| 
 slightest use in delaying operation, since the patient may run c 
 siderable risk from the onset of sepsis ; and therefore immedi 
 amputation should be undertaken. The question of shock ; 
 its influence in deterrninmg operation is discussed elsewhe 
 When there seems a reasonable chance of saving the limb, i 
 cleansed and purified under the strictest antiseptic precautio 
 should gangrene super\ene, it may be removed later. 
 
 (ii.) Prolonged pressure is also capable of producing gangre: 
 such as that which arises from injudicious splint pressure or 
 the form of bedsores. Splint pyessiirc as a cause of gangrene 
 only be regarded as an accidental circumstance or the result 
 carelessness. Where there is a marked tendency to displa 
 ment of fragments after a fracture, it may be necessary to 
 ^.ome considerable degree of pressure to counteract it, and thoi 
 spite of every precaution necrosis of the superficial parts i 
 
 ensue. Pain of a neuralgic type is usually complained of fAs action MI fi f • 
 few days, but even that is not necessarily severe enough to attiMiv them to be 1 ]^^ 
 much attention ; when the limb is freed later on, the dead por*" ' " ""^ 
 
 of the skin is white, anaemic, and insensitive. The necn 
 process may extend to some depth, and hence the greatest 
 must be taken to keep the dead tissues aseptic, as otherwise di 
 suppuration may spread along the muscular and fascial pla 
 and lead to considerable local and constitutional disturbance. 
 
 Bedsores are likely to occur in patients v.ho are kept for a iBafFected tissues 
 time in the recumbent piosture, or in any one particular positBii Acute Spreading 
 The parts most exposed to pressure first become red and Mgrene foudroyant of M 
 gested, and finally ulceration or actual gangrene supervenes, m rapidly fatal and se 
 
 fts of tincture of cat 
 
 fen dry leaves a povv( 
 
 fessure by means of a 
 
 Itients or old people 
 
 fich must be sufficie 
 
 lere is too little water, 
 
 k and no good resu'l 
 
 )comes hard and resi< 
 
 ! employed. When; 
 
 dressed either witi 
 
 kgish cases with resin 
 
 Bsam, mixed with cas 
 
 j.is useful in this con, 
 
 »i.) The miction of coj 
 
 kahzed traumatic gai 
 
 ^amount and characte 
 
 in. Speci 
 
 jlll the forms of gangr 
 Ized by their origin in 
 lich by the virulence n 
 
 Ol 
 
 a general rule, bedsores are not very extensive or deep:] 
 
 occasionally when the patient is debilitated, and especial 
 
 a condition of lowered sensation is present, due to impairnie 
 
 the nerve-supply, as in paraplegia, the process may extend \v 
 
 and deeply, destroying fascia\ laying open muscular sheaths, 
 
 even leading to necrosis or caries of bones. The spinal 
 
 itself has been opened in this way, and death from septic ni 
 
 git is has resulted. To prevent the occurrence of such sore?^ 
 
 most scrupulous attention must be given to the parts expos 
 
 pressure. The nurse should see that the draw-sheet and 
 
 linen are placed smoothly and without creases, and that no 
 
 taminati(Mi by urine or fa-ces is allowed ; if the patient isB>i)y a virulent ort/'m 
 
 spiring freely, the sheet should be frequently changed, so ■post-mortem norter • 
 
 prevent decomposition of the sweat. The skin of the ba"' ' - ' ' 
 
 daily examined, washed with some unirritating soap, and r 
 with a SMotliing, strengthening, and liardening application, siij 
 spirit of wine, methylated spirit, or perhaps, l)etter stilt a mi 
 of brandy and white of egg. It is then dusted over with ;i 
 antiseptic powder, such as boric acid. If the skin becomei 
 it should be painted with collodion, or with a mixture ol 
 
 ,uses.-(i.) The uidivi 
 ic niHammatory condil 
 ir, or from simple maj 
 jnsuming large quar 
 Kards, are especially l| 
 nis, which are particu| 
 ma healthy person. 
 I I'he lesion from whi 
 compound fracture or| 
 liuich contused or veil 
 small and insignificl 
 
 [become infected, and' 
 
 Ihe oyfranism mostl 
 
 ^mt (rdeuui, first isol.-l 
 
 t authors). It is a rodl 
 
 'Slender than that off 
 
 liquefies gelatine, a| 
 
 On injection into 
 
GANGRENE 
 
 t^ 
 
 \ of tincture of catechu and liquor plnmbi subacetatis, which 
 1 dry leaves a powdery film on the surface, and protected from 
 mre by means of a circular hollow water-pillow. Paraplegic 
 ints or old people should at once be placed on a water-bed, 
 h must be sufficiently, but not excessi\'cly, distendeil. If 
 ! is too little water, the weight of the body displaces it to one 
 and no good results ; whilst it there is too much, the bed 
 mes hard and resistan*, and fails in the object for which it 
 employed. When an open sore forms, it must be kept aseptic, 
 dressed either with boric acid ointment, or in the more 
 ^dsh cases with resin and boric acid ointments mixed. Friar's 
 im, mixed with castor-oil (i part of the balsam in S of the 
 is useful in this condition. 
 
 i.) The action of corrosive or caustic chemical? is followed by 
 ;alized traumatic gangrene, the degree of which varies with 
 unount and character of the irritant present, and the duration 
 ; action. All that is needed is to keep the parts aseptic, and 
 I' them to be absorbed or separated by natural processes. 
 
 III. Specific or Infective Gangrene. 
 
 II the forms of gangrene included in this group are charac- 
 
 ed by their origin in the development of micro-organisms, 
 
 ;h by the virulence "^ their products determine the death of 
 
 idected tissues. 
 
 I Acute Spreading ov Spreading Traumatic Gangrene (the 
 
 [tene foudroyant of Maisonneuve). — This disease is one of the 
 rapidly fatal and serious met with in surgery. 
 
 .uses. — (i.) The individual attacked is often predisposed to 
 inHammatory conditions, as a result of > icious or c:;'eless 
 , or from simple malnutrition. Those who are in the habit 
 
 onsuming large quantities of alcohol, even if not actual 
 ;irds, are especially liable to this affection ; but some forms 
 
 rus, which are particularly active, may lead to its development 
 in a healthy person. 
 The Uuon from which it originates is usually severe, such 
 
 compound fracture or dislocation, especially if the soft parts 
 inch contused or very dirty. Less frecjuently it originates 
 small and insignificant pricks, scratches, or abrasions, if 
 V a virulent organism gains access to the tissues. In this 
 lost-mortem porters, nurses, or pathological demonstrators 
 lecome infected, and tlie gravest consequences ensue. 
 I The oY'^anism most commonly present is the Bacillus of 
 iiivit oedema, first isolated by Koch (the Bacillus scpiicus of 
 iiuthors). It is a rod-shaped microbe, somewhat longer and 
 slender than that of anthrax. It is anaerobic, and in its 
 i(|uefies gelatine, and produces an unpleasant penetrating 
 (in injection into the subcutaneous tissues of a mouse^ 
 
 5—2 
 
 V 
 
 tl 
 
68 
 
 A MANUAL OF SURGERY 
 
 hli, 
 
 the animal dies in eight to fifteen hours ; locally, a spreadin] 
 (jedema is produced, the connective-tissue spaces being filled witj 
 fluid containing bacilli, and perhaps some gas-bubbles. iSacil 
 are also found in the exudations which occur in the serous cavitie 
 in the connective-tissues of important organs, and in the blood f( 
 some time after death. 
 
 The Symptoms are those of a hyperacute cellulitis, accompani 
 by general septicemia. The wound early takes on an unhealtl 
 action, the surface becoming covered with sloughs, and a th 
 serous or sero-sanguineous discharge escaping. The inflainm; 
 tory process rapidly spreads along the connective-tissue planes 
 the lim, . which becomes swollen, painful, and brawny. At lir: 
 it is of a dusky purplish colour, but soon the signs of actm 
 gangrene supervene, and the necrotic tissues become crepita 
 and emphysematous, partly from simple putrefaction, partly froi 
 the gaseous developments associated with the growth of tli 
 specific organism. At the same time evidences of profou: 
 toxic disturbance manifest themselves, the patient perha 
 haviiip; a high temperature and being delirious ; but not i 
 commonly fever may be entirely absent, the temperature hei 
 subnormal and coma present. The outlook is exceedin;: 
 grave, death usually ensuing in from five to seven days aft 
 the onset. 
 
 The only Treatment which holds out any hope in dealii 
 with a limb where the disease is rapidly extending is a hiij 
 amputation, even through the shoulder or hip-joint. Any deli 
 is dangerous, although, in spite of the greatest promptitude, tl 
 infection may have progressed so rapidly that death follows froi 
 septicaemia, even after the limb has been removed. In a few cas 
 where the patient is seen early, it may be possible to save boi 
 life and limb by freely incising the affected tissues, and immersii 
 them in a continuous warm antiseptic bath. At the same ti 
 the general health must be attended to by giving plenty of ri 
 nourishment, together with diffusible stimulants, such as ethi 
 and ammonia. 
 
 (b) Wound Phagedena and Hospital Gangrene are conditioi 
 affecting wounds which w^ere seen often enough in the pre-ani 
 septic era, but are now practically unknown, thanks not only 
 antisepsis, but to the increased care directed to ventilation ai 
 hospital hygiene. They consisted in a rapidly spreading ulcei 
 tion or gangrene, which attacked operation wounds a few da; 
 after their infiiction, and as a rule led to rapid death. It 
 fortunately unnecessary to describe or discuss them nowadays 
 
 (r) Necrosis of Bone is practically always due to the develi 
 ment of organisms, and may be either acute or chronic. In tl 
 former, the infiammatory reaction is so severe that the vess 
 are strangled within the bony alveoli ; in the latter, it is larj;f 
 due to an obliterative endiu'teritis, vhich accompanies tl 
 
 irious specific proc 
 
 hapter XVII. 
 
 (d) Cancnim Oris 
 
 [angrenous stomatitis 
 irroundings in ovei 
 itients are always in 
 [alescing from one 
 arious special organ 
 responsible for car 
 lany forms found in 
 le streptococcus py( 
 iprophytic bacilli is t 
 |n abrasion of the mu 
 diseased or dirty toe 
 ml ashy-grey pultace 
 leeks, and from this 
 te mouth and swal 
 itensely f(jetid. The 
 iperficially and deep! 
 :nse, and, should the ] 
 black slough appears 
 nze. In the worst 
 affected and die, ar 
 ay also be involved. 
 the general phenon 
 It only are the toxi 
 isorhed by the lymf 
 ise gi\ mg rise to sept 
 considerable risk of d 
 icial or other veins 
 pticaemia may also 
 cur early in the easel 
 collapse and coma \| 
 The Treatment musj 
 to he saved. The \\ 
 il the pultaceous sloij 
 means of X'olkmaij 
 lached. The denude 
 ire carbolic or stroni 
 ivolved, they must 
 itterwards the child 
 lie with Huids; the 
 tiseptic lotions, sue! 
 [yceride (i in 20), orl 
 chlorate of potash (i| 
 lorate of potash, dil 
 lona, may be adminl 
 iinine. In the mo-stf 
 
GANGRENE 
 
 69 
 
 arious specific processes. This subject is fully discussed in 
 hapter XVII. 
 
 (/) Cancrum Oris and Noma. — Cancrum oris is an infective 
 igrenous stomatitis, aflfecting young children living in squalid 
 iiiroundings in over-populated districts of large cities. Tlie 
 itients are always in a low state of health, and frequently con- 
 escing from one of the exanthemata, particularly measles. 
 arious special organisms have been described from time to time 
 s responsible for cancrum oris ; but it appears that any of the 
 lany forms found in the mouth may be present, and probably 
 le streptococcus pyogenes acting in conjunction with various 
 iprophytic bacilli is the most important. The process starts in 
 n abrasion of the mucous membrane, which, being infected from 
 diseased or dirty tooth, becomes inflamed and gangrenous. A 
 ml ashy-grey pultaceous slough forms on the inside of one of the 
 heeks, and from this the most offensive discharge is poured into 
 le mouth and swallowed, the breath in consecjuence being 
 tensely f(jetid. The gangrenous process gradually spreads both 
 iperficially and deeply ; the cheek becomes swollen, shiny, and 
 inse, and, should the process extend through its whole substance, 
 lack slough appears on its outer aspect, and gradually increases 
 i/.e. In the worst cases, the adjacent bones of the face may 
 affected and die, and the tongue, palate, and even the fauces, 
 :iv also be involved. 
 
 the general phenomena are those of a severe sapra^mia, since 
 
 t only are the toxic products swallowed, but they are also 
 
 sorbed by the lymphatics, and may be inhaled, in the latter 
 
 5e gi\ mg rise to septic pneumonia. Moreover, the patient runs 
 
 considerable risk of developing pyaemia, from implication of the 
 
 cial or other veins in the necrotic process, whilst infective 
 
 pticannia may also supervene. Rigors and high fever often 
 
 cur early in the case, but death is usually preceded by symptoms 
 
 collapse and coma with a subnormal temperature. 
 
 The Treatment must be prompt and energetic if the child's life 
 
 to be saved. The patient should be at once ana-sthetized, and 
 
 i the pultaceous slough scraped from the interior of the mouth 
 
 means of X'olkmann's spoon, until healthy bleeding tissue is 
 
 ached. The denuded surface is then freely rubbed over with 
 
 re carbolic or strong nitric acid. If the bones of the face are 
 
 volved, they must be removed, as also any offending teeth. 
 
 ftcrwards the child should be well fed up, and of course for a 
 
 lie with fluids ; the mouth is to be frequently washed out with 
 
 tiseptic lotions, such as a solution of sanitas (i in 10), boro- 
 
 yceride (i in 20), or permanganate of potash, or with a gargle 
 
 chlorate of potash (10 grains to i ounce). A mixture containing 
 
 lorate of potash, dilute hydrochloric acid, and infusion of cin- 
 
 ona, may be administered for a few days, and then iron and 
 
 linine. In the most severe cases the same treatirent should be 
 
 0: 
 
 .# 
 
70 
 
 A MANUAL OF SURGERY 
 
 adopted, even if the whole thickness of the cheek has been en*'^^^' or cold water, 
 crouched on ; loss of substance must be made {^ood by subse(]uenfte manipulator, wh 
 plastic work. Necessarily, the cicatrization following this cie»H^n'> the temperatu 
 structive process results in a good deal of permanent impainnenWi'"^'^ on, a small am 
 to the movements of the jaw. Bxcessive pain or coi 
 
 Noma is the name given to a similar process occurring ahouBl tlie part. If actu, 
 the genital organs of children, especially the vulva. The TreatBf"^^:''^^! ^nd kept as( 
 ment is practically the same, except that here it may be possilAtinite line of separ? 
 to immerse the patient in an antiseptic bath, thereby diluting tlil -• Burns and Scal( 
 toxic products, and possibly preventing the necessity for havin^nety of wound, nc 
 recourse to more serious surgical procedures. 
 
 (e) For Carbuncle and Boil, see Chapter XIII. 
 
 IV. Gangrene from Thermal Causes. 
 
 I. Frost-bite.- This condition is not very fre(]uently seen ij 
 this country, but is by no means uncommon in regions where 
 winter is more severe. It occurs in those who are exposed to (« 
 cold, and the symptoms are induced more readily if a high wini 
 is blowing, the heat of the body being therei^y more quickly dij^ 
 persed. It may originate in one of two ways : 
 
 (a) From the direct effect of cold on the tissues, which bccoiij 
 shrunken, hard, and of a dull, waxy appearance. No pain 
 experienced in the freezing jirocess, so that 
 
 will by the ac'ion o 
 ', or direct contact w 
 e action of boiling v 
 irf,'ases, the diflferenc 
 I'liction between roas 
 which boil at a 
 icreasingly severe re« 
 Tile E ffect s of b urn; 
 tensity, ancnHe"c[Sra 
 l)i irn were des c ribes 
 ^ retained wilFl 
 a scorclT'or sTiperfic 
 n of tissruer the pn 
 one to ulceration fc 
 peated, as by people, 
 e, the skin becom 
 
 n 
 
 oi 
 
 onlookers! are nioi 
 likely to recognise the condition than the individual hinisel 
 The extremities of the body, where the circulation is a litt| 
 sluggish, and exposed parts, are chieHy liable to be attacked, ai 
 thus the nose, ears, fingers, and toes are most often invoht'd. 
 is more likely to occur in the young and in old people, whoi 
 vita' powers are not very great. Gradually the part shrivels iii 
 
 turns iilack, and is either absorbed or separated by a process ■ijuisitely sensitive^n( 
 ulceration with or without suppuration. The most marked teatiMnsei|uently this is 
 of gangrene from frost-bite is the more extensive implication 
 the superficial parts on account of their greater exposure. 
 
 (h) Fnmi the suhseqiicut iuflawuiatioii that arises in parts wliii 
 though frozen, are not immediately killed. The thawing of siii 
 structures is accompanied by the severest pain, and the proloiij;! 
 ana-mia causes sucli a lowering of the \itality of the vessel w 
 that the re-admission of the circulation is only too likely to 
 followed by an acute inllammation, which terminates in necroi 
 from compression of the vessels by the rapidly-formed exuclatu 
 If it escapes actual death, the part remains red, congested, a 
 painful for some time, and superficial ulcers may even develo| 
 eventually, however, it recovers 
 
 Treatment. — The frozen parts must be thawed very gradiialB/; the muscles are al 
 and the blood admitted into the tissues slowly, if inHaniiiiaMolt' Ijnib is charred ■ 
 '(angrene is to be avoided. They should be gently rubbed wi^lm^ can only occu 
 
 }l\tlkma ab igiie). ] 
 |e cutis, and a bleb 
 picle is removed, th 
 the third de/^'rre th 
 litis vera, but the tips 
 
 jriictures of the skin 
 le hair follicles — rem 
 W the healing p 
 je integument is vet 
 lithelial elements fr 
 |toiin not from the e 
 the cutaneous enve 
 Jle foci scattered o\ 
 I scarcely visible, an 
 elastic from com 
 t 
 
 
 the fourth degree 
 jstroved, as well as 
 
GANGRENE 
 
 7' 
 
 y. 
 
 now or cold water, and warmed by l>ein^ held in the hands of 
 le manipulator, whilst the patient should he placed in a cool 
 loiii, the temperature of which is slowly raised. As reaction 
 iiR'S on, a small amount of warm drink may be cautiously given. 
 xcessive pain or congestive (jedema may be limited by elevation 
 i tlie part. If actual gangrene occurs, the dead tissue must be 
 ndered and kept aseptic, and the case carefully watched until a 
 etinite line of separation has formed. 
 
 2. Burns and Scalds. — These may be considered as a special 
 ariety of wound, not necessarily ending in gangrene, brought 
 bout by the ac'ion of heat ; burns, either by the close proximity 
 or direct contact with, Hame or heated solid bodies ; scalds, by 
 ;e action of boiling water, superheated steam, or other hot iluids 
 lipases, the difference in the effects being comparable to the dis- 
 nction between roasting and boiling. Naturally, iluids such as 
 . which boil at a higher temperature than water, produce 
 reasingly severe results. 
 Tlie E jGFec ts of _b urns a nd sca l ds x ivry with the source of heat, its^ 
 it ensity, and the^duralion o t Its appli cation . t:)ix diff erent degre es 
 Imrn were desc ribed by ' Dupuytren. ;ind hi s classific ation may 
 11 ITe retained wiBi a dvant age. T he /lyst^cgy cc con sisIiT me rely. 
 a scorch or supeTficial congestion of the skin, j4iitliQUt_!Je5?truc- 
 n of tiss^uer the T^aff may, however, remain red, painful, and 
 one to ulceration for a time. Should the scorch be often 
 peated, as by people constantly warming their legs before the 
 , the skin becomes chronically pigmented and indurated 
 thiiiia ah ignc). In the second degree the cuticle is raised from 
 t' cutis, and a bleb or blister results. When tliis bursts, and the 
 litiile is removed, the cutis vera, red and painful, is exposed below. 
 the third degree the cuticle is destroyed, as is also part of the 
 Ills vria, but the tips of the interpapillary processes, including the 
 jiiisitely sensitive nerve terminals, are laid bare and left intact ; 
 insei|uently this is a most painful form of burn. The deeper 
 iiciures of the skin — viz., the sweat and sebaceous glands, and 
 ; hair follicles — remain untouched, so that, although the surface 
 ring the healing process becomes covered with granulations, 
 le integument is very rapidly replaced, since there are so many' 
 itliL'lial elements from which it can grow. The cuticle is able 
 form not from the edge only, as must occur wlierexer the whole 
 the cutaneous envelope is destroyed, but also from innumer- 
 ie foci scattered over the wound surface. The resulting scar 
 scarcely visible, and undergoes no contraction ; it is supple 
 1(1 elastic from containing all the elements of the true skin. 
 the fourth degree the whole thickness of the integument is 
 troyed, as well as part of the subcutaneous tissues. In the 
 'ii the muscles are also encroached upon, whilst in the sixth the 
 ole limb is charred and disorganized. In the last three forms 
 ling can only occur by removal of sloughs and the formation 
 
 C 1 
 
i 
 
 7» 
 
 A MANUAL OF SURGERY 
 
 of a cicatrix, which by its contraction may lead to subse(iue 
 deformity. 
 
 The Local History of a burn may be described in three staj^'e i^' 'o the auto-digestio 
 
 corresponding to the three stages through which an ulcer or 
 lacerated wound passes : (i) The stage of destruction or burnin 
 the various degrees of which have been just alluded to ; (2) t! 
 stage of inflammation and sloughing, whereby the dead tissue 
 
 removed, and the wound converted into a healthy granulatir e structures in close c 
 
 nched-out loss of s 
 ^animation, and their 
 
 bich has been diinini 
 ssel. They probabl)/ 
 some irritating subst, 
 the burnt tissues wh 
 
 sore ; (3) the stage of repair, which follows the course desci 
 elsewhere (p. 171). There are no special characteristics of the 
 processes whicli call for particular note. 
 
 The General or Constitutional Conditions which correspomi 
 these three stages re(]uire a little fuller notice. 
 
 I. As an immediate result of the burning and destruction 
 tissue, the patient lies for a time (greater or less accordin!,' 
 circumstances) in a state of shock. It is important to reco-^nii 
 that the intensity of this depends not so much on the depth oft 
 burn as on its extent, so that total charring of a limb will pro 
 
 at any rate of produ 
 not necessarily fatal. 
 j. When healthy rep; 
 pt aseptic, no abnoi 
 esent, although there 
 iinia. Where, howe 
 ily, this tendency wil 
 ly even die of exhai 
 lyloid changes in the ^ 
 Causes of Death from ] 
 
 ably cause less depression of the system than an extensive supf ftatal event is usually 
 ficial scorch, especially if the latter involves the abdomen. Wh li noxious fumes oft 
 at all prolonged, it is also in part due to the absorption of tn\ ly perhaps be adjuv 
 products from the burnt tissues. During this stage the intern wised. Within the fi 
 viscera, especially those connected with the portal system, becor hp^a from toxa-mia ; 
 intensely congested. 
 
 2. Whilst the separation of the sloughs is being effected, 
 period of inflammatory fever follows, usually of an asthenic tv] 
 and the patient is likely to be worn out unless he is cartti 
 looked after. Any and every form of internal complication in 
 arise during this stage, which usually lasts from four to fourt 
 
 days. Congestion of the brain or lungs is not uncommonly see cm with collodion. > 
 
 but the gastro-intestinal tract is that, perhaps, most genera 
 and seriously affected. Tlie nnicous membrane of the stoiii;i 
 and intestines becomes engorged with blood, leading to vomiti 
 and diarrh(ra, whilst ulceration, or even peritonitis, may siipi 
 vene. 
 
 During the later days of this stage the curious setiuela km 
 as Perforating Ulcer of the Duodenum is liah/le to occur, althou 
 it is admittedly not at all common. The presence of an ulcer 
 the duodenum is suggested by pain in the epigastrium after fi 
 perhaps some \omiting, which may be blood-stained, and possi 
 
 the passage of a motion containing a good deal of altered bino iked in a solution of pi 
 
 but occasionally the first sign of such mischief is the sudd 
 
 collapse of the patient, followed by death, with or \vith( 1 of salicylic or ster 
 
 peritonitis, owing to perforation or excessive ha-morrha sing is produced, w 
 
 (Chapter XXXI. ). The bleeding generally arises from erosinn en it is reapplied, 
 
 the superior pancreatico-duodenal artery. The ulcers usua ch pleased with the r( 
 
 occur in the second part of the duodenum, close to the entrar l\here the burn incku 
 
 of the common bile-duct. In appearance they present a cleai wved with as little ( 
 
 niplications, ulceratio; 
 ii;e, from exhaustion i 
 children is always mo 
 Treatment. — In the si 
 t is retpiired is the \ 
 Jting them over with 
 
 (I be washed anti^ 
 Dw the contained seru 
 sted with boric acid 
 iron-oil (i.e., a mixtur 
 ler) is also much usee 
 tiseptic, although by 
 
 I to 10) this can 
 ihorities have comme 
 cases of burns whei 
 !troyed ; the vesicles 
 
 ter), is applied to the 
 
GANGRENE 
 
 73 
 
 m 
 
 nched-out loss of substance with little or no surrounding 
 lammation, and their distinct liniitation suggests that they are 
 e to the auto-digestion of a distinct arterial area, the vitality of 
 lich has been diminished by a preceding thrombosis of the 
 ssel. They probably result from thr elimination by the liver 
 some irritating substance derived from septic or other changes 
 the burnt tissues which is capable of inducing thrombosis in 
 e structures in close contiguity to the entrance of the bile-duct, 
 at any rate of producing ulceration. Of course the condition 
 not necessarily fatal. 
 
 3. When healthy repair is occurring locally, and the parts are 
 ipt aseptic, no abnormal constitutional condition should be 
 tsent, although there may be a certain amount of asthenia or 
 aiiiia. Where, however, the wounds are septic and suppurating 
 icly, this tendency will be much more marked, and the patient 
 iy even die of exhaustion, combined with hectic fever and 
 ■yloid changes in the viscera. 
 
 Causes of Death from Burns. — If an individual is burnt to death, 
 e fatal event is usually occasioned by asphyxia from the smoke 
 noxious fumes of the (ire ; shock and syncope from fright 
 perhaps be adjuvants, especially if the heart is weak or 
 eased. Within the first few days death results from shock or 
 pse from toxa-mia ; in the second stage, from sepsis, internal 
 plications, ulceration of the duodenum, etc. ; in the third 
 i;e, from exhaustion or intercurrent maladies. The prognosis 
 ildren is always more unfavourable than in adults. 
 reatment. — In the superficial scorches without vesication, all 
 i is refpiired is the protection of the aflected parts either by 
 ting them over with boric acid powder or Hour, or by painting 
 111 with collodion. Where blisters have formed, the cuticle 
 iikl be washed antiseptically and then punctured, so as to 
 the contained serum to escape, and then the area should be 
 ltd with boric acid powder, and covered with aseptic wool, 
 irron-oil (i.e., a mixture of equal parts of linseed-oil and lime- 
 ter) is also much used, applied on lint ; it is, however, not an 
 iseptic, although by adding a small proportion of eucalyptus 
 I to 10) this can be corrected. Latterly some French 
 thorities have commended the use of picric acid as a dressing 
 cases of burns where the cutis vera has not been entirely 
 troyed ; the vesicles are punctured, and then a piece of lint, 
 iked in a solution of picric acid (jo grains to i ounce of sterilized 
 Iter), is applied to the burnt surface, and over this, in turn, a 
 1 of salicylic or sterilized wool is bandaged. Thus a dry 
 :ssing is produced, which may be left /;/ situ for some days, 
 en it is reapplied. We have used this plan, and have been 
 idi pleased with the results. 
 
 iVht'ie the burn includes deeper structures, the clothes must be 
 noved with as little dragging as possible, being cut away if 
 
 n ' i 
 
74 
 
 A MiNUAL OF SURGERY 
 
 f'l 
 
 necessary ; the damaged tissues are then well bathed with sonj 
 antiseptic, such as carbolic lotion (i in 40), and covered ii[) 
 rapidly as possible with lint soaked in eucalyptus oil or weJ 
 carbolisedoil (i in 40). In some cases, where the skin and sin fa] 
 are exceedingly dirty, it is well to anacstheti/e the patient, ad 
 then to cut away parts which must obviously slou^ii ^ 
 thoroughly purity the wound, which is covered with prottn tiv 
 and dressed with cyanide f^au/.e, or some such material. 
 
 At the same time, the f^eneral condition of the patient must 
 be overlooked ; he is possibly in a state of considerai)le slio(| 
 and therefore should be put to bed and covered with warm blank| 
 or ruf,'s, whilst perhaps a little warm stimulating fkiid is I 
 ministered ; in bad cases an intravenous injection of hot salil SEPSIS, INFEOTIC 
 solution is advisable, and it may often be repeated with advaiitaT 
 more than once. In the case of children with very exlcns 
 burns, it is sometimes useful to put them into a hot bath, I 
 which some eucalyptus oil, if obtainable, has been added ; W^ '^ ^ term, soiuew 
 clothes are then removed or cut away, and the patient allowedB""' '^^ ^^^^^ '^'is becom 
 remain for some time, or until the shock has subsided, in W}' '^^ ^" interfere wii 
 warm water, which should, if necessary, be replenished. '•^•^'^ 'in operation wc 
 wounds are then dressed, and the little patient removed to liS "^.^'l^^ ^' the skin, in 
 It may be desirable to repeat the immersion at every dressin;,'.^'^'''^'-^' hands of the 
 
 When a limb has been hopelessly charred or burnt to the hoi '^ "^'^y j^^^o deveic 
 it is useless to retain it, and amputation through the neaiM '"^ abrasion, and tl 
 healthy tissues should be undertaken at the first favounil'!'*^'''" •''yphilitic or cai 
 
 /.. 
 
 IS no essential part of 
 he organisms presen 
 are of two main type 
 'cially the J'rotais vii. 
 oils forms of Sairina 
 r certain circumstan 
 iry pyogenic bacte 
 tococci. 
 
 f method of action ( 
 
 opportunity. 
 
 When the next stage, vi/,., that of inflammation and slouj^'l 
 has been reached, the only reciuisite is to keep the parts ase 
 assisting the natural processes of repair by warm moist appj 
 tions, and snipping away sloughs as they loosen. Gencm 
 attention to the ordinary rules of personal hygiene, and a sir 
 diet, are all the precautions that need be taken. 
 
 When the stage of cicatrisation is reached, the granula 
 
 wounds are treated on general principles. The granulations oy, , - 
 
 become prominent, and stimulating applications, such as toiicW'^*^^'^"^^''' or non-pa 
 them with lunar caustic, may be necessary. In large wouM-'' ^^'^ ''^^'^^^' "r in pas 
 healing should be assisted by skin-grafting, according to 'riiiuisjl' '. ^''^'y "''^y occasi 
 method ; unless some such proceeding is instituted, the woiiiiB' "' '^^'^ 'ii'e rapi 
 likely to become chronic, and healing may be delayed iJeiiB""^' ^'lerefore, that 
 indefinitely. W "'^^n one in which 
 
 ^, so that absolute 
 iimportant preventiv 
 jiien once admitted 
 py, causing putrefac 
 |iiim present, and . 
 kal substances, upon 
 j'. whether local or g 
 F^cible material is pr 
 
CHAPTliR V. 
 SEPSIS, INFECTION, AND INFECTIVE DISEASES. 
 
 Sepsis. 
 
 lis is a term, somewhat loosely applied, to indicate that a 
 
 111(1 or sore has become infected with niicro-orf;anisms in such 
 
 ay as to interfere with healthy reparative action. When it 
 
 jives an operation wound, it is due to contamination from a 
 
 |v state of the skin, impure instruments, lif^Mlures or sutures, 
 
 erilised hands of the surj^eon or assistant, a faulty dressing, 
 
 It may also develop in connection with any unprotected 
 
 or abrasion, and the offensive odour which accompanies 
 
 ected syphilitic or cancerous sores is simply due to this cause, 
 
 is no essential part of the causati\e affection. 
 
 e organisms present in septic affections vary considerably, 
 
 are of two main types : (a) Various non-pathogenic microbes, 
 
 cially the Proteus viilf^'ayis, P. Haiisiii, Miirccocciis pyocU<iiosus, 
 
 Dus forms of Sayciiur, Bacillus siihtilis, Bac. acidi lactici, and, 
 
 r certain circumstances, the Bac. coli communis, and {h) the 
 
 [i;iry pyogenic bacteria, especially the staphylococci and 
 
 itococci. 
 
 be method of action of these organisms is somewhat diverse. 
 le former, or non-pathogenic group, can only develop in dead 
 ts or fluids, or in passive material sucii as blood-clot, pus, or 
 they may occasionally gain an entrance to the general 
 iition, but are rapidly destroyed, and do no harm. It is 
 us, therefore, that a dry wound is less likely to become 
 than one in which there is much exudation of blood or 
 m, so that absolute ha^mostasis and good drainage are two 
 important preventive measures. 
 len once admitted to the part, the organisms rapidly 
 ply, causing putrefaction or other changes of any suitable 
 iiini present, and thus produce irritating or poisonous 
 ical substances, upon the action of which the symptoms of 
 :>, whether local or general, depend. If a large (Quantity of 
 cible material is present, the wound or part may become 
 
 111 
 
IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 1.0 
 
 I.I 
 
 IfrlM IIM 
 " *" lllllJi 
 
 12.0 
 
 1.8 
 
 
 1.25 
 
 1.4 
 
 1.6 
 
 
 ^ 6" — 
 
 
 ► 
 
 Photographic 
 
 Sciences 
 
 Corporation 
 
 23 WEST MAIN STMCET 
 
 WEBSTER, NY 14580 
 
 (716) 872-4503 
 
 
^ .<' if.. 
 
 
 9 
 
 w- 
 
 Vx 
 
 '"/, 
 
 ^ 
 
il i 
 
 76 
 
 A MANUAL OF SURGERY 
 
 very offensive, and a sloughing process may ensue as a result 
 the irritating local action of the toxins, whilst at the same ti 
 general toxic symptoms are manifested, varying in severity w 
 the dose absorbed. 
 
 [h) The latter group of true pyogenic bacteria are capable 
 growth in a similar manner, but in addition are able to in\<i^ 
 and develop in the tissues of the body, and so may give rise 
 spreading inflammation, such as erysipelas or cellulitis, and 
 general infective diseases, such as pyaemia or septicaemia. T 
 is most likely to happen when the wound is dry and contains 
 putrescible material. The lips of the wound become puffy 
 swollen, and if there is much tension, the pain becomes sev 
 and throbbing. The temperature rises, and there may be a rig| 
 Occasionally the process starts in the deeper parts of the woui 
 and then nothing may be obvious on the surface for a few da] 
 except perhaps a little fulness and some tenderness on pressure, 
 
 The local treatment of septic lesions consists essentially in 
 relief of all tension, the removal, as far as possible, of 
 putrescible material, and the appUcation of warmth and moist 
 to the part, if superficial, to encourage the local reparative activ 
 of the tissues. Stitches must be immediately removed, and 
 wound widely opened up, care being taken to ascertain whet 
 or not the pus has burrowed, as if so it must be followed 
 Sloughs may be cut or scraped away under an anaesthetic, and 
 putrid or putrescible material removed, if possible. 
 
 The parts are then thoroughly washed out with some antise 
 solution, and may advisably be treated with peroxide of hydro| 
 or liquefied carbolic ?^id ; but it must not be forgotten thatwh 
 the organisms have invaded the living tissues, no antiseptic] 
 likely to reach them, at any rate, not without also destroying 
 tissues. The wound is then lightly, though thoroughly, pac 
 with gauze soaked in an emulsion of iodoform and glycerine, 
 if there is a deep cavity, it may be desirable to introduci 
 drainage tube, especially when suppuration is present, since 
 does not easily escape along a gauze drainage wick. It is 
 advisable to pack the gauze into the wound too tightly, as thej 
 by the escape of secretions may be prevented, and pain 
 tension may ensue, whilst possibly bacteria may be driven i 
 the tissues cmd give rise to further trouble in the nature 
 erysipelas or cellulitis. Warm, moist dressings, such as an ai 
 septic fomentation, are then applied, or it may be desirable eit 
 to immerse the limb in a hot antiseptic bath for an hour or tj 
 daily, or to keep it in for some days. At the same time the bo^\| 
 must be freely opened, and the general health of the patient ci 
 fully watched. 
 
 The General Conditions which result from the absorption of 
 toxins or ptomaines formed as a result of sepsis have bi 
 described under three headings, viz. : 
 
 SEPSIS, INFECTIO 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 77 
 
 Hectic Fever (p. 37), in which a minimal dose is absorbed, 
 d over a long period of time. 
 
 Septic Traumatic Fever is due to the absorption of a some- 
 larger amount of the poison after an operation or injury, 
 li is followed by septic inflammation. A burn or compound 
 ure which is not rendered aseptic is always accompanied by 
 , ranging from 102° to 104° F, for some days, until the wound 
 curely sealed off by the development of granulation tissue. 
 n once this has occurred, the fever usually disappears, unless 
 c material is retained under pressure. The actual phenomena 
 ected with such an attack are in no ways peculiar. 
 Acute Sapraemia, or Septic Intoxication, results from the 
 rption of a large dose of toxic material. This condition was 
 ong confounded with true infective septicemia, and even 
 though clearly distinguished pathologically, a clinical dis- 
 ion between the two is not always possible, except by await- 
 he result. Sapraemia is essentially a toxaemia, or condition 
 to chemical poisoning ; the blood is not infective — i.e., if a 
 1 quantity is inoculated into anothei' individual, the disease 
 )t reproduced, or, to put it in another way, the symptoms are 
 ;tly proportionate to the dose. Any condition in which there 
 large mass of putrefying tissue or fluid from which absorp- 
 can occur may lead to sapraemia — e.g., a portion of decom- 
 ng placenta in the puerperal uterus, the existence of septic 
 under pressure in the peritoneal cavity, a joint, or elsewhere ; 
 mass of putrefying blood-clot, say, in the pleural cavity after 
 ;netrating wound. 
 
 lie Symptoms usually commence, two or three days after the 
 >e has come into operation, with a severe rigor, followed by a 
 ntained high temperature, although sometimes it is subnormal 
 lie more serious cases. This is associated with loss of appe- 
 al dry tongue, a quick pulse, rapidly becoming weak, severe 
 Jache, and nocturnal delirium of some intensity. The patient 
 t first constipated, but vomiting and diarrhoea may ensue from 
 :ro-intestinal irritation, followed by fatal exhaustion and 
 apse, or he may become comatose and unconscious for some 
 ; before death, according to whether the toxins act chiefly 
 n the alimentary system or upon the cerebral centres. 
 jpncea, from pulmonary congestion, and albuminuria, also 
 iir. Should, however, the putrefying mass be removed in 
 e, the fever will cease as by magic, the tongue cleans, the 
 etite returns, the headache vanishes, and in twenty-four hours 
 patient feels a different individual. 
 
 'ost-mortem Appearances. — Decomposition takes place early, 
 )r mortis is feeble, and cadaveric lividity well marked, espe- 
 ly along the lines of the superficial veins and posteriorly. The 
 x\ coagulates imperfectly, and is dark and tarry in colour ; if 
 wed to stand, the serum which separates from the corpuscles 
 
78 
 
 A MANUAL OF SURGERY 
 
 :;i 
 
 
 is much stained from the breaking-up of the red blood-cells wl 
 occurs in all septic and infective cases. This condition explg 
 the amount of cadaveric lividity, and also the post-mortem st{ 
 ing of the endocardium and tunica intima of the larger vessj 
 wliich is such a marked feature in these cases, and which 
 formerly supposed to result from a diffuse arteritis. Most of 
 serous cavities contain a certain amount of blood-stained fluid,; 
 under almost all the serous membranes are well-marked peteclj 
 especially under the pericardium and pleura. The lunj^^s 
 deeply congested, particularly at the back, and very oedematoj 
 the liver, spleen, and kidneys are enlarged, pulpy, soft, and cj 
 gested, notably the spleen. The epithelium of most of 
 secreting glands, if examined microscopically, gives evidenc^ 
 cloudy swelling. 
 
 The Treatment of acute sapra^mia must be chiefly directedl 
 the local cause. General treatment is merely symptoma| 
 Possibly a good purge may be advisable in the early stages, 
 in the later a supporting and stimulating plan of treatment m| 
 be adopted. Recently it has been proposed to deal with 
 acute toxaemia of peritonitis and similar conditions by the 
 peated injection into the veins of large quantities of saline sq 
 tion (3i. ad Oi.), and excellent results have been obtained by 
 means, the injections being followed by diuresis and diarrh(| 
 which presumably assist in the elimination of the poison, 
 also on Septicaemia, p. 92.) 
 
 Infection. 
 
 An infective process is one due to the activity of miq 
 organisms, the great majority of which are capable of develop! 
 in living tissues — the true pathogenic bacteria or parasites. SiT 
 find an entrance into the body in many ways, as through 
 healthy skin, or by the mucous membranes of the alimentj 
 canal, respiratory tract, or genito-urinary apparatus, or throif 
 wounds and abrasions ; and very often the manifestations! 
 disease differ widely with the channel of entrance. 
 
 A good deal of confusion has existed between the terms ' contagion i 
 ' infection '; and it is well to explain that by ' contagious ' is meant a disJ 
 which can only be transmitted to a healthy person by direct contact withi 
 infected individual, or by the direct transmission of the virus throufjhj 
 intermediate individual or object, provided that the organism has not multip| 
 outside the body. Syphilis is eminently contagious, either directly, from 
 person to another, or indirectly, as by smoking an infected pipe. Thus, 
 tagion is merely a limited type of infection. On the other hand, many infec| 
 diseases are due to organisms which can readily develop outside the body, 
 to the facultative saprophytes, but to these the term ' contagious ' shoukl 
 be applied. 
 
 Local Infective Processes are those caused at the spot of inocij 
 tion by the growth and development of the microbes. Afte| 
 period of incubation — which varies with different organisms, 
 
 SEPSIS, INFECTL 
 
 ring which we may im 
 
 licidal action of the 1 
 
 body — the bacteria 1 
 
 [eterious products of th 
 
 various degrees of inl 
 
 'hese inflammatory foe 
 
 lless rapidity by contin 
 
 the organisms may be 
 
 the bloodvessels in the 
 
 listitutional disturbance 
 
 to the absorption of 
 
 le diseases the general 
 
 some slight local n 
 
 mus and diphtheria. 
 
 Lsified in two divisions 
 
 Igeneral toxaemia, such 
 
 mild attack of goi 
 
 kEmic condition is well 
 
 Iria, etc., the characte 
 
 1 the different toxins. 
 
 lany of the organisms 
 
 ly also develop general 
 
 [utional affections. 
 
 moral Infective Froc( 
 
 plop and multiply in 
 
 »und person with the 
 
 disease. Many of th 
 
 to these general dis 
 
 the latter without e 
 
 jlain its origin. Sept 
 
 [ond stage of syphilis, 
 
 mata, are illustrations 
 
 ^Ve now propose to pa 
 ease met with in sur 
 [eady been dealt with 
 jlitis, erysipelas, sept 
 anthrax, and subsec 
 |ms grouped together u 
 
 us 
 
 Cellulitis (or, as it 
 lease characterized by 
 (the subcutaneous or 
 jcro-organisms, and ru 
 ]en to extensive gangrei 
 bausation. — The one 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 79 
 
 ng which we may imagine that they are struggling with the 
 nicidal action of the tissues, and establishing their foothold in 
 body — the bacteria begin to grow and multiply, and by the 
 iterious products of their activity cause irritation of the tissues 
 various degrees of inflammation. 
 
 "hese inflammatory foci may remain limited, or spread with more 
 less rapidity by continuity of tissue or along lymph channels ; 
 the organisms may be widely disseminated through the body 
 the bloodvessels in the shape of emboli. A certain amount of 
 stitutional disturbance may accompany these manifestations, 
 to the absorption of the toxins produced locally, whilst in 
 le diseases the general toxic symptoms (or toxaemia) associated 
 h some slight local mischief may be extremely severe, as in 
 inus and diphtheria. Hence local infective processes may be 
 isified in two divisions : [a) those in which there is but little or 
 general toxaemia, such as a soft chancre, a tuberculous abscess, 
 a mild attack of gonorrhoea ; and (b) those in which the 
 taetnic condition is well marked, as in erysipelas, tetanus, diph- 
 ;ria, etc., the character of the symptoms varying necessarily 
 th the different toxins. 
 
 Many of the organisms which are the causes of local infection 
 ly also develop generally in the system, and produce grave con- 
 tutional aflFections. 
 
 Beneral Infective Processes are those in which the organisms 
 
 relop and multiply in the blood-stream, so that inoculation of 
 
 luind person with the blood would almost certainly transmit 
 
 disease. Many of the bacteria producing local infection give 
 
 to these general diseases, and, indeed, in surgery we rarely 
 
 the latter without some local condition being present to 
 
 )lain its origin. Septicaemia, pyaemia, acute tuberculosis, the 
 
 ond stage of syphilis, anthracaemia, and probably the exan- 
 
 mata, are illustrations of general infection. 
 
 iVe now propose to pass in review the chief forms of infective 
 ease met with in surgical practice. Acute suppuration has 
 eady been dealt with (Chapter II.) ; it remains to discuss 
 ulitis, erysipelas, septicaemia, pyaemia, tetanus, hydrophobia, 
 i anthrax, and subsequently to deal with those more chronic 
 ms grouped together under the title ' infective granulomata.' 
 
 Cellulitis. 
 
 ellulitis (or, as it used to be termed, diffuse phlegmon) is a 
 ease characterized by the existence of a spreading inflammation 
 the subcutaneous or cellular tissues, due to' the activity of 
 eroorganisms, and running on to suppuration, sloughing, or 
 ;n to extensive gangrene, 
 lausation. — The one essential is the infection of the cellular 
 
8o 
 
 A MANUAL OF SURGERY 
 
 ii 
 
 ■'fi 
 
 tissues with some organism capable of multiplying locally 
 of developing toxic compounds, which not only act at the site 
 
 inoculation, but are also carried along the lymphatics, and , 
 
 their absorption into the general circulation give rise to toxa>n 'P^ ^"^ whole of the s 
 
 oinment symptoms, £ 
 pidly exhaust the p 
 curs beneath the ski; 
 
 phenomena. The entrance of the organisms may lesult from 
 operation wound which has been allowed to become septic, 
 from an accidental breach of surface which has not been render 
 aseptic, or even from the slightest graze, prick, or scratch. De 
 septic wounds which are not properly drained are amongst t 
 most favourable for the development of this condition, especia 
 
 if the general health of the individual is bad, or the surroundin [. ^ along the deej: 
 are of an insanitary nature. Wherever much loose cellular tissB" 
 is present, inflammatory phenomena readily supervene, owing 
 the absorption of septic material from neighbouring contaminat 
 structures, e.g., pelvic cellulitis arising from a septic uterus. 
 
 SEPSIS, INFEC 
 
 stroyed, although the 
 often possible to pass 
 icia over a considera 
 ips a part of the limb 
 a distance from the 
 lervening portion is bu 
 
 Bacteriology. — The less severe types are generally due to the Staphylocoi 
 pyogenes annus or albus, whilst the more severe are caused by the Stycptfltcl 
 pyogenes, which, as will be stated hereafter, is probably identical with 
 organism of erysipelas, and in these cases the cellulitis has more of an erysiJ 
 atous character. In many instances various forms of non-pathogenic organil 
 may accompany the above. The most acute manifestation of the diseJ 
 running on to spreading gangrene, is sometimes the result of infection with] 
 Bacillus of malignant (edema (p. 67). 
 
 lies, which may be in 
 is n ost likely to ( 
 animation following ; 
 ory or a bad compoi; 
 ms the patient runs a 
 dcjemia, or even pyset 
 freatmeut.— With the 
 illus of malignant ced« 
 [anisms which are rt 
 icidal properties of 
 ace careful attention 
 vent its occurrence tc 
 il punctured wounds 
 all penetrating injuri 
 exceptional risk of 
 ■oundings. Should in 
 kation of antiseptic fc 
 prevent their extensi 
 'd upon and the genera 
 lere is any tendency fo 
 Id be made into the b: 
 :iis and irritating disc 
 ed with iodoform anc 
 
 Clinical History. — The symptoms in any particular c 
 necessarily differ somewhat according to the site of inoculati 
 and the virulence of the causative microbes, and hence anyth 
 from a localized suppuration to the acutest form of spread! 
 gangrene may result. In a case of moderate severity, due t 
 prick or abrasion which has become infected, there is oftei 
 period of quiescence for a day or two, during which the viru 
 incubating and the site of inoculation shows but slight sign 
 inflammation, beyond being a little tender. The patient, tho 
 feeling somewhat seedy, is able to continue his work, bir 
 finally obliged to give up, owing partly to the increased pi 
 partly to his general condition. Fever will almost always 
 present to a greater or less degree, and in the more severe t 
 one or more rigors occur. Occasionally, however, the temp 
 ture is subnormal, owing to the depressing effects of the l 
 substances absorbed. The afTected part is found to be 
 tender, and infiltrated ; if superficial, it looks red and angry 
 feels brawny. The course of the case depends to a very I 
 extent upon the treatment adopted ; if freely incised, the proi 
 becomes limited, and although suppuration may occur, therj 
 but little sloughing, and hence repair is readily effected. If, hi 
 
 ever, it is left, or is merely poulticed, the process rapidly spreW^d two or three times 
 and may even involve the whole limb, which becomes greB^nal wall. Another 
 swollen, oedematous, red, and brawny. Intense pain and slW''se the wounds, after 
 lessness, accompanied perhaps with delirium, form the ■■'Continuous warm bat 
 
 I dressings are applic 
 
 of mackintosh in th 
 
 tlie parts moist and 
 
 a regime sloughing 
 
 limited.^ At the same 
 
 be maintained by th 
 
 lulants, whilst quinine i 
 
 pstreptococcic serum 
 
 f've agent, and the 
 
 prair 
 
 ing. The dos 
 
 e va 
 
SEPSIS, INFECTION AND INFECTIVE DISEASES 
 
 8l 
 
 linent symptoms, and these, together with the toxic fever, 
 lly exhaust the patient's strength. Finally, suppuration 
 rs beneath the skin, whilst the cellular tissue sloughs, per- 
 . the whole of the subcutaneous areolar tissue being thereby 
 royed, although the skin only gives way in places. Hence it 
 ten possible to pass a probe between the skin and the deep 
 a over a considerable area. Sometimes the inflammation 
 3 a part of the limb, the chief focus of mischief being found 
 distance from the original site of inoculation, whilst the 
 vening portion is but little affected. Occasionally the trouble 
 ads along the deeper areolar planes, involving muscular 
 es, which may be infiltrated with pus or may actually slough. 
 ; is n ost likely to occur when the disease is due to septic 
 mmation following a penetrating wound, such as a gunshot 
 ry or a bad compound fracture. In all these more severe 
 IS the patient runs a considerable risk of developing general 
 ic?emia, or even pyaemia. 
 
 reatment. — With the exception of those cases due to the 
 
 illus of malignant oedema, cellulitis results from the activity of 
 
 inisms which are readily destroyed, and over which the 
 
 micidal properties of the body have considerable control. 
 
 nee careful attention to the dicta of antiseptic surgery can 
 
 vent its occurrence to a very large extent. Abrasions and 
 
 all punctured wounds should always be carefully protected, 
 
 iall penetrating injuries disinfected, especially if the patient 
 
 5 exceptional risk of infection owing to his occupation or 
 
 oundings. Should inflammatory phenomena supervene, the 
 
 ication of antiseptic fomentations, such as the boracic poultice, 
 
 prevent their extension, whilst the bowels should be freely 
 
 upon and the general health attended to. Failing this, and 
 
 lere is any tendency for the inflammation to spread, incisions 
 
 d be made into the brawny tissues, so as to give exit to the 
 
 us and irritating discharges ; the wounds thus made are 
 
 ed with iodoform and stuffed with gauze, over which the 
 
 dressings are applied ; it is often wise to incorporate a 
 
 of mackintosh in the outer folds of the dressing, so as to 
 
 the parts moist and encourage a free discharge. Under 
 
 a regime sloughing may be entirely prevented, or, at any 
 
 imited. At the same time the patient's health and strength 
 
 be maintained by the administration of suitable food and 
 
 lants, whilst quinine is very useful internally. 
 
 iiistreptococcic serum (p. 89) has also been employed as a 
 
 ive agent, and the results hitherto obtained have been 
 
 raging. The dose varies from 5 to 10 c.c. (i c.c. = 11)^ 17), 
 
 ed two or three times a day beneath the skin of the back or 
 
 ninal wall. Another excellent plan of treatment is to 
 
 rse the wounds, after freely incising the infiltrated parts, 
 
 continuous warm bath, by this means diluting the toxins 
 
 6 
 
 jl 
 
 u: 
 
 
 ' ■ III-' 1 ; 
 
 ;■! Pi 
 
 'ill 
 
 ;ii^i? 
 
82 
 
 A MANUAL OF SURGERY 
 
 to such an extent as to render them innocuous. Warm wati 
 does perfectly well, although it may be boiled before use wi 
 advantage. Antiseptics are practically useless in checking t| 
 disease when once started ; the surgeon has to depend mainly i 
 relief of tension, the removal of toxic discharges, and the an 
 septic power of the tissues. 
 
 Special Varieties of Cellulitis. 
 
 SEPSIS, INFEC 
 
 apparent reason, altho 
 I occasionally results fn 
 
 glands and may origi 
 klling downwarcls alono 
 wration in the submaxilh 
 la certain amount of fever 
 'a inflamed ; it tends to 
 «'Je. even causing the 
 
 ptoms arise from pressu 
 lie inflammation to the g 
 Ihe supervention of dv 
 
 III -r-— "-"iiuii oi pv 
 
 [ally ends in sloughing < 
 {rowing widely if a free 
 Ivided; occasionally a 1 
 [vest constitutional and re 
 ■;;^.!;!!!!!^'"^*^'!°nary 
 
 re pus is threatening to k 
 i^outh ; but it is belter, i 
 '",• /"oi" to suppurati( 
 
 Jiants quinine, and plan 
 Wvic Cellulitis arises frc 
 
 r„ J? _. ^ ^°°.se cellular 
 se{ 
 
 hatic absorption from ^*eT 
 d from the ovary, Fallop 
 fn may also light up the ( 
 ral signs of delpinflam 
 " a tense, firm, painful 
 
 m 
 sv 
 
 Cellulitis of the Axilla not unfrequently follows an infected wound of 
 hand, such as occurs in the post-mortem room, and hence is not uncommoi 
 medical practitioners, students or nurses. It may also be caused by exten 
 from a primary axillary lymphadenitis. The tissues of the armpit beo 
 hard and brawny, the pain is severe, and the disease is liable to spread tow 
 
 the chest walls under or between the pectoral muscles; it may also tri— , ^- ".wv^naiy 
 
 upwards, and lay open the shoulder joint from sloughing of the capsule, anM T^.'^'-^^went must be proi 
 give rise to an acute arthritis. Extensive incisions are required in ord^JJJ^^ '. ''ne into the mids 
 prevent such complications, but respect must be paid to the important ve: 
 and nerves contained in the cavity. 
 
 Submammaxy Cellulitis is usually due to an extension of inflammation 
 the deeper parts of the breast, or perhaps from the cartilages or bones o; 
 chest wall. The areolar tissue beneath the breast becomes infiltrated 
 brawny, and the gland itself is lifted up, and somewhat swollen and tei 
 (See Submammary Abscess.) Free incisions must be made into the infi 
 area along the lower portion of the circumference of the organ. 
 
 Cellulitis of the Scalp results from a septic wound which has traversed| 
 occipito-frontalis aponeurosis, and opened up the subjacent layer of 
 areolar tissue. Suppuration extends to the limits of attachment of 
 
 structure, and hence abscesses are likely to point in the forehead just abovM"™^^ t° an indurated ma: 
 eyebrows, over the zygoma, or along the superior curved line of the occiB^ ,, ^ pubic arch. Absce 
 bone; in addition to the severe general disturbance, the patient runs a ri 
 necrosis of the skull and of various intracranial complications. 
 
 Cellulitis of the Orbit is not an uncommon sequela of penetrating wou 
 this region, owing to the difficulty of rendering them aseptic and of dr; 
 
 them. The whole of the orbital tissues become infiltrated and swollen, thL . „_ ^^^ ^^ 
 
 are oedematous, and the eyeball is thrust forwards. There is a conB'".^^'^"^ to the hypogast 
 
 able likelihood of the inflammation spreading to the meninges, owing Wr^ °'' J^ctal douches, shou 
 
 dura mater being continuous with the orbital periosteum through the for^JJ^^" \,*^® abscesses neec 
 
 by which the nerves and vessels enter. Necrosis of the orbital wall: 
 
 al.'io occur, whilst the eye itself may suffer either from an infective pai 
 
 thalmitis due to lymphatic infection, or from optic neuritis secondary to 
 
 ocular inflammation and pressure, or at a later date from optic nerve at 
 
 secondary to cicatricial contraction around the nerve. If the cellular 
 
 of the orbit sloughs, the subsequent movements of the globe may be 
 
 hampered, or indeed lost, whilst the lids may be drawn back to such an 
 
 as to prevent their complete closure. Treatment. — No penetrating 
 
 of the orbit ought to be closed if therf is any question of septic infei 
 
 indeed, it is often wise to slightly inciease iis size, so as to enable the 
 
 parts to be cleansed. Drainage must always be provided for, and in 
 
 cases this is best accomplished by stuffing it lightly w'.th gauze. If ce! 
 
 follows, the original wound must be opened up, and possibly fresh in 
 
 made either through the lids or through the fornix conjunctivae. Am 
 
 fomentations or poultices are then applied. If panophthalmitis supei 
 
 the eyeball must be incised crucially. 
 
 Submaxillary Cellulitis, or, as it is sometimes termed, Ludwig's .' 
 from the name of the surgeon who first called attention to it, is an i 
 inflammation of the cellular tissue beneath the deep cervical fascia 
 occurs in elderly and weakly individuals or in children, without, as 
 
 nallyorlntosomeofthev 
 Jmtractable forms of urin^ 
 Ipysmia are very likely to 
 
 |e surgeon may be called 
 uppurative stage, when 
 
 re 
 
 [above Pouparfs ligament! 
 
 es are divided to a^suffick 
 
 ••between the transversal 
 
 1 aside in order to reac 
 
 As soon as the subperi 
 
 and only blunt in.strum 
 
 «cess should be well wash 
 
 ler-opening through the vai 
 ^■nal obstruction may de 
 t>ces. and hydronephrosi 
 
 ysipelas is ^ specific a 
 [eve lopment of the Sin 
 F lymphatics of the 
 
 rane, with a decided 
 F loss of tissue, the 
 ^sorption of toxins dev 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 83 
 
 pparent reason, althouf^h probably it spreads from some buccal focus, 
 casionally results from inflammation extending beyond the capsule 
 inds, and may originate in disease of the middle ear, the mischief 
 ling downwards along the digastric muscle. It commences as a brawny 
 ation in the submaxillary region, which is tender, painful, and hot ; there 
 srtain amount of fever, and this increases /rt/'Z/ussiii with the extent of the 
 inflamed ; it tends to spread to the front of the neck and base of the 
 e, even causing the latter to protrude from the mouth. Dangerous 
 toms arise from pressure on important vessels and nerves, from extension 
 I inflammation to the glottis, causing oedema and consequent dyspncEa, or 
 the supervention of pyaemia owing to venous thrombosis. The process 
 ly ends in sloughing of the cellular tissue and suppuration, tne pus 
 wing widely if a free exit by incisions through the deep fascia is not 
 ded ; occasionally a large sublingual abscess may form, causing the 
 st constitutional and respiratory disturbance, whilst in rare instances the 
 may remain stationary and indurated for a considerable time. 
 e Treatment must be prompt and energetic ; a free incision is made through 
 ledian line into the midst of the brawny tissue, or along any line of safety 
 e pus is threatening to form. A sublingual abscess may be opened from 
 louth ; but it is better, if possible, to do so from below, so as to exclude 
 s. Prior to suppuration, fomentations may be used, whilst tonics, 
 ilants, quinine, and plenty of good food are needed. 
 
 [vie Cellulitis arises from extension of inflammation from the pelvic 
 ra to the loose cellular tissue ensheathing them. It may be due to 
 ihatic absorption from septic material contained in the uterus, or it may 
 id from the ovary, Fallopian tube, or prostate. Injuries to the bladder or 
 im may also light up the trouble. It is associated with all the local and 
 ral signs of deep inflammation, and often, indeed, with peritonitis, giving 
 to a tense, firm, painful swelling to be felt per vaginam or per rectum, and 
 itimes to an indurated mass of inflammatory effusion, dull on percussion, 
 [e the pubic arch. Abscesses may form in this effusion, bursting either 
 nally or into some of the viscera, or possibly in both directions, producing 
 tractable forms of urinary or faecal fistulae, whilst venous obstruction 
 lemia are very likely to develop. 
 
 surgeon may be called on to deal with such cases either in the early 
 purative stage, when rest, limitation of diet, small doses of opium, and 
 itations to the hypogastrium, conjoined perhaps with hot antiseptic 
 or rectal douches, should be adopted ; or at a later date, when pus has 
 and the abscesses need to be opened. An incision is generally made 
 bove Poupart's ligament and close to the pubic spine ; the abdominal 
 es are divided to a sufficient extent to enable the surgeon to work down- 
 between the transversalis fascia and the peritoneum, which must be 
 aside in order to reach the broad ligament, where pus is frequently 
 As soon as the subperitoneal tissue is opened, the knife should be dis- 
 and only blunt instruments or the fingers employed. The cavity of 
 iscess should be well washed out and efficiently drained, and possibly a 
 T-opening through the vagina may be required. 
 
 stinal obstruction may develop as a remote sequela from the contraction 
 Irices, and hydronephrosis may arise in the same way from pressure on 
 Eter. 
 
 Erysipelas. 
 
 _('sipelas is c^ specific and contagious infective disease due to 
 
 ivelopment of the Streptococcus evysipelatis (Feiileisen) in the 
 
 er lymphatics of the skin, and occasionally of the mucous 
 
 rane, with a decided tendency to spread and to recovery 
 
 loss of tissue, the constitutional symptoms being due to 
 
 sorption of toxins developed locally. 
 
 6—2 
 
 ape 
 
 n 
 
 '\i\' 
 
 * i ■ 
 
 n 
 
 1 1 
 
 '3 
 i I 
 
 ;h 
 
 h I 
 t ■ 
 
84 
 
 A MANUAL OF SURGERY 
 
 SEPSIS. 
 
 INFL 
 
 Und or showinir 
 fc'iUed idiopathir 
 esents a yellowish, 
 'idence of repair 
 
 I 
 
 per organisms, the 1 
 Ippears, about the foi, 
 .'"-eak open again, 
 P'l'ck-ened margin- 
 lie rash is cr«r,^?..ii ' 
 
 'he rash ,s generally o 
 sappeanng on 
 iffness or hurni 
 inse 
 
 There has been considerable discussion as to whether there 
 any difference between the erysipelas microbe and the ordinan 
 Streptococcus pyogenes found in spreading suppuration. T 
 microscopical characters are indistinguishable, and the growth 
 various reagents is very similar. Inoculation experiments, nion 
 over, certainly seem to indicate that they are closely allied specie 
 and the majority of bacteriologists consider them to be identical 
 the differing effects depending merely on the method of inocul 
 tion and the virulence of the particular organism. The chii 
 objection to this theory is the great difference which exists betwe 
 the ' infectiousness ' of erysipelas and cellulitis. No surgeon c; 
 complain of the presence of the latter in his wards ; none pen 
 the presence of the former, except on compulsion. 
 
 In former days three varieties of erysipelas were described, vi 
 the cutaneous, cellulo-cutaneous and the cellular. In the first ti 
 infection is probably limited to the lymphatics of the skin ; in t 
 
 last (cellulitis), the subcutaneous lymphatic spaces are primarW j , -- *^^a m 
 
 involved, whilst the cellulo-cutaneous variety is probably due ■ • ,,. ° /? ^^^ regions ii 
 an infection of both. An idiopathic form used also to be describM ^ ^ ^^^gnt brownish 
 in which the disease starts without any apparent local origin ; m ^ cases it 
 when one considers that infection may occur through the slighti 
 abrasion, and even through sound skin or mucous membrane, a 
 that the cocci do not exist, as a rule, in the blood, it is evidi 
 that the theory of local infection is in all cases the more proba 
 
 The Causes of erysipelas may be briefly stated as follows : (i.) 
 existence of an abrasion or wound in most cases, and particul 
 of an unprotected septic wound. Thus, it is not uncommon to 
 it associated with neglected scaip wounds or with those conim 
 eating with the mouth, (ii.) A weak, depressed state of the 
 stitution, as from alcoholism, vicious living, diabetes, albu 
 uria, etc. Some people, moreover, seem naturally predisposei 
 the disease, particularly plethoric and gouty individuals, and 
 attack rerders the subject more liable to recurrence aft 
 short period of immunity, (iii.) Bad hygienic surroundings 
 most important additional factor in its production, especially 
 crowding in hospitals and bad ventilation. But these ar 
 merely predisposing conditions ; the only exciting and absi 
 cause is (iv.), the infection with the specific micro-organism, w 
 is very widely diffused in Nature. When once an entrance] 
 been effected, the cocci develop in the superficial lymph cha 
 producing a transient inflammatory condition of the skin, ai 
 concurrent pyrexial state of the individual from the absorpti 
 specific toxins. 
 
 The Symptoms of the disease are usually ushered in by a 
 
 press L 
 
 structures, 'sucir 
 "" '"ay he very sever, 
 
 '^areolar tissues, such 
 y tlien attain conside 
 ivance more or Jess ra 
 
 does 
 
 pan interval, and the 
 |te thickened. Vesicle 
 m, which speedily 1- 
 mon, except in lax r 
 jcasionaJIy, from the s 
 
 i;^ of vitality of the tid 
 isJough, especially abc 
 
 Neighbouring 
 'painful, and this 
 
 ma' 
 
 has not appeared. 
 pmic complications 
 
 "merely shoA\| 
 
 pts, and 
 B'tiinon for 
 
 si 
 
 .. fk . • ^^^ tempe 
 I that IS of grave s: 
 type, the pulse fu 
 
 'ater on the pulse bee 
 
 httenng delirium an 
 
 km IS usually a we 
 
 l^ut this IS due to 
 
 i'on, unless meningit 
 
 [ >s most variable, last 
 
 apses are not uncom 
 
 loccurs in predisposed 
 
 chill, scarcely amounting to a rigor, and by a period of heacMj ,, "^^^^a of the sui 
 and malaise for about twenty-four hours, with some degiMr ^ features to bee 
 pyrexia. These symptoms are followed by the development. |?' ^"^ even absce 
 brierht. rosv-red rash, soreadintr either from the marLnn A., ^ncy 
 
 . . to recurrencf 
 
 pases, and pain and de 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 85 
 
 nd, or showing itself in apparently unbroken skin in the 
 
 illed idiopathir variety. If there is a wound, it usually 
 
 tjnts a yellowish, unliealthy-looking surface, with very little 
 
 ence of repair. If the erysipelatous virus is unmixed with 
 
 r organisms, the healing process may continue until the rash 
 
 ;ars, about the fourth or fifth day, when the young cicatrix 
 
 break open again, exposing a dry and sluggish surface, with 
 
 ickened margin ; it may occur, however, at an earlier date. 
 
 I'ash is generally of a characteristic vivid red colour, always 
 
 ppearing on pressure, and is accompanied by a sensation of 
 
 less or burning, scarcely amounting to pain, except when 
 
 ;e structures, such as the scalp, are involved, and then the 
 
 may be very severe. Swelling is not very marked, except in 
 
 ireolar tissues, such as in the scrotum or eyelids ; the cedema 
 
 then attain considerable proportions. The rash continues to 
 
 mce more or less rapidly, with a continuous margin, and as it 
 
 ads to new regions it fades away from those already involved, 
 
 ing a slight brownish stain and a fine branny desquamation. 
 
 some cases it does not spread evenly, but appears to leap 
 
 r an interval, and then the intervening lymphatics are found 
 
 le thickened. Vesicles and bullae form superficially, containing 
 
 im, which speedily becomes turbid, but suppuration is un- 
 
 inion, except in lax oedematous tissues, such as the eyelids. 
 
 :asionally, from the severity of the inflammation or the low 
 
 e of vitality of the tissues, the skin may become gangrenous 
 
 slough, especially about the umbilicus and genitals of young 
 
 ren. Neighbouring lymphatic glands are always enlarged 
 
 painful, and this may even be noted at a period when the 
 
 has not appeared. Periphlebitis may also be caused, leading 
 
 ;cinic complications. Fever is present as long as the rash 
 
 sts, and merely shows slight diurnal variations. It is not 
 
 pimon for the temperature to rise to 104'^ F., but anything 
 
 that is of grave significance. At first the fever is of a 
 
 type, the pulse full, and the delirium noisy and active ; 
 
 ter on the pulse becomes quick and weak, accompanied by 
 
 luttering delirium and great prostration of the vital powers. 
 
 um is usually a well-marked feature in erysipelas of the 
 
 hut this is due to the general rather than to any local 
 
 ion, unless meningitis supervenes. The duration of the 
 
 is most variable, lasting, as a rule, from one to three weeks, 
 
 apses are not uncommon. 
 
 so-called Idiopathic Erysipelas mainly affects the head, 
 
 curs in predisposed individuals ; it is characterized by 
 
 at oedema of the subcutaneous tissues of the face, which 
 
 the features to become almost unrecognisable. Large 
 
 :orm, and even abscesses about the eyelids. There is a 
 
 ndency to recurrence about the same time of the year in 
 
 ses, and pain and delirium are prominent symptoms. 
 
 Kl. 
 
 i ^i'y 
 
 III 
 
 '■■■• i( 
 
 ■," ' ■ 
 
 HI' 
 
86 
 
 A MANUAL OF SURGERY 
 
 SEPSla, INFI: 
 
 loiinf,' women of a 
 
 ihema solavc follows 
 
 lected from water, 
 
 otected ; though usi 
 
 lie rise to so much j: 
 
 to simulate erysipel 
 
 lat 11 IS limited to t 
 
 iread. In acute ecz 
 
 lulation is quite chai 
 
 ■•athological Anator 
 
 ^tion of the skin col 
 iind invading the lyn 
 ii), whilst in the 
 
 Cellulo-cutaneous Erysipelas is due to an infection of the sk 
 and subcutaneous tissues with the specific virus, and results i 
 suppuration and sloughing both of the skin and subjacent cellu 
 tissue. The signs are those of a diffuse spreading inflammalioi 
 e.g., heat, pain, redness, and swelling of a brawny type at lirs 
 but whicli soon softens and becomes boggy, the skin giving ws 
 and allowing exit to the pus and sloughs. The general sympton 
 are correspondingly severe, and pyaemia may also be present, 
 distinguishing features from ordinary erysipelas, it is staled th 
 
 the margin of the redness is less defined, that the lymphat 
 
 glands are less enlarged, and that it is doubtful whether or nMrely finds the genen 
 the disease is contagious ; the whole nature of this affection Rewhere (p. 77). ^h 
 still more or less suh judice. 
 
 Erysipelas of the Fauces causes a diffuse inflammation of t 
 mucous membrane of the fauces, often spreading to the glot 
 and larynx, and arising either by extension from without, or 
 association with some external manifestation of the disease el 
 where. The fauces and soft palate become of a dusky scar 
 colour, and are much swollen. The voice is either husky 
 absolutely disappears, whilst severe spasmodic dyspncea m 
 arise from the a;dema extending to the glottis. The parts 
 very prone to ulcerate or slough, and the glands at the angle 
 the jaw are enlarged. Fever is usually, though not invariabl 
 present, and great depression of the vital powers. 
 
 Erysipelas of the Scrotum, or, as it is sometimes termed, ac 
 inflammatory cedema, is characterized by the part becomii 
 greatly distended by serum, but without any marked rednej 
 Suppuration and sloughing are not unlikely to follow. It tl: 
 somewhat simulates the appearance produced by extravasatij 
 of urine, but is distinguished from it by the facts that micturitij 
 is usually not interfered with, and that the swelling is not linii 
 in the same way as in the latter affection. 
 
 Diagnosis. — There is not much difficulty in recognising a a 
 of erysipelas if we remember the distinguishing features of Biiahly connected with 
 rash, viz., its method of extension by a broad, sharply-defiiw'yiiph glands will 
 slightly raised and infiltrated red margin. Thus, the exanthenm^^W^osiB. — Erysipela 
 are never limited to one part of the body, and rarely form 
 continuous red patch. Lymphangitis is characterized by strei 
 or lines of redness, not by an area of uniform hyperaemia. 
 phlebitis the skin is seldom red over the inflamed vein, which 
 be felt as a hard knotted cord below. A septic wound with pen 
 discharge closely simulates erysipelas ; but the margin of 
 redness is not so accurately defined, and lymphatic enlarge 
 does not so constantly occur. Diffuse erythema nodosum is rei 
 nised from it by the slight degree of the febrile disturbance 
 
 the presence of outlying patches of redness, which, moreover,B^™urable occurrence 
 not so clearly limited. There is always considerable pain inBsluggish will someti 
 affection, which often involves both legs, and usually occur^ran attack. Chronic 
 
 II 
 
 Section of the 
 
 SHOWING THE LVMPHATI 
 HAVE PRODUCED BUT L 
 
 n 
 
 ^cked there will be 
 
 y become so from 
 
 important of these 
 l?s, and other viscera 
 lous. Pyaemia and 
 
 Erysipelas of th^ 
 «er to life, particuk 
 :onie rapidly exhaus 
 lards infants, who ha\ 
 disease. As a local 
 
 n 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 87 
 
 iiiif^ women of a rheumatic temperament. The so-called 
 tthcma solarc follows exposure to the sun's rays, especially when 
 tlected from water, of parts of the body which are, as a' rule, 
 otected ; though usually of slif^ht importance, it may sometimes 
 ve rise to so much pain, cedema, and constitutional disturbance 
 i to simulate erysipelas. It is readily distinguished by the facts 
 lat It IS limited to the parts exposed and has no tendency to 
 pad. In acute eczema ruhvum the presence of a honey-like 
 iiuhition is quite characteristic. 
 
 Pathological Anatomy.— If a person dies of erysipelas, one 
 trely finds the general signs common to all septic cases detailed 
 ifwhere (p. 77). The rash will have faded, but on microscopic 
 ction of the skin colonies of cocci arranged in chains will be 
 unci invading the lymphatics just beyond the spreading margin 
 11), whilst in the parts which the inflammation has recently 
 
 
 II. — Section of the Spreading Edge of a Patch of Erysipelas, 
 
 SHOWING THE LYMPHATICS OCCUPIED BY CHAINS OF CoCCI, WHICH AS YET 
 HAVE PRODUCED BUT LITTLE EFFECT ON THE TISSUES. 
 
 jacked there will be a considerable excess of leucocytes, pre- 
 pbly connected with the destruction and removal of the cocci. 
 |e lymph glands will also' be found enlarged and congested, 
 'rognosis. — Erysipelas is not peculiarly dangerous in itself, but 
 
 become so from the complications which attend it. The 
 ^t important of these are inflammatory conditions of the brain, 
 
 s, and other viscera, disease of the kidneys being especially 
 pous. Pyaemia and general septic intoxication are also met 
 Erysipelas of the face and head is often attended with 
 kger to life, particularly in old people, whose vital powers 
 [ome rapidly exhausted. The same statement is true as 
 lards infants, who have no power of resisting the invasion of 
 Idisease. As a local complication, erysipelas is not always an 
 
 [avourable occurrence, since wounds which have become chronic 
 I sluggish will sometimes manifest marvellous reparative power 
 pan attack. Chronic lupoid and syphilitic ulcers may rapidly 
 
 I'', 
 
 
 ^'f 
 
 
 ■ m 
 
88 
 
 A MANUAL OF SURGERY 
 
 SEPSIS, INFEC 
 
 cicatrize, and even malignant sores, especially sarcomata, haM^vith lin. iodi, grantii 
 been known to be cured. m healthy skin. The 
 
 The Treatment of erysipelas :- mainly cond:jcted on generftaske's, in which the 
 principles. Prophylaxis must be strictly attended to by observiiMinch or two, the knif 
 every antiseptic detail in the treatment of wounds, especially Btiseptic compresses ai 
 any erysipelas cases are under treatment at the time. When tlBrhe introduction of < 
 disease is prevalent, all operations that can be delayed should IBection with much ber 
 postponed. Single cases should be isolated, and kept out ■immunizing a horse 
 surgical wards if practicable. If, unfortunately, a case develoBthdrawing its blood s 
 in the wards, and cannot be completely isolated, the bed should Billy in France, when 
 placed as far away from others as possible, and especially froBs plan of treatment, 
 those with open wounds which from their position {e.g., the nioutBficutaneously as a dost 
 cannot be properly protected from sepsis. It is usual to surrouBin rapidly diminishes 1 
 the bed with sheets kept moist with carbolic lotion, and the floBs, and in twenty-four 
 around should be sprinkled with the same. Special nurses mi ' 
 
 be told off to attend to the case, and house-surgeons and dressi 
 mvist take extra precautions to prevent the spread of the diseasi 
 
 As to Local Treatment, the old-fashioned plan consisted 
 merely protecting the part from the air, as by painting it a 
 collodion, or covering it with a thick layer of starch or flour, mi 
 perhaps with boric acid or iodoform, or in the more severe c 
 by applying fomentations containing opium or belladonna {e, 
 I ounce of laudanum to i pint of lotio plumbi). When one o 
 siders the bacterial origin of the affection, it is evident that exo 
 in the mildest cases, such methods are very inefficient, whilsl 
 is equally obvious that the local application of cold is absolui 
 
 harmful, as tending still further to depress the vitality of the pBployed after the incisi( 
 Where tension and pain are severe, the parts should be scariBe developed 
 and antiseptic compresses applied, e.g., gauze soaked in czx\m^ erysipelas of the fauce 
 acid (i in 30) or in sublimate solution (i in 1,000); mercuByed over several tin 
 ointment has been rubbed in, and antiseptics injected subcutaBliquor argenti nitrati 
 ously in front of the spreading margin. Perhaps the best resBhlor. (i in 2,000) or 
 have been obtained from thiol, an artificial sulphur compoundBater), whilst a high tr 
 sembling ichthyol in its characters, but without the objectioniBvolved. Diffusible s 
 smell. A 20 to 40 per cent, aqueous solution is painted overBurgently necessary to 
 affected area, possibly after scarification, as well as over m&& 
 neighbouring healthy skin several times a day until the fi 
 disappears ; such treatment is stated to be usually successfi 
 checking the disease in two or three days. 
 
 Pressure may be of some value in limiting the spread c 
 mischief, probably by compressing the lymphatics. A wide 
 
 of adhesive plaster wound around a limb beyond the margin o^^ses (although, as ^ 
 rash is often effectual, and it may be possible in this way to cB'O' and from sapraemij 
 its advance from the scalp to the face or neck. ijatter is merely a che 
 
 Anything that tends to produce a local accumulation of idB'^ trace of the blooc 
 cytes in the skin beyond the spreading edge should be bene«B°' mischief is inoculal 
 in checking its advance, and therefore good may be derivefl[,(^i^^j^]g ^^ t 
 painting around the rash with strong solutions of nitrate of s^tive Medicine^ and°ma^ "* 
 
 an end. 
 
 'institutional Treatm< 
 
 meter. Good food, 
 inine should be freely 
 chloride of iron In t^-di 
 y, is still looked on b 
 cellulo -cutaneous erys] 
 e to relieve tension, 
 tissues, when incis 
 ient, and much fluid ( 
 IS not undertaken, c 
 neous tissue may sic 
 
 Si 
 
 pticaemia is an acute g 
 
 |(ievelopment of some 
 
 It differs from 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 89 
 
 'ith lin. iodi, granting that it is done sufficiently far off to be 
 bealthy skin. The most efficient plan based on this idea is 
 ske's, in which the skin is scarified all round at a distance of 
 nch or two, the knife going just deeply enough to draw blood ; 
 septic compresses are then applied. 
 
 he introduction of sero-therapeatics has been utilized in this 
 ;tion with much benefit. An antistreptococcic senmi,-'' prepared 
 mmunizing a horse with the Streptococcus pyogenes, and then 
 idrawing its blood serum, has been used a good deal, espe- 
 y in France, where Marmorek and others have elaborated 
 plan of treatment. Ten or fifteen c.c. of this serum are given 
 :utaneously as a dose, and repeated once or twice a day. The 
 I rapidly diminishes, the rash ceases to spread, the temperature 
 ;, and in twenty-four to forty-eight hours the disease is usually 
 n end. 
 
 onstitutional Treatment must be of a tonic and supporting 
 racter. Good food, easy of assimilation, stimulants and 
 line should be freely administered, whilst the tincture of the 
 :hloride of iron in J-drachm doses, repeated three or four times 
 ly, is still looked on by many as a specific. 
 n celhilo -cutaneous erysipelas early and free incisions must be 
 ie to relieve tension, and, if possible, anticipate suppuration. 
 e tissues, when incised, look gelatinous from the oedema 
 sent, and much fluid of a sero-purulent type will escape. If 
 is not undertaken, considerable portions of skin and sub- 
 ineous tissue may slough. Antiseptic poultices should be 
 iloyed after the incisions have been made, until granulations 
 e developed. 
 
 erysipelas of the fauces the parts must be painted or freely 
 lyed over several times a day with antiseptic lotions, such 
 iquor argenti nitratis (10 grains to i ounce), liq. hydrarg, 
 hlor. (i in 2,000), or liq. sodae chlorinatae (i part to 15 parts 
 ater), whilst a high tracheotomy may be needed if the glottis 
 volved. Diffusible stimulants and plenty of nourishment 
 irgently necessary to combat the depressing effects of this 
 
 se. 
 
 Septicaemia. 
 
 [pticaemia is an acute gen.^ral infective disorder, arising from 
 development of some variety of pyogenic o'ganism in the 
 It differs from pyaemia in the absence of secondary 
 |sses (although, as explained later, it may be associated 
 lit),, and from sapraemia or septic intoxication by the fact that 
 latter is merely a chemical toxaemia. In septicaemia, if a 
 re trace of the blood taken at a distance from the local 
 lof mischief is inoculated into another animal or individual, 
 
 Itainable at a few hours' notice by telegraph from the Jenner Institute of 
 Itive Medicine, and many large chemists. 
 
 I ! 
 
 li 
 
 
90 
 
 A MANUAL OF SURGERY 
 
 SEPSIS, INFECT. 
 
 I 
 
 the disease is almost certainly transmitted, and often with jl 
 creased virulence; in sapraemia, injection of the blood, except] 
 large quantities, does no harm. 
 
 As to the ultimate cause of septicaemia in man, much discussion has arii 
 owing to the divergence of the results obtained by experimental researj 
 Koch and Davaine have each succeeded in isolating bacilli which produce f: 
 septicaemia in rabbits and mice respectively ; but neither of these is ne( 
 sarily pathogenic to other animals, and neither is the same as the organ!; 
 usually found in human septicaemia, although the symptoms are practic! 
 identical. 
 
 In man various bacteria seem capable of producing this disease under si 
 able conditions — viz., the ordinary Streptococcus pyogenes of acute sprea( 
 suppuration ; the Streptococcus septicus of Fliigge, which is probably identj 
 with the above, though more active; the Streptococcus septopycBmicus, whicl 
 more nearly allied to the erysipelas organism ; or even the bacillus of maligi 
 oedema (Koch). 
 
 If a mouse is infected with its specific bacillus, it remains apparently 
 affected for a period of twenty-four hours (incubation stage), but then becoj 
 languid, its eye loses lustre, it refuses to eat or run about, the respirati 
 become slower, and in about another twenty-four hours it dies, all its functi 
 appearing to be more or less paralyzed. Anatomically, one discovers but 
 naked-eye changes, except a little local inflammatory exudation at the poii 
 inoculation, and slight swelling of the spleen. Microscopically, many ofl 
 red corpuscles are found to be invaded and broken up by bacilli which 
 even be seen within them, and the capillaries, especially in the lungs, are 
 or less blocked by aggregated masses of organisms. 
 
 The pathological processes in human septicaemia are inferred to be 
 similar character — viz., development of organisms in the blood, with disinti 
 tion of corpuscles, especially of the red ; obstruction to capillaries, particiil 
 in the lungs ; formation of toxins as a result of this development ; and pan 
 of the functions of the nerve centres thereby. 
 
 may be blood-stain 
 itams blood. Petechi 
 Er a period of delirium 
 letimes precedes the 
 [exceedingly high, or o( 
 )\v temperature with 
 
 irt. 
 
 Wrative Cases. ~A servan 
 
 Isummer's day that she ha 
 
 bly the insect had come fi 
 
 iTOund. In twenty-four I 
 
 ch:lls and flushes; a pai 
 
 1 rapidly increased in si 
 
 when we saw her, the c 
 
 Ute band of inflammatory" 
 
 - nose across the face to tf 
 
 facial vein, the clot doul 
 
 irature was high, and the 
 irbit with the view of relic 
 t be present, but with no 
 hvithin a week, 
 elderly man, addicted to 
 of his hand. Within tw( 
 en.andintwodaysgangren 
 W the shoulder. The pat 
 
 e Post-mortem Signs a 
 described above (p. -. 
 |ical examination bacte 
 (nternal organs. 
 e Diagnosis has to be 
 le acute exanthemata, in 
 characteristic appearar 
 lite opinion as to the na 
 re IS no clue as to the 
 s associated with som 
 
 septicaemia ma'/ occi 
 
 Clinical History. — Septicaemia occurs most commonly 
 direct inoculation with suitable organisms through small les 
 such as post-mortem wounds, or from scratches or punctj 
 with infected pins or instruments ; it also in rarer cases foli 
 operation wounds and severe lacerated injuries. It is the 
 accompaniment of acute spreading gangrene, and may be 
 with in cellulitis and cancrum oris. As a rule, the indivil 
 attacked is in a depressed and debilitated condition, often detl 
 
 rated by alcoholic or other excesses, so that the inherent gm if^wnatic fever, ciue to 
 cidal activity of the tissues is markedly insufificient to cope W^^ grave anxiety for a 
 the inroads of the disease. Besent ; but if the woun 
 
 The point of inoculation may be the seat of any of the fl disappearance of the 
 of local trouble which we have already described under theB)' a local, and not the n 
 of cellulitis, and this may vary from a mere slight inflamniM" it is known by the abs 
 blush to the acutest form of spreading gangrene. Bsses. 
 
 The General Symptoms are those of fever, often ushered BPiosis. — Septicaemia 
 a distinct and severe rigor ; the temperature reaches loM^ fatal ; but it is to I 
 105° F., and usually remains high, with but slight remissionWient mentioned below 
 no intermissions. Malaise is present, with loss of appetite»'al in diminishing the 
 tongue is brown and parched, the pulse quick and feeble, w Treatment consists in 
 the skin has often a slight icteric tinge. Diarrhoea usually ei»"iination, either by an 
 
 u 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 qi 
 
 lay be blood-stained, whilst the urine is albuminous, and 
 ns blood. Petechiae appear under the skin, and the patient, 
 L period of delirium, becomes comatose, and dies. Dyspnoea 
 imes precedes the fatal issue, whilst the temperature may 
 :eedingly high, or occasionally subnormal ; the association of 
 temperature with a very rapid pulse is always of grave 
 t. 
 
 rative Cases. — A servant-girl, aged about twenty-two, complained one 
 timer's day that she had been stung near the inner canthus by a fly ; 
 y the insect had come from some infected material, and thus poisoned 
 und. In twenty-four hours she was feeling ill and feverish, and had 
 bills and flushes; a painful swelling developed at the inner canthus, 
 rapidly increased in size and spread downwards. At the end of four 
 /hen we saw her, the eye was protruding and much congested, and a 
 ! band of inflammatory thickening could be felt reaching from the roof 
 lose across the face to the neck and jugular region, probably the throm- 
 :acial vein, the clot doubtless extending to the cavernous sinus. The 
 ature was high, and the girl was delirious. An incision was made into 
 )it with the view of relieving tension and giving exit to any pus that 
 be present, but with no result. She rapidly became unconscious, and 
 ithin a week. 
 
 ilderly man, addicted to drink, fell in the street, and grazed the inner 
 : his hand. Within twenty-four hours the whole arm was puffy and 
 1, and in two days gangrene had manifested itself, the infiltration reaching 
 1 the shoulder. The patient was dead from acute septicaemia in five 
 
 ! Post-mortem Signs are simply those of acute septic poison- 
 escribed above (p. 77), with the addition that on micro- 
 cil examination bacteria can be demonstrated in the blood 
 ternal organs. 
 Diagnosis has to be made from the more virulent forms 
 acute exanthemata, in which the patient is destroyed before 
 aracteristic appearances are manifested ; in such cases a 
 |c opinion as to the nature of the affection is often impossible, 
 is no clue as to the origin of the infection. Sapramia is 
 associated with some very obvious focus of putrefaction, 
 septicaemia may occur with but slight local manifestations. 
 raumatic fever, due to wound infection, may be so severe as 
 e grave anxiety for a time as to whether or not septicaemia 
 [cnt ; but if the wound is freely opened up axid drained, the 
 isappearance of the fever proves that the mischief was 
 a local, and not the more serious general, affection. From 
 it is known by the absence of repeated rigors and secondary 
 es. 
 
 osis. — Septicaemia up to the present has been almost 
 fatal ; but it is to be hoped that the modern plans of 
 nt mentioned below, especially serotherapy, may prove 
 al in diminishing the mortality. 
 
 reatment consists in dealing actively with any local focus 
 imation, either by amputation, or by free incisions, purifi- 
 
92 
 
 A MANUAL OF SURGERY 
 
 cation, and drainage ; but unfortunately this is seldom likely to I 
 successful, as blood infection has probably already occurred. ; 
 addition to such means, tonics and stimulants, with plenty 
 suitable nourishment, must be administered. 
 
 It is possible that even this grave disease may become amei 
 able to some of the therapeutic measures which have been su] 
 gested of recent years. Thus, the antistreptococcic serum (p. 8i 
 may be utilized, and cases have been already reported as cured 
 its agency. Another plan which has been adopted is that of tl 
 intravenous injection of considerable quantities of normal sali 
 solution, repeated two or three times a day ; by this meai 
 diuresis and diarrhoea are induced, and it is hoped that thereby t 
 organisms and their products may be eliminated. This treatmei 
 has, however, been introduced so lately that no dogmatic statj 
 ments can be made about it ; it will probably be of greater vali 
 in cases of sapraemia than in those of true infective septicaemia. 
 
 Pyaemia. 
 
 Pyaemia (Greek ttvov, pus, and at/xa, blood) is a disease char; 
 terized by fever of an intermittent type, associated with t| 
 
 formation of multiple abscesses in differe 
 parts of the body, arising from the diflfusij 
 of pyogenic materials from some spot of li 
 infection. 
 
 It was supposed not long ago that pyaemia was i 
 to some specific micro-organism, but it has now 
 definitely proved by Rosenbach that any of the 
 genie organisms can give rise to it ; in fact, theontki 
 pyaemia may arise as a complication following 
 acute abscess, which, as we have already seen] 
 always due to bacterial activity. As a rule, bowel 
 there is a sufficiently rapid development of granj 
 tion tissue to limit the spread of infection, 
 organism most commonly found is the Stnptoai 
 pyogenes, but in a few cases the Staphylococcus p}x 
 aureus has been observed. The mere injectiort 
 cocci into the circulation is not sufficient to give 
 to pyaemia ; if they are few in number, a transj 
 pyrexia may supervene, and then the germiq 
 powei-u latent in the blood destroy them ; but if I 
 dose is large, or the individual is not in a veni 
 sistant condition, septicaemia, and not pyaemia, resi 
 unless special conditions are present which deterf 
 the formation of embolic abscesses. If the cod 
 be injected are mixed with such a material or aa 
 gated into such masses that the organisms are caij 
 on particles too large to pass through the tern 
 arterioles and capillaries, wherever they lodge abscd 
 develop. In human pathology the infective en 
 
 consist of zoogloea masses of organisms, or of infected particles of di^ 
 
 grating blood-clot (Fig. 12). 
 
 SEPSIS, INFE^ 
 
 Fig. 12. — Disinte- 
 grating Clot 
 LYING IN A Vein in 
 A Case of Pyemia. 
 (Tillmanns.) 
 
 The apex of the clot 
 projects into a larger 
 trunk, in which cir- 
 cuit ting blood is 
 present, and from it 
 infected emboli 
 would be detached. 
 
 The Cause of py^m 
 jds to the formation 
 ^culation, such cond 
 Itiltration and disinti 
 ut occasionally in the 
 ntamination which v 
 ons by surgeons has i 
 r antisepsis ; but the 
 bualty work, where e 
 iainmation of the cai 
 traumatic, is very ( 
 the veins being abi 
 ision present from th 
 |ny structures. Infia 
 the course of middl 
 ; lateral sinus, also le 
 b open-mouthed ve 
 onset of the diseai 
 [owed to collect or ren 
 |\\hen an infective en 
 tombus forms upon it, 
 lelop, and thence pa; 
 inding tissues, causii 
 itic type, but later 
 ly such foci may occ 
 der and near the sur 
 ped area of tissue, wit 
 sat first reddish in co 
 m), but soon becom 
 " These abscesses are 
 IS. Similar collectioi 
 ly be found in any or^ 
 Er to emboli derived i 
 organs to be affected 
 •tion of the arterial s 
 jpurative foci in the 
 und joints, etc. If, he 
 [iie portal area, the e: 
 k rise to what is kn 
 many in number, the 
 jmia; this is sometii 
 |ro-organisnis in the b 
 Japs dying before the s 
 ™er cases the genera 
 of toxins from the 
 misms in the blood. 
 |e is little or no devt- 
 se is termed chronic \ 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 93 
 
 The Cause of pyaemia may be stated to be any condition which 
 lads to the formation and detachment of infective emboli in the 
 rculation, such conditions occurring mainly in the veins from 
 itiltration and disintegration of a thrombus {infective phlebitis), 
 jt occasionally in the heart {malignant endocarditis). The venous 
 jntamination which was formerly so much dreaded after opera- 
 [ns by surgeons has now been practically banished from surgery 
 [ antisepsis ; but the disease is still occasionally met with in 
 Liialty work, where efficient asepsis is difficult. Acute infective 
 painmation of the cancellous tissue of bones, whether idiopathic 
 [traumatic, is very commonly associated with pyaemia, owing 
 I the veins being abundant and thin-walled, and considerable 
 Lion present from the unyielding condition of the surrounding 
 Iny structures. Inflammation of the cranial bones coming on 
 [the course of middle-ear mischief, and causing thrombosis of 
 It lateral sinus, also leads to its development. The presence of 
 Ige open-mouthed veins in the puerperal uterus, also explains 
 le onset of the disease after parturition if septic material is 
 lowed to collect or remain in their vicinity. 
 
 ■When an infective embolus lodges in any region of the body, a 
 lombus forms upon it, and in this the micro-organisms rapidly 
 lielop, and thence pass through the vessel wall into the sur- 
 linding tissues, causing inflammation, which is at first of a 
 ■stic type, but later on becomes suppurative. In the lung 
 ■ny such foci may occur, distributed mainly along the posterior 
 Ider and near the surface ; each is sharply limited to a wedge- 
 ■ped area of tissue, with the base directed towards the periphery. 
 ■s at first reddish in colour, from efl'usion of blood (a hamorrhagic 
 mnt), but soon becomes greyish-yellow, from the formation of 
 m. These abscesses are small, and rarely give rise to any physical 
 m&. Similar collections of pus, preceded or not by an infarct, 
 ■y be found in any organ of the body. The lungs, acting as a 
 Kr to emboli derived from the systemic veins, are naturally the 
 Bt organs to be affected, and from the abscesses formed therein, 
 Rction of the arterial system may take place, resulting in fresh 
 Bpurative foci in the liver, spleen, kidneys, brain, and in or 
 Bund joints, etc. If, however, the causative phlebitis is situated 
 Hhe portal area, the emboli are lodged primarily in the li\'er, 
 Bng rise to what is known as Pylephlebitis. When the emboli 
 ■many in number, the symptoms are severe, constituting acute 
 Hnia; this is sometimes associated with a development of 
 ■ro-organisms in the blood, producing pyosepticcemia, the patient 
 Hiaps dying before the secondary abscesses have fully developed. 
 Hther cases the general symptoms are due rather to the absorp- 
 Hof toxins from the local foci than to the development of 
 Hinisnis in the blood. If the emboli are few in number, and 
 He is little or no development of microbes in the blood, the 
 Hase is termed chronic pyaemia. 
 
 ■ \ 
 
 ;, : 1 ' 
 , \ 
 
 ! I I 
 
 ii \'\ 
 
94 
 
 A MANUAL OF SURGERY 
 
 SEPSIS, INFEC 
 
 Clinical History. — The most marked symptom indicating th| 
 onset of a case of Acute Pyaemia is the occurrence during a perid 
 of febrile disturbance of a severe rigor, which is repeated with 
 sort of irregular periodicity, most frequently at intervals of aboj 
 twenty-four to forty-eight hours, somewhat simulating an atiaJ 
 of ague. The rigors do not differ from those occurring in othJ 
 diseases, but they are very severe, and usually followed by proy 
 sweating. Between the rigors the temperature may fall to tl 
 normal, but more commonly remains above it. The skin is hcJ 
 and soon develops an earthy or dull yellow tint, together \vi| 
 erythematous or petechial patches. A sweet, mawkish, hay- 
 smell of the breath is very characteristic. Symptoms of grai 
 depression supervene, and the patient rapidly wastes. The pull 
 becomes soft and weak, the excretions are diminished, andf 
 certain amount of nocturnal delirium is noticed, but no lossi 
 consciousness. The tongue varies, but is often red with vei 
 prominent papillae, and becomes dry and brownish. Towards ti 
 end of the first week secondary abscesses appear ; they are soiiij 
 times unaccompanied by local pain or tenderness, and form vel 
 rapidly ; thus, a knee-joint may fill with pus in the course of| 
 night of quiet sleep. They are, as a rule, small and numeroui 
 if they occur in vital organs, death may result from their lod 
 development. When situated in the subcutaneous tissues, thj 
 are characterized by the almost total absence of a barni 
 of granulation tissue, and hence, even when opened early 
 aseptically, are likely to extend and continue secreting 
 instead of following the usual course of rapid contraction 
 repair which succeeds the aseptic opening of an ordinary ad 
 abscess. 
 
 Not uncommonly in these cases painful patches occur here; 
 there in the subcutaneous tissues, accompanied by hyperaeiiij 
 which fades away after a few days ; such are probably due to 
 impaction of small infective emboli, which the patient has sufficiej 
 vitality to get rid of without suppuration. 
 
 In Chronic Pyaemia the febrile symptoms are much less marke| 
 the abscesses are few in number, and not dangerous unless fori 
 ing in important structures. Thus, a fatal result ensued frora 
 single abscess which developed in the lateral ventricle of the bri 
 of a patient who had no other symptom of pyaemia except! 
 oscillating temperature : it followed an operation on a septic siij 
 leading to a kidney already disorganized. 
 
 The condition of the wound at the onset of pyaemia is aid 
 very unsatisfactory. It gapes open and presents an inactj 
 surface, and any newly-formed scar tissue readily breaks doi 
 A layer of healthy granulations is an almost certain barrier agaij 
 the occurrence of pyaemia, on account of the germicidal poweif 
 the cells constituting it. If the disease arises in connection \i 
 bone, the latter structure is usually seen lying bare at the botti 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 95 
 
 the wound, denuded of its periosteum, and the cancelli filled 
 th sloughy foetid medulla, or pus. 
 
 The duration of a case of pyaemia is very variable. Acute cases 
 ually last a little over a week, whilst the subacute forms may 
 n on for three or four weeks, and chronic cases continue for 
 onths, and may even end in complete recovery. 
 Post-mortem Appearances. — i. The wound is unhealthy, the 
 irface being grey, dry, or sloughy ; if bone is implicated, as in 
 1 amputation or excision, evidence of inflammatory mischief, 
 ther of the periosteum or medulla, is present. 2. The veins 
 ading from the wound may be in a healthy condition, but are 
 lore commonly in a state of septic phlebitis ; the coats are 
 lickened, and the lumen is filled with soft, disintegrating clot, 
 fliich extends for a considerable distance ; the tissues surrounding 
 je vein are also involved in the suppurative process. 3. Secondary 
 bscesses are found in various parts of the body, most frequently 
 I the lungs, and their different stages can be clearly demonstrated 
 0111 the embolic colonies of micrococci, through the stage of 
 Eiiiorrhagic infarction to the complete abscess. The contained 
 us may be of the normal type, or thin and oily ; it is always, 
 owever, swarming with cocci. 4. The general signs common to 
 cases of septic poisoning will be manifest ; they are described 
 
 77- 
 The Diagnosis of pyaemia should not be difficult in the majority 
 
 cases ; but when it originates without any obvious external 
 
 cund, as in a deep-seated abscess, or if the importance of some 
 
 cal lesion has not been appreciated, the initial symptoms may be 
 
 istaken for those of acute rheumatism or ague. 
 
 The Prognosis depends upon the inherent vitality of the patient 
 
 the virulence of the disease. In acute cases it is extremely 
 
 ave, whilst in the chronic type recovery is not only possible, but 
 
 obable, if the local abscesses are favourably situated. 
 
 In the Treatment of acute pyaemia the surgeon is acting at a 
 
 nsiderable disadvantage, in that the disease is only recognisable 
 
 en it has obtained some hold upon the patient, since the recur- 
 
 t rigors, by which it is known, are usually the evidence of a 
 
 [ave general infection of the blood. 
 
 [Local Treatment is most important, and since the disease is in 
 
 majority of cases due to the detachment of infected emboli 
 
 1 a vein, the ideal surgical practice consists in preventing, if 
 
 sible, the further contamination of the general blood-stream. 
 
 is can sometimes be accomplished, in the case of a limb, by 
 
 putation well above the local lesion ; or if the medullary cavity 
 
 I bone is the source of trouble, it may be possible to scrape out 
 
 j;angrenous and offensive medullary tissue, and disinfect the 
 
 ity with pure carbolic acid ; or if it is due to a wound in the 
 
 parts, it may be feasible to dissect out the implicated vein and 
 
 ounding tissues, or at any rate to remove the disintegrating 
 
 
96 
 
 A MANUAL OF SURGERY 
 
 clot after placing a ligature upon the vessel between the thronil^ 
 and the heart. A typical illustration of such treatment is W 
 adopted for septic thrombosis of the lateral sinus complicatij 
 disease of the middle ear, where, after tying the internal jugularl 
 the neck, the sinus is exposed by the trephine, opened, and all 
 septic clot removed, partly from above, partly from below. . 
 mirable results have been thereby obtained. The abscesses must! 
 dealt with, where practicable, by opening them early and wasli^ 
 them out ; such wounds often heal well, and joints which hi 
 been distended with pus may recover with free mobility, OcJ 
 sionally, however, although rigid asepsis has been maintained, 
 suppuration continues, and even sloughing of the abscess wall m 
 follow. If the general condition can be improved, a barrier 
 granulation tissue will form in time, and repair be established. 
 Constitutional Treatment consists in supporting the patieJ 
 strength by nourishing diet and stimulants, and in taking precj 
 tions to avoid bedsores or any local injury. Salicylate of quit 
 may be administered, though its value is doubtful. The antistr 
 tococcic serum may also be utilized, and it may do good in ca 
 which have not progressed too far. 
 
 SEPSIS, INFECl 
 
 tsion which causes nc 
 hst, or a bruise, but 
 »nite solution of contii 
 (y. I>e thus affected, an< 
 tic wounds; where 
 elopment of tetanus 
 trated wounds of the s 
 fy nail, are as likely tc 
 . Infection with the 
 
 W nature of this di^ 
 U portions of soil o: 
 
 lofanimals, they died 
 '" the pus and walls 
 1' were observed. E 
 found that the baci 
 "ated, and, indeed, .i 
 
 Tetanus. 
 
 Tetanus is a local infective disease, due to the activity of 
 Bacillus tetani, and the < haracteristic symptoms are of a toxaj 
 nature. 
 
 Predisposing Causes. — i. Climatic Influences. — It is most ci 
 monly seen in the tropics, where it may be almost epidet 
 probably owing to the heat favouring the development and \i 
 lence of the organisms in the soil ; hot seasons assist its actii 
 and particularly when hot days are followed by cold nights. 
 
 2. Personal Proclivity. — It was formerly considered that negi] 
 horses, and stable attendants were specially liable to this dise 
 owing to some peculiar idiosyncrasv ; but with the recent 
 tions to our knowledge as to the haoitat of the Bacillus tetani, 
 extremely doubtful whether such an idea can be maintaij 
 The organism is a facultative saprophyte — i.e., is Cc:pable of 
 tinning its development apart from the body — and is almost j 
 stantly found in garden soil, dust, or dirt of any kind. TI 
 therefore, who are likely to be much brought in contact witlj 
 ground, e.g., negroes, horses, and agricultural labourers,! 
 most liable to develop the disease, owing to their more con/ 
 exposure to infection. 
 
 3. Bad Hygiene is a most important predisposing condj 
 Every hygienic error favours its appearance, but especial!) 
 overcrowding of sick and wounded people into a limited sj 
 and especially if full antisepsis is impossible. 
 
 Exciting Causes. — i. The existence of a wound. It mayfJ 
 
 [iJ-Bacilli of Tetanus 
 
 FORES LOCATED AT THE E 
 'IILLMANNS.) 
 
 l^ or field soil ; they 
 H man's hand, and ( 
 J'ty was experienced i 
 ■bacillus, but at last 
 '? the pus from an 
 
 for an hour, thereby. 
 
 nes It develops in the 
 
 'and breaking up into : 
 
 s form, but only at or 
 
 pe microbe is known 
 
 organisms are anaerc 
 'deed, are best cultivat 
 lannosphere of hydrogei 
 h and hence do not in\ 
 pre\iously bruised or 
 '■"ation. They grow 
 
 Of septic wounds, the 
 
 present, and so ori 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 97 
 
 m which causes no breach of surface, such as a blow with 
 t, or a bruise, but in the great majority of cases there is a 
 e sokition of continuity of the skin. Any region of the body 
 e thus affected, and it is rare for tetanus to occur in any but 
 
 wounds ; where asepsis has been fully maintained the 
 ipment of tetanus is almost unknown. Punctured or 
 ted wounds of the sole of the foot, perhaps due to a dirty or 
 nail, are as likely to be associated with tetanus as any. 
 nfection with the Bacillus tetani. The hrst clue to the 
 ve nature of this disease was obtained from the observation 
 f portions of soil or garden mould were placed under the 
 f animals, they died in a short time with tetanic symptoms, 
 1 the pus and walls of the resulting abscess characteristic 
 
 were observed. Experimenting in the same way, it has 
 found that the bacilli or their spores are very widely dis- 
 ated, and, indeed, are present in almost every sample of 
 
 Bacilli of Tetanus from Artificial Culture, showing the 
 [ores located at the Ends of the Rods (' Drumstick ' Bacilli). 
 
 |lLLMANNS.) 
 
 or field soil ; they have been found in the grime on a 
 
 ig man's hand, and on dirty surgical instruments. Great 
 
 llty was experienced in isolating and getting pure cultures 
 
 Ibacillus, but at last Nicolaier and Kitasato succeeded, by 
 
 |g the pus from an infected wound to a temperature of 
 
 I for an hour, thereby destroying all the pyogenic and septic 
 
 |)es. It develops in the body as long, delicate threads consist- 
 
 md breaking up into separate bacilli ; in artificial cultures 
 
 form, but only at one end, causing suci an appearance 
 
 |e microbe is known as the 'drumstick ' bacillus (Fig. 13). 
 
 organisms are anaerobic, i.e., flourish apart from oxygen, 
 
 [deed, are best cultivated on nutrient gelatine at blood-heat 
 
 Itmosphere of hydrogen. They are not endowed with high 
 
 and hence do not invade living tissues unless these have 
 
 lre\iously bruised or damaged by the presence of septic 
 
 lation. They grow in the neighbourhood and near the 
 
 of septic wounds, the septic organisms absorbing all the 
 
 present, and so originating the anaerobic conditions 
 
 7 
 
98 
 
 A MANUAL OF SURGERY 
 
 SEP^i/S, 
 
 necessary for their development. The mode of action of thi 
 bacillus consists in a local infection with general toxaemia ; that 
 to say, by its local development in a wound certain substanci 
 are produced which, when absorbed, act on the spinal marroi 
 and brain, producing toxic eflfects very similar to those 
 strychnine. The actual tetano-toxin appears to have the natm 
 of a ferment, its virulence being readily destroyed by exposu: 
 to a somewliat low temperature, e.g., one of 68" C., for about ti 
 minutes. It is not influenced by drying, and its activity is sm 
 that it is stated to be nearly 400 times as poisonous as strychiii 
 
 As to the post-mortem Anatomical Changes, but little need 
 said, since they are not specially characteristic. The niiisci 
 are often pale, or show evidences of rupture and extrax asatii 
 of blood. The peripheral nerves extending from the wound 
 red and congested for some distance, but this is probably only 
 to septic inflammation. The nerve centres frequently jMes 
 areas of softening, and perivascular cellular exudation, witli soi 
 hyperaMuia. 
 
 A few observations are on record in which the bacilli ha\ e 1 
 noticed on the pia mater and arachnoid of the human spinal c 
 and others claim to have transmitted the disease experiment 
 by inoculation of the subdural space with an emulsion of the spi 
 
 fNFj 
 
 ^^^!^^rds'; sometir 
 iJ in rare cases Ja 
 jntract so violently 
 
 Hl'^^fual faculties""^ 
 
 ™^niJJy due to exhar 
 
 ""»^f rarely to asph 
 
 spiratory nuiscJes ' 
 
 ins up to 108", or e 
 
 btinues to rise for a 
 
 ^'^xia ,s mainly due 
 
 1^ surface of tiie body 
 
 Iv albuminous. Denfl 
 
 ;J^-^the disease,^' 
 iCironic Tetanus usu 
 ''' ^n its sympto,„s 
 ' f""^se is usually ] 
 l^^^ mnted to the 
 ction has arisen, or n 
 
 s and especially the 
 
 cord or medulla. If these facts be true, they indicate that Bliaracterized I fi 
 have still nuich to learn as to the nature of the disease. ■ouL'-ii ^nnc., '^ 
 
 Clinical History. — Acute Tetanus usually manifests itself 
 this country two or three weeks after infection (but soineti 
 abroad as early as a few hours or days) by a difficulty in ope 
 the mouth, associated with a cramp-like pain in the musclei 
 mastication and of the neck. This soon becomes so marked 
 it may be difficult even to insert a paper-knife between the ti 
 {trismus, or lock-jaw), causing great difificulty in the administr 
 of food ; to it is added a fixed and rigid condition of the muscli 
 the back of the neck and of the face, the latter producing a cu 
 grin-like appearance (risus sardonicus), whilst dysphagia soon fol 
 from spasm of the pharyngeal muscles. A considerable degn 
 fever is often manifested, but in some cases an apyrexial con 
 maintained until nearly the end. The spasms soon extend ti 
 trunk and extremities, accompanied by cramp-like pains, and 
 fully established they may be excessively painful and violent; 
 the remissions between them but partial. Fortunately the di] 
 usually involves the respiratory muscles late in the attack 
 spasms can be excited by any form of stimulus, such 
 slamming of a door, a draught of cold air, or some volii 
 movement, and are always of a tonic (i.e., continuous) cliar 
 The body is contorted in various directions, and respiration 
 impeded by the fixation of the thorax. Occasionally the 
 arched backwards (opisthotonos) by the contraction of the nil 
 of the back, the recti abdominis being firm and tense-- 
 
 g; spasms, both to. 
 
 u 
 
 e asi 
 , , ' spasms, bot 
 
 .^^^j- Spasm of the 
 
 £/["""'>' are sonj 
 ¥'op/iobicHs which h 
 
 «^«ltobeduetoan 
 j^ecomes compress 
 """n IS uncommon 
 'e acute cases. 
 |e Diagnosis of tetanus 
 f '^e distmguished ft 
 
 "^orfrominfla^nmai 
 J his may he readily 
 r sent m tetanus rigf 
 
 ^^^O'c/imne poisoning lea[ 
 /f ognised from ft ify 
 J^-t, the relaxation" 
 '^fe. so that the mout 
 are involved in the 
 
 CO 
 
 i«^cles of mastication o 
 difficulty should be 
 l^'drophobia, owing to t 
 
 -n the latter case J 
 7 the muscles of 
 of the case, the earh 
 "scuJar contractions,^ 
 
 e 
 
 re 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 99 
 
 )oards ' ; sometimes it is doubled forwards (emprosthotonos), 
 in rare cases laterally {pleiiroathotonos). The muscles may 
 ract so violently as to be ruptured, whilst teeth have been 
 en and the tongue has been almost bitten off. The in- 
 ctual faculties usually remain clear to the end, which is. 
 rally due to exhaustion from a repetition of the convulsions, 
 lore rarely to asphyxia induced by a prolonj^ed fixation of the 
 iratory muscles. Before death the temperature sometimes 
 up to io8", or even, in one case, to 112° F., and it often 
 inues to rise for a degree or two after death ; such hyper- 
 xia is mainly due to the continuous muscular contractions, 
 surface of the body is bathed in sweat, and the urine occasion- 
 albuminous. Death may occur in twenty-four hours from the 
 t of the disease, or not for four or five days, 
 ironic Tetanus usually begins later after infection, is less 
 re in its symptoms, and more likely to be recovered from, 
 course is usually afebrile, and the spasmodic contractions 
 be limited to the wounded part of the body whence the 
 :tion has arisen, or may be general. A special variety of this 
 iiown as cephalo-tetanus, or T. paralyticus (German, kopf -tetanus). 
 ollows injuries within the area of distribution of the cranial 
 les, and especially those about the supra-orbital margin, and 
 baracterized by the association of trismus with facial paralysis, 
 lougli spasms, both tonic and clonic, occur in other parts of 
 hocly. Spasm of the muscles of deglutition and attacks of 
 iacal frenzy are sometimes present, and hence the name 
 h'ophohicus which has been applied to it. The paralysis is 
 osed to be due to an ascending neuritis of the facial nerve,, 
 becomes compressed in the aqueductus Fallopii. The 
 ition is uncommon, and the prognosis not quite so grave as 
 acute cases. 
 
 e Diagnosis of tetanus is rarely difficult. In the early stages 
 St be distinguished from simple trismus arising from dental 
 ion, or from inflammatory ankylosis of the temporo-maxillary 
 This may be readily accomplished by noting that there is 
 resent in tetanus rigidity of the neck muscles. In the later 
 drychnine poisoning leads to a very similar group of symptoms, 
 recognised from it by the contractions being more sudden 
 [olent, the relaxation of the muscles between the spasms 
 te, so that the mouth can readily be opened, whilst the 
 [are involved in the contractions, a rare sign in tetanus, and 
 iscles of mastication often escape. 
 
 ifficulty should be experienced in distinguishing tetanus 
 dyophobia, owing to the very different nature of the con- 
 in the latter case — i.e., clonic and not tonic ; moreover,. 
 ject the muscles of respiration and deglutition, whilst the . 
 of the case, the early hallucinations, and the absence of 
 scular contractions, are also characteristic features. 
 
 7—2 
 
100 
 
 A MANUAL OF SURGERY 
 
 jreacly ,nust he allou-e 
 hroi.;^li the dura M, 
 Mitai convolution on 
 of ste 
 
 ^77'' ^^'^ ^'i-ra n.ate 
 •""t'li convoJuti 
 psohed in 5 c c 
 
 ^^''''•jyl)on.peated;e 
 
 The Prognosis is unfavourable in any case, l)ut the so-callt 
 idiopathic variety is less fatal than tiie traumatic. The lon^^-, 
 the case lasts, and the lower the temperature, the more likclv 
 the i)atient to recover, whilst au acute onset, hyperpyrexia, site 
 lessness, delirium, and strabismus are bad sifi;ns. The lenj,nh 
 the incubation period is also a most important factor, since it h; 
 been shown that if it is under ten days, only 4 per cent, recover 
 whilst if it lasts for eleven to fifteen days, 27 per cent, of cun 
 may be expected, and if the outbreak is delayed for fifteen 
 twenty days, 45 per cent, of the patients li\e. 
 
 Treatment. — Careful antisepsis applied to wounds is the sure 
 means of pyevcntuif^ its occurrence, and the worse the sanita 
 conditions in which patients are found, and the more ragf^^ed t 
 wound, the stricter should be the measures employed. 
 
 If the orif^dnatinf^ sore is accessible, it should be freely exci 
 and the wound cauterized, or the lind) may be amputated ; 1 
 even then the tetanic con\'ulsions may remain for a time, or evj 
 prove fatal, from the amount of poison already in the system. 
 
 In addition to these local measures, the specific tetanus a 
 toxin (prepared by drying the blood serum of an imnuini 
 animal) should be injected. At present the results of 
 treatment have proved disappointing, since few cases of aci 
 tetanus have been saved by it, and the effect even in the n 
 chronic cases is not at all certain. The explanation of this 
 probably in the fact that the serum is in reality an innnuni 
 
 agent {i.e., one which prevents the development of the organis— .,, , _ — wiicu 
 
 and is not capable of dealing with the toxic bodies already <icM^,' . ' ^p^^^^^ered afte 
 on the nerve centres ; so that if a certain dose of the tetano-tiMmn ' ^"^oroforin s)i< 
 has once been absorbed, it will produce its normal efifects 
 though the antitoxin prevents any further development of 
 organisms. The treatment should always commence with a li 
 dose, and smaller amounts should then be administered on 
 twice a day, varying with the severity of the symptoniSj 
 medium dose consists of about 20 c.c. of the fluid anti 
 (Tizzoni's), but 40 or 50 c.c. may be given as the initial inje 
 This is introduced into the subcutaneous tissues of the alxl 
 and back, or in somewhat smaller doses into the veins, and a 
 but little inconvenience. If Behr-ng's dried antitoxic ser 
 employed, 5 to 10 grammes, dissolved in distilled water, m 
 given. 
 
 During the last few years it has been shown by Rouj 
 Bon el that the toxins are so closely attached to the nervj 
 that it is almost hopeless to expect even an intravenous injj 
 of antitoxin to do much good, and hence it has been propq 
 introduce it into the substance of the brain, enabling it tj 
 reach and act on the nerve centres more rapidly. The ohj 
 be gained is to immunize the ineduUary centres and prevej 
 further development of the toxin in the body ; w^hat i^ 
 
 ly between 
 
 "^' '"V' ^''^' centre " 
 
 ''T"^ ^''-' external S 
 
 J !>« applied here or 
 
 tot to allow of ti,e' 
 '"' ')'-'' '"ches deep 
 P-^'-^ '-s essential. P -„ i 
 
 "'^^'^e treatment of 
 ^"''^•"taneous injej In 
 'WW noted. J'^'-^'on 
 
 '"'•/'"(I free from -ill ! 
 '"f st^ffi" P'--«' -'o 
 
 v'^'T-veheen xaunf^.i .. 
 
 i'lis. 
 
 lunted i^ 
 r 
 siioi 
 
 f^'^inervoL system '^ ^,'°^^' 
 
 [''c'<s an abraded suV'^'u^^ 
 pas not at the Hm u ^ '^^ 
 
 ^Dog, rabies - "'"'^°^^" 
 
 ar 
 
 py be some infl^ ^ o^" 
 
 h ^'escribSl J"he7a?"^°'">' 
 b commences f,i?K^'"^'°^ 
 
 P"^«sandirritabiM ^ '^^^' 
 h dog moS i^'^^' ^■'^Pecia 
 
 Vs, and Ts .^ V""^ ^^en its 
 
 ';!"bout"hrs's;v'^'"- 
 
 '^•-y.andthis'Wom. i, 
 ^""ngthewhoie?ttacrti 
 
SEPSIS, INFFXTION, AND INFECTIVE DISEASES 
 
 lor 
 
 r must he allowed to work itself off. The injection is made 
 li the dura mater into the posterior portion of the second 
 
 convolution on each side ; 2*5 c.c. of the dried serum 
 ed in 5 c.c. of sterilized water are injected very slowly, and 
 xy he repeated several times, if an interval of a few days he 
 :1 to elapse hetween each injection. The point selected is 
 midway hetween the external angular process of the frontal 
 .nd the centre point of the line hetween the root of the 
 id the external occipital protuherance. A small trephine 
 3 applied here, or simply a hole drilled throu{,di the skull 
 nt to allow of the introduction of a syringe, which is pushed 
 two inches deep into the hrain. Of course, the strictest 
 
 is essential. Prohahly it will i)e found wise to restrict this 
 I the treatment of the worst cases, and it must he augmented 
 cutaneous injections and the other suhsidiary measures to 
 • noted. 
 
 patient should he kept ahsolutely qc^. t in a darkened 
 uid free from all sources of irritation. Food should he 
 JUS, fluid, and unstinudating ; it has heen suggested to feed 
 tient twice a day hy a stomach-pump under chloroform, 
 the trisnms is very marked, he may he fed through a soft 
 
 catheter passed into the pharynx through the nose, unless 
 3 a sufficient gap hetween the teeth to admit of its entrance. 
 , chloral hydrate, hromide of potash, physostigma, and 
 
 have heen \aunted as heneficial drugs, hut prohahly cases 
 uive recovered after their exhihition would have done so 
 Chloroform should he administer^.d to control the 
 
 Hydrophobia. 
 
 phobia is an acute general infective disease, transmitted from animals 
 
 specially from rabid dogs, wolves, etc. It consists in an affection of 
 
 ll nervous system, and one of its most marked features is the long and 
 
 fcubation period. It never originates idiopathically either in animals 
 
 id although the actual virus has not yet been isolated, there can be 
 
 [hat it is a micro-organism. Infection usually follows a bite ; but if 
 
 pass first through a garment, the virus may be wiped off, and the 
 
 may escape. It has also been proved that if an infected animal 
 
 Is an abraded surface the disease may be transmitted, even when the 
 
 not at the time shown any of the more typical signs of rabies. 
 
 ig, rabies manifests itself three to five weeks after infection, but the 
 
 [es considerably ; the original wound usually heals perfectly, or 
 
 be some inflammatory thickening about it. Two chief varieties 
 
 llescribed-the raging or maniacal, and the quiet or dumb. Rabies 
 
 Icommences with a stage of depression, which is manifested by 
 
 Is and irritability, especially towards other animals, by restlessness, 
 
 nog moping in dark corners, with a depraved appetite, eating any 
 
 pish or dirt, and even its own excreta. This period lasts for two or 
 
 land is perhaps the most dangerous, since there is nothing very 
 
 Ibout the symptoms. It is followed by a period of frenzy and 
 
 [y, and this in turn is succeeded by a stage of paralysis, going on 
 
 during the whole attack the mouth is filled with ropy saliva, which 
 
102 
 
 A MANUAL OF SURGERY 
 
 SEPSIS, INFEC 
 
 the animal vainly tries to scratch away; the" bark loses its ring and Ix^co: 
 hoarse, and as the disease progresses the lower jaw becomes paralyzed ; final, 
 after partial or general convulsions, the animal dies five or six days from tl 
 onset. In the melancholic or dumb form the animal succumbs more rapid; 
 passing through the same stages as the above, with the exception of 
 maniacal period. The disease lasts then but two or three days. 
 
 In Man the incubation period is most variable, lasting from days to moni 
 or years, but as a rule it does not exceed six weeks. During this interval 
 wound heals, although the scar may remain tender and neuralgic. Thedise 
 is ushered in by a vague sense of terror, with illusions of the senses and t 
 turbance of the mind, lasting for about twenty-four hours. Restlossiii 
 sleeplessness, loss of appetite, and a repugnance to fluids follow, with perhi 
 some slight febrile disturbance. The more characteristic symptoms 
 inaugurated by a convulsive stiffness of the tongue, neck, and especiall 
 the muscles of deglutition and respiration, which becomes more marked if 
 attempt is made to swallow. These convulsions are clonic in character, 
 thus differ from those of tetanus ; they become more and more general! 
 being brought on after a time by almost any afferent impulse, however sli| 
 — such as a blast of cold air, a flash of light, a sudden noise, especially sue 
 is caused by the movements of fluids ; swallowing is quite impracticable 
 mouth is usually filled with ropy mucus, which is very difficult to renii 
 The respirations became catchy, and a hiccoughing noise may be produce 
 the spasm of the diaphragm, which is sometimes thought to resemble 
 barking of a dog. Finally, the convulsions may entirely cease, and the pat 
 dies, retaining his consciousness to the end, the fatal issue being due to 
 destructive changes taking place in the medulla, or to exhaustion ; it 
 however, occur earlier, from spasm of the glottis. The disease lasts aboi 
 week, but may be more rapid, killing even in two days. 
 
 The Post-mortem Chauges are mainly negative. Evidences of acute in 
 mation of the lower part of the medulla, including the centres for the 
 loth, and nth nerves, are observed on microscopic examination, the vei 
 being thrombosed, and the connective tissue infiltrated with leucocytes 
 nerve fibres and ganglion cells may also be found degenerated. The s.ili' 
 glands are always somewhat enlarged. 
 
 Preventive Measures should be adopted immediately in all cases of bites 
 dogs which are either rabid or may possibly become so. The circulati 
 the limb should be arrested by a string or bandage, bleeding encouraged 
 some powerful caustic, e.f>., pure carbolic acid, applied as soon as possible] 
 free excision of the part is, however, preferable. 
 
 Pasteur's Preventive Treatment. — A few years back M. Pasteur disco 
 the fact that the injection of an attenuated virus in increasing doses 
 in gradually increasing strength, protects an animal or individual froi; 
 disease, and mirabilc dictu ! will even catch up the poison already inociilj 
 and save the patient from its subsequent development, if too Ions,' a 
 has not been given. The method employed is as follows : A virus of cor 
 and maximum intensity is first obtained by passing the poison from 
 through a series of rabbits, until the disease appears with regularity oi 
 seventh day, all parts of the cord being then equally virulent. The m: 
 inoculated is obtained by mashing up a portion of the spinal cord or nii 
 of the diseased dog in sterilized broth, and injecting it with a hypodi 
 syringe beneath the arachnoid after trephining. All that is now needed 
 take a series of these virulent cords, and dry them by hanging in a ^'asi 
 jar with some caustic potash at the bottom for variable periods, the 
 being thus weakened in its intensity, until at the end of fourteen day 
 completely destroyed. Individuals are inoculated with portions of such 
 pounded up in sterilized broth, beginning with the weakest, and grai 
 increasing the strength of the injection, until a preparation of a cord whii 
 merely hung one day is used. This method of treatment was introdui 
 1885, and the results hitherto obtained have been such as to indicate t 
 
 ive here a most potent pr 
 
 e disease has not been j 
 
 lack-ed an individual, onl 
 
 kce of irritation and dis 
 
 (sniutely quiet. With a 
 
 Iministered internally or 
 
 Jices. All the nourishmei 
 
 Iministered, with the additi 
 
 llhis disease results from ii 
 sheep and cattle the so-c; 
 blated through the skin 
 ahgnant pustule,' althoug: 
 kihrax oedema ' arises from 
 [lungs or intestinal canal 
 ^«n as ' woolsorters' diseasi 
 "ifc Bacillus ant lira CIS (Fig 
 
 :is 
 
 14- Bacillus Anthraci 
 bPLKNic Pulp of j.vf 
 
 AN'MAL. X 1,200. (CrooksI 
 iKXTBOOKOK BaCTERIOLC 
 
 ai 
 
 
 isms, measuring 5 to 20 » 
 "1 the blood of diseased a 
 ariable number of individi 
 bile, grows best at about b 
 -are formed within the b 
 '^?J oxygen- but spore 
 ihe bacilli are readilv 
 position of the carcase in 
 a week. The spores, ho 
 
 so lUion of carbolic acid ki 
 alter a week's immersion 
 
 n of carbolic acid have no 
 
 toot of the tail with a neec 
 
 „7 an animal which died 
 
 •tour hours, and bacilli an 
 
 eanimals are immune aga 
 and one of Pasteur's m 
 
 Fg immunity for cattle 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 103 
 
 liere a most potent preventive agent against hydrophobia, granted that 
 isease has not been allowed too long a start. When the disease has 
 ;ed an individual, only palliative treatment can be adopted. Every 
 » of irritation and disturbance must be removed, and the patient kept 
 itely quiet. With a view to diminish the spasms, chloral may be 
 listered internally, or chloroform inhaled, or cocaine sprayed on the 
 i. All the nourishment that the patient car, possibly take should be 
 listered, with the addition of stimulants. 
 
 Anthrax. 
 
 is disease results from infection with the Bacillus antlinicis, which produces 
 »ep and cattle the so-called 'splenic fever.' In man, if the microbe is 
 lated through the skin, it produces a form of carbuncle known as a 
 gnant pustule,' although occasionally a more diffuse condition termed 
 rax oedema ' arises from local infection ; whilst if the virus is absorbed by 
 jngs or intestinal canal, it originates a general inflammatory disorder, 
 n as ' woolsorters' disease,' or anthracaemia 
 t Bacillus anthiacis (Fig. 14) is one of the largest of the pathogenic 
 
 
 :4.- -lUciLLUs Anthracis, from 
 iPLKNic Pulp of Infected 
 
 ,NIM.'\L. X 1,200. (CrOOKSHANK'S 
 
 Tkxtbook of Bacteriology.') 
 
 
 
 _M£l 
 
 Fig. 15. — Bacillus Anthracis in 
 THE Substance of the Kidney, 
 TO show how the Tissues 
 BECOME Infiltrated by it. 
 X 600. (Crook':hank's 'Text- 
 book OK Bacteriology.') 
 
 sms, measuring 5 to 20 /t in length, and i to i-5( /t in breadth. It is 
 |in the blood of diseased animals in the form of rod ; or threads, composed 
 
 iriable number of individual elements (from twc' to ten). It is aerobic, 
 le, grows best at about blood-heat, and liquefies gelatine. Well-marked 
 
 are formed within the bacillus when cultivated artificially and in the 
 
 Ice of oxygen ; but spore formation has not been observed in the living 
 The bacilli are readily killed by boiling for a "ew seconds, whilst the 
 
 losition of the carcase in which they are present causes tueir death in 
 I week. The spores, however, are very resistant ; for whilst a i per 
 lution of carbolic acid kills the bacilli in two minutes, the spores remain 
 
 ifter a week's immersion. Moreover, alcohol and eien a 5 per cent. 
 of carbolic acid have no effect on them. If a mouse is inoculated, say, 
 
 [•oot of the tail with a needle the point of which has been dipped in the 
 )f an animal which died of splenic fever, it succumbs in less than 
 
 [•four hours, and bacilli are found in nearly every organ of the body, 
 animals are immune against the attacks of anthrax, especially the dog 
 ; and one of Pasteur's most useful discoveries was that of artificially 
 
 Ing immunity for cattle and sheep by inoculating them with an at- 
 
104 
 
 A MANUAL OF SURGERY 
 
 SEPSIS, INFE 
 
 tenuated virus, obtained by exposing a cultivation for some time to a hi^;i:| 
 temperature. 
 
 Symptoms. — Infection with this organism usually occurs amongst grazierl 
 who tend the living animal, or butchers who deal with the carcase ; it is alMj| 
 met with amongst workers in hides or wool. 
 
 Malignant Pustule commences as an angry red pimple at the site of incxiil 
 lation, which rapidly spreads, with much infiltration of the base, whilst thj 
 centre becomes covered with vesicles, the serum within which contains the! 
 typical bacilli. There is no pain associated with this stage, but only greail 
 itching and irritation. As the pustule extends, the central part becomes grtv,r 
 and finally black, constituting an eschar or slough, whilst around it upon aji 
 area of deep brawny congestion and oedema is a narrow ring of vesicles. The) 
 process gradually becomes more marked locally, whilst the lymphatic glandif 
 and vessels are also enlarged and involved in the disease. Generally, there isi 
 a certain amount of fever and malaise, which does not become pronounced 
 until about the fourth day. The temperature then rises to 102° or 103° F., the! 
 pulse becomes rapid and irregular, the respirations shallow and embarrasstl, j 
 whilst signs of grave constitutional mischief, such as delirium or coma, maail 
 fest themff^lves. If no treatment is adopted, or if it be undertaken toolaie.f 
 the unfortunate individual rapidly succumbs, generally in less than a wetsl 
 from the onset, but sometimes in thirty to forty hours. Occasionally a easel 
 runs a more favourable course, limiting itself to the local manifestations, which | 
 gradually clear up, the slough separating and the oedema disappearing. 
 
 Anthrax cvdcma runs a rapidly fatal course ; it is usually seen about the face! 
 and eyelids, the skin becoming red and brawny, as in erysipelas, and after al 
 time covered with vesicles, whilst finally gangrenous patches appear. The I 
 lymphatic trunks and glands are also involved. 
 
 Woolsorters' Disease (or anthracajmia) is the term applied to the general] 
 condition resulting from the development of these bacilli in the body withuuil 
 any external lesion. The virus gains access to the system either by swallowing I 
 or inhaling the dried spores. If they enter the respiratory tract, the patient 
 complains of fever and malaise for a few days, followed by the development 
 of a sero-fibrinous pleuro-pneumonia, the exudation containing large numbers oi 
 bacilli. This runs a rapid course, with high fever, great dyspnoea, impairment 
 of the circulation, and finally collapse. If the bacilli enter the stomach, they 
 are usually destroyed by the acid chyme ; but should any of them or their | 
 spores reach the intestine, the alkaline contents form a suitable breedins 
 ground, and the walls of the gut are soon attacked and the disease becomes I 
 general. Colic, cramps, vomiting, and blood-stained diarrhoea are the most | 
 marked features in such a case. 
 
 The Treatment must be active and energetic where possible. In the local I 
 affection, excision of the necrotic patch, and of all the infiltrated tissues 
 around, and the application of the actual cautery or of pure carbolic acid, are 
 the only hope. For the general disease merely symptomatic treatment can k 
 adopted. De-emetised ipecacuanha has been much recommended, both as a | 
 local application after excision, and also internally in woolsorters' disease. 
 
 We now come to a group of diseases which have been classified 
 by Virchow under the term Infective Granulomata. They are all 
 characterized by the formation of growths moie or less resembling; 
 granulation tissue, whicn either persist or undergo various de- 
 generative changes. They are all infective in nature, and most 
 of them chronic in their progress, although acute manifestations 
 are occasionally met with. Five conditions are included unckr 
 this heading, viz. : Syphilis, Tuberculosis, Glanders, Leprosy, 
 and Actinomycosis. Syphilis is dealt with elsewhere (Chapter 
 
 XXXIX.). 
 
 The remaining four must be described here. 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 105 
 
 Tuberculosis. 
 
 By tuberculosis is meant a condition resulting from the develop- 
 ment within the tissues of the body of certain definite anatomical 
 structures, known as tubercles, and caused by the growth and 
 activity of the Bacillus tubevculosis. Before the fact was established 
 hat such lesions were due to a micro-organism, they were usually 
 termed strumous or scrofulous, and even at the present day these 
 two names are occasionally employed to indicate that condition 
 of constitutional weakness which predisposes to the appearance of 
 tuberculous disease. It is better, however, to avoid the use of 
 such misleading terms. 
 
 etiology. — I. The individual is often predisposed to the develop- 
 ment of this disease by some inherited weakness, as indicated by 
 the fact that parents, relations, or ancestors have suffered from 
 some similar affection, or that it has occurred in other branches 
 of the same family. It is becoming doubtful, however, whether 
 heredity plays such an important part as was formerly attributed 
 to it, and whether the disease is not much more commonly due to 
 direct infection. Considerable ingenuity has been exercised in 
 describing \arious types of physiognomy supposed to be charac- 
 teristic of a tuberculous inheritance, and although not always 
 present, these appearances are not unfrequently observed. Two 
 chief varieties are described, viz., the sanguine and the phlegmatic. 
 In the former, the individual is slight and well proportioned, 
 possessing a thin, delicate skin, often freckled, and so transparent 
 that the subcutaneous veins are readily seen. The hair is fine 
 and auburn-coloured, or even reddish, the conjunctivae are thin 
 and pearly, the eyelashes well developed, and the fingers long 
 and tapering. Such children are usually excitable and precocious 
 in their habits, and possess taking manners. The phlegmatic type 
 is characterized by a short, stunted stature, with somewhat coiirse 
 features, and strong though somewhat short limbs. The skin is 
 coarse and muddy-looking, the lips thick, the hair rough and 
 brown. In children of either type there is a considerable tendency 
 to the development of eczema, inflammation of the mucous mem- 
 branes, and a subacute enlargement of the lymphatic glands, all 
 of which are simple in nature, but may constitute a suitable nidus 
 for the development of tubercle, especially if the child is run down 
 by some preceding illness, such as measles or scarlet fever. They 
 also suffer frequently from cracked lips, and as a result of the 
 irritation caused thereby considerable infiltration and thickening 
 may follow. Although tuberculous disease is most frequently 
 seen in young people or children, no age is exempt from its 
 attacks, even elderly persons being affected by what is known 
 as 'senile tuberculosis.' These senile manifestations differ in no 
 ^vay from those met with in the young. 
 
io6 
 
 A MANUAL OF SURGERY 
 
 1. Unhealthy siivroundings and had hygiene certainly predispose to 
 its development ; hence it is seen, perhaps, in its severest forms 
 amongst the poor, although it is only too common amongst the 
 rich, arising usually from improper feeding and want of fresh air 
 in the case of children, and not unfrequently from faulty hygiene 
 or carelessness, especially as to judicious clothing, in adults. 
 
 3. A local nidus suitable for the development of the micro- 
 organism usually exists, although tuberculous infection occasion- 
 ally follows wounds and punctures in previously healthy parts, 
 Thus, as already mentioned, lymphatic glands in a condition 
 of chronic enlargement and hyperaemia form a suitable breedini;- 
 ground for the bacillus, as also bones and joints which are in a 
 state of congestion as a result of slight and often overlooked 
 injuries. '^ y^y 
 
 4. The [ultimate exciting cause of tuberculosis is the develop- 
 
 Fig. 16. — Bacillus Tuberculosis in and around Giant Cell. (Crook-| 
 shank's ' Textbook of Bacteriology.') 
 
 ment within the tissues of the Bacillus tuberculosis (Fig. 16). Thisl 
 organism, which was originally isolated by Koch, is always present, 
 though not always recognisable, in the products of the disease,! 
 It exists in the form of fine straight rods, the individual bacilli I 
 being 2 /x to 5 /u. in length, and '2 /m to "3 /x in breadth. They arel 
 always cultivated artificially with difficulty, growing best onj 
 glycerine agar-agar, and only slowly on coagula'ted blood seriiirJ 
 at the temperature of the body. The colonies produced consistl 
 of yellowish-white or greyish scales, more or less cheesy inj 
 appearance. The organism gains admission to the system either I 
 through some abrasion of the skin, or by the digestive tract witlij 
 some article of food, especially milk, or by inhalation, its presence! 
 in the dust of rooms occupied by phthisical individuals havingi 
 been frequently demonstrated, and being due to the desiccation of| 
 Ih.e sputum. 
 
 The infective nature of the disease has been abundantly! 
 
• 5 
 
(N 
 
 •/. 
 
 o 
 
 •«n 
 
 
 
 DCS 
 
 ^ 2 S « 
 
 W I- -M (1, 
 
 (1. (U (U 
 
 "1 O c? P r 
 
 U 
 
 ■*^"r-._ ' V^'A^- 
 
 ^^-r:' 
 
 rt -M C tZ 
 
 rt E 
 
 o C^ 
 
 
 « '7, 
 
 w J3 5 cc 
 
 ">^' 
 
 SEPSIS, INF 
 
 ;t3 .: 
 
 -n .2 c ♦'^ 
 
 demonstrated by clii 
 few jears. Thus, it 
 animals, especially to 
 of the eye of the rat 
 fact that the growth 
 watched, and that s 
 region. Transmissic 
 frequently occurred 
 abrasion of the skin, 
 been wounded whils 
 well-known example 
 were infected with tu 
 the rite of circumci 
 arrested by suction, 
 stage of consurnptioi 
 tuberculosis, whilst ot 
 penis or disease of tli 
 phthisical patients, oi 
 thorough disinfection. 
 Pathological Anatoi 
 idevelopment of the sc 
 [together, and produce 
 hanges, whilst the tisi 
 isappear, being repla( 
 which the tuberculc 
 Miliary tubercles ca 
 lemi-translucent nodu 
 he process which le; 
 lences in or around 
 tudied in the pia mat( 
 ioine area of lowered 
 ads to an overgrow 
 indarteritis, which m 
 rn is followed by a p 
 
 jig connective tissues 
 fessei, and the format] 
 
 I the earlier stages a 
 lective-tissue cells, di: 
 loodvessel, thus givin 
 \k styiicture of a full; 
 [illows : In the centre 
 
 f nuclei, which are oft 
 kether at one or oth( 
 [ant cell, and form a 
 jtuated the cells of 
 Irger than ordinary U 
 larly-defined oval nu 
 Ihough they are d 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 107 
 
 demonstrated by clinical and experimental work during the last 
 
 few years. Thus, it can be readily transmitted by inoculation to 
 
 animals, especially to rabbits and guinea-pigs, the anterior chamber 
 
 of the eye of the rabbit being a very favourite spot, owing to the 
 
 fact that the growth of the characteristic neoplasm can be readily 
 
 watched, and that spontaneous tuberculosis never occurs in this 
 
 rei,non. Transmission of the disease to the human subject has 
 
 frequently occurred from direct inoculation through a puncture or 
 
 abrasion of the skin, as in the case of surgeons whose fingers have 
 
 been wounded whilst operating on tuberculous cases. Another 
 
 well-known example is that in which a number of Jewish children 
 
 were infected with tuberculous disease by the Rabbi who performed 
 
 the rite of circumcision. The bleeding in this ceremony is 
 
 larrested by suction, and in this case the Rabbi was in the last 
 
 [stage of consumption. Several of the infants died from acute 
 
 Ituberculosis, whilst others developed tuberculous ulceration of the 
 
 Ipeiiis or disease of the inguinal glands. The risk of living with 
 
 Iphthisical patients, or of occupying their rooms without previous 
 
 Ithorough disinfection, is also fully admitted at the present day. 
 
 I Pathological Anatomy. — The tuberculous process consists in the 
 
 Idevelopment of the so-called grey or miliary tubercles, which run 
 
 ■together, and produce larger masses, and these undergo secondary 
 
 ■changes, whilst the tissues invaded become inflamed and gradually 
 
 ■disappear, being replaced by pulpy granulation tissue, in the midst 
 
 If which the tuberculous foci can be seen. 
 
 I Miliary tubercles can be recognised by the naked eye as greyish, 
 ■emi-translucent nodules, rarely exceeding a millet-seed in size. 
 ■The process which leads to their formation almost always com- 
 ■lences in or around the small vessels, and can perhaps be best 
 Itiidied in the pia mater. The bacilli are presumably brought to 
 Mine area of lowered vitality, settling in the tunica intima. This 
 leads to an overgrowth of th'^ endothelial elements — i.£., to an 
 ■ndarteritis, which may spread for some distance — and this in 
 ■iirn is followed by a proliferation and infiltration of the surround- 
 Big connective tissues, resulting in the obliteration of the affected 
 ■essel, and the formation of the characteristic tuberculous nodule. 
 In the earlier stages all that is seen is an ill-defined mass of con- 
 ■ective-tissue cells, distinctly nucleated, and aggregated around a 
 ■lood vessel, thus giving rise to no very characteristic appearances. 
 Mk structure of a fully-developed tubercle (Plate II., Fig. i) is as 
 Blows : In the centre lies a giant cell, containing a large number 
 ■ nuclei, which are often arranged around its periphery, or grouped 
 Bgether at one or other pole. Delicate processes extend from the 
 ■ant cell, and form a fine network, in the meshes of which are 
 ■tuated the cells of the surrounding zone. These are rather 
 ■rger than ordinary leucocytes, with a granular protoplasm and a 
 ■early-defined oval nucleus. They are known as epithelioid cells, 
 ■though they are derived from the neighbouring connective 
 
 
io8 
 
 A MANUAL OF SURGERY 
 
 SEPSIS, INFECTl 
 
 tissues, and are, in fact, identical with fibroblasts. Around thei 
 are collected a large number of smaller cells, probably leucocyte! 
 and these merge into the surrounding structures, which an 
 gradually changed into granulation or fibro-cicatricial tissue. l| 
 many cases the giant cell is absent, and, indeed, it must in no wa 
 be looked upon as a characteristic feature of tubercle, since siicl 
 cells are often met with in syphilis and other conditions wheif 
 active tissue changes are taking place. Its origin is a littl 
 doubtful, but it is probably derived from an enlargement of or{ 
 connective-tissue corpuscle, or by the union of several such cell! 
 No vessels are present in the tuberculous neoplasm, and as a resuj 
 degenerative changes are certain to follow. Not unfrequentlvF 
 number of these tubercles develop close together, and under the^ 
 circumstances the intervening structures disappear, being 
 placed by granulation tissue, which may in part become furthJ 
 transformed into cicatricial tissue. By the use of appropriaj 
 staining reagents it can be demonstrated that bi.cilli are preseJ 
 in the giant cell, and sometimes in the zone of epithelioid cell 
 surrounding it (Fig. i6), but as soon as degenerative chang| 
 commence, the organisms can no longer be recognised. 
 
 If the disease progresses, caseation always ensues, owiii 
 partly to the defective nutrition of the neoplasm, partly to tli 
 specific action of the bacillus or its products. Not only dol 
 the centre of the miliary tubercle undergo this change, but aM 
 the granulation tissue around or between the separate nodulej 
 A caseating focus of yellow or crude tubercle, as it used to 
 termed, consists of a degenerating centre surrounded by a zonej 
 granulation or fibro-cicatricial tissue, in which are scattera 
 miliary tubercles, and which in turn gradually runs into nornil 
 tissue (Plate II., Fig. 2). 
 
 The ultimate result of this process depends to a large extent ( 
 the general health of the individual and the treatment which 
 adopted. 
 
 1. If the parts are kept at rest, and free from external iiritj 
 tion, and if the constitutional weakness is combated by suitalj 
 measures, the destructive process may come to an end. 
 such a case the peripheral layer of granulations is converted mi 
 dense fibro-cicatricial tissue, which forms a sort of capsule, an 
 checks the advance of the disease. The caseous material is eithi 
 remo\'ed by an invasion of leucocytes, or becomes calcified, usuaU 
 leaving a firm fibrous nodule, perhaps interspersed with calcareoj 
 particles. Possibly some of the tuberculous material persists in 
 latent state in this mass, like an ' extinct volcano,' ready to 
 lighted up into activity if the opportunity is given. In 
 advanced cases the diseased tissue may be so completely removj 
 as to leave scarcely any trace of its existence behind. 
 
 2. The caseous material is often transformed into a yellowij 
 fluid, usually known as pus, by a process of emulsification, diicj 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 109 
 
 absorption of fluid from the hyperaeniic tissues around, and 
 Iting either from mechanical causes, or more probably from 
 ictivity of the tuberculous organisms, or possibly from infec- 
 with ordinary pyogenic or septic bacteria. In such cases a 
 mic or subacute tuberculous abscess results, the structure and 
 acters of which have been already described (p. 35). 
 ne of the chief features of tuberculous disease is its great 
 iency to diffusion. This may occur (a) locally, by direct con- 
 ity of tissue, or by extension along neighbouring lymphatics or 
 idvessels ; or (h) distant viscera or organs may become infected, 
 lably through dissemination by the bloodvessels. Thus 
 lisis is a not uncommon sequence of a similar affection of 
 es, joints, or lymphatic glands, (c) Moreover, any tuberculous 
 )n may lead to acute geneval tuberculosis, in which the disease is 
 :tered widely throughout the body, giving rise to rapid emacia- 
 1, high fever of an intermittent type, and usually severe 
 rha'a, dyspnoea, and delirium or coma, death ensuing in a few 
 ;ks. 
 
 'reatment. — It must be fully recognised that tuberculosis is an 
 ctious, and therefore, to a large extent, a preventable disease, 
 I it is the duty of all medical practitioners to do everything in 
 ir power to limit its ravages. We cannot here enter into this 
 iject, but would merely mention the dangers to the general 
 )lic arising from the distribution of milk obtained from tuber- 
 bus cows, and from the indiscriminate expectoration of tuber- 
 )us sputum. 
 
 !urative treatment is based on the assumption that natural 
 
 cesses of repair have a considerable influence upon the course 
 
 he disease. When Koch first discovered the bacillus, a great 
 
 ietus was given to surgical treatment, and some authorities 
 
 It so far as to maintain that it was as necessary to extirpate 
 
 ry particle of diseased tissue as in a case of cancer. The 
 
 duluin has now slowly swung back, and we are more and 
 
 e endeavouring to promote healthy repair of the lesions by 
 
 stitutional measures. The value of an abundance of fresh air 
 
 illy admitted, and many sanatoria for the open-air treatment of 
 
 lisis and other tuberculous lesions are being built or planned. 
 
 lis country residence by the seaside, especially in such bracing 
 
 es as Margate, or, if that be too cold, Ramsgate, Bournemouth, 
 
 entnor, is usually recommended. At the sam^ time, plenty 
 
 ood food, such as milk and eggs, must be taken. Local foci 
 
 Id be kept at rest, and, if the disease is external, elevation 
 
 steady pressure (as by Scott's dressing) are desirable acces- 
 
 On the other hand, if a tuberculous lesion is suffi'^iently 
 
 ized and suitably situated, as when it occurs in the lymphatic 
 
 ds of the neck, total excision is the ideal treatment, although 
 
 las sometimes to be satisfied with scraping. In this process 
 
 possibility of disseminating the disease by too vigorous 
 
 ?s. 
 
no 
 
 A MANUAL OF SURGERY 
 
 SEPSIS, INFECl 
 
 manipulations must not be overlooked. Any open tuherculou 
 sores should be well scraped, and the surface then swabbed o\| 
 with liquefied carbolic acid, and dressed with gauze soaked in ; 
 iodoform emulsion. 
 
 The manifestations of tubercle as it affects special organs ail 
 dealt with elsewhere under the appropriate headings (see diseasj 
 of skin, bones, joints, lymphatic glands, kidney, testis, etc.). 
 
 ! 1 
 
 Olanders. 
 
 Glanders is primarily a disease of the horse, ass, or mule, which is tram 
 mitted to men by direct inoculation, and hence is usually seen only in stabj 
 attendants and those brought in contact with such animals. It is characterize 
 by the development of inflammatory swellings under the mucous meml)rane( 
 the respiratory tract, which break down and ulcerate, and by the formation] 
 similar growths, embolic in origin, in the lungs and other viscera. 
 
 There is now no doubt that the disease is due to a definite micro-or^anisiJ 
 the Bacillus mallei, which was isolated about 1882 by Schutz and Loftier, aii 
 has since been cultivated outside the body ; the experimental evidence as toil 
 being the cause of the malady is quite complete. 
 
 In Horses and other animals, glanders manifests itself by a formation 
 larger or smaller rounded swellings in the mucous membrane of the nosj 
 which break down and ulcerate, giving rise to a thin, sero-purulent dischargi 
 and perhaps destruction of the bones and cartilages. The lymphatic gland 
 especially those under the jaw, early become enlarged, constituting the ' fare! 
 buds ' of farriers, and by their ulceration may leave ragged, foul sores. Ta 
 lymphatic trunks to and from the glands are involved (' corded veins '), whill 
 the lungs and internal viscera may also be infected, and undergo destrucdJ 
 changes, usually ending in suppuration. The disease runs either an acui 
 course, killing in six or twelve days, or is more frequently chronic, lastiq 
 perhaps for years. 
 
 In Man, glanders usually starts about the hands and face, but occasionally] 
 the nasal mucous membrane. In acute cases the incubation period lasts froj 
 three to five days, and is succeeded by the occurrence of malaise and febrij 
 disturbance, followed by severe pains in the bones and joints. The site i 
 inoculation becomes swollen and infiltrated, and suppuration and ulceratid 
 follow. The lymphatics leading from this to the nearest glands are enlarga 
 and inflamed. These phenomena are succeeded by an eruption of papula 
 whicli somewhat resemble those of small-pox, but each papule goes on to tU 
 formation of an ecthymatous-looking ulcer. It is not an uncommon feature^ 
 these sores, when placed over a bony surface, to involve the periosteum andl; 
 bare the subjacent bone. Similar changes occur in the viscera, muscles, anj 
 joints, and these being associated with high fever of an asthenic type, maj 
 suggest the existence of pya;mia. In such cases death may ensue in seven I 
 ten days. 
 
 In Chronic Glanders similar symptoms are met with, but the course 
 slower; there is little or no fever; the disease is less extensive, and intej 
 missions are not uncommon. Total recovery is stated to occur in 50 per cen 
 of the cases. 
 
 It is important to determine the Diagnosis as early as possible, in order I 
 undertake energetic local treatment. The local lesions are distinguished frol 
 small-pox by the presence of the characteristic bacilli in the discharge, by tif 
 fact that they more extensively involve the subcutaneous tissues, and by tn 
 absence of umbilication. Chronic cases resemble syphilis and tuberculosis, hi 
 the history of exposure to infection from animals suffering from the disease f 
 most important, as also the result of cultivations made from the dischargi 
 When the bacilli are grown on potatoes, a colony of a yellowish, honey-lif 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 in 
 
 •acter forms in two or three days, which gradually turns to a chocolate- 
 vn colour. 
 
 reatment in acute cases can be of use only when undertaken early, and 
 ire general infection has ensued. The local foci should be thoroughly 
 rpated, either by the knife or by scraping and applying some active 
 lerizing agent. The same treatment must be adopted in chronic cases, 
 may then need frequent repetition. 
 
 Leprosy. 
 
 fprosy (syn.: lepra, or elephantiasis Grcecofum) is a general infective disease 
 to the Bacillus lepra, characterized by the formation of granulation-like 
 plasms, which arise primarily in connection with the skin and nerves. 
 ;he bacilli of leprosy closely resemble those of tubercle, being .j to 6 /i long 
 I I )i broad (Fig. 17). They are 
 ined by most of the ordinary 
 ihods of demonstrating bacteria, 
 1 are found in abundance in the 
 iues; but the disease has not yet 
 in transmitted to animals. 
 Leprosy, though formerly common 
 this country, is now but rarely 
 a, and has then been imported. 
 Iceland, Norway, Russia, and the 
 isi it is still frequently met with, 
 lough the compulsory separation 
 epens enforced in Norway is much 
 Dinishing the number in that coun- 
 , It is apparently contagious, 
 lugh this is denied by some 
 ihorities ; and there is consider- 
 ledifliculty in settling the matter, 
 ing to the unusually long incuba- 
 iperiod — perhaps years. Opinions 
 fer also as to whether or not it is 
 ismitted by heredity : and although 
 
 to a recent period it was generally conceded that the father could pass 
 in, even this is somewhat doubtful. 
 
 jrmptoms. — Two chief varieties of leprosy exist, viz., the tuberculated, and 
 
 anaesthetic, or non-tuberculated ; but the two are often associated. 
 
 ^berculated or Cutaneous Leprosy is the form most commonly seen in 
 
 rope. Nothing may be noticed for months or years after exposure to the 
 
 itagion, and then, after a period of malaise, associated with dyspepsia, 
 
 rrhcea, and drowsiness, a distinct febrile attack is noted, lasting for days 
 
 »eeks ; it may be ushered in by a rigor, and the temperature is usually of 
 
 Emittent type. This is followed by, or associated with, the appearance of 
 
 red, hyperaimic spots, which are from the first infiltrated, slightly 
 
 d, and hyperaesthetic ; they are usually situated on the forehead or 
 
 ks, on the outer side of the thighs, or on the front of the forearms. They 
 
 fade away and disappear entirely, and then again become evident, or 
 
 1 patches may be developed, and always with febrile symptoms. After a 
 
 iable period ' tuberculation ' ensues ; numbers of little pink nodules form 
 
 the site of one or more of the erythematous patches, and these gradually 
 
 tease in size and coalesce, until possibly they become as large as a walnut 
 
 len's egg, and are then of a brownish-yellow colour. Almost any part of 
 
 surface of the body may be invaded in this manner, but the face is 
 
 daily prone to be involved, and the resulting disfigurement is very 
 
 ked, a curious leonine appearance being imparted to the features. The 
 
 ules are more or less anaesthetic from the pressure of the infiltration on 
 
 Fig. 
 
 17. — Leprosy Bacilli contained 
 WITHIN Epithelial Cells. 
 
 t\ 
 
113 
 
 A MANUAL OF SURGERY 
 
 the nerves, and the ultimate result of the process may vary considemli!; 
 resohition sometimes occurs, or the nothiles may he transformed into if 
 pressed and ni^jmented cicatrices, or ulceration may ensue. Visceral oin 
 
 EUcations and enlargement of the lymphatic glands follow, any fresh depus 
 eing associated with febrile phenomena. The testes atrophy, and sevm 
 f)ower is lost in both sexes. Death is usually due to septic phennmeni 
 aryntjeal obstruction, or disease of the lungs or kidneys; but the patient ma 
 live for many years. 
 
 The nodules consist of masses of granulation tissue, and scattered throiij; 
 them are numbers of large cells, containing multitudes of bacilli (V\fi r 
 Considerable difficulty exists m cultivating these organisms, but Ducrevh; 
 succeeded by using an alkaline medium, and excluding air. 
 
 Anaesthetic, or Non-tuberculated, Leprosy is the most common form mi 
 with in hot climates. The earliest phenomena consist in a certain amount 
 malaise without appreciable fever, together with sharp tingling or lancinai::i 
 pains and tenderness along the course of certain peripheral nerves. The iiln 
 median, peroneal, and saphenous nerves are those most often affected. Thi 
 is followed by muscular weakness, running on finally to paralysis, varim 
 modifications of sensation, and trophic phenomena, involving at first onlyt! 
 
 SHPSIS, INFEC 
 
 The fungus is transmit! 
 lost often within the husk 
 [jaw, turning these into 
 iitli'), in which, after a ti 
 laltiple abscesses, which 
 latory mass riddled with 
 iual type, but in addition 
 (isolated by the fingers, a 
 mj; calcareous changes. 
 e finds in the interior ; 
 hich are arranged more 
 lere is a layer of club-sh; 
 (ntre in a very tvnical fas! 
 
 V\r,. i8. — An/T.sthetic Leprosy ok the Hand, producing Contractio: 
 THE Fingers, together with Trophic Sores and Absorption ok ti^ 
 1'halanges. 
 
 skin, but later on attacking bones, joints and muscles Circular yellowisl 
 white patches are observed in the skin, spreading peripherally, and tendingf 
 run together, forming large irregular ovals; the border is often raised, aij 
 hypersensitive, but the central portions become atrophic, dry, white, aii 
 anaesthetic. The anaesthesia gradually spreads, and serious lesions, partly di 
 to trauma, partly arising from trophic changes, result. The muscles atroplj 
 and contract, and give rise to deformity, the hands sometimes becomii 
 markedly 'clawed,' as in ulnar paralysis (Fig. i8). Intei-.tiMal absorption | 
 the bones of the peripheral portions of the limbs may le-id ilie fingers, ta 
 and other portions to shrivel up and disappear, preceded by ankylosis of tl 
 joints. The affected nerves can usually be felt distinct'y ..r'.arged and tenda 
 Visceral lesions are not so marked in this as in the other fc/rm of the diseai 
 and the patient may retain a considerable degree of health and strengtl 
 whilst his sexual powers are not much interfered with. Finally he dies frof 
 general debility, or from various complications, but the case may last twenl 
 or more years. 
 
 The Treatment is still very unsatisfactory. Chaulmoogra oil, administer^ 
 both internally and externally, is the drug most frequently depended on,' 
 latterly intra-muscular injections of sublimate have been employed with soij 
 success. 
 
 Actinomycosis. 
 
 Actinomycosis is a disease mainly of cattle, but occasionally seen in ma| 
 due to the growth of the ray fungus (actinontyces). 
 
 
 19.— Actinomyces in 
 
 jln Man the disease occui 
 
 Itention was first drawn to 
 
 |e fungus from chewing o: 
 
 1st during the process of g 
 
 fd maxilla, causing dififuse 
 
 alized empyemata have 
 
 «ciaily about the cajcum 
 
 poiogical phenomena ma 
 
 Rlized tumour, in the ja 
 
 pltrating mass, in which a 
 
 ■ affected equally with th 
 
 'process is not dangeroi 
 
 pns, or by septic contami 
 
 i'e of the jaw (Fig. 20), c 
 
 p of which is tolerably 
 
 iilar, and even surface, ar 
 
 iskin over it is usually 
 
 wnces, with a peculiar y 
 
SEPSIS, INFECTION, AND INFECTIVE DISEASES 
 
 "3 
 
 The fungus is transmitted to animals with their food, having been found 
 35t often within the husk, or sheath, of barley. It usually attacks the tongue 
 jaw, turning these into hanl infiltrated masses (the ' wooden tongue ' of 
 tile), in which, after a time, suppuration at many foci appears, producing 
 ultiple abscesses, which discharge externally, and leave a diffuse inrtam- 
 jtory mass riddled with sinuses. The pus from such abscesses is of the 
 mal type, but in addition contains firm yellowish gritty bodies, which can 
 [isolated by the fingers, and consist of masses of the fungus, perhnps under- 
 jing calcareous changes. On microscopic examination of these L(jllections, 
 (e finds in the interior an abundant mycelial development, the iibres of 
 ihich are arranged more or less in a radiating fashion, whilst peripherally 
 liere is a layer of club-shaped bodies or processes which radiate from the 
 intre in a very typical fashion (Fig. 19). 
 
 •-U|— ^'^^ ^ 9 
 
 flG. KJ.-ACTINOMVCE.S IN TISSUES. (FrOM CrOOKSHANk's ' TEXTBOOK OK 
 
 Bacteriology.') 
 
 Iln Man the disease occurs much more commonly than was expected when 
 
 llention was first drawn to it, and is probably due to direct inoculation with 
 
 le fundus from chewing or eating fresh corn, or by inhaling the spores with 
 
 |st during the process of grinding corn. It has been found in the tongue 
 
 1 maxilla, causing diffuse induration and suppuration; in the lungs, where 
 
 alized empyemata have resulted ; in various parts of the intestinal canal, 
 
 «cially about the caecum ; and in the skin. Wherever situated, the same 
 
 |ithological phenomena manifest themselves, viz., either the formation of a 
 
 alized tumour, in the jaw possibly simulating an epulis, or of a diffuse 
 
 [filtrating mass, in which abscesses form and open at many spots. The bones 
 
 : affected equally with the soft parts, and may become cariou 5. In itself 
 
 : process is not dangerous, but may become so by involving important 
 
 feans, or by septic contamination. The commonest site for it is close to the 
 
 ]gle of the jaw (Fig. 20), constituting a cervico- facial tumour, the appear- 
 
 of which is tolerably characteristic. At first the mass has a smooth, 
 
 Jilar, and even surface, and merges gradually into the surrounding tissues ; 
 
 skin over it is usually hyperaemic. As time passes, little nodular ex- 
 
 wnces, with a peculiar yellowish apex, form here and there on the surface 
 
 8 
 
114 
 
 A MANUAL OF SURGERY 
 
 of the tumour, and these finally soften, point, and burst, giving exit to a sma 
 amount of glutinous pus, in which the actinomycotic nodules can be demon 
 strated. When all the fur^us has been discharged, the abscess contract^ 
 and the wouD 1 closes. The cicatrization induced by the constant repetition!; 
 this process makes the surface of the mass curiously nodular and puckers 
 and this condition, when present, is almost pathognomonic. Trismus is ; 
 exceedingly constant symptom in the cervico-facial form of the disease, comii 
 
 Fig. 20.— Cervico-Facial Actinomvcosis. (Bv kind Permission ofi 
 
 Mr. Malcolm Morris.) 
 
 on early, and being apparently independent of the size of the mass or] 
 involvement of nerves. 
 
 The Treatment most recently advised consists in the administration of la 
 doses of iodide of potassium (grs. 20 or 30 three times a day), which seejd 
 have almost as great an influence in this disease as in syphilis. Thisalij 
 may suffice when there is no open wound ; but if open sores are pres 
 surgical measures must also be employed. Extirpation of all the infiltra 
 tissue, either by the l<nife or by vigorous scraping, should be undertaken, 
 the part freely cauterized; in fact, it must be treated in exactly the 
 way as a diffuse tubercular mass. This ca'i, however, only be very parti^ 
 carried out in the visceral affections. 
 
 Tu: 
 
 Lthough the term ' 
 Itlling which may he 
 Irposes its application 
 Itined as ' a mass of ne 
 bliout fulfilling any p: 
 Iniiiiiation.' The fact 
 l^iiishes it from infiar 
 "f or later to the for 
 jJification of it; inflf 
 Ipear completely, and ( 
 Ipeitrophies are exclu< 
 [pdid more or less on s 
 f composed of an incr 
 instance, the blacksn 
 ml) or portion of a Hm 
 Icannot be considered 
 Itlopment of normal ti 
 l^s to the Causes of t 
 f) are all in the first i 
 , ' up hy some form 
 jonnal de\'clopment of 
 Pow on the breast is 
 lation caused by smok 
 m lip, and many other 
 |reo\er, even if, as supj 
 ||a and sarcomata resul 
 irritation or breacli 
 I or determine the acti 
 N of some malignan 
 pnce of a constitutions 
 Nisposition of the pj 
 fjion is usually found 
 pl that tumours may 
 Ns of undeveloped ar 
 
CHAPTER VI. 
 
 TUMOURS AND CYSTS. 
 
 LTHOUGH the term ' tumour ' is often used for any abnormal 
 selling which may be met with in the body, yet for scientific 
 iirposes its appHcation is much more hmited. A tumour may be 
 ftined as ' a mass of new formation that tends to grow or persist, 
 ithout fulfilhng any physiological function, and with no typical 
 nuination.' The fact that it has no typical termination dis- 
 inuishes it from inflammatory overgrowths, which always lead 
 Ler or later to the formation of fibro-cicatricial tissue, or some 
 ixlification of it ; inflammatory growths, moreover, may dis- 
 [pear completely, and often temporarily diminish in size. Pure 
 [pertrophies are excluded by this definition, since they always 
 Lend more or less on some increased physiological function, and 
 I composed of an increased development of normal tissues, as, 
 I instance, the blacksmith's biceps. Congenital o\'ergrowth of 
 limb or portion of a limb also occurs, and is known a^ 'gigantism '; 
 |iiinnot be considered a tumour, being merely an exaggerated 
 lelopment of normal tissues. 
 
 ■As to the Causes of tumours, but little is known. Probably 
 pare all in the first instance local de\elopments, and ma) ')e 
 ■ted up by some form of injury or irritation, which dpi en; . - s 
 ■oniial development of some of the tissues of thc^ part- Thus, 
 Bow on the breast is often responsible for an adMo.iia; the 
 itation caused by smoking a clay pipe may produce en' the'ioma 
 ■he lip, and many other illustrations readily suggest then, selves. 
 Rreover, even if, as supposed by some pathologists, the carcino- 
 ■aand sarcomata result from jnfection, it is probable t.iat some 
 lal irritation or breach of surface is needed to allow entrance 
 ■ or determine the activity of, the organisms. The hereditary 
 ■lire of bome malignant tumours is sometimes thou^'ht lo he 
 Bence of a constitutional origin ; hvt although it may indicate 
 Btedisposition of the patient to tlieir development, sone local 
 Bdition is usually found to determine it. Cohnheim luu; sug- 
 ■ed that tumours may be due to excessive growth in small 
 ■ions of undeveloped and undifferentiated embryonic mateiial, 
 I 8—2 
 
Ii6 
 
 A MANUAL OF SURGERY 
 
 
 [shorter period of suffe 
 J The degree of mali^r 
 line the local phenon 
 Institutional symptoms 
 jcr is slow in its progn 
 kroys life merely by 
 Ircoma, on the other h 
 lowth, but the most cxf 
 jrm in the viscera. T'-., 
 
 or, as he terms them, foetal residues, left among the normal tissij"' ^ungating mass r 
 These remain in a condition of suspended activity, until soiiftthologists). (5) Sec( 
 local lesion excites their development. As an illustration may ■JUf'^o lymphatic glai 
 mentioned the fact that many branchial cysts do not appear tBchexia develops in th( 
 adult life ; evidently the embryonic cells were present from birtBt-'t! pressure of the gi 
 but required some special stimulus to call them into activity. H the absorption of toxi 
 is also probable that the presence of cartilage in many tumours Bthi" and emaciated, t 
 the parotid and testis may be explained in a similar way ; in w" <^" it ; the appetite 
 former case it is due to the inclusion of a portion of MeckeW'^'y-^ooking. (7) pij 
 cartilage ; in the latter, to the fact that the testis develops 
 the posterior abdominal wall not far from the notochord, 
 evidently cartilaginous cells from this source become inclu 
 within it. 
 
 Tumours may be divided into two great classes from a clinii 
 standpoint, viz., the benign and the malignant. 
 
 Benign or Simple Tumours are characterized by the de\eli 
 ment being strictly local, by their more or less exact limitati 
 being frequently encapsuled, and by their method of grow 
 
 which results from a proliferation of all the cells constituting tl»"' by the blood- st' rui 
 structure. There is no tendency to infiltrate or invade surrouB'"'"on in the lynipliafic 
 ing tissues, which are merely pushed aside and compressed.B '"^ans of the 1/mpna 
 pain being caused except as a result of pressure. The capsule' differences art met m 
 formed by an ensheathing layer of fibro-cellular tissue, caused »™t 'is occur both in th( 
 the chronic irritation and inflammation engendered by the gro«"'i'|'ous epithelioma ne 
 and development of the mass; hence enucleation is easy, M; viscera generally 2sca 
 recurrence uncommon. They are not unfrequently multiple, ■"^s applied to the. 
 may be hereditary : but these characters are no evidence cBt"(-e'n the malignant 
 constitutional taint. 
 
 Malignant Tumours, unless removed by operation, are ah 
 invariably fatal. The following are the chief characteristic 
 malignancy : (i) The primary growth is usually single, ra| 
 multiple. (2) It progresses steadily and constantly, but 
 varying rapidity in different cases. (3) The local developme 
 characterized by an infiltration of the surrounding tissues, w 
 are gradually replaced by the tumour substance. A capsu 
 rarely formed, or, if at all, only in the early stages, and thus| 
 limits of the growth are not clearly defined. Moreo\er, 1 
 varieties spread locally along the efferent lyn:phatics, and h 
 although the growth may appear to have been coiiipl 
 remc ed, recurrences are very common, owing to thenon-nn 
 of these prolongations (or, as they are termed by the lay pi 
 ' roots ') of the disease into apparently normal tissue. 
 malignant tumour, with all its ramifications, is compl! 
 removed, it does not recur. The impossibility of kiioj 
 whether all the growth has been removed, or liow far itj 
 extended into the surrounding tissues, is responsible fo 
 frequent recurrences. (4) When a malignant tumour in\ad 
 skin, it usually leads to ulceration, and then not uncoiniii 
 
 irhe Classification of Ti 
 
 jatomical, partly embr 
 I'ow-ing groups are descr 
 II. Tumours derived fro 
 lno\vn as the Connectiv 
 
 (i) Embryonic co 
 («) Myxom; 
 (b) Sarconic' 
 
 (2) Fully-develop 
 
 {(i) Lipoma 
 
 (b) Fibroma 
 
 Uj Chondroi 
 
 (<i) Osteoma 
 
 (e) Myoma ( 
 
 (/) Neuroma 
 
 (g) Angioma 
 
 i^i) Odontom 
 
 (0 Lyniphac 
 
 'ympi,:; 
 
 
TU?WURS AND CYSTS 
 
 117 
 
 fungating mass results (the fungus hamatodes of the older 
 ologists). (5) Secondary deposits are often found in neigh- 
 ing lymphatic glands or distant viscera. (6) An apyrexial 
 lexia develops in the later stages, partly due to the pain, partly 
 le pressure of the growth on important structures, and in part 
 le absorption of toxic products from the tumour. The patient 
 lin and emaciated, the face drawn and with an expression of 
 
 on it ; the appetite is impaired, and the skin often sallow and 
 ly-looking. (7) Finally, death ends the scene, after a longer 
 lorter period of suffering. 
 
 he degree of mali^ ancy varies with different tumours. In 
 e the local phenomena predominate, whilst in others the 
 dtutional symptoms are the more important. Thus, rodent 
 r is slow in its progress, and produces no visceral deposits ; it 
 roys life merely by implication of vital parts. Melanotic 
 onia, on the other hand, may produce only a small primary 
 ith, but the most cixt'nisi- 'ely diffused secondary deposits may 
 1 in the viscera. T\\\i Tirrcmata are very frequently dissemi- 
 (1 by the blood- st' 'lui, aiiu hence secondary growths are not 
 nion in the lyaipb.fidc g ands whilst the carcinomata spread 
 neans of the lympnatics. E\en among the latter consider- 
 
 differences art met with; thus, in glandular cancer secondary 
 vths occur both in the lymphatics and the viscera ; whilst in 
 imous epithelioma neigh Uoaimg lymphatics are affected, but 
 viscera generally sscapa. The term semi-malignant is some- 
 s applied to tho;-c; gro^/ths which are on the borderland 
 
 He 
 
 en the malignant 
 
 gro-i/ths which 
 vnd oenign. 
 
 Classification of Tumours is conducted along 
 
 on 
 
 lines partly 
 these grounds the 
 
 oinical, partly embryological, and 
 
 ing groups are described : 
 
 'umours derived from mesoblapti-- tissue, constituting what 
 own as the Connective Tissue 3:rc»r li • 
 
 (i) Embryonic connectiv 'ssue tumours : 
 
 (rt) Myxoma (mucric"* t u i-)).r). 
 
 {h) Sarcoma. 
 (2) Fully-developed ( onnecti'.e tissuf tumours: 
 
 [a) Lipoma (fatty tumour). 
 
 {b) Fibroma (fibrous timiour). 
 
 (f) Chondroir.a (cartilaginous tumour). 
 
 {d) Osteoma (bony tumour). 
 
 {e) Myoma (muscle tumour). 
 
 (/) Neuroma (tumour in connection with nerves). 
 
 {g) Angioma (tumour compo<^ed of bloodvessels). 
 
 {h) Odontoma (tu;\our connected with the teeth). 
 
 {i) Lymnhadenom,'. ox iy.t..phargioma (tumours of 
 lympiiatic origin 
 
 ' ii 1 
 
ii8 
 
 A MANUAL OF SURGERY 
 
 II. Tumours derived from epiblastic or hypoblastic structuresj 
 or Epithelial Tumours : 
 
 (i) Innocent varieties : 
 
 (a) Papilloma (wart-like growth). 
 
 (b) Adenoma (glandular new formation). 
 (2) Malignant growths, or the carcinomata : 
 
 (a) Epithelioma (cancer of skin or mucous menl 
 
 brane). 
 
 (b) Rodent ulcer (cancer of sebaceous glands). 
 
 (c) Columnar carcinoma (cancer arising from tuhulaj 
 
 glands, e.g., Lieberkiihn's follicles, or froij 
 ducts lined with columnar epithelium). 
 
 (d) Acinous carcinoma (cancer arising in glandj 
 
 with spheroidal epithelium). 
 
 I. The Connective Tissue Grc 
 composed of Embryon. ; 
 
 Tvinours: (i) Tumours 
 .nective Tissue. 
 
 Myxoma. — A myxoma is a tumour consisting of connectivl 
 tissue cells, surrounded and separated from each other by A 
 
 Fig. 21. — Myxomatous Tissue, showing the Ste ,late Cells with tmeiI 
 Bran'ching Processes separated by Translucent Interoelliu| 
 Substance. (Tillmanns.) 
 
 intercellular substance of a mucoid character ; a similar type ( 
 material occurs normally in the substance of the umbilical corJ 
 The cells are usually polygonal in shape, and present long brancliej 
 processes which interlace with those from adjacent cells (Fig. 21I 
 The intercellular substance is homogeneous and translucent, conf 
 taining wandering connective tissue corpuscles, and traversed 
 bloodvessels ; the density of the tumour varies inversely with t 
 amount of intercellular substance. It is not uncommon for i 
 form of growth to be associated with sarcoma, and hence i 
 thorough and early removal of the mass is always advisable. 
 
TUMOURS AND CYSTS 
 
 119 
 
 Myxomata occur as rounded tumours, perhaps lobulated, in the 
 eighbourhood of mucous membranes — e.g., the face, intestine, 
 nd bladder ; they also grow in the sheaths of nerves, and are the 
 ommonest form of simple tumour of the spinal cord. Mucous 
 olypi of the nose were formerly considered of this nature, but at 
 he present time rhinologists look on them as merely consisting of 
 Edematous granulation tissue. 
 
 Sarcoma (Greek, a-ap^, flesh = a flesh like tumour). — By a sar- 
 «ma is meant a tumour formed from some kind of immature or 
 pibryonic connective tissue ; that is to say, it consists of cells of 
 jarying size and shape, held together by a delicate reticulum, 
 ;hich penetrates between each of the cellular elements. The 
 tructure is, thus, not unlike that of inflammatory new formations, 
 lit differs from it in that there is a considerable tendency to 
 evelop into higher types of tissue, such as bone, cartilage, etc., 
 [though the embryonic character of the growth still persists at 
 le periphery. From carcinoma it is recognised by the fact that 
 1 all except the alveolar sarcomata the structure is more or less 
 niforni, and the cells are not grouped in alveoli separated from 
 ne another by stroma ; moreover, there is no intercellular tissue 
 etween the epithelial cells of a cancer, whereas, with suitable 
 reparation, it can always be demonstrated between the cells of a 
 ircoma. 
 
 A sarcoma always arises from pre-existing connective tissue, 
 nd hence is of mesoblastic origin ; occasionally it starts from the 
 eeper parts of the skin, but even here it is probably derived from 
 le same embryological basis. It may be at first well defined, 
 nd even in some cases encapsuled ; but many forms from the 
 rst, and all later on, infiltrate the surrounding tissues, replacing 
 em with their own particular structure, a process which can be 
 ell observed in sarcomata of muscles. The blood-supply is very 
 Hindant, and, indeed, may be so free as to cause the tumour to 
 iilsate. The vessels consist of spaces or clefts within the tumour 
 ibstance, and are lined merely by the most delicate endothelium ; 
 irteries and veins in the neighbourhood are much dilated. 
 iterstitial haemorrhage is frequent, owing to the thinness of the 
 ssel walls, and cysts may in this way be produced. Dissemina- 
 is usually dependent on the relation of the tumour to the 
 ;ins. As already stated, the veins communicate with spaces 
 jllowed out of the tumour substance ; into and along these 
 le sarcomatous tissue may bu''row, until the apex of this intra- 
 LscuJar growth projects into the lumen of a vessel in which the 
 
 ood is freely circulating. It may be detached by some slight 
 
 lechanical injury, and is thsn carried away as a malignant 
 
 iibolus ; if a large portion is set free, it may lodge in the right 
 
 *ot the heart, or in the lungs, and cause a fatal result. Smaller 
 iiboli are either detained in the lungs, or pass through into the 
 
 i 
 
120 
 
 A MANUAL OF SURGERY 
 
 general circulation, giving rise to secondary growths wherevi 
 they are arrested ; it is quite usual for general visceral implicatij 
 to be secondary to the pulmonary growths. Nothing is known ; 
 to the existence of nerves or lymphatics in sarcomata ; occasional 
 however, dissemination by way of the lymphatic glands is mi 
 with, especially in melanotic sarcoma, lympho-sarcoma, a{ 
 sarcoma of the tonsil, testis, and thyroid body. Various sccondaM 
 changes are apt to occur, e.g., fatty degeneration, mucoid softeninj 
 and hsemorrhage, whilst calcification is not uncommon. 
 
 On naked-eye examination, a sarcoma presents a more or 
 homogeneous appearance, the colour varying with the amount] 
 the blood-supply, from a greyish-white in the fibro-sarconiatal 
 a deep maroon colour in the myeloid. On scraping the c| 
 
 surface, juice, like that fromf 
 cancer, is never obtained, evj 
 when the tumour has been r| 
 moved from the body for son 
 time, and thus the cohesion 
 .he cells impaired ; a milky suj 
 stance then sometimes appeaa 
 whilst in myeloid sarcoma a slinj 
 flui'' -^scapes, but it in no \\\ 
 resembles that obtained fromf 
 cancer. 
 
 This form of malignant diseal 
 occurs most commonly in youj 
 and middle-aged people, especia| 
 affecting the first and fourth 
 cades of life ; it may also be co 
 genital. The degree of malignancy varies considerably, soij 
 forms being almost benign, or, at any rate, only locally malignaj 
 whilst others are exceedingly virulent in nature. 
 
 Sarcomata are divided artificially into the following <,froui 
 depending on the size, shape, arrangement, and character of 
 constituent cells : (a) The round-celled ; (b) the spindle-celle 
 (c) the myeloid ; (d) the alveolar ; and (c) the melanotic. 
 
 (a) Bound-celled Sarcomata (Fig. 22) consist of a mass of rou 
 cells containing a very definite circular or oval nucleus ; the intj 
 cellular substance is slight in amount, and often homogeneous! 
 character. The mass is very vascular, and may even pulsaj 
 it is soft, like granulation tissue, and usually grows rapia 
 Several subdivisions are described : (i.) The small rouiid-ai 
 sarcoma is extremely malignant, infiltrating surrounding paj 
 and early giving rise to secondary deposits ; lymphatic gla^ 
 are not unfrequently affected in this variety. Any part of 
 body may be involved, and it may be met with at any al 
 (ii.) The large round-celled sarcoma is made up of larger cells, whj 
 contain one or two large oval nuclei with an abundant protopla 
 
 Fig. 22 — Small Round -celled 
 Sarcoma infiltrating xMuscular 
 Tissue. (Tillmanns.) 
 
TUMOURS AND CYSTS 
 
 121 
 
 md. A well-marked stroma is interspersed between the cells, 
 an alveolar arrangement is sometimes present ; it occurs in 
 same position as the former, but is rather less malignant. 
 Lymphosarcoma is very similar in structure ; the cells, how- 
 , are small, and the intercellular substance is of a delicate 
 ular nature, corresponding to the retiform tissue commonly 
 nith in lymphatic glands. Such tumours grow rapidly, and 
 exceedingly malignant ; they usually start in lymphatic glands, 
 1 the lymphoid tissue of mucous membranes, and are dissemi- 
 d by means of the lymphatics. For the clinical characters of 
 e tumours, see Chapter XI. (iv.) Glioma or glio-sarcoma is 
 iably a variety of round-celled sarcoma which develops in 
 lection with the nervous system ; but there is some doubt as 
 
 Fig. 23. — Spindle-celled Sarcoma. 
 
 individual cells have been separated, and the characteristic nuclei can be 
 
 seen. 
 
 lether it should be considered a sarcoma at all. It consists 
 
 3und cells from which a number of delicate filamentous pro- 
 
 es are furnished ; they probably originate from the neuroglia, 
 
 :elis of which they much resemble. Gliomata are found grow- 
 
 rom the retina in children, forming tumours which, situated 
 
 rst v/ithin the eye, sooner or later invade the lymph spaces 
 
 ounding the bloodvessels in the orbit, and also spread back- 
 
 s along the optic nerve to the chiasma, and thence downwards 
 
 le opposite eye, or upwards to the brain. They are also 
 
 d as primary growths in the cerebral substance, and some- 
 
 s in the spinal cord. They have no general malignancy, but 
 
 destroy life as a result of their local development. 
 
 I Spindle-celled Sarcomata (Fig. 23) consist of large or small 
 
 lie cells, which are often arranged in a somewhat fasciculated 
 
 ner with a greater or less amount of intercellular substance. 
 
 n consisting of small cells, the tumour grows rapidly, and is 
 
 !r and less succulent than the round-celled variety. In 
 
 ! cases the intercellular substance is very abundant, and 
 
 )rillated in character as to cause the tumour to be known as 
 
122 
 
 A MANUAL OF SURGERY 
 
 TU, 
 
 a fihro-sarconia (the 'recurrent fibroid' of Paget). They ni»^ ° "'■^.^'^ "umbers of 
 
 originate in any part of the body, but more especially fr J''^''''^'^ in a consideral: 
 
 aponeuroses, fasciae, tendons, etc., constituting localized growtj^'^^. '^^^^ substance be 
 
 which are at first tolerably well defined, but later on invade a* , ^^^^f. ^^^y a good 
 
 infiltrate surrounding parts. When growing rapidly, the c 
 
 become less fusiform in shape, and may even approach to t| 
 
 round cell in character, after passing through a stage known 
 
 the oval- or oat-shaped sarcoma. These tumours, consistint; 
 
 small spindle cells, are usually very malignant in character, exc 
 
 when of the fibro-sarcomatous character, and then the tende 
 
 to become disseminated is less marked, although there is usu 
 
 Fig. 24. — Myeloid Sarcoma, showing the Multi-nucleated Mve 
 Cells (Myeloplaxes) lying amongst the more abundant Spi^ 
 Cells. (Green's 'Pathology.') 
 
 a considerable risk of local recurrence. The large spiiidlc-i 
 sarcomata are softer and of a deeper colour than the former, 
 grow from the fibrous tissues, and not uncommonly froinj 
 viscera. The congenital sarcoma of the kidney is of this naj 
 though some of the cells become transversely striated, lool 
 like muscle fibres ; such tumours are sometimes called ' 
 sarcomata.' 
 
 (c) Myeloid Sarcomata (Fig. 24) are characterized by the 
 
 liber of distinct nucle 
 periphery of the eel 
 rcle; they may be 
 lerous interlacing pro( 
 very evident. There 
 iiind them as in the 
 ours are soft in consi 
 tained. They are ex 
 morrhage into their su 
 with serum and a y( 
 iiring matter of the bl 
 la dark maroon colour c 
 arance of a pomegra 
 uis are always of a ch 
 nation of haematin. T 
 :omata, but rarely or n( 
 :er in the lymphatic j 
 lahly rapid, and they ma 
 oina is almost invariab: 
 icular sites, symptoms ; 
 in amount of doubt exi 
 |inc]uded amongst the sa 
 a. since their clinical his 
 progress are of a be 
 and the term ' myelc 
 i)een suggested for 
 dicating in measure 
 ire and structure. 
 Alveolar Sarcoma (Fig 
 variety in which the 
 ?rouped together in alv 
 Wed by a distinct fibr 
 '»: On microscopic 
 ation they closely resen 
 but on carefully p 
 i^ a section with a cam 
 i'rush, it will be foi 
 'he stroma sends delic 
 i:!(ations between each 
 cells. This variety 
 iiiris most commonly fo 
 ;"? from the skin, and 
 '■onally of a melanotic n 
 Melanotic Sarcoma is ] 
 
 tl] 
 
 i: 
 
TUMOURS AND CYSTS 
 
 123 
 
 f large numbers of nuilti-nucleated giant cells {myeloplax.s), 
 ded in a considerable quantity of round or spindle cells, the 
 lillular substance being usually of a gelatinous nature. The 
 id cells vary a good deal in size, but always contain a large 
 2r of distinct nuclei, which are not distributed regularly in 
 jriphery of the cell, as in the case of the giant cells of 
 :le ; they may be regular in outline, or prolonged into 
 'ous interlacing processes, although these latter are usually 
 :ry evident. There is also no definite arrangement of cells 
 d them as in the tubercular giant-cell systems. These 
 irs are soft in consistency, and or scraping a sUmy fluid is 
 led. They are exceedingly vascular, and may pulsate, 
 orrhage into their substance is common, giving rise to cysts, 
 with serum and a yellowish fibrinous clot stained with the 
 ing matter of the blood. When fresh, the growing edge is 
 lark maroon colour on section, and has been likened to the 
 ranee of a pomegranate ; when preserved in spirit, these 
 irs are always of a characteristic brown colour, owing to the 
 tion of haematin. They are the least malignant of all the 
 iiata, but rarely or never giving rise to secondary deposits, 
 in the lymphatic glands or viscera. Their growth is 
 bly rapid, and they may attain enormous dimensions. Myeloid 
 na is almost invariably found growing from bones ; for the 
 ular sites, symptoms and treatment, see Chapter XVII. A 
 n amount of doubt exists as to whether these tumours should 
 pluded amongst the sarco- 
 
 since their clinical history 
 rogress are of a benign 
 ind the term ' myeloma ' 
 een suggested for them, 
 icating in measure their 
 and structure. 
 veolar Sarcoma (Fig. 25) 
 ariety in which the cells 
 )uped together in alveoli, 
 ted by a distinct fibrous 
 On microscopic ex- 
 ion they closely resemble 
 but on carefully pen- 
 a section with a camel's- 
 rush, it will be found 
 e stroma sends delicate 
 ations between each of 
 lis. This variety of 
 is most conmionly found 
 
 
 ^(i^A 
 
 .«> 
 
 
 Fig. 25. — Alveolar Sarcoma. 
 
 (FlLLMANNS.) 
 
 The individual cells in the alveoli are 
 here apparently lying in close con- 
 tact, but in reality there is a certain 
 amount of intercellular substance 
 placed between each of them. 
 
 from the skin, and is 
 nally of a melanotic nature, and always very malignant. 
 Melanotic Sarcoma is perhaps the most virulent of all this 
 
134 
 
 A MANUAL OF SURGERY 
 
 group of tumours. It almost invariably originates from pigmented 
 structures, e.g., the deeper layers of the skin or the retina. It is, 
 however, sometimes met witli growing from the nuicous mem- 
 brane of the lips and gums. It consists of round or spindle cells, 
 often arranged in alveoli, whilst in other cases club-shaped pro. 
 cesses of epithelium may penetrate into the subjacent tissues, thus 
 causing it to resemble epithelioma. The most prominent feature 
 is the brown colour, owing to a deposit within the cells of granules 
 of melanin. The amount of this pigmentation varies consider- 
 ably, some tumours being of a deep brown or brownish -black 
 colour, and then consisting of flattened plaques, whilst others 
 are of a papillomatous nature, and show but slight discoloration, 
 especially if growing rapidly. The tumour soon spreads to the 
 nearest lymphatic glands, and secondary deposits in the \ iscera 
 follow. So great is the malignancy, that, according to Ericbsen, 
 if the primary growth has attained the size of a filbert, local! 
 treatment is of but little value. The original tumour is often not 
 very large, and the secondary deposits are similarly characterized 
 by their number rather than by their size, scarcely an organ in 
 the body being free. 
 
 Of late years a more benign type of melanosis has been described, and is 
 now well recognised by dermatologists. It usually spreads from a conj^eniiall 
 mole as a deeply pigmented patch, which may extend over an area of several] 
 square inches, and presents at first no sign of induration or infiltration ; im 
 stage microscopic examination reveals no change in texture except pigmema-l 
 tion of the deeper layers of the cutis vera. Sooner or later, a tumour developsl 
 in the centre of this patch, and may be either a sarcoma or a cancer, but mort| 
 frequently the former. It is not very rapid in its course, but if left alone «il 
 finally become disseminated. In treating this type of melanosis, it is essentialj 
 to remove every portion of pigmented tissue as well as the tumour. 
 
 Some degree of uncertainty exists as to the position which should 
 assigned to the tumour known as an endothelioma ; it originates in mesoblasiid 
 tissues, but is somewhat similar in nature to the cancers, for which, indeet' 
 it has often been mistaken. It arises from the endothelial cells of seroa^ 
 membranes, lymphatics or bloodvessels, and usually consists of columns ( 
 cells supported by a fibro-cellular stroma. It is seen most frequently arisi:! 
 from the cerebral membranes, but may also be observed in glandular orgaJi 
 such as the breast, parotid, testis, or ovary. On serous membranes it raal 
 give rise to large tumours, from which secondary deposits in glands or visceij 
 are after a time developed, but the rate of dissemination is not great. If 
 glands the tumour usually starts as a more or less cylindrical proliferation^ 
 the endothelial cells of the arterioles or lymphatics ; this gradually ewm 
 along the vessel and usually leads to its obliteration, whilst either thecellsl 
 the surrounding tissues undergo a mucoid or hyaline change ; this arrana 
 ment in cylinders or columns led to the name cyUndyoma, which was olil 
 applied to it. The tumour runs a slowly malignant course, comparable! 
 that of some of the less virulent sarcomata, and its nearest homologuej 
 probably an angio-sarcoma. 
 
 The Treatment of sarcoma consists in its removal as early ai 
 completely as possible. This may be a simple matter in caa 
 where the tumour is encapsuled, but even then recurrence is va 
 
 likely to follow 
 considerable mar' 
 growtli is more di 
 to get heyond its 
 \ery had. 
 
 In liopelessly im 
 
 been employed as 
 
 Se\eral cures ha\'( 
 
 fluid, which consi; 
 
 (lysipi'latis and Mi 
 
 intensely to.xic, anc 
 
 ;; minim, are grad 
 
 reaction usually foj 
 
 two or three such e 
 
 into the abdominal 
 
 In fa\()iiral)]e cases 
 
 I celled .sarcomata an 
 
 I ment, whilst ossifyii 
 
 [all, affected. 
 
 (2) Tumours const 
 
 Lipoma.— A fatty 
 tissue, infiltrated wi 
 differs in no respect 
 ordinary adipose ti 
 and is not \-ery freely 
 plied with blood\-esse 
 
 U'hen localized 
 m it forms a tuni 
 [soft and semi-fiuctua 
 in consistence, rour 
 and lohulated in out 
 ind if occurring in 
 subcutaneous tissues, 
 ■' " becomes dimpled 
 ife' it from side 
 Me, owmg to the 
 hat fibrous trabec, 
 fss from the capsule 
 he skin. The growth 
 siially encapsuled j 
 Wy movable; but 
 [■^posed to pressure 
 iction, as when situa. 
 1 ;i man's shoulder a 
 Jbhed by the braces, 
 ^ructures. Such grou 
 
 ( 
 
TUMOURS AND CYSTS 
 
 125 
 
 likely to follow unless the capsule is also taken away, and a 
 considti;il)li' niar;.^in of tissue beyond it. Where, however, the 
 (rrowtli is more diiTuse, the only hope lies in cutting widely, so as 
 m '^et beyond its furthest limits ; the prognosis of such cases is 
 
 very bad. 
 
 In hopelessly inoperable cases somewhat similar measures have 
 been employed as for the similar stage of cancer (vide p. 145). 
 Several cures have now been recorded from the use of Coley's 
 fluid, which consists of a sterilized culture of the Streptococcus 
 cn'sipt'latis and Micrococcus prodigiosus in bouillon. This fluid is 
 intensely toxic, and the injections, conmiencing with doses of half 
 a minim, are gradually increased up to 7 or 8 minims ; severe 
 reaction usually follows, and the surgeon should aim at obtaining 
 two or three such eftects each week. The fluid is introduced partly 
 into the abdominal wall, and partly into, or around, the tumour. 
 In fa\ourable cases the growth gradually dwindles. The spindle- 
 celled sarcomata are apparently the most suitable for this treat- 
 ment, wliilst ossifying and melano-sarcomata are but little, if at 
 jail, aflected. 
 
 (2) Tumours consisting of Fully-developed Connective Tissue. 
 
 Lipoma. — A fatty tumour is an o\ergrowth of fil)ro-cellular 
 [tissue, infiltrated with fat. On microscopical examination it 
 [differs in no respect from 
 ordinary adipose tissue, 
 and is not very freely sup- 
 plied with bloodvessels. 
 
 When localized (Fig. 
 1^6) it forms a tumour, 
 soft and semi-fluctuating 
 in consistence, rounded 
 land lobulated in outline, 
 and if occurring in the 
 [subcutaneous tissues, the 
 
 ;kin becomes dimpled on 
 
 noving it from side to 
 
 ;ide, owing to the fact 
 
 [hat fibrous trabeculae 
 
 lass from the capsule to 
 
 Iheskin. The growth is 
 
 isually encapsuled and 
 
 :eely movable ; but if 
 
 ixposed to pressure or 
 
 fiction, as when situated 
 
 ra a man's shoulder and 
 
 ibhecl by the braces, it becomes firmly adherent to surrounding 
 
 jlructures. Such growths are either single or multiple, in the 
 
 Fig. 26. -Lipoma, showing Characteristic 
 
 Lobulated Outline. (From King's 
 
 College Museum.) 
 
ia6 
 
 A MANUAL OF SURGERY 
 
 latter case perhaps occurring; in hundreds, and are most coui 
 nionly found about the trunk or tlie upper extremities. It 
 been stated that lipomata travel from one point of the both J 
 another by the action of ^'ravity, but it is somewhat duuhtfj 
 whetlier this ever occurs. Occasionally subcutaneous tuniouij 
 become pedunculated and pendulous. 
 
 Deep inter-nuiscular lipomata are sometimes met with, and tlj 
 diaj^'nosis may tlien be uncertain, since their mobility and lobulatd 
 outline are masked by the superjacent tissues ; they have evti 
 been mistaken for sarcomatous growths. Still more difiicult 
 recofi^nition are those known as parosteal lipomata, f^aowinj^^ froj 
 the outer surface of the periosteum. They are often con<,^enita| 
 and appear as soft swellings, lying beneath the muscles in cloa 
 proximity to a bone and suggesting the presence of a chronl 
 abscess- We obserxed one a httle time back growing just ahof 
 the angle of the jaw beneath the masseter. 
 
 Pericranial lipoma is of a somewhat similar nature. It is usuall 
 congenit ' in origin, and often the cranium is perforated andf 
 connection established with the meninges. An angioiuatoi] 
 element is sometimes present in these growths. 
 
 By the term Diffuse Lipoma is meant a fatty infiltration of tlJ 
 subcutaneous tissues of some region of the body, particular! 
 beneath the chin and at tiie back of the neck, and more rarely 
 the pubic region. These growths are often multiple and aliiioj 
 always synunetrical. They usually occur in individuals \\\] 
 drink freely and take but little exercise. Their size diminishj^ 
 on limiting the amount of alcohol and making the patient a 
 physical work. 
 
 Occasionally the connective-tissue basis of a lipoma underf;oJ 
 modifications ; e.g., it may become increased in .unount, coil 
 stituting a Fibro-lipoma, or be transformed into mucoid tissul 
 giving rise to a Myxo-lipoma ; or, again, the vessels may hecoi'S 
 dilated, originating a Nsevo-lipoma ; and even a Sarco-lipoma iii:| 
 de\elop. 
 
 Localized or diffuse overgrowths are often met with in til 
 sub -peritoneal fatty tissue, constituting Subserous Lipomatj 
 They occur not unfrequently in the lower part of the abdonia 
 and may extend into the inguinal and crural canals, formid 
 the so-called fatty tumour in these parts. By their traction 
 process of peritoneum may eventually be drawn down, and a tnj 
 hernia produced. A similar condition occurs in the anteril 
 abdominal wall, small pedunculated masses of fat projectiij 
 through congenital or acquired openings in the linea albai 
 linea semilunaris ; these are sometimes known as Fatty HeMJ 
 of the Linea Alba, and are often painful. 
 
 Lipoma Arborescens is the term applied to a villous outgrouj 
 of fatty tissue, met with in the interior of joints, and usuall 
 associated with osteo-arthritis. There is often a consideralf 
 
 londroma.— Cartilagin 
 m in connection with 
 pist of hyaline cartila^ 
 jture and devoid of ve< 
 prs in the form of pe 
 lether by vascular conn^ 
 ■othe substance of the c 
 
TUMOURS AND CYSTS 
 
 127 
 
 rease in the amount of intra-articular fluid, and the condition 
 s ihin been designated ' .-iynovitis lipomatosus.' 
 The Treatment of iiponidta consists in tlieir removal. When 
 ;\' are loos<ely encapsuled, this is a very simple matter, all that 
 required in many cases being to s(]ueeze the mass forwards 
 tween the thumb and finger, making the skin tense over it, and 
 ;n to incise the capsule freely, when the tumour almost jumps 
 t; but if there are many adhesions it may not be so easy. In 
 r clilluse forms 'c and hygienic measures should first be 
 
 cd. When an ( ^ .dtion is recjuired, however, it is well to cut 
 rough the whole thickness of the tumour at once, and deal with 
 ch half separately, dissecting it away from its deep attach- 
 ents. 
 
 Fibromata consist of overgrowths of fd^rous tissue ; they were 
 riiierly divided into two groups, tlie hard and the soft, and 
 though there is no essential difference between them, it is a 
 Hill clinical distinction. 
 
 The Hard Fibroma is composed of firm dense tissue, which 
 
 eaks on section with the knife, the exposed surface showing 
 
 imerous trabeculse of glistening fibres, similar in character to 
 
 ose met with in a tendon. Microscopically, interlacing fibrillx* 
 
 seen, which are sometimes arranged concentrically around the 
 
 wdvessels ; there but few nucleated cells in the more slowly 
 
 owing tumours. > vascular supply is somewhat defective, 
 
 lough dilated vtu.. .>,re often present, especially in the capsule, 
 
 d sometimes in the substance of the mass; these, if opened by 
 
 ration, may lead to profuse ha3morrhage. Hard fibromata 
 
 met with in the form of epulis, fibrous polypus of the nose, keloid, 
 
 not uncommonly in connection with the sheaths of nerves. 
 
 Soft Fibromata develop as localized o\ergrowths of the sub- 
 
 aneous fibro-cellular tissue, or as the so-cailed Molluscum 
 
 rosum of the skin. In the latter case many different forms of 
 
 (nvth are met with ; sometimes a development of small 
 
 (iules occurs, scattered widely over the surface, usually pinkish, 
 
 dwith the skin over them somewhat corrugated ; these may be 
 
 related with changes in the underlying nerves (p. 133). It also 
 
 ists in the form of pendulous folds, perhaps involving a large 
 
 :aof the trunk ; the so-called pachydermatocele of the scalp is 
 
 tliis nature. 
 
 'X 
 
 Ikondroma. — Cartilaginous tumours are met with growing 
 ler in connection with bones or in certain soft tissues. They 
 isist of hyaline cartilage, which, mstead of being uniform in 
 ture and devoid of vessels as at the articular ends of bones, 
 urs in the form of pellets or nodules oi varying size, held 
 ether by vascular connective tissue, which may even penetrate 
 the substance of the cartilage. The cells are also less regular 
 
128 
 
 A MANUAL OF SURGERY 
 
 in shape than is the case with normal cartilage, and are 
 arranged according to any definite plan. 
 
 Chondromata are liable to become calcified, and even ossifiei 
 When large, the central parts may undergo a mucoid chani;i 
 giving rise to a cavity which, if sepsis is admitted, becomes e 
 ceedingly foul. They are not uncommonly accompanied in thei 
 growth by sarcomatous and other elements. 
 
 When growing from the long bones, chondromata usually st; 
 from beneath the periosteum, and are independent of the epipl; 
 seal cartilage, although it has been suggested by Virchow tl 
 they may originate from a nodule of cartilage which has been d 
 placed from its usual situation during an attack of rickets. Tin 
 constitute firm lobulated encapsuled tumours, and give rise to 
 pain, except when they encroach on neighbouring nerves. Th( 
 often attain a great size. The growth may extend secondai 
 into the medullary canal, and thus cause expansion of the bone: 
 it may erode the compact tissue, and lead to spontaneous fract 
 Amputation of the limb will probably be necessary, unless 
 case comes under observation in the early stages, when the tunn 
 can be gouged or scraped away. 
 
 Chondromata also originate from the smaller bones, usually fi 
 
 those of the hand (Fig. .27). In such c 
 the growth commences in the inte: 
 close to the epiphyseal cartilage ; sev 
 tumours may be present in the same i 
 vidual. The bone is expanded by 
 growth, and the parts become much 
 formed. Treatment consists in inci 
 the capsule, and scooping out the ci 
 laginous tissue, a proceeding which 
 result in defective growth and subseqi 
 deformity. 
 
 Chondromata are also found /// thti 
 parts, especially affecting the parotid 
 submaxillary glands, and the testes. 
 the parotid gland they are usually 
 ciated with mucous and fibrous tiss 
 few glandular elements being also 
 They develop from the capsule of the j 
 or immediat* iy beneath it, and are usually simple in n 
 though occasionally they may become sarcomatous. Subnia 
 chondroma is frequently an almost unmixed cartilaginous tu 
 though other tissues may exist. 
 
 Overgrowths of cartilage, known as EccLondroses, occur a 
 the articular cartilages in connection with osteo-arthritis ; 
 also arise from the cartilages and septum of the nose, and 
 the laryngeal cartilages. Some of the loose bodies which fo| 
 joints are of a similar nature. 
 
 nol 
 
 Fig. 27. — Multiple 
 
 Chondromata of 
 
 THE Fingers. 
 
 bedded in the mass. 
 
PLATE III. 
 
 ,Tm j-i 
 
 t 
 
 Exostosis of thi; Radius. 
 
 This growth occurred in a young man aged twenty-three years. It will be: 
 
 that it has caused great deformity of the uhia. 
 To face p. i2g.l 
 
 Osteoma. — Bony turn 
 
 y the ivory. 
 
 [cancellous Osteomafa 
 
 hicular end of a bon^ 
 
 Ited portion of the epi: 
 
 Iparated from its origii 
 
 lis well known that ir 
 
 le epiphyseal cartilar- 
 
 lery of the bone becon 
 
 lis easy to understand 
 
 Insists of cancellous be 
 
 F ^\'hich it grows (Fi| 
 
 |ay attain to a large 
 
 1 28.— Diagrammatic Rep 
 lAiio.N- OF Cancellous Exc 
 ►owing from the Lowe 
 
 FTHE Femur. 
 
 Iproximity to the epiphysej 
 
 %e IS indicated, as also it« 
 
 teinous covering and the^ 
 
 Jtich occasionally lies ov 
 
 W ni.). It necessari 
 tongenital. As the ind 
 I become separated frc 
 ffling to the amount of 
 lor It may still remain 
 I Its growth and devel 
 llage covering it, as we 
 prsa occasionally forms 
 ps as a result of fricti 
 |n known as Exostosis I 
 [the joint. An effusion 
 r "'■St evidence of the ( 
 poses are not unfrequ 
 pary. The most comi 
 
TUMOURS AND CYSTS 
 
 129 
 
 gteoma. — Bony tumours are of two chief forms : the cancellous 
 the ivory. 
 
 ancellous Osteomata are usually met with growing near the 
 cular end of a bone, being derived originally from some iso- 
 d portion of the epiphyseal cartilage, which has perhaps been 
 arated from its original connection after an attack of rickets. 
 s well known that in this affection irregular outgrowths from 
 epiphyseal cartilarT occur, and if one of these near the peri- 
 ;ry of the bone becomes shut off from its epiphyseal attachment, 
 5 easy to understand its development into a tumour, which 
 isists of cancellous bone, capped by a layer of hyaline cartilage, 
 m which it grows (Fig. 28). It is pedunculated or sessile, and 
 y attain to a large size, leading to considerable deformity 
 
 28— Diagrammatic Represen- 
 Iation of Cancellous Exostosis 
 
 IROWING FROM THE LoWER EnD FiG. 29. —SUBUNGUAL EXOSTOSIS. 
 
 THE Femur. (Bland Sutton.) 
 
 [proximity to the epiphyseal car- 
 
 ige is indicated, as also its carti- 
 
 ginous covering and the bursa 
 [tich occasionally lies over its 
 
 liimit. 
 
 Bte III.). It necessarily develops in young people, and may 
 longenital. As the individual grows, the basis of attachment 
 become separated from the epiphysis to an extent corre- 
 jiding to the amount of growth which has taken place at that 
 [,or it may still remain attached to the epiphyseal Une. As a 
 its growth and development cease at maturity, when the 
 tlage covering it, as well as the epiphyseal cartilage, ossifies. 
 pa occasionally forms over the most prominent part of these 
 irs as a result of friction or pressure, giving rise to the con- 
 In known as Exostosis Bursata ; this cavity may communicate 
 Ithe joint. An eflfusion of blood or serum into the bursa may 
 le first evidence of the existence of such a growth. Multiple 
 loses are not unfrequently met with, and are then often 
 |itary. The most common situation for such a tumour is the 
 
 9 
 
130 
 
 A MANUAL OF SURGERY 
 
 I 
 
 bryonic in charactei 
 iroughout. Again, in 
 id definite walls, and 
 ssages in the tumour 
 llyomata are met wit 
 ly in the walls of t 
 ondary changes som 
 irocystic disease of 
 
 inner condyle of the femur, close to the adductor tubercle. .Amp^vn bv th f 
 exceedingly troublesome variety is the Subungual Exosto J absence ^f ^ 
 (Fig. 29), which develops as a rounded, cherry-like swelling undMctJon deoen 1 ^^^'^,** 
 the nail of the great toe. It is very painful, owing to the densiKhe sarcoma ^ °? u 
 of the tissues involved, and should be treated by removingtBnhrvnniV ir,\u^^^. 
 nail, incising the tissues over it down to the bone, and clippjnif 
 
 away with cutting pliers. Fig. 30 reprj 
 
 sents a skiagram of an exostosis gruwi 
 
 from the proximal phalanx of the thumb, 
 Ivory Exostoses de\'elop most frequen 
 
 on the inner or outer aspect of the cran 
 
 bones, especially affecting the orbit, 
 
 ternal auditory meatus, antrum, and fron 
 
 sinus (Fig. 31). They consist of mas: 
 
 of very dense compact tissue, covered 
 
 periosteum, from whicn they grow. Tl 
 
 are usually lobulated, and when situa 
 
 in the frontal sinus, or growing from 
 
 under surface of the skull, may gi\e 
 
 to serious symptoms from irritation 
 
 compression of the brain or its membra 
 
 In a few cases necrosis has resulted 
 
 they have sloughed out, thus brini; 
 
 about a spontaneous cure. 
 
 Occasionally diffuse overgrowth of 
 
 bones of the skull (Hyperostoses) are 
 
 with, affecting either the calvariuiii al 
 
 being then probably syphilitic in natun 
 
 the facial and cranial bones, as in leontij 
 
 ossea. New formation of bone soinetii 
 
 occurs in the substance of tendons w 
 exposed to irritation 
 
 Fig. 30. — Skiagram of 
 
 Exostosis growing 
 
 FROM THE Base of 
 
 Proximal Phalanx of 
 
 Thumb, showing Open 
 
 Cancellous Texture 
 
 AND Origin near the 
 
 Epiphyseal Carti- 
 lage. 
 
 are exposed to irritation or excei 
 action, e.g., the tendon of the adductor longus in riders, prodm 
 what is known as ' the rider's bone.' 
 
 The Treatment of osteomata consists in their remo\al ^^[[,5^ u , 
 
 possible. This may be tolerably simple in the case of the caiiceBjjj t- J' ^^^.f' ^^^ 
 osteomata of the limbs, but is sometimes a most formidable prw 
 ing when dealing with sessile compact exostoses of the calva 
 
 jr.- Ivory Exostosis g 
 '" «"T« ON the Orbit an 
 
 (From specimen 
 
 in 
 
 "lahgnant disease 
 prostatic myomata, see 
 utnours consisting of 
 Myoma. — Myomata almost always consist of unstriped mm scrit)ed, but 
 
 fibres (Leiomyoma or fibromyoma), forming rounded and often eiBjjj.^j 
 
 suled tumours, the cells of which are long and fusiform, and coMj^^ ' t'^® -Neurom 
 a rod-like nucleus. Bundles of these cells are grouped togetheK^j <fanp-r ^^"^ °" ^^^' 
 fasciculi, which are arranged more or less regularly. ThetuiMjf "r^ iP^ CQiis and 
 themselves are not very vascular, but vessels of considerablM|j^ , . '^'^t one cas( 
 
 are found in the capsule. It is often difficult to distiiM ^^Jr^ m children 
 these tumours microscopically from fibromata on the one ■[jg^-j. ,., ^ ^". diniens 
 and from fibro-sarcomata on the other. From the formerthB„„,/ ^ f "Poma, or 
 
 ^and may be freely ren 
 
TUMOURS AND CYSTS 
 
 »3« 
 
 wn by the fact that individual cells can be recognised, and by 
 absence of wavy tendinous fibrillar ; from the latter the dis- 
 tion depends on the facts that other types of tissues may occur 
 le sarcoma and that the growing edge is usually more or less 
 jryonic in character, whilst a myoma is of the same structure 
 lughout. Again, in a myoma the bloodvessels have distinct 
 definite walls, and in a sarcoma they are simply clefts or 
 sages in the tumour substance. 
 
 lyomata are met with in the uterus and prostate, and occasion- 
 in the walls of the alimentary canal and in the ovary, 
 ondary changes sometimes occur, e.g., mucoid softening, as in 
 o-cystic disease of the uterus, calcification, ulceration with 
 
 ji— Ivory Exostosis growing from Frontal Sinus, and encroach- 
 
 5 BOTH ON THE OrBIT AND THE CrANIAL CaVITY. (BlAND SuTTON.) 
 
 (From specimen in the College of Surgeons' Museum.) 
 
 use haemorrhage, and possibly consequent septic inflammation, 
 |st malignant disease may supervene. For the characters of 
 [prostatic myomata, see Chapter XXXVI. 
 lumours consisting of striped muscle fibres (Rhabdomyoma) 
 been described, but are exceedingly rare. 
 
 luroma. — True Neuroma is seldom met with, only fi\^e un- 
 ited cases being on record. It is formed by a mass of newly- 
 led ganglion cells and nerve fibres, which may be medullated 
 It. In all but one case it involved the sympathetic system, 
 pccurred in children or young people. The tumours may 
 considerable dimensions, are often multiple, and may be 
 [soft, like a lipoma, or firm. They are insensitive and inno- 
 land may be freely removed. 
 
 9—2 
 
132 
 
 A MANUAL OF SURGERY 
 
 |i ' 
 
 Ully due to involven 
 
 Ito the supervention i 
 
 fnation. The disease 
 
 khough progressing s 
 
 known treatment is 
 
 our become Jar^e ai 
 
 In connection with i 
 
 ivelopment of fibrous 
 
 ive already describee 
 
 icroscopical examinat 
 
 thod, the presence o 
 
 ie growths, showing 
 
 gin. So excessive d( 
 
 ii a form of elephantij 
 
 isia of the scalp tissue; 
 
 APlexiform Neuroma 
 
 urring congenitally o 
 
 trigeminal or superfi( 
 
 h the former conditioi 
 
 latinous type (myxo-f 
 
 isists of a plexus of tl 
 
 consistence, held tc 
 
 False Neuromata, or those developing in connection with t 
 sheaths of nerves, are more common, and may be described und 
 three headings : 
 
 I . Solitary Pseudo-Neuroma, which may be innocent or mali| 
 nant, the former being a fibroma or myxoma, the latter usually 
 sarcoma. It may project from one side of the nerve, or nioi 
 frequently causes the nerve fibres to be separated and spread oi 
 over it (Fig. 32). It moves more freely in a direction at rig] 
 
 angles to the axis of the ner 
 than along its course. When di 
 veloping from a small name! 
 subcutaneous twig, it is termed 
 painful subcutaneous nodule (Woo( 
 and then gives rise to intense pi 
 of a neuralgic type, especially win 
 compressed or irritated, or wh 
 exposed to cold. A false neuroi 
 growing from a larger mixed ner 
 {trunk neuroma) is less painfi 
 because there are relatively fev 
 nerve fibrillae, and the mass is [ 
 exposed. A growth on a pi 
 
 motor nerve, though sensitive, Bjly separable ' into the 
 not associated with radiation Bdulated character so tl 
 pain. It is uncommon for tumoiMing of boiled ta' ' 
 of this nature to lead to complMxiform neuroma 1^^ a^m 
 paralysis or anaesthesia, unlMpiy between and into t 
 they are of a malignant natu«extent, the growth mj 
 They occur most frequently fcred for cosmetic 
 healthy adults, and in women 
 little more commonly than in men. 
 
 Treatment. — A neuroma, if painful, should be removed, ci 
 being taken, if possible, not to interfere with the continuity of 
 nerve fibrillae. If this cannot be accomplished, the nerve must 
 divided, and the ends united by immediate suture. 
 
 2. Diffuse or Generalized Neuro- fibromatosis {Recklinghausi 
 disease). — This consists of a diffuse thickening of the nerve sheai 
 causing multiple elliptic or spherical tumours, or a generali; 
 enlargement. The growths may be encapsuled and limited or 
 they may be few in number, or hundreds may be present, and t 
 are usually whitish and firm in texture. They originate from 
 endoneurium of the primary nerve bundles. Any part of the 
 pheral nervous system may be affected, including the sympathei 
 but it is most common in connection with the cranial nerves 
 the large plexuses of the trunk. The actual symptoms are soi 
 times very slight, but the tumours may be sensitive to pressi 
 and some one of them, more exposed than the others, may be 
 
 Fig. 32. — PsEUDO - Neuroma : 
 Fibrous Tumour growing 
 FROM Nerve Sheath, and 
 causing the Fibres to be 
 widely stretched over it. 
 
 1 . P^ 
 
 Iter than m the forme 
 
 nges are rare. 
 The bulb formed up 
 Jision is sometimes desci 
 Iconsists of a mass of fi 
 fed up within which a 
 py are almost always 
 [painful unless adherer 
 [e, or to the cicatrix, w 
 TO traction upon them 
 
 igioma.— Several dist 
 ited arteries or veins 
 to those in which 
 
 « aneurisms and 
 
 ory. 
 
 tree main types of ang 
 s; (2) the cavernous 
 
 a 
 va: 
 
 quisitely tender. Motor phenomena are rare, and paralysiWjig gimpiQ jt~-,, 
 
 IS e 
 
TUMOURS AND CYSTS 
 
 »33 
 
 lally due to involvement of the nerve roots in the spinal canal, 
 to the supervention of sarcoma, which is a not uncommon ter- 
 lation. The disease may start at any time during life, and 
 rough progressing slowly, sooner or later terminates fatally, 
 known treatmen* is of any avail, but should any particular 
 nour become larj^e and tender, it may be removed. 
 In connection with this disease one frequently finds a large 
 relopment of fibrous growths of the skin, similar to what we 
 ve already described as molluscum fibrosum. On careful 
 croscopical examination of specimens stained by Weigert's 
 ithod, the presence of nerve fibrillae can be demonstrated in 
 Ese growths, showing that they are really neuro-fibromatous in 
 igin. So excessive does this overgrowth occasionally become 
 jiaform of elephantiasis is produced, e.g., the irregular hyper- 
 isia of the scalp tissues known as a pachydermatocele. 
 A Plexiform Neuroma is a special modification of this process, 
 nirring congenitally or in young people, and usually involving 
 ! trigeminal or superficial cervical nerves ; it may be associated 
 th the former condition. The overgrowth is of a softer, more 
 latinous type (myxo-fibromatous), and the resulting tumour 
 Dsists of a plexus of thickened, tortuous, vermiform strands, of 
 [t consistence, held together by loose connective tissue, but 
 lily separable into their constituent elements, which are of a 
 Julated character, so that the dissected mass looks " not unlike 
 lins of boiled tapioca on a string" (Alexis Thomson). The 
 ixiform neuroma is almost always subcutaneous, but often dips 
 tply between and into the substance of muscles. When limited 
 extent, the growth may be dissected out, and this is usually 
 |uired for cosmetic purposes. The final prognosis is rather 
 Iter than in the former condition, as secondary sarcomatous 
 inges are rare. 
 
 ;. The bulb formed upon the proximal end of a nerve after its 
 ision is sometimes described as a neuroma (Traumatic Neuroma). 
 consists of a mass of fibro-cicatricial tissue containing spaces, 
 led up within which are prolongations of the axis cylinders. 
 ey are almost always present in amputation stumps, but are 
 )ainful unless adherent to the periosteum of the neighbouring 
 e, or to the cicatrix, when every movement of the nearest joint 
 ises traction upon them, and induces severe neuralgia. 
 
 iigioma. — Several distinct varieties of tumour consisting of 
 ted arteries or veins exist, but the term angioma is applied 
 to those in which a new formation of bloodvessels occurs ; 
 ce aneurisms and varicose veins are not included in this 
 ^ory. 
 
 tree main types of angioma maybe described : (i) The simple 
 us; (2) the cavernous naevus ; and (3) the plexiform angioma. 
 le Simple Naevus is exceedingly common, and consists of a 
 
«j4 
 
 A MANUAL OF SURGERY 
 
 
 mass of dilated capillaries, bound together by a small anion 
 of connective tissue. It is usually congenital, and may increa 
 rapidly in size during the first few months of life. It is iocatj 
 in the skin, or may also involve the subcutaneous tissues, i)iit tl 
 tubular form of the constituent vessels always remains. It ml 
 be of a bright red colour or of a dusky tint. For a fuller accoiJ 
 see Chapter X. If untreated, simple naevi may persist unchangj 
 or may disappear ; in a few rare instances they suddenly begin] 
 grow in later life, giving rise to a considerable vascular pron 
 nence, purplish in colour, and even becoming pendulous. Such 
 tumour is soft and easily compressible, being in reality a caverno 
 angioma ; it may ulcerate, and profuse haemorrhage may resu 
 Treatment consists in electrolysis, if excision is impracticable. 
 The Cavernous Naevus consists of dilated spaces, where 
 tubular form of the constituent vessels is lost, the arteries usiia 
 
 opening directly into thj 
 walled cavities lined with end 
 thelium without the interve 
 tion of capillaries (Fig. A 
 The tumours are thus inorej 
 less erectile in nature, son 
 what resembling the corp 
 cavernosum. They are 
 with in the skin and sut 
 taneous tissues, constituting i 
 fuse or circumscribed tumol 
 of a reddish-blue colour, wl 
 can be emptied on pressu 
 but rapidly refill when suclJ 
 removed, and in which pul 
 tion is occasionally present, 
 similar condition arises in 
 viscera, especially the liver, ; 
 then is always acquired, and 
 is not difficult in suitable ca 
 to demonstrate that it has been formed by a dilatation of! 
 capillaries between the lobules, the liver substance meanwj 
 disappearing by a process of simple atrophy. Occasional^ 
 cavernous angioma undergoes a process of spontaneous curj 
 the result of some inflammatory affection similar in natur^ 
 phlebitis, a non-vascular fibro-cystic mass remaining. 
 
 Under the term Plexiform Angioma may be included the ciij 
 aneurism, or aneurism by anastomosis, the former term 
 applied by some authors to tumours consisting of large ves 
 and then most commonly seen about the scalp and face, and 
 latter to a congeries of small vessels. The treatment is alwa 
 matter of considerable difficulty (see Chapters XVII. and XXI 
 Odontoma. — Tumours originating from some abnormal co 
 
 Fig. 33. 
 
 -Section of Cavernous 
 
 Angioma. 
 
 Ion of the teeth or 
 Rland Sutton, in his 
 |ifferent varieties, seve 
 man. We can on] 
 tiese, and must refer 
 lutton's book for a fu 
 Id this condition, for 
 le jaw,' the mandibli 
 fcrms, consisting of 
 jeveloped as irregula 
 (occurs most frequer 
 ) a growth of enormc 
 lev are often termed, 
 levelopment of a cavit> 
 [the permanent set, 
 uption is impossible 
 II a thickening and 
 Iround a tooth sac. 1 
 Iwer animals, but ar( 
 I Radicular Odontome 
 cement, developing , 
 kvere pain, and ma) 
 lirrounding bone. (5) 
 loineration of the va: 
 Innation of a tooth, i 
 lejaw. They may be 
 jimours described as os 
 
 Lymphadenoma and 
 
 jeveloping in lymphati 
 palso the conditions ar 
 
 In. Tumours derived fi 
 
 Such are either innoc 
 imours being the papill 
 liecarcinomata. 
 jPapillomata consist in 
 
 mucous membrane, w 
 lie from the developmt 
 uiiflower-like mass ; tl 
 pective tissue of the 
 le growth, which is 
 [lithelium never dips dc 
 sue, the growth being 
 [ntripetal, as in the case 
 Divever, a papilloma w 
 * Bland Sutton, ' ' 
 
TUMOURS AND CYSTS 
 
 >35 
 
 ion of the teeth or teeth-germs are known as 'odontomes.' 
 JIand Sutton, in his work on tumours, '■■ has described seven 
 iferent varieties, several of which are, however, rarely met with 
 man. We can only deal here with the more important of 
 liese, and must refer our readers to Chapter XXIV. and to 
 utton's book for a fuller description, (i) Epithelial Odontome. 
 n this condition, formerly known as ' fibro-cystic disease of 
 
 DC 
 
 jaw,' the mandible is most commonly affected. A tumour 
 
 )rms, consisting of spaces lined by epithelium, which are 
 
 eloped as irregular outgrowths from the enamel organ. 
 
 occurs most frequently in young people, and may give rise 
 
 a growth of enormous size. (2) Follicular Odontomes, or, as 
 
 ley are often termed, ' dentigerous cysts,' are produced by the 
 
 elopment of a cavity around a misplaced or ill-developed tooth 
 
 the permanent set, which often lies horizontally, so that its 
 
 ruption is impossible. (3) Fibrous Odontomes are the result 
 
 ;i thickening and condensation of the connective tissue 
 
 round a tooth sac. They are most frequently observed in the 
 
 wer animals, but are also said to occur in rickety children. 
 
 Radicular Odontome is the term applied to a tumour composed 
 
 cement, developing at the root of a tooth. It gives rise to 
 
 vere pain, and may result in septic inflammation of the 
 
 rounding bone. (5) Composite Odontomata consist of a con- 
 
 oiiieration of the various forms of tissue entering into the 
 
 innation of a tooth, and developing in the neighbourhood of 
 
 lejaw. They may be very large, and probably some of the bony 
 
 imours described as osteomata of the antrum are of this nature. 
 
 ;v 
 
 Lymphadenoma and Lymphangioma. — The primary tumours 
 eloping in lymphatic glands are described in Chapter XL, 
 also the conditions arising from the dilatation of lymphatics. 
 
 n, Tumours derived from Epiblastic or Hjrpoblastic Structures. 
 
 Such are either innocent or malignant in nature, the innocent 
 imours being the papillomata and adenomata, and the malignant, 
 lecarcinomata. 
 
 Papillomata consist in an outgrowth of the papillae of the skin 
 mucous membrane, which may be simple in nature, or compo- 
 te from the development of lateral offshoots, giving rise to a 
 lulirtower-like mass ; they may be sessile or pedunculated. The 
 innective tissue of the papillae, with its vessels, also extends into 
 le growth, which is sometimes exceedingly vascular. The 
 lithelium never dips down into the subcutaneous or submucous 
 sue, the growth being only centrifugal in development, and not 
 etripetal, as in the case of the epitheliomata. Not unfrequently, 
 wever, a papilloma which has become irritated may take on 
 * Bland Sutton, 'Tumours and Cysts.' Cassell and Co. 
 
 •I' 
 
136 
 
 A MANUAL OF SURGERY 
 
 malignant action. Clinically, a papilloma is distinguished from aa 
 epithelioma by the base being free from infiltration. 
 
 Papillomata of the skin are met with in the form of harij 
 excrescences, such as waits or corns ; but if growing fron 
 moist parts, as from the prepuce, they may be soft and vasculaij 
 Occasionally warts may grow to such an extent as to constitutJ 
 horn-like projections or cauliflower-hke growths. 
 
 Papillomata of the mucous membranes are usually villous i| 
 character, constituting long, fimbriated tufts, covered with a thij 
 layer of epithelium, and containing delicate bloodvessels, whicj 
 readily give way, and may lead to considerable haemorrha^'J 
 They are most commonly observed in the bladder, but occasion 
 ally in the pelvis of the kidney, and on the intestinal nuicou 
 membrane, especially in the rectum. They also occur on thl 
 true vocal cords, and are then wart-like, and hard in consistency 
 Growths of a very similar nature, but somewhat more sol 
 texture, are found within the ducts or acini of glandular visced 
 such as the breast. Condylomata and mucous tubercles, de\elo[| 
 ing in the course of syphilis, are also of a papillomatous nature, 
 
 Adenomata consist of new growths arising in connection wid 
 secreting glands, and in structure simulating somewhat closely tlj 
 organs from which they rise. They differ from them, howevt 
 in that they are incapable of producing the characteristic secretioi 
 that they are devoid of ducts, and that the mimicry is inconipletj 
 since the alveoli are less perfectly developed, and may be entire! 
 occupied by several layers of epithelial cells. The epitheliuif 
 howe^'er, does not pass beyond the basement membrane into t^ 
 connective tissue, and hence they also are distinguished from ca 
 cerous tumours by the new formation being centrifugal, and nl 
 centripetal, in its growth. A variable amount of connective tissi 
 is always present, and may be normal in texture, or may niaij 
 fest various modifications. Adenomata are usually encapsuM 
 being merely connected with the original gland by a pedicj 
 through which the vessels enter. When growing from muco 
 membranes, they are sometimes pedunculated, as in the so-callj 
 polypus recti. The alveoli in some cases become distended wf 
 effusion, giving rise to a cysto-adenoma or adenocele. They i 
 absolutely free from malignancy, except when, as occasiona 
 happens, the connective tissue undergoes a sarcomatous chanJ 
 whilst sometimes carcinoma intervenes. "When of large size,th 
 may give rise to symptoms by compression of important structun 
 Any glandular organ may become affected with adenoma, 
 several varieties will be described hereafter in the chapters on I 
 breast, thyroid body, prostate, testis, etc. They are also foundl 
 congenital tumours in connection with the thyroid body, post-a| 
 gut, and possibly the kidney. The growth is usually slow, ' 
 occasionally becomes rapid. 
 
TUMOURS AND CYSTS 
 
 137 
 
 arcinoma. — The malignant forms of epitliclial new growth are 
 
 wn as cancers or carcinoniata, of which the following varieties 
 
 described; viz., epithelioma, rodent ulcer, columnar carcinoma, 
 
 glandular or acinous cancer. The te.m ' colloid cancer ' is also 
 
 d to indicate a degenerative change occurring in some forms. 
 
 'he essential character of a cancerous growth consists in an 
 
 imited multiplication of the epithelial elements of the organ 
 
 icked. In some cases this may result in the formation of a 
 
 lerficial outgrowth of a papillomatous type (Fig. 35), while 
 
 p processes or columns of cells advance into the tissues 
 
 ng the lymphatic channels, and even burst through the base- 
 
 nt membrane of glandular alveoli. The irritation of this 
 
 eiopment leads to an infiltration of the surrounding structures 
 
 h round cells, which are presumably inflammatory in origin, 
 
 the agency of which the normal tissues are disintegrated and 
 
 noved, and a stroma of variable density develops around the 
 
 ithelial outgrowths. Hence all cancerous tumours may be said 
 
 consist of a fibro-cellular or fibro-cicatricial stroma (Plate IV., 
 
 g. i), within the alveoli of which are collections of epithelial 
 
 is, sometimes arranged in a methodical manner, but more 
 
 [en packed irregularly together, and with no intercellular tissue 
 
 itween them. The alveolar spaces are in reaHty dilated 
 
 nphatics, and hence it is easy to understand that carcinomata 
 
 E disseminated along these vessels; the cancer cells are epithe- 
 
 1 in origin, and of very variable size and shape; but they 
 
 lays retain more or less the cha -acters of the epithelium from 
 
 lich they are originally developed, so that, e.g., a squamous 
 
 ithelioma is never derived from a part covered with columnar 
 
 [helium, or vice versa. Bloodvessels ramify through the stroma, 
 
 lare more or less abundant according to its density. Speaking 
 
 lerally, cancers are less vascular- than sarcomata, although there 
 
 [greater amount of hyperaemia immediately around them. A 
 
 isiderable degree of pain, usually of a neuralgic type, is often 
 
 nplained of, but the tumours are not necessarily tender to the 
 
 ch. 
 
 Itiology. — Formerly cancer was considered to be of consti- 
 
 mal origin, resulting from some morbid condition of the blood, 
 
 in favour of this view the immense difficulty of eradicating it 
 
 educed, as also its hereditary nature in many cases. It is 
 
 however, generally admitted that it is primarily local in 
 
 [in, and probably the result of the inoculation and development 
 
 me specific organism. The chief arguments in favour of its 
 
 origin are as follows : (i) That it often occurs in individuals 
 
 up to the time of its onset, have been in perfect health ; 
 
 at cachectic symptoms only manifest themselves in the later 
 
 of the disease, being then readily explicable by excessive 
 
 the absorption of septic discharges, loss of blood, or possibly 
 
 Itoxic effect of some material absorbed from the growth ; 
 
■38 
 
 A MANUAL OF SURGERY 
 
 (3) that the original neoplasm is always sinf^le, multiple tiinunirsi 
 l)einf,' the result of infection from the primary growth ; (4) that] 
 some definite focus of local irritation may frequently be traced ai 
 the cause of the tumour — e.^'., the irritation of the lip hy a sli(,ri 
 clay pipe, tlie presence of ulceration or cicatrices of the toiii^ue 
 resulting from ragged teeth, syphilitic affections, etc. It is alsi 
 interesting to note that cancer usually involves the intt'stin 
 canal in situations where there is a sudden change of calihrq 
 gi\ing rise to increased friction from the passage of the contents 
 e.g., at tlie upper and lower ends of the cesophfigus, nt the pylonisl 
 the ileo-ca^cal valve, either end of the sigmoid flexure, the lowei 
 part of the rectum, and the anus. (5) Moreover, if an early ani 
 thorough operation is imdertaken, the growth can be complete! 
 eradicated from the system, whilst even if it recurs, it usuall' 
 attacks the cicatrix of the neighbouring glands, indicating tli 
 the removal has been incomplete. 
 
 The infective nature of cancer is still siih judice. Clinical e\ iden 
 exists to indicate that cancer can be transmitted from one persi 
 to another, but it is somewhat scanty in amount. Thus, cancer 
 the cervix uteri has been known to be followed by epithelioma 
 the penis in the husband. Again, it has been shown by Shattoi 
 that in certain houses (called by him ' cancer houses ') one 
 of indwellers after another has been attacked by this disea: 
 Experimental research, as to the transmissibility of cancer fromui 
 individual to another, is necessarily unobtainable, althougli it hi 
 been proved that, in a person already suffering from cancer, 
 portion of the growth transplanted to a distant part of the boi 
 will grow, and lead to the formation of a similar tumour at the si 
 of inoculation. Attempts have also been made to transmit t| 
 disease to animals, but with a very slight degree of success, ev 
 in cases where the point of inoculation has been previoui 
 irritated. Hence the \iew that cancer is due to infection depe: 
 rather on the analogy of the disease to other chronic infective 
 orders than on anv well-ascertained facts. The relation of cani 
 to Fsorospermise has been much discussed of recent years, and 
 some authorities the disease is supposed to be due to tli( 
 
 Lark's interesting ex 
 intraperitoneal de\elr 
 broadcast throughout 
 Jiecessarily contained 
 Idea IS that cancer is 
 tpitlu'lium placed in 
 W. in lyniphatic spac( 
 
 organisms. Their opinions, which are not generally acceplj 
 are based on the following facts : {a) That in the majorityj 
 cancerous growths certain abnormal bodies resembling the coccif 
 of psorosperms have been demonstrated within the epith/ 
 cells ; but even if these ' cancer bodies ' are of this nature, it 1 
 yet to be proved that they are causative, and not concurn 
 manifestations, whilst it is probable that they are merely foa 
 colloid degeneration, [h) In rabbits suffering from undoulj 
 psorospermosis, outgrowths somewhat similar in nature to epij 
 lioma have been detected in the biliary ducts and certain visq 
 and these growths have even been produced by artificial inoo 
 tion with the organisms. Mention must be made here ofj 
 
 Epithelioma {syn. .• Si 
 y this term is meant 
 om tliose portions of 
 ith s(]uamous epithe 
 :oluninar ejiitlielioma 
 escrii)ed separately. 
 Epithelioma is usua 
 (lividuals, although 
 iy it is seen in yot 
 lie, Any portion of 
 lay lie the site of thi? 
 also the mucous men 
 e mouth, pharynx a 
 a^us, and that lin 
 [enito-urinary tract. 
 only results from' 
 fltinued irritation, as 
 Ir tongue, whilst on the 
 always associated wit 
 ireskin. Old scars, esp 
 ev become ulcerated, f 
 I'e invaded, and th 
 ay supervene on in 
 ipus. 
 
 Clinically, epithelioma 
 ;k«1 on as a maligna 
 Ikich not only grows 
 C" the surface, 
 
 rrows deeply into 
 
 ues ; sooner or later 
 in loJlows. Several 
 ic forms are dest 1 i 
 y occur ; -1 n .,^|g 
 
 IS, w'-' 
 cen 
 
 to a inewhrit crat 
 '^^(F'g- J4 • f^Thec 
 K process may extend ( 
 tne appearance of a c 
 
 ly resembling a roden 
 
 SOI 
 
 : 
 
 rh 
 
 11 I': 
 evertec 
 ulceration. 
 
lUMOUUS AND CYSTS 
 
 »J9 
 
 ick's interesting experiment in which he caused an extensive 
 raperitoneal developinctU of cancer in a rabbit by siatterinj^ 
 nulcast tlirouj^diout the cavity the scrapinj,'s of an oxaty which 
 cessarily contained a vast niunber of Hvinf^ epithelial cells. His 
 •a is that cancer is merely the outcome of the development of 
 itht'lium placed in unusually favourable nutritive conditions, 
 .. in lymphatic spaces. 
 
 Epithelioma (jj/;;. .■ Squamous Epithelioma, Epithelial Cancer).— 
 
 ; this term is meant a cancerous tumour j^rowinj^' from skin or 
 
 )in those portions of the mucous mend)ranes which are covered 
 
 th scjuamous epithelium. The variety formerly known as 
 
 luninar ejiithelioma is really of glandular orif^in, and will be 
 
 scribed separately. 
 
 Epithelioma is usually met with in middle-nj^red or elderly 
 
 dividuals, although occasion - 
 
 iv it is seen in young adult 
 
 (e, Any portion of the skin 
 
 lay he the site of this tumour, 
 
 5 also the mucous membrane of 
 
 je mouth, pharynx and ceso- 
 
 haRus, and that lining the 
 
 enito-urinary tract. It com- 
 
 pily results from some long- 
 
 ontinued irritation, as in the lip 
 
 I tongue, whilst on the penis it 
 
 always associated with a long 
 ireskin. Old scars, especially if 
 ley hecome ulcerated, are likely 
 I be invaded, and the disease 
 
 ay supervene on intractable 
 
 pus. 
 
 [liuically, epithelioma may be 
 
 Dked on as a malignant wart, 
 
 liich not only grows outward 
 
 om the surface, but also 
 
 irrows deeply into adjacent 
 
 sues ; sooner or later ulcera- 
 
 Ji follows. Several rhara<:ter- 
 
 ic forms are d< - i T ' {a) It 
 
 V occur a a n Jular indurated 
 
 s, w ■' ' W everted <'dges 
 
 cen ulceration, iving 
 
 to a inewhr't crateriform 
 
 r (Fig. j4 . ( I The destruc- 
 
 process may extend equally with the new formation, leading 
 
 [the appearance of a depressed p e, with sharply-cut edges, 
 iely resembling a rodent vdcer. {c) Occasionally the superficial 
 
 Fig. 34. — Typical Efitheliomatous 
 Ulcer, SHOWING Heated-up Mar- 
 gins AND Deep Central Crateri- 
 form Excavation. (College of 
 Surgeons' Museum.) 
 
I40 
 
 A MANUAL OF SURGERY 
 
 outgrowth is excessive, and the destructive process hni 
 giving rise to a projecting cauhflower-like mass, which is soft an| 
 easily bleeds (malignant papilloma, Fig. 35). (d) A chronic epith 
 lioma is sometimes seen, in which the fibrous stroma contrac 
 and compresses the columns of epithelial cells ; the surface is th 
 indurated and wart-like, with but little ulceration, whilst the bai 
 is very hard, and the progress of the case much less rapid tlian 
 other forms. 
 
 The disease, as a rule, early infects neighbouring lymphai 
 glands, which become the seat of a similar growth, and, if supej 
 ftcial, sooner or later involve the skin and give rise to characteri;, 
 ulceration. As the disease progresses, more distant groups 
 lymphatic glands are attacked ; it is unusual to find this form 
 
 llumnar. Within the 
 bns 01 squamous cells 
 |en, known as ' epithel 
 k^hhourhood of the ad 
 kbundant exudation < 
 
 lEodent Ulcer is genen 
 I epitheliomatous type 
 Inds. It is usually m, 
 InalJy observed in tho 
 Vency on the upper 
 dinner and outer cam 
 
 
 Fig. 35. —Papillomatous Type of Epithelioma. 
 
 cancer disseminated through tlie internal viscera, but it ceita| 
 may occur. The glands sometimes become cystic, especii 
 the neck, and on cutting into them a thin, turbid fluid like sero^ 
 escapes, mixed, perhaps, with masses of epithelial debris; 
 time to time similar material is discharged through the resulj 
 sinuses. Ulceration into the main vessels of the neck may 
 follow, and cause death from haemorrhage ; otherwise the 
 event is due to cachexia and exhaustion. 
 
 Microscopically, an epithelioma consists of club-shaped coli 
 of epithelial cells, ramifying in the subcutaneous tissues,] 
 interlacing freely with each other, so as to produce an irre^ 
 network, the meshes of which are occupied by a fibro-ce 
 growth (Fig. 36). The superficial cells in epithelioma are usj 
 squamous in type, but in the deeper parts prickle cells are 
 unfrequently observed, whilst the processes are bounded 
 tolerably definite layer of cuboidal epithelium, tending to l)ej 
 
 
 Fig. 36.— Sect/on 
 
 iJermis; 6. cerium ; c subc 
 
 [ha>r follicle; /cancerous 
 Krous cell groups; h. pr 
 
 [repidermic globe; /(below 
 
 jences as a papule or 
 H perhaps, by an a 
 f gradually in all d; 
 fcpace with the new g 
 rtat depressed surface 
 wiiiaed by a slightly-ra 
 "f stages one can ofter 
 jneath the skin beyonc 
 tile discharge, and imr 
 observed, the scar, ho 
 
TUMOURS AND CiJTS 
 
 141 
 
 inar. Within the processes, concentrically arranged coUec- 
 ol squamous cells round one or more enlarged cells are often 
 known as ' epithelial nests ' (Fig. 36, i). The stroma in the 
 bourhood of the advancing columns is always infiltrated with 
 lundant exudation of leucocytes. 
 
 lent Ulcer is generally admitted to be a cancerous tumour of 
 )itheliomatous type, commencing probably in the sebaceous 
 s. It is usually met with in elderly patients, though occa- 
 lly observed in those under forty, and is seen with special 
 ency on the upper two-thirds of the face, the skin below 
 iner and outer canthi being the chief seats of election. It 
 
 Fig. 36.— Section of Epithelioma. (Ziegler.) 
 
 lermis ; b, cerium ; c, subcutaneous areolar tissue ; d, sebaceous gland ; 
 pair follicle ; /, cancerous ingrowths from the epidermis ; g, deeply-set 
 licerous cell groups; h, proliferating fibrous tissue; i (above), cell nest 
 epidermic globe ; / (below), sweat gland. 
 
 pees as a papule or flat-topped nodule in the skin, sur- 
 [d, perhaps, by an area of hyperaemia. Tlie infiltration 
 Is gradually in all directions, but the ulceration usually 
 lp;ice with the new growth. The ulcer has a smooth but 
 lluit depressed surface, is pei haps covered with granulations, 
 luided by a slightly-raised, indurated, rolled-over edge. In 
 \i' stages one can often detect evidences of the new forma- 
 leath the skin beyond the edge. If kept aseptic, there is 
 lie discharge, and imperfect attempts at cicatrization are 
 Ibserved, the scar, however, readily breaking down ; but 
 
142 
 
 A MANUAL OF SURGERY 
 
 when septic, the surface is covered with sloughs, and an abundani 
 offensive discharge escapes. The condition is painless ; neif^li 
 bouring lymphatics are not enlarged, and the general health doe 
 not suffer, except in the later stages. The progress of the case \\ 
 slow, but continuous, and although it spreads superficially rathej 
 than deeply, sooner or later underlying structures become inl 
 volved, and nothing hinders the destructive process, even tlij 
 bones of the skull being eroded, and the dura mater exposed. 
 
 Microscopically, the growth is very similar to an epithelioiiia| 
 consisting of interlacing columns of epithelial cells, intersperse 
 with fibro-cellular tissue. The chief differences consist in th| 
 facts — (i.) that the constituent cells, although epithelial, are nq 
 epidermic in character, being smaller, more globular, never of tlJ 
 ' prickle-cell ' type, and rarely showing signs of keratinizationj 
 hence, ' cell nests ' are uncommon, although they are sonietiiiK 
 observed, (ii.) The deep processes are not so distinctly columnal 
 or club-shaped, spreading laterally beneath the unaffected skil 
 rather than deeply ; their outline is also more clearly defined, an 
 frequently angular on section, (iii.) There is less cell infiltratiq 
 around the new formation. 
 
 The Treatment of rodent ulcer consists in free excision \v!i' 
 practicable, a margin of at least half an inch being allowed 
 round, and the defect made good by skin-grafting or by soiii 
 plastic operation. Where such cannot be undertaken, the ulcj 
 may be thoroughly scraped, and the surface treated with nitrf 
 acid, chloride of zinc paste, or some other caustic, the wound beiii 
 allowed to heal by granulation. 
 
 Columnar Carcinoma. — This affection, which was formiii 
 termed ' columnar epithelioma,' is in the majority of cases a trj 
 glandular cancer. It is met with most frequently in the aliment;ij 
 canal, arising from any portion of it in which colunmar epitheliil 
 occurs, and usually originating as an overgrowth of Lieberkiilii 
 follicles (Fig. 37). These form a projecting growth from 
 surface in the same way as a papilloma springs from the skin, I 
 also penetrate deeply into the submucous and muscular co; 
 The deep processes retain an imperfect alveolar arrangement, 
 between them is found a certain amount of fibro-cellular stroiJ[ 
 upon the character of which the hardness of the tumour depeiil 
 In the firmer types the stroma is abundant, and fibro-cicatriciaf 
 quality, the growth of the tumour being slow; in the softer; 
 more rapidly-growing forms the stroma is less abundant, and ml 
 of a simple fibro-cellular nature. On section of a limited portT 
 of the growth, it would often be impossible to distinguish it frf 
 a simple adenoma of Lieberkiihn's follicles ; but if a large sectj 
 including the whole thickness of the intestinal wall, is examin 
 the extension of the glandular tissue into and between the iiij 
 cular fasciculi at once indicates the malignant nature of the 1 
 
 llceration usually oc( 
 Vlie more chronic fori 
 louring lymphatics an 
 tiiilst later on the di; 
 lenerally disseminated 
 lervical portion of th< 
 Itinds such as the liv 
 
 
 |« 37 Section through 
 Stom; 
 
 [Mucosa ; i, submucosa; r, n| 
 from the mucosa, has invj 
 has accompanied here anc 
 
 Ipnior maxilla, originat 
 hihrane lining the anti 
 
 Glandular or Acinous C 
 
 p a malignant form of < 
 
 flerasdoesanepithelion 
 ["'*^ glandular acini, fr 
 tie basement membi 
 "Pliatics into surrounc 
 cess already describe 
 fm of stroma varies 
 
TUMOURS AND CYSTS 
 
 '43 
 
 ceration usually occurs, giving rise to a typical sore, bounded 
 the more chronic forms by indurated and everted edges. Neigh- 
 Liring lymphatics are implicated, as in the case of all cancers, 
 ilst later on the disease spreads to the viscera, and may be 
 lerally disseminated. A similar type of growth occurs in the 
 vical portion of the uterus, and occasionally in the ducts of 
 inds such as the liver and breast. It is also met with in the 
 
 G jy. Section through Advancing Margin of Columnar Cancer of 
 Stomach, x 25. (Ziegler.) 
 
 iMucosa ; b, submucosa ; c, muscularis ; d, serosa ; e, neoplasm which, starting 
 trnm the mucosa, has invaded the other layers. Small-celled infiltration 
 has accompanied here and there the formation of the neoplastic tubules. 
 
 |perior maxilla, originating in the tubular glands of the mucous 
 Vnbiane lining the antrum. 
 
 Ifllandular or Acinous Cancer.— Glandular cancer may be looked 
 
 IS a malignant form of adenoma, bearing the same relation to the 
 
 iter as does an epitheliomti to a benign papillonui. The epithelium 
 
 |the fflandukir acini, from which it originates, is not retained 
 
 'the basement membrane, but travels beyond it along the 
 
 ihatics into surrounding parts, which are transformed by a 
 
 (ess already described into the tumour substance. The 
 
 Nnt of stroma varies considerably, and according to whether 
 
144 
 
 A MANUAL OF SURGERY 
 
 it is abundant or small in quantity, the tumour is hard or soft i 
 consistence, and slow or rapid in growth. To the former tvj 
 the term Scirrhus is applied ; to the latter, Encephaloid. 
 
 Scirrhus is met with most frequently in the breast, but al 
 occurs in the prostate, pancreas, and pyloric end of the stomaci 
 The clinical features of the disease as seen in the breast 
 described in Chapter XXX. On naked-eye examination 
 scirrhous tumour appears as a hard nodular mass, the limits j 
 which are imperfectly defined. When cut across, it creaks iindj 
 the knife, and presents a yellowish -white surface, which rapid 
 becomes concave owing to the contraction of the fibrous stroiin 
 It has often been compared to the section of an unripe peari 
 turnip, both on account of the grating sensation imparted to 
 knife, and from its appearance. On scraping the cut surface wii 
 the blade of a knife, a typical cancer juice is obtained, consisti{ 
 of epithelial cells and debris. 
 
 On microscopical examination, the tumour is found to consi 
 of an abundant and well-marked stroma, the acini of whij 
 are filled with epithelial cells (Fig. 38). In the centre faif 
 degeneration is often present, small cysts being occasional 
 produced in this way. At the periphery the growth may he st 
 extending in all directions along the lymphatics, whilst a roun 
 celled infiltration of the surrounding tissues is also evident. 
 
 Where the stroma is very excessive, the cell elements, an 
 indeed, the whole tumour, may un'^ergo atrophy, owing t( 
 compression of the nutrient vessels, constituting the \an4 
 known as atrophic scirrhus. 
 
 Encephaloid or Medullary Cancer is tlie term given to a j^no\J 
 of a similar nature, in which the stroma is much less abund( 
 than the cell elements. It constitutes a soft, rapidly growii 
 tumour abundantly supplied with bloodvessels, and very tJ 
 affecting neighbouring lymphatic glands. The skin over surlj 
 tumour is stretched, and dilated l)lue veins can be seen throuf,'!i| 
 Ulceration occurs early, and from this surface a foul, hleediij 
 fungating mass sprouts up, formerly known as a ' fungus liaiJ 
 todes.' Encephaloid cancer is met with in the breast, ttsj 
 kidney, and a few other glandular organs. 
 
 On section it is found to be composed of a soft whitish ma 
 somewhat resembling brain substance. It is usually very vascuj 
 perhaps pulsating, and hemorrhagic extravasation into its tissa 
 is not uncommon. An abundant juice is obtained on scrapij 
 Under the microscope it is seen to be composed of large f^^roi 
 of spheroidal epithelial cells, held together by a scanty stroiiiaj 
 
 Colloid Cancer results from a degeneration of the epithelial cj 
 of a glandular or columnar cancer. Its most frequent sita 
 Vvithin the abdominal cavity, in connection with cancers ari;? 
 from the stomach, intestine, or omentum. 
 
 M 
 

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 ^ 
 
To the naked eye 
 [the spaces being fill! 
 [varying density. Mil 
 Idistinguishable, being 
 jstance. Towards the! 
 Iseen in process of degl 
 JR-ithin them and presr 
 
 The Treatment of C^ 
 
 |by operation, together 
 
 or, in some cases,! 
 Ihe lymphatic area conl 
 not to cut across the 
 the glands. If sucl 
 a sufficiently early ds 
 iwing to the tendency 
 eradication is usuj 
 ecurrence is therefore 
 In cases where rem 
 acticable, owing to its 
 move a portion of the 
 lustics. Of these the 
 usually applied as a pi 
 In other instand 
 th by tying the chie 
 ision of sensory neri 
 St temporary relief. 
 Of recent years other 
 atment of inoperable 
 ction of pyoktanin c 
 ucts, such as Coley's 
 koming suggests tha 
 ery small in the case 
 n hopeless cases, all 1 
 ce free from irritat 
 health is maini 
 sive pain is kept in 
 ihia. 
 
 I a cyst is usually m 
 istinct lining membn 
 
 material. The ten 
 jety of manifestations 
 llact that conditions \ 
 [sometimes termed cyi 
 
 ilier. For practical 
 tllows : 
 
TUMOURS AND CYSTS 
 
 HS 
 
 To the naked eye colloid cancer presents an alveolar structure, 
 e spaces being filled with translucent gelatinous material of 
 rying density. Microscopically, the epithelial cells are rarely 
 itinguishable, being replaced by a structureless colloid sub- 
 ince. Towards the growing margin, however, the cells may be 
 en in process of degeneration, globules of the material forming 
 thin them and pressing the nucleus to one side. 
 
 The Treatment of Cancer consists in the removal of the tumour 
 
 [operation, together with a wide margin of healthy tissue around 
 
 or, in some cases, of the whole organ affected, as well as 
 
 e lymphatic area concerned, and, if practicable, in one mass, so 
 
 , not to cut across the lymphatic vessels passing from the growth 
 
 I the glands. If such is conducted in a thorough manner and 
 
 ; a sufficiently early date, a good result may be anticipated ; but, 
 
 iving to the tendency of all cancers to spread along lymphatics, 
 
 s eradication is usually a matter of the greatest difficulty. 
 
 lecurrence is therefore very liable to ensue. 
 
 In cases where removal of the disease by the knife is im- 
 
 Hcticable, owing to its extent, it may sometimes be possible to 
 
 move a portion of the disease, the remainder being dealt with by 
 
 lustics. Of these the most satisfactory is chloride of zinc, which 
 
 usually applied as a paste, a little opium being added to allay 
 
 in. In other instances it has been proposed to starve the 
 
 iwth by tying the chief nutrient artery, and to diminish pain by 
 
 ision of sensory nerves ; such can, however, only give the 
 
 fit temporary relief. 
 
 recent years other methods have been suggested for the 
 atment of inoperable malignant disease — e.g., the interstitial 
 lection of pyoktanin or methyl violet, or of various bacterial 
 ucts, such as Coley's fluid (p. 125). The evidence at present 
 koming suggests that the practical value of these proceedings 
 very small in the case of the cancers, 
 hopeless cases, all that can be done is to keep any ulcerated 
 ,ce free from irritation, and if possible aseptic, whilst the 
 leral health is maintained by suitable diet and drugs, and 
 ssi\ e pain is kept in check by the administration of opium or 
 |tphia. 
 
 Ojrsts. 
 
 |y a cyst is usually meant a more or less rounded ca\ ity, with 
 jstinct lining membrane, distended with some fluid or semi- 
 material. The term is used very loosely, being applied to a 
 [ety of manifestations which it is difficult to classify, owing to 
 that conditions which are pathologically similar in origin 
 ometimes termed cysts in one part of the body, and not so in 
 ter. For practical purposes, however, they may be grouped 
 |lows : 
 
 10 
 
146 
 
 A MANUAL OF SURGERY 
 
 I. Cysts of embryonic origin, or arising in connection with 
 embryonic remains. 
 
 II. Cysts arising from the distension of pre-existing spaces (dis- 
 tension cysts). 
 
 III. Cysts oi new formation. 
 
 IV. Cysts of degeneration. 
 
 I. Cysts of Embryonic Origin, or arising in connection with 
 Embryonic Remains. 
 
 I. The most important cysts to be considered under this head- 
 ing are those known as Dermoids. These are characterized hythej 
 existence in abnormal situations of cavities Hned with epithelium,} 
 from which may be developed any form of cutaneous appendage J 
 — e.g., hairs, nails, teeth, etc. — whilst the space is usually occupiedl 
 by sebaceous or mucous contents. The structure of the lining) 
 wall is very similar in nature to skin or mucous membrane, con- 
 sisting of stratified epithelium, from which a considerable f,'ro',vth| 
 of sebaceous glands and hair follicles often takes place. 
 Several varieties of dermoids are described : 
 (a) Sequestration Dermoids are cysts arising from the incom-i 
 plete disappearance of surface epithelium in situations where,! 
 
 during embryonic life, fleshyl 
 segments coalesce. Thus, in 
 almost any part of the iiiiddlei 
 line of the body such tumoiirsl 
 may develop, owing to the 
 fact that there is here a iinionl 
 of two lateral segments.! 
 Similarly, they are not un 
 common about the face and] 
 neck, occurring along the line 
 of the facial and branchi 
 clefts. Perhaps the mosi 
 common position for them i 
 this region is the upper portioi 
 of the orbito-nasal cleft, hehin 
 and to the outer side of th 
 eye (Fig. 38). It is not unusual 
 to find the skull defective be 
 neath them, and a pedici 
 extending from the deep sidej 
 connecting them with the dun 
 mater. Sequestration den 
 moids appear as rounded, 
 definitely limited tumours, 
 over which the skin glides freely, but are usually somewhal 
 adherent to the deeper parts. They are firm and elastic to thi 
 
 Fig. 38. — Dermoid Cyst, growing at 
 THE Outer Angle of the Orbit. 
 (Bland Sutton.) 
 
 loucli, and filled with 
 Nattened epithelial c( 
 This form of dermoid 
 those occurring abou 
 beneath them, it is pe 
 life, unless the tumour 
 for this is that the b< 
 and thus closes the c 
 some cases it may be 
 membrane by disseci 
 portion left behind sho 
 otherwise, recurrence i 
 
 Hydatid of 
 Murgagiii. 
 
 I Fir, 39. -Diagram of Adui 
 
 AND n 
 
 ih) Dermoids may i 
 I canals and passages, ai 
 These are chiefly met 
 duct (Chapter XXVIII 
 
 (') Ovarian Dermoide 
 They are lined with sk 
 of cutaneous appenda 
 cavity may be more or 
 ofteethset in bonyalv( 
 nipples and mammse. 
 
 2, Cysts occasionally 
 
 W ; such have been a 
 
 {"d epithelial odontom( 
 
 Hentigerous cysts, the li 
 
TUMOURS AND CYSTS 
 
 147 
 
 ouch, and filled with sebaceous material, containing fatty debris, 
 lattened epithelial cells, perhaps hairs, and occasionally teeth. 
 fhis form of dermoid may be removed without difficulty, but in 
 ;hose occurring about the scalp, with the bone hollowed out 
 beneath them, it is perhaps advisable to delay operation till adult 
 life, unless the tumours are rapidly increasing in size. The reason 
 for this is that the bone gradually grows up around the pedicle, 
 and thus closes the communication with the cranial cavity. In 
 some cases it may be difficult to remove the whole of the lining 
 membrane by dissection, and under these circumstances the 
 portion left behind should be destroyed with cautery or caustics ; 
 otherwise, recurrence is almost certain to follow. 
 
 Hydatid of 
 Morgagiii. 
 
 Paradidymis or 
 
 Mesonephros. 
 
 Kebelt's tubes. 
 
 Fir, 39 -Diagram of Adult Testicle, to show Relation of Mesonephros 
 AND ITS Ducts. (Bland Sutton.) 
 
 (i) Dermoids may also arise in connection with embryonic 
 canals and passages, and have then been called Tubalo-Dermoids. 
 These are chiefly met with in connection with the thyro-glossal 
 duct (Chapter XXVIII.) and the post-anal gut (Chapter XXL). 
 
 (c) Ovarian Dermoids are usually unilocular, and of large size. 
 They are lined with skin, from which an abundant development 
 of cutaneous appendages is sometimes observed. Thus, the 
 cavity may be more or less filled with hair, whilst large masses 
 of teeth set in bony alveoli are also seen in this situation, and even 
 nipples and mammae. 
 
 2. Cysts occasionally arise in connection with the formation of the 
 Mh ; such have been already alluded to under the terms follicular 
 wd epithelial odontomes (p. 135), the former being also known as 
 dentigerous cysts, the latter as fibro-cystic disease of the jaw. 
 
 10 — 2 
 
148 
 
 A MANUAL OF SURGERY 
 
 Tl 
 
 3. Various cysts develop in connection with the remains of\ 
 the Wolffian body, as also from its tubules and duct. It must W 
 remembered tliat this body arises in the posterior abdominal wall 
 near to the origin of the kidney and testis, and that part of it 
 enters into tlie formation of the latter ; hence one is not surprised 
 to find that its remains are closely associated with that organ in | 
 the scrotum. 
 
 In the male (Fig. 39) the Wolffian body atrophies almost cum-i 
 pletely, being represented by a few blind tubules, situated close to 
 the epididymis, and known as the paradidymis, or organ of 
 (iiraldes. Fibro-cystic disease of the testis (adenoma testis) is 
 said to arise from this structure. The majority of the ducts of 
 
 Fig. 40. — Diagram to represent the Cyst Regions ok the Ovarv 
 
 (Bland Sutton.) 
 
 A, Oophoron, or ovarian tissue; B, paroophoron, or tissue of the hilu.s; ("J 
 parovarium ; K, Kobelt's tubes ; G, Gartner's duct ( = main Wo'ffian dtict) 
 
 the Wolffian body form the vasa efFerentia testis ; a few of thej 
 upper ones, however, contract no attachment to the .{land, ancj 
 their free ends (known as Kobelt's tubes) may becon;e dilatedJ 
 and form small cysts, situated close to the hydatid of MorgagniJ 
 which structure represents the remains of the Miillerian )ody and 
 duct. It is possible that an encysted hydrocele of the eoididymi^ 
 sometimes arises from one of these unobliterated tubules. Thii 
 main duct of the Wolffian body forms the lower portions of 
 epididymis and vas deferens. 
 
 In the female (Fig. 40), the remains of the Wolffian body ard 
 sometimes met with as a series of closed tubes in the neighbourl 
 hood of the ovary (paroophoron). Cysts may arise in connectioif 
 with this structure, and are chiefly characterized by their innej 
 walls being the seat of proliferating papillomata. The W'olffiaij 
 
 j;ul)ules can almost alw 
 I constituting the parovai 
 Icysts formed from the 
 lanilocular, and filled wi 
 
 BO definite pedicle, and 
 Ijome of the terminal 
 Ijhich project from the 
 |are known as cysts of '. 
 Generally atrophies, but 
 lofthe broad ligament 
 laear the urethral orific 
 I Cysts may occasionally 
 I projecting into the later 
 1 4. The processus vagi 
 j applied to the protrusio 
 reform the tunica vagir 
 
 ihe round ligament ( 
 I obliterated, but sometin 
 I distended with a clear 
 I in the male an encysted 
 hirocele of the round ligat. 
 
 II. Cysts due to t] 
 
 [a] Exudation Cysts a 
 J are unprovided with ex 
 I inflammatory nature. 
 lor endothelium. As 
 I mentioned those which 
 Itiody, as also conditioi 
 I canal of the nervous 
 j forms of ovarian cysts 
 I follicles. 
 
 Exudation cysts linec 
 Imore numerous. Enla 
 Ininica vaginalis, funicul 
 Itornis of ganglia, are of 
 jtrusions of the synovial 
 Ibown as Baker's cysts. 
 
 A Serous Cyst is suppc 
 Jspaces, giving rise to i 
 lendothelium, and contaii 
 jigrowth, when met wit 
 j»;liere, is usually called i 
 fim is also found in th( 
 
 \V) When a collection 
 Isocalled Cyst of Extravi 
 
TUMOURS AND CYSTS 
 
 149 
 
 niles can almost always be recognised in the broad ligament, 
 nstituting the parovarium, or organ of Rosenmiiller. Parovarian 
 gts formed from the distension of this structure are usually 
 ilocular, and filled with a clear limpid serous fluid ; they have 
 definite pedicle, and strip up the layers of the broad ligament. 
 line of the terminal tubes may be converted into small cysts 
 lich project from the fimbriated ends of the Fallopian tube, and 
 e known as cysts of Kobelt's tubes. The main Wolffian duct 
 nerally atrophies, but occasionally runs down between the layers 
 the broad ligament close to the uterus, to open in the vagina 
 ;ar the urethral orifice, being then known as Gartner's duct. 
 ysts may occasionally arise in connection with this structure, 
 :ojecting into the lateral fornix of the vagina. 
 4. The processus vaginalis, or funicular process, is tlie term 
 pplied to the protrusion of peritoneum which precedes the testis 
 )torm the tunica vaginalis, and which in the female accompanies 
 le round ligament {canal of Nuck). Normally it becomes 
 Witerated, but sometimes portions of it remain patent, and are 
 istended with a clear straw-coloured serous fluid, constituting 
 ] the male an encysted hydrocele of the cord, and in the female a 
 ^imele of the round ligament. 
 
 11. Cysts due to the Distension of Pre-existing Spaces. 
 
 (d) Exudation Cysts arise from the distension of cavities which 
 re unprovided with excretory ducts, and are frequently of an 
 iflammatory nature. Such spaces may be lined with epithelium 
 
 endothelium. As illustrations of epithelial cysts may be 
 mentioned those which arise in connection with the thyroid 
 lody, as also conditions due to the distension of the central 
 anal of the nervous system (syringo-myelocele), and those 
 arms of ovarian cysts which arise from distension of Graafian 
 
 licles. 
 
 Exudation cysts lined by a serous or endothelial wall are much 
 rare numerous. Enlargements of bursae, hydroceles of the 
 unica vaginalis, funicular process, or canal of Nuck, and somt 
 )rms of ganglia, are of this nature. Diverticula or hernial pro- 
 pjsions of the synovial membrane of joints also occur, and are 
 nown as Baker's cysts. 
 
 \ Serous Cyst is supposed to arise from the distension of lymph 
 paces, giving rise to uni- or multi-locular cavities, lined with 
 Ddothelium, and containing a limpid straw-coloured fluid. Such 
 
 growth, when met with in children, either in the neck or else- 
 here, is usually called a. cystic hygroma ; a somewhat similar con- 
 ition is also found in the breast. 
 
 h) When a collection of blood forms in a pre-existing cavity, a 
 ^called Cyst of Extravasation is produced. Such is met with in 
 
 Jt 
 
ISO 
 
 A MANUAL OF SURGERY 
 
 the pelvis or tunica vaginalis (ha^matocele), and also occasionally 
 on the surface of the brain, constituting what is known as aii 
 arachnoid cyst. 
 
 {c) Retention Oysts always arise from obstruction to the escape 
 of some natural secretion from a f^land duct or tubule. The 
 cavity thus formed is lined with epithelium, whilst, owin^ to the 
 irritation produced by the tension, a fibro-cicatricial wall of 
 \ariable thickness is developed outside. There is often a con- 
 siderable formation of intracystic growths, especially in the 
 breast, whilst the contents generally consist of the inspissated 
 secretion, perhaps mixed with blood. 
 
 Retention cysts may develop in connection with any glandular 
 tissue. The majority are described under the appropriate headings, 
 viz., Mammary cysts, Renal cysts. Pancreatic cyst, etc. 
 
 III. Oysts of New Formation are such as occur apart from 
 any embryonic condition or pre-existing cavity. The following 
 varieties may be described : 
 
 {a) An Implantation Cyst is one which arises from the accidental 
 intrusion into the subcutaneous or submucous tissues of epitlielial 
 cells which retain their vitality, and are enabled to develop a cyst 
 very similar in nature to a dermoid ; in fact, it may be k)oked I 
 on as an A cqnired or Tyaumatic Dermoid. Such an occurrence is ' 
 usually brought about as the result of an injury, especially from j 
 punctured wounds ; thus, cysts of this nature have been met 
 with in the fingers or palm of the hand as a consequence of the 
 penetration of some sharp instrument, whilst they are also occa- 
 sionally seen in the anterior chamber of the eye, following an 
 iridectomy. They are, moreover, observed in the axillae of cattle, 
 as a result of goading them with some siiarp implement. The 
 clinical signs and treatment are siinilar to those of a Germoidj 
 cyst. 
 
 {h) Cysts sometimes form around foreign bodies, which thus] 
 become encapsuled. They are lined either by granulation tissue | 
 or endothelium, surrounded by a variable amount of fibro-cicatricial 
 tissue. 
 
 (r) Blood Cysts are sometimes of doubtful origin. Some of them I 
 certainly arise from extravasation of blood, and in such cases 
 coagulated blood, or a thin serous fluid, is found within, the cavity] 
 being perhaps lined with laminated fibrin. In many cases a so- 
 called blood cyst is really a soft sarcoma, into which haemorrhaf^ej 
 has occurred ; but in addition to these, a few instances are on| 
 record in which a thin-walled cavity existed, occupied by blood, 
 and readily refilling after it had been tapped. Such conditions! 
 have been most frequently observed in the neck (see Chapterj 
 XXVIII.). 
 
 {d) Parasitic Cysts are produced by the irritation caused by the! 
 growth within the tissues of certain living organisms. Thus, inj 
 the disease known as trichinosis, derived from eating unsound! 
 
TUMOURS AND CYSTS 
 
 I5« 
 
 pork, the Trichina spiralis, a small round worm, develops in large 
 numbers in the voluntary muscles, and becomes surrounded by a 
 capsule which is subsecjuently calcified. 
 
 The most important of these parasitic cysts is that caused by 
 the development within the body of the scolex stage of the Tania 
 ickiiwcoccus, giving rise to what are known as Hydatid Oysts. 
 This disease is i uuch more common in Australia than in this 
 country. The Tania echinococcus (Fig. 41) is a 
 minute tapeworm, less than half an inch in 
 Icnfjth, which inhabits the intestinal canal of 
 do^'s ; it consists of four segments, the posterior 
 one being larger than the rest of the body, and 
 containing the genital organs. When mature, 
 this last segment becomes filled with ova, which 
 are discharged, and these find their way into the 
 human stomach by the media of water or un- 
 cooked vegetables, such as watercress, which 
 have been contaminated with the dog's excreta. 
 The process of digestion sets the embryo free, 
 and by means of a crown of little hooks which 
 It possesses, as well as four suckers, it is enabled 
 to bore its way through tlie walls of the stomacii, 
 and thence travels by the bloodvessels to the liver 
 or some other part of the body. As a result of 
 the irritation caused by its presence, a sac forms 
 which originally consists of three layers : ex- 
 ternally, a fibro-cicatricial layer, then an inter- 
 nediate lamellated layer of chitinous material 
 (true ectocyst), and finally the cyst is lined by a 
 protoplasmic germinal layer {endocyst), from 
 which may be developed solitary taenia heads 
 or scolices, also provided with four suckers and 
 circlet of hooks, whilst sometimes groups of 
 them, known as brood-capsules, may arise in the 
 same way (Fig. 43). Daughter-cysts are not 
 unfreijuently formed from the scolices, and they 
 in their turn may pass through the same changes, 
 although as a rule they are barren. Occasionally 
 tven the main cyst may be sterile (acephalocyst), 
 and in such cases the walls become very defi- 
 nitely laminated. The fluid contained in the cyst varies much in 
 amount, but is always of low specific gravity, not more than 1007 ; 
 It is colourless, but slightly opalescent, limpid, and contains but a 
 trace of albumen, although a considerable amount of chloride of 
 sodium is present. On examining the fluid microscopically, the 
 cliaracteristic hooklets are observed. The organs usually affected 
 !iy liydatid disease are the liver, kidneys, and brain, but any part 
 of the body may be attacked. Occasionally in the liver, and 
 
 Fig. 41. — T/F.NiA 
 
 Echinococcus. 
 
 X ABOUT 20. 
 
 \r 
 
152 
 
 A MANUAL OF SURGERY 
 
 usually in bone, multiple cysts develop quite distinct from each 
 other, and with no general cyst-wall. 
 
 Fir.. ,}2.--HvDATiD Cyst (Diagrammatic), showing Daughter-Cysts and 
 Brood-C'iPsules growing from the Walls. (After Bland Sutton.) 
 
 Fig. 43. — Diagrammatic Section of Wall ok Cyst. 
 
 It, Fibro-cellular capsule, here somewhat exaggerated ; b, lamellated chitinous 
 layer, or ectocyst ; c, hrood-capsules developing from the protoplasmic 
 layer, or endocyst ; d, scolex, or separate head, enlarged. 
 
 For the diagnosis and treatment of hydatid cyst of the liver, see 
 Chapter XXXI. 
 
 In other regions, if the tumour cannot be removed by dis- 
 
 section, reliance musi 
 |,)fthe growth renders 
 
 IV. Cysts of Dege: 
 
 I especially those whei 
 Thus, mucoid degene 
 myomata, chondroma 
 Occasionally cysts fo 
 
 Ihk-^ frequently as a 1 
 
TUMOURS AND CYSTS 
 
 153 
 
 section, reliance must be placed on drainage, where the siti:ation 
 i)fthe growth renders this practicable, or aspiration. 
 
 IV. Cysts of Degeneration arise in connection with tumours, 
 especially those where the blood-supply is not very abundant. 
 Thus, mucoid degeneration is not uncommon in fibromata, fibro- 
 niyoiiiata, chondromata, and even in the harder forms of cancer. 
 Occasionally cysts form in the sarcomata from this cause, but 
 nif-^ frequently as a result of haemorrhage. 
 
 m* 
 
CHAPTER VII. 
 
 WOUNDS. 
 
 A WOUND has been defined as the forcible solution of continuity 
 of any of the tissues of the body ; but the term is more cotnmonly 
 limited to irjuries of the soft parts, involving the skin or mucous 
 membranes. Lesions in which the skin does not participate, and 
 in which the deeper structures, such as bones, ligaments, etc., are 
 not involved, are spoken of as contusions. 
 
 A Contusion is any subcutaneous wound or injury due to the | 
 agency of external \iolence, causing laceration of the cellular 
 tissue, '.vithout necessarily involving such deeper structures as I 
 nuiscles, tendons, nerves or bones. The signs are usually very 
 obMous, viz., pain, bruising, or discoloration of the part, and 
 swelling. These are readily explained by the injury inflicted on] 
 'Jie subcutaneous tissues, which in the worst cases may be entirely 
 disorganized and separated from the skin. The amount of bruinnf,'! 
 varies with the part injured and the severity of the lesion; thus, 
 in the eyelids, scrotum, and vulva, where the tissues are lax, the] 
 ecchymosis will be very extensive and of a black colour; on the 
 scalp there is, on the other hand, but little swelling, if the injury] 
 does not include bleeding beneath the aponeurosis of the ocripito- 
 frontalis. Again, the condition of the patient's genera! health! 
 influences the amount of blood effused ; in a strong man in good! 
 training, but little bruising is seen, whilst in those of a languidl 
 temperament and relaxed tissues, a slight injury often produces aj 
 very conspicuous ecchymosis. Blebs and bulhr may form over! 
 the injured spot in bad cases. The changes that occur in a bniisej 
 are well known, the colour passing from a blackish-purple throuL;hI 
 various shades of brown and green to a yellow, which gra(iuall\j 
 fades and disappears; this is due to the disintegration of the red 
 corpuscles, and staining of the tissues by the haemoglobin thus! 
 set free, or by the products formed during its removal. When 
 liKmoirhage has taken place into the deeper parts or under deiisd 
 fasci.ne, it is often some days before the bruise ' comes out,' and 
 this may occur at some distant spot, f.^^, in the eyelids after 
 blow on the scalp, whilst after a fracture of the neck oi tlid 
 
 humerus the blood 
 planes, and the bruij 
 In a bruise or ec 
 infiltrated with bloo( 
 localized, collecting 
 tissues, and remain i 
 somewhat resembles 
 its history, having si 
 !ia\ ing appeared wit! 
 moreover, though at 
 whereas an abscess h 
 m\ the softening oc 
 liseniatoma varies sor 
 deposit of fibrin may 
 tluid centre, which gr 
 absorbed. This is w( 
 haematoma, where the 
 out and the fluid centi 
 the impression of a d 
 the blood may be absc 
 residuum may become 
 persists indefinitely ; t 
 unfreriuently pigmente 
 and a slightly pigmenti 
 fluid, and constituting 
 nection with the cereb| 
 I may ensue owing to i 
 I in\asion of organisms 
 In forming an opir 
 I injury, one nuist be ) 
 tissue involved, the a 
 and vitality of the ind 
 U'lere may be a goo( 
 under less favourabl 
 injured tissiies may ree 
 ! The Treatment of a 
 I cold or evaporating U 
 feding, but such mus 
 or where much lacerat 
 ofthe injured parts . 
 hxcept under special ci 
 lartery, or when some d 
 ht once with the injure 
 ppsis the dread of op 
 jesists. yet it should no 
 |»hen a tense and paii 
 llatanf the thigh, reco 
 l»n aseptic puncture, fc 
 
WOUNDS 
 
 m 
 
 humerus the blood may travel along the muscular and fascial 
 planes, and the bruise first appear about the elbow. 
 
 In a bruise or ecchymosis, the tissues are, as a rule, merely 
 infiltrated with blood, but occasionally the extravasation is more 
 localized, collecting in a cavity formed by the laceration of the 
 tissues, and remaining as a fluid swelling, or Hsematoma. If 
 somewhat resembles an abscess to the touch, but differs from it in 
 its history, having supervened imn jdiately after an injury, and 
 having appeared without any heat or other sign of inflammation ; 
 moreover, though at first fluid and soft, it soon becomes harder, 
 whereas an abscess is preceded by a stage of brawny infiltration, 
 md the softening occurs later. The subsequent history of a 
 lismiitoma varies somewhat according to circumstances, (a) A 
 deposit of fibrin may be formed peripherally, leaving for a time a 
 tluid centre, which gradually disappears, and the whole is finally 
 absorbed. This is well exemplified in a sub-pericranial cephal- 
 hsmatoma, where the contrast between the fibrinous deposit with- 
 out and the fluid centre is sometimes so accentuated as to give 
 the impression of a depressed fracture, (b) The fluid portion of 
 the hlood may be absorbed almost entir' \y, and the solid fibrinous 
 residuum may become organized into a firm fibroid tumour which 
 persists indefinitely ; the mass is more or less laminated, and not 
 unfretjuently pigmented, (c) The fibrin may be entirely absorbed, 
 uid a slightly pigmented fibrouf; (.c^pSule formed containing serous 
 uid, and constituting a definite .; such is best seen in con- 
 nection with the cerebral tunics {arachnoid cyst), (d) Suppuration 
 may ensue owing to infection from within the body, or from an 
 invasion of organisms through abraded skin. 
 
 In forming an opinion as to the gravity of a subcutaneous 
 injury, one must be guided by the part injured, the extent of 
 tissue involved, the amount of blood extravasated, and the B'^e 
 and vitality of the individual. In the less severe cases, though 
 re may be a good deal of bruising, recovery will ensue, but 
 inder less favourable conditions sloughing and death of the 
 injured tissues may result. 
 
 The Treatment of a bruise usually consists in the application of 
 cold or evaporating lotions and pressure in order to check the 
 leading, but such must be used with care in old weakly individuals 
 or where much laceration of the tissues has taken place, for fear 
 of the injured parts dying. The skin should never be incised 
 except under special circumstances, such as the rupture of a large 
 artery, or when some definite advantage is to be gained by dealing 
 at once with the injured structures; for though under careful anti- 
 sepsis the dread of opening recent collections of blood no longer 
 exists, yet it should not be lightly undertaken. At the same time, 
 when a tense and painful haematonia exists, as under the fascia 
 lata of the thigh, recovery can be hastened and pain relieved by 
 an aseptic puncture, followed by careful compression. In general 
 
156 
 
 A MANUAL OF SURGERY 
 
 bruising of the body from a fall or extensive injury, pain can often 
 be relieved by applying fomentations or by a hot bath. There is 
 generally a certain amount of fever and constitutional disturbance 
 for a few days, and these are c calt with by purgatives and a suit- 
 able limitation of diet. 
 
 Open Wounds. 
 
 An open wound may be defined as a solution of continuity of 
 any superficial part of the body, including skin or mucous mem- 
 brane. Various kinds of wounds are described, such as the 
 incised, lacerated, contused, punctured, poisoned, and gunshot; 
 but, of course, the most important distinction to draw is between 
 the infected and the n^ i -infected. 
 
 I. Incised Wounds. — An incised wound is one made by any 
 sharp cutting instrument, but occasionally a wound not produced 
 in this manner may be characterized by similar appearances; 
 e.g., the skin of the knee or elbow may be cleanly split open from 
 falling on it with the limb flexed, and occasionally a policeman's 
 truncheon will lay open the scalp almost as evenly as if a knife 
 had been employed. 
 
 The special features of an incised wound are as follows : 
 
 1. The haemorrhage is free, from the fact that the vessels are 
 cleanly divided. The amount necessarily depends on the size of 
 the vessels involved, and the vascularity of the part ; its continu- 
 ance, upon the density of the structures allowing or not of con- 
 traction and retraction of the severed ends. 
 
 2. Separation of the lips of the wound also occurs, the amount 
 depending upon the elasticity and character of the parts involved, 
 
 3. Bruising of the margins of the incision is absent, so that under 
 ordinary circumstances rapid healing (by first intention) should 
 obtain. The surfaces, to begin with, are lined by a microscopic 
 layer of damaged tissue, some of which may be actually dead ; 
 hut if suitable precautions are taken, this is absorbed, and in no 
 way interferes with satisfactory union. 
 
 Treatment of Incised Wounds. — Seven essentials must h 
 attended to if liealing by first intention is to be obtained, viz. : 
 
 (i.) The Arrest of aU Bleeding. —If there is general oozinf(, 
 exposure to the air is often quite sufficient ; or sometimes it may 
 be supplemented by pressure for a few minutes with an aseptic 
 sponge. Arteries and veins will need a ligature, but if situated 
 close to the skin, they may often be secured by passing under the 
 bleeding spot the needle used for the suture. 
 
 (ii.) Sterilization of the Wound and its Surroundings.— When 
 made by the surgeon through skin which has been previously 
 purified, and if efficient precautions as to hands, instruments, etc., 
 have been taken, there is no need to flush out the wound with 
 any antiseptic. All such substances are more or less irritatin',', 
 and when introduced into a fresh wound are likely to increase 
 
WOUNDS 
 
 »57 
 
 exudation and render drainage necessary. In such cases it will 
 siiftice to cleanse the parts with sterilized salt solution. 
 
 In casualty work, however, a wound, though cleanly cut, is 
 made through dirty skin, and portions of clothing, dirt, and 
 splinters of wood or glass may be carried in. Under these 
 circumstances the wound and its surroundings must be thoroughly 
 purified, according to the rules given on p. 180, and a free use of 
 I in 20 carbolic lotion, or even of Lister's ' strong mixture ' 
 (5 per cent, of carbolic acid with "2 per cent, of corrosive sub- 
 limate), is advisable, whilst foreign bodies are removed. 
 
 (iii.) The coaptation of the opposed surfaces by means of sutures 
 may now be undertaken. Many sul^stances have been, and are, 
 employed for this purpose, but amongst the best are fine silver 
 wire, silk, horsehair, silkworm gut and catgut. In casualty work, 
 ;ind for parts of the body where but little scar is subsequently 
 desirable, as in the face, horsehair and silkworm gut, being non- 
 absorbent, are perhaps the best materials to employ ; but in 
 ordinary operative work, which will be more certainly aseptic, 
 ind where the after-treatment is more efficient, fine catgut or silk 
 may be used. There are three chief varieties of sutures, viz., 
 le buried, the deep, and the superficial. 
 
 Buried siiiures are now largely employed, since a foreign body 
 nay be saftl^ inserted into the tissues, if both it and the wound 
 ire aseptic. Catgut and silk are the agents made use of, and 
 lerves, tendons, muscles or fascia; are the structures mainly dealt 
 with. In deep wounds it is always most desirable to effect union 
 in this way of all the divided tissues (that is, to build the part up 
 iij^ain), and not merely to unite the skin over them. 
 
 Deep stitches, or sutures of relaxation, are required in cases wliere 
 iliere is difficulty in bringing the edges of the wound together, in 
 order to transfer the tension from the healing margin to tissues 
 turtiier away, the edges being thereby relaxed. For this purpose 
 thick silver wire may be employed, inserted i or i| inches from 
 the margins, and tied directly, or lead buttons may be interposed 
 next to the skin, and the ends of the wire fastened round the 
 projecting edges, thus diffusing the pressure over a greater space. 
 They are generally removed at the end of two or three days. 
 
 Superficial stitches, or sutures of coaptation, must be so inserted 
 as tu bring the edges of the wound into contact without undue 
 pressure, and without any folding in of the skin. Various 
 methods are employed, viz.: I. The interrupted suture (F'ig. 44, A), 
 in which each stitch is separately finished off, the knot lying well 
 to one side of the incision. This is generally utilized for wounds 
 which are of irregular shape or in which there is tension. 2. The 
 imrs stitch (Fig. 44, B) is a continuous one, in which the thread 
 is carried on from point to point, and only fastened at the ends; 
 it is not to be recommended. 3. The blanket or buttonhole stitch 
 
 H 
 
 44, C) is the form of continuous suture which should be 
 
158 
 
 A MANUAL OF SURGERY 
 
 employed for extensive wounds or incisions. In it the needle, 
 after traversing the lips of the wound, is carried under the slack 
 of the thread, so that the loop of each stitch, as it is tightened, is 
 maintained at right angles to the edge of the wound, whilst tiie 
 intermediate portion lies parallel to it. To fasten it off, the needle 
 is passed in the opposite direction through the edges of the 
 incision, with the free end long enough to prevent it cf)min|,'| 
 through, and so enable it to be tied to the double portion carried I 
 through by the needle. 4. The quilled suture is not often eniployed. 
 
 Flo. 44.- Various Forms of Suture. 
 
 A, interrupted suture ; B, continuous suture ; C, blanket stitch. At the lowed 
 end the needle has just been passed and the way in which it catches ud 
 the loop is indicated. At the upper end the method of finishing ofl 
 (originally suggested by the late Mr. Maunsell) is shown : viz., the needla 
 is passed in the opposite direction to all the other stitches, the free end 
 being left long, so as to enable it to be tied into a knot with the doublej 
 thread which the needle has carried through. 
 
 It consists in tying the stitches round a quill or portion of catheteij 
 on either side of the wound, so that the deep surfaces may Ix 
 maintained in apposition, whilst the superficial portions sre lefl 
 clear for additional sutures. The only conditions under which ij 
 is now used are in the operations for ruptured perineum, or foj 
 extensive perineal or urethral fistuhp. 5. The Uvisted or Jif^un-oji 
 suture is still occasionally made use of for harelip or scalp wounds! 
 
 but has many disadv; 
 the sides of the woun 
 ihe fingers, and mainti 
 the needle in a figure-( 
 Plasters are sometin 
 must be very small a 
 treatment. A fine ase 
 (iv.) Drainage musi 
 »uard against the irriti 
 or exudations. In woi 
 pleteness of the ha^rr 
 tearing or laceration ol 
 :\ or 48 hours, in orde 
 the wound is dry and a; 
 by the dressings, it ma 
 When drainage is re 
 Chassaignac answers w 
 surface, and stitched to 
 slipping in or out. De 
 hut with no distinct ac 
 liorsehair or a strip of ^ 
 (\.) All fresh sourcei 
 must he excluded by so 
 (vi.) Rest to the in 
 arran},^enient of splints," 
 ivii.j The general 
 Item to attend to. In 
 pos.sible, be previously 
 regulated ; in casualty 
 as soon as convenient, . 
 The conditions whic 
 lirst intention are essei 
 mentioned above, and r 
 the bleeding, causing st 
 the wound ; (ii.) the pi 
 septic material ; (iii.) t 
 |iv.) imperfect drainag 
 [v.) subsequent infectio 
 |«c.; (vi.) lack of rest t 
 jilitions, such as deficie 
 Icauses, resulting in war 
 I Should signs of infl 
 |»ouncl, it is probable 
 liccoinpanied by fever. 
 lender such circumstan 
 |»me or all of the stitch 
 I "hen an accumulatioi 
 l%r parts of the wc 
 
 
WOUNDS 
 
 159 
 
 it has many disadvantages. A pin or needle is passed through 
 e sides of the wound, which are brought into apposition with 
 e fingers, and maintained by twisting silk around either end of 
 e needle in a figure-of-8 fashion. 
 
 Plasters are sometimes used instead of sutures, but the wounds 
 ust be very small and insignificant which only require such 
 eatment. A fine aseptic suture is in most cases preferable. 
 (iv.) Drainage must, if necessary, be provided, in order to 
 lard against the irritation and tension caused by retained blood 
 r exudations. In wounds where there is doubt as to the com- 
 leteness of the haanostasis, or where there has been much 
 ;aring or laceration of the tissues, it is wise to insert a tube for 
 4 or 48 hours, in order to allow effused blood to escape ; but if 
 le wound is dry and aseptic, and efficient pressure can be exerted 
 ly the dressings, it may be dispensed with. 
 
 When drainage is required, the indiarubber tube introduced by 
 'hassaignac answers well ; the end should be cut flush with the 
 urface, and stitched to the edges of the wound so as to prevent it 
 ilipping in or out. Decalcified bone tubes have been substituted, 
 )ut with no distinct advantage. For small wounds, a strand of 
 liorsehair or a strip of gauze or protective will usually suffice. 
 (\ .) All fresh sources of irritation and infection of the wound 
 must be excluded by some form of antiseptic or aseptic dressing. 
 (vi.) Rest to the injured part must be secured by such an 
 arranf^enient of splints, slings, or bandages as may be necessary. 
 (vii.) The general health of the patient is a most important 
 Item to attend to. In an operation case the bowels should, if 
 possible, be previously opened, and the patient's diet carefully 
 regulated ; in casualty work a good purge should be administered 
 as soon as convenient, and the food and drink limited. 
 The conditions which prevent healing of an incised wound by 
 nrst intention are essentially the reverse of the seven requisites 
 mentioned above, and may be epitomized thus : (i.) Non-arrest of 
 le bleeding, causing separation of the lips or deeper portions of 
 le wound; (ii.) the presence of impure foreign bodies or other 
 septic material ; (iii.) the edges not being brought into contact ; 
 imperfect drainage leading to tension on the stitches ; 
 subsequent infection of the wound owing to a faulty dressing, 
 (vi.) lack of rest to the part ; and (vii.) constitutional con- 
 itions, such as deficient general vitality from disease or other 
 causes, resulting in want of action in the wound. 
 Should signs of inflammation show themselves in an incised 
 »'ound, it is probable that they are septic in origin, and will be 
 accompanied by fever. Union by first intention rarely occurs 
 under such circumstances, and, indeed, it is better to take out 
 some or all of the stitches at once, and thus relieve tension (p. 76). 
 When an accumulation of blood and serum takes place in the 
 deeper parts of the wound whilst the integument is healing, it 
 
 etc. 
 
i6o 
 
 A MANUAL OF SURGERY 
 
 often suffices to partially open the incision, squeeze or press out 
 the fluid, and insert a small tube or gauze drain. 
 
 II. Lacerated or Contused Wounds. — Such injuries are caused 
 by blunt instruments, by machinery, missiles, the wheels of a 
 vehicle, etc. They are characterized by the following signs : 
 
 1. The Haemorrhage is, as a rule, but slight, since the vessels 
 are torn across irregularly, and not cut cleanly ; the middle and 
 inner coats, which give way first, are curled up within the con- 
 torted outer coat, forming a barrier sufficient to prevent loss of 
 blood. The vessels, moreover, being elastic, may be pulled out 
 of their sheaths, and may sometimes be seen pulsating upon the 
 surface. 
 
 2. The Lips gape less than in an incised wound, and are 
 irregular, torn, and bruised. More or less extensive portions of 
 dead tissue have to be disposed of before repair can take place, 
 and hence this form of wound usually heals by granulation. 
 When a limb is torn completely off, the tendons are often left 
 long, and the muscular bellies project from their fascial sheaths, as 
 flabby congested masses, since the skin gives way at a higher j 
 point than the subjacent structures. 
 
 The Progress of the case depends largely upon the (luestion 
 whether the wound is or is not aseptic. 
 
 In an Aseptic lacerated wound it may be possible to bring the 
 edges together by suture or otherwise, and, even though thev 
 are a little bruised, healing by a slightly delayed first intention 
 is possible, if drainage is provided. If the wound remains open,! 
 dead portions of tissue are absorbed, unless large and resistant,, 
 and an aseptic granulating surface results. There may be soinei 
 simple traumatic fever for a day or two, but it is of li:tle con 
 sequence. 
 
 If the wound is Septic, however, inflammatory phenomenal 
 supervene, resulting finally in a granulating surface. Three] 
 stages may be described in the course of the case, viz. : 
 
 (a) The stage of injury, resulting in shock. 
 
 (b) The stage of inflammation and sloughing, associated with 
 
 septic traumatic fever. 
 
 (c) The stage of repair by granulation, or prolonged suppura. 
 
 tion, with exhaustion and hectic fever in the worst cases, 
 The inflammatory period lasts a week, ten days, or more, accord' 
 ing to circumstances, and during this period the patient is iiabli 
 to various forms of septic trouble, including secondary luemor- 
 rhage, toxaemia, pyaemia, and traumatic gangrene. 
 
 The Treatment of contused and lacerated wounds varies witl 
 their character, and no absolute rule of practice can be laid (low 
 to suit all cases. The following routine is that usually adopted: 
 
 (a) Immediate Treatment. — The great desideratum in all thei 
 cases is to render the wound aseptic. To accomplish this ii 
 
 severe injuries, it is 
 after shaving the ski 
 in,'s are scrubbed wi 
 of a sterilized nail-br 
 or doubtful tissues 
 vessels are secured t 
 for drainage, since ti 
 exudation ; occasiona 
 for this purpose. 1 
 advisable to remove r 
 scissors or knife, if th 
 dressing of the usual 
 IS scanty and asepsis i 
 open, or, at any rate, 
 fully with gauze inipre 
 {!>) Subsequent Tres 
 measures adopted to ol 
 wound remains free fr 
 Inond careful dressir 
 isco\ered with slougl 
 artificial means before 
 poultices will consider 
 rdnemhered that seco 
 fad tissues are finalb 
 matory fever continues 
 It closely watched. \\ 
 ol)tained, it is treated 
 stin-grafting possibly be 
 The (luestion of Ampi, 
 «ith the graver forms oJ 
 lare now saved which w(l 
 'sacrificed. Hard and fl 
 to amputate and when 
 f" Its own merits. Ad 
 pnts must be carefuilvl 
 pe patient. An old pel 
 '»un;' one, and hence ad) 
 "icli one would certaif 
 my of the individuJ 
 it^'if^e, for some men al 
 distant state than othei 
 K must also bj taken 
 Kieral diseases, such a' 
 le to resort to radicJ 
 
 J lie vitality of the extl 
 'ore frequently than aij 
 
 ^'^■'^f of the latter are sc 
 t''e wound is of the gi 
 
WOUNDS 
 
 i6i 
 
 ;vere injuries, it is wise to anaesthetize the patient, and then, 
 iter shaving the skin, if necessary, the wound and its surround- 
 ings are scrubbed with soap and carbohc lotion (i in -^o) by means 
 f a sterilized nail-brush. Foreign bodies are renio- ed, and dead 
 r doubtful tissues cut away, if unimportant, whilst bleeding 
 essels are secured by ligature. Ample provision must be made 
 )r drainage, since the carbolic irrigation of itself causes much 
 xudation ; occasionally it is desirable to make a counter-opening 
 jr this purpose. The wound is closed by sutures, but it is 
 (Ivisable to remove ragged and torn fragments of skin with the 
 cissors or knife, if there is sufficient tissue around ; an antiseptic 
 ressing of the usual type is then applied. If, however, the skin 
 i scanty and asepsis not assured, it is better to leave the wound 
 ipen, or, at any rate, only to partially close it, packing it care- 
 iilly with gauze impregnated with iodoform. 
 (1)) Subsequent Treatment depends on whether or not the 
 neasures adopted to obtain asepsis have been successful. If the 
 vcund remains free from infection, nothing special is called for 
 x\ond careful dressing. If it becomes septic, anH the surface 
 s covered with sloughs, these must be removed by natural or 
 irtificial means before healing can occur ; the use of antiseptic 
 poultices will considerably expedite matters, but it must be 
 remembered that secondary haemorrhage may occur when the 
 liead tissues are finally detached. During this period inflam- 
 matory fever continues, and the patient's general health must 
 [le closely watched. When once a clean granulating surface is 
 toined, it is treated in the same way as any healing wound, 
 ikin-},'rafting possibly being needed in the more extensive cases. 
 The (}uestion of Amputation will sometimes be raised in dealing 
 ith the graver forms of lacerated wounds, although many limbs 
 ire now saved which would inevitably in former days have been 
 acrificed. Hard and fast rules cannot be laid down as to when 
 amputate and when not to do so; each case must be treated 
 '" its own merits. Apart from the local lesion, the following 
 mis must be carefully considered : (a) The age and vitality of 
 iie patient. An old person has less recuperative power than a 
 oiin;,' one, and henceadamag.^d limb may often be left in a youth 
 hich one would certainly remove in an elderly person. The 
 ality of the individual is perhaps even more important than 
 icuffc, for some men at sixty are in a much more healthy and 
 sistant state than others at forty. The habits, as to temperance, 
 ., must also h^ taken into consideration, and the existence of 
 enerai diseases, such as diabetes or albuminuria, might induce 
 le to resort to radical rather than conservative measures. 
 The vitality of the extremity injured. A leg has to be sacrificed 
 are frequently than an arm, since the vitality and reparative 
 iwer of the latter are so much greater, [c) The septicity or not 
 the wound is of the greatest significance, since, if infection can 
 
 II 
 
162 
 
 A MANUAL OF SURGERY 
 
 he prevented, the chances of preservinf,' the limb are greatly im. 
 proved, and one would then often delay operation, whereas stpsis 
 would turn the scale in favour of radical interference. 
 
 The local conditions which suggest or determine the perform, 
 ance of an amputation may be conveniently divided into two 
 groups, viz., where amputation is essential, or where it is doubtful. 
 
 A. Amputation is certainly called for — 
 
 1. To trim up the stump of a limb torn ofT by machinery, or tut 
 off by the passage of a railway train over it, or carried away by a 
 cannon-ball. 
 
 2. When the whole limb or one complete segment of it has 
 been totally disorganized, or crushed to pulp, though still retain- 
 ing its connection with the l)ody. 
 
 3. In cases where gangrene is imminent or has superxened, 
 especially if it is of the spreading type. 
 
 4. When severe septic symptoms develop in a case where an 
 attempt is being made to save a limb, the retention of wliich was 
 from the first doubtful ; or when exhaustion supervenes from pro- 
 longed suppuration, 
 
 5. In severe compound lacerations of the foot in old people, 
 involving the bones and laying open the common synovial cavity, 
 Septic arthritis and necrosis are then very apt to ensue, whilst tin; 
 distance of the foot from the centre of the circulation increases the | 
 likelihood of gangrene. 
 
 B. Amputation is doubtful in the following conditions : 
 
 1. Compound comminuted fractures in parts other than the I 
 foot do not pey se require amputation, even if neighix)uring joints 
 are implicated. By careful attention to antisepsis, free drainaj^'e, 
 and the removal of detached fragments of bone and foreign bodies,! 
 which should usually be accomplished imder an anaesthetic, linibsl 
 formerly condemned to amputation can not only be preser\ed, Initl 
 also restored to a considerable degree of functional usofuiness.l 
 The final decision will mainly depend on the age, condition, andj 
 previous habits of the individual. 
 
 2. When the soft parts have borne the brunt of the injury, and 
 have been extensively stripped from the bones, amputation is 
 no means an essential, provided that they can be restored to thtirj 
 original position, that there is a reasonable probability of thei^ 
 vitality being maintained, and that the utility of the limb wi 
 not be hopelessly impaired, as a result of lesions to the nervesj 
 after the wound has healed. The surgeon has here to carefully 
 balance the risk run if an attempt is made to save the limb, and 
 the value that the limb if saved will subsequently be to thd 
 patient. For instance, when the muscles of the forearm ha\J 
 been extensively torn up in a machine accident, it is a (luestion 
 whether it is worth while exposing the patient to the risk of gra\i 
 sepsis, when it is probable that under the best circumstances tli^ 
 limb will be of little practical use. 
 
 3. Laceration of tl 
 determine amputatioi 
 ur nerves are injured 
 [ i)ld and feeble folk, 
 Jelay. 
 
 As to the Period wl 
 I dent, there is no doub 
 iii)n is performed the 
 the risk of septic infec 
 :he shock in some cast 
 !o delay interference u: 
 hhecase in severe crus 
 !ion in this locality be 
 In the opinion of the s 
 • presence of a crushed 
 IWhen, however, septic 
 jrfinove the limb, there 
 lacurred, as used to be 
 Iway, the fe\er and con 
 |ut the amputation wc 
 
 III. Punctured Woui 
 
 hlxHit by any form of pe 
 I;. a sword or bayonet. 
 Ia4mihcant, the chief 
 
 Istriictu res — blood vesse 
 liavities or viscera ope 
 jiiniost entirely upon tl 
 Isalways considerable ( 
 tin long and narrow 
 m\ burrow in all direct 
 Wounds resulting fro 
 Iwious from their size ; 
 iose inflicted by the 
 jtwroughly syringed ou 
 pained, and the skin oj 
 pifi^e has ceased ; if i 
 fpendent spot. Seri(j 
 W important vessels 
 Piediate opening up 
 Plithe injured structui 
 I file commonest punt 
 > those produced by 
 fort in the body, especi 
 fseen soon after the 
 f'liediate removal, a 
 hsionally necessitatinj 
 Needle not be remo\ 
 
WOUNDS 
 
 163 
 
 3. Laceration of the main artery of a limb need not in itself 
 eterinine amputation ; but if in addition to this the bones, veins, 
 r nerves are injured, and especially in tiie lower extremities of 
 lid and feeble folk, amputation should be undertaken without 
 lelay. 
 
 As to tile Period when a limb should be removed after an acci- 
 lent, there is no doubt that, as a {,'eneral rule, the sooner amputa- 
 ion is performed the better ; the lonj,'er it is delayed, the greater 
 he risk of septic infection and absorption. On the other hand, 
 he shock in some cases may be so profound that it is better policy 
 delay interference until reaction is established; this is especially 
 he case in severe crushes close to the hip-joint, prim.iry amputa- 
 ;ion in this locality bein}^ frecpiently fatal. At the same time, if 
 n the opinion of the surf,'eon shock is being perpetuated by the 
 presence of a crushed limb, it should be immediately remoxed. 
 When, however, septic fever is present, and it seems desirable to 
 remove the limb, there is no need to wait until defervescence has 
 occurred, as used to be taught ; as soon as the septic part is taken 
 away, the fever and concurrent phenomena will also cease, pro\ ided 
 liut the amputation wound is maintained aseptic. 
 
 ill. Punctured Wounds and Stabs. — These may be brought 
 ilxHit by any form of penetrating instrument, from a pin or needle 
 ;i sword or bayonet. The external opening may be in itself 
 insif^nilicant, the chief danger arising from the damage to deep 
 structures — bloodvessels or nerves being divided, and serous 
 cavities or viscera opened. The subsecpient symptoms depend 
 ilmost entirely upon the cpiestion of septic infection, since there 
 always considerable difficulty in efficiently draining the deptlis 
 a long and narrow wound. Collections of pus readily form 
 ud burrow in all directions. 
 
 Wounds resulting from the modern sword-bayonet, tliough very 
 minis from their size and depth, are not so difficult to heal as 
 ihose inflicted by the old triangular blade. They sliould be 
 boroughly syringed out with warm carbolic lotion (i in 20), well 
 bined, and the skin opening not allowed to close until all dis- 
 iari(e lias ceased ; if necessary, a counter-opening is made at a 
 wndent spot. Serious ha-morrhage or paralysis, indicating 
 liat important vessels or nerves have been di\ided, calls for 
 mediate opening up of the wound, so as to expose and deal 
 ith the injured structures. 
 
 The commonest punctured wounds met with in civil practice 
 :e those produced by needles, which are frequently broken of) 
 lort in the body, especially in the h.ands, feet, knees, or nates. 
 seen soon after the injury, it is advisable to undertake their 
 nmediate removal, a proceeding sometimes very simple, but 
 casionally necessitating a deep and difficult dissection. Should 
 needle not be removed, it may travel about the body along 
 
 11 — 2 
 
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IMAGE EVALUATION 
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 WEBSTER, N Y. I4S80 
 
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164 
 
 A MANUAL OF SURGERY 
 
 the muscular and fascial planes, and there is no knowing where 
 it may lodge or come to the surface, or how long it may remain 
 in the body. It occasionally finds its way into the pelvis of tlu 
 kidney, and constitutes the nucleus of a renal calculus. 
 
 For the detection of penetrating foreign bodies of a metallic 
 nature, or of splinters of glass or stone, the so-cailed X rays of 
 Rontgen are exceedingly valuable. They are produced by ppssinj,' 
 a powerful electric current through a modified Crookes tube. or. 
 as it is now termed, a ' focus tube.' This consists of a thin glass 
 bulb, into which are fixed two terminals — one, the negative, 
 concave, and the other, or positive pole, a platinum plate set at 
 an angle so as to reflect the rays generated at the negative end to 
 the convexity of the bulb. A very high vacuum must be present 
 in the tube. The rays thus generated, though invisible to the 
 naked eye, have an actinic power, and are capable of affecting a 
 photographic plate in the same way as ordinary sunlight. They 
 are also able to penetrate many substances which are impermeable j 
 to ordinary light, although others resist their passage. Most of] 
 the soft tissues of the body are readily traversed, but bones and 
 to a much less degree tendons are sufficiently resistant to cast a , 
 shadow on the plate, and it is the fixation of these shadows thati 
 constitutes the peculiarity of the so-called ' skiagram.' If a lind)| 
 with a supposed foreign body within it is placed over a sensitive! 
 dry plate, held in a non-metallic dark slide or a black envelope,] 
 and the tube just above it, so that the convex portion on which| 
 the rays impinge is nearest the limb, a skiagram is produced 
 which, on development, shows the osseous tissues, the outline 0^ 
 the limb, al^i the foreign body, if it exist (Plates V. and VI.). 
 
 A modification of this process has led to the production of th^ 
 Cryptoscope. This consists of a cardboard screen coated witli 
 platino-cyanide of potassium or tungstate of soda, and if employed 
 instead of a sensitive plate on the further side of the limb to th^ 
 tube, the appearances produced can be seen by the naked ey( 
 Since it is possible in this case to move the limb from side to side 
 or to rotate it, a better idea can be obtained of the position of thj 
 foreign body ; by simple skiagraphy, it is often difficult to tell on 
 which side of a bone the foreign substance lies. Still better results 
 have been obtained by the application to this method of the 
 principle of the stereoscope. Special methods of localizing foicii^n 
 bodies have been introduced of late, but they are too complicated 
 to be referred to here. 
 
 IV. Gunshot Wounds. — It is impossible in a work such as this 
 to go minutely into the subject of gunshot wounds, but it is 
 essential to indicate their most important features, and in whati 
 respect they differ from other forms of injury already descrilied.i 
 The character of a gunshot wound varies according to the natur 
 of the projectile, the arm employed, the velocity of the missiieil 
 

 ^ 
 
 \\'':^i\ 
 
 ^ 
 
 '■ 'V'''.-^'*' 
 
 \ 
 
 ■:■', ''.■'i.i< 
 
 ';i S;V,';i'' ;\i 
 
PLATE y 
 
 Skiagram of Hand, with Xi:i:ni.i'; kmhicddicd in tiik Palm, close to the 
 
 CaKI'US. 
 
 To /ace Plate /'/., A/r. '(C;; //. 164 and ifii.] 
 
 Si'LiNTKR OK Glass 
 It will he noted that 
 ioliui- I'latt- /'., Ih-tXi'i-cn 
 
I'LATi: \'l. 
 
 SvLWTv.R f)K Glass in Hand, CLOsii to Mktacakpal 1)Onu of the Indkx 
 
 FlNr}i;K, 
 
 It will l,c noted that the glass casts (]uite as dense a shadow as the needle in 
 
 I'late V. 
 
 Tojiur riali' /'., /•i-/zi',yii /</•. 164 niiif if 5.) 
 
the distance from th 
 the part of the body 
 
 The wounds infli 
 Lee-Metford, Maus> 
 those produced in f 
 considered in the ev( 
 <;reat muzzle velocit; 
 To this end the bar 
 rotate on its own lor 
 would rotate on its 
 modified, whilst the 
 ;nore highly explosi\ 
 
 The modern bulk 
 ;i core of lead harder 
 enclosed in a cover, 
 (,"'., 80 per cent, of c 
 and Mauser). The 
 2,000 feet per secon^ 
 second for a Mause 
 within 500 yards mi 
 of 2,000 yards the 
 866 feet for a Snider 
 
 The effect of these 
 but not nearly so r 
 although the worst u 
 say 500 or 750 yards 
 phenomena may also 
 best marked feature 
 stiaight and direct, \ 
 so commonly the cas 
 of no great importan 
 nerves are not injure 
 somewhat ' like a bu^ 
 and tends to be a lift 
 vasation occurs into 
 bleeding is often slig 
 poitions of clothing 
 first intention if reas 
 cicatrices finally look 
 pustules. Vessels ar 
 they are actually in t 
 of the damage to thi 
 passing between the 
 either being injured. 
 bleeds freely, and m; 
 irolied by a tourniqu( 
 aneurism may resuli 
 comnion in the recen 
 
WOUNDS 
 
 i6s 
 
 i 
 
 the distance from the body at which the firearm was discharged, 
 ihe part of the body struck, and the direction of the shot. 
 
 The wounds inflicted by the modern small-bore rifle {e.g., the 
 Lee-Metford, Mauser, or Krag-Jorgenson) are very different to 
 those produced in former days. The desiderata that have been 
 considered in the evolution of the modern rifle have been to secure 
 ,'ieat muzzle velocity, a low trajectory, and clean and hard hitting. 
 To this end the barrel has been rifled so as to cause the rifle to 
 rotate on its own longitudinal axis (without such rifling the bullet 
 would rotate on its short axis), and the bullet has been greatly 
 modified, whilst the old form of gunpowder has given way to 
 more highly explosive substances. 
 
 The modern bullet is a long, thin, conical body, consisting of 
 a core of lead hardened by the addition of 2 per cent, of antimony, 
 diclosed in a cover, jacket or mantle of some smooth, hard metal, 
 
 ;'., 80 per cent, of copper and 20 per cent, of nickel (Lee-Metford 
 and Mauser). The muzzle velocity is very high, amounting to 
 2,000 feet per second for a Lee-Metford rifle, and 2,300 feet per 
 second for a Mauser. The trajectory is nearly flat ; anything 
 within 500 yards may be fired at point-blank, whilst in a range 
 of 2,000 yards the bullet only rises 194 feet, as compared with 
 866 feet for a Snider bullet. 
 
 The efifect of these arms varies to some extent with the range, 
 tint not nearly so much so as was formerly maintained ; and 
 although the worst wounds are usually produced at a short range, 
 iwy 500 or 750 yards, yet quite simple wounds with no disruptive 
 phenomena may also be caused at a similar distance. One of the 
 best marked features of these wounds is that the bullet tra\els 
 stiaight and direct, without lateral deviation or deflection, as was 
 so commonly the case in the old days. Simple flesh wounds are 
 of no great importance per se, granted that important vessels and 
 nerves are not injured. The aperture of entry is small, and looks 
 somewhat ' like a bug-bite ' ; the aperture of exit is slightly largei, 
 and tends to be a little more slit-like. A certain amount of extra- 
 vasation occurs into the tissues around the track, but the external 
 bleeding is often slight. There is but little tendency to carry in 
 poitions of clothing or septic material, and the wound heals by 
 first intention if reasonable precautions are taken. The external 
 cicatrices finally look very similar to those produced by bad acne 
 pustules. Vessels and nerves are not likely to be injured unless 
 they are actually in the line of the bullet ; the accurate limitation 
 of the damage to this line is evident when one hears of a bullet 
 passing between the abdominal aorta and the vena cava without 
 either being injured. If a large artery is cleanly hit, the patient 
 bleeds freely, and may die of haemorrhage, unless it can be con- 
 trolled by a tourniquet. If the artery is button-holed, a traumatic 
 aneurism may result, whilst arterio- venous wounds have been 
 common in the recent South African campaign. There has been 
 
1 66 
 
 A MANUAL OF SURG Eli Y 
 
 some difference of opinion as to the cliaracter of the injuries to 
 hones ; that larj^e masses of cancellous tissue {e.g., the lower end 
 of the femur) can he drilled cleanly without fracture is certain : 
 hut such wounds are sometimes associated with much splintering 
 and in\()l\ement of neif^hhouring joints, possihly as a result of a 
 short range, or of expansion of the hullet from the tearing down 
 of the mantle. If a hullet hits cleanly the compact shaft of a lon||f 
 hone, it may smash the whole hone into small fragments, or the 
 force may he more localized in its action, though always severe. 
 Such connninuted wounds are very likely to hecome septic, if 
 there is a long transport to the field hospital, and then fragments 
 undergo necrosis and serious inflammatory phenomena may 
 follow. Head wounds are much less fatal than might be 
 imagined from the experimental work that has heen undertaken. 
 At close range frightful disruptive effects are produced which are 
 almost certain to he fatal (see Chapter XXII.) ; at a longer ranj^^e 
 comparatively little mischief is done, except along the line of the 
 missile. The inner tahle is always more splintered than the 
 outer, and of course a certain amount of hrain suhstance mayl 
 escape. Ahdominal wounds are also much less serious than 
 formerly, a mortality of go per cent. (American Civil War) heinj,' 
 replaced hy one of 40 per cent, in the recent campaign, and that 
 without operation (Treves). The mere penetration of one or more 
 coils of intestine is not sufficient to cause general peritonitis ; the 
 wound is \ery small, and peristalsis seems to come to an en 
 entirely as soon as the patient is struck, so that neighhouring coils] 
 of intestine or the omentum suffice to prevent faecal extravasa-i 
 tion ; indeed, many of the patients suffer hut little constitutional 0: 
 local disturhance. Of course, an empty intestinal canal is a favour 
 ahle condition, and this is not unfrequently present on the tiel 
 of hattle. Bloodvessels may he wounded in the mesentery, an 
 death result from haemorrhage ; solid viscera, such as the live: 
 or spleen, are often damaged hut little, granting a fairly Ions 
 range. On the whole, the effects of these modern hullets is tfl 
 disahle without killing, unless a vital part is struck. 
 
 Soft-nosed Bullets {e.g., the Dum-Dum) are characterized l)y thd 
 mantle heing ahsent at the top, whilst the lead core is usually fred 
 from antimony. The result of this is that as soon as the hullej 
 strikes, the lead core mushrooms out, and terrihle mutilation ol 
 destruction of surrounding tissues ensues, whilst hones are con/ 
 minuted and solid viscera pulped. A similar result follows fror 
 ruhhing or cutting off the top of the Lee-Metford or Mause 
 hullet, or even from incising the cover in two or three places. 
 
 Martini-Henry and Snider Bullets produce wounds which 
 intermediate in their severity hetween the preceding two. Tl 
 aperture of entry is usually small, that of exit large and witj 
 everted edges. Portions of clothing are frequently carried in 
 these missiles, and add to the risks of sepsis. 
 
WOUNDS 
 
 167 
 
 Shell Wounds have no special peculiarities beyond their severity 
 lid the ghastly nature of the injuries which may he inflicted by 
 lem, depending on the irregular shape of the fragments into 
 hich the shell bursts. 
 
 Dangerous wounds may be inflicted by small sliot, as, for 
 istance, when one of the pellets enters the eye, whilst the wads 
 r other portions of the cartridge may also be carried into the 
 ody. A blank cartridge, if discharged iit a short distance, may 
 roduce a severe wound, and under such circumstances the skin 
 round is likely to be burned and blackened, leaving a permanent 
 luish-black tattooing of the tissues. 
 
 The treatment of gunshot wounds is conducted in accordance 
 rith general surgical principles, although it may have to be 
 omewhat modified by the patient's environment and by the fact 
 hat after a battle the pressure of work may be such that all 
 engthy operative procedures have to be discarded. The first 
 ssential is to protect the wound from infection, and for this 
 jurpose the small packet of antiseptic dressing carried by all our 
 oldiers is admirable. Bleeding is, if possible, controlled by a 
 ourniquet ; and splints must be improvised for broken limbs, if 
 )racticable. As soon as the wounded man reaches the field 
 lospital, the wound is more thoroughly explored and cleansed ; 
 'oreign bodies are removed, bleeding points secured, and if the 
 bullet has not escaped and can be readily detected, it should be 
 extracted. When lodged deeply, various appliances have been 
 ntroduced to locate the exact position of a bullet, e.g., Nelaton's 
 )orcelain-ended probe or more complicated electrical contrivances, 
 uch as the telephone probe. Skiagraphy has also a large field 
 usefulness before it in this direction. Comminuted fractures 
 re carefully investigated, detached fragments of bone are 
 emoved, and if an attempt is made to save the limb, splints, etc., 
 re carefully applied. Primary amputations for bullet wounds 
 re not very common at the present day, except when great com- 
 luition of bone or hopeless involvement of vessels and nerves 
 IS occurred. Wounds of the skull always demand the most 
 reful attention ; even when the bullet has penetrated cleanly and 
 jcaped, each opening must be trephined so as to allow of the 
 moval of depressed splinters of the inner table. This rule holds 
 Dod e\'en when a bullet has merely ploughed a groove or track 
 ong the calvarium without penetration. The results of such 
 eatnient have been most admirable. 
 
 The treatment of abdominal wounds produced by small-bore 
 tie fire is generally one of expectancy. It has now been 
 mndantly proved that patients can recover in the most astonish- 
 fashion from bullet wounds which have traversed the 
 )donien from side to side or from front to back, and therefore 
 iless there is some very clear indication, operation is better 
 oided. Moreover, the practical difficulties connected with 
 
 ■V, \ ■■-- 
 
i68 
 
 A MANUAL OF SURGERY 
 
 abdominal sections, the frequent lack of sterilized water, of towels, 
 and the dirty condition in which the patient is, owing to the 
 exigencies of the campaign, together with the length of time tli.it 
 such an operation takes — all these constitute reasons for not 
 interfering unnecessarily. Abdominal distension from ha'morrhaj^e 
 is one of the chief indications for laparotomy. In civil practice 
 the ordinary rules of treatment are followed (Chapter XXXI.). 
 
 V. Poisoned Wounds. — The great majority of poisoned wounds 
 are due to some definite micro-organism, and we have discussed 
 their nature and characteristics elsewhere. A few only remain to 
 be dealt with here. 
 
 Stings of Insects, such as bees and wasps, may be exceedingly 
 irritating and painful, but are not dangerous, unless some local 
 complication, such as erysipelas, supervenes, or the stings are 
 very numerous, as when a swarm of angry bees settles on a 
 person, or the part involved is such as to lead to serious swelling, 
 as in the pharynx or tongue, oedema of the glottis possibly arising 
 under such circumstances. All that is usually needed is the 
 application of a weak alkaline lotion, whilst a common and 
 efficient domestic remedy is a sliced fresh onion applied to the 
 part. Care must also be exercised to ascertain that the sting 
 and poison sac are not left in the body. 
 
 Some varieties of flies and spiders are also extremely virulent, 
 and it is possible that actual disease can be transmitted by the 
 former. Thus, if a fly bites a person after feeding on putrid 
 carrion, some form of septic inflammation may be originated ; 
 anthrax may also be spread in this way. Mosquitoes, too, play 
 an important role in the growth and development of filariae. 
 
 Snake-bites require but Httle notice here, as they are exceedingly 
 rare in this country, the common adder [Pelias bents) being the 
 only venomous one likely to be met with, and even with this the 
 poison is not sufficiently virulent to do much harm unless the 
 individual attacked is a child or a person in a very bad state of 
 Jiealth. The poison is conveyed to the wound from the glands 
 and poison sac situated on either side of the upper jaw through 
 fine canals in the specialized teeth, which open at their apices ; 
 these teeth are so delicate in some snakes that it may be difficult 
 to find the wounds produced by them. The effects of an adder's 
 bite are not, as a rule, noticed immediately, but come on in the 
 course of an hour or so ; extreme prostration supervenes, with a 
 weak pulse, cold clammy perspiration, dilatation of the pupils, and 
 perhaps delirium in bad cases, merging into coma. 
 
 The Treatment consists in preventing the absorption of the 
 virus by tying a ligature firmly above the wound, which should 
 then be laid open so as to allow of free bleeding, and the surface 
 excised or cauterized. The collapse resulting from absorption of 
 the poison is best remedied by the administration of stimulants or 
 the hypodermic injection of strychnine. 
 
IVOfJNDS 
 
 169 
 
 In India and other countries many varieties of poisonous snakes 
 an; met with, and wounds are fre(iuently fatal ; indeed, in India it 
 is stated that 12,000 individuals are yearly destroyed in this way. 
 The symptoms come on rapidly, and are (extremely severe, althouf^h 
 tliey are modified according to the \ ariety of snake. The treatment 
 must necessarily be more energetic ; probably the introduction of 
 Fraser's antivenine will be the means of saving life. 
 
 The Anatomical Tubercle, or Butcher's Wart ( Verruca iiccrogcmca), 
 consists in a papillomatous development usually on the knuckles 
 or wrists, of those who are exposed to wounds either in the dead- 
 house or slaughter-house. It is in all probability a manifestation 
 of tuberculous infection, and, indeed, resembles somewhat closely 
 the appearance of lupus when it develops on the hands. Treat- 
 ment consists in the application of a powerful caustic, whilst in 
 had cases it is necessary to scrape the surface before cauterizing. 
 
 Dissection or Post-mortem Wounds have obtained an unenviable 
 notoriety as being fertile in the production of serious inflammatory 
 disturbance, and although the graver forms are less common now 
 than formerly, yet they are still met with occasionally. It is 
 well known that bodies are most virulent within a few hours of 
 death, and hence the post-mortem room is more frequently respon- 
 sible for these affections than the dissecting room ; moreover, the 
 care which is expended upon the preparation of subjects by in- 
 jecting them with antiseptics reduces the dangers which might 
 arise from the latter source. 
 
 Inflammatory disturbances may arise under these conditions 
 irom several distinct causes : 
 
 1. The presence of strong antiseptics, such as arsenic, often 
 irritates abrasions, and causes tenderness and congestion of the 
 matrices of the nails. 
 
 2. The organisms occurring in actual putrid material have no 
 power of attacking living tissues, although considerable irritation 
 may be caused by them if small sores or abrasions are present. 
 
 3. Pathogenic organisms are frequently found in bodies soon 
 after death, and are especially virulent when developing in the 
 exudations from serous membranes, such as the peritoneum, and 
 hence both the surgeon who operates on the living subject, and 
 the pathologist who examines the body after death, are alike 
 exposed to the greatest risk either from an accidental puncture or 
 from the infection of some abraded surface. It is also possible 
 tor infection to occur through the hair follicles of an unbroken 
 skin. 
 
 The lesions originated by any of these means vary in their 
 nauire with the method of inoculation, the virulence of the 
 organisms, and the power of resistance of the individual. In the 
 simpler cases all that ensues is a limited irritation of some abrasion 
 or scratch, which rapidly disappears on the application of some 
 sedative or antiseptic lotion. Suppurative folliculitis, or even. 
 
170 
 
 A MANUAL OF SURGERY 
 
 boils, arise from infection of the hair foMicles, and in worse cases 
 the various forms of onychia, paronychia, or diffuse celhihtis, 
 with or without suppuration in the nearest lymphatic f^lands. 
 Severe toxa'mic syniptoins usually accompany the last-named 
 conditions, and even acute septicaemia may develop. T\k- 
 inunediate treatment indicated for a dissection wound is to tie 
 a lif^ature or handkerchief around the base of the wounded 
 fnif^'er, so as to encourage bleeding and pre\ cut the absorption of 
 toxic materials ; the part is then well washed under a tap ui 
 cold water, iiumersed in an antiseptic solution, and sucked for 
 some minutes ; an antiseptic dressing must then be applied. 
 Any inllammation which arises subseciuently must be treated 
 according to the general rules of surgery, 
 
 A common result of poisoned wounds of the fingers, whatever 
 their origin, is inflanuuation of the nail matrix (Chapter XIII.), or 
 of the tissues of the fingers, constituting a whitlow ; and it will 
 be convenient to describe the latter condition at this place. 
 
 A Whitlow (Piu'oiiychia or Panaritium) occurs in four different 
 forms, of which one is a true cellulitis, another a teno-synovitis, a 
 third is r. localized inflammation of the skin, and the fourth 
 involves the terminal phalanx. 
 
 {a) The Subcuticular wliitlow consists merely in a development of pus 
 beneath the cuticle wliich separates it from the cutis vera. It is very painful, 
 but otherwise is of little importance. A boracic poultice, preceded bv the 
 removal of the loose cuticle, is all that is needed in its treatment, 
 
 (b) The Subcutaneous whitlow is a true cellulitis, commencing in the pulp 
 
 of a finger, but often spreading upwards to 
 involve the palm. The finger becomes swollen 
 and painful, the pain being increased by 
 pressure or by hanging down the arm. 
 Gradually both these symptoms increase in 
 amount, the back of the finger becoming a>de- 
 matous, and the pulp more or less red. The 
 swelling is at first hard and brawny, and even 
 when pus is present it may be difficult to detect 
 fluctuation unless the afwcess is nearly pointing 
 Constitutional sympt< mis are not, as a rule, very 
 severe, though the intensity of the pain may 
 exhaust the patient. The hand should be 
 elevated, and the finger poulticed. A free 
 incision should be early adopted, and this may 
 be accomplished by fixing the patient's hand 
 under one's own left arm, and cutting in the 
 middle line towards the finger-tip. The in- 
 cision, though free, must not extend too deeply, 
 or the tendon sheath may be opened and in- 
 fected. Occasionally the pus forms at one or 
 otlier side of the finger, and the incisions must 
 then be suitably modified. The wounds should j 
 be dressed antiseptically after such incisions, 
 and no longer poulticed. 
 
 (c) The Thecal form of whitlow is really a suppurative teno-synovitis of the! 
 flexor sheaths. The signs are much the same as in the former variety, onlyj 
 
 Fig. 45. — Diagram of Syno- 
 vial Sheaths ok Flexor 
 Tendons OF Hand. (After 
 Keen and White.) 
 
 more severe, becaiis 
 
 may be mentioned 
 
 fstreme pain causec 
 
 tendon. The swellii 
 
 lit tlie hand. It is 1 
 
 cate witli the comn 
 
 usually in the liuje 
 
 (f-'iK- 45). In the las 
 
 metacarpal bones; h 
 
 palm in the .same' u 
 
 incision must be ma( 
 
 possible the adhesion 
 
 them from sloughing! 
 
 ca.ses the pus may bu 
 
 openings ; or the pori 
 
 the phalanges ; tlie ii 
 
 palm is involved, cart 
 
 superficial palmar ai 
 
 made ahmg the niidc 
 
 than the centre of tli( 
 
 the level of the wrist- 
 
 ■langer. 
 
 ('O The Subperioste 
 
 variety ; but it occasio 
 arising either idiopatl 
 riie inflammation mai 
 the palm. Free incisic 
 treatment required. 
 
 In former days h 
 I'lit increased kno\ 
 'iiii|<ing the stateuK 
 which, however, is 
 TOund, and that tl 
 tissue of the body 
 subcutaneous conne 
 I not synonymous wit 
 tissue which has sufi 
 fibro-cicatricial tissu 
 bond of union betw 
 however, true regene 
 bone, tendon, nerves, 
 liaye not been too ex 
 . The general facts 
 'iolIows:_The margii- 
 I area of tissue in a st^ 
 sloughing of the part 
 condition of thrombo 
 I in their turn are sligli 
 I "on and partly from t 
 lofthe wound is genei 
 
WOUNDS 
 
 171 
 
 [iinrc severe, because tin; pri)t;ess is often nuire e!\teiisive. As special features 
 may be mentioned tbe inability of the patient to bend the finder, and tlie 
 extreme pjiin caused on attempting to do so, owinj; to the involvement of the 
 tendon. The swelling also is more marked, and usually extends to the dorsum 
 ol tiie hand. It is important to remember that the llexor sheaths communi- 
 cate witli the common palmar slieath — always in the case of the thumb, 
 usually in the little (iiiKer, but not in tlie iiulex, middle, and ring liuf^'ers 
 (l''K- 45)- In l''^^ l"^^' '^■^^f- suppuration ceases at the level of the heads of the 
 metacarpal bones; l)Ut occasionally it oversteps this limit, and involves the 
 palm in the same way as in the thumb and little finger. Free and early 
 iiu ision must be made to anticipate such extension, and also to limit as far as 
 possible the adiiesions wiiich tlie tendons are liable to contract, or to pre\ent 
 them from slougiiing owing to the acuteness of the inflammation. In neglected 
 cases the pus may burrow to the dorsum of the fingers, necessitating counter- 
 (iptnings ; or the periosteum may be affected, leacling to disease or death of 
 the phalanges; the interphalangeal joint:! may also be disorganized. If the 
 palm is in\(ilved, care must be taken in incising the abscess not to wound the 
 superficial palmar arch or its digital branches. Tlie incision should be 
 made along the middle of the metacarpal bones involved, and not higher 
 than the centre of the palm ; but an opening may also be necessary close to 
 iliu level of the wrist-joint, and this can be made in the middle line without 
 ,!anger. 
 
 ((/) The Subperiosteal whitlow may be merely a complication of the itn'cal 
 variety ; but it occasionally starts as an acute necrosis of^ the terminal phalanx, 
 iirising either idiopathically or as a result of infection from the nail ma'rix. 
 ilie inflammation may be limited to the end of the finger, or may sp'-f^ad to 
 the palm. Free incisions, and the removal of the bone, if dead, cone ' Ue the 
 treatment retjuired. 
 
 Repair of Wounds. 
 
 In former clays five different methods of repair were described, 
 but increased knowledge and further research warrant us in 
 making the statement that there is but one method of repair, 
 which, however, is modified according to the conditions of the 
 wound, and that this process is essentially the same whatever 
 tissue of the body is involved, be it bone, muscle, tendon, or 
 subcutaneous connective tissue. It must be noted that repair is 
 not synonymous with regeneration. It is very unusual for any 
 tissue which has suffered from a serious lesion to be regenerated ; 
 libro-cicatricial tissue, or some modification of it, forms the new 
 1 bond of union between the damaged parts. In a few tissues, 
 however, true regeneration has been noted — e.g., in striped muscle, 
 I bone, tendon, nerves, and glandular structures, provided the lesions 
 I have not been too extensive. 
 
 The general facts as to the process of repair may be stated as 
 
 hollows: The margins of the wound are always bounded by an 
 
 area of tissue in a state of lowered vitality, even if no bruising or 
 
 sloughing of the parts is present. The divided vessels are in a 
 
 condition of thrombosis as far as the next patent branches, which 
 
 their turn are slightly dilated, partly as a result of this obstruc- 
 Ition and partly from the reflex irritation of the injury. The surface 
 of the wound is generally covered with a film of lymph or blood- 
 
173 
 
 A MANUAL OF SURGERY 
 
 clot, whilst any spaces left in the interstices of the tissues are 
 similarly occupied. 
 
 (a) The first stage in the process consists in an abundant 
 exudation of small round cells, presumably leucocytes, whose 
 function is to remove all dead or damaged tissue, as well as to 
 break up, disintegrate, and finally absorb, any blood-clot whicli 
 is present. These cells are derived from the surrounding vessels, 
 and are accompanied by a certain amount of serous oozing, so 
 that we have here the early manifestations of a slight inflamma- 
 tory reaction, which, if it does not extend beyond certain limits, 
 is a beneficial proceeding. Should it, however, become excessive. 
 
 Fig. 4G. — New Vessel Formation. (After Tillmanns.) 
 
 if, A small bud-like projection from the wall of a capillary ; h, the union of 
 such buds one with another, or with the branching processes of connec- 
 tive tissue cells ; c, the canalization of these processes. 
 
 as when bacterial invasion is present, injurious results may follow. 
 Much discussion has arisen among pathologists as to whether this 
 stage of repair is to be considered inflammatory or not in origin ; 
 the phenomena are, however, so exactly similar to those occurring 
 in the earliest stages of inflammation that it is impossible to draw 
 any line of distinction between them. 
 
 (b) The exudation of leucocytes is soon followed by the appear- 
 ance of a number of larger cells with more distinct nuclei, and in j 
 which cell division is always accompanied by karyokinesis ; these 
 are termed fibroblasts, and are now considered the active agents inj 
 the reparative process. There is some difference of opinion as to 
 
 the origin of thes( 
 lieim dogma, the} 
 the more recent 1 
 others, indicate tl: 
 fixed connective ti 
 the neighbouring 
 form a layer of c 
 surfaces or lips of 
 cytes disappear, s 
 tion, and others \ 
 fibroblasts. 
 {c) The vasculavi 
 
 Fl'i. 47.~DlAGRAM OF 
 
 Tile wound is occup 
 capillaries extend 
 has unitec' across tl 
 
 ie( 
 
 Stage in the process 
 from the walls of tl 
 plasm (Fig. 46, a), w 
 increase in length, an 
 o^er to unite with 
 capillaries, or with 
 occasionally they un 
 ■The connecti\e tissi 
 and send out branc 
 
 Mroin the vessel wall' 
 hecome canalized (F 
 
 M'shed between them 
 jnto them. The new 
 
 I I'ecomes lined with dt 
 
WOUNDS 
 
 173 
 
 the origin of these cells ; formerly, in accordance with the Cohn- 
 heim dogma, they were supposed to be migrated leucocytes, but 
 the more recent researches of Thiersch, Ziegler, Tillmanns, and 
 others, indicate that they are derived from the multiplication of 
 fixed connective tissue corpuscles or of the endothelial cells lining 
 the neighbouring capillaries. Whatever their origin, they soon 
 form a layer of cellular tissue which lies upon or between the 
 surfaces or lips of the wound, whilst the previously effused leuco- 
 cytes disappear, some finding their way back into the circula- 
 tion, and others serving as pabulum for the nutrition of the 
 fibroblasts. 
 ((■) The vascularization of this cellular layer forms the next 
 
 I ■.'•■." 'f 
 
 Fi'i. 47. — Diagram of Healing by Fikst Intention. (After Billroth.) 
 
 The wound is occupied by a fibro-cellular growth, into wliich loops of 
 capillaries extend, constituting granulation tissue, whilst the epithelium 
 has unitec' across the surface. 
 
 Stage in the process. This is brought about by the outgrowth 
 from the walls of the nearest capillaries of solid rods of proto- 
 plasm (Fig. 46, a), which appear first as minute buds, but rapidly 
 increase in length, and may be single or double. They soon bend 
 over to unite with similar threads growing out from other 
 capillaries, or with the wall o' another vessel (Fig. 46, b), or 
 occasionally they unite with the vessel from which they started. 
 The connective tissue cells may also become spindle-shaped, 
 and send out branching processes to unite with the offshoots 
 from the vessel walls. After a time these protoplasmic threads 
 become canalized (Fig. 46, c), and a connnunication is estab- 
 lished between them and the mother vessel, so that blood passes 
 [into them. The new capillary wall, at first homogeneous, soon 
 I becomes lined with definite endothelial cells, and strengthened by 
 
 . ;; 
 
174 
 
 A MANUAL OF SURGERY 
 
 the connective tissue which forms around it. By this means 
 a soft vascular tissue is produced, known as gvamdation tissue 
 (Plate IV., Fig. 2), consisting of loops of capillaries supported by 
 large nucleated cells with a varying amount of intercellular sub- 
 stance, which, at first homogeneous, soon becomes fibrillated in 
 texture. 
 
 (d) The tya Its formation of this granulation tissue into Jibyo- 
 cicatricial tissue is next proceeded with. Formerly it was sup- 
 posed that the cells of the granulation tissue were themsehes 
 transformed into the fibres from which scar tissue is developed, but 
 this idea is now abandoned in favour of one which maintains that 
 the fibrillae are derived as an intercellular exudation. By the 
 contraction of these fibres the cells become flattened out and 
 compressed, and the newly-formed vessels constricted, so that as 
 time passes the scar tissue becomes less and less vascular, and 
 consequently firmer and denser, as well as smaller. 
 
 {e) Whilst this last stage is in progress, the surface of the 
 wound is covered over with cuticle, which spreads inwards from 
 healthy epithelium in the neighbourhood of the wound, and espe- 
 cially from the deeper layers of the rete Malpighii. 
 
 As already stated, the general process of repair sketched above 
 is modified according to the character and condition of the wound. 
 Four chief modifications are met with in surgery : 
 
 1. Healing by First Intention or Primary Union occurs in cleanly- 
 cut aseptic wounds where the lips are unbruised and brought 
 together, so that no extensive collection of blood or discharge 
 between them is possible. A thin layer of blood-clot lies between 
 the surfaces of the wound and penetrates into its meshes, and the 
 contraction of this clot is at first the chief means of keeping the 
 deeper parts in apposition. There is but a microscopic line of 
 damaged tissue, which, together with the blood-clot, is easily 
 absorbed, and the process runs a typical course, as sketched 
 out above, union being effected in five to seven days. (See P'ig. 
 47, and Plate VII., Fig. i.) 
 
 2. Healing by Granulation, or second intention, as it used to be 
 termed, is met with {a) in cases where there has been definite loss 
 of substance, so that the lips of the wound are not, or cannot be 
 approximated ; as also [b) when the surface of the wound is 
 bruised or damaged so that portions of tissue have to separate by 
 sloughing ; or [c) when the advent of sepsis has prevented the 
 occurrence of primary union. 
 
 When a small amount of aseptic dead tissue is present, it is 
 removed as previously described (p. 55) by an invasion of leuco- 
 cytes from the surrounding vessels, which disintegrate and gradu- 
 ally absorb it. These are followed by the fibroblasts, which fortn 
 a layer of granulation tissue on the surface of the wound (Fig. 48). 
 If there is much slough to be dealt with, the vitality of the granu- 
 lation tissue cannot be maintained beyond a certain distance from 
 
WOUNDS 
 
 175 
 
 its source of nutrition, and so by a process of simple anaemic 
 ulceration the unabsorbed dead portion is cast off and a granu- 
 lating surface remains. If the slough is septic, ulcerative inflam- 
 mation occurs in the adjacent living tissue, which brings about a 
 similar result, though accompanied by suppuration and septic 
 fever. J^When, however, there is a simple loss of substance, 
 with no bruising or damage to the tissues, the course of events is 
 as follows : The blood-stream in the superficial capillaries having 
 been [arrested, adjacent vessels become dilated, and from these 
 an exudation of plasma and leucocytes results. The plasma 
 coagulates on the surface and forms a layer of fibrin, entangled 
 in the rneshes of which are a number of white corpuscles, so 
 that the wound becomes covered with a film of whitish -yellow 
 
 Fig. 48. — Diagrammatic Representation of the Later Stages of 
 Healing by Granulation. (After Billroth.) 
 
 material known as lymph. This gradually increases in amount 
 and thickness, and is vascularized from below into granulation 
 tissue, this process occupying from 4 to 7 days (Plate IV., 
 Fig. 2, p. 144). 
 
 The healing of a granulating wound is brought about by the 
 conxersion of the granulations into fibro-cicatricial tissue, and by 
 the surface becoming covered with cuticle. The contractile 
 tendency inherent in all cicatricial tissue produces two results 
 from its presence in the base of the wound beneath the super- 
 ficial layer of granulations : (i.) The surface area of the v/ound 
 is diminished in all directions, a most important element in 
 the healing process, since if the base is adherent to some dense 
 resisting structure repair is slow and difficult, and the wound 
 may remain open as a so-called chronic ulcer. When the granu- 
 lating surface is very extensive, contraction may proceed to such 
 an extent as to obliterate many of the vascular channels, and by 
 thus depriving the superficial tissues of their adequate nutrition, 
 
176 
 
 A MANUAL OF SURGERY 
 
 the healing process may be indefinitely prolonged, (ii.) The 
 depth of the wound is diminished, partly by the continuous growth 
 of granulation tissue from below upwards, but also by the con- 
 tractile base lifting the deeper structures to the surface. If 
 the base of the wound cannot be raised, the cicatrix is usually 
 depressed and adherent to the underlying parts. 
 
 During the process of repair the wound takes on the appearances 
 already described as characteristic of a healing ulcer (p. 48). 
 
 3. Healing under a Scab is a proceeding that can only take ph,ce 
 in very small wounds, such as superficial grazes and abrasions, 
 and is practically identical with the granulating process, except 
 that, instead of an artificial dressing applied by the surgeon, the 
 lesion is covered by a scab which consists of clotted blood or dried 
 exudation. Should sepsis be admitted, pus is likely to accumulate 
 beneath the scab and give trouble. 
 
 4. Healing by Organization of Blood-clot is only obseiAed in 
 strictly aseptic wounds where there is definite loss of substance, 
 as in the deep channels made in the treatment of bones thickened 
 by chronic osteitis. Blood is allowed to collect and coagulate so 
 as to fill the cavity, and the surface is covered with protective to 
 prevent irritation from the dressings. The dark coagulum shows 
 no trace of change for some days, but gradually the peripheral 
 portions become granular and yellowish-white in colour ; these 
 are gradually vascularized and transformed into granulation 
 tissue, which in time spreads over the whole surface from 
 periphery to centre, and then healing occurs as described above. 
 The clot is absolutely passive in this process, being infiltrated by 
 leucocytes and removed by degrees, and thus merely serves as a 
 basis of support or scafifolding for the building up of the granula- 
 tion tissue which replaces it. 
 
 A Scar is a mass of fibroid tissue covered by epithelium, which 
 has been formed in the repair of a wound (Plate VII., Fig. 2). It 
 is at first vascular, and contains cells of the connective tissue type; 
 but after a time, as contraction continues, the cell elements become 
 flattened out, fewer in number and less obvious, the intercellular M 
 fibrous tissue more abundant, and the \'essels constricted, so that ^ 
 finally a scar becomes well-nigh bloodless. Where superficial, its 
 colour changes from red to white, and if of small size it may 
 almost disappear, but never absolutely, unless the subcutaneous 
 tissue has not been involved. When the parts around become 
 injected by any cause, such as sharp friction, the anaemic scar 
 tissue again becomes evident by contrast. Lymphatics, nerves, 
 hairs, and cutaneous glands are all absent, except perhaps at the 
 periphery, and the epithelial covering itself is merely a uniform , 
 layer without papillae. 
 
 The Pathological Phenomena connected with scars are as I 
 follows : 
 

 
 
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I. Excessive Cc 
 
 espt'cially when tl 
 the joints. A wel 
 iiio\cinent, and 
 burned hand maj 
 unsi^ditly mass, Ctl 
 the chin may be di 
 and the lower hp| 
 the neck. The 1\ 
 the cicatrix, and tl 
 ]mist be remembei" 
 as the main vessel 
 surface, and thus l| 
 ilivided, there is oftf 
 normal positions, ii| 
 any length of time 
 gradual extension 
 risk of lacerating t 
 secondarily. The 
 contraction has no\ 
 of skin-grafting or 
 lie dealt with by 
 promising for a tinii 
 
 2. Overgrowth of 
 r^tituting what is k 
 most frecjuently occ 
 tuberculous patients 
 itself as a fibroid i 
 perhaps a number 
 uccupies the region 
 like processes into 
 merely of a hyperpl 
 nothing is known. 
 
 I pruritus or itching, i 
 fit occurs on expos 
 
 lis useless, since th( 
 cicatrix and in the s 
 
 |it often disappears s] 
 
 3. Ulceration of I 
 I troublesome conditic 
 
 4. Painful Scars c 
 hmninal in the cicat 
 |;lie bulbous end of n 
 |tach case further opt 
 
 at any rate the ] 
 latter the stump mu 
 laitected nerx'e remoA 
 
 ]■ Malignant Dise 
 
WOUNDS 
 
 >77 
 
 I. Excessive Contraction, which may lead to great deformity, 
 especially when the wound has occurred in the dexure of any of 
 the joints. A web-like mass of iihroid tissue then forms, limiting 
 iiK)\cment, and requiring operative interference. A seriously 
 burned hand may by cicatricial contraction be fused into an 
 unsij,ditly mass, called a club hand, of little use ; and, similarly, 
 the chin may be drawn down and practically fixed to the sternum, 
 ;ind the lower lip everted, as the result of a burn on the front of 
 the neck. The Treatment of such conditions consists in dividing 
 the cicatrix, and thus freeing the parts, during which process it 
 uist be remembered that deeper structures of importance, such 
 as the main vessels and nerves, may be adherent to the under 
 >uiface, and thus be endangered. When once the scar has been 
 divided, there is often no difficulty in restoring the parts to their 
 normal positions, although when the contraction has existed for 
 any length of time it may be advisable to do this slowly, even by 
 ^Tiulual extension with a weight and pulley, so as to avoid any 
 risk of lacerating the deeper parts, which are usually contracted 
 secondarily. The raw surface formed by the opening out of the 
 contraction has now to be covered with epithelium by some form 
 of skin-grafting or by a plastic operation ; most of the cases can 
 le dealt with by Thiersch's method, but the results, though 
 promising for a time, are often ultimately disappointing. 
 
 2. Overgrowth of the scar tissue is sometimes met with, con- 
 stituting what is known as the false or Alibert's Keloid, This 
 most frequently occurs in the scars of burns or of wounds in 
 tuberculous patients, but may arise from any cicatrix, presenting 
 itself as a fibroid indurated mass of a dusky red colour, with 
 perhaps a number of dilated vessels coursing over it, which 
 aupies the region of the old scar, and may possibly send claw- 
 ike processes into neighbouring healthy structures. It consists 
 iiierely of a hyperplasia of the scar tissue, but as to its a:}tiology 
 :;othing is known. With the exception of somewhat severe 
 pruritus or itching, its presence entails no inconvenience, although 
 ::it occurs on exposed parts it may be very disfiguring. Remoxal 
 is useless, since the keloid almost always recurs in <"he new 
 icatrix and in the stitch holes. After a longer or shorter interval 
 tnt'ten disappears spontaneously. 
 
 Ulceration of Scars, the result of defective nutrition, is a 
 Itruuhlesome condition to deal with, as repair is usually slow. 
 
 4. Painful Scars arise from either the implication of a nerve 
 I'lniinal in the cicatrix, or the pressure of a contracting scar upon 
 I'Jie bulbous end of a divided nerve, as in amputation stumps. In 
 
 each case further operation is necessary ; in the former the cicatrix, 
 I f at any rate the painful portion of it, is excised, whilst in the 
 latter the stump nmst be opened up, and the enlarged end of the 
 |i!lected ner\e removed. 
 
 5. Malignant Disease of Scars is of an epitheliomatous type, and 
 
 12 
 
 
178 
 
 A MANUAL OF SURGERY 
 
 appears as a hard tumour with everted edges, a thickened base. 
 and usually a good deal of fijctid discharge. The prof^^ress 
 is \ery slow, since the vascularity of the tissue is slight. It is 
 painless, from the absence of nerves, and as long as the disease is 
 limited to the scar, no lyn->phatic implication will be noted. As 
 soon, however, as the malignant growth invades healthy tissues, 
 the usual phenomena show themselves. The diseased tissues may 
 be freely dissected out, having regard to subjacent structures, and 
 the wound closed by some plastic method. 
 
 Methods of Treating Wounds. 
 
 It is unnecessary in a work such as this to occupy space in 
 describing the plans which were adopted in the treatment of 
 wounds in pre-antiseptic days ; and although even now there are 
 practitioners who scoff at the teachings of Lister, and maintain 
 that merely cleanliness is needed, yet the majority of enlightened 
 men make some profession of using either the antiseptic or aseptic- 
 plan of treatment, or some combination of the two. Unfortunately, 
 failure in carrying out all the necessary precautions leads not 
 unconnnonly to suppuration, and we cannot emphasize too stron|,dv 
 the urgent necessity of attention to the minutest details if success 
 is to be secured, especially since so many of the operations now 
 undertaken are only justifiable under such conditions. 
 
 The Antiseptic plan of treating wounds, originally introduced 
 by Lord Lister, is an outcome of the germ theory of putrefaction. 
 It has for its )bject the prevention of bacterial development in the 
 wound by the use of chemical agents, some of which are true 
 germicides, capable of destroying the bacteria, whilst others merely 
 prevent or inhibit their growth. Innumerable methods of apply- 
 ing this treatment ha\e been adopted, and multifarious antiseptic 
 agents have been used, prominent among them being carbolic 
 acid, corrosive sublimate, iodine, iodoform, salicylic acid, boric 
 acid, etc. 
 
 Carbolic Acid, the first antiseptic introduced by Lister, lias a direct germi- 
 cidal action in strong solutions-, and an inhibitory effect in weaker ones. The 
 crystals, when heated with lo per cent, of water, constitute an oily fluid known 
 as pure or liquefied carbolic acid, which is a powerful though superficial 
 caustic, and may be employed without much fear to infected lesions, in 
 order, if possible, to sterilize them. Thus, it is always well to treat tuberculous 
 wounds with this fluid after scraping them, in order to destroy any portions 
 of tuberculous material which may have escaped the spoon. The liquid 
 carbolic dissolves in water on the application of a little warmth, and tlie 
 I in 20 and i in 40 solutions are those mainly employed ; the former is an 
 efficient and potent antiseptic, but must be used carefully on delicate skins 
 Carbolic acid is frequently somewhat crude and impure, and many of the irri- 
 tative and toxic phenomena are due to cresylic acid and other substances wiiicli 
 should not be present. General absorption of this reagent leads to darkening 
 of the urine, which may become olive-green or even black in colour, and this 
 carboluria is often associated with a rise in temperature and some intestinal 
 irritation, whilst diseased kidneys may be seriously affected. 
 
 Corrosive Sublimat 
 
 is usually employed it 
 sionally the last of the 
 to it, constituting w 
 solutions are inhibitor 
 reliable. They have 
 no hardening or rouj^ 
 soaked in a sublimate 
 skin, it acts as a dire 
 pustules, owing to the ; 
 have not been destroy^ 
 in sublimate solutions 
 ance. It must be ren 
 mercury may be salivj 
 
 Biniodide of mercur 
 in tiie form of a solu 
 of the hands or of the 
 
 Boric or boracic aci 
 when stronger remedi 
 infants. It is also use 
 inflammatory phenomi 
 
 Iodoform is a yellow 
 probably acts by being 
 Commercial iodoform 
 he shown by dusting it 
 develop. It is theref 
 carbolic lotion or some 
 culous wounds, and, in 
 the development of th 
 no per cent.) and inje 
 open wounds exist, gai 
 may be packed into 
 undue absorption of t 
 order to avoid the un 
 are of doubtful value. 
 to mix it with ^^j par 
 which has a powerfu' 
 
 Chinosol is a yellow 
 freely soluble in water 
 
 Lysol is another use 
 water, and as a 2 per 
 as the vagina, external 
 is somewhat sticky, an 
 
 Permanganate of po 
 same way as oxidizin 
 utilized for dressings, 
 of cavities or wounds 
 peroxide of hydrogen, 
 times its volume of nas 
 directly into a septic v\ 
 commences to efferveL 
 which is likely to brir 
 particularly indicated 
 abscess cavities, and t 
 in solutions of varyin 
 advantage of staining 
 
 
 Whilst the pract 
 antiseptics employ( 
 
WOUNDS 
 
 179 
 
 Corrosive Sublimate is a valuable though very poisonous remedy, which 
 is usually employed in solutions of i in 2,000, i in 1,000, or i in 500.. Occa- 
 sionally the last of the^e tliree solutions has 5 per cent, of carbolic acid added 
 to it, constituting what is known as Lister's stroiif^ mixture. Sublimate 
 solutions are inhibitory in action rather than germicidal, but are potent and 
 reliable. They have less power of penetration than carbolic acid, but have 
 no hardening or roughening influence on the skin. If, however, a dressing 
 soaked in a sublimate solution (i in 2,000) is kept for long in contact with the 
 skin, it acts as a direct irritant, and may lead to an abundant formation of 
 pustules, owing to the activity of the germs in the deeper parts of the cutis which 
 have not been destroyed by the antiseptic. Instruments should not be placed 
 in sublimate solutions, as, even if plated, they soon lose their bright appear- 
 ince. It must be remembered that individuals very sensitive to the action of 
 mercury may be salivated by this agent. 
 
 Biniodide of mercury is a potent antiseptic, which has been chiefly employed 
 ,n the form of a solution of methylated spirit (i in 500) for the purification 
 Lif the hands or of the skin of the patient. It is of course e.\tremely toxic. 
 
 Boric or boracic acid is a mild and weak antiseptic, which may be utilized 
 when stronger remedies might prove harmful, e.g., in plastic operations and 
 nfants. It is also useful when antiseptic fomentations are required in treating 
 mriammatory phenomena. 
 
 Iodoform is a yellow powder of characteristic and unpleasant odour, which 
 probably acts by being decomposed in the tissues and slowly giving off iodine, 
 i'ommercial iodoform is usually contaminated with a variety of germs, as may- 
 be shown by dusting it over a film of nutrient gelatine and allowing them to 
 levelop. It is therefore wise to wash the iodoform before use in i in 20 
 carbolic lotion or some such antiseptic. Its chief value is in septic or tuber- 
 culous wounds, and, indeed, it seems to have a specific inhibitory action upon 
 the development of the Bac. tuberculosis. It may be suspended in glycerine 
 iio per cent.) and injected into tuberculous tissues, joints or abscesses; or if 
 open wounds exist, gauze soaked in this emulsion, as it is incorrectly termed, 
 may be packed into them with advantage. Toxic effects may follow frorrf 
 undue absorption of this drug. Various substitutes have been proposed in 
 order to avoid the unpleasant smell, e.g., aristol, orthoform, etc., but they 
 are of doubtful value. Perhaps the best means of obviating the odour is 
 to mix it with J,, part of Coumarin, the active principle of the Tonquin bean, 
 which has a powerful aroma. 
 
 Chinosol is a yellow substance, harmless and free from toxic qualities; it is 
 ireeiy soluble in water, and possesses powerful antiseptic properties. 
 
 Lysol is another useful antiseptic derivative of coal-tar. It is freely soluble in 
 water, and as a 2 per cent, solution may be used in syringing out cavities, such 
 as the vagina, external ear, etc. One of its great advantages is that the solution 
 is somewhat sticky, and tends to cling to the tissues and prolong its action. 
 
 Permanganate of potash, sanitas, and peroxide of hydrogen all act in the 
 same way as oxidizing agents ; they are necessarily unstable and cannot be 
 utilized for dressings, and are therefore chiefly employed in the disinfection 
 of cavities or wounds already contaminated. The most potent of these is 
 peroxide of hydrogen, which is sold as a fluid capable of setting free 10 or 20 
 times its volume of nascent oxygen. It is quite unirritating, and may be poured 
 directly into a septic wound, or even into the peritoneal cavity ; forthwith it 
 commences to effervesce, liberating its oxygen, and forming a frothy foam, 
 which is likely to bring to the surface any loose foreign bodies. Its use is 
 particularly indicated in the tioatment of septic ulcers, carbuncles, sloughy 
 abscess cavities, and the like. Sanitas and permanganate of potash are used 
 in solutions of varying strength and act more slowly ; the latter has the dis- 
 advantage of staining the tissues with which it is brought in contact. 
 
 Whilst the practice differs in various surgical schools as to the 
 antiseptics employed and the details of their application, yet the 
 
 12 — 2" 
 
I So 
 
 A MANUAL OF SURGERY 
 
 principle in some form or otiier is now f^'oncnilly adopted. \\ ^ 
 shall here sketch out the usual routine followed at Kinj^^'s Coll(■^f(■ 
 Hospital in undertal<in<^' an operation, or in the treatment of a 
 wound, and indicate a few of the modifications introduced by otlici 
 surj^^eons. 
 
 i. The hands of tlie surgeon are rendered jnire by washing them tlinrou^^'hlv 
 with soap and water; tiie nails are cut, il ntmiA be, and cleansed, special atten- 
 tion being directed to the reflection of skin at their base, where septic material 
 is so apt to collect ; for this purpose a purified nail-brush is employed witli 
 advantage, Tiie hands are then immersed in carbolic lotion (preferably i in 20), 
 wliiiii penetrates the skin, .and acts more efficiently tiian a sublimate s(iluti(]ii, 
 although the carbolic is liable to render the skin rough anil harsh. Mcnce 
 many surgeons utilize a i in i.ooo sid)limate solution, or a solution of l)iniii(li(lt; 
 of mercury in rectified spirit (i in 500), after very thorougii washing with soap 
 and sterilized svater. The iiands, once purified, should not be drietl except (in 
 a sterilized towel, and, indeed, it is better to keep them moist, and re-dip them 
 from time to time during the operation. Another plan which has been utilized 
 successfully and gives good residts consists in immersing the hands and tdie- 
 arms in a saturated solution of permanganate of potash, after thorougii washinj; 
 with soft soap and water, until they become a deep mahogan} red cojdiir 
 They are then placed in a saturated solution of oxalic acid until completely 
 decolorized, anil finally washed over with a sid)limate solution. This metiioJl 
 causes a certain amount of irritation of the skin of the forearms. It isprohaiije 
 that in the majority of cases the sterilization of the hands remains imperfect, 
 but the surgeon must conscientiously work away to try and eftect asepsis. 
 Some authorities have been so concerned at the imperfection of their results 
 that they are in the habit of operating in sterilizeil gloves; it has, however, 
 been demonstrated lately that such is no real protection. 
 
 ii. All instruments are sterilized in a bath of carbolic lotion (i in 20), wiiicli, 
 it must be remembered, takes an apjireciable time to ilestroy microbes, and 
 therefore if during an operation a fresh instrument is suddenly called for, which 
 has not been previously purified, it is not enough just to momentarily innnerse 
 it in the solution, but it is first placed in liquefied carbolic acid for a few 
 seconds, and then rinsed through the i in 20 solution. Special care is directed 
 towards the forceps, to see that the teeth and serrations are free from dried 
 blood-elm and other dirt. Should an instrument fall on the floor during the 
 operation, it is, of course, not used again until thoroughly repurified. lioilin;^ 
 the instruments either in carbolic lotion or in a weak solution of bicarbonate 
 of soda (i per cent.) for 20 minutes is also a potent means of rendering them 
 aseptic, and should always be employed after using them for a septic case 
 The water should be boiling before they are immersed, and thus discoloration 
 will be avoided, 
 
 iii. Sponges, unless very carefully treated, are a fertile source of sepiic 
 infection ; they are thoroughly purified in strong carbolic lotion before use, 
 and wrung out of a i in 40 solution during the operation. Unless tiie surgeon 
 can be absolutely certain of the nurse, it is better to use only a limited number 
 of sponges— say, two — and for the assistant to cleanse them in a bowl of lotion 
 placed in a suitable position. Portions of wool, Gamgee tissue, or gauze, soaked 
 in carbolic or sublimate lotion, are advantageously employed when there isany 
 <loubt as to the sterilization of the sponges. It is also advisable not to use 
 sponges for tubercular disease or rectal operations, or for any conditions wliere 
 pus is present. 
 
 In cleansing sponges after an operation, the following procedure is adopted: 
 They aie first thoroughly wrung out of cold water, and then placed to soak for 
 some hours in a fairly strong solution of washing soda They are then again 
 well rinsed in cold or hot water, so as to remove all the soda, and finally 
 immersed in a solution of carbolic acid (i in 20), in which they are kept lil 
 required. 
 
 IV. The ligatures 
 
 I in 20 carbolic loti( 
 ill order to prevent s 
 at least half an houi 
 coils, and not wouni 
 Catgut, on the other 
 tor too long, as it is 
 ever, be boiled in c 
 harming it ; it is thei 
 2 hours, and is trans 
 V The skin of the 
 and then thoroughly 
 septic compress foV 
 anesthetized, a final 
 with turpentine or et 
 finally, it is flushed o 
 too energetically, wi 
 hiniodide of mercury 
 carbolic acid, but is n 
 to the same extent. 
 carbolic acid will be 
 into the blood-strean 
 does the quality of tlu 
 l)y contrasting 'that o| 
 that of a child or of a 
 in various regions of t 
 modified according to 
 may accumulate dem? 
 ear, toes, or corona gl; 
 When the operation 
 uith warm carbolic lo 
 a protection over the \ 
 hy wiping peripheralb 
 lias been utilized for t" 
 until re-purified. 
 
 vi The area of the 
 and these are covered 
 are first soaked in a so 
 solution, and kept war 
 tlie stronger solution 
 irrigated with a i in 
 II in 2,000) ; but suci 
 cf subsequent oozing, 
 aseptic condition of evi 
 cavity or the interior 
 since they are always 
 endothelial lining, wh. 
 rule of practice which 
 Mtiscpsis for the external 
 always be certain, how 
 septic irrigation may hi 
 vii. Before closing t 
 secure absolute haDinos 
 outofhotcarboliclotioi 
 It may be advisable, es 
 suitable drainage-tube 
 Ihis is unnecessary. T 
 septic cavities, such as 
 of chloride of zinc (40 
 
WOUNDS 
 
 i8i 
 
 iv. The ligatures <iiid sutiires of catgut or silk are soaked for some liours in 
 
 I ill 20 carbolic lotion hctorc use. Silk rucjiiires \'er\' tliordugli piirifu-ation ; 
 111 order to prevent stitcli suppuration, it is advisable to boil it tborouj,'lily for 
 at least bait an bour loefore placiii;^ it in carbolic lotion ; it sliould be in loose 
 toils, and not wound on a reel, as tben only tbe outside strands are reached. 
 (atKut, on the other hand, must not be l)oiled or immersed in carbolic lotion 
 tor too Ion),', as it is apt to become rotten and break when used. It may, how- 
 ever, be boiled in cumo! at a temperature of 165' C for an hour without 
 harming it; it is then dried at a temperature of 100" C. in a liot-air oven for 
 J hours, and is transferred to sterilized test-tubes. 
 
 \ . Tile skin of the patient is shaved prior to operation if the part is hairy, 
 and then thoroughly washed with soap and water, and covered with an anti- 
 septic compress for some liours. When the patient is on the table and 
 aiuTsthetized, a final cleansing is undertaken. The part is first well rubbed 
 witli turpentine or ether, to remove all fat and grease, and then witli soft soap : 
 tinaliy, it is fiusiied o\er with strong carbolic lotion, or even scrubbed, but not 
 tiK) energetically, with a nail-brush. Corrosive sublimate (i in 1,000) or 
 liiiiiodide of mercury in rectified spirit (i in 500) is sometimes used instead of 
 carbolic acid, but is not so satisfactory, since it is unable to penetrate the skin 
 to the same extent. It must not be forgotten tliat a very vigorous use of 
 carbolic acid will be followeil by local irritation, as well as by its absorption 
 into tiie blood-stream, especially in protracted operations. Again, not only 
 lilies tlie quality of the skin vary in different individuals (as may be illustrated 
 li\ contrasting that of a coal-heaver, who probably bathes once a year, with 
 that of a child or of a lady, which is soft, clean, and delicate), but it also differs 
 in various regions of tiie body, and hence the process of purification must be 
 modified according to the thickness of the integument. Any part where dirt 
 may accumulate demands scrupulous attention, f.^'., the umbilicus, external 
 ear, toes, or corona glandis in persons with long fi)reskins. 
 
 Wlien the operation has been completeil, the skin around is again cleansed 
 witli warm carbolic lotion (i in 40), after a piece of dressing has been placed as 
 a protection over the wound. This cleansing should always be accomplished 
 by wiping peripherally away from the centre, and any sponge or swab which 
 has been utilized for this purpose should not be allowed to touch the wound 
 until re-purified. 
 
 vi. The area of the operation or wound is surrounded witli mackintoshes, 
 and these are covered by towels wrung out of hot carbolic lotion. The latter 
 are first soaked in a solution of i in 20, and then wrung out of the hot i in 40 
 solution, and kept warm until required, otherwise the skin may be burnt by 
 the stronger solution. During the operation the wound may he occasionally 
 irriftated with a i in 40 carbolic solution, or with corrosi\'e sublimate 
 
 II in 2,000) ; but such is not always advisable, as it increases the amount 
 I'f subsequent oozing, and is really unnecessary if one is certain as to the 
 aseptic condition of everything employed. When dealing with the peritoneal 
 cavity or the interior of a joint, the less one employs antiseptics the better, 
 since they are always more or less irritating, and lead to desquamation of the 
 endothelial lining, which it is so important to maintain intact. In fact, the 
 rule of practice which we are endeavouring now to establish is tlw strictest 
 Mtiicpsis fur the external parts, but asepsis for the interior 0/ the uviuid ; one cannot 
 always be certain, however, that tiiis ideal has been attained, and then anti- 
 septic irrigation may be resorted to. 
 
 vii. Before closing the wound, the surgeon must use every endeavour to 
 secure absolute haemostasis. It must be well cleansed with a sponge wrung 
 iiutof hot carbolic lotion, or, if necessary, irrigated with sterilized salt solution ; 
 it may be advisable, especially in large wounds of vascular parts, to insert a 
 stiitable drainage-tube and stitch it flush with the surface, but in many cases 
 this is unnecessary. The incision is then closed. Wounds communicating with 
 septic cavities, such as the mouth or rectum, should be purified with a solution 
 of chloride of zinc (40 grains to i ounce), and then powdered with iodoform, 
 
I82 
 
 A MANUAL OF SURGERY 
 
 and eitlier I"ft open f)r lif,'litly pluKKt-d ; septic contamination is hy tliis means 
 ilelaycd, and c\('n \viu;n it does occur, it may be kept under contrui hy frL'i|iifiit 
 tlressinj,' and irriKalion. 
 
 viii. I'inally, acarefully arranged antiseptic dressing is applied, and tlic |iart 
 bandaged and put on a splint or in a slinj,'. as may best suit the recjuiremfnts 
 of the case, absolute rest and quiet bein^' essential if rapid healing is to he 
 obtained 
 
 ix. After-treatment. If no (lraina),'e-tube has been employed, and tju; 
 tlressiii),' is not soaked throuKb, it niay be left untouched for seven or (■ij,'lit 
 (lays, at the conclusion of which period it is removed, the stitches are taken 
 out, and in all probability the wound will be completely healed. When a 
 <lrainaKe-tube has been inserted, it is usual to take it out at the end of twenty- 
 four or fortv-eij,d)t iionrs ; there is no advantage in keeping it in longer, since 
 it is oidy re(|uired for the removal of t!ie sero-sanguineous fluid which exiules 
 immediateiv .after tiie operation. Siiould the discharge be very abundant and 
 soak tiirough the dressings, tiiere is no neecl to remove them and re-drtss 
 during the first twenty-four liours ; all tliat should be done is to damp the 
 stained external bandages with i in 20 carbolic lotion, and then pack on some 
 more gauze or wool. This may even, if necessary, be repeated a second time. 
 
 As to the different forms of Dressing, we must content ourselves 
 with a few words as to those ordinarily employed. Lord Lister 
 pointed out some years hack that the main essentials of a ^'ood 
 dressinf,^ consisted in its containing some trustworthy antiseptic 
 ingredient ; in this agent being so stored up that it cannot he 
 dissipated before the next dressing; in its l)eing entirely iin- 
 irritating ; and in the capacity of the fabric to readily absorb 
 blood or serum that may ooze from the wound. The orij^nnal 
 antiseptic dressings, viz., the carbolic and eucalyptus gauzes, and 
 even the alembroth gauze and wool, failed to fulfil these require- 
 ments ; but in the double cyanide of mercury and zinc gauze we 
 have a material which is to all intents and purposes perfect. It 
 should be moistened with carbolic lotion (i in 40), and may then 
 be applied to the Avound without fear. Over this fresh portions 
 are placed, taken from the stock supply (which is always kept in 
 a mackintosh covering after being damped witii carbolic lotion, 
 I in 20), and finally over all a liberal covering of sterilized or; 
 antiseptic wool, so as to diffuse the pressure, which is applied hy I 
 means of careful bandaging. The best material for bandages is 
 butter-cloth, since it is light and adapts itself easily to the outlines] 
 of the part. 
 
 Other dressings, such as boric lint, iodoform gauze, etc., are! 
 occasionally employed, but they are not so satisfactory for generalj 
 use as the cyanide gauz*^'. 
 
 Of late years many Continental and American surgeons have I 
 been attempting to eliminate the irritating properties of chemicalj 
 antiseptics by the adoption of what is called Aseptic Surgery. Inl 
 this, asepsis is obtained by means of heat, the most powerfulj 
 germicide in our possession ; the instruments, ligatures, sutures,! 
 and dressings are sterilized by placing them for an hour or inorel 
 in a hot-air chamber, raised to such a temperature as to destroyj 
 all germs, or by boiling them. Antiseptics are, however, used inl 
 
 order to purify the f 
 and his assis'tants. 
 MKcess, but require 
 septic method. Wl 
 111 a large teaching 
 in the work, there 
 precautions are also 
 his assistants, and e 
 tables, etc., are disini 
 lliat we, who h;i\c h 
 aiul have seen the o 
 antiseptics as inappe 
 practice which certa 
 under all circuiustai 
 iitlier plan, the objec 
 insome slight inad\ 
 is no doubt perfect, 
 |ouing to the necess 
 matter almost imposs 
 
 General C( 
 
 I. Shock.— By the 
 
 [condition of the ner^ 
 jtiiHulus, which is eii 
 liiiedulla from the per 
 I injured part, or may c 
 |eniotional centres thrc 
 
 The term collapse is ap 
 
 tadiftenng from it main 
 
 lily some exhausting disea 
 
 Icompiete. The collapse ( 
 
 lluiany condition associat 
 
 havfjive rise to it, c); pr 
 
 same time septic absorpt 
 
 l^.arked ; thus in acute pe 
 
 Inrciilation and tox.-Emia, 
 
 j:> recovery, unless the le: 
 
 Ji^pervene and prove fatal 
 
 Isvmptoms are the result o 
 
 I'ae to acute peritonitis. 
 
 The degree of sho( 
 IMinly influenced by t 
 I («) The severity and 
 lated either by the ni 
 K the superficial exte 
 I'le injury extends. \ 
 aries directly with th< 
 found, the greater th 
 
 f 
 
IVOUNDS 
 
 «83 
 
 order to purify the skin of the patient and the liands of tiie surj^'eon 
 iiml his assistants. Tiiis phin has been employed with much 
 success, hut retpiires more attention to details than does the aiUi- 
 ,eptic method. W'Irti; our assistants are cionstantly chan^^iu).;, as 
 in a larj^e teaching' hospital, and where many hands are enj^O'if^ed 
 in tile work, there is much j^ncater lisk of failure. IClaborate 
 precautions are also taken as to the dress both of the surj^ecju and 
 his assistants, and even of onlookers ; whilst operatinf^' theatres, 
 uhles, etc., are disinfectcul in a careful manner. It is only natural 
 that we, who ha\e had the prix'ile^'e of working' with Lord Lister, 
 and luu'e seen the excellent results following the intellif^^ent use of 
 antiseptics as mapped out above, should still clinj^' to that line of 
 |u;ictice which certainly can be carried out with more [precision 
 iindcr all circumstances, both in private and hospital, than the 
 itlier plan, the objects of which may at any moment be defeated 
 iiv some slif^'ht inad\'ertence or oversight. The theory of Asepsis 
 is no doubt perfect, but its practical application is often difficult, 
 owing to the necessity of having sterilizers always at hand, a 
 matter almost impossible in cases of emergency in private practice. 
 
 General Conditioi. ; connected with Wounds. 
 
 1. Shock. — By the term 'shock' is meant a general depressed 
 
 [condition of the ner\ous system, resulting from some eiu;rgetic 
 
 htiniulus, which is either transmitted to the \'ital centres in tlie 
 
 malulla from the peripheral sensory or sympathetic nerves of an 
 
 injured part, or may descend to them from a disturbance of the 
 
 jeniotional centres through the nerves of special sense. 
 
 Tlie term collapse is applied to a condition very similar in nature to shock, 
 Silt differing from it mainly in its onset, which is gradual, and often preceded 
 |i)\ some exhausting disease, and by the fact that muscular relaxation is more 
 Icomplete. Tlie collapse of cliolera is one of the most typical manifestations, 
 Itiutany condition associated with loss or derivation of fluids from the vessels 
 Imy give rise to it, e.g., prolonged vomiting or serious ha;mcrrhage. If at tiie 
 ]<ame time septic absorption is taking place, the symptoms are still more 
 Inarked ; thus in acute peritonitis the two factors, removal of fluid from tiie 
 [circulation and toxnemia, are proceeding concurrently. Shock usually tends 
 |io recovery, unless the lesion is of a serious nature, and then collapse may 
 apervene and prove fatal ; thus, after rupture of the intestine the immediate 
 jivrnptoms are tlie result of shock, but they are quickly followed by the collapse 
 |t'je to acute peritonitis. 
 
 The degree of shock experienced in any particular case is 
 Isiainly influenced by the following factors : 
 
 (a) The severity and extent of the injury, which may be calcu- 
 lated either by the number of sensory nerve terminals afifected, 
 |i/., the superficial extent of the lesion, or by the depth to which 
 injury extends. Speaking generally, the amount of shock 
 Jiaries directly with the depth of the wound, since the deeper the 
 |«ound, the greater the violence which has produced it ; but in 
 
M 
 
 184 
 
 A MANUAL OF SURGERY 
 
 some cases extensixe superficial wounds produce a more se\ere 
 effect than limited deep ones, owing to the larger number of ner\ es 
 in\oIved, along which stimuli can be carried to the centres ; thus, 
 an extensive superficial burn is more likely to produce fatal shock 
 than the complete incineration of an extremity. 
 
 (/;) The site of the injury. The more essential and sensiti\e the 
 organ injured, and the more closely it is connected with the chief 
 sympathetic or cerebral centres, the greater will be the shock; 
 thus, a small wound of the intestine, stomach, or any of the \iscera. 
 is much more serious than an extensi^■e accident to one of the 
 limbs. This fact is sometimes of practical value in the determina- 
 tion of the exact nature of abdominal injuries. When severe 
 shock with abdominal pain lasts for twenty-four hours after an 
 accident, the surgeon may be almost certain that some internal 
 viscus has been seriously damaged, and should at once consider 
 the advisability of performing laparotomy. 
 
 (r) The nervous susceptibility of the patient is a most important 
 element, for the more highly organized the nervous system, the 
 greater is the amount of shock experienced, and vice versa. Prison 
 surgeons bear this out, for amongst the coarser and baser types of 
 criminals operations may be performed without an anaesthetic in a 
 surprising manner ; amongst negroes and other tropical races 
 pain is borne with fortitude, and operations are attended with very 
 slight general effects. 
 
 (d) The expectation or not of the injury. \\'hen the whole ner\ous 
 system is maintained in a state of tension, anxiously expecting the 
 receipt of some painful impression, the effect produced will natu- 
 rally be increased ; whilst if the attention is diverted, and interest 
 actively aroused in other things, the shock at the time is much 
 diminished, though its effects may be subsequently greater. Tims, 
 in the keen excitement and nervous tension of a battle, soldiers 
 ha\e often been wounded severely, and yet not known it at the 
 time ; whilst the pain of the most trifling cut may produce deep 
 shock when the patient is in a state of dread and anticipation. 
 
 The Symptoms \ary with the injury inflicted, from a slight 
 momentary giddiness and faintness (known ordinarily as an attack 
 of syncope or a fainting fit) to immediate and complete prostration, 
 insensibility, and even death. The pulse is at first small, slow, 
 and weak, but soon becomes irregular, extremely rapid, and often 
 imperceptible ; the countenance is pallid and shrunken, and the 
 brow co\'ered with cold sweat ; the respirations are slow and 
 shallow, whilst the temperature is usually subnormal. 
 
 After an interval, the length of which depends on the severity 
 of the lesion and the treatment adopted, reaction occurs, being 
 introduced by increased depth and frequency ot the respirations; 
 the pulse becomes slower and fuller, the surface warmer, whilst 
 consciousness and muscular power are gradually restored. Durinj; 
 this period it is not unusual for an attack of vomiting to supervene, 
 
 probably due to I 
 which has been re: 
 
 When the accic 
 blood, the phenom 
 shock ; the pulse i 
 the blood is alten 
 he present. 
 
 Sometimes reac 
 of the mental or 
 traumatic delirium 
 other to intense r< 
 sive burns. It is 
 element has been i 
 times applied to th 
 
 Occasionally th 
 pearance for some 
 Especially is this 
 injury has been e> 
 nient are such th; 
 perturbation passe 
 similar to the abov 
 thenia than of real 
 occurs to a persoi 
 the phenomena of ; 
 themselves when t 
 
 Pathology. — The 
 teristic, but they al 
 over the vascular, 
 parts of the body 
 viscera, lungs, at 
 practically no bloo 
 much distended a 
 sudden injury, an 
 contraction. The 
 means simple, and 
 the complex resu 
 through the cardie 
 early syncope wit 
 fact that if a frog 
 sharply struck, tl 
 the vagi are previc 
 peripheral injury 
 directed to the g 
 are closely connec 
 this way sudden 
 epigastrium, or b 
 hot. This inhibit 
 
 i( 
 
 mammals. 2. Inl 
 
WOUNDS 
 
 185 
 
 probably due to hyperaemia of the brain following the anaemia 
 which has been responsible for most of the preceding symptoms. 
 
 When the accident or operation has resulted in serious loss of 
 blood, the phenomena of haemorrhage are associated with those of 
 shock; the pulse is sometimes of the haemorrhagic type (p. 191); 
 the blood is altered in its characters, and great restlessness may 
 be present. 
 
 Sometimes reaction is accompanied by great irritability, either 
 of the mental or muscular systems ; in the one case leading to 
 traumatic delirium, which is always of grave import, and in the 
 other to intense restlessness, as in the shock which follows exten- 
 sive burns. It is possible that in both these conditions a toxic 
 element has been introduced. The term erethitic shock is some- 
 times applied to these manifestations. 
 
 Occasionally the evidences of shock are delayed in their ap- 
 pearance for some time after the injury, and come on gradually. 
 Especially is this the case after railway accidents when no great 
 injury has been experienced ; for a time the anxiety and excite- 
 ment are such that no depression is noticed, but as the mental 
 perturbation passes off, the individual experiences symptoms very 
 similar to the above, but probably rather of the nature of neuras- 
 thenia than of real shock (see Chapter XX.). When an accident 
 occurs to a person in a state of intoxication, it is not unusual for 
 the phenomena of shock to be delayed for some time, only showing 
 themselves when the effect of the alcohol has passed away. 
 
 Pathology. — The post-mortem evidences are not very charac- 
 teristic, but they all point to a loss of control of the nervous system 
 over the vascular, resulting in anaemia of the brain and superficial 
 parts of the body, and enormous engorgement of the abdominal 
 viscera, lungs, and great venous trunks ; the heart contains 
 practically no blood, although it is probable that the right side is 
 much distended at the time of death, especially when due to 
 sudden injury, and subsequently empties itself by post-mortem 
 contraction. The explanation of the phenomena of shock is by no 
 means simple, and several factors are probably needed to produce 
 the complex result. i. Re'lex inhibition of the heart's, action 
 through the cardio-inhibitcry centre in the medulla explains the 
 early syncope with slow pulse. It is a well-known physiological 
 tact that if a frog's abdomen is opened and the exposed intestine 
 sharply struck, tlie heart s^ops in a condition of diastole, whilst if 
 the vagi are previously divided, no cfieci is produced. Any severe 
 peripheral injury may lead to such a result, especially those 
 directed to the great sympathetic centres in the abdomen which 
 are cloi^ely connected with the vital centres in the medulla. In 
 this way sudden death may be produced by a severe blow in the 
 epigastrium, or by drinking a glass of very cold water, when 
 hot. This inhibition of the heart's action is ne>er prolonged in 
 inamnials. 2. Inhibition of the vasomotor centre In the medulla 
 
1 86 
 
 A MANUAL OF SURGERY 
 
 is probably the cause of the maintained depression of the patient 
 after an injury. This produces dilatation of the smaller arterioles, 
 especially in the splanchnic area, and thus a marked lowering of 
 the general blood-pressure follows. The supply of blood to the 
 brain and surface is therefore diminished, the portal system beinj,' 
 overfull. Most of the symptoms of shock can be explained in this 
 way, although it is evident that a large haemorrhage ouglit to 
 produce exactly the same effects. 3. A third factor has therefore 
 been suggested in the production of shock, viz., exhaustion of the 
 nerve centres, which thus lose their control over the muscular and 
 circulatory systems. 
 
 Diagnosis. — i. From the general results of hamorvhage. Rest- 
 lessness and thirst are then prominent signs, together with a sense 
 of dyspnoea, causing rapid respiratory efforts ; the mental con- 
 dition, moreover, is less affected, and the patient is generally 
 sensible ; the surface is excessively blanched, and the pulse may 
 have a marked hemorrhagic wave. 2. In concussion of the hvain 
 there are superadded to the symptoms of shock those more par- 
 ticularly connected with the region affected, i.e., the intellectual 
 centres, so that unconsciousness is the predominant feature, whilst 
 loss of memory of the accident and of the events which followed 
 is often noticed. 3. When vomiting is approaching undcy the 
 influence of an anc^stJietic, the patient's pulse usually becomes weak 
 and rapid, and the countenance pale. This condition closely simu- 
 lates shock, and is often distinguished from it only by the pro|,Tess 
 of the case. Under such circumstances, if vomiting is plainly 
 imminent, it is often wise to increase the amount of anaesthetic, as 
 the patient is usually not fully under its influence. 
 
 Treatment. — In slight cases very little is needed beyond resting 
 quietly for a few minutes, or the exhibition of some aromatic 
 stimulant to the nostrils, such as ammonia or smelling-salts. In 
 the more severe cases the patient is laid recumbent, with the head 
 low ; hot bottles, well protected, and blankets are applied to the 
 trunk and extremities to maintain and increase the bodily tem- 
 perature. If able to swallow, a little warm tea or stimulant mayi 
 be administered ; but if unconscious, a hot coffee or brandyj 
 enema, small in bulk, or a hypodermic injection of ether 
 strychnine (1H_ ii.-vi. of the B. P. injection), is necessary. It musi 
 be borne in mind that the patient has, in most cases, only to hi 
 tided over a certain period of depression before reaction naturall 
 follows, so that it is important to economize vital power, and nc 
 to waste it by over-stimulation, which is also apt to cause exces 
 sive reaction later on. 
 
 The intravenous infusion of hot saline fluid (i drachm of chloridi 
 of sodium to i pint of water) has been employed with consider 
 able success of recent years. The modus operandi is descrihed al 
 p. 193; the fluid should be introduced at a temperature hetwee; 
 105° and 110° F. Several pints may l)e injected to begin w' " 
 
WOUNDS 
 
 i87 
 
 the exact amount being governed by the reaction of the patient. 
 If after a few hours symptoms of depression again supervene, the 
 injection should be repeated. 
 
 An important question is often raised as to the advisability of 
 performing an operation during shock. As a general rule, it may 
 be stated that operation should be deferred until reaction has 
 come on, unless the presence of the injured organ, such as a badly 
 rushed limb, is evidently prolonging the condition. Under these 
 circumstances a hypodermic injection of morphia may improve 
 tiie condition by relieving pain ; otherwise, the limb should be at 
 once removed, and it will be often found that, as the patient passes 
 under the influence of the anaesthetic, the pulse improves, and the 
 ?tate of shock disappears, the anaesthetic shielding the medullary 
 centres from the painful afferent stimuli. Again, it may often be 
 possible to deal with urgent cases without delay by the use of a 
 iiline injection into the venous system prior to operation. Pro- 
 longed shock after an accident is always a serious symptom, and 
 often indicative of internal injuries; the importance of such must 
 iic carefully considered before deciding on the treatment. 
 
 Shock may to a large extent be prevented during operation by 
 a careful attention to such details as keeping the patient well 
 covered up and as warm as possible, by minimizing haemorrhage 
 r.rough bloodless methods of operating or the use of forci-pressure 
 lorceps, and by rapidity of execution. A hypodermic injection of 
 strychnine given just before the operation is also useful ; and it 
 must be remembered that incomplete anaesthesia tends to increase 
 the shock rather than to prevent its occurrence. It is also 
 
 Ivisable, in cases where the pulse is weak, to use ether rather 
 kn chloroform. 
 
 v.; .;, 
 
 11. Traumatic Fever. — Traumatic fever is that which follows 
 Itk receipt of an injury, whether simple or compound, or after an 
 joperation. Two main varieties are described : 
 
 {a) Simple Traumatic Fever occurs after subcutaneous injuries, 
 Isuch as sprains, contusions, fractures, etc., and after aseptic 
 Joperation wounds or compound injuries. It is thus found in con- 
 liitions where micro-organisms are absent, or, if present, are in 
 Isuch a state as to be practically impotent. The generally acknow- 
 liedged cause is the absorption from the blood clot or inflammatory 
 Isudation of some chemical substance (possibly the fibrin fer- 
 pnt), wliich has a pyrogenic effect upon the medullary centres. 
 iProbably the fever following aseptic operations is largely de- 
 Itrmined by the use of irritating antiseptics, which increase the 
 jmidation, and lead to considerable damage of the tissues ; if mild 
 
 intiseptics or sterilized salt solution are alone used to irrigate 
 kpen aseptic wounds, this so-called ' reactionary fever ' will be 
 tent, unless other elements, such as retained serous discharge 
 
 f accumulation of l)lood, are present. Occasionally fever is 
 
i88 
 
 A MANUAL OF SURGERY 
 
 observed in cases where we have no grounds for supposing that 
 absorption of fibrin ferment is taking place ; it may then be due 
 to some peripheral irritation, e.g., a badlj'-fitting splint, and dis- 
 appears immediately on the removal of the cause. 
 
 The symptoms are those of slight pyrexia, reaching ioo° or 
 ioi° F. within twenty-four or forty-eight hours of the injury, with 
 coated tongue, loss of appetite, etc., gradually passing off in three 
 or four days. If thus limited, it is of no prognostic importance. 
 
 (b) Symptomatic Traumatic Fever is that caused by the absorp- 
 tion either of the products of putrefaction, resulting from the vital 
 activity of non-pathogenic organisms in discharges, blood-clot, or 
 dead tissue ; or from the absorption of the toxins connected with 
 a development of pathogenic organisms in the wound or its sur- 
 roundings ; or from the supervention of some general infective 
 disorder. All these different conditions have been dealt witli else- 
 where, and require no further notice. 
 
 III. Tra-umatic Delirium. — Although delirium is merely a 
 symptom which is superadded to others in certain cases, it is 
 occasionally of so pronounced a character as to demand special 
 attention. Three forms are met with : 
 
 (a) The Active Delirium, which accompanies severe injuries, 
 particularly in plethoric, and often in previously healtliy indi- 
 viduals, whose environment has been suddenly changed from that] 
 of everyday life to a sick-bed in a hospital ward. Septic con- 
 tamination of fhe wnnnd is usually present, and the delirious state j 
 is associated and runs a parallel course with the traumatic fever. 
 It is not usually of a violent type, although the patient may be i 
 irrational and restless; he mo\'es the injured part without any] 
 evident appreciation of the pain which, if conscious, he must suliler, 
 but he is easily restrained by the exhibition of firmness and tactj 
 on the part of the attendant. The symptoms are most marked at 
 night, and comnience at the end of forty-eight hours, Uisting, as a 
 rule, for two or three days. There is a distaste for food, which,] 
 however, can be overcome by gentle persuasion. 
 
 Treatment, — Patients in this condition must never be left ; the] 
 diet should be light, but nourishing ; the bowels are thorouf,dilyf 
 opened, and an icebag to the head may be useful. The wouiidj 
 should be freed from any septic accumulation. 
 
 (b) Delirium of a Low Muttering Type is met with in indi\ idualsl 
 of low vitality, exhausted by dissipation, drink, disease, or fault\J 
 hygienic surroundings. It is commonly associated with fever o^ 
 an asthenic type, such as is seen towards the end of septic ori 
 infective diseases. The patient usually lies on his back, starinJ 
 vacantly upwards, is incoherent, takes no notice of surroundinj,| 
 objects, and is observed to pick at the bedclothes and mutter to 
 himself unintelligibly. There is often, in addition, an involuntary 
 escape of urine or faeces. The mouth is generally open, the 
 
WOUNDS 
 
 189 
 
 loiif^^ue dry, brown and cracked, and viscid mucus collects about 
 the teeth {soydcs). 
 
 The Treatment should be directed to careful nursing and feeding, 
 as by that means alone can the patient be sa\ed. 
 
 ((■) Nervous Traumatic Delirium is observed in individuals who, 
 previously of intemperate hal)its, have suffered some serious 
 injury, such as a compound fracture. The violent symptoms do 
 not set in till about the third day, but are usually preceded by 
 some amount of sleeplessness and wandering at night, or the 
 patient may have short snatches of sleep, from which he awakes 
 semi-delirious. This gradually increases, and is followed by 
 violent delirium of the worst type (dclinuvi tremens), in whicli the 
 patient is haunted by terrifying visions of reptiles, horrible insects, 
 and the like, from which he tries in vain to escape. During this 
 stage of excitei ent he is with difficulty restrained from jumping 
 out r'" bed ; in many instances these patients are remarkably 
 cunnliif^, and, managing to elude the vigilance of their attendants, 
 will succeed in escaping from the room by the door or window, 
 and so inflict serious, and even fatal, injuries upon themselves or 
 others. There is always a trenmlous condition of the extremities 
 and of the tongue, wliich is white and coated, whilst the bowels 
 are obstinately confined. The pulse and temperature vary con- 
 siderably, and the skin is often moist and clammy. The violent 
 stage is always followed by profound exhaustion, in which the 
 patient may gradually sink into a state of coma and die. In a 
 case of fractured leg, the struggles of the patient will cause con- 
 siderable displacement of the limb, and necessitate constant 
 attention to prevent further mischief. The limb should never be 
 tixed to the bed, but slung in a Salter's swing or immobilized in 
 plaster of Paris. 
 
 Treatment. — In c. ". where an attack of delirium tremens is 
 considered imminent, either from the previous history of the 
 patient, the tremulous state of his hands and tongue, or his Sleep- 
 lessness, the best treatment to adopt is to support the strength by 
 Miitable food and a medium dose of stimulant, combined with free 
 ■.Hirging and, if need be, soporifics (chloral, bromide, paraldehyde, 
 ir morphia) ; under such a regimen the symptoms usually soon 
 disappear. In the acute maniacal attacks the patient must be 
 lully controlled and guarded, but with as little manifestation of 
 restraint as possible. Nourishing food (possibly of a fluid type), 
 vith a certain amount of stimulant, should be administered during 
 I'.hequiet intervals, and sleep obtained by drugs, especially morphia 
 ' ypoderniically ; a quarter of a grain should be given at first, and 
 I'liore if necessary. Free purging is of course essential. 
 
,...,. 
 
 CHAPTER VIII 
 
 H^MOBBHAGE. 
 
 By the term hamorvhagc is meant any loss of blood, whether in- 
 significant and immediately arrested by natural means, or more 
 excessive and requiring treatment to prevent its continuance. 
 Although most conunonly due to some injury, whether suh- 
 cutaneous or inflicted through the skin, it may be predisposed to 
 by weakness of the vascular tissues, especially if associated with 
 increased blood-pressure. Certain diseases, such as purpura and 
 scurvy, are characterized by a tendency to bleeding, and there is 
 one congenital condition, haemophilia, in which it is difficult to 
 stop the flow of blood when once started. 
 
 The character of the bleeding differs according to the vessel 
 from which the blood escapes. Arterial Hsemorrhage consists 
 in a flow of bright scarlet blood, which escapes at first pa 
 saltum, i.e., in jets synchronous with the heart's beat, and may 
 be derived, not only from the proximal, but also from the distal 
 end of the divided vessel, if the collateral circulation is suffi- 
 ciently abundant. If, howe\er, it is derived from a deep artery, ; 
 the blood may well up from the depths of the wound and not i 
 escape in gushes. In Venous Haemorrhage the flow is usually 
 continuous, and the blood of a dark red or almost black colour. 
 If, however, a large vein is wounded, such as the internal juf^ular, 
 the blood may escape with a very definite spurt, owing to respira- 
 tory or other influences. Capillary Haemorrhage is marked by 
 general oozing from a raw surface, the blood trickling down into I 
 the wound, and filling it from below upwards. By Extravasation j 
 of Blood is meant the pouring out of blood from a wounded vessel! 
 or vessels into the lax areolar planes immediately adjacent, whichj 
 become swollen and boggy. The usual constitutional signs willj 
 be manifested as a result of such extravasation, and, indeed, fatal! 
 haemorrhage may occur in this way without any escape upon thej 
 surface of the body. Subcutaneous or submucous ha;morrliage| 
 is also met with in the form of small localized petechiae, arising; 
 n-om injuries, or from changes in the blood or vessel walls 
 (as in purpura, scurvy, and septicaemia). Epistaxis is the terni| 
 given to bleeding from the nose. By Haematemesis is meant the 
 
HEMORRHAGE 
 
 191 
 
 vomiting of l)lood ; it may either have been swallowed, as in some 
 cases of fractured base of the skull, where the pharyngeal mucous 
 membrane has been torn, or it may have originated from the 
 upper part of the intestinal tract. The blood is usually curdled 
 and brownish in colour, somewhat resembling coffee-grounds, 
 from the action of the gastric juice upon it. Hamoptysis is the 
 title given to the escape of blood from the air-passages, whether it 
 results from injury or disease. Hamaturia is a condition in which 
 blood is passed in the urine. By Melaena is meant the passage of 
 dark tarry blood with the faeces. It is always the evidence of 
 disease or injury to the intestine sufficiently far from the anus to 
 allow the blood to become altered in character by the action of 
 the intestinal juices. Blood derived from the rectal mucous mem- 
 brane usually retains its bright red colour. 
 
 Constitutional Effects of Haemorrhage. 
 
 If the haemorrhage is severe, as from division of a large artery, 
 death results from syncope. The surface of the body becomes 
 cold, clanuny, and pale; the lips, ears, and eyelids are livid; the 
 patient gasps, his respirations become quick and sighing, and 
 death ensues after perhaps a few convulsi^•e twitches of the limbs. 
 
 i If consciousness is retained at all, patients often coiuplain of the 
 sight failing, and a sense of increasing darkness, immediately pre- 
 ceding the fatal termination. These effects depend as much on 
 
 I the rapidity of the bleeding as on the total amount of blood lost ; 
 
 I people can stand gradual loss of blood much better than when it 
 
 I escapes suddenly. 
 
 I If the haemorrhage is not so great as to kill immediately, the 
 
 I patient faints, and on recovering is in a condition of severe collapse 
 
 I and weakness, which continues for some time; he is also liable to 
 
 ■ recurrent attacks of syncope, any one of which may be fatal. 
 
 I If the haemorrhage is more gradual, but continuous, as in cases 
 I of piles or uterine: fibroids, the patient becomes profoundly anaemic, 
 land the lips, ears, and conjunctivae are pearly white ; dyspnoea 
 ■ensues, owing to the insufficient amount of blood present, and in 
 
 ■ consequence the patient is extremely restless, tossing about in bed. 
 
 ■ Any sudden exertion, or even sometimes the attempt to sit up, is 
 
 ■ iollowed by a sensation of faintness ; noises are heard in the ears, 
 lihe sight becomes dim, or is even temporarily lost (amblyopia), 
 I: id severe headache may be complained of, all arising from 
 Bcerebral anaemia. The pulse often becomes what is known as 
 m^monhagic in character, i.e., frequent, large, and compressible, 
 WM collapsing entirely between each beat, and markedly dicrotic. 
 BjThese peculiar features are due to the sudden passage of a small 
 ■amount of blood through a vessel which is practically empty and 
 ■tntirely collapsed. From the defective vis-a-tcrgo, oedema of the 
 Hstremities luay result. 
 
 V '^'f 
 
192 
 
 A MANUAL OF SURGERY 
 
 During,' the continucince of haemorrhage the blood pressure 
 necessarily falls ; but unless a volume equal to a third of the 
 total bulk of blood in the body is lost, it quickly rises again to the 
 normal after the bleeding has ceased. This rise in blood pressure 
 is partly due to a diminution in the size of the vascular area, 
 owing to vasomotor contraction of the peripheral arterioles and of 
 the splanchnic area, but is also caused l)y an increased fknv of 
 lymph into the circulation. This lymph is accompanied hv a 
 large number of leucocytes, and hence well-marked leucocytosis, 
 lasting for five or six days, always follows any severe ha3morrhaf,'e. 
 The number of red blood-cells is also reduced, whilst the amount 
 of haemoglobin in each is diminished, and the specific gra\ityofj 
 the blood falls considerably. 
 
 Children and elderly people alike bear the loss of blood badlv 
 but whereas children rapidly reco\er from the innnediate effects,] 
 elderly people do not. 
 
 General Treatment of Haemorrhage. 
 
 When the loss of blood has been severe, the patient must he] 
 kept quiet with the head low, whether syncope is present orj 
 not. Stimulants may be necessary to maintain the heart's actionj 
 but should be given with discretion for fear of re-starting the| 
 bleeding. If death appears to be imminent, the arms and le; 
 should be bandaged, or the abdominal aorta compressed in orderj 
 to confine the blood as much as possible to the head and trunk. 
 
 ' No patient should be allowed to die of haemorrhage.' vSuch 
 was the dictum of the late Mr. Wooldridge of Guy's Hospital] 
 based on a knowledge of the value of transfusion and infusion] 
 By Transfusion is meant the transference of blood from on( 
 individual to another ; it may be accomplished by two methods 
 the direct and indirect. Direct or immediate transfusion consists ir 
 injecting the blood of the donor directly into tlie vessels of tli^ 
 recipient. The objection to this method is that an individual call 
 rarely spare sufficient blood to be of any real use, and hence thj 
 results are unsatisfactory. Indirect or mediate transfusion is carried 
 out by whipping the blood from some healthy individual 
 individuals so as to remove the fibrin, and after straining throiij. 
 fine linen it is injected, either pure, or diluted with saline solutioi; 
 
 During the last few years it has been recognised, howevej 
 that the success of tnis proceeding depends on the introduction of 
 sufficient quantity of fluid as a temporary substitute for the hloc 
 wdiich has been lost, rather than on itr, quality; for it has be( 
 proved that the transfused blood of another person is rapid! 
 destroyed and eliminated. Hence transfusion has now been 
 placed by what is known as Infusion, which consists in injectii 
 large quantities of some bland fluid into the vessels, and by tl 
 means greatly improved results have been obtained. All tl 
 
 apparatus needed is 
 'iHilhous, bjiint, and 
 [connected by means 
 he fluid (l'i.r, ^^^^ 
 aphena, should be , 
 wdinal or ob]i(nie in< 
 exclude air, is then in 
 jiist below the bulb, 
 I riie amount injected 
 produced, but, to be 
 
 Fig, 
 
 49- — Infusion intc 
 
 F 5 pints have not unc 
 a rule, one injection 
 niorrhage, but where s 
 Nr three times. 
 fstothe material, a wc 
 f drachm of chloride . 
 W -6 per cent.), at a 
 M crystals of salt sho( 
 ■%' ^^'iter, so as to ster 
 H bulk. Of cour: 
 
HAEMORRHAGE 
 
 193 
 
 pparatus needed is a metal or glass cannula, the end of which is 
 ulbous, blunt, and bevelled, which can be tied into a vein, and 
 onnccted by means of a rubber tube with a reservoir containing 
 he fluid (Fig. 49). A vein, c.^^., the median basilic or internal 
 aphcna, should be exposed, tied below and opened by a longi- 
 udinal or oblicpie incision ; the cannula, tilled with lotion so as to 
 ;xclude air, is tlien inserted, and a ligature placed round the vessel 
 list below the bulb, so that on witlidrawal it can be tightened. 
 Ihe amount injected varies with the circumstances and the effects 
 produced, but, to be efficacious, some pints are usually needed; 
 
 1 ^ 
 
 Fio. 49.— Infusion into Vein of Forearm, (Down Brothers.) 
 
 U 5 pints have not uncommonly been employed for the purpose. 
 sa rule, one injection is all that is required in dealing with 
 Iniorrhage, but where shock is present ii may need to be repeated 
 I or three times. 
 
 l\s to the material, a warm saline solution is the best, consisting 
 la drachm of chloride of soda to a pint of sterilized water (or 
 fat -6 per cent.), at a temperature of 105° to 110° F. The 
 crystals of salt should be dissolved in a small quantity of 
 hi<^ water, so as to sterilize it, and this is then diluted to the 
 jired bulk. Of course, the apparatus is most scrupulously 
 
 13 
 
 
194 
 
 A MANUAL OF SURGERY 
 
 purified, either liy boiling for some minutes or by efl'cctive 
 inuiiersion in carbolic lotion, and no air must be admitted. The] 
 injection is made slowly, so that the solution may be f^aaduallyj 
 mixed with the blood. It has been found by experiment that 
 after an infusion followinj; ha^morrhaf^e the specific f;ra\ily ofj 
 the blood is only lowered for a very short period, and rapidly 
 rises to a normal level, or may even be raised above the normal. j 
 This suf(fjfests that the increased amount of fluid is sucked up hy 
 the tissu(>s, and explains why it is sometimes necessary to repeat] 
 ttie injection more than once. 
 
 Another plan sometimes used with success consists in thej 
 introduction of warm fluid into the rectum, or throuj^di an aspirator! 
 needle connected with a tube and funnel into the loose connective] 
 tissue of the buttock or abdomen. In the latter case the funnel) 
 must be held at some heif^ht in order to gain sufficient pressurej 
 and by this means several pints may be injected. 
 
 Natural Arrest of Haemorrhage. 
 
 This can best be described under two headings, viz., (i) thd 
 temporary arrest, and (2) the permanent. The processes are niucli 
 the same for arteries, veins, or capillaries ; but since the arrest oj 
 arterial haemorrhage has been more thoroughly investigated, and 
 is the most important, we shall deal mainly with it. 
 
 The Temporary arrest of arterial haemorrhage is brought ahouj 
 by three principal factors : 
 
 (i) The coagulation of the blood, which occurs in and around 
 the vessel, and without which death would ensue from the nieres| 
 scratch. The greater the loss, up to half of the total amount 
 l)lood in the body, the more coagulable it becomes. 
 
 (2) Diminution in the force of the heart's action always followj 
 haemorrhage, from anaemia of the cerebral centres, a beneficei] 
 provision whereby coagulation is facilitated and the flow of Moo 
 checked. Unless the syncope is profound, stimulants shoull 
 therefore be carefully avoided, for fear of causing a recurrence i 
 the bleeding by increasing the power of the heart's beat. 
 
 (3) Changes in and around the vessel play a most iniportaij 
 part in completing the process. 
 
 They consist in the retraction of the artery within its sheath 
 reason of its inherent longitudinal elasticity ; if, however, it is onl 
 partially divided (or, as it is called, ' button-holed '), this conditiq 
 cannot obtain, and the haemorrhage is more likely to continii 
 As a result of this retraction, the rough and uneven inner liniii 
 of the sheath is exposed, and upon this the blood coagulates asj 
 flows, thus gradually producing what is known as the extern 
 coagulum. At the same time the transverse muscular and elas^ 
 fibres in the vessel wall cause contraction of the open mouth, a« 
 thus, as the force and calibre of the blood-stream diminish, tJ 
 
 lexternal coagulum ij 
 |:ilirin, until at last it 
 luwliac impulse to c 
 livliich extends to the 
 liaternal coagulum nt 
 livards as far as the nt 
 ]s arrested for the tim 
 
 The Permanent clo5 
 [consists in a modificai 
 
 Alter the cessation 
 l-ott in consistence ai 
 iiiuuth of the vessel, 
 
 IfiG, 50.— Early Stage OF ( 
 HON OF Artery after L: 
 
 laethrombus is seen above 
 !liesiteofligature,thaton 
 mal (upper) side being tiJ 
 commencing cell infiltratil 
 tees of tlie clots is also i| 
 ,:both these diagrams th, 
 Arougliout for clearness 
 iracted. 
 
 Fance, and perhaps , 
 i'le vessel wall contra! 
 F, It does not unite, [ 
 [.•the injury, a simple 
 }lHpera3mic condition I 
 levasa \asoruin, and il 
 pde the coagulum af 
 F leucocytes break u 
 lt;i\as:e which result f/ 
 Jah..\v giant cells, prl 
 f ":';'>' 'Assisting in thil 
 ^Iterates concurrentlvf 
 nr fil)rol)lastic cellsl 
 
HAEMORRHAGE 
 
 «9S 
 
 xternal coaguluin is able to increase in size by fresh deposits of 
 ilirin, until at last its resistance is too f^reat for tlie diminished 
 ardiac impulse to overcome, and tlie sheath is tilled with clot, 
 vbich extends to the divided mouth of the vessel. From this an 
 aternal coaj^ailum next develops, which sometimes extends up- 
 ards as far as the nearest patent branch. Thus the luemorrliage 
 5 arrested for the time being, and preparation made for — 
 
 Tlie Permanent closure of the wound in the artery, which merely 
 consists in a modification of the general process of repair. 
 
 After the cessation of the huimorrhage, the internal coagulum, 
 soft in consistence and dark red in colour, extends from the 
 aiouth of the vessel, or from the site of the ligature, for some 
 
 30. -Early Stage of Oblitera- 
 tion OF Artery after Ligature. 
 
 Fig. 51. — Later Stages of the 
 Same Process. 
 
 Ihe thrombus is seen above and below 
 thesiteof ligature, that on the proxi- 
 mal (upper) side being the larger ; 
 commencing cell infiltration of the 
 bases of the clots is also indicated. 
 
 Tlie clots are shrinking, and the lowest 
 portions are being transformed into 
 granulation tissue. Proliferation of 
 the tunica intima is also seen, reach- 
 ing beyond the apices of the clots. 
 
 h both these diagrams the arteries iiave been represented of the same size 
 throughout for clearness' sake ; in reality, the lumen would be much con- 
 tracted. 
 
 iistance, and perhaps to the next collateral branch (Fig. 50). 
 "lie vessel wall contracts upon this coagulum, with which, how- 
 iver, it does not unite, except at and near its base. As a result 
 ithe injury, a simple plastic arteritis is set up, evidenced by 
 hyperaemic condition of the vessel wall, due to dilatation of 
 evasa vasorum, and its infiltration with leucocytes, which also 
 ivade the coagulum and cause its base to become decolorized. 
 be leucocytes break up the clot, traversing the natural lines of 
 Savage which result from its contraction, and gradually remove 
 a few giant cells, probably deri\ed from the leucocytes, occa- 
 nally assisting in this process (Fig. 53). The tunica intima 
 jToliferates concurrently, causing a secondary infiltration with the 
 irsier fibroblastic cells in that part of the thrombus which is 
 
 13—2 
 
196 
 
 A MANUAL OF SURGEIiY 
 
 {ullici't'iU to the NC'ssi'l wall ( l■"i^^ 52); whilst a j^Mowtii of cellular 
 hiitls or <;raiiulatioiis, which ;^M;ulually increase in size and enrioach 
 on the hunen of the \essel, sprinj^'s up in those parts where the apex 
 of tlu» clot lies free and unadhei'ent (l'i,l,^ 51). Thus, the base of tlir 
 clot is transformed into a cellular mass (.li'ri\ed from prolileration uf 
 the tunica intinia, and by the development of new vessels from 
 the vasavasorum into j^M'anulation tissue; wliilst the cellular hmls 
 which f,n"ow from tlie walls, and extend nearly to the nrxt 
 collateral branch, are also similarly chaufj^ed. The free conical 
 extremity of the clot i-ontracts, and is <,n-adually remo\ed, partly 
 by the activity of leucocvtes which infiltrate it honi the base. 
 partly by the erosive action of the surroundin.if ^granulation tissuL-. 
 
 
 A 
 
 Fig 52.— Earlv Stage of Ok(;aniz.\tion of Thromul's, to show thk 
 Infu^tration of the Clot with Leucocytes and Connective Tissik 
 Cells derived from the Endothelium. (Tillmanns.) 
 
 A, Tunica media. B, Tunica intima, undergoing proliferative clianges, and 
 therefore tliici\ened. C, liiood-clot lying in lumen of vessel, bocomiriL,' 
 infiltrated witli leucocytes (small dark cells) and larger fibroblasts derived j 
 from the endothelium. 
 
 A similar set of changes occurs at the distal side of the li<,faturLd 
 in an artery tied in its continuity, i^lthough the thrombus is[ 
 smaller and less firm. The ligature it^^elf may be infiltrated by 
 leucocytes, and replaced by granvdr.cion tissue, or may he en- 
 capsuled. A rod of granulation tissue is thus developed, blocking 
 the vessel, and this, by the usual process of repair, is transformed j 
 into a firm cicatricial cord in the course of a few months (Fig. 53) 
 
 The arrest of haemorrhage from veins and capillaries is morel 
 easily accomplished, the collapse of the walls, together with thej 
 formation of the external coagulum, being sufficient for thisj 
 purpose. The later steps are similar to those occurring in anj 
 artery, except that there is but little internal coagulum. Inj 
 capillaries, unless some constitutional condition such as lia'mo-j 
 
 piiiliii is preseiu, tl 
 Mallow coagulatitj 
 
 Sun 
 
 Many different 
 siaiH'cs. for the e 
 ri'iiicmbered that 
 always temporarily 
 ;ir its permanent si 
 
 Fi<;, 53.— Organized 'I 
 
 Co.VNECTIVE TiSHU 
 LAKI/ED FROM THK 
 
 Twi 
 
 ^Vhci'c the hlccdiiif. 
 y,i]riiculav vessel, the l'( 
 I. Cold may be e 
 lotion, or simple exp 
 I lieing removed for th 
 [that ice and unsteri 
 rent is of most \alue 
 I or into cavities, such 
 . Position. — Whe 
 Itspecially the lower 
 |arresti.ig it. The ve 
 is always follow^i 
 [proceeding of which 
 [exsanguinate a limb 
 I"! operations which o 
 3. Direct Pressure. 
 
H.EMOlUiHAGE 
 
 197 
 
 |iiiili;i is present, the morr fallirif,' toj^a'thcr of tlic walls is siiflirienf 
 t.iiilKnv coiij^uilalion lu lal<c place, and thus sli)[) the l>leeclinJ,^ 
 
 Surgical Treatment of Haemorrhage. 
 
 M;iny (lilferent nietluKls are neecU'd, under xaryin^; circum- 
 stances, tor the e(Tecti\e arrest of ha'niorrhat^'e. It must be 
 reiiienibered tiiat dijjfital pressure o\er tlu; l)leedin},'-point will 
 always temporarily check the most furiiMs (nitl)urst whilst means 
 for its permanent stoppage are heinf,^ arranged. 
 
 1 h 5J — OkGANIZEO ThROMUL'S in VkSSKL, showing TlIK NKWLV KOKMKU 
 
 Connective Tissue occupvinc; the Lumen ok the Vessel, and vascc- 
 
 LAKI/EU EKOM THE VasA VasOKUM. (TlLLMANNS.) 
 
 Two giant cells are seen in tlie centre. 
 
 Where the bleeding, though profuse, does not come from any one 
 :.uiiculay vessel, the following measures can be utilized : 
 
 1. Cold may be employed in the form of ice, cold water or 
 tion, or simple exposure to the air, all clots, rags, pledgets, etc. 
 
 iiing removed for this purpose; it must, howexer, be remembered 
 ;:iat ice and unsterilized water may convey sepsis. Such treat- 
 jiiient is of most \alue for general oozing from vascular structures 
 jirinto ca\ities, such as the mouth, vagina, or rectum. 
 
 2. Position. — Where the bleeding is from one of the extremities, 
 jtspecially the lower, elevation is a most important factor in 
 
 ariesti.ig it. The veins are emptied by the force of gra\'ity, and 
 
 I tills is always followed by a reflex contraction of the arteries, a 
 
 proceeding of which surgeons also avail themselves in order to 
 
 exsanguinate a limb previous to applying the rubber tourniquet 
 
 |in operations which one desires to render as bloodless as possible. 
 
 3. Direct Pressure. — The skilful application of an antiseptic 
 
198 
 
 A MANUAL OF SURGERY 
 
 dressing, combined with pressure, is often effectual in arrestin'f 
 haemorrhage. General oozing from cut surfaces, which can be 
 brought into anposition, as from an amputation wound, may he 
 ch -eked by applying a firm bandage over them, or by incorporatinj,' 
 in the dressing a purified sponge, wrung out almost dry. hi 
 cavities or hollows, either natural or made by operation, bleedinf( 
 may be stopped by plugging with strips of dressing, or by 
 graduated layers of antiseptic wool. This form of packing has 
 in a large measure taken the place of the old 'graduated com- 
 press,' which consisted of layers of lint devoid of antiseptic 
 qualities, gradually increasing in size, superposed one over the 
 other. Such dressings should be retained firmly in position for 
 twenty-four hours, after which, if no further haemorrhage has 
 occurred, the bandages may be slackened, but it is usually advis- 
 able to retain the deep plugs a little longer. 
 
 4. Hot Water (130'' to 160° F.) is a powerful haemostatic. A 
 certain proportion of carbolic acid or corrosive sublimate should 
 be present to render the water aseptic, or it should have been 
 previously boiled ; it must also be sufficiently hot, otherwise l)leed- 
 ing is encouraged rather than checked. It is supposed to act by 
 stimulating the involuntary muscular fibres of the vessel wall to 
 contract ; but probably the coagulation of the albumen of the 
 l)lood is an important factor, as unless the water is hot enouf,di to 
 blanch the surface of the wound the bleeding is not stayed. 
 
 5. Chemical Agents may be used to check oozing from spongy 
 parts, or bleeding from deep organs or cavities. If they are 
 applied locally, and act primarily by causing coagulation of the 
 l)lood, they are known as Styptics, or astringents. Such are the 
 liquor ferri perchloridi or pernitratis, tincture of matico, tannic or 
 gallic acids, alum, nitrate of silver, fibrin ferment, styptic colloid, 
 cocaine, suprarenal extract, etc. If the drug is administered 
 internally, and acts by increasing the coagulability of the blood, 
 or by causing constriction of the vessels, it is termed a Haemostatic 
 — e.g., opium, ergot, turpentine, hamamelis, acetate of lead, 
 chloride of calcium, etc. In applying a styptic, it is essential 
 that the surface of the wound should first be thoroughly cleansed, 
 and all coaerula removed. A portion of the dressing dipped in 
 the solution is applied to the surface, or the drug is sprinkled or 
 sprayed upon it. The objection to most of these agents is that 
 healing by first intention is often hindered, whilst in the case ol 
 perchloride of iron extensive sloughing may result. Probably the 
 most powerful styptic is suprarenal extract, which, however, loses 
 its virtues when kept in solution for more than an hour or two- 
 One of the dried tabloids (grs. 5) may be dissolved in 2 drachms 
 of a 5 per cent, cocaine solution, and this is sprayed over the part, 
 or applied on a piece of dressing. 
 
 6. Cauterization is not very largely employed for the arrest ofj 
 haemorrhage, except from bones and from tissues thickened by 
 
H.^MORRHAGE 
 
 199 
 
 inflammat:on, where retraction and contraction of the vessels are 
 difficult. It need in no way interfere with primary union if the 
 skin is not touched, for the minute sloughs formed are quite 
 aseptic, and will either be absorbed or cast off in the discharges. 
 The chief objection to this method is the risk of secondary 
 hemorrhage when the sloughs separate. The cautery is some- 
 times used for the bloodless removal of vascular tumours, either 
 as a galvano-cautery, or a Pacquelin's knife, or the ordinary clamp 
 and cautery. It must be remembered that, in order to effectually 
 seal the mouths of the vessels, the cautery must be at a dull red 
 or hlack heat ; a bright red-hot iron cuts through a vessel as 
 cleanly as a knife, and does not stop the haemorrhage. 
 
 When the bleeding is more serious, and originates from some definite 
 vessel or vessels, other and more vigorous measures have to be 
 adopted. Digital pressure suffices to arrest it for a time, whilst 
 preparations are being made to ligature or otherwise treat the 
 wounded vessel. If possible, a ligature should be applied with 
 antiseptic precautions, but other means are used : 
 
 1. Acupressure was introduced by the late Sir James Simpson 
 in order to obviate the use of ligatures. The introduction of 
 aseptic absorbable animal ligatures has made such a method only 
 necessary in exceptional circumstances. Four different plans of 
 applying acupressure have been described, but the principle under- 
 lying all is the same. A needle is passed either under the vessel 
 from the skin, or over the vessel from the surface of the wound, 
 and, if placed accurately, is quite sufficient to stay the bleeding. 
 With it, however, is sometimes combined the pressure of a loop 
 of silk or wire passed figure-of-8 fashion around the ends of the 
 needle. 
 
 2. Forcipressure is a plan of stopping haemorrhage by crushing 
 the divided end of the vessel between the strong and deeply 
 serrated blades of a pair of forceps with scissor handles pro- 
 vided with a catch ; those known by the name of Spencer Wells 
 are the most convenient. In dealing with s'.iall vessels, it is 
 quite sufficient to leave the forceps app'^ed Ci a few minutes, 
 perhaps twisting them before remo\;il: but with the larger it is 
 advisable to apply a ligature. In deeo wounds where it is 
 difficult, or almost impossible, to tie the vessel, the forceps may 
 
 . be incorporated in the dressings, and not. removed for 24 hours. 
 
 3. Torsion was used as a means of sea Ing the ends of divided 
 vessels before aseptic ligatures were intrcd iced. It may be applied 
 in two ways, viz., (a) Limited Torsion, which is employed for the 
 larger vessels. The artery is drawn ou : of its sheath for about 
 half an inch with one pair of forceps, anc'. held close to the tissues 
 by another pair appliei! transversely, whilst the g"asped ead -5 
 
 I twisted sufficiently to thoroughly close it ; it should not, howover, 
 I be twisted off. [b) Free Torsion is used for the smaher A^isstl? 
 I which cannot be so completely isolated from surroup 'uig sl'uc- 
 
200 
 
 A MANUAL OF SURGERY 
 
 tures ; the vessel is laid hold of with its sheath or connective 
 tissue covering, and twisted as much as necessary. 
 
 The eflFect of torsion is that the inner and middle coats are 
 ruptured just abo\e the spot grasped, and tend to curl upwards 
 into the lumen of the vessel, whilst the outer coat is twisted up 
 beyond. A coagulum forms upon the injured structures, ami the 
 suKsefpient processes to secure permanent occlusion are similar 
 to those described above. The advantages claimed in faxour of 
 torsion are that it is easier to twist the vessels than to tie them, 
 tliat there is less liability of secondary haemorrhage, and that no 
 foreign body is left in the wound. As to the ease of application, 
 it is doubtful whether torsion has any ad\antage over ligature, 
 and certainly when asepsis is maintained the two last statements 
 do not hold good, for secondary haemorrhage is practically univnown 
 in aseptic surgery, and the catgut ligature is not more of a foreij,Mi 
 body than the damaged end of a twisted vessel. Torsion is, 
 however, occasionally useful in plastic work. 
 
 4. Ligature is at the present day the method most freciuently 
 employed for arresting bleeding from a definite source. 
 
 The materials used ha\"e varied considerably from time to time. 
 Originally silk or hempen threads well waxed were utilized, and 
 inasmuch as no steps were taken to purify them, and as they had 
 always to separate by a process of ulceration, cutting their way 
 through the \essel walls, it is not surprising that secondary 
 haemorrhage frequently followed. The ends of the ligature were 
 left long and hanging out of the wound, and were occasionally 
 pulled on by the surgeon to ascertain if they were ready to come 
 away. Since then efforts have been made to obtain a ligature of 
 sufficient strength to secure the \essel, of sufficient resistance to 
 maintain its hold in spite of being soaked in the body fluids, 
 and yet of such material as to be finally absorbed, or so pure 
 and unirritating as to become encapsuled in the tissues. Cat,!,nit 
 suitably prepared is the material most frecjuently employed, but 
 inasnuich as commercial catgut, e\en when rendered aseptic by 
 inuuersion in carbolic acid, swells up in w-arm blood serum, and 
 becomes a soft, pulpy mass in half an hour, it is necessary to 
 harden and render it more resistant by steeping it for twehe iiours 
 in a solution of chromic acid (5 parts of gut to i of chromic acid 
 in 100 parts of water), and subsetjuently for twehe hours in 
 100 parts of sulphurous acid solution. It is then dried, and is of 
 a greenish colour. It must not be forgotten that catgut is prepared 
 from sheeps intestines, by allowing the latter to putrify in water 
 and then scraping away the mucous and nuiscular coats, leaving,' 
 only the subnmcous tissue with its elastic fibres, which is twistedj 
 up into long strands. It is obvious that very efficient steriliza-j 
 tion is necessary to make a material thus prepared fit for surgicalj 
 work (p. 181). 
 
 Sterilized silk is another agent employed, whilst animal tissue?.,| 
 
 such as kang-aroo t( 
 Ballance and Edm 
 from tlie peritonei 
 their continuity, an 
 [Recently a cellulo 
 prospects of replac 
 more dang^erous an 
 Ligatures may b 
 in an open wound, 
 liiial means of cccli 
 WJK .1 applied to 
 he taken to select 
 ness of which is j 
 lumen of the vessf 
 artery should |)e ck 
 forceps, sj is to ir 
 rom.din; tissue as 
 '. '^hiMh cxi ts, sh 
 'loir .. 'Die ligai 
 ound -t and tiec' in 
 lot ^''P. i-g; the r 
 \rhen the applicatii 
 .'liroid tissue, it ma^ 
 moans of an ordinary 
 
 \"'hen a v-ssel is 
 alile I) choo,e the sp 
 interfere rs little as 
 importance, and give 
 whilst the fc^rmatior 
 'lampered by the too 
 nperati\e procedures 
 Effects of Ligatviri 
 'csult, if the \-essei n 
 hlie inner and ink 
 
 ?'|';i up slightly, „!„i^; 
 
 \'Ms within t' 2 <rni^. 
 ii«l in its continuity 
 ilie ligature. Tlie ch- 
 
 I '^(^ artery is obliterat 
 f'Jfd, then manifest t 
 plastic lymph and ce 
 
 Ipture, and if the h 
 
 |""s plastic mass, wii 
 
 ]:' repair. If tlie 
 j(^ut its way our tin 
 kint, thesepaivafi.i- 
 
 |''J ii-e risk of secori 
 'f internal cc^ir/,i!^,„, 
 
 igpj 
 
 r 
 
HEMORRHAGE 
 
 20 1 
 
 Fic;. 54. — Reef Knot. 
 
 such as kangaroo tendon and strips of ox aorta, have their advocates. 
 Ballance and Edmunds advise the use of gold-beaters' skin, prepared 
 from the peritoneum of the ox, as a material for tying vessels in 
 their continuity, and excellent results have followed its employment. 
 Recently a celluloid ligature has been introduced, and holds out 
 niospects of replacing by a safe and harmless material all these 
 more dangerous animal preparations. 
 
 Ligatures may be applied either to the divided end of an artery 
 in an open wound, or to an artery in its continuity, the effects and 
 linal means of occlusion being in l)oth cases very similar. 
 
 \V1k .1 applied to the open end of a divided vessel, care should 
 be taken to select a ligature the thick- 
 ness of which is proportionate to the 
 lumen of the vessel to be tied. The 
 iutery should be cleanly picked up with 
 forceps, sj is to include as little sur- 
 I roi'iidin;.^ tissue as possible, and where 
 ', -luaih e.\i ts, should be withdrawn 
 'roll' \. Tiie ligature is then passed 
 ouiK! 't and tied in a knot which will 
 lot slii"), e.g.^ the reef knot (Fig. 54). 
 I When tlie application of a ligature is difficult, as in very dense 
 I .'broid tissiie. it may be adxisable to pass it under the \essel by 
 I nK\ins of an ordinary curved needle, and then to tie it. 
 I \''hen Ti \ essel is to be secured in Us continuity, the surgeon is 
 I ;iMe I ) choo,e the spot to which to apply the ligature ; he should 
 I interfere rs little as possible with other anatomical structures of 
 I importance, and give every assistance to the collateral circulation, 
 I whilst the formation of the internal coagulum should not be 
 I hampered by the too close proximity of a branch. Details of such 
 ioperutixe procedures . "' be found in Chapter IX. 
 I Effects of Ligatiiro - ". )n the Vessel Wall. — The innnediate 
 1 result, if the vesse' nas ^ ^.:n tied in the usual way, is to divide 
 
 ■ the inner and mi'.' r. cr.,'«-s. which are separated from the outer and 
 Ban! up slightly, \J.i1l. ' '^ • outer coat is constricted and thrown into 
 
 ■ folds within t' 2 gra^j <J th^ ligature (Fig. 55). If an artery is 
 
 ■ (■(1 in its continuity, the same effect is produced on each side of 
 B;:.eliu;ature. The changes already described, by means of which 
 
 ■ : e artery is obliterated and transformed into a ftbro-cicatricial 
 
 ■ rd, then manifest themsehes in due order. An exudation of 
 
 ■ ;lastic lymph and cells occurs into the sheath and around the 
 
 ■ ature, and if the latter is aseptic, the whole is embedded in 
 H'iiis plastic mass, which undergoes the ordinary changes seen 
 
 ■ repair. If the ligature, however, is septic and irritating, it has 
 
 ■ 'ocut its way out thr^.-^Tji the vessel wall by an ulcerative process 
 
 ■ ikin t,j the sepaiVvn. ■'.■ of .\ ouptic slough, thus exposing the patient 
 H'Miie risk of secori ry haemorrhage from the disintegration of 
 Be internal cc^r^nlum. The period at which a septic ligature is 
 
202 
 
 A MANUAL OF SURGERY 
 
 separated varies with the size of the vessel, from a week or eif^'ht 
 days for an artery the size of tlie radial or ulnar to twelve or 
 fourteen days for the subclavian or carotid. 
 
 Of late years an old idea has been resuscitated, and has gained 
 a considerable amount of support from son\e surgeons, viz., that 
 occlusion of a \essel is satisfactorily accomplished by merely 
 bringing the walls into close apposition by an animal ligature of 
 
 suitable size, and that division of the 
 inner and middle coats is not only 
 unnecessary, but prejudicial, and 
 favours secondary haemorrhage. 
 Where asepsis is fully maintained, 
 satisfac'cory occlusion follows either 
 plan ; but it appears to us that the 
 division and curling up of the inner 
 and middle coats must facilitate the 
 ileposit of fibrin and process of repair, 
 i\t any rate, it would seem safer to 
 apply a ligature to a main vessel on 
 the face of a stump with sufficient 
 tightness rather than to err on the 
 otlier side. In cases where, perforce, 
 the artery must be tied at a spot 
 where extensive atheroma or cal- 
 careous degeneration is present, it 
 may be advisable to use broad animal 
 ligatures, such as strips of ox aorta 
 (Barwell), or prepared portions of 
 gold-beaters' skin, and only to tighten 
 the knot sufficiently to occlude the vessel with as little damage 
 to the coats as possible. The same plan must also be adopted 
 in dealing with arteries of great size, such as the innominate, 
 the first part of the subchuian, or the common iliac ; the non- 
 observance of this precaution results in aneurismal dilation at the 
 point of ligature, and this to secondary haemorrhage and perhaps to 
 death. 
 
 2. The Ligature itself undergoes changes, which result in its 
 partial or total absorption, if such be possible, or in its beconiini,' 
 encapsuled if absolutely unabsorbent. The leucocytes attack 
 any soft material, such as silk or catgut, insinuating themselves 
 amongst the fibrillae, and finally remove them by the samel 
 digestive process which leads to the absorption of a small aseptii 
 slough. Multinucleated cells are often present, and probably taki 
 some part in the proceeding. Finally every trace of the ligatiin 
 disappears, and its place is taken by a ring of fibrous tissue, 
 Orclinary chromicized gut usually lasts for about a fortniglit ; si" 
 is similarly attacked and removed, but much more slowly. Othei 
 animal substances employed are dealt with in the same way, and 
 
 I^""'- 55- — Effect of Tying a 
 
 Lir.ATL'KE FIKMLV AKOUNI) 
 
 AN Artery. 
 
 The ligature was tied at two 
 levels, and the artery then 
 laid open longitudinally. 
 
 even silver wire 
 after a time and 
 3- The effect 
 or any other pi; 
 blood through t 
 the next patent 
 for a short time 
 to contract, and 
 may or may nc 
 con\eyed to the 
 mosing branches 
 a collateral circnla 
 tain the vitality 
 permanently enla 
 thickened. If fo 
 sufficient, gangre 
 furthest away fron 
 of least vitality, j 
 which receives e'nc 
 
 Three forms of a 
 reactionary, and se 
 Primary Arterial 
 -from an open 
 punctured suhcutai 
 occurs, constitutin. 
 or if the vessel is*" 
 traumatic aneurism 
 of both these cone 
 eiiipJoyed to finalb 
 surgeon's persona 
 nold good in all 
 speaking of the liga 
 A. Primary artei 
 Wood is here pourec 
 tliat tlie full constitv 
 ^^^ principles that 
 tonorrhage were fi^ 
 Je importance of ; 
 Hunterian plan of i' 
 upon by Guthne, vm 
 ater surgeons, den 
 enunciated as follows 
 I- Ihattheiesselm 
 Je-xpose it being u 
 
 F part, the rule of 
 
HEMORRHAGE 
 
 20J 
 
 even silver wire is not unaffected, its surface becoming roughened 
 after a time and slightly eroded. 
 
 3. The effect on the Circulation is the same whether ligature 
 or any other plan of occlusion is adopted. The passage of the 
 blood through the vessel ceases, and its proximal end as far as 
 the next patent branch, though remaining somewhat distended 
 for a short time by the impact of the blood-stream, soon begins 
 to contract, and is ultimately converted into a fibrous cord, which 
 may or may not be pervious for a short distance. Blood is 
 conveyed to the vessels of the limb below the ligature by anasto- 
 mosing branches which rapidly undergo dilatation, and establish 
 a collateral ciyculatioti, sufficiently free as a general rule to main- 
 tain the vitality of the part. These collateral branches become 
 permanently enlarged, lengthened, and tortuous, and their walls 
 thickened. If for any reason the collateral circulation is in- 
 sufficient, gangrene is likely to supervene, starting in the parts 
 furthest away from the centre of the circulation, or in the structures 
 of least vitality, and spreading upwards until a part is reached 
 which receives enough blood to keep it alive. 
 
 
 Arterial Haemorrhage. 
 
 Three forms of arterial haemorrhage are described, viz., primary, 
 reactionary, and secondary. 
 
 Primary Arterial Hsemorrhage is met with under two conditions 
 —from an open wound, or where an artery is ruptured or 
 punctured subcutaneously, so that extravasation into the tissues 
 occurs, constituting either a severe bruise if the artery is small, 
 or if the vessel is large what has been badly termed a ' diffuse 
 traumatic aneurism.' The general rules for the surgical treatment 
 of both these conditions are identical, and although the agent 
 j employed to finally arrest the bleeding varies according to the 
 surgeon's personal predilections, yet the underlying principles 
 ihold good in all cases. We shall limit ourselves mainly to 
 [speaking of the ligature, as we almost always employ this agent. 
 
 A. Primary arterial haemorrhage from an open wound. The 
 [blood is here poured forth upon the surface, and escapes freely, so 
 [that the full constitutional effects are experienced. 
 
 The principles that guide us in the Treatment of primary arterial 
 Ihsmorrhage were first recognised by the late Mr. John Bell, but 
 Ithe importance of acting upon them, and not trusting to the 
 jHunterian plan of ligature at a distance, was first fully insisted 
 lupon by Guthue, whose large experience, confirmed by that of 
 jlater surgeons, demonstrated their accuracy. They may be 
 |enunciated as follows : 
 
 I. That the tessel must be secured at the bleeding-point, an operation 
 jto expose it Ix-ing undertaken if necessary. However infiltrated 
 Ithe part, the rule of cutting down to expose the wounded vessel is 
 
204 
 
 A MANUAL OF SURGERY 
 
 to he adhered to, with one or two exceptions noted helow, and 
 this for two reasons : {a) It is often inipossihle to know the exact 
 source of the liainorrhafj;e unless it is laid bare. Thus, the 
 hleedinj,^ from a punctured wound of tlie front of the le^^ which 
 was apparently deri\'ed from the anterior tibial artery, was pnjxwl 
 on incision and careful dissection to come from the peroneal, the 
 pimcture ha\in£^ passed between the bones. In the axilla and 
 groin such uncertainty often exists, {b) Proximal ligature of a 
 vessel at some distance above the l)leeding spot is very conuiionlv 
 insufficient to arrest the ha3morrhage, since collateral circulation 
 is quickly established, or, though apparently effective for a time, 
 reactionary haemorrhage is very likely to ensue. 
 
 2. That both ends of the wounded vessel must be secuved if it is 
 completely di\ided, whilst if it is only punctured, a ligature must 
 be placed on each side of the pimcture, and the complete di\ ision 
 of the vessel effected. The ease with which collateral circulation 
 is established justifies such treatment in the case of all arteries 
 of large size. Thus, where the facial artery is divided, jets of 
 blood are emitted from each end quite freely, and with nearly 
 as much force from ' e distal as from the proximal. Occasionally 
 the distal end of a njoeding vessel retracts amongst the infiltrated 
 tissues to such an extent as to render its isolation impracticable. 
 The surgeon nuisi then t'-'^st to plugging of the wound from the 
 bottom, but not ihail every effort has been made to secure it, 
 When a \essel has been divided close to the main trunk from 
 which it arises, it practically corresponds to a punctured wound 
 of the trunk, and must be treated as such by double ligature above 
 and below the opening. 
 
 It is only needful to undertake the measures detailed al)()\c in 
 cases where primary ha3morrhage is actually proceeding. If it 
 has been once arrested, it is unnecessary to search for the bleeding' 
 spot unless the patient is very faint and collapsed, and the suri^eon 
 has reason to anticipate that a large trunk has been injured, 
 Under such circumstances it may be needful to seek for and tie 
 it at once, otherwise recurrent haemorrhage is likely to ensue 
 when the heart's action becomes more vigorous. 
 
 There are a few exceptions to the general rule of tyins,' a 
 wounded vessel at the injured spot, e.g., where the depth of the 
 dissection needed might endanger important parts, as in dealing: 
 with tlie deep palmar and plantar arches, or with the secondary 
 branches of the carotid. 
 
 In the actual treatment of any particular case, the haMn()rrha,i,'e 
 should be temporarily arrested by compressing either the bleedint; 
 point with the thumb or finger, or the main trunk at a fa\uurable 
 spot nearer to the heart, against some resisting structure, such 
 as a subjacent bone. Tha common cavotid is controlled by graspin.t; 
 the neck from behind, and compressing the artery by tbe lingers j 
 placed along the anterior border of the sterno-mastoid against the 
 
 trans\-erse proces 
 tubercle). Sucli 
 inferior thyroid \a 
 third part of its c( 
 placed immediate 
 resting over the j 
 order to maintain 
 imposing the fin<j 
 pressure is to be k 
 well padded may 
 may he made and 
 ilij^ntal pressure. 
 lower jaw just in 
 the hihial and coro 
 index finger into 
 lip between it and 
 he compressed ag 
 the occipital at a t 
 tuberance against 
 kachial artery, the 
 tin<(ers pressed in 
 against the burner 
 commanded just a 
 the forearm, one f 
 porarily controlled i 
 the abdominal wall 
 at a point a little al: 
 above its bifurcatio 
 ;mmou femoral arte 
 lii^ainent. The sur 
 patient as the arter' 
 tips or thumbs to pr 
 the pubic ramus. 'J 
 may sometimes be i 
 i!ie thigh may be en 
 over tbe other. Cai 
 one side or the oth 
 artery has to be cor 
 *e hands may be 
 I Such pressure will si 
 trom any part of the 
 inUriov and posterior t. 
 hions upon the foot, 
 plishes this by gras] 
 other compressing t 
 finger's breadth behir 
 I I'etween the two mall 
 As digital comprej 
 
HAEMORRHAGE 
 
 205 
 
 transverse process of the sixtli cervical vertebra (Cliassaij^jnac's 
 tubercle). Such pressure will also control the vertebral and 
 interior tiiyroid vessels. The subclavian is to be compressed in the 
 third part of its course aj^ainst the first rib by the fin<(er or thumb 
 oLiced immediately behind the clavicle, the palm of the hand 
 lestiiif,' over the shoulder. A good deal of force is required in 
 order to maintain the pressure, and this may be gained by super- 
 imposing the fingers or thumb of the other hand. Where the 
 pressure is to be kept up for some time, the handle of a doorkey 
 well padded may be employed in the same way, or an incision 
 mav be made and the vessel exposed, and directly controlled by 
 dii,ntal pressure. The facial artery is compressed against the 
 !,nver jaw just in front of the masseter muscle. Bleeding from 
 the labial and coronary arteries is commanded by inserting the 
 iiidex finger into the corner of the mouth, and compressing the 
 Up between it and the thumb outside. The temporal artery should 
 'le compressed against the zygoma just in front of the ear, 
 the occipital at a spot about i^ inches from the occipital pro- 
 tuberance against the superior cur\ed line. To control the 
 '<m(hial artery, the arm should be grasped from behind, and the 
 tin^'ers pressed inwards along the inner margin of the biceps 
 against the humerus. The radial and ulnar arteries are easily 
 coninianded just above the wrist by using both hands to grasp 
 the forearm, one for each vessel. The abdominal aorta is tem- 
 porarily controlled in slim individuals with ease by pressure through 
 the abdominal wall against the body of the third lumbar vertebra 
 at a point a little abo\'e and to the left of the umbilicus, i.e., just 
 above its bifurcation ; in stout persons this is impossible. The 
 mmon femoral artery is best compressed just below Poupart's 
 ligament. The surgeon should stand on the same side of the 
 patient as the artery to be controlled, and use either the finger- 
 dps or tlunnbs to press the vessel upwards and backwards against 
 the pubic ramus. The fingers of one hand placed over the other 
 may sometimes be necessary to maintain sufficient conmiand, or 
 ihe thigh may be encircled by the tw'o hands, and one thumb laid 
 over the other. Care must be taken not to let the vessel roll to 
 jiie side or the other, and so escape compression. When the 
 artery has to be controlled for some time, as in an amputation, 
 die hands may be used alternately, the one to rest the other. 
 Such pressure will suffice for the temporary arrest of haemorrhage 
 irom any part of the lower limb. If it is desirable to control the 
 mkriov and posterior tibial arteries close to the ankle during opera- 
 dons upon the foot, the assistant who steadies the limb accom- 
 phshes this by grasping the toes with one hand, and with the 
 other compressing the vessels, the posterior tibial at a spot a 
 finger's breadth behind the internal malleolus, the anterior midway 
 I'etween the two malleoli. 
 As digital compression cannot, however, be comfortably main- 
 
206 
 
 A MANUAL OF SURGERY 
 
 tained for lonj,', mechanical compression of a linih as hy tourni(iuct 
 or elastic bandage must l:>e resorted to. Possil)ly the screw- 
 tourniquet will be the best to apply, as it can be relaxed and 
 tightened again as often as is necessary during the operation. 
 In some cases it is advisalile to exsanguinate the limb by cleNu- 
 tion before applying the tourni([uet. The wound is then, if need 
 be, enlarged l)y incisions, which whilst freely laying the parts 
 open should inflict the least possible damage on surrouiulin" 
 structures. All coagula are removed, and the wounded \essel 
 looked for. It may be needful to relax the tournicjuet, and allow 
 a jet or two to escape, in order to ascertain its position. Both 
 ends should be sought for and tied, a proceeding easier said than 
 done. This especially applies to the distal end, which retracts, 
 and often does not bleed at tlie time of operation, but may do so 
 when tlie collateral circulation becomes established. 
 B. For Subcutaneous Rupture of an Artery, see p. 214. 
 
 Recurrent, Intermediate, or Reactionary Arterial Haemorrhage. 
 
 Such are the terms applied to bleeding which recurs within 
 twenty-four hours of an accident or operation. Its occurrence 
 is an evidence of the failure of the means employed to per- 
 manently arrest the primary loss of blood, and may result from 
 two chief causes : {a) Defecti\e application of a ligature, which 
 comes undone from being badly tied (a ' granny ' knot), or slips 
 ofif from including within its grasp other structures as well as the j 
 arterial wall; or {h) the coagula lying in the mouths of divided | 
 \essels are not sufficiently firm to withstand the increasing blood- j 
 pressure which supervenes after the shock has passed away, or j 
 which may be due to excitement or the injudicious administration j 
 of stimulants. It is usually due to the second of these causes, 
 and is then not very serious, inasmuch as it can only arise fromj 
 the smaller vessels, all the larger ones having probai)ly been 
 recognised and tied during the operation. The term should not 
 be applied to the oozing of blood or blood-stained serum sol 
 common after operations, but only used for those cases which} 
 demand treatment, and where considerable pain and tension arej 
 caused by the accumulation of blood in the wound. 
 
 Treatment. — Elevation and the pressure of a firm bandage are] 
 often (juite sufficient to arrest this form of bleeding ; but if un- 
 successfid, the wound nmst be opened up, washed out with hot! 
 or cold lotion, and any bleeding vessel tied. The actual cauteryl 
 may even be employed to check oozing from cicatricial surfaces,! 
 and if it is not allowed to touch the skin, and the wound keplj 
 aseptic, no delay in its healing need be occasioned. Should th^ 
 bleeding persist, antiseptic plugging nmst be resorted to. 
 
 Under this title 1 
 ItouiuIs which occu 
 ^usually due to sej 
 irequent cause of a 1 
 U antiseptic surger} 
 j.io\ve\er, cannot bt 
 I pharynx, etc., it is st 
 The Fundamental 
 l.'iia^^e is without doi 
 nay act in various 
 l:he cocci may gain 
 Internal coagulum, 
 jJown the barrier w 
 [occurrence. This pi 
 hdarteritis, which k 
 ahsorhent ligature, ai 
 in this latter way 1 
 ressels ligatured in t 
 |;iie opening up of tl 
 'nf(er. We desire 
 l:n all the conditions e 
 I round. In the lattei 
 vessel which is relied i 
 jot all the tissues is ca 
 lot ensuring the patie: 
 Irence of secondary h 
 I impossible. On the 
 Jilestructive process re 
 |;^e part is temoorari 
 |»o-organisms and t 
 Various other cor 
 I Contributory Causes o 
 \n\ he coarse, irritatij 
 readily absorbed. 
 laulty. Thus, it ma) 
 Incomes loose, offering 
 
 Y f'le sheath may ha 
 jntality of the vessel 
 tmiinished. (iii.) The 
 |3 branch immediatel} 
 
 ■^'lateral circulation, c 
 
 Y t'le part may not Ik 
 ■'"[lition of the arterij 
 
 l^iltiiy, being possibly 
 
 Y "lost important coi 
 
HEMORRHAGE 
 
 207 
 
 Secondary Haemorrhage. 
 
 Under tliis title are included all forms of haemorrhage from 
 aninds which occur after the lapse of twenty-four hours. It 
 i< usually due to sepsis, and was formerly \ery common, being a 
 anuent cause of a fatal termination ; hut since the introduction 
 1 antiseptic surgery it is out seldom seen. Where antisepsis, 
 however, cannot be efficiently carried out, as in the mouth, 
 Isliarvnx, etc., it is still occasionally met with. 
 The Fundamental Cause in the production of secondary hffimor- 
 hage is without doubt a septic condition of the wound. This 
 hiay act in various ,,ays. Thus, in a vessel entirely divided, 
 |;he cocci may gain entrance througli the open mouth to the 
 Internal coagulum, and by causing its disintegration, break 
 Jown the barrier which Nature had raised against such an 
 occurrence. This process is assisted by an ulcerative form of 
 periarteritis, which leads to the maceration and softening of an 
 absorbent ligature, and to weakening of the vessel walls. It is 
 in this latter way that secondary haemorrhage is induced in 
 I vessels ligatured in their continuity, the loss of support due to 
 the opening up of the septic wound being also an element of 
 |Janj,'er. We desire here to emphasize the marked alterations 
 n all the conditions existing in a septic as opposed to an aseptic 
 I round. In the latter it is not only the clot in the lumen of the 
 vessel which is relied on to prevent accidents, but the vital action 
 lot all the tissues is calculated to work in the same direction, that 
 of ensuring the patient against haemorrhage; in fact, the occur- 
 rence of secondary haemorrhage in an aseptic wound is almost 
 Jinipossible. On the other hand, when sepsis supervenes, a 
 destructive process replaces that of repair, and the activity of 
 \k part is temporarily paralyzed by the toxic infiuonce of the 
 picro-organisms and their products. 
 
 \'arious other conditions may be mentioned, however, as 
 I Contributory Causes of secondary haemorrhage : (i.) The ligature 
 ym be coarse, irritating, or septic, or it may consist of material 
 r,oo readily absorbed, (ii.) Its mode of application may be 
 liaulty. Thus, it may have included other structures, and so 
 |i)ecomes loose, offering an insufficient bar to the blood-pressure ; 
 u the sheath may have been opened too freely, and thus the 
 Jvitality of the vessel w^all dependent on the vasa vasorum is 
 liiminished. (iii.) The ligature may have been placed too near 
 \i branch immediately concerned in the establishment of the 
 Itollateral circulation, or where there is a considerable back-flow, 
 lit the part may not have been kept absolutely at rest, (iv.) The 
 jiondition of the arterial wall at the site of ligature may be un- 
 l^ealthy, being possibly the seat of atheroma or fatty degeneration, 
 |i most important complication if the wound becomes septic. 
 
208 
 
 A MANUAL OF SURGERY 
 
 I 
 
 (v.) The state of the Mood may he unfavourahle to the repair (i 
 any wound, whether in an artery or not, e.g., in all)uminiu i,i or 
 diabetes. (\i.) Increasetl l)l()(Klpressure after tiie n<,faturc df ,, 
 vessel may lead to secondary ha.Muorrlia<4;e, as in plethora, JhiLjht\ 
 disease, traumatic fever, or from injudicious excitement, or tin- 
 unwise administration of stinudants. 
 
 The Phenomena are usually preceded by those of septic con- 
 tamination of the wound, to which a sli}^dit occasional loss of 
 blood is added. This continues with more or less frequency and 
 severity, until either the patient is worn out by the constant 
 repetition of small losses, or is destroyed by one or two severe 
 gushes from the larger vessels. The earlier the bleeding occurs, 
 the less serious it is, as it probably comes from the sinallei 
 vessels, and can be easily dealt with. When, howexer, it does 
 not super\ ene till late, as on the tenth or twelfth day, it usuallv 
 arises from the larger trunks, and is increasingly severe. When 
 originating from a vessel tied in its continuity, it generallv 
 comes from the distal end, and that for the following reasons; 
 {a) The internal coagulum is here less firm, and forms later than 
 at the proximal end ; (h) the pressure at the distal side of the 
 ligature, which is at first nil, is continually increasing as the 
 collateral circulation is established, whilst proximally it gradually 
 diminishes as the vessel contracts, and the blood-flow is dellected 
 into other channels ; and (c) the main vasa vasorum always run 
 into and along the \essel wall in the same direction as the blood- 
 stream. Hence the effect of isolating the artery in its sheath and 
 ligating it is to diminish the \itality of the arterial tunics and to 
 impede repair just below the point of ligature. 
 
 The Treatment is a matter of grave anxiety until the wound 
 gets into a healthy state, inasmuch as the surgeon can ne\er he 
 certain that the bleeding will not break out again, although it 
 may have been temporarily stayed ; hence such a case must he 
 most carefully watched. If the wound is in a lind), a tourni(iuet 
 should be lightly adjusted abo\e it as a precautionary measure, 
 so that at a moment's notice it may be tightened. 
 
 When arising from an avteyy entirely divided across, as in an 
 amputation stump, elevation of the part, exposure to the external 
 air, bathing it with cold lotion, and then redressing and tirnily 
 bandaging it, may be all that is needed in the early and mild cases, 
 A recurrence will necessitate the re-opening of the wound, and 
 the application of ligatures to the bleeding points, if practicable. 
 The actual cautery may be employed where the tissues are too 
 rotten to hold a ligature. Means should be adopted to remove 
 septic sloughs, as by a Volkmann's spoon, and if possible to render 
 the wound aseptic by swabbing it out with strong carbolic lotion 
 (i in 20), or with a solution of chloride of zinc. The wound 
 should then be powdered with iodoform, packed with cyanide 
 gauze, and firmly bandaged. If occurring later in the case, the 
 
 J 
 
 uoiiiul should be 
 tlie bleeding \l'ss 
 surrounding stru( 
 .septic state of the 
 re-. imputation pei 
 ni;i n \essel near i 
 iir iiij), proximal li 
 treatment be unsu( 
 
 When comin_ 
 indicated alxne sh' 
 the treatment \arie 
 a \essel of the tnini 
 he freely opened 
 helow, whilst e\-ery 
 hy plugging with i 
 li;^ature is impossi 
 I.-™, after using cc 
 ahovc and below 1 
 li^^ature should be a 
 or finally amputatii 
 scarcely wise to att 
 the less abundant 
 ceases, gangrene is 
 not super\'ene, ha?m 
 such circumstances i 
 
 lileeding from the 
 
 :n tliat the walls, wl 
 
 fllectually checks fut 
 
 involved, or if the w 
 
 very considerable am 
 
 dark, purplish stream 
 
 more difficult from th 
 
 liitre is no definite je; 
 
 Treatment of Venoi 
 
 I extent must be empl 
 
 Hess frequently requin 
 
 and thus the bleeding 
 
 whole circumference 
 
 puncture or tear can ( 
 
 hnaipon the calibre 
 
 I'oth the main artery , 
 
 'cin in order to tie it, 
 
 The dangers of venc 
 
 jtitutional s/mptonis i 
 
 plwliich have been g 
 
HEMORRHAGE 
 
 209 
 
 woiiiul slioulcl be freely opened up, aiul ;ui iittcnipl made to secure 
 the lilecdinj^ vessel by isohitinj^ it tor souie little distance from 
 surroundinj^f structures. If this fails, owiu}^^ U) the slouf^Miy or 
 M.'Ptic state ot the tissues, the artery must be tied just abo\e, or 
 ic. imputation performed. When the bleeding comes from the 
 ii];in \essel near the trunk, as after amputation at the slundder 
 ,ii- hip, proximal ligature can alone be de[)ended on, should local 
 trcaliiH'iil be unsuccessful. 
 
 When coming fyom an ai'tcyy tied in its continuity, the means 
 
 indicated above sliould be adopted in the early stages. Later on, 
 
 the treatment \aries a little according to the situation. If from 
 
 ;i vessel of the ti'unk, such as the carotid or iliac, the wound must 
 
 be freely opened up, and the artery secured again abo\-e and 
 
 liflow, whilst e\ery effort is made to combat tlie septic condition 
 
 by plugging with antiseptic materials. Failing this, if prcjximal 
 
 lii;;iture is impossible, one can only trust to pressure. In the 
 
 ,!);;;, after using cold, pressure, and ele\ation, one would re-tie 
 
 above and below through the original wound. If this fails, a 
 
 lij,';iture should be applied higher up through a separate incision, 
 
 or finally amputation be performed. In the Ic^;, however, it is 
 
 scarcely wise to attempt le-ligature at a higher spot, owing to 
 
 the less abundant collateral circulation. If the luemorrhage 
 
 ceases, gangrene is \-ery likely to ensue ; whilst if the latter does 
 
 not su|)er\ene, haunostasis will probably not be effected. Under 
 
 ^uch circumstances amputation must be undertaken without delay. 
 
 Venous Hsemorrhage. 
 
 lilceding from the smaller veins rarely recjuires much attention, 
 •1 that the walls, when once dix'ided, rapidly collapse, and this 
 .itccUially checks further loss of blood ; but if the larger veins are 
 nvolvcd, or if the walls are thickened and rigid, as in \'arix, a 
 vciv considerable amount may be lost, the blood welling up in a 
 dark, purplish stream from the wound, and rendering its arrest the 
 •nore difficult from the fact that, except in \eins of the largest size, 
 :htre is no definite jet or gush to guide one to the wounded spot. 
 
 Treatment of Venous Hsemorrhage. — The same means to a large 
 extent must be employed as for arterial haemorrhage, but it is 
 less frequently required, since the smaller veins collapse naturally, 
 and thus the bleeding stops. It is never adxisable to occlude the 
 whole circumference of a large vein if it can be avoided, since a 
 puncture or tear can often be secured without seriously encroach - 
 Hi; upon the calibre of the tube. In amputations it is usual to tie 
 ioth the main artery and vein. Where it is difficult to reach a 
 lein in order to tie it, the wound may be stuffed. 
 
 The dangers of venous haniiorrhage are fourfold: (i) The con- 
 
 Mutional s^'mptoms arising from the actual loss of blood, details 
 
 lot which have been given above; (2) the thrombus which forms 
 
 H 
 
aio 
 
 A MANUAL OF SURCERY 
 
 may iKTonio ilisplaced us an cinhnlus ; (3) septic infection (if tin 
 tlironibus lyin;( in the nioutii dI the \essel may lead to py;iiiiia 
 and (4) the entrance of air into veins, which, thouj^h rarely nm 
 witii, is tVau^dit with, the most uijjjent (lanf^^er to the patient. Trie 
 .'lir becomes elnnned up in tlie eaxities of the ri«,Mit side of tic 
 heart, forminj;- a s[)uni()us, frothy mixture amon<^'st the colunin;!' 
 carnea', which the heart can only with (hfliculty eject ; thu' tlw 
 circulation is liroui^dit to a standstill in spite of forcible eai lia. 
 contractions, and the patient dies fn^ni anainia of the lun<,^s and 
 brain. 
 
 The Cause of the entry of air is usually a wound of sonif 
 \ein in what is known as the ' danf,'erous ref,non ' of the nerk or 
 axilla, but occasionally it may occur in other positions, 'i'liere is 
 but little blood-pressure witliin the veins at any time, but durinj,' 
 inspiration the movements of the thorax exercise an aspiratoiv 
 or suction effect upon the blooil in the \eins ol the neck, a n is| 
 important element in tin maintenance of the venous flow. Am 
 condition wiiich tends to prevent the collapsinj^^ of the w.ill- oi 
 the \eins, or brinj^'s about what is termed their canalization, 
 i-redisposes to this accident. Thus they may be held ojicii at 
 spots where they pierce the deep fascia or the platysma ; if ilu 
 coals are thick and ri.Ljid from inflannnation, or surroiuulcd li\ 
 indurated tissue, or button-holed as by excision of a portion (1! 
 the walls or di\ ision of a branch close to the main trunk, or it 
 undue traction is exercised upon the pedicle of a tumour contain 
 infj a wounded vein, then the oriticci may remain patent, and air 
 is readily sucked in. If, howe\'er, the \eins are very distended. 
 and the intravenous pressure lii^di, as is often seen in the opera- 
 tion of tracheotomy, then the wound of a \ein, e\en in tlu' 
 dan,L(erous area, usually results in blood escaping from it rather 
 than air entering it. 
 
 Signs. — The entrance of air into a wounded \ein is accompanied 
 by a hissing, gurgling, or sucking sound, which is quite charac- 
 teristic. A few bubbles of air may also be seen clinging about 
 the aperture in the \essel. If only a small ar.iount has entered, 
 no bad results may follow ; but the usual effect of this accident is 
 to produce sudden and severe faintness, and if the patient is con- 
 scious, a feeling C)f dyspncea and distress, which is partly cardiac 
 in origin, partly due to obstruction to the flow of blood throuj^h 
 the lungs. The pulse becomes rapid and almost imperceptible, 
 the pupils widely dilated, and death usually follows, preceded 
 perhaps by con\'ulsions, although the fatal issue may be postponed 
 for a few hours. If the patient sur^•i^'es, no after-effects remain. 
 
 Treatment. — This accident can usually be avoided by dealing j 
 cautiously with all veins in operations about the neck. Sliouki it 1 
 occur, any fresh entrance must be at once checked by placing a j 
 finger o\-er the bleeding point or pouring lotion into the wound, 
 The vein should be secured by ligature as soon as possible. Com- 
 
 pression of theche 
 order to squeeze 01 
 cliance of attaining 
 is essential to main 
 head is lowenul, an 
 or the abdominal 
 respiration are used 
 ijvercome the pulir 
 also applied to the t 
 
 f'li^ is usually o 
 i'eneral oozing fr,,] 
 Jmvn to fill the ca\ 
 Jant from inllanied 
 tissue, which pre\-en 
 usjaliy be arrest^'d , 
 I '■''''''<" lift water, by 
 
 Methods of dealin 
 Carotid Artery. 'I'roai 
 
 A'!) Iioth ends ,sliniil,ri) 
 
 Jugular Vein. Tk- a 
 
 ;;:;ieii. 
 
 I Secondary Branches oft 
 
 "alY'niiesu vessels citiK 
 fl wound of tlie pterv 
 vternal cannid hotwt 
 
 -d -IS more satisfact. 
 laiilatK.n IS not tlierel.v 
 
 I vertebral Artery,— Tlie 
 
 is it IS scarcely possible 
 
 camtKl; andlu-nce mistak 
 
 jiwever, to control tlie c 
 
 l^eitliersideof the ster 
 
 "■■'f " '""St follo^v tlK 
 
 J eedm« point, To do tin 
 
 Ifa? the posterior border 
 
 n processes of the ver 
 
 a be secured by clippi„ 
 
 l^taken of the nerve n 
 
 seuse of styptics must be 
 hid not be tied bv mistn 
 
 Hevmebral trunk, an.l 
 
 b 7, f*^™*' Mammary. 
 
 Mo th,s vessel is usua 
 
 r or l„„^,.s. If recofrni. 
 
 fal cartilage to gain accei 
 
 'He sternum, 
 
 [Dtercostal Haemorrhage 
 
 ^KM'ie rib, and i. not 
 *ls in the groove. Trca 
 J lower border of the rib 
 Ke a portion of the bon 
 
ILV.MOKRHAGE 
 
 2lt 
 
 prcssion of the chest has been recommended by some riuthoritiesin 
 order to squeeze out the air that lias entered ; but tliere is httle 
 chance of attainiiii,' tliis v\u\. To combat the f^^iMinal symptoms, it 
 is essential to maintain a f^^)oil supply of blootl to the brain. The 
 head is lowered, and, if need be, the limbs raised and bandaged, 
 or tlie abdominal aorta compressed. Stimulants and artificial 
 respiration are used in order to maintain the hi'art's action and to 
 overcome the jnilmonaiy obstruction. Warmth and friction are 
 also applied to the extremities. 
 
 Capillary Haemorrhage. 
 
 This is usually ol little si^Miilicance. It is characterized by a 
 Ueneral oozing' from the wounded surface, the blood trickling' 
 Uown to fill the cavity from the bottom. It is often \cvy abun- 
 dant from inllamed parts, and especially from fibro-cicatricial 
 tissue, which pri'\-ents the closure of the \essel mouths. It can 
 Lsiially be arrested by a little pressure, or by the application of 
 cold or hot water, by styptics, cauterization, or plu^ff,^nf,^ 
 
 Methods of dealing with Haemorrhage from Special Sources. 
 
 Carotid Artery, 'rrcitment is impossible unless the surj^'eon is on lliu spot, 
 liv':ii",i l)i)tli ends sliould be tied. 
 
 Jugular Vein. -Tie, or stitcii, if possiitle, without occluding the whole 
 
 1 hnifii . 
 
 Secondary Branches of the Carotid -It may be difficult to secure tlic divided 
 
 mils of llu'se vessels eitiier in llie neck or he.id, c.f;., in a cut throat or a punc- 
 
 (1 wound of the pterygoid rej^ion. Under such circumstances, ligature of 
 
 \ternal carotid l)et\veen tlie superior thyroid and lingual has been r'jcom- 
 
 ;(1 as more satisfactory than tying tlie common carotid, since the cerebral 
 
 :rciilati!)n is not thereby affected. 
 
 Vertebral Artery.- — The source of such bleeding may be dillicult ti < ascertain, 
 Ileitis scarcely possible to compress this vessel without also including the 
 anuitl ; and lience mistakes in diagnosis have often arisen. It may lie feasible, 
 I livever, to control the carotid alone by pinching it up by the fingers placed 
 :r. either side of the sterno-mastoid, without interfering with the vertebral. 
 VM'.mait inust follow the usual course of cutting down and tying at the 
 'tedinf,' point. To do this the incision must be enlarged, or a new one made 
 i: Tij,' the posterior border of the sterno-mastoid in order to define the trans- 
 hrse processes of the vertebra'. In the upper part of its course the vessel 
 :.iybe secured by clipping away a transverse process if necessary, clue care 
 -mg taken of the nerve roots; otherwise, plugging of the vertebral canal or 
 |:euse of styptics must be depended on. It is most essential that the carotid 
 uld not be tied by mistake in these cases, as thereby more blood is directed 
 he vertebral trunk, and the bleeding is correspondingly increased. 
 The Internal Mammary Artery rarely calls for treatment, since a punctured 
 'Jiul of this vessel is usually complicated with some graver mischief to heart, 
 teror lungs. If recognised, tie at the bleeding spot, pcissibly removing a 
 Istal cartilage to gain access. The vessel lies about ^ inch outside the border 
 11 ;he sternum. 
 
 ]Merco8tal Haemorrhage usually results from penetrating wounds also in- 
 "vni; the rib, and i^ not easily stopped, on account of the position of the 
 ;^els in the groove. Treatment. -Incise the periosteum longitudinally along 
 Muwer border of the rib, and detach it and the vessels from the groove ; or 
 pjve a portion of the bone, and thus expose the bleeding point ; or in some 
 
 14 — 2 
 
212 
 
 A MANUAL OF SURGERY 
 
 cases a suture passed round the rib a little above the injury has suffictHJ : or 
 af,'ain, pressure may be employed by pushing a piece of aseptic gauze, like a 
 pocket, through the wound into the pleural cavity, and then stuffing it ti;,'htlv 
 witli wool or strips of gauze, so that on pulling upon it the vessel may he 
 effectually compressed. 
 
 Wounds of the Vessels of the Extremities need treatment according to the 
 principles enunciated above. Only one or two require special mention. 
 
 Wounds of the Palmar Arches were formerly much more dreaded than 
 they are at present, when thorough antisepsis and the use of the clastic 
 
 tourniciuet allow us to explore the depth.s of a 
 wound without much danger or diflicultv. The 
 position of the wound will usually indicate 
 whether the bleeding conies from the superficial 
 or deep arch, but in case of doubt it is well 
 to remember that pressure on the ulnar trunk 
 mainly affects the superficial arch, whilst pres- 
 sure on the radial will chiefly intluence the 
 deep. A wound of the superficial arch presents 
 little trouble in treatment, as it can be readilv 
 secured by catch forceps and ligatin-e ; but the i 
 deep arch is not so easily dealt with. It lies 
 just over the bases of the metacarpal bones 
 (Fig. 56, n), and to expose it the wound must be 
 freely enlarged by a longitudinal incision, ancl| 
 the tendons turned on one side or separated. 
 It may be possible to secure the vessel bvi 
 forcipressure forceps, and these may be left! 
 on for twenty-four hours if a ligature cannotl 
 be applied. Of course the strictest asejisis isl 
 needful in such cases, and passive movementl 
 of the fingers must be early undertaken, in order! 
 to prevent troublesome adhesions. Failinj; snchfl 
 means, or in septic wounds, a modification ofj 
 the old graduated compress may he employed 
 the wound is carefully and thoroughly plugged with gauze, and over this tli 
 fingers are firmly bandaged. The patient is kept in bed for a few davs, and 
 the arm elevated. Pressure on the main vessels above is scarcely necessary 
 the compress is accurately applied. The bandages may be relaxed at the end 
 of twenty-four hours, but the deep dressing should, if possible, not l)e toucheq 
 for three or four days. If, in spite of this, bleeding recurs, the main vessel ofl 
 vessels of the limb must be tied. Ligature of the ulnar and radial at the uri; 
 is generally insufficient to control it, as there is often a communicating branc 
 of some size passing from the anterior interosseous to the deep arch, and 
 hence it may be needful to secure the brachial artery, ascertaining first, In w 
 ever, by pressure that such would be efficacious ; for occasionally there is 
 high division of the brachial, or a vas aberrans may exist, which would conipd 
 the surgeon to tie the third part of the axillary. 
 
 Bleeding from the Plantar Arch must be conducted on exactly similar 1 
 Tlie Gluteal, Sciatic, or Pudic arteries may be wounded by stabs in th 
 buttf 'jk. Tn'titiiiciit.— Enlarge the wound in the direction of the fibres of th 
 gluteus maximus, i.e., downwards and outwards, and secure the bleeding vessi 
 The gluteal trunk emerges from the pelvis at the junction of the middle an 
 inner tliirds of a line from the posterior siijieri )r iliac spine to tiie f^rel 
 trf>chanter ; tlie pudic crosses the ischial spine at ihe junction of the middj 
 and lower thirds of a line from the posterior superior iliac spine to the tnli 
 ischii. The sciatic emerges from the pelvis just above and a little external 
 the latter spot. The pudic may also be divided in the perineum by a penetratid 
 wound. Failing ligature of any of tliese arteries at the seat of bleeding, t| 
 main trunk of the internal or common iliac may need to be secured. 
 
 Fig. 56.— Hand, to show 
 POSITION OF Palmar 
 Arches. 
 
 A, !<adial artery ; B, Ulnar 
 artery ; C, Superficial 
 arch ; D, Deep arch. 
 
HJEMORRHAGE 
 
 213 
 
 Hsemophilia. 
 
 By hrcmophilia, or the haemorrhagic diathesis, is meant a congenital and 
 Hereditary disease characterized by a tendency to persistent and uncon- 
 trollable bleeding from slight wounds, whether open or subcutaneous. This 
 condition is often associated with extravasation of blood into the joints, and 
 certain consecutive phenomena (chap. xiy). The family history is always 
 interesting, the disease being usually transmitted thruugli the females to the 
 males of a succeeding generation, whilst the former often escape entirely. 
 Ihe pathological cause of this affection has not yet been ascertained, no 
 change in the vessels or constitution of the blood having been discovered. 
 Unless haemorrhage is actually occurring, nothing abnormal is noticed, but 
 i mv injury is sure to be followed by excessive bleeding ; spontaneous sub- 
 cutaneous ecchymoses frequently occur, as also bleeding from the mucous 
 1 membranes. Hence no operations must be undertaken on such patients unless 
 bsolutely urgent, even such a small matter as the extraction of a tooth having 
 [proved fatal. 
 
 The Treatment of haemophilia should be directed more to correcting the 
 
 I constitutional defect than to pursuing the usual practice in dealing with 
 
 hsemorrhage. The application or administration of haemostatics, and sub- 
 
 iiances which tend to promote coagulation and the formation of fibrin, should 
 
 beresorted to. Calcium chloride, i drachm to h pint of water, given by enema, 
 
 or30grs. by the mouth, repeated several times a day, has been recommended, 
 
 Khilst fibrin ferment, suprarenal extract, and cocaine should be employed 
 
 iocallv. Position and pressure are attended to, and in severe cases the actual 
 
 cautery may prove useful, or the prolonged application of cold. 
 
INyUR 
 
 CHAPTER IX. 
 
 INJURIES AND DISEASES OF ARTERIES- 
 LIGATURE OF ARTERIES. 
 
 Injuries of Arteries. 
 
 -ANEURISM- 
 
 Contusion of an artery is the result of violence applied directly tol 
 the vessel wall. The effects vary with the severity of the injury] 
 and with the condition of the arterial tunics. If atheroma or] 
 calcification exists, thrombosis often follows slight injuries, andl 
 dry or senile gangrene may ensue ; hut in healthy arteries a good! 
 deal of N'iolence is needed to produce such an effect, as theirl 
 natural elasticity enables them to yield or slip aside, and thus thel 
 consequences are usually insignilicant. 
 
 Rupture or Laceration may follow more severe blows or strains,! 
 weakness or disease of the arterial wall predisposing to it. Itj 
 occasionally results from attempts to reduce old-standing disloca-f 
 tions, or to break down intra-articular adhesions when tlie \esseu 
 has become fixed in some abnormal position. If the rupture isj 
 partial, tlie inner and middle coats are usually torn through, andl 
 by projecting into the lumen of the vessel constitute a val\e whiclij 
 pre\ents the passage of blood, and leads to subse(|uent thronihosisl 
 and occlusion. In other cases, where the injvuy to the coats is] 
 slight, a thrombus may form, which leads to obliteration; or, if 
 the lesion is limited to one side, tlie clot may become organized 
 over that spot, narrowing, but not interfering with the lumen of the 
 vessel, and lea\ing an area of weakness from whicli an anturisiii] 
 may subsequently develop. Again, when complicated with a septic 
 wound, an ulcerative form of peri-arteritis may ensue, giving risej 
 later on to secondary lurmorrhage. It is also stated that the 
 adxentitia is occasionally torn without injury to the tunica intiiiiaJ 
 and that an aneurism may result from a protrusion of the lattetf 
 coat through the wound in the former, such an occurp.mce niuslj 
 be exceedingly rare. A dissecting aneurism (p. 228) may also 
 result under special circumstances from such an accident. 
 
 Complete Rupture of an artery often leads to but little hanior-j 
 rliage in a severe lacerated wound, such as is produced when 
 
 liinh is torn off : th 
 ievel than the adv 
 coat and sheath co 
 It, however, the art 
 as a fracture or dis 
 ..(instituting the c( 
 Aneurism. The ob 
 is no true sac wall 
 listing of an ill-defin 
 exudativju, and in pj 
 condition may ensu 
 where the track Icc 
 clot or some extern? 
 Symptoms. — The 
 
 thing had given wa} 
 the part injured, anc 
 the vessel. These 
 1:1) Locally, the form 
 the skin over whicl 
 .onded and bluish, 
 the tumour is tlirea 
 local heat except in 
 present, and some 
 heart's action, althoi 
 1(1) Disiiilly, diminisl 
 to,i(ether with loss 
 temperature. It lie; 
 colour is either whi 
 udematous if the e; 
 trunks, (c) Gcncyally, 
 themselves in \aryin 
 
 I lost and the characte 
 
 Results.— (i) The 
 
 the skin becomes so ( 
 
 help is not at hand, t 
 
 the bleeding continm 
 
 I ill a limb, to such an ( 
 
 I loss of blood. (2) Sh 
 ot fever, may result : 
 lacteria through the : 
 
 I lieconies red, hot, (X'd( 
 a large abscess. Ruj: 
 cunchule the case if 
 The pressure of the e 
 
 I arteries needed for the 
 the extremity, whi 
 riie process may bc' 
 
 coagulation occurring 
 
INyURIES AND DISEASES OF ARTERIES 
 
 215 
 
 limb is torn off: the inner and middle coats give way at a higher 
 ievel than the adventitia, and curl up within it, whilst the outer 
 coat and sheath contract over them, and thus prevent bleeding. 
 It, however, the artery is ruptured in a subcutaneous injury, such 
 as a fracture or dislocation, extensive extravasation often ensues, 
 constituting the condition badly termed a Diffuse Traumatic 
 Aneurism. The objection to this name lies in the fact that there 
 1; no true sac wall as in an aneurism, the only boundary con- 
 -istin^^of an ill-defined mass, partly coagulum, partly inflammatory 
 cxudativjn, and in part thickened and infiltrated tissues. A similar 
 condition may ensue from a punctured wound dividing a vessel, 
 where the track leading to it is valvular or becomes closed by 
 dot or some external application. 
 
 Symptoms. — The patient usually feels a snap, as though some- 
 [\m\i had gi\en way, accompanied by a sudden pain, localized to 
 the part injured, and often shooting down the limb in the line of 
 the vessel. These are succeeded by the following phenomena : 
 l(i) Locally, the formation of a diffuse, rapidly increasing swelling, 
 the skin over which is at first normal, but soon becomes dis- 
 .jiided and bluish, and finally bright red and oedematous, when 
 the tumour is threatening to give way. There is no increased 
 local heat except in the later stages. Distinct pulsation is usually 
 present, and some amount of bruit, synchronous with the 
 heart's action, although these subsequently become less obvious. 
 ((')) Distally, diminished sensibility in the limb (Quickly follows, 
 to,i,'ether with loss of pulsation in tb.e vessels and a fall of 
 temperature. It lies more or less useless and flaccid, and in 
 colour is either white and blanched, or may be congested and 
 udeiiiatous if the extraxasated blood presses upon the venous 
 trunks, (c) Geneyally, the signs of ha:;morrhage and shock manifest 
 themselves in varying degree, according to the amount of blood 
 lost and the character of the \'iolence. 
 
 Results. — (i) The swelling may increase steadily in size until 
 the skin becomes so distended as to vuptiiyc or slough, and then, if 
 help is not at hand, the patient dies of hauuorrhage. Occasionally 
 the bleeding continues into an internal cavity, or into the tissues 
 
 Iota limb, to such an extent as to cause death witliout any external 
 loss of blood. (2) Sitpptinitioii, accompanied by the general signs 
 ot fever, may result from auto-infection, or from the entrance of 
 laeteria through the small \al\e-like wound. The whole swelling 
 
 Incomes red, hot, (edematous, and excessively tender, looking like 
 a kuf,fe abscess. Rupture and external luemorrhage will probably 
 
 Icunclude the case if surgical assistance cannot be obtained. (3) 
 Ihe pressure of the extravasated blood upon the veins or on the 
 
 I arteries needed for the collateral circulation may detcrnune gaiigyene 
 of the extremity, which is almost always of the moist type. (4) 
 The process may become more or less limited after a time liy 
 
 I coagulation occurring in the divided mouth of the vessel, which is 
 
 > I 
 
2l6 
 
 A MANUAL OF SURGERY 
 
 thus occluded. Collateral circulation may be established, and] 
 thereby the health and vitality of the limb are maintained, whilst 
 the blood-clot is absorbed or organized. 
 
 The Treatment is necessarily the same as for a divided artery \ 
 communicatin<; with an open wound, viz., to cut down and tie! 
 both ends. The circulation is first temporarily arrested by an 
 elastic tournic^uet, a free incision made, and all coagvda removed. \ 
 The bleeding points are then sought for and tied, the tounii(]uet i 
 being relaxed to allow them to become evident. If the distal j 
 end cannot be found, the wound is not closed, but should he! 
 stuffed with gauze, and allowed to granulate, a tourniijuet 
 being kept loosely about the limb ready to be tightened at 
 ny moment, if necessary. When suppuration is threatening,', 
 the same plan must be adopted, viz., free incision and tyin^^ the 
 ends of the vessel if they can be found ; but in cases where ! 
 from the a.'dematous and unhealthy state of the surroundini; 
 parts this is impracticable, it will be necessary either to tie the 
 main trunk on the cardiac side of the rupture, or to trust to the ; 
 pressure of a graduated compress. If gangrene is imminent, 
 or if secondary haemorrhage occurs, amputation is the only 
 resource. 
 
 Penetrating Wounds of arteries, if completely dividing the 
 vessel, are always followed by hemorrhage, although the blood 
 may be unable to escape if the wound in the skin is small or j 
 valvular, or if the opening is closed by blood-clot or dressin^^; 
 uiider these circumstances, the signs due to subcutaneous rupture j 
 of a vessel are produced. The amount of bleeding in open wounds | 
 varies according to the character, direction, and extent of thej 
 lesion, and with the size of the vessel. If a large artery is cleanly 
 cut across, the bleeding is copious, whilst from a small vessel it i 
 soon ceases, owing to the contraction and retraction of the coats. ' 
 When an artery is buttonholed — i.e., when a small segment of the j 
 wall is cut through — the haemorrhage is often continuous and 
 prolonged, since retraction cannot take place. The treatment of 
 this condition consists in completing the division of the injured 
 trunk, if it is a small one, thus allowing of contraction and re- 
 traction, or, if the vessel is of large size, in tying it above andi 
 below the opening, and dividing it between the ligatures. 
 
 If the wound is in the long axis of the vessel, it gapes hut little, | 
 and the loss of blood is often slight, whilst if transverse or ohli(iue, 
 both contraction and retraction tend to increase the size of thej 
 opening, rendering it more nearly circular, and therefore thej 
 haemorrhage in such cases is considerable (Fig. 57). 
 
 If a small artery is divided close to its origin from a large main! 
 trunk, the blood escapes with a jet, the strength of which is 
 proportionate to the blood-pressure in the main trunk, and not 
 to the size of the vessel divided. In such a case the niain| 
 trunk must be tied above and below the wound, and di\ided 
 
INJURIES AND DISEASES OF ARTERIES 
 
 217 
 
 •letween the ligatures, and the distal end of the divided branch 
 also secured. 
 
 A good many attempts have been made of late to effect the 
 jnion of wounds in the walls of arteries without causing their 
 obliteration, and with some success. Small longitudinal wounds 
 aay certainly be sutured, the stitches being of the fine3t silk and 
 ipplied so that the edges of the tunica intima are brought accu- 
 •ately into apposition ; Heidenhain reports a case where a wound 
 :'3cms. long in the axillary artery was successfully sutured in 
 iliis way. End-to-end union of a divided artery has also been 
 obtained in one case,* the upper end being invaginated into the 
 lower ; such a procedure can, however, only be required under 
 very exceptional circumstances. 
 
 In punctured wounds of arteries the size of the penetrating 
 ;ody is all-important. A vessel may be tra\'ersed by a needle 
 
 A B C D 
 
 Fk',. 57.— Effects of Wounds in Arterial Wall (Diagrammatic). 
 
 |.Ui)ngitudinal incision — but little gaping ; B, oblique incision — greater open- 
 ing, but not much ; C, small transverse incision — wound gapes, becoming 
 more nearly circular; D, large transverse incision — wide aperture, owing 
 to retraction of arterial tunics. 
 
 Uithout haemorrhage or any subsequent ill effect, but a larger 
 puncture results in extravasation. If it ceases after a time, the 
 
 Ulood-clot is absorbed, and the wound in the vessel closed by a 
 cicatrix, which may subsequently yield to the blood-pressure, and 
 
 hi*e rise to a circumscribed aneurism. This occurrence is not 
 
 |iinfrequent in the neighbourhood of the wrist from glass wounds, 
 involving the radial or ulnar trunks, and hence is not uncommon 
 
 [among window-cleaners or mineral- water bottlers. 
 
 Arterio-Venous Wounds are not so frequent in the present day 
 
 las formerly, when venesection was in vogue. They follow 
 
 penetrating wounds which involve an artery and vein lying in 
 
 close contact, e.g., at the bend of the elbow between the median 
 
 [basilic vein and the brachial artery, in the neck between the 
 
 * J. B. Murphy, Medical Record, January 16, 1897. 
 
2l8 
 
 A MANUAL OF SURGERY 
 
 internal jugular and carotid, in the groin i)etween the femoral I 
 vessels, and occasionally in the orbit. Two conditions may result. 
 An Aneurismal Varix is produced by a direct communication j 
 between an artery and a vein, no dilated passage intervening; 
 between the s'essels (Figs. 58, A, and 59). The \enous walls,] 
 unfitted to withstand arterial pressure, are thereby dilated and 
 rendered varicose. A pulsating venous tumour results, thej 
 
 A B 
 
 Fig. 58. — Diagrams ok Aneurismal Varix and Varicose Aneurism 
 A, Artery; V, Vein ; AN, Aneurism. 
 
 dilatation extending for a variable distance above and below the 
 opening, and at each beat of the heart a loud whizzing sound can i 
 be heard, likened by some authors to that caused by an imprisoned j 
 bluebottle buzzing in a thin paper bag. 
 
 Treatment. — Nothing is usually required beyond the application! 
 of an elastic bandage or support to prevent further enlargement, 
 
 Fig. 50. — Aneurismal Varix at J5end ok Elkow, due to Aunor.mal Co.m- 
 
 MUNICATION liETWElCN MEDIAN BasILIC VeIN AND BRACHIAL AkTEKV. 
 
 Should any pain or inconvenience be caused, firm pressure may 
 be applied over the artery abo\e, over the sac, and also upon the 
 vein below ; and failing this, the whole mass may be removed, 
 ligaturing both artery and \ein above and below the comnuinica 
 tion. If the artery can be reached without interfering witli the! 
 vein, it will suffice to tie the former above and below the abnormal 
 opening. This operation should not be undertaken in the neck 
 for the carotid-jugular \'arix unless absolutely essential. In the| 
 orbit electrolysis may be used with advantage. 
 
 INJUl 
 
 A Varicose Anei 
 
 differs from tl - al 
 the artery and the 
 ihe vessels are plac 
 extravasation of 1: 
 :he false type, its ■ 
 or),'anized clot and 
 
 iffuse. The phy 
 varix, except that 
 palpation, whilst a 
 tension of the vein; 
 
 Surgical Treatnii 
 aneurism is small, 
 aneurismal sac ex 
 i;anner. Simple 
 alinormal comnuir 
 Hood in the sac to ( 
 in size, when the a 
 urgent cases digit 
 occasionally succes 
 
 \'arious forms of 
 
 which are usually 
 
 I Traumatic, Infectiv 
 
 I and Fct'iarteyitis an 
 
 t which either start 
 
 troin without ; in be 
 
 involved, and the \ 
 
 [lliat the whole tliicl 
 
 1. Traumatic or 
 
 1 5i;ch as total or par 
 etc. The phenonu 
 
 I occlusion of the \-e;; 
 itssel walls from th 
 
 I the tunica intima ; 
 
 2. Infective Arte: 
 [hecomes in\aded ai 
 
 tioiii inflammation 
 
 lartentis), and is us 
 
 nd spreading ulcer 
 
 le.Midationof leucoc} 
 
 the peptonising aci 
 
 softening of the vess 
 
 hvith each other. 
 
 paired, that they yie 
 
 H'«^, unless throm 
 
INJURIES AND DISEASES OF ARTERIES 
 
 219 
 
 A Varicose Aneurism, though brought about by the same cause, 
 differs from tl above in that an aneurismal sac exists between 
 the artery and the dilated vein (Fig. 5S, B). It is produced when 
 the vessels are placed at a short distance from each other, or when 
 extravasation of blood has separated them. The aneurism is of 
 the false type, its walls being composed entirely of newly-formed 
 orf^anized clot and cicatricial tissue ; it is almost certain to become 
 iffuse. The physical signs are similar to those of aneurismal 
 viirix, except that the aneurism can be sometimes detected by 
 palpation, whilst a soft bruit may be heard over it, and the dis- 
 tension of the veins is not (juite so marked. 
 
 Surgical Treatment is always required in these cases. If the 
 aneurism is small, the dilated vein is tied above and below, the 
 aneurismal sac extirpated, and the artery secured in a similar 
 ;;;\nner. Simple ligature of the artery abo\e and below the 
 limornial communication will sometimes suffice, allowing the 
 ■ilood in the sac to coagulate ; the veins will subsecjuently diminish 
 in size, when the arterial blood-pressure is remo\ed. In the less 
 ar^'ent cases digital pressure to the iirtery above the sac is 
 occasionally successful. 
 
 ': i' 
 
 Inflammation of Arteries. 
 
 \'arious forms of inflanuuation of the arterial wall are met with, 
 which are usually named from the cause producing them — 
 Traumatic, Infective, or Embolic arteritis. The terms Endartevitis 
 . and Periarteritis are used to distinguish inflammatory conditions 
 which either start from the tunica intima, or reach the \essel 
 from without ; in both cases, however, the middle coat is generally 
 involved, and the process may even finally spread beyond it, so 
 that the whole thickness of the arterial wall is attacked. 
 
 1. Traumatic or Plastic Arteritis is the result of some injury, 
 such as total or partial dixision of the vessel, laceration, bruising, 
 etc. The phenomena are merely those of repair, resulting in 
 
 I occlusion of the vessel, viz., congestion of and exudation into the 
 I vessel walls from the vasa vasorum, togetlier with proliferation of 
 I the tunica intima; they ha\'e been already described at p. 195. 
 
 2. Infective Arteritis is a condition in which the arterial wall 
 heconies inxaded and softened by bacteria. It frefjuently results 
 lioni inflammation ad\ancing inwards from the exterior (peri- 
 
 I arteritis), and is usually seen in connection with septic wounds 
 and spreading ulceration. The vasa vasorum are dilated, and an 
 exudation of leucocytes occvu's, as a result of the bacterial invasion ; 
 the peptonising action of the toxins thereby produced leads to 
 softening of the vessel walls, the fibres of which lose their cohesion 
 with each other. Finally, their resisting power may be so im- 
 paired, that they yield before the blood-pressure and cause haemor- 
 rhage, unless thrombosis has previously sealed the vessel. In the 
 
 
330. 
 
 A MANUAL OF SURGERY 
 
 
 smaller arteries this is usually the case, hut in those larger than 
 the radial there is considerable danger of bleeding, especial]) if 
 the irritation is confined to one side of the vessel. Secondary 
 haemorrhage from arteries tied in their continuity is generally due 
 to this cause, as also bleeding from phthisical cavities, the \ essels 
 having previously lost the support of surrounding tissues, and 
 being more or less dilated or aneurismal. Acute abscesses, septic 
 ligatures, and malignant tumours may weaken an arterial \\all 
 and lead to hemorrhage, whilst the infective agent sonictiiiies 
 reaches the walls from within, as from an infective thrombus or 
 embolus. 
 
 3. Embolic Arteritis. — When a vessel is blocked by a simple 
 embolus, obliteration as a result of a simple plastic arteritis is the 
 usual consequence. But if the embolus contains some irritatin),^ 
 or infective material, as in a case of mfective endocarditis or 
 pyaemia, an abscess may result, or if the irritant is less intense, 
 the process may stop short of suppuration, and yet an aneurisnial 
 dilatation of the softened wall takes place. The latter process is 
 the most common cause of spontaneous aneurism in children. 
 
 4. Acute Endarteritis is met with rather as a pathological 
 curiosity than as a condition of any clinical import. It is usually 
 associated with acute endocarditis, however produced, or may 
 accompany some of the chronic forms described below. It is 
 evidenced by the presence on the inner aspect of the vessel of 
 more or less raised patches, somewhat pinkish and gelatinous in 
 appearance, soft and elastic in consistency, and although the polish 
 is lost, the endothelium is usually intact. It is found in the aorta, 
 or in smaller vessels, especially near inflamed wounds. 
 
 5. Chronic Endarteritis is an exceedingly common affection, 
 and the followmg forms may be described : 
 
 {a) Simple Chronic Endarteritis, resulting in Atheroma (Gr, 
 ddn'ipr], ' gruel ' or ' pap '). This condition is constantly found in 
 elderly people, but especially in drinkers and those who have 
 suffered from chronic Bright's disease, gout, or syphilis ; it arises 
 from continual strain and increased blood-pressure, and hence 
 often starts in the convexity of the aortic arch, at the spot where 
 the impact of the blood-stream is most felt as it is ejected 
 from the ventricle, or in places where a vessel passes over or | 
 around some bony projection, or at the bifurcation of a main 
 artery, or where a large branch is given ofif, thus causing a sudden i 
 decrease in its lumen. It is rarely found in the smaller arteries,] 
 except those of the heart or brain. 
 
 The pathological phenomena consist at first of a proliferation of I 
 the deeper parts of the tunica intima, giving rise to opa(iue,[ 
 milky-looking, non-vascular patches (Fig. 60, g), which niayj 
 organize into fibroid tissue, or undergo fatty degeneration [c andf 
 /). They are arranged longitudinally or around the mouths ofj 
 large branches. The tunica media is more or less involved in the! 
 
 iNyi 
 
 process, and th( 
 
 soon as the fatty 
 
 yellowish in colo 
 
 and irregular in < 
 
 size, and coalesce 
 
 or cheesy in cons 
 
 aliscess,' althoug' 
 
 consisting of fatt 
 
 plates of choleste 
 
 lea\'ing a weaken ( 
 
 aneurism may ari 
 
 allowing the cont 
 
 d 
 c 
 b 
 a 
 
 !■>' Co,— Section OK A 
 
 ' 'ntima considerably 
 
 '•m'^clia;^/, adventi 
 
 (ietritus ; /, and/,, 
 
 ^^itli leucocytes ; //', 
 
 "here it probably ^ 
 's known as an « ath 
 ''"le become thicker 
 '"e hreach in the 
 '"'-ly take place, e^ 
 'occurred. Again, tl 
 'nj,' into the substam 
 
INJURIES AND DISEASES OF ARTERIES 
 
 221 
 
 process, and the achcntitia is often thickened externally. As 
 soon as the fatty chan<^'es have commenced, tlie patches become 
 vellowish in colour, somewhat elevated from the inner surface, 
 and irregular in outline ; they are small at first, but increase in 
 ,i/.e, and coalesce one with another. The contents are now iluid 
 or cheesy in consistency, constituting the so-called 'atheromatous 
 abscess,' althouf^h no true pus exists, the pultaceous material 
 onsisting of fatty granules and debris, with oil globules and 
 plates of cholesterine (Fig. 60, f^). It may be absorbed entirely, 
 laving a weakened spot in the wall of the vessel, from which an 
 aneurism may arise ; or the tunica intima may gi\e way over it, 
 allowing the contents to be swept into the general circulation, 
 
 ■\'. 1 
 
 g 
 
 f 
 
 - A 
 
 lV,,6o.— Section OF Atheromatous Cerebral Artekv. x 50. (Ziegler.) 
 
 J, Intima considerably thickened ; b, bounding elastic lamella of intima ; 
 c, media; d, adventitial c, necrosed denucleated tissue with masses of fatty 
 detritus; /, and/,, detritus witli cholesterine tablets; g, intima infiltrated 
 with leucocytes ; //, infiltration of adventitia with leucocytes. 
 
 where it probably does no harm, and the raw surface left behind 
 is known as an ' atheromatous ulcer.' The outer coat has by this 
 time become thickened, and hence no inuiiediate ill result follows 
 the hreach in the inner coats, although subsequently dilatation 
 may take place, even though cicatrization of the ulcer has 
 occurred. Again, the blood may find its way through the open- 
 inf( into the substance of the wall and strip up the inner from the 
 
222 
 
 A MANUAL OF SURGERY 
 
 outer layers, constituting^ a ' dissectinpf aneurism '; or a localized 
 throniDus may form, causing occlusion of the vessel. 
 
 Not uncommonly the cheesy contents of the abscess become 
 inspissated, and later on inCiltrated with lime salts, resultin^^ In 
 the formation of calcareous plates, which are either covered with 
 endothelium, or expensed to the blood-stream, and hence may (.ausf 
 thrombosis, or become detached as an embolus, or the blood inav 
 get in under the plate and form a dissecting aneurism. 
 
 A condition of endarteritis e\idenced by proliferation ol the 
 tunica intima is always met with in chronically inflamed tissues, 
 as also in diabetes ; such does not, however, run on to atheroma. 
 
 a 
 
 h 
 c 
 
 Fig. 6i. — Syphilitic Arteritis, x 150. (Ziegler.) 
 
 a, Intima f,'reatly thickened liy newly-formed fihro-cellular tissue ; /), fenes- 
 trated elastic lamina of Henle ; f , muscle fibres of media, infiltrated 
 towards the left ; d, adventitia thickened by cell infiltration and hyperplasia 
 
 {b) Chronic Syphilitic Endarteritis is chiefly met with in the 
 tertiary stage of the disease, and is characterized by an over- 
 growth of the tunica intima (Fig. 61, a), which is usually limited 
 l-)y Henle's elastic lamina (/;), but is sometimes associated with 
 infiltration of the media (f), and nuich more so of the adven- 
 titia {d). The change occurs in the smaller arteries, especially 
 those of the brain or kidneys, or in the neighbourhood of guminata, 
 and but rarely in the larger vessels, although a considerable per- 
 centage, of individuals affected with internal aneurism have 
 suffered from syphilis. It differs from simple atheroma (i) in 
 attacking small arteries ; (2) in affecting the whole circumter- 
 ence of the vessel, and not merely patches; (3) the newly- 1 
 
 INJ 
 
 formed tissue I 
 
 de^fi'neiati(Mi ; a 
 
 vessel rather tha 
 
 the cerebral arte 
 
 plegia, may n-sul 
 
 in It is still 11 
 
 called Endarterit: 
 
 not. In some ca 
 
 other marked ins 
 
 arteries are gradi 
 
 health, as a result 
 
 diminished in \'ita 
 
 coinerted into a tl 
 
 tinalJy occludes tlii 
 
 common, is associj 
 
 ((/) Chronic Tube 
 
 tion of the tunic; 
 
 adventitia, in all p 
 
 in fact, tubercles at 
 
 mass grows the \( 
 
 typical anatomical 
 
 [culotis endarteritis 1 
 
 ot the mischief, aiu 
 
 [tissue this change c; 
 
 Fatty Degent ratio: 
 
 "i'''L'ly the tunica in 
 vd'lowish \n colour r 
 ) 
 
 tie significance ; L 
 Itlif tunica intima g 
 m\ then an aneurisn 
 T"!!e most usual seat 
 
 Primary Calcareous 
 Iti the smaller arteri 
 feeople at the same t 
 Itc, and commences 
 ['•res of the tunica 
 k-s which transfor 
 tfc like gas-pipes, 
 m of blood, the ai 
 lealthy artery. 
 1 riie affected limb r 
 ^■d unpaired nutritio 
 Flips and spasms o, 
 f The endotheliun 
 f then thrombosis i 
 
INJURIES AND DISEASES OF ARTERIES 
 
 223 
 
 foinuHl tissue becomes vascular, and does not underj^o fatty 
 Jeffcneration ; and (4) it leads to narrowinj^' or occlusion of the 
 vessel rattier than tt) \v(!ak('nin<^^ and dilatation. When involvin<jf 
 the cerebral arteries, various forms of monoplegia, or e\'en hemi- 
 ple^na, may result. 
 
 (V) It is still more or less an o]ien f]uestion whether die so- 
 calk'tl Endarteritis obliterans or proliferans is truly syphilitic or 
 not. 1" some cases a syphilitic history has been present, but in 
 other marked instances it has been entirely absent. The main 
 irteries are {gradually obliterated in persons a})parently sound in 
 iiealtli, as a result ot which the peripheral parts become ana:mic, 
 diminished in vitality, or even ganj^renous. The tunica intima is 
 converted into a thickened and vascular mass, which narrows and 
 tiiially occludes the lumen. This disease, which is by no means 
 iDiiiinon, is associated with considerable local pain. 
 
 (,/) Chronic Tuberculous Endarteritis is met with as a prolifera- 
 tion of the tunica intima, with or without thickenini,^ of the 
 adventitia, in all jilaces in wiiich tubercle is actively de\ elopinjf ; 
 ,n fact, tubercles are usually formed around arterioles, and as the 
 mass grows the vessel is slowly occluded and replaced by the 
 ivpical anatomical structure of the miliary tubercle. The tuber- 
 culous endarteritis may, howe\er, spread widely beyond the focus 
 ui the mischief, and in almost any portion of pulpy granulation 
 tissue this change can be seen. 
 
 Degeneration of Arteries. 
 
 Fatty Degentration occurs independently of atheroma, invohing 
 
 iiKielv the tunica intima, and manifesting itself in small patches, 
 
 lyellowish in colour and stellate in shape. As a rule, it is of but 
 
 significance ; but occasionally the infiltration is deeper, and 
 
 [the tunica intima gives way, causing the so-called fatty erosion, 
 
 land then an aneurism, possibly of the dissecting type, may arise. 
 
 ITliciuost usual seat of this trouble is the aorta. 
 
 Primary Calcareous Degeneration (Fig. 62) is chiefly met with 
 
 the smaller arteries of the extremities. It occurs in elderly 
 
 beople at the same time of life as the calcification of cartilages, 
 
 ftc, and connnences by the deposit of lime salts in the muscular 
 
 kes of the tunica media, constituting a series of calcareous 
 
 jinss which transform the elastic expansile vessels into rigid 
 
 ilies like gas-pipes, through which can alone pass a minimal 
 
 liipply of blood, the amount of which cannot be regulated as in a 
 
 hy artery. 
 , The affected limb passes into a condition of chronic anajmia 
 impaired nutrition, resulting in coldness of the feet or hands, 
 blips and spasms of muscles, sensations of pins and needles, 
 fc. The endothelium is not removed except in the later stages, 
 ithen thrombosis may be produced, or a similar result may 
 
224 
 
 A MANUAL OF SUliCEKY 
 
 INJUi 
 
 arise from the lodf^mcnt of nn enibolus. Senile ^^anf^frenf is u 
 common leiniiniUion of such aitci iai ( hanj^'es. I'rom the ^^'iicral 
 ri-,M(Uty of the vessel, and the nu'lliod of deposit of tiie hnie-salts, 
 it follows that aneurism is not likely to occur. 
 
 Amyloid Degeneration of the \ iscera commences in the arterial 
 walls, l)ul is describeil elsewhere (p. 37). 
 
 The Eifects of Arterial Inflammation and Degeneration art 
 |)otli local and peripheral. Locally^ Thrombosis may he produced 
 
 Fig. 62.— Primary Calcakkous Degeneration ok Arteries. (Fro.\i 
 CoLLECiic ov Surgeons' Museum.) 
 
 whenever the lining endothelium is remo\ed and a raw s; ULel 
 exposed, upon which fibrin can collect. Under ♦'^'•^ ^ nnousi 
 coating repair is often effected without further con .lun; but] 
 
 if the l)lood-streain is retarded, or the lumen of the t narrowed, 
 complete thrombosis is likely to follow, the clot cxilh ing iinei 
 distance up or down the vessel, or even from a branch int thej 
 main trunk, w^hich may be blocked by this means. Aneurism] 
 is also a result of any weakening of the arterial tunics. Oblitera- 
 
 tion of the artery 1 
 ,ir from excessive | 
 or tuberculous disi 
 without. Lastly, 
 ivcusionally met vv 
 Pt'riphcyally, c!ef( 
 vitality are the m 
 tu various forms o 
 Krene is due to cal 
 tiiin of the heart f( 
 siiftcning of the bt 
 cfehral vessels. 
 dftached from area 
 
 All Aneurism is ii 
 the interior of an ar 
 of the vessel walls. 
 Causes. — Aneuris 
 viz., the spontaneoi 
 tion has been made 
 the former the coat; 
 in the latter they n 
 iwt br forgotten tli 
 lalile to injury as, 
 vessels, and thus no 
 [the two forms. T 
 [lirouped under two 
 I. Changes in th( 
 (the intravascular 
 Uims(, e.fr., atheron 
 predisp(jse to aneu 
 .syphilitic or gouty 
 a,L;e), in whom, a 
 j the power of the hej 
 jnieaiis diminished. 
 Nstic to aneurisma 
 la penet.-ating wounc 
 [I'ntetrrity of the va: 
 1, a cicatrix in 
 ak spot predi 
 N '^ in the smal 
 f 'n causes of 
 pi} in the brain ar 
 2. Increase in tht 
 »hen due to heavj 
 Excitement and ncr 
 
INJURIES AND DISEASES OF ARTERIES 92$ 
 
 tion of the artery tuay follow, either in conseriiience of thrombosis, 
 X from excessive prohferation of the tunica intiina (as in syphilitic 
 ,ir tuberculous disease), or from f,'raclually increasing; pressure from 
 \vith()Ut. Lastly, Spontaneous Rupture is another local efU'ect 
 iKcasionally met with. 
 
 Peripherally, defective blood-supply and consecjuent lowered 
 vitality are the most marked results of arterial disease, leadinj; 
 lu various forms of ulceration and j,'an{;rene. Thus, senile \i,'i\x\- 
 ^<rene is due to calcareous changes in the arteries, fatty degenera- 
 tiiin of the heart follows atheroma of the coronary arteries, whilst 
 siftL'iiing of the brain may ensue from various afTections of the 
 
 rt'hral vessels. Similar results may also arise from emboli 
 iktaclu'd from areas of local disease. 
 
 Aneurism. 
 
 An Aneurism is a tumour filled with blood communicating with 
 the interior of an arterv, and due to dilatation of part or the whole 
 of the vessel walls. 
 
 Causes. — Aneurisms have been divided into two great classes, 
 VIZ,, the spontaneous and the traumatic, and a necessary distinc- 
 tion lias been made between them on account of the fact that in 
 the former the coats of the artery are primarily diseased, whereas 
 in the latter they may be previously healthy. However, it must 
 not be forgotten that persons with diseased arteries aie just as 
 liable to injury as, and even more so than, those with healthy 
 j vessels, and thus no strict line of separation can be drawn between 
 I the two forms. The causes of aneurism may be conveniently 
 grouped under two headings : 
 
 1. Changes in the Vessel Walls, by which their resistance to 
 the intravascular pressure is diminished. Many varieties of 
 
 \kh\sc, e.g., atheroma, whether starting from within or without, 
 I predispose to aneurismiil dilatation, especially if occurring in 
 syphilitic or gouty men about middle life (thirty to fifty years 
 pi a;;e), in whom, although the arterial tunics may be weakened, 
 the power of the heart and the resulting blood-pressure are by no 
 means diminished. Calcification, on the other hand, is antago- 
 nistic to aneurismal dilatation. Any injury, either a direct blow, 
 japenet-ating wound, or a severe strain, may so interfere with the 
 [inteirrity of the vascular coats as to result in aneurism, and, 
 1, a cicatrix in an arterial wall must always be looked on as 
 ik >pot predisposing to dilatation. The lodgment of jin 
 l<» in the smaller arteries is stated to be one of the most 
 tn causes of spontaneous dilatation of these vessels, espe- 
 |:iali\ in the brain and extremities of young people. 
 
 2. Increase in the Blood-Pressure is another factor, especially 
 [ivhen du( to heavy strain or exertion, which leads to irregular 
 fxcitemeni and acreased action of the heart. Steady laborious 
 
 15 
 
226 
 
 / MANUAL OF SURCERY 
 
 cmployiiieiit, such ;is is seen niuonf^st iulisans ;iiul nu'tlianii s, or 
 regular exercise, docs not appear to predispose to this condiiion ; 
 but irregular ititcnuidenl edoits, in which for the lime hcjnjr 
 every power is strained to its utmost, are \-ei y liable to dedimiiK. 
 its occuricnce. A day's exiM tion in the lumtiiif,' or shootiii;; (i,.||| 
 by an elderly man, accustomed to sedent.ny occupations, is dltcn 
 the cause ol some \ascular lesion, such as aneurism, ap(i|i|i\v, 
 etc. Hence aneurisms ar(> more lre(|uently seen anion};.! www 
 than in women, in the proportion ot seven to one ; whilst they aic 
 nuich more co'nmon amonj; the dwelleis in Northern ( limatcs 
 than in the more letharf^ic and ease-loving; iidiai)ilants nl [\w 
 Soutii. Tlie ener^,'y and activity ol the An^lo Saxon lace cspc 
 ciallv predisjiose them to this ilisease. 
 
 Structure and Formation of an Aneurism. Formerly uiimIi 
 stress was placed on th<' terms iruc and fahc, as apphcd im 
 aneutisms, the term 'tnu'" meaning; that all the coals dI ilnj 
 vessel were j. resent, whilst the 'false' were those in whi( li ihi- 
 sac wall comprrcd little or none of th(> orij^inal arterial limiis, 
 'Phis distinction i,: of comparatively little value, since no aiiciiiisiiij 
 which lias attained to any si/e is in nudity true. The .«;(/( < onsisisj 
 more or less evidently of a distension of all or part of the origin, ill 
 walls of the vessel whilst it is small ; but as the .uiem ism m- 
 creases, the original structure is lost sij^ht of, and, uKlcid, isi 
 replaced by a mass of newly-formed fibrous tissue, due to a (iin.j 
 dcnsation and mattinj; to^^ether of the surroundinj; sti ucliiiisJ 
 with or without an internal lininj; of laminated fibrin de|)osit('(l mij 
 parts where the encK)theliuin of the tvmica intiina has disappcand, 
 The toiitnits o( (he sac ilejiend on the character, a}4;e and si/c c.h 
 the anemism. \\ hilst still small and with a complete endotlicli.ill 
 liniufi;, it merely contains fluid blood, the amount of which varies 
 with each lieat of the hean ; but as the tumorn fjrows, anj 
 (>speciallv if it is of \\\c sacculated type, tlu> whole or pait of ll 
 interior beconu>s lined with a deposit of fibrin, upon which, af^.iinj 
 other layers form, until possibly in rare cases the entire cavilv il 
 occluded, and a sitontaneous cmc results. The old(>st lamina' ;ir« 
 dry and yellowish white in colour (the so-called (/(7»r liot oi biiKil 
 those more recently deposited are softer and more reddish, wiiilsl 
 that last formed is merely like ordinary blood (oagulnm (ttie />((»/(! 
 (•/('/ of Hroca), No sinijle lamina co\cms the whole arcM. init \:w\ 
 is arran};c'cl ovc>r layer (b'ij.';, (13) in such a manner that the oldts 
 and necessarily the smallest lamina' are nearest to the sac wall. 
 
 'I'hrce chief varieties of aneurism have been desciilu'd: th| 
 fusiform, sacculated, and dissectinf^^ 
 
 I, The Fusiform Aneurism (b'if;, (14, ;\) is one in which ilicwhoB 
 lumen of the vessel is more or less ecpially expanded, su thai till 
 swc'lliui; is tidiular in character. It is clue rather to a i;('iurl 
 increase of blood-pressure, or to a widely extended discaso o\ tli 
 arterial walls, than to any localized lesion or injury, ami luiice 
 
 ,irt' altaclied to ll 
 
ANKVUISM 
 
 227 
 
 iiioic cominonly met with in tlu^ lar^^cr internal vessels than in 
 ihiisc ol the exticMiities. When it docs occur in tlic latter situa- 
 IJiiii, it ^ives the ease a nun li more serious aspect. Not only is 
 tlu' \(ssel dilated, hut the tube is eloUf^Mted, and <(msidcral)le 
 >,tnK tuial chaiif^es are present in the walls. The tunic a intima is 
 siially represented throuf^hout the whole extent of the sac, but is 
 Vlvcned and atheromatous in palclu's, the margins and surfaces 
 ,„ (;il( areous plates heiii^j indie ateil by llo( culi of (ibri?i, which 
 are iiltaclied to Ihem, althouf^'h no ref^'ular laminated depi>sit 
 
 IISII 
 
 ihii 
 
 Ih.. <>,i. Sa( ( I'l.A I i:i) Ar4i:ui<isM, (Mcskum of KoVAr, CoLLi.t.ic (jk 
 
 SUI<(.I'.()NS ) 
 
 |Tlii'sm;ill iiHMilli ol the saccule is clearly seen, and (Ik; cavity is ntarly fdled 
 
 with laminated clot. 
 
 present. The tunica media is stietched, atrophied, and 
 
 i;r;uti(ally nonexistent, whilst the ad\cntitia is mm h thi(kened 
 
 I'V iiillnnmatory new formation and by incorporation with the 
 
 hiirroiuidin^ tissues. The proj^ress of fusiform aneurisms is 
 
 |:;tii('rally slow, so that in some situations, r.^^, the thorax, they 
 
 :i«\ attain enormous dimensions, and cause f.,aave symptoms by 
 
 Itticir pressure. A natural cuic is almost impossible, and hent e, 
 
 unchecked by treatment, a fatal termination is caused by 
 
 Iniptiire or by implication of important neij^dibourin}; structures. 
 
 jlrciUKMtlly one portion of the aneurismal wall yields more 
 
 twM another, and thus to the fusiform swellinf,' is superadded a 
 
 15—2 
 
228 
 
 A MANUAL OF SURGERY 
 
 localized sacculation, which by its rapid increase in size mav 
 quickly destroy life. 
 
 2. A Sacculated Aneurism (Figs. 63 and 64, B) is due to the 
 yielding of some weak patch in the vessel wall which does not 
 involve the whole circumference, or, as just mentioned, it niav 
 spring from a fusiform aneurism. It communicates with the 
 interior of the artery by an opening of variable size. All trau 
 matic aneurisms are of this type, whether they are due to the 
 yielding of a cicatrix, or to the partial division of the coats of the 
 vessel, and hence they are most commonly met with in the ex- 
 tremities. It is possible that in some very early specimens all 
 the original vascular tunics may be present, but such an occur 
 
 A U C 
 
 Fig. G4. — Diagrams of Fl'sikorm, Sacculated, and Dissecting 
 
 Aneurisms. 
 
 In the first the walls are expanded, but more or less normal in texture; in the I 
 sacculated, the normal structure of the arterial wall ceases abruptly at the j 
 commencement of the saccule ; in the dissecting, the arterial wall is split j 
 into two lamella;. 
 
 rence must be extremely rare. Generally one can trace the inner! 
 and middle coats to the mouth of the saccule, and there they aiej 
 suddenly lost, the wall being constituted by a mass of fibro- 
 cicatricial tissue, upon which laminated fibrin readily forms, thiisj 
 increasing its thickness and power of resistance. Their progress! 
 is, however, mucli more rapid than that of the fusiform, and theyj 
 generally rupture or become diffuse, although occasionally al 
 natural cure results. The blood as it enters the sac impingesl 
 against the wall furthest removed from the heart, and thencej 
 eddies back in circles, coagulation being thereby favoured, as 
 also by the retardation of the blood-stream. 
 
 3. A Dissecting Aneurism (Fig. 64, C) is one in which the blood 
 
ANEURISM 
 
 229 
 
 forms a cavity within the wall of the vessel by stripping up the 
 inner from the outer half, the line of cleavage being within the 
 nnddle coat, half going with the adventitia, half with the intima. 
 It is usually the result of extensively diffused atheroma which 
 has so weakened the structure of the tunica media that should 
 ^,iice the blood find an entrance through an atheromatous ulcer 
 into tliis layer, it is easily able to separate the inner from the 
 outer half. The blood thus driven into a cul-de-sac may remain 
 limited to this cavity for some time, or it may find its way out- 
 wards through the adv^entitia, and become diffused externally, or 
 it may find its way back through another atheromatous spot into 
 the interior of the vessel. The condition occurs chiefly in the 
 thoracic aorta, but cannot be recognised ante-moytem. 
 
 Symptoms and Signs of a Circumscribed Aneurism. — These may 
 lie divided into two groups : the intrinsic and extrinsic. 
 
 Intrinsic Signs. — A tumour, pulsating synchronously with the 
 heart's beat, is present in the course of a vessel. The pulsations 
 are distensile or expansile in character, i.e., the whole tumour 
 increases in size at each systole, and that evenly in all directions, 
 io that if the tumour is lightly grasped in any position the fingers 
 are separated. If the supplying vessel is compressed on the 
 proximal side, the pulsation ceases, and the tumour diminishes 
 in size and becomes softer ; this is more marked in fusiform than 
 in sacculated aneurisms. The application of pressure to the sac 
 [itself, whilst the afferent trunk is compressed above, will still 
 j further diminish its size. On removing the pressure, the swelling 
 regains its old dimensions in a certain definite number of beats, 
 usually not more than two or three. Pressure on the distal side 
 of the sac makes it more tense and the pulsation more marked, 
 Unless such compression is very prolonged. On auscultating the 
 tumour, a bruit of variable character may be heard. Usually it 
 is loud, harsh, and systolic, but sometimes quiet and musical. It 
 is occasionally double in some forms of sacculated aneurism, and 
 in the aorta when regurgitation through the aortic valves is also 
 present. The bruit is loudest and most rasping in the fusiform 
 variety, and may be absent in the sacculated form, where the 
 [mouth is small and the cavity nearly full of clot. Great dis- 
 tension of the sac is unfavourable to the production of the bruit. 
 The Extrinsic Signs of aneurism are those occurring in neigh - 
 Ikirin;; or distal structures from its constantly increasing size 
 and pressure, and the interference produced by it with the 
 tirculation. The pulse in the vessels below is diminished and 
 ielayed, its diminution being caused partly by the obstruction 
 experienced, but also in some cases by the pressure of the sac 
 ];:pon the trunk above or below the tumour. The delay is due to 
 ilif interference with the transmission of the heart's impulse by 
 At intervention of the aneurismal sac. The dicrotic notch is 
 lasually ubsent. The smaller vessels engaged in establishing 
 
230 
 
 A MANUAL OF SURGERY 
 
 collateral circulation may be compressed, and thus the vitality of 
 the limb considerably impaired. Pressure on the accompanyin.r 
 vein or veins results in diminution of their calibre, and possibly a 
 localized thrombosis, together with congestion and fcdenia distalh', 
 whilst gangrene may be the final outcome if the case is not 
 efficiently treated. Compression of nerves occasions neural<;ia, 
 spasm, or paralysis. Muscles are displaced, expanded, and attenu- 
 ated ; bones may be eroded, as evidenced by a deep, constant, 
 boring pain, and even spontaneous fracture may ensue; whilst 
 joints are encroached upon and disorganized. Tubes, such as the! 
 trachea or oesophagus, are often injuriously constricted and hiidj 
 open by ulceration. It is an interesting fact to note that rcsistinf; 
 tissues, like bone, are much more liable to be eroded than elastic,] 
 yielding structures, such as cartilage, and in cases where the 
 vertebral column is encroached upon by an abdominal or thoracic j 
 aneurism, the bones always manifest greater destructive chanj,'esj 
 than the intervertebral discs. 
 
 The increased difficulty in propelling the blood through the! 
 sac usually induces a certain amount of compensatory hyper- 
 trophy of the heart. Occasionally emboli consisting of fragments] 
 of laminated fibrin become detached, and lead either to a spoii 
 taneous cure, or to gangrene of the parts supplied by the vessel,, 
 or to death of the indi\'idual if the brain is invcjlved. Gaitf;y(m\ 
 may also be induced as a result of the diminished blood supply to 
 peripheral parts, especially if associated with interference withj 
 the \'enous return. It is usually of the dry type, and ofttni 
 involves merely one or two fingers or toes ; but when attacking! 
 more fleshy parts, or if due to venous congestion, it is moist in 
 character. 
 
 The Differential Diagnosis of a circumscribed aneurism is noi 
 difficult, if due weight is given to the above symptoms and si},'nsl 
 but the following conditions may simulate it somewhat closely] 
 I. A tumour or chronic abscess situated near an artery, and deriviiid 
 transmitted pulsation from it, is recognised by the impulse heind 
 merely heaving in character, and not expansile ; by tlie pulsatioij 
 ceasing entirely if the tumour is lifted from the vessel, or allowe 
 to fall away from it by assuming a suitable position ; by the sizj 
 of the tumour not diminishing if the pulsation is stopped 
 pressure on the vessel above ; and by the fact that after stoppagl 
 of the pulsation the first beat is ecjual to the subse(|uent one^ 
 whereas in an aneurism it almost always requires more than on 
 beat to re-establish the strength and force of the impulse. Mor^ 
 over, the pulse below is not affected in the same way or to tli 
 same extent as when an aneurism is present. 2. A pulsatti^ 
 sarcoma or mrvus is known by being rarely limited exactly to th 
 line of the artery, pulsation being present in situations where 
 aneurismal dilatation could not be felt, and being less forcible an 
 regular in its character. The consistency of the swelling is nio| 
 
ANEURISM 
 
 231 
 
 varial)le, and pressure over the afferent trunk does not diminish 
 Its size to any marked extent. Moreover, a sarcoma is usually 
 more adherent to the deeper structures, and its limits are not so 
 ;iccunitely defined. 3. The pain caused by an aneurism may 
 lead it to be mistaken for rheumatism or neuralgia (e.g., for sciatica 
 in popliteal aneurism), and in every case of obstinate pain of this 
 kind the arteries should always be carefully examined with the 
 intention of eliminating such a possible cause of the trouble. 
 Natural Terminations and Results. — i. Spontaneous Cure, though 
 of unusual occurrence, may arise in saccu'ated aneurisms from a 
 variety of circumstances, and is a well-recognised phenomenon. 
 (iij It may be due to the gradual deposit within the sac of fibrin, 
 which, in the first place, limits the expansion and extension of the 
 aneurism, but may finally increase to such an extent as to cause 
 obliteration of its cavity. Such a termination can only occur in 
 saccules with small mouths, and that also in vessels of the second 
 :iia},niitude, hardly ever in the aorta or larger trunks, the impetus 
 of the blood stream being too great to permit of the necessary 
 deposit of fibrin, (b) It may arise as the result of the sudden 
 j coagulation of all the blood in the sac f) om the stoppage of the 
 circulation, owing to the lodgment of an embolus either at the 
 mouth of the aneurism or in the trunk immediately below, (c) The 
 aneurism may become so large as to compress the main vessel, 
 I either going to or coming from it, thus bringing about its own 
 cure, {d) Again, if the sac becomes inflamed, consolidation may 
 [occur with or without suppuration, although the latter process, as 
 will he seen anon, is attended with serious danger to life and limb. 
 In the non-inflammatory conditions the sac becomes more and 
 [more firm, the pulsation less forcible and distinct, the bruit 
 diminishes, and finally consolidation is effected a firm fibroid 
 iMiour alone remaining, which gradually shnnks, whilst the 
 cjllateral circulation is opened up so as to supply the limb below. 
 It is sometimes by no means easy to recognise the fibroid mass 
 resulting from the spontaneous consolidation of an aneurism, and 
 in making a diagnosis the history has mainly to be depended on. 
 The existence of a tumour in the line of an artery, the probable 
 occlusion of the main trunk, and the fact that the circulation is 
 carried on by means of collateral branches, are the chief points 
 jjhich can be ascertained by a physical examination. 
 
 2. Diffusion and Rupture result from yielding of the walls of a 
 Iflcculated aneurism, perhaps as an outcome of some mechanical 
 injury, or in the case of internal aneurisms from simple over- 
 l&tension. 
 
 When an internal aneurism suddenly gives way, the patient 
 
 liisually experiences a sensation of pain in the part, and iiecomes 
 
 bale, cold, and faint, possibly dying within a few minutes or, at 
 
 Imost, hours ; or there may be a sudden gush of blood from the 
 
 mouth if the trachea or oesophagus has been opened. Sometimes 
 
232 
 
 A MANUAL OF SURGERY 
 
 ! 
 
 t 
 
 s 
 
 internal aneurisms leak slowly, and the final stage lasts some 
 days. 
 
 When an external aneurism yields, it may do so slowly or 
 (juickly. If the blood becomes effused slowly (constituting^ what 
 is sometimes called a leaking aneurism), the tumour grudually 
 increases in size, and its outline is less clearly limited ; the pulsa- 
 tion diminishes in force and distinctness, and the signs of pressure 
 upon the veins or nerves become more urgent, until, perhaps, 
 gangrene supervenes ; after a time the process may cease, and 
 even a spontaneous cure result. If the aneurism ruptures suddenly^ 
 the patient experiences severe pain in the part, which becomes 
 tense, swollen, and brawny ; all pulsation ceases both in the 
 aneurism and below it, and gangrene of the limb follows, or 
 even death from syncope, arising from the amount of hlood 
 extravasated, either externally if the skin gives way, or into the 
 tissues and under the fasciae. Suppuration may also occur in ! 
 these cases, the skin becoming red and inflamed, and finally j 
 external rupture may follow. In the absence of history the re- 
 cognition of diffuse aneurisms is by no means simple, especially! 
 when they become inflamed, and then only the most careful 
 attention to the facts to be made out by digital examination can j 
 determine the nature of the case. 
 
 3. Suppuration of the sac is an exceedingly serious, but hynoj 
 means a usual, complication of aneurism. It may arise in the} 
 following ways: {a) After ligature of the main vessel above,! 
 especially when the wound becomes septic, and there is a good] 
 deal of loose cellular tissue around the sac, as in the axilla; 
 {b) after diffusion, partial or complete, of an aneurism, where thej 
 cavity is filled with clot, and there is great tension upon sur- 
 rounding parts. Auto-infection or the presence of an infective! 
 embolus may finally determine the suppurative process. Thai 
 tumour shows signs of inflammation, becoming hot, red, painful,! 
 and swollen, and the skin over it may pit on pressure ; whilst fever] 
 and general constitutional disturbance are also present. Soonerj 
 or later, if left to itself, the tumour points at one spot and Inirsts,! 
 giving exit to a mixture of blood clot, pus, and a greater or less! 
 amount of bright red blood. The patient either dies at once from! 
 syncope, or a little later from secondary ha^Miiorrhage and septic j 
 poisoning, unless efficient treatment is adopted. Occasionally, buti 
 very rarely, the afferent trunk becomes plugged by a thronilnis,! 
 and spontaneous cure may thereby be induced. 
 
 Treatment of Aneurisms. 
 
 I. General Treatment is employed as an accessory to surgicaj 
 measures, or must be depended on entirely in cases where loca 
 means are impracticable or contra-indicated, such as in interna 
 aneurisms ; it is then to be looked on rather as palliative in nature 
 than curative. The general condition of the patient must be care-j 
 
ANEURISM 
 
 833 
 
 fully investigated, since aneurisms are associated either with 
 plethora or with an enfeebled and cachectic state of the system. 
 
 In plethoyic individuals, where the disease often runs a rapid 
 
 course, absolute rest, both mental and physical, must be enjoined, 
 
 with the removal of all sources of irritation and worry. The 
 
 liowels are freely opened by a calomel purge at the commencement 
 
 of treatment, and watery stools should be subsequently induced 
 
 bv 20 grain doses of pulv. jalapa? co. two or three times a week, 
 
 ;oas to increase the plasticity of the blood. The heart's impulse 
 
 may be diminished by the use of aconite, or even by venesection 
 
 when it is very forcible. Iodide of potassium is useful both for 
 
 :tducing blood -pressure and in cases where a syphilitic history is 
 
 ;'esent. The diet must be judiciously and gradually diminished, 
 
 1 stimulating articles being eliminated, and only highly nutritious 
 
 k/erial allowed, and that mainly of the nitrogenous type, with as 
 
 ;;tle fluid as possible. Various special methods, e.g., Tufnell's, 
 
 Valsalva's, etc., have been recommended, but it usually suffices 
 
 J limit the dietary as much as is in conformity with the patient's 
 
 :onifort and well-being, and not to allow more than about a pint 
 
 jftluid in the day. 
 
 n weakly individuals, whilst enjoining strictly a recumbent 
 psture, the surgeon should prescribe iron and a somewhat more 
 tvral diet, in order to improve the quality of the blood. 
 II. The Surgical Treatment of aneurisms has varied much at 
 jierent times and in the hands of different surgeons ; the con- 
 [ition, situation, and surroundings of the tumour also materially 
 inliuence the line of treatment to be adopted. 
 
 Whichever of the plans described below is selected in any par- 
 alar case, the general health must be carefully attended to, 
 the condition of internal organs fully investigated beforehand, 
 great harm may follow injudicious interference, if internal 
 eiirisnis co-exist. The following are the main methods made 
 Is of in the treatment of aneurisms : 
 
 Compression. — Although compression had been adopted 
 
 fore Hunter introduced ligature of the main vessel in the treat- 
 
 of aneurisms, its value was lost sight of for a time, and for 
 
 re-introduction we are mainly indebted to the activity and skill 
 
 the Dul)lin surgeons, who proved that in well -selected cases a 
 
 ecan be effected by its means as safely as by the ligature. 
 
 Compression may be continuous or intermittent. If intermittent, 
 
 \i applied over the main vessel leading to the aneurism by 
 
 tans of fingers (digital compression), or by mechanical con- 
 
 vances, for as long a period as the patient can bear, which 
 
 aally does not exceed thirty minutes, especially if there is any 
 
 ::\e in the immediate neighbourhood liable to be pressed upon. 
 
 TO seems to be no necessity to completely arrest the How of 
 
 d through the sac, so long as the blood -pressure is sufficiently 
 
 linished to permit of coagulation within it. Continuous pressure 
 
234 
 
 A MANUAL OF SURGERY 
 
 can, as a rule, only be maintained under an anaesthetic, and in 
 such cases the circulation through the sac is entirely stopped, so 
 as to allow not only of its contraction, but also in some instances 
 of the rapid coagulation of its contents. Such pressure may l)e 
 effected by the fingers of relays of dressers, taking shifts of ten to 
 fifteen minutes at a time ; but inasmuch as this is excessively 
 tiring and difficult to maintain efficiently, arrangements should he 
 made whereby some weight, such as a conical shot-l)aJ,^ rests 
 upon the thumb or finger employed, thereby relieving nuisciiliirj 
 strain. Tourniquets may be similarly utilized, but are less satis- i 
 factory, since they require more skilful and accurate adai)tation, 
 and are liable not only to slip out of place, but also to bruise 
 the coats of the vessels. The best appliance of this nature is 
 probably Petit's tourniquet. Esmarch's elastic bandage lias been 
 used with success, principally for aneurisms of the lower extremi- 
 ties, notably the popliteal. The limb is first elevated for soiiiej 
 moments, and then the elastic bandage applied from the toes to! 
 the upper part of the limb, passing loosely over the aneurism.! 
 An indiarubber tourniquet is then placed round the thigh, so asl 
 to arrest the circulation completely {Reid's method). The lind) hasi 
 in this way been left bloodless for an hour and a half, but wej 
 cannot recommend the proceeding. 
 
 As to the value of compression — although in suitable cases \i 
 certainly has been successful, and may be given a trial before 
 ligature, yet it is unwise to persevere with it for too lonj;, lesl 
 the collateral circulation be increased to an undesirable extent|| 
 and thus the success of the subsequent operation interfered with^ 
 Especially is this the case in plethoric individuals with hijj 
 arterial tension. On the other hand, in feeble, weakly patients 
 where gangrene of the limb might be anticipated, the opening d 
 of the collateral circulation by compression, even if the aneurisi^ 
 is not thereby cured, is by no means a disadvantage. Neccssaril) 
 in all cases, the part of the skin to which pressure is applied mus 
 be carefully protected from local irritation by shaving and removi 
 of hairs, by the use of dry aseptic dusting-powders, and by seeinj 
 that the surface of any pad employed is perfectly smooth, and tli 
 skin not wrinkled beneath it. 
 
 2. Ligature of the main vessels leading to or coming from till 
 aneurismal sac must next be considered. The oldest procedurd 
 the Operation of Antyllus, consisted in laying open the saij 
 turning out the clots, securing the vessels above and below, an 
 allowing the wound to heal by granulation (Fig. 65, A). Pej 
 formed, as it was originally, without anaesthetics or antiseptic 
 it was naturally attended with great mortality, since, even 
 secondary haemorrhage did not occur from the main trunk, it wi 
 liable to follow from any of the branches which arose from tl| 
 dilated portion of the vessel. 
 
 In Anel's Method (Fig. 65, B) the artery was tied just ahoj 
 
 the sac on the cardi 
 provL-d dangerous, 
 suited, either from 
 sepsis, or from injii 
 yielding of the arte 
 periarteritis. 
 Hunter's Opera^jo: 
 jihe main vessel on 
 aneurism, was first 
 k attained is not t 
 sac, l)ut to allow th 
 impulse, and in sm 
 
 Fig. 65 Methoi 
 
 A, Metliod of Antyllus ; 
 D, Brasdo 
 
 contraction of the sac 
 jciot within it. The 
 I transformed into a nu, 
 jsiost likely to succeed 
 liiid not large enough 
 Iprts, whilst it is desir 
 mt size should inter 
 h- It should be as 
 IKina healthy conditi 
 I'Pplied. The operatic 
 Itardiac disease co-exi; 
 Jpresent, suggesting tj 
 lad rendering undesi 
 Ipressure, as by occlus 
 lover the vessel does 
 
ANEURISM 
 
 235 
 
 the sac on the cardiac side, with no branch intervening ; this also 
 proved dangerous, since secondary haMnoiihage frequently re- 
 sulted, either from suppuration within the aneurism owing to 
 stpsis, or from injury to the sac during the operation, or from 
 yielding of the arterial wall at the site of ligature from septic 
 periarteritis. 
 
 Hunter's OperaMon (Fig. 65, C), which consists of ligature of 
 
 I the main vessel jn the cardiac side at some distance from the 
 
 aneurism, was first performed by him in 1785. The object to 
 
 I k attained is not to absolutely cut oflF the blood-supply to the 
 
 ac, i>ut to allow the blood to enter it with a greatly diminished 
 
 impulse, and in small amount at first, thus permitting of the 
 
 -H 
 
 A. B. C. D. E. 
 
 Fig. G5 Methods ok applying Ligatures for Aneurisms. 
 
 A, Method of Antyllus ; B, Anel's operation ; C, the Hunterian operation 
 D, Brasdor's operation ; E, Wardrop's method. 
 
 contraction of the sac wall and of the gradual deposit of fibrinous 
 Iclot within it. The sac thus becomes consolidated, and finally 
 jtransforined into a mass of firm fibroid tissue. The operation is 
 liiiost likely to succeed in cases where the aneurism is well defined 
 land not large enough to exercise injurious pressure on surrounding 
 Irarts, whilst it is desirable, though not essential, that no branch of 
 |irt;e size should intervene between the point of ligature and the 
 |iac. It should be ascertained, if possible, that the vessel wall 
 sin a healthy condition at the spot where the ligature is to be 
 lipplieci. The operation is contra-indicated (i) in cases where serious 
 jardiac disease co-exists, or when an internal aneurism is also 
 present, suggesting that the whole arterial system is affected, 
 liad rendering undesirable any sudden increase of the blood- 
 Ipressure, as by occlusion of a main vessel ; (2) where pressure 
 per the vessel does not control the circulation through the 
 
236 
 
 A MANUAL OF SURGERY 
 
 sac; (3) where the peripheral vessels are extensively cahil'ied; 
 
 (4) where {,'angrene of the liiiih is threateniiif,' or present; (jrj 
 
 (5) where bones or joints have i)een seriously involved. 
 
 Distal Ligature is only practised for aneurisms situated ini 
 positions where it is impracticable to deal with the artery on thel 
 cardiac side of the sac, such as the innominate, lower part ofl 
 the carotid, or first part of the subclavian. Brasdor's Operation! 
 consists in tying the main trunk beyond the sac, so as U) totally 
 cut off the circulation through it (Fig. 65, D). In Wardrop'sj 
 Operation a ligature is placed on one or more of the distal branchesl 
 (Fig. 65, E). In the former the sac gradually contracts, andl 
 thus allows of the deposit of hbrin ; but it has been sug<,'t'stedl 
 that the cure is usually effected by an extension of the act ofl 
 coagulation from the site of ligature to the sac. In the latter) 
 proceeding, where the circulation is only partially controlled, the! 
 diminution of the size of the aneurism goes on much more slowly, 
 and the chances of the deposition of clot in the sac are corre- 
 spondingly lessened. 
 
 It is not unusual, after the application of a ligature to a iiuiinj 
 artery for aneurism, to observe a return of pulsation in the sac atterj 
 a few days. In the majority of cases this only continues for ashortj 
 time, and is by no means an unfavourable sign, indicating there- 
 establishment of the collateral circulation ; but if it commences al 
 week or ten days after the operation, it is more likely to persist,! 
 and will then indicate that the ligation of the vessel has failed in| 
 accomplishing the object tor which it was adopted. It is niostl 
 frequently seen in cases where the main vessel has been tied ad 
 some distance from the sac, as in the superficial femoral for 
 popliteal aneurism, and where one or more large and iniportantj 
 collateral branches carry blood into the artery below the ligature 
 or directly into the sac. The most favourable conditions foij 
 gradual consolidation jire those in which the blood reaches the 
 aneurism from below fr^e from impulse. A few cases are recorded 
 in which the artery has become pervious at the seat of ligature 
 after some months, or a fresh aneurism developed at a spot conJ 
 tiguous to the original tumour. The early recurrence of pulsaJ 
 tion needs no treatment in most instances, since it disappears 
 spontaneously ; but when it comes on at a later stage, it deiiiandg] 
 serious attention. Rest elevation of the limb and judicious 
 pressure over the trunk j.bove the site of ligature, should first hej 
 tried. These failing, the following courses are open : {a) The 
 artery may be again tied, either nearer the sac when feasible, od 
 further away from it ; (b) where the aneurism can be reachedJ 
 it may be cut down on and dissected out, the best course to adoptj 
 if it be practicable ; or {c) amputation just above the aneurisn 
 may be called for as a last resource, when the tumour is rapidly 
 increasing or threatening to become diffuse, or if gangrene is 
 impending. 
 
 3. Complete Extir 
 
ANEURISM 
 
 a37 
 
 3. Complete Extirpation of the iuiL-urismal sac may he looked 
 jii iis the hest and most satisfactory method of treatment. The 
 jac is thus dealt with as if it were a tvimovr, althoiif^^h, owinj^ to 
 tlie adhesions always present, complete separation of the wall 
 [roin surroundinf,' parts is often difficult. The limb is exsan- 
 guinated by elevation, and in suitable cases the aneurism is 
 ;emo\ed without opening; it, and the vessel secured by lif^ature 
 [lOVc and below, as also any branches which may arise from it. 
 When, however, a larj^e saccule obscures the main trunk, it may 
 X necessary to open it and turn out its contents before attempting 
 ;> extirpation. Not unfreciuently the vein will be encroaclied on 
 in this dissection, and it may have to be removed ; bad results are 
 [jot likely to follow, since probably its lumen has been already 
 iiminished by the pressure of the seic, and an efficient collateral 
 lienoiis circulation established. This method has hitherto been 
 Lhietly applied to small aneurisms of the peripheral vessels, and, 
 •jideed, in the majority of such cases no other plan need be con- 
 sidered ; surgeons are now, however, extending its scope to the 
 iarijer trunks, such as the popliteal, carotid, external iliac and 
 klavian, from each of which aneurisms have been successfully 
 fttirpated, whilst as far back as 1883 one of us removed in this 
 Java recurrent femoral aneurism, involving the vein, with a good 
 ;6ult.'' It is also attempted as an alternative to amputation for 
 current, diffused, and suppurating aneurisms. The results of 
 is operation which have been recently recorded are most 
 jtncouraging : primary unicjn of the wound is often obtained, and 
 jiience tlie length of treatment is curtailed, whilst all cha' cs of 
 lecarrence are removed. Statistics also show that there is less 
 iger of gangrene, and this depends, as Pearce Gould has 
 |j«inted out, on the fact that only one set of collateral circulation 
 called upon, viz., that recjuired to bridge the gap made by 
 [moving the aneurism, whereas in the Hunterian operation a 
 iouble set is needed, viz., at the site of the ligature, and round 
 •iie consolidated aneurism. It is obvious that the nutrition of the 
 I'mb is best secured when what Gould calls the ' irreducible 
 iiinimuni ' of operative treatment, viz., the occlusion of the vessel 
 tnly at the site of the aneurism, is undertaken. Secondary 
 [iimorrhage is also less likely to occur. 
 f Electrolysis has been occasionally employed in dealing with 
 |':.oracic aneurisms when a saccule has developed in an accessible 
 kition. The clot thus formed is soft and liable to break up, 
 iiid the results have not been very satisfactory. For details of 
 [ft nietliods of employing electrolysis, see p. 281. 
 j.The Introduction of Foreign Bodies into the Sac {Moors 
 ■'itlwd) lias not been followed by much success, although a few 
 lases of abdominal aneurism seem to have derived temporary 
 Ibetit from it. Steel wire has been usually employed ; it is 
 * Lancet, 1883, ii., p. 1082. 
 
238 
 
 A MANUAL OF SUHGllRY 
 
 firmly wound round a cotton reel to \fWe it a spiral coil, and 
 inserted into tlie sac through a very line cannula. Vatyiiu' 
 lenf,'tlis from lo feet to 26 yards have been introduced. 
 
 6. The combination of the last two methods has been attended 
 by some \ery happy results, especially in the hands of Stewart of 
 Philadelphia. •■ He introduces a variable len^'th of f^old or sil\ti 
 wire (No. 30 f;auf,'e), preferably the former, throuj^h a siiudl 
 cannula, and then electrolyses throuf^h the wire which is attat 'led 
 to the jiositive electrode, whilst the nef,'ative electrode is placed 
 on the back. The current is f^radually increased up to 60 or ^0 
 milliampl-res, and the whole proceedinj; lasts about 30 minutes. 
 I'inally, the wire is cut short and pushed into the sac. Several 
 most brilliant results have followed this plan of treatment, in- 
 cluding the cure of an innominate aneurism, the patient livinf,' 
 for three and a half years, and of an aneurism of the abdominal 
 aorta, dealt with by transperitoneal operation. 
 
 7. Acupuncture has been occasionally tried for many years, hut 
 without much advantage. Macewen, however, has again drawn 
 attention to the method, and suggested some modifications in the 
 technique. He passes fine needles into the interior of tiie sac, 
 and with them scratches the posterior wall so as to cause a certain 
 amount of inflanunatory thickening, and thus determine a deposit 
 of fibrin. Whether the benefit is actually due to this needliii),' is 
 a little doubtful, since the walls of an aneurismal sac are usually 
 sufficiently rough already, and it is quite possible that any advan 
 tage derived from the proceeding is due to the introduction of a 
 foreign body and the deposit thereon of clot. 
 
 8. Amputation may be required in the treatment of aneurisms 
 under a variety of circumstances : {a) when gangrene of the liinli 
 has occurred or is inmiinent ; {h) for diffusion or suppuration of 
 an aneurism when everything else has failed ; {c) for secondary 
 haemorrhage as a last resource ; {d) in some cases of recurrent 
 aneurism ; {e) when joints have been opened or bones enxled to 
 such an extent as to impair the utility of the limb ; and finally, 
 (/) in a few cases of subclavian aneurism amputation at the 
 shoulder-joint has been practised in order to diminish the amount j 
 of blood flowing through the sac. 
 
 The Treatment of a Diffuse Aneurism \'aries somewhat according 
 to whether the diffusion is slow or rapid. In the leaking aneurism,] 
 which increases in size somewhat slowly, the main vessel Icadin;,; 
 to the swelling may be tied, if this has not already been under- 
 taken, and the influence of this measure, combined with rest,! 
 elevation, and careful general treatment, observed. Should ihej 
 process not be stayed, the case is treated as a diffuse or ruptnniX 
 aneurism by laying open the sac, after exsanguinating the limb bvj 
 elevation and the use of an elastic band, and securing, if possible,! 
 
 • British Medical 'journal, August 14, 1897 ; Philadelphia Medical Jouymll 
 June 25, 1898. 
 
 the niain vessel , 
 
 iipen into the s,-i 
 
 of iiK ipient gan 
 
 amputation nujsl 
 
 ilt'peiul on (he v(\ 
 
 The Treatment 
 
 anxiety from the 
 
 jrttry above the i 
 
 certainly be corre 
 
 Ity that measure 
 
 application of an 
 
 continue, the anei 
 
 an ebstic tournicji 
 
 secured above and 
 
 branches opening 
 
 strips of aseptic g; 
 
 case, for fear of a i 
 
 should gangrene tl 
 
 ■^(Sid of supply has bi 
 
 and cleared of coaf 
 
 the cavity stuflfed ; 
 
ANEUHISM 
 
 >39 
 
 he Muiin vessel al)ove and below, as also any hranches which may 
 ipt'ii into the sac, if they can he found. If there is any evidence 
 .,t incipient gangrene, or if secondary haMiiorrhage supervenes, 
 iiiiputation iiuist he undertaken. In such cases everything will 
 iltpcnd on tlu- cflicient maintenance of asepsis. 
 
 The Treatment of an Inflamed Aneurism is always a matter of 
 inxiety from the risk of recurrent and fatal ha'morrhage. If the 
 artery above the aneurism has not been previously ligatund, it wovdd 
 certainly be correct practice to tie it, and watch the effect produced 
 by that measure, together with rest, elevation, and the local 
 application of an icebag. If the inflammatory symptoms still 
 iDiitinue, the aneurism sliould be laid freely open after applying 
 ant'liistic tourniquet, the coagula turned out, and the main trunk 
 ^'ciirt'd above and below. If bleeding still continues from smaller 
 hranches opening into the sac, the cavity is carefully plugged with 
 >trips of aseptic gauze, but a strict watch must be kept over the 
 case, for fear of a return of the l)leeding. Should this happen, oi 
 slioiikl gangrene threaten, amputation alone remains. // the main 
 lissd of supply has been pyeviously tied, thusixcahould still be laid open 
 
 ind cleared of coagula, all bleeding points secured if possible, and 
 the cavity stuffed ; amputation is, however, likely to be required. 
 
 Special Aneurisms. 
 
 Aneurism of the Thoracic Aortii is dealt with rather in medical 
 
 ilian in surgical text-books; it is, however, of such importance as 
 
 to demand a short notice here. Any part of the thoracic aorta 
 
 iiiav he affected, and the symptoms arising therefrom are very 
 
 vaiiahle. The fusiform type is most connnonly met with in the 
 
 early stages, a limited sacculation often supervening as the disease 
 
 i advances. In the ascending part of the arch the swelling rarely 
 
 I reaches a great size, especially if it is intra-pericardial, the sac 
 
 j usually rupturing before marked pressure signs are evident. 
 
 I When arising from the transverse part of the arch, the symptoms 
 
 vary with the direction taken by the enlargement. If it projects 
 
 ii|ii\(i/'(/i-, it may manifest itself as a pulsating tumour at the 
 
 episternal notch, and then usually causes cerebral effects by 
 
 interference with the circulation through the carotids, or by 
 
 Ipressure on the venous trunks. If it extends anteriorly, it may 
 
 licrm a large tumour with comparatively slight pressure effects, 
 
 [except the pain arising frorri i«^5 erosion of the tnoracic wall ; it 
 
 Ithen appears as a pulsating swelling to the right of the sternum. 
 
 jlfthe enlargement takes place aither posteriorly or down imrds within 
 
 k* concavity of the arch, symptoms due to its presence, in the 
 Isliape of dyspnoea and dysphagia, are early produced from the 
 Idose contiguity of the trachea, oesophagus, and pulmonary vessels. 
 jDyspnua may also be due to pressure upon the left recurrent 
 llaryngeal nerve, causing paresis of the crico-arytenoideus posticus 
 
240 
 
 A MANUAL OF SURGERY 
 
 muscle, and difficulty in opening the glottis ; the voice, moreover 
 becomes harsh and the cough hard, with what has been descrihed 
 as a ' metallic ring ' about it, which is extremely characteristic, 
 Laryngeal or tracheal stridor may be noticed in these cases, and 
 a dragging of the trachea synchronous with the heart's action (the 
 so-called 'tracheal tug'). 
 
 Aneurisms of the descending; arch and thoracic aorta often attain 
 considerable dimensions, and may project posteriorly to the left 
 of the vertebral column, causing a pulsating . .v^elling. Tlie onlv 
 prominent symptoms are pain due to erosion of ribs or xertehri 
 and interference with deglutition, which may be so great as to 
 suggest the presence of an oesophageal constriction ; in fact, before 
 a bougie is passed in any case of dysphagia, it is always ad\ isahle 
 to eliminate, if possible, the presence of an aneurism. Auscultation 
 in the left vertebral groove may reveal the existence of a systolic 
 bruit whero such a conditio a exists. 
 
 Treatment. — Little can be done beyond ordinary medical 
 measures, such as rest, diet, and the administration of iodide of 
 potassium. In some cases where the tumour could be felt in 
 front, pressure o\er the sac, or the application of an ice-bag, has 
 been employed, but without much effect. The introduction of 
 coils of iron wire or horsehair has been attempted, and in one or 
 two cases with partial or temporary success ; whilst electrolysis has 
 been employed where the patients we: e healthy, and sacculated 
 aneurisms, with but small openings into the aorta, supposed to 
 exist. Stewart's method of electrolysis has also been attended with 
 good results in a few cases, and Macewen's plan of acupuncture 
 has been followed with some amount of benefit. Dyspnea niav 
 be at times severe, but tracheotomy should never be undertaken, 
 death seldom resulting from this cause. 
 
 Surgical treatment, such as ligature of the right carotid and ri'^ht 
 subclavian, or of the left carotid alon- 'las been adopted in cases 
 of aneurism of the ascending aorta or of the arch. A certain 
 amount of improvement has followed some of the operations, init 
 of eleven cases reported by Kiister five died within the first ten 
 days. The principles underlying such proceedings are certainly 
 at variance with those guiding our usual treatment of an aneurism, 
 and it is (juite possible that the improvement was as much due to 
 the enforced rest m bed as to the operation. Of course, if the 
 lower end of the carotid is involved in the aneurismal swellinu, 
 distal ligature may be undertaken with good prospect of benefit, 
 as in a case which we recently pi blished." 
 
 Innominate Aneurism is usu;;lly of the tubular variety, and 
 frequently associated with a similar enlargement of the i.orta. It 
 presents a pulsating tumour behind the right steino-cla\ icular 
 articulation — i.e., between the heads of origin of the sterno- 
 
 * British Medical Joiiyiial, Deceml^er 3, iSyS. Tlie patient was doing well 
 two years and a half after the operation. 
 
 mastoid — projeci 
 into tiie subcla' 
 forwards. The 1 
 The pulse in b 
 diininisiied ; a'de 
 the head and net 
 the right innom 
 on the left side : 
 superior \-ena ca 
 a marked sympi 
 hrachial ner\es, 
 and dilatation of 
 
 K. 66— Al'l'LlCATH 
 
 A, Aorta , I A, inn 
 
 \vnipathctic trunk 
 tri.hea, which ni; 
 tlie ri;,;u recurren 
 paralysis of the ri<. 
 '-n the lesophagus, 
 
 riie course of t 
 'inmioidy results 
 
 Treatment has 
 althou;,di surgical 
 ol benefit or cure. 
 iodide of potassiun 
 tliL' most hopeful 
 
 muT 
 
ANEURISM 
 
 24 1 
 
 mastoid — projectinjj^ eitlier into tlie episternal nolcli or outwards 
 into the sul)cla\ian trianf,de, and perhaps pushiiifj; the chi\icle 
 forwards. The eftects produced by its pressure are \ery \-ariahle. 
 The pulse in both the rij^dit temporal and radial arteries is 
 diminished; a'dciua of a brawny character of the rif^ht side of 
 tiic head and neck, and of the rif^ht arm, is caused by pressure on 
 the rij,dit innominate \ein, whilst less connnonly similar chan<(es 
 on the left side may follow compression of the left \ein or of the 
 superior vena cava; pain shootinj,' into the neck and arm is often 
 a marked symptom, arisin<i from implication of the cervical and 
 brachial ner\es, whilst hypera'mia of the ri,t,dit side of the face 
 and dilatation of the ri<fln: pupil may result from irritation of the 
 
 . f/i.-Ari'LicATioN OF I-icArcRiis '■ni' Innominatk Ani lkism (Akter 
 
 Kl<ir-iu:i,.-.) 
 
 A, Anita. lA, inridmiiuite aiu'urisni ; S, siibcL'wian artery; C, carotid , 
 
 \', vert'l'ial artery. 
 
 >}iiip;uhetic trunk. Dyspiuva is induced by direct pressure on lie 
 tri Ilea, which may be displaced or flattened, or by irritatic.n .^f 
 theri;.;,. recurrent larynj^eal ner\e, causing; partial or complete 
 paralysis of the rij^ht \'oc;d cord. Dysphagia occurs from pressure 
 "11 the (esophaf,ais. 
 
 The course of the case is slowly progressive, and death most 
 uiniiionly results from asphyxia or from rupture of the sac. 
 
 Treatment has been mainly and most commonly medical, 
 
 althou^'li surj.;ical measures ncnv hold out a considerable prospect 
 
 t beneht or cure. Rest and the administuitior of lar^e doses of 
 
 imlide of potassium may cause improvenienl. but distal lij^ature is 
 
 ilie most hopefid proceeding;. It is ob\io'isly impossible tt) cut 
 
 16 
 
242 
 
 A MANUAL OF SURGERY 
 
 off all tlie Mood passing^ through the sac to the three main di\isions 
 — \iz., tlie carotid, subclavian, and \ertebral — with safety to the 
 jiatient. Ligature of any ont of these alone offers hut little 
 prospect of improvement ; thus, the only case benefited by ligniurf 
 of the subchuian was one treated liy W'ardrop, in which tlif 
 carotid also had been independently and by accident bkxked; 
 whilst the only cure recorded after tying the carotid was proiiahlN 
 due to subse(|uent suppuration within the sac (Evans). Lii^ature 
 of both carotid and subcla\ian, with an interval of more tlian a 
 week between the two operations, has practically the saiiic effect 
 as a single ligature, for by that tijue the collateral circulation will 
 have been established. The results following such practice are 
 better than those gained by ligating a single \essel, but not su 
 good as those from tying both vessels at the same time (Fig. 66). 
 Simidtaneous ligature is doubtless the best plan of treatment to 
 adopt ; it places the sac in the best possible condition for the 
 deposit of iibrin, whilst the additional step of tying the third part 
 of thesubcla\ ian does not materially add to the risk of the operation, 
 which is mainly due to the effect on the cerebral circulation. 
 
 Aneurism of the Commo.i Carotid is usually situated at the 
 upper part of the trunk near the bifurcation, and more often on 
 the rif^ht than on the left siae. The root of tlie right carotid as it 
 springs from the innoiniuate is also not unfrequently dilated, hut 
 the intra-thoracic portion of the left carotid is rarely affected, 
 except in conjunction with aneurism of the aorta. No other 
 external vessel is so frecpiently the se;it of aneurism in women. 
 
 The ordinary intrinsic si/^us of an aneurism are present, and the 
 pressure symptoms are mainly referable to interference with the 
 cerebral circulation, to irritation of the cer\ical sympathetic trunk, 
 or to pressure upon the larynx, pharynx, or trachea. The pro>;rc.ss 
 of these cases is usually slow. 
 
 Diagnosis. — Fyoiii siuiilay disease at the root of the neck the dis- 
 tinction is often made with diflicdty, since either an aortic, 
 innominate, or subclavian aneurism may push upw.'uds so as , 
 to simulate it somewhat closely. Percussion and auscultation ofi 
 the u|:»}HT part of the chest, together with a careful in\estif,'ati()ii 
 into the history of the case, and a digital examination of the liniitsj 
 of the pulsating mass, may suffice to determine the point, llolinesj 
 suggests trying the effect of carefully applied distal pressure for aj 
 few hours ; in a carotid aneurism the tension becomes distinctlyj 
 less as the collateral circulation commences to enlarge, whiLstj 
 in an aortic aneurism no difference is observed. The prcssur^ 
 effects must also be carefully considered. ' Pressure on the 'ef 
 recurrent laryngeal ner\e would distinguish an aortic aneurism 
 from one on tin- right \essels ; pressme on the right ner\e in \\V 
 manner excludes an aortic aneurism. Pressure on the left innoiiij 
 inate \ein indicates aortic aneurism rather than innominate ; comi 
 pression of tlu; internal jugular or subclaxian \ein only points td 
 
 carotid or su 
 
 aneurism of t 
 
 pheral pulses \ 
 
 piiJses should 
 
 aneurism of tl 
 
 indicated ; if tl 
 
 -side of tl'- Je 
 
 aneurismaj, th. 
 
 '''t; left temper 
 
 transverse part 
 
 radial and temi 
 
 ference with th. 
 
 "■'i'J«t an afifect 
 
 coric-pondin^r , 
 
 fallacy i,;ust noi 
 
 ■'"'iy i>e occludec 
 
 '"f '>eing diJate 
 
 taken mto consic 
 
 ^'f tlie sphycrrp 
 
 '''«'W^, tniiioitys, 
 
 oirotid aneurism 
 
 r''"ciples detaile( 
 
 ^•'tcsar ■ :^^^^ 
 
 careful .•,,. ,,■ . 
 
 luhiitwrr or cysth 
 
 •I'leiinsm by noti 
 
 '"i<i side .of the n 
 
 "wst fixed part of 
 
 f 'e sterno-mastoic 
 
 '''wn during de-, 
 
 ■ineunsm close to'' 
 
 '^'M^^cmcHt of the ti 
 '"tHrnal from he 
 
 suftc.ently to cau 
 ^'^"du.on is usua 
 ^''i<-''"' P«"lpation. 
 [ Treatment \\' 
 
 '"'"'nation, nmpyc, 
 «^es, the vessel be 
 f s'xth ^.ertel,ra 
 f""^li the ^•ertel 
 '■'"■' <'"")-hyoi(| is 
 ^:ei>e.ally with gre', 
 '■'^' "^T'^-. proximal 
 "P^'rat.on (lirasdor' 
 
 Aneurism of the E 
 
 '"'^■^'^".'^ion of one 
 
 II 
 
ANEURISM 
 
 243 
 
 carotid or subcla\ian iineurism. A " tracl^eal tug" indicates an 
 aneurism of the aorta ' (P. Gould). The differences in the pcfi- 
 pkcnil pulses may also give useful information. The two radial 
 pulses should he first examined ; if they are etiually affected, an 
 aneurism of the ao*'ta on the cardiac side of the innouJnate is 
 indicated ; if they are equal and normal, an aneurism on the distal 
 side of tl"; left subclaxian. If the left radial pulse is alone 
 aneurismal, the root of the left subclavian is diseased, whilst if 
 the left temporal is also affected, it suggests an aneurism of tlie 
 transverse part of the arch beyond the innominate. When both 
 radial and temporal vessels on the right side show signs of inter- 
 ference with the pulse, innominate aneurism is probably present, 
 whilst an affection of only one of t.iese branches indicates that the 
 coiici-ponding carotid or subclavian is dilated. One source of 
 fallacy n;ust not be forgotten, viz., that any one of these trunks 
 may l)e occluded or compressed by a neighbouring aneurism with- 
 out being dilated, and hence the quality of the pulse nuist be 
 taken into consideration rather than its actual volun^ie, and to this 
 end the sphygroograph is a useful adjunct in diagnosis. From 
 iihscess, tmnouys, oy enlarged glands with a transmitted impulse, a 
 carotid aneurism is recognised by an application of the geneial 
 principles detailed abo\'e (p. 230) ; but when the artery conuuuni- 
 cates ar ' loulse to a mass through which it passes, only \ery 
 rareful "x:;! .ination will reveal the exact nature (^f the case. 
 Pulsating oy cystic goitre may be distinguished from a carotid 
 I aneurism by noting that the goitre is not, as a rule, limited to 
 one side .of the neck, the isthmus being also invohed; that the 
 most lixed part of the tumoiu" is in the median line, and not under 
 I the sterno-mastoid muscle, and that the swelling nunes up and 
 I Jown during deglutition, an aneuris'u remaining fixed. An 
 I aneurism close to the bifurcation may be simulated by an abnormal 
 I irniUf^cment of the terminal hyanclies, the external carotid crossing tiie 
 I internal from behind fcnwards, and being pushed outwards 
 I sufficiently to cause a pulsating swelling beneath the skin. This 
 I uindition is usually symmetrical, and can be recognised by 
 I aireful palpation. 
 
 I Treatment. — When the aneurism has been situated near the 
 I bifurcation, cvmpyession has been practised with adxantage in a few 
 I ci'.i-es, the vessel being controlled above the trans\ erse process of 
 I the sixth vertebra, so as not to interfere with the circulation 
 I through the ■/ertebral. Ligature of the carotid aiiove or below 
 I the onio-hyoid is, however, the treatment usually adopted, ;uid 
 
 ■ itenerally with great success. If the aneurism is near tlie root of 
 
 ■ tile neck, proximal Hgature becomes impracticable, and the distal 
 
 ■ -cratioii (Brasdor's) must be undertaken. 
 
 I 
 I 
 
 Aneurism of the External Carotid is seldom met with, except as 
 '111 extension of one iiuohing the l)i furcation. The usual pheiio- 
 
 16—2 
 
244 
 
 A HANUAL OF SURGERY 
 
 inena are presented near the an.nle of the jaw, and well abcne the 
 thyroid cv. "tilage. Pressure results are early experienced, <-.;'., 
 paralysis of one side of the tongue through implication of the 
 hypoglossal ner\e, aphonia, or dysphagia. In suitable cases, the 
 sac may he dissected out after securing the branches arisini,^ from 
 it, as recently reconunended hy Walsham.''' Failing this, i!ie 
 connnon trunk must be tied. 
 
 Aneurism of the Internal Carotid (extracranial portion). — Ihin' 
 
 is but little difference between the symptoms arising from tliis 
 condition and those caused by an aneurism of the bifurcation or 
 of I lie external carotid, except that the swelling projects iiiDif 
 into the pharynx, from which it is separated merely b\ the 
 pharyngeal wall. It appears as a tense pulsating tumour, placed 
 immediateh- under the mucous membrane, and looking dan^ei- 
 ously like an abscess of the tonsil. The Treatment consists in 
 tying the common carotid. 
 
 Intracranial Aneurism. — Any of the arteries within the skull 
 may become the site of an aneurism, but this condition (hcuis 
 more commonly upon the internal carotid and its branches than 
 upon those arising from the \ertebrals, although the basilar .ucerv 
 is more often afVected than any other single vessel. The aneurisms 
 are generally fusiform in character, and their origin is often 
 extremely obscme, a blow or fall being sometimes adduced lo 
 explain them ; in children they are stated to result from thr 
 lodgment of septic emboli. They sometimes grow to a (on 
 siderable size before causing obvious symptoms; the patient uku, 
 in fact, have continued without any manifestation of the disease. 
 until suddenly seized with a rapidly fatal apoplexy from rupture 
 of the sac. If there are any symptoms, they are due rather to 
 compression of the brain than to erosion of the more; resistant 
 bony structures. I'ain which is more or less fixed and continuous 
 may be complained of, or there may be a feeling of pulsation, 
 or of opening and shutting the top of the skull. vSight, hearing. 
 and other functions of the brain, may also be interfered with, luit 
 physical changes in the eyes, such as optic neuritis or atrophy, are 
 not induced, unless there is direct pressure on some part of the 
 optic tract. Occasionally a loud whizzing bruit may be heard 
 on auscultating the skull. The only Treatment possible, if a 
 diagnosis can be established, is ligature of the common carotid 
 artery, and e\-en this will be of little use if the basilar is 
 affected. 
 
 An Intra-orbital Aneurism is recognised by the existence of a 
 pulsating swelling of the orbit, causing protrusion of the eyehall 
 (exophthalmos) and congestion of tlie conjunctixal and deeper 
 
 * Tiiiiis Mid Chir. Sill., I'eoruary 28, iHijij. 
 
 '.irticuJarly those 
 
ANEURISM 
 
 245 
 
 vessels. A feeling' of ptiin or tension in the orbit may exist, 
 and gradiuilly vision is impaired, whilst the cornea may become 
 op.uiue from exposure, due to the inability of the lids to cover 
 it ; finally, the whole {jflobe may be disorganized. The symptoms 
 sometimes commence with a definite snap q: crack, as though 
 something had given way in the orbit ; or they may follow a 
 penetrating injury or a blow. Occasionally the condition is con- 
 ijenital, or arises soon after birth. 
 
 Several pathological lesions are included under the title ' intra- 
 orbital aneurism': {a) If congenital, it is probably a case of 
 aneurism by anastomosis; this, however, is not common, being 
 present only in two out of seventy-three cases collected by 
 Ki\ ington ; {h) if traumatic in origin, whether due to a pene- 
 trating injury or not, the case is probably an aneurismal varix 
 between the internal carotid and cavernous sinus, or a genuine 
 traumatic aneurism of the ophthalmic artery ; {c) if idiopathic, it 
 IS possibly due to thrombosis of the cavernous sinus, or to spon- 
 uineous aneurism of the internal carotid or ophthalmic arteries. 
 
 Diagnosis.^ — To determine the precise cause of a pulsating 
 tumour of the orbit is by no means an easy matter, inasmuch as 
 sarcomata are occasionally met with exhibiting many of the 
 characters of intra-orbital aneurism. Careful palpation will, liow- 
 -^ver, generally demonstrate the existence of a more definite 
 tumour, and a less-marked expansile pulsation in the sarcoma, 
 whilst the bruit is less distinct. The distortion of the eyeball 
 and ocular axis is often considerable in nialignant tumours, but 
 
 iMon is not so early affected. 
 
 Treatment. — Electrolysis and ligature of the common carotid 
 
 e the only means which hold out any prospect of success, 
 ail J of these the former should always be first tried. In the 
 mn^'enital cases its application has been very successful, but in 
 those due to trauma it is very likely to fail. 
 
 ; I 
 
 Subclavian Aneurism is most frequently seen in men, and 
 particularly those who use their arms nuich in lifting, such as 
 Mildiers and sailors ; the right \essel is more often affected than 
 the left. Any jiart of tlie arterv may be invoked, but the greatest 
 dilatation naturally occurs in the third portion. A pulsating 
 tuiiioiu" de\'elops in the subclavian triangle, which may reach 
 ahme the cla\i(de, but chiefly extends backwards, outwards, and 
 >!o\vn\vards, causing pressure effects upon the veins and nerves 
 if the arm, and also hiccough by irritation of the phrenic. 
 Hicasionally it encroaches on the dome of the pleura and ai^ex 
 111 the lung, and has been known to burst into the pleural ca\-ity. 
 It does not increase in size very rapidly, i^eing surrounded by 
 dense unyielding structures, and never compresses the trachea or 
 H'snphagus. 
 
 Nu difficulty present.^ itself in Diagno»;;o as a rule, although in 
 
246 
 
 A MANUAL or SURGERY 
 
 the early stages it may be somewhat simulated by a normal 
 artery pushed forwards by an exostosis of the first rib, or bv a 
 supernumerary cervical rib. A pulsating sarcoma growing Ironi 
 any of the neighbouring structures may also resemble it scjine- 
 what closely, but the pulsation is then rarely so limited in extent 
 as in an aneurism, and a definite tumour can usually be felt. 
 
 The Treatment of subclaxian aneurism is sunounded with 
 tlifficulties, and the results hitherto obtained have been most 
 imsatisfactory. Extirpation has been undertaken in one case* 
 with success after turning up the middle third of the clavicle, huf 
 the aneurism is seldom sufficiently limited to allow of the aiiplica- 
 tion of this ideal proceeding. Should any undilated portion of 
 the artery be a\ailable outside the thorax, digital compression on the 
 cardiac side may be attempted. Direct pressure, manipulation, 
 gahano-puncture and needling the sac according to Macewen's 
 method, have been adopted with occasional success, but cannot 
 be relied on. Ligature of the innominate trunk suggests itself as the 
 operation to be adopted for cure by the Hunterian method, and 
 recent records would certainly encourage one to repeat it in anv 
 suitable case, since most of the fatal results occurred prior to the 
 introduction of antiseptic surgerv, death resulting from sepsis or 
 secondary ha'morrhage. It would appear that the simultaneous 
 ligature of the carotid or vertebral trunks with the innominate is 
 essential to success, in order to prevent the rapid backtlow on the 
 distal side of the ligature which otherwise occurs ; in addition. 
 the coats of the vessel must be approximated by a broad animal 
 ligature, e.g., of gold-beater's skin, and not di\'ided. Successful 
 cases ha\e been reported by Coppinger (January, 1893), Lewtas 
 (18S9), Danks (1SS3), IJurrell, C. J. Symonds (1894), and Smytli 
 of New Orleans (1865). In the last case secondary hajmorrhajje 
 ensued, which was, however, controlled by tying the vertebral 
 and filling the wound with shot, the patient subsequently li\in,i^ 
 ten years ! 
 
 Ligature of the first part of the subclavian has also been attempted 
 for the cure of aneurisms involving the lower part of the vessel. 
 but until recently it was so uniforndy fatal that it was con- 
 sidered quite an unjustifiable proceeding, the first nineteen cases 
 all dj-ing. Glutton,! however, has reported a successful case, 
 the ligature being applied (without dividing the coats) on the 
 proximal side of the thyroid axis and internal mammary vessels, 
 which were also secured. The first part of the axillary and the 
 superior intercostal had also to be tied before pulsation in the 
 aneurism ceased. Ligature of the second part of the subchnian 
 has been advantageously employed in suitable cases where the 
 aneurism was situated below it. Distal ligature of the third part 
 has also been attempted, but without much success. 
 
 * Moynihan, Anihils of Surmiy, July, uSyS. 
 I Trims. Med. Chiv. Soc, vol. Ixxx., p 391 
 
 As a last resour 
 or have failed, the 
 Ciisson may be fc 
 ..iisfid ligature as m 
 usually unsuccess 
 blood needed for t 
 >ac, and there is n( 
 ,it the limb. A fe 
 have been reportec 
 
 Axillary Aneurii 
 
 ^tretched arm, or 
 dislocations, or of 
 merely those due t 
 pressure, which m; 
 of the arm. Whe 
 p'llsaling swelling 
 It placed lower do 
 totally fill up the I 
 upwards, or the an 
 conditions of seriou 
 should not be diflic 
 ':kitds with a transr 
 1/ ///(' humerus, are 
 method of onset an 
 well as by a careful 
 Treatment.— Con 
 ?:ibcla\ian artery is 
 tully adopted. Th 
 dii^ital pressure, an 
 siderahle period ol 
 care must be taken 
 collateral circulatio 
 clavicle, it may be 
 artery, due care bei: 
 
 Aneurisms of the 
 forearm, recjuire no 
 traumatic in origin, 
 
 Abdominal Aneur 
 
 i^eat of aneurism, eit 
 "r at the bifurcatio 
 •irising at that spot 
 the sacculated ty[)e. 
 on the splenic or me 
 Signs.— A pulsatii 
 line, and either close 
 
ANEURISM 
 
 247 
 
 As a last resource, where the above measures are impracticable 
 or have failed, the plan sugj,'ested by the late Sir William Fer- 
 iTusson may be followed, \iz., amputation at the slioiihhr-joint and 
 'jisiitl ligature as near the sac as possible. Distal ligature alone is 
 usually unsuccessful, owing to the fact that the great bulk of the 
 lilooil needed for the nutrition of the arm still passes through the 
 ,,ic, ;ind there is no means of checking this except by the removal 
 
 1 the limb. A few successful results of such heroic treatment 
 
 .,ive been reported. 
 
 Axillary Aneurism is usually the result of fails on the out- 
 -tretclied arm, or injuries to the shoulder, such as fractures or 
 dislocations, or of attempts to reduce them. The Symptoms are 
 merely those due to the presence of a pulsating tumour and its 
 pressure, which may cause pain, local and neuralgic, or (I'dema 
 ,ii the arm. When the upper part of the vessel is affected, a 
 irilsaling swelling is felt immediately below the clavicle, Avhilst 
 it placed lower down it projects more into the axilla, and may 
 totally fill up the hollow. Occasionally the clavicle is displaced 
 upwards, or the aneurism may extend beneath it into the neck, 
 I mditions of serious import as regards treatment. The Diagnosis 
 >liou]d not be diflicult. Chronic enlargement and abscess of tlie axilUwy 
 iknds with a transmitted impulse, or a pulsating sarcoma of the head 
 
 f ikf humerus, are recognised by a careful consideration of the 
 iicthod of onset and of the original situation of the swelling, as 
 Aell as by a careful digital examination. 
 
 Treatment. — Compression or ligature of the third part of the 
 
 ;bcla\ ian artery is recpiired, and both plans have been success- 
 :;illy adopted. The former nuist be carried out by means of 
 difjitai pressure, and will probal)ly have to extend over a con- 
 Mcierahle period of time. Where ligature is employed, great 
 
 arc must be taken not to wound the branches which carry on the 
 collateral circulation. If the aneurismal sac extends under the 
 clavicle, it may be necessary to secure the second part of the 
 artery, due care being taken of the phrenic nerve. 
 
 Aneurisms of the brachial artery, or of any of the vessels oi" the 
 lorearni, refjuire no special notice. They are almost invariably 
 :rauniatic in origin, and should be treated by extirpation. 
 
 Abdominal Aneurism. — The abdominal aorta may become the 
 seat of aneinism, either at the upper part near the cudiac axis, 
 ir at the bifurcation ; in the former case, some of the branches 
 •iriMug at that spot are also usually invoked, and the disease is of 
 the sacculated type. Occasionally aneurisms form independently 
 on the splenic or mesenteric vessels. 
 
 Signs. — A pidsating tumour is observed, usually near the middle 
 iine, and either close to the umbilicus or in the epigastric notth ; 
 
248 
 
 A MANUAL OF SURGERY 
 
 the pulsation is expansile in type, and remains the same in character 
 whatever the position of the patient. Pressure signs are mainly 
 confined to pain, localized in the hack from erosion of the verl(lir;c, 
 or ncuralj^Mc from pressure on tiie solar plexus or lund)ar nir\i's, 
 whilst (i'dema of the lower extremities may arise from compression 
 of the \ena ca\a. There may he some concurrent derangement 
 of the intestinal functions. 
 
 Diagnosis.— Many conditions give rise to epigastric pulsation. 
 hut the majority of them can be readily distinguislied from 
 ahdominal aneurism hy careful examination, if necessary, under 
 an ana'Sthetic. Cardiac pulsations may he felt in the epigastrium 
 when the heart is dilated, hut shoidd he easily recognised ; as also 
 an impulse transmitted from the aorta through a collection of 
 fa'ces, or a cancerous growth. The examination of such a case 
 should he conducted not only in the dorsal decubitus, hut also 
 with the patient lying on his abdomen, or kneeling forwards so as 
 to remox'e the weiglit of the viscera from the aorta. The pulsation 
 will under such circumstances cease, or become much diminished. 
 A large accumulation of ahdominal fat will seriously interfere with 
 any satisfactory inxestigation. 
 
 The Treatment of ahdominal aneurism is necessarily one of 
 great difliculty from its position and relations. Ligature of the 
 \essel even on the distal side has never yet been attempted for tlii.> 
 condition, and hence, failing medical treatment by rest and diet, 
 coiiiprcssiiii! has been relied on, being applied either on the distal or 
 proximal sides of the sac. In six cases of proximal compression 
 three successes were reported, one failure, and two deaths ; in four 
 cases of distal pressure, two failures and two deaths. Chloroform 
 is needed for the application, and Lister's tournicjuet has usually 
 been employed. Tlie patient's diet is limited on the precedinj,' 
 day, and only fluid nutriment gi\en on the day itself; the bowels 
 nnist he thoroughly and completely emptied. Care must he taken 
 not to injuriousl}' conipriss the \iscera, for the pressure has often 
 to he maintained for some considerable time, \arying from one to 
 twenty hours ; if properly adjusted, hut little force is needicl. It 
 is still within the realm of pcjssibility that ligature of the aorta in 
 a suitable case may pro\e successful. More recently treatment 
 by needling the sac has been employed, and certainly in Maeewen's 
 hands at least one case has been brilliantly successful. There is 
 also one instance on record where the introduction of wire into 
 the sac, combined with electrolvsis through the wire hy vStewart's 
 method, cured an aneurism as large as an orange; the abdomen 
 was oi)ened, antl electrolysis was maintained for thirly-se\en 
 minutes. 
 
 Iliac or Inguinal Aneurism arises from either the coniiDon or 
 external iliac, or honi the connnon lenujral, and usually tends to 
 spread upwards towards the abdominal cavity. It is fretiuently 
 
 j,icculated in type, an 
 p shape is determi 
 |>(ial or other struci 
 
 .;;iiptoms are \ery t 
 ixrienced in the \ein 
 liniiot be well mista 
 l-rtcially when situat 
 
 ilistiiiguish from a j 
 I Treatment.— Aledic; 
 riiinal aneurisms ; j 
 Iminon iliac, where tl 
 
 i!)e ahdominal pari* 
 iNUccess. It is carri( 
 
 ■the lingers, and m;i 
 Ircssure. Ligature of 
 frmed for inguinal ant 
 
 lit'ing employed in 
 |:r is sometimes neec 
 N of the retro-peri 
 h.hut the introducti( 
 Id the recognition of t 
 liddJe coats in such 
 1-cptic animal ligatures 
 J« rti instances ligatiiyc 
 
 ililfused iliac or in 
 Iked, six of the pat 
 \. sur\i\ing as long 
 
 ticahle, extirpation s 
 pssful case has beer 
 
 [Aneurisms of the G 
 
 piiatic in origin, anc 
 pin the buttock, the 
 ptic notch, whilst tb 
 :^"iv intrapehic. Pu 
 pi on au.scultation. 
 
 |atic nerx'e is a prou 
 My. The Diagnosis 
 ping sarcoma, and 
 pin the practice of t 
 pits hitherto obtained 
 ^ins; out the clot, an. 
 
 fjiiirnit,^ operatix-e de> 
 i.'iiture of the internal 
 
 jalitahle degree of su( 
 •|"1 was employed. 
 
 Ny siniplilies the op 
 
 pproreeding are mot 
 
ANEURISM 
 
 249 
 
 ccul'ited in type, and is certain sooner or later to become diffuse. 
 > shape is tleterniined hy the unecpial pressure exercised by 
 cial or other structures, sometimes lea(hn<f to lobulation. The 
 iiplonis are very typical, li.id pressure effects are mainly e\- 
 friciiced in the \eins and nerves of the \v<^. The Diagnosis 
 lannot be well mistaken in the early staj^'es, but later on, and 
 jirtially when situated hij^di in the iliac fossa, it may be difficult 
 ilistinj^'uish from a pulsatinj^^ sarcoma. 
 
 Treatment. — Medical treatment alone is of little a\ail in curinj^' 
 ,'uin:il aneurisms; but proximal compression of the aorta or 
 immun iliac, where the situation of the swellinj^f and the thickness 
 {the abdominal parietes permitted it, has had a certain amount 
 ;uLcess. It is carried out by means of a tourni(]uet, shot-baf(, 
 the imgers, and may be adxantaf^'eously cond)ined with distal 
 ::t>siire. Ligature of the external iliac has been frefjuently per- 
 bied for inguinal aneurism, and with such success as to warrant 
 ■.M\x\\i, employed in all suitable cases. Ligature of the common 
 ;x is sometimes needed for aneurisms in tlie iliac fossa. The 
 wihs of the retro-peritoneal operation were by no means satisfac- 
 :;v,l)ut the introduction of the trans-peritoneal method of lij^^ature 
 si the recof^nition of the importance of not di\iding the inner and 
 die coats in such a large vessel, combined with the use of 
 ptic animal ligatures, are certain to lead to better results. In 
 Veil instances ligatnre of the abdominal aorta has been undertaken 
 •diffused iliac or inguinal aneurism, and in all a fatal issue 
 iowed, six of the patients dying within forty-eight hours, only 
 t sur\i\ing as long as the tenth day. Of course, wherever 
 acticable, extirpation should be resorted to, and at least one most 
 icessful case has been published. 
 
 Aneurisms of the Gluteal and Sciatic Arteries are usually 
 
 p)iatic in origin, and present as pulsating swellings of variable 
 
 bin the buttock, the gluteal situated at the upper part of the 
 
 Imtic notch, whilst the sciatic lies more deeply, and may be 
 
 ply intrapelvic. Pulsation is well marked, and murmurs are 
 
 pd on auscultation. Pain in the limb from pressure on the 
 
 ptic lUTNe is a prominent symptom, especially in the sciatic 
 
 Kty. The Diagnosis is by no means simple, especially from a 
 
 liiating sarcoma, and many instances of mistakes ha\e occurred 
 
 a in the practice of eminent surgeons. Treatment. — The best 
 
 K'Jts hitherto obtained ha\e followed the laying open of the sac, 
 
 :.ini; out the clot, and tying the afTected trunk — a proceeding 
 
 i\mn<^ operatixe dexterity and skill of the highest order. 
 
 Bitiiie of the internal iliac has also been performed, and with 
 
 ['editable degree of success, even where the old extra-peritoneal 
 
 pod was employed. The use of the trans-peritoneal route 
 
 ply simjilihes the operation, and the more recent records of 
 
 p proceeding are most satisfactory. At the present time it 
 
 t 
 
2;o 
 
 A MANUAL OF SURGERY 
 
 should certiiinly l)c undertaken in preference to tlie phin ul l.iyiii^ 
 open the sac. 
 
 Femoral Aneurism is the title given to one forming in the (oiirsn 
 of the superficial femoral artery. It is not uncommonly luhulaij 
 and occurs almost inxariahly in males, and as often on one side dfl 
 the bcxly as the otiier. The Diagnosis nectls no discussion, as tliel 
 disease runs a typical course, and the Treatment consists either inl 
 extirpation, compression at the groin, or ligature of the cuninion| 
 or superluial femoral trunk. 
 
 Aneurism of the Profunda Femoris Artery is a \ ery ran- con-| 
 dition, presenting the ordinary features of a pulsating tiinunit^ 
 situated amongst the muscles on the inner side of the tliiL;li, liJ 
 causing no diminution of the pulse in the popliteal or tiliiaj 
 vessels. The suiH-rficial femoral may be felt coursing mcr iij 
 but (]uite distinct. Compression by a shot-bag in the '^min] 
 or jiy a tournifpiet, may be sufiicient to effect a cuie, uiiilsi 
 ligature of the common femoral or external iliac may be resortecf 
 to, if necessary. 
 
 Popliteal Aneurism (I'ig. 67) occurs almost invariably in inenj 
 constituting a pulsating tumour in the ham, rendering the knej 
 
 painful and stiff, and so much do the symj)] 
 toms resemble those of chronic rhcumatisn 
 that in e\ery such case the popliteal spacJ 
 should be examined. The limb is usualij 
 semiflexed, and the aneurism, which is of 
 sacculated type, often increases rapidly i| 
 size. If the main swelling is situated to tlif 
 front of the vessel, there is some likelihoo 
 of the knee-joint becoming implicated, anl 
 neighbouring bones carious ; when it extena 
 posteriorly, diffusion is not uncommon^ 
 followed by gangrene, on account of tl; 
 pressure exercised not only upon the \ei^ 
 but also upon the articular brandies of tfc 
 popliteal artery, which are most iiiiportaij 
 factors in maintaining the collateral circulj 
 tion. The diagnosis has to be made froj 
 chronic enlargement and abscess of tlf 
 glands in the ham, but in these there is lei 
 disturbance of the circulation in the fool 
 from bursal tum.ours, by their want (jf mobilil 
 and pulsation ; or from solid tumours, 
 pulsating sarcoma of the femur or lihia, fro 
 which it can be recognised by attention to the general princip^ 
 already enunciated. In a few instances spontaneous cure 
 resulted from the pressure of the sac upon the artery above. 
 
 t'lo. 67. — I'0I'LITi:.\I. 
 .\NECKiSM. 
 
ANEURISM 
 
 25« 
 
 Treatment. — Compression is eminently successful in many of 
 ]cse cases, whether applied in the f,aoin or by Reid's method. 
 ii.';Uiirc! of the femoral artery at the apex of Sciapa's trianf^ie is, 
 I wovtM, the plan most commonly adopted, and with the j^aeatest 
 cj^iss. In cases where either of these methotls has failed, or 
 mere the aneurism has become diffuse or recurred, extirpation of 
 sac is the best course to adopt. 
 
 Ligature of Vessels. 
 
 Ligation in continuity is an operation performed to arrest the 
 
 bof blood to the j)eriphery, in order either to check luemor- 
 
 lage, or to promote the cure of an aneurism, or to diminish the 
 
 iieof f,nowth of some tumour, or to beneficially inlluence some 
 
 tnpheral or^an by reducinj^' its blood-supply (as in tyin^ the 
 
 pernal iliac for enlarf^^ed prostate), or as a preliminary to reniov- 
 
 •sonie vascular structure, such as the tongue. 
 
 |T!ie Instruments needed are as follows : scalpels, dissectinjjf 
 
 [ceps, director or blunt dissector, fortipressure or artery forceps, 
 
 |tjnt hooks, retractors for deep wounds, aneurism needle, ligature, 
 
 (lies, and sutures. 
 
 |lht' Material to be employed for the ligature has been discussed 
 
 sewht'ie {p. 200). Sulpiiuro-chromicised catgut is that most 
 
 jimonly employed for all but the largest trunks, and for its 
 
 blication to an artery in its continuity the following plan may 
 
 liadopted : A ime loop of catgut having been passed under the 
 
 Bsel by means of an aneurism needle, a prepared ligature, con- 
 
 jins of three strands of catgut about 10 inches long, knotteil 
 
 ijethtr at each end, is threaded through the loop, which is then 
 
 prawn, carrying the ligature under the \essel. The advan- 
 
 pof tiiis method are, that the aneurism needle, b'^ing threaded 
 
 psucli line gut, passes easily and without friction, whilst the 
 
 tlie loop to draw the ligature back obviates the difficulty, 
 
 |ire the artery is deeply placed, of threading the needle il 
 
 mxi unarmed, as is sometimes advised. The substitution of 
 
 pe strands for a single ligature distributes the pressure over a 
 
 prarea. and is considered more certainly to effect occlusion. 
 
 bto the Operation itself, the strictest asepsis must be main- 
 
 pd, the skin and instruments being thoroughly purified pre- 
 
 blv. The artery is examined, as far as is possible, so that a 
 
 pile portion may be selected for applying the ligature. An 
 
 -ion is made cleanly and neatly through the skin and sub- 
 
 tneous tissues, and of sufficient size to allow of the necessary 
 
 tipulutions. The various structures met with on the way 
 
 |te artery are recognised, and drawn, if need be, to one or 
 
 [Other side, so as to lay bare the sheath of the vessel. It 
 
 post important that these anatomical landmarks or rallying 
 
 hould each be seen or felt in order, so that the operator 
 
s>rvi 
 
 % ^ n% 
 
 ^. 
 
 
 
 IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 1.0 
 
 I.I 
 
 m m^ 
 ■- IIIIIM 
 
 ;: m 
 
 M 
 
 2.2 
 2.0 
 
 1.8 
 
 
 1.25 
 
 — 
 
 1.4 
 
 1.6 
 
 
 -• 6" — 
 
 
 ► 
 
 Photograpiiic 
 
 Sciences 
 
 Corporation 
 
 23 WEST MAIN STREET 
 
 WEBSTER, N.Y. 14580 
 
 (716) 872-4503 
 
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 Q- 
 
 (P.r 
 
 i 
 
2?2 
 
 A MANUAL OF SURGERY 
 
 :■■. ■■•',j 
 
 may not be led astray or miss the vessel. Naturally it is easiea 
 to iind the artery in the living subject than in the dead, th| 
 pulsation being of the greatest assistance. The sheath, liavinJ 
 been exposed, nuist now be opened over the situati(>n of M 
 artery by a few delicate strokes of the l.nife ; a portion of M 
 sheath should be picked up between the blades of the forcepsl 
 incised along the longitudinal axis, and stripped off the artervj 
 taking care to keep the back of the knife towards the vesse 
 This incision should be about 4 inch in length, and shoukl opeij 
 not only the general, but also the special, sheath of the artery, 
 such exist. Each side of the incision in the sheath may then I 
 grasped with catch forceps, so as to steady it, whilst the aneuri?n| 
 needle is inserted unarmed, and gently manipulated up and dowiij 
 so as to free the vessel all round, a matter of no great difificultv 
 if the sheath has been sufficiently opened, and the actual arterial 
 wall fairly exposed. The ligature may then be passed throuijl 
 
 Fk 
 
 68. — Position of Fingers and Hands in tvinc Licatuki:. 
 
 (TiLLMANNS.) 
 
 f I 
 
 tlie eye of the needle, and carried round the vessel. It is tiedi 
 a direction exactly at right angles to the longitudinal axis, anc 
 doing so the artery must not be dragged out of its sheath, hiu^' 
 ligature should be tightened by the tips of the forefingers meetinj 
 upon it (Fig. 68). A reef-knot is all that is necessary for securitV 
 more complicated knots are too bulky to be recommended. 
 
 The rule usually followed is to pass the needle fi'0)ii impoytant sUi 
 tityes, such as the vein, but really this is a matter of little importand 
 when the above directions have been carefully carried out,anJ 
 especially in superficial vessels. Should the vein he ciccidcnhili 
 puiictitred, the needle must be at once withdrawn, and the piinij 
 ture in the vein secured by ligature, whilst the artery is tief 
 a little higher or lower. In dealing, however, with the sinaiij 
 vessels, where the vena comites are in close contact with tl^ 
 artery, no harm will attend their inclusion in the ligature. 
 
 We have already discussed the (juestion of whether or not til 
 ligature should be tied so as to divide the inner and middle coati 
 in very large trunks like the innominate, first part of the siil 
 clavian, or conuuon iliac, it is wiser only to completely approxj 
 mate the walls, and not attempt any rupture of the intinia. 
 
 It is a well-known fact that all arteries are maintained in tlj 
 
 [irious pressure of a 
 
LIGATURE OF VESSELS 
 
 253 
 
 I'tiody more or less upon the stretch, as evidenced by their retrac- 
 Icon within the sheath on complete division. A certain amount 
 |oi lonf(itudinaI tension must therefore always exist upon any 
 p,irt of an artery to which a li<j;ature has been applied in its 
 jcontinuity, a condition which may presumably predispose to 
 [secondary haemorrhage. To obxiate this, it has been suggested 
 ItJiat two ligatures should be applied, and the vessel di\ided 
 jbetween them. This plan may be used with advantage in situa- 
 Itions where the artery is easily reached, but is scarcely feasible in 
 Icnie of the deeper operations. 
 
 After - Treatment. — -The ordinary antiseptic precautions are 
 
 [taken in regard to the wound, which should be healed and all 
 
 Ititdies removed in eight days ; but the patient must be kept at 
 
 ]iest for some time longer to allow the tissues to consolidate, 
 
 :specially in dealing witJT the larger \-essels and in elderly people. 
 
 \hen the main artery to one of the extremities has been tied, the 
 
 iiih should be w-rapped in cotton-wool and slightly raised. If 
 
 Itiiere is any likeliiiood of gangrene, as in the lower limbs of 
 
 kderly people, the extremity should be thoroughly purified, and 
 
 Irapped in aseptic wool immediately after the operation, in order 
 
 [to avoid septic complications. 
 
 There are two great dangers liable to follow the ligation of an 
 ^rtery in its continuity : 
 :. Secondary Haemorrhage {vide p. 207). 
 
 ;. Gangrene, which may arise from a variety of causes : 
 Troin simple loss of vitality, the maximum amount of blood 
 Mismitted by the collateral circulation being insufiicient to 
 jiiaintain in life the whole of the part supplied by the artery 
 L'uted. This is particularly the case when the peripheral vessels 
 pin a condition of calcareous degeneration. The tissues which 
 hceive the smallest amount of blood die first, e.g., the fingers or 
 ps, 0'- the subcortical white substance of the brain. Severe loss 
 blood after the operation, as from secondary hemorrhage, is 
 ^Iso sufficient in some cases to determine tissue necrosis. Under 
 ; circumstances it always takes on the dry form if involving 
 |lie terminal joints of a limb, but in more fleshy parts it may be 
 Nst. (/;) Interference with the venous return, as by injury to 
 li^ vein during operation, such as inclusion in the ligature, or 
 |lirombosis induced subsequently by septic periphlebitis, is very 
 ' to cause gangrene, and then it is of the moist type ; the in- 
 liirious pressure of a tight bandage, obstructing the venous circulr.- 
 wi'l have a similar effect, {c) Injudicious after-treatment, 
 luch as too great elevation of the limb, the application 01 cold 
 ptions, an icebag, or fomentations during the period of diminished 
 plity immediately following the operation, or e\ en an attack of 
 psipelas, may also bring about the death of some of the tissues 
 pvolved. 
 Every precaution must be taken to prevent the occurrence of 
 
254 
 
 A MANUAL OF SURGERY 
 
 ■ L 4 
 
 'n 
 
 gangrene, as indicated abo\'e, and as soon as there is any sus- 
 picion of its onset the whole Hmb must be thoroughly purified 
 and subsequently maintained aseptic. The Treatment of aseptic] 
 gangrene following ligature is expectant in character, the parts 
 being allowed to separate naturally. But if there is much pain 
 or any tendency to spread, or if septic mischief is present, ;,nvinJj 
 rise to fever and general disturbance, it is wiser to remove the! 
 limb well above the line of demarcation. 
 
 The Innominate Artery, as already mentioned (p. 246), lias now been tiedj 
 with success on six separate occasions out of a total of twenty-seven operations 
 and it may be anticipated that strict asepsis will enable surgeons to deal with 
 this vessel in the future without the terrible mortality that has hithertu accom- 
 panied the operation. 
 
 Operation. — An incision is made along the lower third of tlie anterior bordei 
 of the sterno-mastoid, and is prolonged downwards to sweep over the uppei 
 edge of the episternal notch. The platvsma, the superficial and deep fascii 
 are divided, and the anterior jugular vein secured if necessary between twi 
 ligatures ; the sterno-mastoid is drawn outwards, and its inner tendinous fibn 
 are divided, whilst the sterno-hyoid and -thyroid muscles are severed close i( 
 the sternum and drawn inwards. The carotid sheath is now laid l)are am 
 opened at its lower part, so as to expose the carotid artery and enable it ti 
 tied, and by following this downwards the innominate trunk is reached, 
 some cases it may expedite matters to remove portions of the sternum ai 
 inner end of the clavicle. The right internal jugular and innominate veins Ij 
 to the outer side of the vessel, but if much engorged may project over il 
 artery, and must then be drawn aside by retractors, whilst the inferior thyroi 
 plexus may course directly in front of the vessel, and even need to be liftatun 
 To the outer or right side are placed the vagus nerve and pleural sac, ai 
 these must be carefully separated from the artery, whilst the needle is pas 
 from without inwards, and from below upwards. A double-curved aneurii 
 needle will probably be required to effect this. A broad animal ligati 
 should be used for this vessel, and the inner and middle coats must not 
 divided. 
 
 Collateral Circulation. — Intniimnial : Vertebrals and carotids in the cir( 
 of Willis. 
 
 Face and Necli : Branches of the two external carotids across middle line. 
 
 Trunk : First aortic intercostal i^ith superior intercostal of subclavian ; iipi 
 aortic intercostals uith thoracic branches of axillary and intercostals of intei 
 mammary ; deep epigastric and phrenic ivitli terminal divisions of intei 
 mammary. 
 
 The Carotid Artery may be tied at one of two places, either above or 
 the level at which it is crossed by the anterior belly of the omo-hyoid. 
 line of the vessel is indicated by that drawn from thesterno-clavicularartic 
 tion to a point midway between the angle of the jaw and the tip of themasj 
 process, the bifurcation being situated on a level with the upper border off 
 thyroid cartilage. 
 
 Lifiatui'c above the Omo-hyoid. — This operation is usually chosen, if practical 
 since the vessel is here more superficial, the ligature being applied on a level J 
 the cricoid cartilage. The patient lies upon the back, w ith the chin raisedl 
 the head turnetl a little towards the opposite side. A j-inch incision is ma| 
 the line of the vessel, the centre on a level with the cricoid (Fig. O), \). 
 skin, platysma, antl fasciae are divided, and the anterior edge of the sti 
 mastoid clefined as the first rallying-point. The deep fascia is incised aioa 
 inner border, so that it may l)e drawn aside by a retractor; the stenio-ma 
 branch of the superior thyroid artery may lie divided at this stage, and a| 
 passing between the facial and anterior jugular may also need to be ligatl 
 
 On the inner side of 
 
 [rending forwards a 
 
 (he angle formed by 
 
 lelt and the sheath 
 
 upon it. It is open 
 
 needle is passed fror 
 
 L.pened, the vagus ne 
 
 Li^'iitKir Mow the O 
 
 [the above, but lower 
 
 \ ilie sterno-clavicular 
 
 [liaps the anterior fibn 
 
 ! muscles are retracted 
 
 jawn iijnvards. Th( 
 
 [ineneeclle being passe 
 
 :.iar both internal juei 
 
 ?.irtof their course ai 
 
 ' '"e artery. The in 
 
 Iton aside or ligature 
 
 The effects of ligature 
 
 pportance. Statistics 
 
 Iterated on cerebral sy 
 
 |!.rni of syncope from c 
 
 erebral softening, caus 
 ,:= ikely to result in abo 
 
 ff acute form of co 
 
 I'lhin a few hours, po^ 
 
 Nulla or to irritation 
 
 : 10 subacute infiamm 
 
 ttnesection. 
 
 Collateral Circulation 
 
 hlracranial : Commuij 
 ^;ernal carotids and ve 
 Nunda cer\-icis i^jth 
 fnnches of occipital anc 
 
 ligature of the Intenij 
 
 ;7r age and traurn^ 
 
 "'e life-ature is usuall 
 
 r.acticallv the sai 
 
 e[ An incision is mac 
 „^tre being opposite 
 
 ^'"■''II backwards, an 
 '"""P- The exte;na 
 ''f' and then the in 
 -Und the aneurism 
 ■^^ Collateral Circulati 
 
 llifature of the Externa] 
 
 Iwlymg the ligafJre 
 
 P 
 
 P«s- An incision is n« 
 ^'^^,;" length, its cem 
 
 IV ' '^'a'-^tric sough 
 
 My. difficult by the 
 
 !■ cial and superio, 
 
 ihe superior Jarv 
 
 ^"ecessarily be avoided) 
 
' ;^ 
 
 LIGATURE OF VESSELS 
 
 255 
 
 On the inner side of the wound the omo-hyoid muscle must now be looked for, 
 trendin.i,' forwards and upwards from under cover of the sterno-mastoid. In 
 the an,t;le formed by these two structures the pulsation of the vessel should be 
 lelt and the sheath readily recognised, with the descendens cervicis nerve 
 upon it. It is opened on the inner side, and the artery well cleared. The 
 i needle is passed from without inwards, and if the sheath has been efficiently 
 opened, the vagus nerve will run no risk of being included. 
 
 Liiiitiii'c hclo'u' the Omo-hyoid. — The incision is made in a similar direction to 
 
 ijhe above, but lower in the neck, reaching from the cricoid cartilage nearly to 
 
 the sterno-clavicular joint. The sterno-mastoid is drawn outwards, and per- 
 
 Ihapsthe anterior fibres may need to be divided ; the sterno-hyoid and -thyroid 
 
 Irauscles are retracted inwards or divided, and tho omo-hyoid can usually be 
 
 lirawn upwards. The sheath is thus exposed, and opened on the inner side, 
 
 jthe needle being passed as in the previous operation. It must be remembered 
 
 jthat both internal jugular veins are directed towarrls the right side in the lower 
 
 [part of their course, and hence the left vein is likely to lie somewhat in front 
 
 i the artery. The inferior thyroid veins may also be seen, and need to be 
 
 l\ix\\ aside or ligatured. 
 
 The cfficts of ligature of the carotid upon the brain are of great interest and 
 
 -iportance. Statistics go to prove that in about 25 per cent, of the patients 
 
 Iterated on cerebral symptoms manifest themselves, either immediately in the 
 
 ;:rm of syncope from cerebral anaemia, or in the course of a few days from 
 
 |.:erebral softening, causing convulsions, coma, and even death. A fatal issue 
 
 i'likely to result in about half the cases thus affected. Occasionally a some- 
 
 phat acute form of congestion of the lungs follows ligature of the carotid 
 
 iithin a few hours, possibly due to interference with the circulation in the 
 
 feedulla, or to irritation or injury to the vagus or sympathetics ; it may run 
 
 to subacute inflammation, and is best remedied by free stimulation, or 
 
 |v:?.e^ection. 
 
 1 Collateral Circulation. — Intnicyanial : Circle of Willis. 
 
 I IxUdiiiViial : Communications across the middle line of branches of the 
 luernal carotids and vertebrals ; inferior thyroid 'u'ith the superior thyroid ; 
 diinda cervicis li'ith princeps cervicis of occipital ; superficial cervical d'ith 
 Innches of occipital and vertebral. 
 
 [ligature of the Internal Carotid is rarely needed, but has been employed for 
 
 acrrhage and traumatic aneurisms. Any part of the vessel may be tied, 
 
 ;the ligature is usually placed just above the bifurcation. The operation 
 
 practically the same as for securing the common carotid, only at a higher 
 
 tl An incision is made along the anterior border of the sterno-mastoid, 
 
 tetitre being opposite the great cornu of the hyoid bf)ne ; the muscle is 
 
 well backwards, and the posterior belly of the digastric is now seen and 
 
 •ra up. The external carotid presents itself, and is carefully displaced 
 
 sards, and then the internal carotid in its sheath appears. The latter is 
 
 ■.al, and the aneurism needle passed from tlie jugular vein. 
 
 ^e Collateral Circulation to the brain is maintained by the circle of Willis. 
 
 iture of the External Carotid is occasionally required, the site of election 
 |i applying the ligature being between the superior thyroid ami lingual 
 Eches. An incision is made along the anterior border of the sterno-mastoid, 
 pes in length, its centre corresponding to the great cornu of the hyoid 
 t The edge of the muscle is defined and drawn outwards, and the posterior 
 yof the digastric sought for above, the hypoglossal ner\e lying just below 
 Ithe sheath is now opened below the tip of the great cornu of the hyoid bone, 
 fk' needle passed from without inwards. The operation may be i-enilered 
 klingly difficult by tlie presence of enlarged glands or \eins, especially the 
 l-ii, facial and superior thyroid, which often lie directly in front of the 
 The superior laryngeal nerve is placed immediately behind it, and 
 kneccssarily be avoided. 
 
 I I 
 
2S6 
 
 A MANUAL OF SURGERY 
 
 Collateral Circulation. 
 
 portion). 
 
 Viilc ligature of common carotid (eNtracrr 
 
 ami 
 
 Ligature of the Lingual Artery is cliierty needed as a preliminary in renidv^ 
 of tile organ for malignant disease ; it is also occasionally emplnved 
 traumatic cases. Tiie vessel can he secured eitlier close to its ori:,'in fnn 
 tile external carotid, or in the submaxillary triangle under comt ,,i m 
 Iiyoglossus muscle. The latter operation is more commonly perlnrmed, lij 
 the former is the better, inasmuch as the dorsal branches arisini^ from 
 vessel at the posterior border of the Iiyoglossus are also included. 
 
 In till' Sulinntxillaiy Tiian^k. — The patient lies on the back, with tlj 
 
 Fir,. 69. — Incisions kok Various Opek.vtions on Hkad ani' Nixk 
 
 A, For ligature of carotid ; V, for ligature of vertelM-al artery ; IS, fi>r li^auirei 
 of suhciavian ; C, for ligature of the first part of the axhlarv ; M. tor thel 
 internal mammary ; H, for the lingual ; E, flap incision used in trephining 
 for meningeal ha-morrhage ; V, flap incision for operations on tlie roots nfi 
 the fifth nerve 
 
 shoulders raised, and the head extended backwards and turned tt) tliej 
 opposite side. A crescentic incision commencing about i inch below anJj 
 external to the symphysis menti, and skirting the angle of the jaw, is made, f 
 the centre opposite the great cornu of the hyoid bone (Fig. O9, H). Thel 
 integument and platysma are divided, the lower border of the suhmaxillaiv 
 gland is defined, and along it the deep fascia is incised. The gland is iiowj 
 tlrawn upwards, and held o\er the margin of the jaw with a retractorj 
 (Fig. 70, Gs). On thoroughly opening up the wound the two bellies ot the| 
 
 through wiiich it cai 
 
 &'■ fascia, but must 
 
LIGATURE OF VESSELS 
 
 257 
 
 ,astric muscle {M hiv) are seen converging to the hyoid bone (Z), the 
 
 Interior belly passing superficial to the fibres of the mylo-hyoid muscle 
 
 '\m\ho), which course nearly transversely to the mandible, and of wiiich the 
 
 .-terior fibres may be di\ided with advantage. Tiie digastric tendon is drawn 
 
 |;un with a blunt lK)ok, antl in the space thus clearetl tlie hyoglossus muscle 
 
 ',[ l\\of^l) becomes evident, with its fibres passing vertically upwards, and 
 
 :;iiing upon it the hypoglossal nerve (5), coursing forwards tf) get undercover 
 
 idle myloiiyoid, and a little lower the ranine vein. The fibres of the 
 
 voijlossus are now divided transversely midway between the nerve and the 
 
 (:vnd lione, and in the opening made by their retraction is seen the artery (3), 
 
 j ■:;ij,' on the middle constrictor. Sliould it not be found in this situation, the 
 
 laision in the hyoglossus should be extended backwards, and the vessel will 
 
 ien usually come in sight. 
 
 kthc Ncc/i close to its Origin. — An incision is made along the anterior border 
 ;;tiie sterno-mastoid similar to that needed for ligature of the external carotid. 
 
 li(.. 70. — Li(;.\TURE ov Ijx 
 
 (a'.\; 
 
 ArTKKV. (Tll.LM.W.XS.) 
 
 i't siiliiTiaxillar)' gland (Gs) has been drawn over the side of tlic jaw with a 
 hook ; Z, hyoid bone; i, external carotid ; 2, internal jugular; 3, lingual 
 artery ; 4, ranine branch of facial ; 5, hypoglossal ner\e ; .1/ hiv, digc stric ; 
 M styl, stylohyoid ; M myho, myloiiyoid ; M 'lyci^l, hyoglossus. The 
 place wliere the artery is tied is indicated bv a window in llie hj-oglossus, 
 through wiiich it Ciin be seen. 
 
 T'l-Miiterior border of the muscle is drawn outwards, and the great cornu of 
 Midiyoid liDue defined. Tlie small space is now cleared between that bony 
 
 process and the posterior belly of the digastric, in which the artery can be felt 
 iK^h!!;.;; upon the middle constrictor, and secured just as it rises from the 
 
 fflenial carotid. Tlie operation is by no means so simple as the former. 
 
 Tile Facial Artery may be exposed and tied through a horizontal incision, 
 |:;nch in length, maile directly over the vessel as it crosses the lower border of 
 i'- jaw immediately in front of the masseter. The platysma will need division, 
 1 1^ 'Veil as the skin and fascia. 
 
 The Temporal Artery is reached in front of the auditory meatus, and as it 
 |t''^-^es the zygoma, through a vertical incision. It is merely co\ered by skin 
 |Ki1 fascia, but must be carehilly isolated from the auriculo-teuiporal ner\e. 
 
 17 
 
258 
 
 A MANUAL OF SURGERY 
 
 
 f: 
 
 The Occipital Artery is tied through an incision extending from tlie aptw of 
 the mastoid process backwards for about 2 inclies towards tlie occipital pro- 
 tuberance. The posterior fibres of the sterno-mastoid, the splenius and 
 trachelo-mastoid are divided so as to expose the artery as it emerges from the 
 groove on the under surface of tiie mastoid process, where it is easily secured 
 
 The Subclavian Artery has been tied in each part of its course, but niosi 
 frequently in the third. Ligatures of the first antl second parts are such unusual 
 l^roceetlings that we must refer students to larger text-"<)ooks for descriptions 
 
 Lif^iitiiir 0/ the third part is performed for axillary aneurism, for h.rmorrha^'e, 
 as a distal operation for aortic or innominate aneurism, and sometimes as a 
 jireliminary to amputation of the upper extremity. The patient is placed on 
 the back, close to the edge of the table; the arm is well depressed, and the 
 head turned to the opposite side. The skin is now drawn down by the leli 
 hand, and an incision j or 4 inches long made over the clavicle (l"ig ()(), ]]; 
 On releasing the skin it retracts upwards, so that the wound comes to he 
 situated about -h inch above the clavicle, and thus the external jugular vein is 
 more efficiently protected. The incision shoukl be placed witii its centre about 
 I inch to the inner side of the middle of the cla\'icle, and should expose the 
 space between the sterno-mastoid and trajiezius muscles, the fibres of wiiicli 
 ■ire di\ided to a suitable extent if they abnormally encroach upon the hone 
 The skin, superficial fascia and nerves, with the platysma, are dixided alon;' 
 the whole length of the incision, as also the deep fascia. The external jui^'ular 
 and other veins now come into view, often constituting a plexus, which nia\ 
 gi\e the surgeon much trouble ; when possible, they should be gently drawn 
 out of the wa)- by means of blunt hooks, but if necessary they must be tli\ iiled 
 between ligatures. The cellular tissue is then further incised in the line ot 
 the wcMuid, care being taken to avoid the transverse cervical and supra- 
 scapular arteries, the iformer of which is above the line of operation, whilst 
 the latter is hidtlen behind the clavicle, and should not appear. The posterior 
 belly of the omohyoid, if seen at all, is drawn upwards. Various layers oi 
 fascia must be carefully cut or torn through until the nerves of ;he brachial 
 plexus appear ; the finger can then readily define the scalene tuliercle on the 
 first rib. The subclavian \ein is situated in front of the finger, hut on a 
 lower level, whilst the artery itself can be detected pulsating under the pulp 
 of the finger between it and the rib. The cords of the brachial plexus are 
 placed abo\e and external to it, the lower cord passing down behind. The 
 needle is insinuated from above downwards, antl must be kept very close tn 
 the artery to pre\ent all possibility of including the lowest cord of the plexus 
 The operation in a thin patient may be easy, but in a stout subject, with a 
 short thick neck and high clavicle, the greatest difiiculty may be experienced 
 in finding the vessel. The chief dangers arise from wounding the aneurismal 
 sac, the pleural cavity, or the superficial \'eins, whilst the proximity of the 
 cords of the brachial plexus must not be fi-rgotten. 
 
 Collateral Circulation. — Hionuic set : Branches of the aortic intercostals and 
 internal mammary u7//( thoracic branches of axillary. 
 
 Scapular set : Suprascapular and posterior scapular icith subscapular and its 
 dorsalis branch in the \enter or on the dorsum of scapula. 
 
 Acromial set : Suprascapular i^ith acromio-thoracic. 
 
 The Internal Mammary Artery (Fig. 69, M) may be exposed and tied by 
 dividing the intercostal aponeurcjsis and muscles for an inch or more from 
 the outer edge of the sternum, from which margin it is distant about h inch 
 If the vessel lias been divided, and the ends have retracted, it may be necessary 
 to excise a portion of costal cartilage in order to secure both ends -a most] 
 necessary proceeding, owing to the freedom, of the collateral circulation and 
 the consequent liability to continued haemorrhage. 
 
 Ligature of the Vertebral Artery has been undertaken for wounds. 
 
 tori 
 
 -econdary h.-emor 
 
 lit epilepsy, but w 
 
 tion, though by n 
 
 .■^urgical j^rocediirt 
 
 the posterior bord: 
 
 tascia cli\ided, a it 
 
 DC, and its belly di 
 
 Mnvid, together \ 
 
 i,)nj,'us colli niuscl 
 
 artery lying upon 
 
 vertebra must be r 
 
 entering the canal 
 
 anteriorly, is drawi 
 
 inwards. A few ; 
 
 resulting contractio 
 
 iipnn as satisfactory 
 
 Ligature of the 1 
 ;he},'rowth of agoit 
 The superior thvrc 
 external carotid.' "] 
 nastoid has its cen 
 the external carotid 
 :rom it. 
 
 The inferior thyroid 
 :he sterno-mastoid, e 
 •nusede and the subja 
 .md -thyroiei usually 
 H.\th cervical \erteb 
 :maiediately below. 
 recurrent nerve as pq 
 
 file Axillary Artei 
 
 operation for sul)cla\ 
 a:v'h,and possiblv for 
 "! the brachial, one w 
 >m fails. Two class 
 'perati\-e surgery. 
 I. Lis^jtnre of the firs 
 incision, with its con< 
 I wthin I inch of the 
 i%'59, C). Thecla 
 co.sio-coracoid membr 
 pectoralis minor to th 
 [.iMsinay be divided in 
 iiilly traced backwards 
 rwpinRas far as possi 
 I'te within and below 
 louter side The needle 
 *« .should besubseq 
 . 'outline recommende 
 I'll; course of the artery 
 r^itoid, and certainly ' 
 I'^Jing, as any part o 
 
 Lif^ntuve of the thin 
 |™ is luilv abducted , 
 lesion is made in the 
 I" i'e thirds of the sp, 
 >rder of the coraco-b,- 
 
 f( 
 
LIGATURE OF VESSELS 
 
 259 
 
 •econdary hamorrhaj,'e after Iif,'ature of the innoiiiinatc, and in the treatment 
 lit epilepsy, i)Ut without much permanent henefit in tlie last case. The opera- 
 tion, tiioLigii by no means easy, is usually successful as far as the immediate 
 -iir;,'ical procedure is concerned. An incision is made alonj,' the lower half of 
 lie posterior border of the sterno-mast<jid (Fig. 69, V), the platysma and deep 
 
 iMia divided, a few of the posterior fd)res of the muscle itself inciseil if need 
 
 , ami its belly drawn well forwards. Tiie scalenus amicus muscle is clearly 
 liiicil, together with the plirenic nerve. Thi; interval between it and the 
 
 :ij,'us colli muscle can now be demonstrated, with the ascending cervical 
 artery lying upon it. The anterior transverse process of the sixth cervical 
 iiitebra must be made out. Just below this the vertebral vessels are found 
 riitering the canal in the transverse process, and the vein, which is placed 
 .interiorly, is drawn outwards to allow the needle to be passeil from without 
 
 iiwarcls. A few sympathetic twigs are included in the ligature, and the 
 asulling contraction of the pupil may (according to MacCormac) be lookeil 
 iipiin as satisfactory evidence that the vertebral has been in reality secured. 
 
 Ligature of the Thyroid Vessels is sometimes used as a means of arresting 
 
 ;ik: growth of a goitre. 
 
 File <iiptn'i)r thyroid aiiciy is tied by an operation similar to tiiat for the 
 
 Aternal carotid. The incision along the anterior margin of the sterno- 
 
 Kistoid has its centre opposite the upper b;)rtler of the thyroid cartilage ; 
 
 ;ne external carotid is dertnetl, and the superior thyroid secured as it rises 
 
 :!'im it. 
 
 T!ie inferior tliyroid artery is reached by an incision along the inner border of 
 :hesteriio-mastoid, extending upwards from the clavicle for j inches. This 
 muscle and the subjacent carotid sheath are drawn outwards, the sterno-hyoitl 
 .md -thyroid usually needing to be ilivided. The transverse process of the 
 Mxth cervical vertebra is sought for, and the vessel found passing inwards 
 .mmediatelv' below. It is taken up just behind the carotid, anil as far from the 
 recurrent nerve as possible. 
 
 Tlie Axillary Artery is tied for punctured wounds of the axilla, as a distal 
 operation for subclavian aneurism, occasionally for wounds of the palmar 
 arL'li.and possibly for secondary hajmorrhage from the brachial, [•"or aneurism 
 if the brachial, one would nowadays prefer extirpation of the sac if compres- 
 sion fails. Two classical operations are described and practised in classes on 
 i'jierative surgery. 
 
 I Liiiiititrc of tlie first part of the vessel is usually undertaken through a curved 
 incision, with its concavity upwards, extending from the ccjracoid process to 
 uithin I inch of the sterno-clavicidar joint, and i inch below the clavicli 
 Fig. 69, C). The clavicular origin of the pectoralis major is divided, and the 
 
 I costo-coracoid membrane exposed, reaching from the upper border of the 
 pectoralis minor to the clavicle. Sundry branches of the acromio-thoracic 
 
 UMs may be divided in this proceeding, and tied, and the trunk is then care- 
 ully traced backwards with a blunt dissector and forceps to the main vessels, 
 
 i*epingas far as possible to the lower border of the subclavius. The vein 
 iies within and below, and the cords of the brachial plexus above and to the 
 
 jouterside The needle is passed from below upwards. The divided muscular 
 
 jr,bres should be subsequently sutured together. 
 Guthrie recommended that the vessel shoulil be tied through an incision in 
 iiie course of the artery dividing the pectoralis major, or separating it from the 
 
 liieltoid, and certainly for a punctured wound this is the most desirable pro- 
 
 iKeding, as any part of the vessel can thus be reached. 
 2. Ligiitiirc of the third part of the artery is performed from the axilla The 
 
 larmis fully abducted, and the surgeon stands between it and the body. An 
 pision is made in the course of the vessel at the junction of the anterior and 
 
 |ni:i!dle thirds of the space between the axillary folds (Fig. 71, A). The inner 
 
 |iiiirder of the coraco-brachialis muscle is clearly defmed, and forms the first 
 
 17 — 2 
 
26o 
 
 A MANUAL OF SURGERY 
 
 v% 
 
 rallying-point ; it is drawn slightly outwards, and tin; niudian nerve, In^i.thcr 
 with tile musciiiii-cutaneoiis trunk, at once conies into \icw. < 'n ch'awin^' these 
 inwards, tlu; artery itsell' is seen, with the \ein to the inner side, together with 
 the internal cutaneous ner\e. The needle is passed from the \ein. 
 
 Collateral Circulation. — If above the acroniio-thoracic, the same as fur tin 
 third iv'irt of the sul'cla\ian ('/i''). 
 
 If above the subscapular and circumflex: Long thoracic and intercdstals 
 ?>77// thoracic i)ranciies of subscapular; suj)rascapidar and posterior si apuLir 
 uit/i scajiular branches of sui)scapular ; suprascajmlar and acromio-thni;u,, 
 ■U'it/i }K)sierior circumllex in the deltoid. 
 
 If below the circumflex, same as for ligature of brachial above the superior 
 profunda- /.('., posterior circumflex u'itli superior profunda in the deltoid. 
 
 The Brachial Artery may need to be ligatured for haniorrhage fmni the 
 palin.'u- arches, or fi-Mm a wound in the forearm or .about thi; elliuw, fi ;■ 
 aneurisms, or for arterio-venous wounds at the beiul of the elbow. Ii may In- 
 tietl in one of two places : 
 
 I. A! the Miildlc of tlw Arm.- The arm is held away from the side at a ri','hi 
 angle, with the hand supine, but with no support beneath it, for Icar 1 1 
 
 Fir,. 71. — Inxisions kok tying thic Arti:rii;s of tiii-: Ai;m. 
 
 A, 'i'liird part of the axillary; B, brachial; C, brachial at the bend of the 
 elbow ; 1), middle third of radial ; G, middle lliinl of ulnar: li and 
 lower thirds of radial ami ulnar. 
 
 pushing forward'-, the triceps and displacing the \-essel. The surgeon stands j 
 between the arm and the trunk. An incision 2 inches long is made in thelinel 
 of the vessel along the inner border of the liiceps muscle (h'ig. 71, 1-i), and thej 
 thin fascial investment of the limb di\-ided. The inner edge of the muscle isj 
 clearly exposed, anil bv drawing it slightly forwards the median nerve isJ 
 brought into view, and perhaps the basilic \ein. The nerve, which is at thisl 
 spot crossin.g the arter\' from without inwards, is drawn inwards, and tliej 
 sheath of the \-essel found beneath it. The artery is separated from its vensl 
 comites, and the ligature passed and tied. 
 
 The operation is by no means always an easy one, as there are many traps 
 into which the beginner may fall. Thus the median ner\e may cross behinj 
 the vessel instead of in front of it ; the basilic vein ma\' lie o\er its situatinnJ 
 and be mistaken for it; or there ma\- be a liigh di\-ision, and two iriinksl 
 usually lying close together, must then be sought for instead of one. Thenirisl 
 common n^.istake consists in not defining the biceps muscle, and in seekin,s,'tj| 
 the artery behind its proper situation. 
 
 2. At the Bend of the Elhoic. — An oblique incision is made, about 2 ine'ie 
 long, parallel to the inner border of the biceps tendon, its lower end cotj 
 responding to the crease of the elbow (Fig. 71, C) The wound should' 
 placed at alxnit an angle of fortv-ti\e degrees to the axis of the limb, and tj 
 the outside of, and nearly parallel to, the median basilic vein, which, if seer 
 must be drawn inwards. The bicipital fascia is now incised, and the arteij 
 with its venae comites exposed in the loose fat, the median nerve being wej 
 away on the inner side. The needle is passed from within outwards. 
 
 Collateral Circul 
 
 lerior circumtiex in 
 If below the ori^ 
 
 ilhow-joint. 
 
 The Ulnar Arter 
 
 .iirect wounds. In 
 liie wrist, in the latl 
 -icreotyped operali( 
 ii.m room or dead-h 
 i".i:ul that the arter\ 
 ■,'ibe radial side of 
 ::iJicate(l by a ij,,^ , 
 Nimespot below. 
 
 I, At the /[-'m/.— , 
 
 '.urn the flexure oft! 
 
 .'.iM-ia is opened ; the 
 
 .i:iil the vessels are 1 
 
 .ilnarside of the arte 
 
 and not included in t 
 
 2. Ill the Middle of t, 
 
 she anterior edge of t 
 
 1™ bone (Fig. yi^ Q 
 
 iviweeri the flexor' cri 
 
 :r and opcMied up ■ j 
 
 d;>tingnish. If the a: 
 
 :■ wards the ulnar, anc 
 
 !-ins, with the ner\ i 
 
 ::!isiake consists in g^t 
 
 fnrtions of the fleN.,,- 
 
 Kifiis- Occasionally 
 
 i^-.^inner nia\- pass U 
 
 arpi iihiaris and the \\ 
 
 The extreme upper I 
 
 ""li'jiie incision e.xteiui 
 
 Pi'"i".i,' up the ante- 
 
 I'rachial. 
 
 Radial Artery. -Th, 
 k;ulnf the elbow to t 
 
 radialisandthesupina 
 »«"ng in the space i 
 
 hnult-hox), between the 
 I raiLscles. 
 
 .'• •-^/ the Baek of tht 
 pl'^'ve-mentioned intert 
 h^mvnrdsto the base of 
 
 Mde between the tend 
 I'li^ radius to the base 
 
 :™ is found beneath tl 
 
 f- "f fascia is then 
 
 ^artery is exposed, cr 
 
 jW'mpanyuig the tend, 
 
 ■■'>eme,„, „f „^^, j,^^^^^^ 
 
 \-. -ilw-e the Ilm/ani 
 
 :-M'r carpi radialis. T! 
 
 ;''^".v>'erveli laments a. 
 •■^"'al' 'Superficial vein 
 
 c, 
 il 
 
LIGATURE OF VESSELS 
 
 261 
 
 ColUiteral Circulation. — If abest; tlu- orij^in ol tlie supmiT prol'uiul.i,, pos- 
 ■eiior circumtlex in ilcltoul uith ;iscoiuli!ii,' branclu's of supfrior prolmida, 
 II bcliiw the origin of the inferior profiuula, tiie anastomoses around the 
 
 ;i)i)W-jiiint, 
 
 Tlu! Ulnar Artery rarely needs ligature except for palmar lia'morrhage or 
 ,;ia'Ct wounds. In the former case the artery can easily l)e secured just aliove 
 iif wrist, in the latter case i)y enlarging tiie original wound. The following 
 .icRMitvped ojierations are described, but are more often seen in the I'xamina- 
 ■ ;,,n room or dead-house than in the operating theatre. It should be born<! in 
 ;ni;ul that the artery curves inwards from the centre of the bend of the elbow 
 ythe radial side f)f the pisiform bone. The lower two-thirds of its course is 
 .viicated liy a line drawn from the internal comlyle of the humerus to the 
 >ame sjiot below, 
 
 I. At till' 11';/.';/. -An incision about i inch in length is m;ideelirectl\- upwards 
 'som the ilexure of th(! wrist in the line of the xi'ssel (l"ig. 71, !■'). The deep 
 lascia is opened ; the tendon of the flexor carpi ulnaris drawn to the inner side, 
 j;h1 the vessels are then seen, accompanied by the nerve which lies to the 
 ilnar side of the artery. If possible, the vena' comites should be separated, 
 ami not inchuled in the ligature. 
 
 J. /;; llic Middlcof tlw Foicaiin.--\n incision is made along a lint; drawn from 
 ;;n.' anterior edge of the tip of tiie inner condyle to the railial siili; of tiie jiisi- 
 irmbone (Fig. 71, G). The white line indicating the inti;rmuscular septum 
 :i-,t\veen the flexor carpi ulnaris and Hexor sublimis digitorum is then sought 
 : ; ;uk1 ojiened up ; it is often very slightly marked, and may be diHicult to 
 ,;Minguisli. If the correct interspace has been opcmed, the surgeon is directed 
 ; v.iuds the uhiar, and readily Ihids the vessels uiuler cover of the llexor carpi 
 ;.!:;;u-is, with the ner\e lying a little way to the inner side. The most ct)mnion 
 nr-iialic consists in getting loo far to the radial side, and in separating \arious 
 prtions ot the flexor sublimis, or in jiassing between it and the palmaris 
 ;i';ij;iis. Occasionally, e\ en when the correct interspace has been entered, a 
 liesinner ma\- pass beyond the vessels, and find himself lietween the flexor 
 arpi ulnaris and the llexor prohindus. 
 
 The extreme upper limit of the ulnar artery can also be reached through an 
 li'uliiiue incision extending along the upper border of the pronator teres, thus 
 
 pining up the ante-cubital fossa, and exposing the bifurcation of the 
 iTacliial. 
 
 Radial Artery. —The line of the vessel extends from the middle of the 
 
 btiiil (if the elbow to the interspace at the wrist between the llexor carpi 
 
 raiiialis and the supinator longus. It then turns outwards, and may be lelt 
 
 iieating in the space described by l''rench anatomists as 'la tabatiere ' (or 
 
 hniiff-box), between the tendons of the extensor primi and secundi internodii 
 
 I imi.scles. 
 
 I, At the Back of the W'list the vessel may be secured by opening up the 
 
 liwve-mentioned intertendinous hollow, where the artery is found coursing 
 
 .^:!wnrds to the liase of the first interosseous space. An oblicjue incision is 
 
 IrnJe between the tendons, extending from the back of the styloid process of 
 
 ihii radius to the base of the first metacarpal bone. The superficial radial 
 
 vein is found beneath the skin, and a few twigs of the radial nerve. A deeper 
 
 j aver of fascia is then divided, passing between the tendons, and beneath it 
 
 I 'He artery is e.vposed, crossing the incision oblicjuely. The synovial sheaths 
 
 hcconipanying the tendons should not be opened, or some limitation of the 
 
 p..ivements of the thumb may result. 
 
 Above the Wrist an incision is made in the line of the vessel (Fig- 71, F), 
 j'vhidi is found after division of the fascia between the supinator longus and 
 
 iexor carpi radialis. The radial nerve has pas.sed to the dorsum ere this, and 
 
 iany nerve filaments are seen they are derived from the external cutaneous. 
 '•small superficial vein usually lies over the artery. 
 
263 
 
 A MANUAL OF SURGERY 
 
 -i 
 
 < ^;'i 
 
 •r^^ 
 
 3. Ill till' Mithllc or U/'f'cr Third of the Fciiitiiii an incision is made in the lim 
 of tlie vessel (l'"i,','. 71, !>), and tlie inner liorder of tiu; supinator loii>,'ns suiihIh 
 for and r(,'tra(-ted Tlie sessi-ls are found under cover of this structure, with 
 tile radial nerve to the outer side, tliouj,di sejiarateil by an iiiter\al above 
 
 Ligature of the Abdominal Aorta has been undertaken "i eleven instance, 
 for si'vere primary or seduulary lia innrriia^'e, or for diiluse in^'iinal or ilja, 
 aneurism, wiien no other method of treafnuMit was practicable. All thor 
 cases ha\e proved fatal, though one patient operated on by Montcim ii, 
 South America survived till the tt.'iith day. It has not been performed siiuc 
 tile introduction of strict antisepsis; and inasmuch as the fatal issue was in 
 most instances evidently due to septic contamination of the wound an.l 
 secondary hamorrhage, and as the operation lias certainly been successlul ii, 
 animals, it is possible that we mav yet be able to chronicle a sati;sfactnr\ 
 result as a trium|)li of modern surj,'ery. 
 
 Twf) distinct plans of operation ha\e been followed, viz., the trans-peritnnt;il, 
 and the extra- or retro-peritoneal. The latter method, performed thn)iif,'li n 
 lateral incision on the left side, reaching from the tip of the tenth rib (i(juii- 
 wards, and involving the stripping forwards of the peritoneum and its content, 
 is both diflicidt and dangerous; and inasmuch as we need not tear openiiis,' lii^r 
 peritoneal ca\ity, there now remains no occasion for sucli a complicated dis- 
 section. The //in/,s-/'('r//(i//i'((/ operation consists in opening the alxjome'n thrmi:;!' 
 an incision slightly to the left of the middle line, liaving the umbilicus on a 
 level with its centre. The intestines are retracted on either side, and the 
 posterior layer of the serous membrane covering the aorta carefully divided: 
 there is then no difliculty in passing a ligature around the vessel. I'os.sihlv | 
 the same precaution to prevent excessive backflow of blood would be advisabl' 
 as in tying the innominate, \dz., to secure one or both of the commnn jlini 
 trunks in acklition ; such would in no way interfere with the establishmemifl 
 the collateral circulation. 
 
 The Common Iliac Artery extends for a distance of 2 inches from the bifurca- 
 tion of the aorta op])osite the left side of the body of the fourth lumharj 
 vertelira to the front of the sacro-iliac synchondrosis. It may be reached, .lij 
 the aorta, by two methods, the trans- and the retro-peritoneal. 
 
 In the vi'tvo-pcyitoneal operation (Mott's method) a curved incision is mailel 
 through the abdominal jiarietes similar to that for ligaturing the external iliac,| 
 but extending higher (Fig. 72, A). The muscles and fascia transversaiis ars 
 carefully divided, and the jieritoneum, together with its contents, stripped up 
 and held out of the way with a broad retractor. The ureter wiiicli cros.sestliej 
 arterv is usually carrietl forwards with the peritoneimi. The vessel is now soii:;!: 
 for, carefully cleaned, and a ligature passed from right to left (of the patienti ' 
 both sides of the body, the vein lying behind the artery on the right side, anil 
 behind and internal to it on the left. A similar method, known as Marceliiij 
 Duval's operation, may be undertaken through an incision (Fig. 72, B) sinchi 
 long, which, commencing about i.^ inches fi'om the pubic spine, runs |iarall 
 to, and a little way above, Poupart's ligament for i\ inches, and is thendirecti 
 at right angles to the ligament towards the umbilicus. After the divisium 
 the abdominal muscles the operation is performed in the same way as till 
 above, and is perhaps better, inasmuch as the artery lies almost directly heliin 
 the incision. 
 
 The tvans-pcyitoiical plan has already been undertaken witii success in 
 few cases, and will probalily supersede all other methods. An incision 
 made in the median line with its centre a little below the umbilicus 
 peritoneum opened, the intestines retracted, the vessel sought for and exposd 
 by an incision through the posterior layer of the parietal peritoneum, andl 
 ligature passed and tied. The ureter which crosses the artery just above 1 
 bifurcation must be carefully avoided. 
 
 Collateral Circulation after Ligature of Common Iliac Artery. — Blood reach 
 
 tlie cxtcnial i/nu- ai 
 arteries „■///, the c 
 intercostals /.///( tj 
 liranclies are siipj, 
 lumbar; (/,) (h,.. ,„ 
 tomosis of the two 
 lumorrlioidnl, ;,,„| 
 
 Ligature of the I 
 rha^e h-om, or auc 
 cnmmonly afiected 
 ing the size of an ' 
 (! inches in iengd, 
 line below then, iibii 
 
 / 
 
 i'lG. 72.-I.Vc,sio.V.. 
 
 l*-^'ott's incision for t> 
 'O'' t'le same • r 
 
 '"""'f >• •■ D, incision 
 "e"'y« modified 
 hooper's incision 
 Scarpa's triangle ; 
 
 F'fie bifurcation of th 
 
 I* If passed without w 
 
 ./'•e Collateral Circu a 
 
 f'"^'"n of the common 
 
 /''t Gluteal Artery occ 
 
 r spot IS indicated bv 
 K-'n.tl,epc,ster!2.. 
 
 *°«tJi this muscle is tlJ 
 
LIGATURE OF VESSELS 
 
 263 
 
 lie c.v/O'Hii/ ///id cai)(l its hrrinclies by means of tlu; anastomoses of the lumbar 
 irterifs ..'///( tlie ciicunillcx iliac, and of tiie superior epi),'astric, lumbars, and 
 inttTCostals uilli tlie superlicial and deep epij,'astric. Tl\e iiitiiiuil iliitc and its 
 linuu lies are supi)li('di)y the union of {0) the lumbar l)ranrhes ,,//// the ilio- 
 !um!'.'ir; (/>) the middle saeral ,.ith the lateral sacral ; (<) the relro-pubic anas- 
 • luiisis of the two obturator arteries : and (1/) tliecommiinicationsof thepudic, 
 I innrrhoidal, and vesical truid%s ,. /7/( tiiose of the opposite side. 
 
 Ligature of the Internal Iliac Artery is occasionally performed for ha'mor- 
 
 • a:^!' ironi, or aneurisiii of, one of its brandies, the ^biteal beiiij,' tliat most 
 
 iiiinonly affected, and lately has been recommended as a means of diminish- 
 
 m; till' size of an enlar^eil prostate. The trunk is a short one, at most 
 
 :' iiiciies in length, and is best readied by opening: the abdomen in the middle 
 
 .;iiel)el<nv tiie umbilicus (Fif,'- 72, C), pushing aside the intestines, and seardiinj,^ 
 
 Fig. 72. 
 
 -Incisions for Operations on Lowkr Part of Abuomkn 
 AND Thighs. 
 
 .VMott's incision for tying common iliac artery ; B, ]\Iarcellin Duval's incision 
 (or the same ; C, incision for trans-peritoneal ligature of internal iliac 
 artery ; D, incision for excision of hip by the anterior method ; F, Aber- 
 netiiy's modified operation for ligature of external iliac ; G, Astley 
 Cooper's incision for same ; H, ligature of femoral artery at apex of 
 Scarpa's triangle ; K, ligature of femoral artery in Hunter's canal. 
 
 lie: ihe bifurcation of the common iliac. The posterior layer of tlie perito- 
 am is tiien carefully incised, the ureter avoided, and an armed aneurism 
 piilt; passed without wcjunding the \ein. 
 
 The Collateral Circulation is the same as that given for the internal iliac 
 liiiusion of the common iliac. 
 
 ThcGluteal Artery occasionally needs to be secured at its point of emergence 
 Km the pelvis tliroiigh the upper part of the great sacro-sciatic foramen. 
 pkspot is indicated by the junction of the inner and middle thirds of a line 
 pwn from the posterior superior iliac spine to the top of the great troclianter. 
 'lincision is made in the direction of this line, i.e., along the fibres of the 
 pens maximus, which are separated and held apart. The deep fascia 
 path tills muscle is then opened up, and the space between the gluteus 
 
264 
 
 A MANUAL OF SURGERY 
 
 meclius and pyriformis defined. Through this tlie upper margin of tlie sacrn- 
 sciatic note)) can be detected, as also tlie pulsation of the artery. Tiiu vessel 
 must be secured as deeply as possible on account of its early division. It is 
 always a trouble- ^me dissection, and possibly in most cases it would lie wiser 
 to deal with the trunk of the internal iliac. 
 
 The Sciatic and Pudic Arteries seldom require to be tied, but may lie reached 
 oppr)site tlie ischial spine, at the junction of the miildle and lower thirds of a 
 line drawn from the posterior superior iliac spine to the tuber isclui. An 
 incision about 4 inches in length is made over this spot, correspondinf; in 
 direction to the fibres of the gluteus maximus, which are separated and well 
 retracted. Thespine of the ischium and lower border of the pyriformis should 
 now be defined, and the vessels and nerves seen emerging from the foramen 
 The pudic vessel lies to the inner side of the sciatic ; the ligature is passed as 
 high as possible. 
 
 The External Iliac Artery is easily accessible in any part of its course, which 
 measures from j.\ to 4 inches in length ; it has but few branches, and those 
 situated low down. Its position is indicated by the lower two-thirds of a line 
 drawn from the bifurcation of the aorta to midway between the anterior 
 superior spine and the symphysis pubis, i.e., to a point a little internal to the 
 middle of i'oupart's ligament. 
 
 Many suggestions as to the best means of reaching the artery have lieen 
 made, and both trans- and extra-peritoneal methods have been adopted. It is 
 so readily secured, however, by the latter that it seems unnecessary to open th.e 
 peritoneum. There are two chief forms of extra-peritoneal operation. 
 
 Astlcy Coof'cv's Operation .—An incision is made parallel to the outer half of 
 -Poupart's ligament, commencing a little to the inner side of its centre, and 
 iij inch abcne it, and extending upwarrls and outwards to about i inch internal 
 to the anterior superior spine (Tig. 72, G), i.e., over the internal abdominal rin<,' 
 The external oblique aponeurosis is divided along this line, and the exposed 
 lower margins of the internal oblitiue and trans\'ersalis muscles arching over 
 the inguinal canal are drawn upwards by retractors. The transversalis fascia 
 and loose sid)peritoneal tat are now opened witli forceps and director, and the 
 \essel is felt pulsating immediately under the finger. It is \-ery important nut 
 to damage either the epigastric or circumflex iliac arteries during this manipu- 
 lation, since they are most essential factors in establishing the collateral circu- 
 lation, whilst the circumflex iliac vein crossing the main trunk must also be 
 avoided. The needle is passed from within outwards, the ligature tied, and 
 the di\-ided muscular and aponeurotic structures brought accurately to^'ether 
 by buried sutures. 
 
 Ahenietliy's Modified Operation is more commonly utilized. The inci-ii'n, 
 about 4 inches in length, extends from a point ih inches within and above the 
 anterior superior iliac spine to just external to, and A inch above, the middle 
 of Poupart's ligament (Fig. 72, P.). Through this the aponeurosis of the 
 external oblitpie is divided along the course of its fibres, as also tlie intern.il 
 oblicjue and transversalis. The trans\-ersalis fascials now carefully incised: 
 it varies considerably in thickness, being sometimes well de\eloped, hut is 
 occasionally so attenuated as to be scarcel)- recognisable, and in such cases 
 the peritoneum may unintentionally be opened. In the present day this is an 
 accident of slight importance, the wound being readily closed by a continuous 
 suture, and no harm resulting. The lingers are now introduced into the 
 wound, and the peritoneum and its contents stripped from the iliac fos.^a. 
 and drawn inwards and forwards, where they are kept out of the way hya 
 broad spatula. In the space thus opened up one can see the iliacus niusdi' 
 covered by its fascia, and to its inner side the rounded outline of t!ie psoas. 
 The vessel lies to the inner border of this, and can usually be readily found, 
 enveloped in a fascial sheath, with the genito-crural nerve coursing over it, and 
 perhaps some lymphatic glands upon it. The artery is separated from the 
 
 vein which lies to the 
 if the transversalis fa; 
 strip it up together wi 
 it, when they may be 
 
 On comparing the 
 Liner plan. By Cooj 
 cdlateral branches, w 
 ifthat is diseased and 
 c:ioice is possible. Ir 
 away from collateral 
 diseased, the common 
 bv extending the inc 
 fiated to exist in this 
 ays, when the muscle 
 rat careful asepsis, tl 
 iiiiliout drainage tube: 
 
 Collateral Circulatic 
 :nary, lumbar, and los 
 ;iieath of rectus. 
 
 Pesterior set : Glutea 
 iirst perforating of pro 
 
 External set : Ilio-hu 
 :!:acan(i ascending br? 
 
 Intaiial set : Olnurat 
 :r.:ernal pudic uvY// sup 
 
 Tlie Common Femora 
 
 r.casure in amputation 
 
 ::m it is likely to inter 
 
 :■;< better practice to t 
 
 ::'.dsion over the line c 
 
 IVupart's ligament. 1 
 
 avoided, the fascia lata 
 
 tiir>' passed from the ir 
 
 Collateral Circulatioi 
 
 ir.iernal pudic with extt 
 
 E.\!mial set : Circum 
 
 Pnkrior set : (duteal 
 
 first perforating ; come 
 
 sscular of popliteal. 
 
 The Superficial Fern 
 
 Ktv.een the anterior si 
 I PI the internal condvh 
 
 I may he secured at 
 I cr in "Hunter's canal. 
 U^iitiii-e at the Ape.v 
 iineofthe arterv, the c 
 h-upart's ligament (Fit 
 Imer border of the sart( 
 :!. ilie muscle being dr.- 
 perhaps brought into vi 
 «-!ii at this spot, and 
 I ;Wind the arterv, so tl 
 '*'!!.;' taken to keep it c 
 Collateral Circulation 
 i isastoniotica magna, ai 
 I'rofunda femoris by 
 id articular branches 
 
LIGATURE OF VESSELS 
 
 265 
 
 vein which lies to the inner side, and tlie needle passed from within outwards. 
 lithe transversalis fascia lias not been properly opened, it is quite possible to 
 i:rip it up together with the peritoneum, and carry the vessels forwards with 
 ;i, when they may be found under cover of tiie spatula. 
 
 On ccmparing the two operations, we are very distinctly in favour of tiie 
 xt'-r plan. By Cooper's nietiio'l the artery is tied very close to important 
 ; Ilaieral branches, whilst but a small portion of the trunk is exposed, so tiiat 
 ;>that is diseased and unsuitable for the application of a ligature, no further 
 c:ioice is possible. In Abernethy's, on the other hand, the vessel is tied well 
 away from collateral branches, and if the exposed portion of the trunk is 
 d-eased, the common iliac can be reached and secured without much dilliculty 
 iv extending the incision upwards. As to the greater tendenc}- to hernia 
 v.ated to exist in this method, this may have been the case in pre-antiseptic 
 li.ivs, when the muscles were not suturecl for fear tif retaining septic discharges ; 
 kw careful asepsis, the use of buried sutures, and tiie possibility of doing 
 : ;hiiiit drainage tubes should render such a sequela impossible. 
 
 Collateral Circulation.- — Anterior set: Superior epigastric of internal mam- 
 r.arv, huiibar, and h^wer intercostals .wV/; superficial and deep epigastric in 
 ^hcath of rectus. 
 
 Pritciior set : Gluteal and sciatic u'ith internal and external circumflex and 
 ;ir,~i perforating of prtjfunda at back of great trochanter (crucial anastomosis). 
 
 External set : Ilio-lumbar and gluteal uith deep and superficial circumflex 
 ;!iacand ascending branch of external circumflex. 
 
 hUrihd set : Obturator i.itli internal circumflex ; and terminal di\isions of 
 :r.',ernal pudic ;.'///; superficial and deep external pudic. 
 
 The Common Femoral Artery is Imt rarely ligatured, except as a preliminary 
 r.'.casure in amputatif)n at tlie hip-joint, since the number of brandies arising 
 rm it is likely to interfere with its sound occlusion ; under other circumstances 
 ■IS better practice to tie the external iliac. It may be readied by a \ertical 
 '.'jisidn o\er the line of the vessel, extending both a little abo\-e and below 
 1' upart's ligament. The sujierficial lymphatic; and \eins must l)e carefully 
 avnicled, the fascia lata disitled, the sheath exposed and opened, and tiie liga- 
 lur,' passed from the inner side. 
 
 Collateral Circulation. — Internal set : Obturator 'uitli internal circumflex, and 
 ;r.icriial pudic U'it/i external pudic. 
 
 Extiiiial set : Circumflex iliac u'itli ascending branch of external circumflex. 
 
 l'.'>liriiir set : Ciluteal and sciatic uvY/; internal and external circumflex, and 
 first perforating; comes nervi ischiadici u'ith perforating of the profunda and 
 KBscular of popliteal. 
 
 T'le Superficial Femoral Artery is indicated by a line drawn from midway 
 .'.'.v.eon tlie anterior superior spine antl the svmphysis pubis to the tuberosity 
 
 itlie internal contlvle, the limb being flexeil, abducted, and a little everted. 
 i;i;iay he secured at ' the site of election,' i.e., at the apex of Scarpa's triangle, 
 
 rin Huiiter's canal. 
 
 L'w/»ir at the Apex of Searpa's Trian/^le. — A 4-inch incision is ni.ule in the 
 iiMof the artery, the centre being about 4 indies (or a hand's lireadth) below 
 i upart's ligament (Fig. 72, .H). Tiie integument and fascia; are divided, the 
 icner border of the sartorius exposed, and the siieath found immediately behind 
 '■'.the muscle being drawn s: lightly outwartls ; the middle cutaneous nerve is 
 ;-rhaps brought into \-ie\v. A muscular branch to tlie sartorius may be met 
 ■'■jii at this spot, and should be separately ligatured. The vein is placed 
 i^iiind the artery, so that the needle may be passed either way, special care 
 -'".,' taken to keep it close to the vessel. 
 
 Collateral Circulation. — Ifxternal circumflex with lower muscular of femoral, 
 j Kastomotica magna, and superior articalar of popliteal. 
 
 I'rofiiiKJa femoris i)y its perforating and terminal branches with the muscular 
 Uail articular branches of femoral and popliteal. 
 
266 
 
 A MANUAL OF SURGERY 
 
 Ligature in Hunter's Canal. — An incision 4 inclies in length is made along the 
 line of tlie artery in the middle of the thigh (Fig. 72, K). The sartorius 
 is exposed by divisicm of the fascia lata, its fibres running downwards and 
 inwards ; its outer border should be defined, and tlie muscle retracted inwards 
 The aponeurotic covering of Hunter's canal is now in view, stretching between 
 the adductor longus and vastus internus ; it is incised, and the sheath of the 
 vessel found below it, with the nerve to the vastus internus lying to its outer 
 side, tlie long saphenous nerve crossing it from without inwards, and the vein 
 passing behind it, to become external lower down. The needle may be passed 
 in either direction, and the ligature should not be placed too low on accmini 
 of tlie contiguity of the anastomotica magna. A common mistake made bv 
 students in tying this artery on the dead subject is to burrow down alonj,' the 
 vastus internus on the outer side of the vessels ; this is to be avoided b\- alwavs 
 
 Fig. 73. — I.N'cisioNs for Ligaturk of THii Utper Part of the Poplithal |.\:, 
 
 AND OF THK POSTERIOR TlHIAL ARTERIES (B, C, AND D). 
 
 E, Site for Introduction of Knife in Tenotomy of Tiihalis 
 Posticus; F, Ditto for Tendo Achillis. 
 
 keeping close to the under surface of the sartorius until the glistening trans- 
 verse fibres of Hunter's aponeurosis are clearly visible. 
 
 Collateral Circulation is maintained through the profunda and its branclie'; 
 
 The Popliteal Artery may be tied either just after it has passed through t!iej 
 adductor opening, or in the depths of the popliteal space, but preferably in the! 
 former situation. Neither operation is often required. 
 
 To tie the upf-ir part, the limb is fully abducted and everted so as to enable! 
 the adductor tubercle and tendon of the adductor magnus to be clearly dcfinedj 
 An incisicvn, 4 inche.i in length, is then made from the tubercle upwards 
 (Fig. 73, A), and the tendon exposed. The internal saphenous vein and nervej 
 may be seen, but are drawn backwards by means of a broad retractor, togeihirl 
 with the sartorius, gracilis, and semi-membranosus. If possible, the iirancli >i 
 
LIGATURE OF VESSELS 
 
 267 
 
 ihe anastomotica magna which courses along the tendon should be spared. 
 The fascial space behind is now opened up, and tlie artery found surrounded 
 ;,, a good deal of loose connective tissue. The vein is usually seen on the 
 
 ijier side, and is here very thick and dense, so that in the dead subject it can 
 iv readily mistaken for the artery. 
 
 Ihe louri' pari is tied through an incision in the middle line of the popliteal 
 space, dividing the deep fascia, and drawing out ol tlie way the heads of the 
 astrocnemius muscle, and the internal popliteal nerve. The vein is superficial 
 ; ,the artery, and is found by following the short saplienous trunk. The needle 
 ij passed from the inner side. 
 
 Mfi. 74. — Incisions for Liga- 
 ture OF Anterior Tibi.al 
 
 (.\ AND B), AND TeRONEAL 
 
 (C) Arteries. D, Site for 
 Intkoduction of Knife in 
 Tenotomy of Peronei. 
 
 Fig. 75. — Incisions for 
 Ligature of Lower 
 P a r t o f a n t e r I o r 
 
 TlIilAL (A) AND DORSALIS 
 
 Pedis (B) Arteries. [C, 
 Site for performing 
 Tenotomy of Tibialis 
 Anticcs. 
 
 Collateral Circulation is maintained by the anastomoses around the knee- 
 
 I joint , 
 
 The Posterior Tibial Artery but seldom requires to be ligatured except 
 
 fwhrrmorrhage, or on tlie face of amputation stumps; hence tlie operations 
 
 |iiescril)ed below are rarely seen away from the dead-house. The line of the 
 
 I vessel is indicated by one drawn from the centre of the popliteal space to 
 
 midway l)etween the internal malleolus and the inner tuberosity of the 
 
 oscalcis. 
 
 I In the Middle of the Calf. — The leg is placed on its outer side, and fie.\ed, 
 land an incision 4 inches long is made a finger's breadth behind the inner 
 
268 
 
 A MANUAL or SURGERY 
 
 border of the tibia (Fig. 73, B), dividing the skin and subcutaneous tissues, the 
 long saphenous vein and nerve being drawn aside if necessary. The tiliial (iri"i!i 
 of the soleus is thus exposed, and incised directly t(nvards the tibia, until the 
 fibrous aponeurosis on its deeper surface is met with. This having l,ocn cm 
 through, the muscle is drawn backwards with the retractor, and the vessels 
 ensheathed in a deep layer of fascia, arc seen lying on the flexor Ioit'iis 
 digit(.rum, and with the posterior tibial nerve to the outer side. The \enrr' 
 comites are separated, if possible, and the ligature passed from the nerve. 
 Sometimes the above-mentioned aponeurosis is in the substance of the srjleu.s 
 and a thin layer of muscular fibres e.xists on its deeper aspect. 
 
 2. //( the Lourv TJiird of tlic Leg. — An incision is made midway bet\veen tiie 
 tendo Achillis and inner border of the tibia (Fig. 73, C). The skin and fascia , 
 including the upper part of the internal annular ligament, are di\ided, and the 
 vessels seen lying on the flexor longus digitorum, with the nerve behind and to 
 the outer side. 
 
 3. Beliind tlie MaUeolus. — An incision is made about a finger's breadth fidni 
 the malleolus, curving round its lower border (Fig. 73, D). The deep fascia 
 (or, as it is here termetl, the internal annular ligament) is divided over the 
 vessels between the tendons of the flexor longus digitorum and flexor propriiis 
 hallucis, and the artery is then readily cleared and ligatured. The sheaths c: 
 the tendons should not be opened. 
 
 The Anterior Tibial Artery is found along a line stretching from a point 
 midway between the outer tuberosity of the tibia and the head of the filiula 
 above, to the central point between the two malleoli below. It may he tied in 
 three situations. 
 
 1. /;; the Upper Third of tlie Leg. — An incision is made exactly in the line of 
 the artery (Fig. 74, A), and the deep fascia incised. The intermuscular space 
 between the tibialis anticus and the extensor communis digitorum is upened 
 The vessel lies between these muscles upon the interosseous membrane, the 
 anterior tibial ner\'e bchig to the outer side. 
 
 2. Ill the Middle of tlie Leg (Fig. 74, B). — The same intermuscular space is 
 opened, being indicated here by a definite white line, due to a slight siih- 
 fascial deposit of fat. The vessels lie Ijetween the tibialis anticus and the 
 deeply placed extensor proprius hallucis, the nerve usually lying on the arter\ 
 and needing to bo drawn aside. 
 
 3. /// the Lower Third of tlie Leg. — An incision is made in the line of the artery, 
 reaching upwards for 2 inches from a point just above the ankle (iMg, 75, A). 
 The deep fascia and upper part of the annular ligament are divided, and the ! 
 vessel is found between the tendons of the tibialis anticus and of the extensor ] 
 proprius hallucis, the nerve lying to the outer side. 
 
 :iire, piinctiu-e, co 
 
 The Dorsalis Pedis Artery extends from the centre of the line between the] 
 two malleoli to the interval between the bases of the first two metatiu'sal | 
 bones. An incision is made in this direction (Fig. 75, B), the deep fascial 
 opened, and the artery found lying between the extensor proprius hallucis, 
 which has now crossed and is internal to the vessel, and the innermost slip of I 
 the extensor brevis ligitorum. It is by no means easy to find, and for practical! 
 purposes the best plan would be to divide the vessel by an excision extending] 
 to the bones, and then pick up and tie the bleeding encls. 
 
 The Peroneal Artery can be reached through an incision along the posteriori 
 border of the centre of the fibula, the leg being laid on its inner sidej 
 (Fig. 74, C). The outer edge of the soleus is definecl and drawn inwards, theJ 
 lower fibres of attachment to the fibula beingdivided, if necessary. Thellexorl 
 knigus hallucis is thereby exposed, and incised in such a manner as to allow! 
 the surgeon to reach the postero-internal border of the fibula ; the artery isj 
 then readily found lying in an osseo-aponeurotic canal. 
 
 I (liirinj,^ iin-olution o: 
 
 I feiitage of calciuni 
 
CHAPTER X. 
 
 SURGERY OF THE VEINS. 
 
 Thrombosis. 
 
 llv Thrombosis is meant intravascular coagulation in any part of 
 the circulatory system. Normally the blood remains in a fluid 
 omlition, owing to some interaction between it and the vessel 
 walls, the character of which is not yet fully understood. Any 
 [actor producing a disturbance of this normal efjuilibrium may 
 (ietemiine thrombosis, and any part of the vascular tract may be 
 ffected by it, whether the heart, arteries, veins, or capillaries. 
 We ha\ e already discussed some of the conditions associated with 
 capillary or arterial thrombosis ; that which follows, whilst 
 reterring primarily to venous thrombosis, is also in a measure 
 •jue of the other forms. 
 
 The Causes of venous thrombosis may be arranged under three 
 headings : 
 
 ii) Chan<j;cs in the vessel i^'dls, as a result of which the integrity 
 nf the endotlieliinu is disturbed — e.g., injury (either division, rup- 
 uire, puncture, compression, or contusion), inflammation, or 
 >;t:i,'eneration (as in varicose veins). 
 
 \i) Changes in the constitution of the blood, whereby its coagula- 
 bility is increased. Excess of excretives, as after pregnane}^ 
 iluiing involution of the uterine walls, may have this effect, or the 
 ircsence of toxins arising from bacterial activity ; hence septic 
 ibeases are commonly associated with thrombosis. Great loss 
 "i Wood up to a half of the whole amount in the body also 
 increases its coagulability, but excess of leucocytes, as in leuk;emia, 
 ;::is the opposite effect. A. E. Wright has shown that the per- 
 centage of calcium ■ hloride in the blood is an important factor. 
 
 0-6 per cent, of this salt is present, coagulation is hastened, 
 
 ind he has proposed to reduce the loss of blood during opera- 
 
 ;ions to a minimum by injecting into the rectum half an hour 
 
 j previously a pint of warm water containing in solution 2 oz. of 
 
 I this salt. In one or two cases in which we liave seen it used, 
 
 t appears to have been efficacious, but its general utility 
 
270 
 
 A MANUAL OF SURGERY 
 
 is doubtful, since it might lead to coagulation in unwishcd-lor 
 localities. 
 
 (3) Diiuinishcd rate of the blood stream predisposes to throinliosis 
 if some other condition is present to determine it. Lister showed 
 years ago that blood can remain Huid for a long time if contined 
 in a tube formed of a suitable length of the vein wall ; but when 
 either of the preceding factors is present, a retardation of the 
 blood stream materially assists in causing coagulation. Tlni?. 
 when a vein is pressed upon by a tumour, the obstruction to 
 the blood flow produces a clot at the spot where the nutrition 
 of the wall is interfered with. After fevers, such as typhoid or 
 rheumatic, where the character of the blood is somewhat altered 
 and the action of the heart weakened by changes in the nuiscular 
 fibres, the defective vis-a-tergo causes a retardation of the flow 
 in the veins, as a result of which the intravenous pressure is 
 diminished, and the valves are only partially pushed back, spaces 
 being left behind them in which the blood stagnates. Coagulation 
 is probably determined by some slight injury or pressure which is 
 not noticed by the patient, or by some lessened vitality of the wall 
 of the vein, or by disintegration of the leucocytes and setting free 
 of fibrin ferment owing to the defective circulation. The clots 
 thus formed behind the valves gradually increase in size until 
 the whole lumen of the vessel is obstructed. The 7jhitc h^' of 
 pregnancy is sometimes induced in the same way, although it is 
 probable that in most cases the coagulum extends to the femoral 
 \ein from the uterine plexuses. A similar condition occurs during; 
 or after appendicitis, and is then probably due to the direct action 
 of inflammatory phenomena around the iliac vein. 
 
 The Character of the clot varies according to whether it is 
 deposited slowly or is due to a rapid coagulation of the blood. 
 In the former case the so-called White Thrombus is met with, 
 which is formed upon, and adheres to, the vessel wall, and 
 gradually increases by fresh deposits of fibrin until it entirely 
 blocks the channel. As to the method of formation of this 
 thrombus many different opinions have been given. Zahn, by 
 experimentally irritating the veins of the mesentery or tongue 
 of a frog, saw the thrombus formed from what he inuigined was 
 a collection of leucocytes, which adhered to the injured spot, 
 and after a time, losing their definition and outline, were changed 
 into a fibrinous mass. Later researches, however, seem to indi- 
 cate that the formative elements in a white thrombus are not 
 leucocytes, but the so-called hccmatoblasts of Hayem, or the 
 ' blood plates of Bizzozero,' those minute colourless elements ot 
 the l)lood which only become apparent on special preparation. If 
 a certain number of red corpuscles are entangled in the meshes of 
 the clot, it is termed a Mixed Thrombus ; the more rapid its forma- 
 tion, the greater the number of red corpuscles present. Should 
 the blood coagulate en masse in a vein, as after its total division or 
 
SURGERY OF THE VEINS 
 
 271 
 
 iii;ature, an ordinary Red Thrombus is produced, which at first is 
 not adherent to the wall, but becomes so later on, especially at its 
 :,;ise. A similar type of clot is usually found post-movtent capping 
 
 ■;iv white clot which has formed previously. 
 
 The Effects of thrombosis may be considered under the follow- 
 
 lif headings : local, distal, and proximal. 
 
 Locally, the following conditions may obtain: {a) The clot 
 
 ;iv be organized into connective tissue, a fibrous cord replacing 
 
 ae vessel in the same way as was described for arterial throm- 
 
 osis in a previous chapter (p. 195). 
 
 , The lumen of the vein may be re- 
 
 .tablished by cleavage and shrinking 
 
 : the thrombus to one side of the vein 
 
 all, or by canalization of the clot or of 
 
 ;.f fibrous cicatrix replacing it, owing 
 
 itlie dilatation of the vessels contained 
 
 vithin. {c) The clot may soften, dis- 
 
 ;nte. 
 
 ;rate, and be washed away 
 
 Fig. 76. — Thkombus ano 
 Embolus. (Keen and 
 WiuTi: ) 
 
 m 
 
 inute particles into the circulation. If 
 .lis is unattended with sepsis, no harm 
 :>ed follow; but if septic in origin, 
 ,)cal abscesses, or even diffuse suppura- 
 
 .ion. may occur along the vein, together 
 
 villi general pyjemia. {d) The clot may 
 
 -nrink or become loosened in an ampulla 
 
 : a varicose vein, forming a fibrinous 
 
 ra.ss which is subsecjuently infiltrated 
 
 nth calcareous particles, constituting a 
 
 :ein stone or PJilebolith. 
 Distally, congestion of the terminal 
 
 Veins is caused by the obstruction to 
 
 •.lie circulation, and if a main trunk is 
 
 iffected, oedema of the liml) follows, 
 
 and possibly ulceration or gangrene. In 
 
 iivourable cases the collateral circula- 
 
 ;ion is soon established by the opening up and dilatation of other 
 venous channels, which after a time become ^'aricose, and if 
 -ituated superficially, are often very obvious. Thus, if the common 
 iemoral or external iliac vein is occluded above Poupart's liga- 
 'ient, the internal saphenous and superficial epigastric veins 
 tcome distended and varicose, and the latter is seen coursing 
 jp the abdominal wall towards the umbilicus, and uniting with 
 '■■'i same branch on the opposite side to find its way to the 
 japhenn vein of that limb. If the inferior vena cava is obstructed, 
 'lie mammary and epigastric veins become dilated and tortuous, 
 standing out prominently on the anterior abdominal wall. 
 Proximally, the process may gradually extend upwards, and 
 iaally involve larger and more important trunks than that in 
 
 A, Thrombus /;; situ: B, 
 bolus detached from 
 same. 
 
 em- 
 the 
 
272 
 
 A MANUAL OF SURGERY 
 
 which it originated. Moreover, a portion of a thrombus iiiny 1^, 
 detached as an Embolus (Fig. 76, B). If the clot is undergoing 
 molecular disintegration and only minute pcjrtions are set free, 
 they are filtered off by the lungs or kidneys, and no symptoms 
 need be caused. If, however, a large portion is detached, ur<(ent 
 dyspnu'aand even death occur from obstruction to the pulnionarv 
 vessels and subsecjuent arrest of the circulation. If the cliit 
 becomes septic and fragments conveying organisms are carried 
 into the circulation, pyaemia is the result, preceded, however, in 
 the })ortal area by pylephlebitis — i.e., suppurative phlebitis of the 
 portal trunks in the liver. 
 
 The Clinical Signs and Treatment of venous thrombosis are the 
 same as for phlebitis {q.v.). 
 
 Embolism. 
 
 An Embolus is the term applied to any foreign body which 
 travels for a greater or less distance in the bloodvessels until it 
 becomes lodged within them and causes obstruction. There are 
 four main varieties of embolus : [a) Simple Emboli, Cf^., blood- 
 clot, granulations or fibrinous ^•egetations from the cardiac 
 valves after acute endocarditis, atheromatous plates, air-bubbles, 
 fat globules, etc. (/;) Infective Emboli consist of either zooj^dda 
 masses of bacteria or disintegrated portions of blood-clot carrying 
 micro-organisms and originating a pya'mic abscess where\er thev 
 lodge. (i) Malignant Emboli are formed by portions of some 
 malignant growth, from which the various secondary deposits 
 originate; such are met with more frequently in the sarcomata 
 than in the carcinomata. (d) Parasitic Emboli also occur, such 
 as the o\'a and scolices of the Ticnia ccliinococcus, and the Filiuui 
 sanguinis hominls. 
 
 Emboli may be detached from the heart, veins, or arteries, 
 although necessarily they are never arrested in a systemic vein, 
 but only in the arteries or portal vein. They are of all sizes, and 
 the character of the resulting symptoms depends much on this. 
 A large embolus started in a peripheral vein lodges in one of lhe| 
 branches of the pv.lmonary artery, and may cause instant death 
 a smaller one is arrested in one of the smaller arteries of the lun,^ 
 and may do but little harm, Avhilst minute ones may possibly pas: 
 through the pulmonary capillaries to the left side of the heart 
 and subsequently become impacted in the systemic vessels. 
 
 Eifects of an Embolus. — The Local effects of the lodgment oi 
 a simple embolus consist, firstly, in the deposit of iibriii upo; 
 it, rendering the obstruction complete ; organization of tii' 
 thrombus usually follows, although occasionally it may di* 
 integrate and disappear. Under these circumstances a weak s\xi. 
 may be left in the arterial wall, from which an aneurism is subi 
 sequently developed. The local effects of infective, malignan' 
 and parasitic emboli are dealt with elsewhere. 
 
 The Distal eftei 
 
 relation of the \-ei 
 
 (I) Should the 
 
 anastomotic bran 
 
 capillary anastom 
 
 occurs in most casi 
 
 structures, no syn 
 
 i.irge, or supplies 
 
 may follow even 
 
 embolus of the ce 
 
 nianent blindness, 
 
 (:;) Should the e 
 
 artery ' {i.e., one \! 
 
 the terminal capif 
 
 circulation, the obi 
 
 portion of the an.-ei 
 
 uf yellow softening 
 
 i-r spleen, the resul 
 
 arteries is the devi 
 
 a wedge-shaped are 
 
 lieconies de\itali/je( 
 
 tinner than the j 
 
 properly stained j 
 
 ■mmk area becom 
 
 to lead to extra\aso 
 
 oilour results, kno\ 
 
 I appearance, the inf 
 
 tissue developed fr 
 
 linally results in the 
 
 perhaps, a tew hajii 
 
 iorthe production of 
 
 iiidney, and brain ; 
 
 [tree to allow of its 
 
 i;cciir. 
 
 Effects of the 
 
 ':i the Brain, tlie niidd 
 ■immediate hemiplegia 
 jfinimonlv leaves some i 
 lire less marked, but ane 
 |:^e Central Artery of tb 
 |;-iliiced; the branches 
 iHTmes n-dematous, thu 
 l-s as a cherry-red 'spot 
 Ipues around. In the 
 Ji'Se vessel ; whilst, if a 
 l->pn.ra is produced, foil 
 j*ss, l)rnnchial breathi 
 laehepatic artery causes 
 llycosuria. The portal v. 
 
 1 
 
SURGERY OF THE VEINS 
 
 273 
 
 The Distal effects of embolic obstruction depend entirely on the 
 t'iation of the \essel blocked to the surrounding circulation. 
 
 (1) Should the embolus be lodged in an artery which gives off 
 iiiastomotic branches below the point of obstruction, or if the 
 
 ipillary anastomosis is abundant, a transient anaemia is all that 
 , cms in most cases. If the artery is small, or goes to unimportant 
 
 -uuclures, no symptoms need arise froni this ; but if the vessel is 
 iif,fe, or supplies delicate and important tissues, serious results 
 i;iv follow even a temporary arrest of the circulation ; thus, 
 
 riiibolus of the central artery of the retina always causes per- 
 laneiit blindness, although the retina still lives. 
 
 (2) Should the embolus block what Cohnheim called a ' terminal 
 
 .iitery ' (i.e., one with no anastomosis between the embolus and 
 
 ;he terminal capillaries), or a vessel with insufficient collateral 
 
 circulation, the obstruction will lead to death of, at any rate, a 
 
 Dortion of the an.'emic region — e.g., gangrene in a limb, or white 
 
 i,r yellow softening in the brain. In an organ such as the kidney 
 
 ui Jipleen, the result of enibolic obstruction to one of the terminal 
 
 arteries is the development of what is known as an infarct — i.e., 
 
 a \vedj,^e-shaped area of tissue with the blocked artery at its apex 
 
 iifcomes devitalized, and in consequence looks white and feels 
 
 nrmer than the surrounding parts. The tissues cannot be 
 
 pniperlv stained for microscopic purposes. Sometimes the 
 
 ,t;;;iniic area becomes engorged with blood to such an extent as 
 
 to lead to extra\asation, and a firm, solid patch of a dark red 
 
 f.ilour results, known as a hgemorrhagic infarct. Whatever its 
 
 appearance, the infarct is subsecjuently invaded by granulation 
 
 iijsue (lexeloped from the surrounding healthy parts, and this 
 
 :;iially results in the formation of a depressed cicatrix containing, 
 
 perhaps, a few iKcmatoidin crystals. The conditions necessary 
 
 iorthe production of an infarct are met with in the lungs, spleen, 
 
 kiJney, and brain ; in the liver the anastomosis is generally too 
 
 1 :rire to allow of its formation, although it has been known to 
 ;cur. 
 
 Effects of the Lodgment of Emboli in Various Organs. 
 
 In the Brain, the middle cerebral artery is most commwidy blocked, resultin<^ 
 
 .mmediate hemiplegia, which may be almost entirely recovered from, but 
 
 iiimonlv leaves some impairment of function. In children the symptoms 
 
 I ire less marked, but aneurism of the affected vessel occasio.ially follows. In 
 
 J e Central Artery of the Retina, sudden, total and irremedial blindness is 
 
 l;:diiced; tlie branches ( f the vessel rae seen to be almost empty, tiie retina 
 
 JKomes adematous, the macula alone retaining its normal colour, appear- 
 
 laj as a cherry-red spot, contrastii g markedly with the pallid cedematou ) 
 
 jtiiues around. In the Lung, fatal results superver.e from obstruction to a 
 
 ItLte vessel ; whilst, if a smaller one ;s blocked, a certain amount of pain and 
 
 ]:v>piiii?a is produced, followed by the formation of an infarct, as indicated by 
 
 -kss, bronchial breathing, and bronch^.'phony. In the Liver, an embolus of 
 
 Is hepatic artery causes sudden hypochondriac pain, and perhaps a passing 
 
 Iflycosuria. The portal vein and its branches are not unfrequently obstructed 
 
 i8 
 
274 
 
 A MANUAL OF SURGERY 
 
 by emboli, wliicli, being usually of a septic nature, give rise to py.Tinic 
 symptoms (pylepiilebitis). In tlie Spleen, a sudden pain in the left Iiviki- 
 cliondrium is experienced, tlie organ becomes enlarged, and a considcvahlt' 
 rise of temperature may follow. In the Kidney, sudden pain in the Inin 
 and a temporary ha'inaturia constitute the main symptoms. Ir ''■ ■ '- " ■ 
 localized tdccration or extensive gangreiu; is likely to follow, a 
 
 ch 
 rise 
 
 and a temporary ha'inaturia constitute the main symptoms. In tlie Intestine 
 localized tdccration or extensive gangreiu; is likely to follow, accordiiii; lo [jn. 
 size of the vessel obstructed. In the Limbs, the emboli usually lodge at the 
 bifurcations of main vessels, often saddling across tlie fork, and blocking i)'ith 
 branches. Sudden pain is felt at the spot, shooting downwards, and eitlur 
 recovery or gangrene ensues (p. 50). 
 
 Phlebitis. 
 
 Phlebitis, or intlainmation of the \ ein wall, arises iVom a 
 \ariety of causes, and is not uncommon in surgical practice. The 
 followin.i,^ forms may be described : 
 
 1. Simple Phlebitis, in which a more or less localized iiillani- 
 niation of the wall of a \ein is attended by thromlxjsis ; it cxlcnd.-, 
 for a \ ariable distance up and down the \essel, I)ut usually not 
 further than the next patent branches, {a) it may arise from 
 iitJiii'Y, either subcutaneous or open, or from the continued pressure 
 and irritation of a tumour or aneurism ; (b) it may be idiopdhic 
 in nature. attackin,L( the larger \eins of the lower extremity, or 
 vessels which ha\e been long subject to \arix, especially in goutv 
 individuals. [c) It may follow primary thrombosis, the hlund 
 usually clotting lirst in one of the pouches or ampulla,' of a \;ui- 
 cose N'ein ; or {d) it may be induced by inflanmiation of the tissues 
 around the \ein { periphlebitis), usually of septic origin. 
 
 2. Infective Phlebitis is a much more serious condition, inas- 
 much as the thrombus resulting therefrom is always invaclcd hv 
 micro-organisms, and the disease is often of a spreading t} pe. It 
 was this form of phlebitis which in the old days so coninionlv 
 followed operations, and made surgeons fear any interference! 
 with veins; it has now been almost banished as a se(|uela of 
 surgical operations l)y antisepsis, and there is no more fear of 
 dealing with veins than with any other tissue of the hod v. It 
 may, howe\er, arise (a) in traumatic cases where asepsis has nut 
 been attended to or has failed, the organisms in\adliig the clot 
 which lies in the open mouth of the vein ; or (b) as a result of! 
 septic periphlebitis in wounds, or in septic inflannnation of hones,! 
 such as when a septic luastoiditis leads to disease of the niastoidl 
 emissary \-ein and of the lateral sinus. The usual results areS 
 localized or spreading suppuration in the course of and around tliel 
 vein, and general pyccmia. (c) It may possibly be induced bvi 
 auto-infection of the clot present in simple phlebitis. 
 
 The Morbid Anatomy of phlebitis shows nothing unusual : tlie 
 walls of the vein are congested and thickened, and the endo^ 
 thelial lining is hypertrophied ; the thrombus contained in the 
 \'essel varies in its characters. If infected, it becomes soft and 
 pultaceous, resembling dirty-looking pus ; a localized abscess nia)i 
 
 "ery sign of infla 
 
SURGERY OF THE VEINS 
 
 375 
 
 form, or the suj^i'juration may extend for some distance alonj,' and 
 aiDund the \ein. In the more faxourable cases the spread of the 
 iiil(( lion is limited by the terminal portions of the clcjt remaininj^' 
 tiriii and imaffccted. 
 
 The Symptoms of inflammation of a superficial \ein are suffi- 
 lii'iuly ol)\ ious. The \ essel becomes swollen, hard and painful, 
 with localized enlar},'ements or knobs corresponding to the valves, 
 ,ir to the pouches in \aricose veins. The skin oxer them is 
 ilusky and conjj;ested, and there may be some oxlenia of the 
 ;v>;i()n from which the blood flowing in the \ein is gathered ; 
 •Jiis, however, rarely amounts to much, since the collateral cir- 
 uilalion is always abundant. If suppuration occurs, the signs of 
 ;i localized abscess are noted ; on opening this, care must be 
 devoted to maintaining the part aseptic in order to pre\ent, as 
 lar as possible, the extension of the inflamtnation. 
 
 When the deeper \eins are in\ol\ed, it may be imjjossible to 
 detect them on palpation, although a blocked conunon femoral is 
 easily felt ; but the acute deeply-seated pain and marked oxlema 
 are characteristic exidences of what has occurred. The o-dema 
 is of a more or less solid character, similar to what is seen in 
 •white leg,' in which probably lymphatic obstruction plays a 
 part. Obliteration of the vessel, and any of the local, distal, or 
 general processes detailed under thrombosis (p. 271) may result. 
 
 The onset of Septic Spreading Phlebitis is marked by fe\er and 
 perhaps ligors, whilst the local signs are due to the rapid extension 
 jf a suppurative inflaimnation along the \ein and its branches, so 
 that a large tract of tissue is \ery quickly invaded, and diffuse 
 suppuration follows. The development of pya-mia would be indi- 
 Mted bv a repetition of the rigors. 
 
 Treatment of Simple Phlebitis. — The limb nuist be kept abso- 
 iatelv at rest to limit the inflannnation and to prexent the 
 detachment of end)oli, and also elevated to assist venous return. 
 Locally, belladonna fomentations may be applied, or the parts 
 mav he painted with glycerine and extract of belladonna, 
 ^\\athed in a thick layer of cotton-wool, and lightly bandaged. 
 The patient should be kept on an unstimulating, though 
 I nutritious, diet, and the general health attended to. When 
 ■.very sign of infliunmation has svd)sided, and sufficient time 
 |i;asl)een allowed for the absorption or organization of the clot 
 six to eight weeks), massage may be connnenced, to assist in 
 [the removal of cedema and local thickening, and an elastic 
 iiandaj,a> is usually serviceable in restoring the circulation. 
 Operation is sometimes undertaken in cases of phlebitis associated 
 |nth varix (p. 278), but not wdien the deeper veins are involved. 
 tahscesses form, however, they must be opened antiseptically. 
 Spreading Infective Phlebitis is tr'^ated by following up the sup- 
 |fiirati\ c process with the knife, laying open the tissues around the 
 -■volved \'eins. The wounds thus raade should be treated with 
 
 iS— 2 
 
376 
 
 A MANUAL OF SURGERY 
 
 ;)V 
 
 |)(.'i"c)xicle of hytlio^^^oii and lij,d)lly stuffed ; at llii' saim: liinc, the 
 limb is raised and kept absolutely ([uiet. Should pyjeinic plic- 
 noniena de\-elop, it may be possible to pdace a lif^'ature betwtin 
 the disiiUef,M'atinf,' clot and the heart, and to scrape or wash awav 
 the septic mass; thus, in septic thr()nd)osis of the lateral sinus, 
 followinff suppuration in the middle ear, the internal ju<;ular \eiii 
 should be lij^Mtured, the lateral sinus opened, and the clot removed. 
 Of course, such treatment is (ndy feasible in cases where a single 
 trunk is affected. When the process affects the veins of a linih, 
 and cannot be stoj)ped by either of these plans of treatment, the 
 question of amputation may e\en ha\e to be raised. 
 
 Varicose Veins, or Varix. 
 
 A vein is said to be varicose, or in a condition of varix. 
 N\ hen it has become permanently lenj^^thened, dilated, and more 
 or less tortuous. The superficial \eins of the leg, especially the 
 internal and external saphena, are those most commonly affcc ted; 
 the spermatic veins are often in a similar condition, consUtutinj,' 
 what is known as a varicocele, whilst piles are primarily due to 
 varicosity of the luemorrhoidal plexus. We shall here only deal 
 with the first of these three manifestations. 
 
 Causes. — Varix is induced by any condition which leads to a 
 frecjuently repeated or more or less permanent distension of a vein, 
 such as prolonged standing, as in those serving behind counters : 
 the pressure of tight garters, especially if worn below the knee; 
 prolonged or forcible exertion of the limb, as possibly in cyclists, 
 whereby the blood is driven from the deeper into the more super- 
 licial \eins ; the pressure of a pregnant or displaced uterus, ur of 
 a pelvic tumour. Obstruction to and occlus'jn of the deeper 
 veins is another well-recognised cause of ^•arix, and we have 
 already drawn attention to the effect produced by Idocking of the 
 common femoral \ein and inferior vena cava. A less known 
 instance is the varix of the internal saphena or some of its 
 branches below the knee, which follows thrombosis of the vena 
 comites of the posterior tibial, due to strains of the leg and similar 
 injuries. If the thrombus is absorbed, the dilatation disappears: 
 but if the block is permanent, the varix persists and usually 
 extends to just below the knee. Any abnormal communication 
 between an a^lery and a vein also causes varicosity, from the 
 inability of the latter to withstand arterial blood pressure {ridi 
 Aneurismal \'arix, p. 218). Inherited weakness, or the relaxation 
 of system due to sedentary habits, must be looked on as pre- 
 disposing causes. The tendency to varix increases with age till 
 the middle period of life is reached. When a vein is varicose 
 and its walls are thin and expanded, the val\es become incompe- 
 tent, and the superincumbent weight of the blood tends to still 
 further increase the mischief. 
 
 Morbid Anato 
 
SURGERY OF THE VEINS 
 
 277 
 
 Morbid Anatomy. To tho naked eye a varicose vein in an early 
 >Uij;f appears lliic l<enecl, tlislendcd, and tortuous; the walls are 
 so thick that the vein when cut across does not collapse, but 
 presents a f^^'lpin<^' mouth, like an artery ; the waives atrophy, and 
 .irc functionally useless. AI'tiT a time the walls become further 
 >tretched and irre<,aUarly expanded, forminj^ pouch-like dilatations, 
 uhicli are very ob\ious under the attenuated skin, to which they 
 arc often adherent. Microscopically, the chan<,'e consists in a 
 tuuisformation of the normal structures of the \ein wall into 
 lihro-cicatricial tissue. The tunica media is mainly affected, most 
 of the muscular fibres disappearing,', whilst the tunica intima is 
 Imt little chan{,fed, and the adventitia thickened. 
 Ill the pouches the middle coat is atrophied, 
 and, indeed, is often completely absent. 
 
 Clinical History. — The enlarj^ed veins are 
 >een ramifying,' under the skin with a more or 
 less tortuous and serpentine course (Fig. 77), 
 ;uk1 they often feel thickened. One or more 
 veins may be affected, and the tortuosity may 
 be at parts so 1 .i;ked as to constitute large 
 clusters of dilateu vessels, which look bluish 
 under the attenuated skin. 
 
 The Effects of this condition are \ery varied. 
 The circulation in the lower parts of the leg 
 may be impaired, especially that of the skin. 
 The limb feels hea\y and painful ; forcible 
 exertion may cause a sensation of tension, and 
 after standing or exercise there is usually a 
 little (edema of the ankle. The capillaries in 
 the papilhe often become dilated, appearing as 
 minute reddish puncta, which subsequently 
 run together and form brownish patches of 
 piq;mentation. Eczema is induced by the irri- 
 tation of rough and coarse trousers or du't, 
 often terminating in actual ulceration. Any 
 bion, such as a scratch or abrasion, instead 
 of healing readily under a scab, tends to spread p,(; 77— Vakix of 
 and form an ulcer. Injury to the vein may Internal Saphkna 
 lead to thrombosis and spontaneous cure, 
 but coagulation sometimes occurs idiopathically in the pouches, 
 and the clot may subsequently shrink and form a small fibrinous 
 or calcareous mass, known as a ' phlebolith.' Gouty persons 
 with varicose veins are especially prone to attacks of phlebitis. 
 if these are limited in extent, no serious liarni results ; but 
 soinetimes the thrombosis spreads into deeper or larger veins, 
 whilst fragments of clot may be detached as emboli. Occasionally 
 the dilated pouch of a varicose ^'ein gives way, and an alarming 
 gush of blood results ; the same may follow the extension of 
 
278 
 
 A MANUAL OF SURGERY 
 
 ulceration through the vein wall. The blood under these circum- 
 stances is derived, not only from the lower, but also from the 
 upper end, inasmuch as the valves have become incompetent ; a 
 column of blood extending from the right auricle is thus tapped 
 near its lower end, and, unless prompt precautions are taken, the 
 patient's life may be lost. 
 
 The Treatment of varicose veins may be described as palliative 
 and radical. 
 
 Palliative Treatment consists in removing any source of obstruc- 
 tion in the shape of tight garters, in limiting the amount of stand- 
 ing, in moderate massage, together with the application of cither 
 an elastic stocking or an indiarubber bandage. The bowels 
 should be kept well open, and the general health attended to. 
 Eczema may be treated by the application of soothing and chyini,' 
 ointments, e.g., ung. zinci benzoatis ; or if the skin is chronically 
 infiltrated and thickened, by the use of weak tarry applications, 
 e.g., ol. Rusci (i part to 4 of vaseline), or of ichthyol (5 or 10 per 
 cent, in vaseline), \^aricose ulcers are treated on ordinary prin- 
 ciples, or by Unna's method (p. 47) ; but repair is often delayed 
 till the veins have been dealt with by operation. 
 
 Radical Treatment consists in the excision of the distended veins, 
 Before operating it is important to make certain that tiie con- 
 dition is not due to thrombosis of the deep trunks, as interference 
 would then do more harm than good, and the varix would be 
 certain to recur in neighbouring collateral veins. Operation is 
 specially indicated when thin, dilated pouches exist ; when elastic 
 stockings cannot be comfortably worn, as in the tropics; when 
 ulcers exist which refuse to heal ; or when the condition is very 
 extensive and painful, and especially if large bunches of dilated 
 veins are seen. It may not be practicable to remove all, but if 
 the largest and most prominent are taken away, the others will 
 probably shrink and disappear. There are two chief plans of 
 doing this: (a) Small portions are removed at several dififerent 
 situations. The skin is pinched up over the vein, and incised by 
 transfixion ; the vessel is usually bared by this means, but may 
 need a little cleaning. An aneurism needle is passed beneath it, 
 and the vein isolated sufficiently to allow of its being grasped by 
 two pairs of forceps, and divided between. Each end is now 
 freed, and drawn out of the wound as far as possible ; it is then 
 ligatured and removed. Probably 2^ inches of vein may be taken 
 away through a i-inch incision. The wound is sutured without 
 drainage and dressed, (b) Long incisions are made, perhaps 6 j 
 inches or more, through which larger clusters of veins may bej 
 dealt with. The wound should not lie over the most dilated parts 
 of the vessel, as there the skin is often thin and unhealthy, but 
 should be curved so as to include as much sound skin as possible, 
 whilst crossing the vessels once or twice. All collateral branches, 
 especially the deep ones, must be secured, and this, in fact, con- 
 
 stitutes the grec 
 anastomosing cl 
 been advocated 
 of the internal s 
 superjacent coJi 
 ialual:)le additio 
 excised. 
 
 Inflamed Vari 
 
 a natural cure ( 
 
 superficial phleb 
 
 should be fo]low( 
 
 justifiable to exc 
 
 to first secure by 
 
 any risk of em bo 
 
 also required wh 
 
 and tlireatening t 
 
 hood of the sap 
 
 I tin.f,-- detached a; 
 
 Haemorrhage fn 
 
 tieatinent. The 
 
 compre,ssion, and 
 
 elevated, until eitl 
 
 t'the wound, or ^ 
 
 A nan-US is a ^ 
 subcutaneous or si 
 vessels held toget 
 ^'enital origin, or 
 tliey may shrink a 
 ?!ze more or less 
 and persist througl 
 Hie Capillary Nj 
 I slightly raised i] 
 I according to the 
 ^ ^-esent, and with . 
 j surface, in which 
 "iisists merely of 
 Wiiiinunicating wi 
 |tO;'ether by loose c 
 represent in the 
 |5;!!all, not exceedin 
 flies they extend 
 r^ry superficial in c 
 jHitutmg the ' port-1 
 lifieluoino-rhage is 
 Occasionally a nc 
 
SURGERY OF THE VEINS 
 
 2/9 
 
 stitutes the great advantage of the operation, viz., that so many 
 anastomosing channels are obhterated. A simpler procedure has 
 been advocated by Trendelenburg, viz., the removal of a portion 
 of the internal saphena high up, so as to break the weight of the 
 superjacent column of blood. In suitable cases it is a most 
 valuable additional measure, but the enlarged vein should also be 
 excised. 
 
 Inflamed Varicose Veins are not unfrequent, and may result in 
 a natural cure of the condition. The symptoms are those of a 
 superlicial phlebitis, and the treatment indicated for that condition 
 should be followed. In cases where there is much pain it may be 
 iustifiable to excise the thrombosed vessels, taking the precaution 
 to lirst secure by ligature the vein above the clot, so as to prevent 
 any risk of embolic detachment. Operation of a similar type is 
 also required when thrombosis is gradually spreading upwards, 
 and threatening to affect the deep trunks, e.g., in the neighbour- 
 hood of the saphenous opening ; or when portions of clot are 
 Ifing detached as emboli giving rise to pulmonary symptoms. 
 
 Haemorrhage from a Ruptured Vein needs prompt and decisive 
 ueatment. The bleeding spot should be commanded by digital 
 impression, and the patient laid on the back with the litnb 
 elevated, until either a pad of antiseptic dressing can be applied 
 
 nthe wound, or a handkerchief or bandage secured over it. 
 
 Nsevus. 
 
 A iKEvus is a vascular tumour developing in the skin and in 
 subcutaneous or subamcous tissues, and consists of a congeries of 
 vessels held together by connective tissue. Naevi are of con- 
 ,'enital origin, or develop soon after birth. Left to themselves, 
 they may shrink and disappear, but more often they increase in 
 j'lze more or less rapidly, whilst sometimes they remain passive 
 and persist through life. Two chief varieties are described : 
 
 The Capillary Naevus (or mother's mark) occurs in the form of 
 a slij,fhtly raised fattened mass, bright red or purple in colour, 
 according to the relative amount of arterial or venous Ijlood 
 present, and with oc< asionally a somewhat irregular or nodulated 
 sartace, in which larger vessels may be seen ramifying. It 
 onsists merely of a mass of capillaries lined with endothelium 
 communicating with a few arterioles and venules, and held 
 toijether by loose connective tissue. Several such growths may 
 be present in the same individual, and they are usually quite 
 s:iiall, not exceeding an inch or two in diameter, though some- 
 times they extend widely over the face and neck, and are then 
 very superficial in character, and somewhat dusky in colour, con- 
 5iituting the ' port-wine stain.' If cut into, they l)leed freely, but 
 ttie JKemcrhage is easily stopped by pressure. 
 Occasionally a nasvoid development may be observed involving 
 
 •U 
 
28o 
 
 A MANUAL OF SURGERY 
 
 half the body, and limited almost exactly by the middle line; this 
 condition is known as iia-vus unins latcris. It may consist of a 
 purely vascular manifestation, or the skin may be hypertrophied 
 and covered with small soft papillary excrescences. In a case 
 under our observation recently, the trunk, head, and limbs were 
 distinctly asymmetrical, the naivoid half being larger and better 
 developed, except in the case of the leg. 
 
 Treatment is usually simple in the extreme. Small superficial 
 nai\i can be completely cured by some form of cauterization, such 
 as the application of the electric or actual cautery, ethylate of soda, 
 or nitric acid ; in applying fluid caustics, the surrounding skin 
 must be protected by a thick layer of vaseline. In exposed 
 situations electrolysis [vide infra) is the best plan to adopt in order 
 to prevent the formation of a scar, but excision will often give an 
 equally good result. 
 
 The Cavernous or Venous Nsevus most cOnmionly invokes both 
 skin and subcutaneous tissues, but is sometimes purely sub- 
 cutaneous. It consists of a more or less prominent swelliui,', 
 soft to the touch, and easily compressible, but reiiUing when 
 the pressure is removed. There is no pulsation or bruit, and the 
 mass may be lobulated. If subcutaneous, the skin over it is 
 somewhat bluish in colour, but the mixed forms are dusky red, 
 Occasionally it may undergo spontaneous cure from inflammation 
 and thrombosis, and cysts are sometimes found in the cemre of a 
 niuvoid mass, indicating that a partial attempt at this process has 
 occurred. \'enous na:vi consist of a collection of vascular spaces 
 lined with endothelium, some tubular-like veins or capillaries, 
 others mere pouches, held together by fibrous tissue. 1 he arterial 
 supply is not very great, but the arteries usually open directly into 
 the venous spaces without the intervention of capillaries (p. 134!, 
 
 The Treatment is by no means as simple as in the foroKn- 
 varieties. The following plans may be mentioned : 
 
 1. Excision of the growth should always be adopted where 
 practicable. Cases which formerly were dealt with by strant^ula- 
 tion are now treated by this means. The bleeding is never Ljreat, 
 even if the na'\oid tissue is encroached upon by the knife, aiul 
 only a few vessels will need to be tied. Circular growths should 
 be removed by crescentic incisions, and a little undercutting will 
 always enable the edges to be easily approximated. 
 
 2. Strangulation of na?vi with ligatures was largely used in tl;e 
 old days, and is even now practised occasionally ; but it is 
 essentially bad, and has not a redeeming feature. Any na^viis 
 whicii can be cured by strangulation can also be excised; the 
 process is both painful and tedious, and the strangled tissue may 
 become a source of septic infection. The wound remaining after 
 the mass has sloughed away is large, and lea\es an ugly depressed 
 cicatrix, contrasting most unfavourably with the linear scar 
 following excision. 
 
SURGERY OF THE VEINS 
 
 281 
 
 3. The Injection of coagulating and irritating fluids, such as 
 perchloride of iron or pure liquefied carbolic acid, has been 
 employed, but has no advantages over electrolysis, and is more 
 ;ivky and less certain in its results. 
 
 ^, Where excision is impossible, or where it is important to 
 itave no scars or only minute ones, Electrolysis should be em- 
 ployed. It consists in the passage of a current of high electro- 
 niotive force through the mass, producing chemical and physical 
 changes in the contained blood. A Stohrer's battery can be 
 ased, or any suitable collection of cells, connected in series. 
 Both needles may be inserted into the mass, but it is wiser 
 onlv to use one or more needles connected with the positive 
 pole, whilst the negative pole is attached to a large electrode 
 Moistened and placed on some indifferent part of the body, such 
 as the arm, back, or thigh. The needle is often with advantage 
 made of iron or steel, since it is usually corroded, and the chloride 
 ol iron thus formed acts beneficially in determining coagulation 
 ofthe hlood; it must be carefully and thoroughly insulated v/hen 
 Jeep n;tvi are treated, so as to protect the skin and prevent the 
 current passing through it. The use of the negative pole is more 
 ::ki'ly to produce scarring, since a caustic sodium compound is 
 lormed ai'ound it, and this may lead to sloughing of the tissues ; 
 ihe clot, moreover, is loose and spongy, whilst a much firmer 
 coagulum occurs around the positive pole. If the positive pole 
 i abne is introduced, a current equal to about 200 milliamp^res, as 
 measured by a galvanometer, may be passed for 10 or 15 minutes; 
 j if both poles are used, a current half this strength is sufficient. 
 Ail anaesthetic is needed, and the immediate effect should be to 
 I make ttie mass feel hard and firm by the coagulation of the blood ; 
 e tuniour is subsequently disintegrated and absorbed. The 
 )plication may require to be repeated several times, and the 
 j needles should be freely worked about through the mass. Not 
 |micomnionly the child becomes pale and faint if the na:vus is 
 on the head, probably as an effect of the strong current upon the 
 [cerebral centres. For the treatment of superficial naevi, there is 
 I necessity to have the needle coated; it is introduced into the 
 jmass in a number of places, especially where any definite vessels 
 are seen, and of course does not penetrate deeply. A very short 
 application of the current usually suffices at each puncture; the 
 nsvoid tissue turns white, and there is a little bubbling of gas 
 around the needle. It is best to deal first with the periphery of 
 ansvus, and then, when its extension is arrested, the central 
 parts can he treated. Of course some scarring cannot be avoided, 
 and hence it is wise not to do too much at one sitting, and to 
 make the intervals sufficiently long to allow cicatrization to take 
 [place. 
 
 A Nsevo-Lipoma is the name given to a somewhat rare tumour, 
 |in which a fatty element is blended with na;void tissue. It is 
 
282 
 
 A MANUAL OF SURGERY 
 
 usually of congenital origin, or, at any rate, appears early in lifej 
 and is probably due to the undifferentiated formative cells of the 
 embryo developing in a twofold direction so as to produce noil 
 only fatty connective tissue, but also vessels. It gives rise td 
 a swelling, lobulated and doughy, like a fatty tumour, altliough 
 is usually a little denser in texture than the ordinary lipoma. I^ 
 may be possible to reduce its size by compression, but no thrill oa 
 pulsation can be detected ; a few dilated veins or capillaries arq 
 often seen on the surface. The only treatment is excisicni of tH 
 mass. 
 
 Venesection. 
 
 Venesection or phlebotomy is a means of treatment which „„ 
 largely fallen into disuse of late years, but is still occasional! 
 
 hai 
 
 Fig. 78. — Venesection, 
 
 employed with benefit. When a patient is becoming cyanose 
 and asphyxia is threatening either [a) as a result of pulmonar; 
 engorgement from mitral incompetency, owing to the heart hein| 
 unable to drive the blood into the systemic circulation ; or (h) 
 a consequence of some accident involving the chest wall ai 
 lungs, whereby the blood-aerating surface is so diminished th 
 it cannot deal with the blood reaching it through the rif(ht sidi 
 of the heart, which hence becomes enormously distended 
 threatens to stop in a condition of diastole ; or (c) where inflai 
 mation of the brain is pending, and the pulse is hard and fu 
 or {d) in many inflamm.atory states in strong, full-blooded ind: 
 viduals where the pulse tension is high — in any of these conditionj 
 venesection may be used with advantage. 
 
 The median basilic vein at the bend of the elbow is that usuall; 
 opened, since it is larger than the median cephalic, though placei 
 more directly over the brachial artery, from which it is separatei 
 by the bicipital fascia. 
 
 Bequisites. — A pad of antiseptic wool or gauze ; a strip 
 bandage about 4 feet long ; a lancet : a graduated bleedin 
 
 g-ho\vl| 
 
SURGERY OF THE VEINS 
 
 283 
 
 jsd finally a stick or bandage to be grasped by the hand, so as to 
 Lise contraction of the muscles, thus pressing the blood froni the 
 Itepinto the superficial veins along the communicating branch 
 Ithich enters the median just below its bifurcation. 
 
 Operation. — The patient should be seated in a chair ; standing 
 Ijould produce syncope tqo rapidly, whilst the recumbent posture 
 j allow too great an abstraction of blood before Nature's 
 Iteer-signal (i.e., syncope) is evident. The skin in front of the 
 ; having been purified, as also the fingers of the surgeon and 
 jiiie lancet, the pad is placed on the front of the arm, and the 
 Itandage tied firmly over it, so that the \enous circulation may be 
 lasted whilst the arterial supply is unimpeded. Grasping the 
 Lick firmly causes the veins to become prominent. The median 
 Ifciiic is now steadied by the left thumb, and an oblique incision 
 Lde into it in the axis of the limb (Fig. 78). Blood will flow 
 t;ni it in • full stream, and is collected in the bowl. When 
 ':s;!ticient has been withdrawn, the stick is removed from the 
 |s;ient's hand, the surgeon's thumb is placed over the bleeding 
 
 ;)t, the bandage above is relaxed, the pad placed over the 
 and and firmly bandaged in position ; the arm is kept at 
 
 !:-; for a few days to allow the small incision to heal. Occa- 
 I aally neuralgic pain is caused by the implication of some of the 
 
 ::e?of the internal cutaneous nerve in the cicatrix; whilst, if 
 Itiancet is plunged too deeply, an arterio-venous wound may be 
 
 :.duced. 
 
DIS 
 
 CHAPTER XI. 
 DISEASES OF THE LYMPHATICS. 
 
 Affections of Lymphatic Vessels. 
 
 Acute Lymphangitis, or Inflammation of the Lymphatic Vessels] 
 — The Cause is almost invariably the absorption from an impure 
 wound of septic material, with or without bacteria. In eitheti 
 case the toxins diffuse themselves along the lymphatics, and 
 rise to irritation and inflammation of the surroundin^j;- tissuesj 
 which may run on to suppuration, especially if pyogenic organisma 
 have also been taken up from the wound. The process is usually 
 limited by the nearest lymphatic glands, which filter off the toxid 
 products, but occasionally it spreads beyond them, and may !,'iva 
 rise to general infection of the system. Dissecting or post-morttiii 
 wounds are not unfrequently of this nature. 
 
 Morbid Anatomy. — The walls of the lymphatics become hyperj 
 aemic and infiltrated, and the tissues around are inflamed. 11 
 lymph is said to coagulate in the vessels, forming a pinkish clot, I 
 
 Clinical Signs. — The characteristic appearance is that of hnered 
 lines or streaks following the course of the lymphatics, peibapj 
 up to the nearest glands ; the parts thus inflamed are tender and 
 oedematous. If the mischief is limited to the main trunks {tnkki 
 lymphangitis), these red lines remain isolated from each other; bul 
 if all the smal'er lymphatic channels of a part are affected {I'diforit 
 lymphangitis), the redness merges into a generalized blush, and thl 
 condition is practically identical with cellulitis. Localized foci i 
 suppuration often follow, the redness increasing, and the parti 
 becoming dusky and brawny, until finally the centres soften anJ 
 fluctuate. These phenomena are associated with the general sign! 
 of fever and malaise, the temperature rising to 102" or 103', po^ 
 sibly attended by rigors, vomiting, and diarrhcea. 
 
 The Diagnosis of acute lymphangitis from erysipelas turns o| 
 the more localized and patchy or streaky character of the rednes 
 whilst the margin is by no means so sharply limited or defined; 
 in the latter disease. 
 
 Under suitable t 
 raration may occur 
 J^elkiiar tissue trave 
 yi abscesses in th( 
 llvniphatic vessels 1: 
 jiolid or lymphatic 
 Ices from general se 
 1-jppuration. 
 
 Treatment is first 
 
 Imust be thoroughl- 
 
 irritating toxins to 
 
 ;Ktin a slightly ele\ 
 
 Ibtions, or treated w 
 
 Jopened as soon as tl 
 
 is remedied by 
 
 [iciioiis complications 
 
 Constitutional tre; 
 
 |p;ir»e, followed l)y 
 
 Icjnstipation is not th 
 
 ^ordered, together v 
 
 Chronic Lymphang; 
 back, or is met wit 
 ijiiently seen in conne 
 patics of the penis 
 jespecially in cases o: 
 pied by a solid (t'c 
 Irsement of the ingui 
 [reatnient, the swellir 
 
 itukiriilous type o 
 Iriniary focus, say, 
 leposits along the ly 
 
 t of firm consistenc 
 fatiirall}- such a ca; 
 bination. The tyea 
 I'possible, liy excisioi 
 
 ; Tronic distension 
 iectasis, occi 
 lor acquired. 1 
 8tlie more localized 
 I Congenital enlargeii 
 lot tbe tongue (;/mr; 
 P connective tissue 
 F of the lymphatics 
 jiymphVarixof the 
 {'icon<,renital condit 
 F be affected, and 
 
DISEASES OF THE LYMPHATICS 
 
 285 
 
 I'nder suitable treatment resolution rapidly follows, hut sup- 
 
 .ration may occur either in the glands or in some loose mass of 
 icellular tissue traversed by the lymphatic trunks, or as a chain 
 
 abscesses in the course of the vessels. Occasionally the 
 
 I'lvmphatic vessels become permanently occluded, and a form of 
 
 did or lymphatic ctdema results. In a few cases the patient 
 
 cies from general septicaemia, or from exhaustion following diffuse 
 
 |,i;ipuration. 
 
 Treatment is iirst of all directed to the septic wound, which 
 Iraust he thoroughly purified, so as to cut off the supply of 
 liiritating toxins to the lymphatics. The limb itself is kept at 
 |;;jt in a slightly elevated position, and either irrigated with cold 
 
 lions, or treated with belladonna fomentations. Abscesses are 
 
 ?ened as soon as they develop. Any subsequent cx'dema of the 
 
 rab is remedied by massage and firm bandaging, provided no 
 
 ::nous complications are present. 
 
 Constitutional treatment consists in the administration of a 
 |-.iiS,'e, followed by quinine and tonics, care being taken that 
 
 jBjtipation is not thereby produced. A light and nutritious diet 
 
 [sordered, together with stimulants, if necessary. 
 
 Chronic Lymphangitis either results as a sequela of an acute 
 
 ack, or is met with as a separate condition. It is most fre- 
 
 pntly seen in connection with venereal disease, the dorsal lym- 
 
 ptics of the penis becoming enlarged, hard, and cord-like, 
 
 Specially in cases of primary syphilis. This is usually accom- 
 
 pied by a solid (edematous condition of the prepuce, and en- 
 
 Vement of the inguinal glands. Under appropriate anti-syphilitic 
 
 peatment, the swelling subsides in a few weeks. 
 
 Miihciruloits type of chronic lymphangitis also exists in which a 
 
 liniary focus, say, on a finger is associated with secondary 
 
 leposits along the lymphatics up the arm. Each nodule is at 
 
 pt of firm consistency, but gradually softens and breaks down. 
 
 aturally such a case is liable to be followed by general dis- 
 
 fcaination. The tycatment consists in the removal of each focus, 
 
 [ipossible, by excision. 
 
 i Chronic distension and dilatation of lymphatic vessels, or 
 ppliangiectasis, occurs in a vari«ty of forms, and may be con- 
 
 lor acquired. The term lymphangioma is sometimes applied 
 stlie more localized types. 
 I Congenital enlargement of the lips {macvochcilia, Chapter XXIV.), 
 
 the tongue {macroglossia, ibid.) depends on an overgrowth of 
 It connective tissue of the part, associated with chronic disten- 
 pnofthe lymphatics. 
 
 [lymph Varix of the superficial vessels is occasionally met with 
 ii congenital condition. Any part of the surface of the body 
 fiiy be affected, and the lesion manifests itself as a series of 
 
286 
 
 A MANUAL OF SURGERY 
 
 small vesicles, which persist and are unaccompanied by any m^ 
 llanimatory redness, thus serving to distinguish it from herpes] 
 They contain lymph, and, if opened, a considerable flow of thi^ 
 fluid (lyiiipliui'i'lura) may result, lasting for some time. Tliev have 
 been observed most frecjuently on the inner side of the thii/h, and 
 on the prepuce. Treatment consists in laying them open, and 
 cauterizing the base ; if the deeper lymphatics are als(j affected] 
 pressure should be employed. 
 
 Congenital Hygroma is a condition occurring in children, due td 
 the distension of subcutaneous lymphatics, as a result of which 
 multilocular cystic swelling is produced. It has been sugj^^ested 
 that it is due to the persistence of certain embryonic structures 
 but there is no warrant for this supposition. For a furthej 
 description, see Cliapter XX\TII. 
 
 Acquired Forms of Lymphatic Obstruction may result u cm anil 
 conditions which impede the onward flow of lymph. A few cases 
 are on record in which the opening of the thoracic duct has been 
 obstructed or compressed. In such the consecjuence has usuali 
 been a rupture of the receptaculum chyli, with a large exudation i 
 lymph or chyle into the pleural or peritoneal cavities. 
 
 The condition known as Chylous Hydrocele, in which there is 
 an effusion of milky fluid (presumably chyle) into the tunicJ 
 vaginalis, is probal)ly due to some such obstructive cause. In 
 case under our care the lymphatics of the spermatic cord wi r 
 dilated bv a similar fluid in a beaded manner. 
 
 Rupture or Division of the Thoracic Duct during operations nii 
 the neck is manifested by an escape of chylous fluid, wliiclj 
 coagulates on standing ; if the ilow continues, exhaustion quicld 
 follows. Cases, however, have been published showing that th^ 
 condition is not necessarily fatal, and that if the wounded vess 
 can be secured, as by ligature or forcipressure, recovery niaj 
 ensue. In such instances the thoracic duct probably opens bj 
 several mouths into the subclavian vein, and only one of till 
 branches has been injured. 
 
 More chronic forms of lymphatic obstruction arise from thj 
 deposit of tuberculous or cancerous material in the lyniphatij 
 glands, from repeated attacks of subacute lymphangitis, due t| 
 the continuous irritation of a large ulcer or extensive eczema i 
 from the growth within the lymphatics of 
 
 the leg, or 
 organisms. 
 
 ^'■S- 
 
 IVIP. 
 
 the Filaria sanguinis hominis. The latter cnii 
 dition is the cause of the disease known as Elephantiasis Arabiu 
 whilst the former may give rise to a spurious form of thi 
 affection, known as Pseud-elephantiasis. Three chief phenonien 
 manifest themselves as the outcome of such obstruction, viz 
 {a) Solid or lymphatic cedcma, a condition in which the subcutaneoii 
 tissues become firm, infiltrated, and brawny, but the fluid cannd 
 be expressed from them, as in an ordinary cjedema ; [h) hypt'i'j'l'^ 
 follows, affecting not only the subcutaneous tissues, which ai 
 
DISEASES OF THE LYMPHATICS 
 
 287 
 
 rjrkedly thickened and increased in amount, but also the skin, 
 Iwich becomes coarse and wart-like in appearance, and is very 
 )rone to ulcerate ; and (c) lyiiipliatic fistula are liable to develop, 
 iom which a larf,fe amount of iluid exudes {lymphoyrJuva). 
 
 Solid (cdema of the prepuce is a not \ery unfrequent com- 
 Ipiication of suppurative balanitis, and occurs most usually in 
 loses of syphilis. The dorsal lymphatics can be felt enlarged, 
 
 ithe prepuce becomes swollen and indurated to such a degree 
 Itsat retraction is impossible. In cases of hypospadias, where 
 Ite prepuce is voluminous and hangs like a hood over the glans, 
 jtlie occurrence of solid cedema renders it so prominent as almost 
 Im resemble the glans in colour and size. 
 
 The removal of tuberculous glands from the neck may be followed 
 
 kvapulTy condition of the lower half of the face, which remains 
 
 ifk%^A for some time, but after a while regains its usual size. 
 
 A B 
 
 Fig. 70. — Elhi'iiaxtiasis ok Fkkt. 
 
 cheeks are occasionally involved in a solid (X'dematous process 
 beading from either side of the nose, and due to attacks of 
 pnic lymphangitis, caused by the absorption of toxins from sores 
 liuiceis within the nostril. The thick lips occurring in tuberculous 
 pireii are of a similar nature, and due to the constant irritation 
 licacks along the margins. 
 
 I The pseud-elephantiasis arising from chronic ulcers, or from 
 kase of the lymphatic glands, can usually be dealt with by the 
 ttjsure (jf an elastic bandage ; but the limb is very likely to 
 bam permanently enlarged, and in some cases where intrac- 
 ple ulceration and lymph fistulae exist amputation is the best 
 Itatment. 
 
 I Elephantiasis Arabum (syn. : Barbadoes leg) requires but little 
 tee he.e, as it is seldom seen in this country, being mainly 
 Med to the tropics, especially the West Indies and South 
 :a. The legs, scrotum, and vulva are the parts most fre- 
 ely attacked, but the face or breast may also be affected. It 
 Nests itself as a hyperplasia of variable size of the sub- 
 pneous tissues, whilst the skin becomes thickened and wart- 
 
288 
 
 A MANUAL OF SURGERY 
 
 1) 
 
 like (Fig. 79, A and IJ), and from it a copious clisch;ui'c 01 
 lymph may escape. The parts sometimes attain I'lioniionJ 
 dimensions, the scrotum even reaching to the ground when tlJ 
 patient is sitting. The disease persists for many years, and i| 
 not directly fatal. 
 
 The condition is due, as already mentioned, to the oh^tructinJ 
 caused l)y the development of the Filaria sauf^uiiiis liowini^ in th] 
 lymphatics. These are spread (according to Manson) hy tlJ 
 agency of mosquitoes, in whose bodies the intermediate sta«a' i] 
 passed. The dead mosquito, with its parasitic contents, fal 
 upon the water, and in this way the ova lind an entrance into tlij 
 human stomach, where the young worm is set free, bores throu" 
 the gastric mucous membrane, and finally becomes lodged in tliJ 
 lymphatics, especially those of the extremities. Not more than twi 
 or three pairs of mature filarix' are generally present in the saiiij 
 individual. The body of the female worm (which attains a leni^tf 
 of 3 inches) is mainly occupied by the reproductive orf^ans, anj 
 a countless number of embryonic filarial are produced. Soiiij 
 remain coiled up in the lymphatic spaces, and give rise to ihj 
 phenomena of lymphatic obstruction. Others become uncoiled 
 and are then about .^.^ inch in length ; they find their wav intj 
 the blood stream, usually at night, and can be readily seen unde 
 the microscope. Manson claims that they are taken into 
 body of the mosquito with the blood which it abstracts, and thi^ 
 a fresh generation is developed. 
 
 The Treatment is extremely unsatisfactory. Of course, if onl 
 can localize the situation of the parent filaria^-, as lias heel 
 possible in a few cases, they should be excised ; but more fr( 
 quently one has to depend on less satisfactory measures. Wl 
 the face or trunk is involved, but little can be done. When thi 
 scrotum is affected, the morbid tissue can be freely dissectej 
 away, sufficient skin being left to cover in the wound if possible 
 the penis and testes must first be isolated, and then the scrotiiii 
 amputated, a tourniquet being used to restrain the bleeding. I| 
 the leg elastic bandages, elevation, and possibly scarification, ma 
 l)e useful in the slighter cases ; but where the limb is enormous' 
 enlarged the greatest measure of success seems to have followe 
 ligature of the main artery, so as to diminish the blood supply, anj 
 so check the growth by a process of starvation. Failing thi| 
 amputation is the only resource. 
 
 Affections of Ljntnphatic Glands. 
 
 Acute Lymphadenitis, or Inflammation of Lymphatic Glands, 
 The Cause of this condition is almost always the absorption 
 some irritative material (toxic or infective) from the peripherj 
 When a part becomes inflamed, there is always an increased liol 
 through the efferent lymph channels, owing to the exudatioir 
 
 the result of this 
 iympli is carried, 
 process is at an e: 
 in the inflamed r 
 >erious a/lection, 
 ilition of the lym| 
 also absorbed, sup 
 lymphatic glands 
 which Nature elin 
 that certain peripl 
 produce en large mc 
 many forms of ce 
 causes lymi^hatic 
 hinders the absorp 
 Occasionally aci 
 lesion, being attrib; 
 ins ; possibly in so 
 oat in other instar 
 dands is really du 
 interference with 1 
 result in suppuratic 
 Pathologically, th 
 3:id exudation into, 
 iar^'er than usual. 
 >H. Tlie capsule 
 ptii-udenitis, or infl; 
 [a^snciated with it, 
 if little importanc 
 "lay become so ext 
 cellulitis. 
 
 Clinically, the sig: 
 I are characteristical 
 enlarged, tender, an 
 I'ed and (edemat<jus 
 :> at first hard and 
 I early contract adhes 
 weven extend wi( 
 1 5 much loose areola 
 I! the general phenc 
 [are usually well mar 
 The Treatment co 
 [sources of irritation, 
 pust be kept at rest 
 l»ound or causati\-e 
 |J5 may be needed 
 jfoiiientations are aj 
 |*e administration o 
 |"«ssary. As soon 
 
DISEASES OF THE LYMPHATICS 
 
 289 
 
 ihe result of this is an increase in size of the f,dands to which the 
 'vniph is carried, which quickly subsides when tlie inllannnatory 
 lirocess is at an end. If, however, irritating toxins are produced 
 .11 the inflamed area, they give rise to a more prolonged and 
 >t,rious affection, whether accompanied or not by a similar con- 
 dition of the lymphatic vessels. When pyogenic organisms are 
 ;il?o absorbed, suj^puration almost invariably results. In fact, the 
 vinpliatic glands must be looked on as the Alters by means of 
 vhich Nature eliminates many sources of disease. It is curious 
 that certain peripheral infective conditions are not at all liable to 
 produce enlargement of the glands, r.,i,^, spreading gangrene, and 
 iiiany forms of cellulitis ; possibly the acuteness of the process 
 ■aust'S lymphatic thrombosis in the efiferent trunks, and thus 
 hinders the absorption of the noxious material. 
 Occasionally acute lymphadenitis arises without any obvious 
 lesion, being attributed in such cases to strain, as from over-walk- 
 ing; possibly in some an unnoticed cutaneous lesion is the cause, 
 but in other instances it seems probable that the swelling of the 
 •imds is really due to a strain, which may ha\e induced some 
 interference with the flow of lymph. It does not necessc'urily 
 result in suppuration. 
 Pathologically, the condition is characterized by hyperrrmia of, 
 and exudation into, the gland, which becomes redder, firmer, and 
 larger than usual. Suppuration usually starts in more than one 
 spot. The capsule becomes in\olved, and finally yields, whilst 
 peri-adenitis, or inilannnation of the surrounding tissues, is always 
 associated with it, e\en in the early stages ; the latter may be 
 little importance, but when the capsule has given way it 
 ;;.av become so extensive as to constitute a diffuse suppurative 
 •elhilitis. 
 
 Clinically, the signs and symptoms of a localized inflannnation 
 
 i are characteristically manifested. The glands can be felt as 
 
 [enlarged, tender, and rounded masses, the skin over them being 
 
 ;td and irdematous ; when pus has formed, the swelling, which 
 
 :i at first hard and brawny, becomes soft and fluctuating. They 
 
 harly contract adhesions to neighbouring tissues, and suppuration 
 
 hay even extend widely beyond the glands, especially where there 
 
 1 .5 much loose areolar tissue, as in the axilla. Fever, malaise, and 
 
 ill the [general phenomena associated with an acute inflammation, 
 
 K usually well marked. 
 
 The Treatment consists, in the first place, in the removal of all 
 liources of irritation, both physical and physiological. The part 
 jnastbe kept at rest and protected from injury, and the offending 
 pound or causative lesion dealt with by such antiseptic measures 
 |js may be needed to hasten its restoration to a healthy state. 
 jfomentations are applied over the gland, and the patient, after 
 like administration of a purge, may be given quinine and iron, if 
 jiecessary. As soon as pus has formed, it should be let out by aa 
 
 19 
 
acjo 
 
 A MANUAL OF SURGEIiY 
 
 incision, and the wound dressed antiseptically. Linseed -meal 
 poultices, whilst useful in encovujif,dng the formation of pus, are 
 most uiulesirahle after the abscess has been opened {vide Tmat- 
 mcnt of Acute Abscess, p. 33). 
 
 Special Forms of Acute Lymphadenitis. 
 
 riu; Axillary Glands arc usually affected ,is a result of poisoned wounds of 
 tlie liand or fingers, altliougli otiier glands exist lower dt)\vn in the ami, viz 
 the supra-condyloifl, just above Uie internal condyle. Hoils in tlu: a\ill;i,iiul 
 excoriations or septic wt)unds of the breast may also cause an axiliar\ ahstess 
 In this region a suppurati\e jieri-adenitis is often superadded, extending widely 
 under and between the pectoral muscles, reaching even up to the clavicle 
 ("are must be taken in opening such an abscess to avoiil the main vessels In 
 cutting h'om above downwards, midway between tlie anterior and p'lstericir 
 axillary folds, whilst Hilton's method should be adopted in all ca.ses wlicre the 
 pus is situated deepi}-. 
 
 In the Groin there are three groups of glands : (i) The oblique set. nuuiin^ 
 parallel to I'oupart's ligament, and becoming intlamed in ailections of the , 
 penis, scrotum, perineum, anus, bvittock, and lower part of the ahdcimen; 
 (j) a superficial vertical set, running with the long saphenous vein, and receiving! 
 lympii from all the superficial parts of the limb, except pc^rhaps tlmse fmiii | 
 which the blood is returned bv the external saphenous vein, the pupliteal I 
 glands receiving the lym,.,i from tii'.:. r"gion ; and (•;) the deep vertical set. 
 receiving the deep lymphatics of the limb. Abscess in the groin is opened bv 
 a vertical incision, so as to allow the wound to gape when the patient sits, ami j 
 prevent pocketing of matter. 
 
 Suppuration in the glands of the Neck is exceedingly commr)n, arising mo.^tj 
 often from affections of the scalp (eczema or pediculosis), ear (otorrh(ea or J 
 eczema), throat, or lips. As to the exact distribution of the lymphatics wel 
 must refer students to anatomical text books. When opening a cer^icall 
 abscess, care must be taken to avoid important structures, such ns thoexternall 
 jugular vein, and to make incisions across the fibres of the platysnia in orderj 
 to gain space for efficient drainage. 
 
 Chronic Lymphadenitis. — Three A'arieties of chronic ini1atiima-i 
 tion of lymphatic glands are met with, viz., the simple, syphilitic,j 
 and tuberculous. 
 
 I. Chronic Simple Lymphadenitis is a condition resulting fror 
 some peripheral irritation, which is insufficient to cause an acute 
 attack. It also occasionally results from blows and strains, as in 
 over-walking, being in such c^ses possibly due to obstruction tq 
 the lymphatic flow, owing to cor pression or rupture of the efferenj 
 vessels. The glands beeo'ne enlarged, tender, and painful, bat 
 as a rule they do not l;ecome adherent to one another, or 
 adjacent structures, and show but little tendency to suppurate 
 This condition often precedes, and, indeed, may be looked on 
 a predisposing cause of, tuberculous lymphadenitis. The Treatj 
 ment consists in keeping the part at rest, removing if possible 
 sources of local irritation, combined perhaps with the local applj 
 cation of iodine paint, or friction with iodide of potassium or iodic 
 of mercury ointment. The general health should also be attende 
 to, especially in children predisposed to the development of tut 
 culous disease. 
 
 2. Chronic Syp] 
 
 .ire invoK-ed in st 
 ./) 'I'he priiTiary j 
 indolent bubo in 
 hard, somewhat li 
 little pain is notit 
 never due to the : 
 5ome septic niattt 
 much more infiltra 
 chancres than in tl 
 the second stage, \ 
 in many parts of tli 
 11) In the tertiary 
 :rue giunniatous cl 
 the absorption of 
 For further particu 
 3. Chronic Tuber( 
 diildren or young 
 the de\eIoi)nient o 
 those whose surra 
 .-ondition is deteric 
 tresh air. Some b 
 t.rm of pcdiculosi 
 glenoids, or ecyni; 
 ni; f,dands become 
 Sr.nderson says, ' ; 
 The bacilli are cor 
 .gaining access thro 
 iiiroiigh a healthy 1 
 nie body may beco 
 |;'iands of the necl< 
 ■atenate, are much 
 Hie axillary and ing 
 ivhilst tuberculous , 
 I tke affection known 
 The course of th< 
 leadings, although i 
 wessarily follow on 
 raanifestation of the 
 [jlands, which canno 
 pathologically, from 
 ■^aybe enlarged to 
 I Mks pinkish in colo: 
 %, all that is not 
 wpuscles, together 
 P'l-oiis capsule and 
 ■jccurred, the charact 
 m, but there is at 
 
DISEASES or THE LYMPHATICS 
 
 291 
 
 .•. Chronic Syphilitic Lymphadenitis. — The lymphatic glands 
 ,.ic involved in sc\iM;d ways in tliu course of sy}>hiHlic lUst'ase : 
 Id) The prinuiry lesion is associated with the development of an 
 indolent bulxj in the nearest lymphatic }^dands, which become 
 h;ir(l, somewhat like almonds or bullets beneath the skin. Hut 
 little pain is noticed unless suppuration is takinjiif place ; this is 
 never due to the syphilitic virus alone, l)ut to the absorption of 
 -line septic matter ko\\\ the pritnary lesion. There is usually 
 liUKh more infiltration and enlar<^^'jinent of },dands in extra-j^^enital 
 iluincres than in those occurrinj:^ about the {,'enital organs, {h) In 
 ihe second stage, wluin general infection has occurred, the glands 
 ;i many parts of the body are aliccted in the same indolent fashion. 
 1 In the tertiary period the lymphatic glands may undergo a 
 ■rue gummatous change, or become enlarged and tender owing to 
 ■iie absorption of septic material from a broken-down gunuiia. 
 For further particulars and Treatment, see Chapter XXXI X. 
 \. Chronic Tuberculous Lymphadenitis occurs most commonly in 
 hiklren or young adults, who have inherited a predisposition to 
 ;he de\elopment of tuberculous disease, and more especially in 
 ihose whose surroundings are unhealthy, and whose general 
 ondition is deteriorated by insufficient or bad food and want of 
 :rtsh air. Some local focus of irritation is usually present in the 
 ; rm of pediculosis capitis, decayed teeth, chronic otorrh(x;a, 
 iilenoids, or eczema of the face. As a result of this, neighbour- 
 11^' ,i,dands become chronically inflamed, and, as Sir T. Jiurdon 
 Sr.nderson says, ' the soil is thereby prepared for the seed.' 
 The bacilli are conveyed to the gland by the blood or lymph, 
 ,'aining access through some breach of surface, or even perhaps 
 ■..iiough a healthy mucous membrane. Any lymphoid tissue in 
 lie body may become the seat of tuberculous disease ; Init the 
 ,'iands of the neck, especially the submaxillary and the con- 
 catenate, are much more commonly involved than any others. 
 Theaxillary and inguinal glands are also not unfrequently affected, 
 whilst tuberculous disease of those in the mesentery gives rise to 
 I the affection known as ' tabes mesenterica.' 
 The course of the case may be described under the following 
 headings, although it must l)e remembered that the stages do not 
 I necessarily follow one another in exact sequence : (i.) The earliest 
 manifestation of the disease consists in a fleshy enlargement of the 
 hlands, which cannot at first be distinguished, either clinically or 
 pathologically, from a simple chronic hyperplasia. The gland 
 I aaybe enlarged to many times its natural size, and on section 
 I )oks pinkish in colour, and is of firm consistence. Microscopic- 
 i!ly, all that is noticed is a great increase in the lymphoid 
 Mpuscles, together with some overgrowth and thickening of the 
 Jkous capsule and trabecular. When tuberculous infection has 
 occurred, the characteristic nodules can be seen under the micro- 
 kope, but there is at first no change in the naked-eye appearances. 
 
 19 — 2 
 
292 
 
 A MANUAL OF SURGERY 
 
 (ii.) Caseation follows sooner or later, and since the tuberculous 
 nodules are often disseminated widely through the gland, many 
 caseating foci will be found, (iii.) Calcification of the caseous 
 detritr" sometimes occurs in those cases which are tendin.i,^ to 
 recovery. Such is accompanied by a fibroid thickening of the 
 gland, resulting from overgrowth of the capsular and trabecular 
 connective tissue. This change is most frequently obserxed in 
 the metliastina) and mesenteric glands, and is not very unconinion 
 in the neck, (iv.) More frequently suppnvation ensues, sometimes 
 from a simple emulsification of the caseating material, sometimes 
 from infection with pyogenic organisms from without. Foci of pus 
 de\elop at various spots in the glandular parenchyma, and when 
 once formed, these tend to amalgamate and cause the destruction 
 of the rest of the glandular tissue, the fibrous trabecula:; reniainin<{ 
 longest vmaffected, so that finally the gland is represented by a 
 single abscess cavity surrounded by a pyogenic membrane of the 
 ordinary tuberculous type, in which traces of the capsule can be 
 observed. Se\'eral of these abscesses may merge into one another, 
 and thus a large multiloculated cavity, containing pus mixed with 
 curdy debris, is formed. {\.) A certain amount oi pcri-adcnitisk 
 almost always present, though not to any great extent in the early 
 stages ; wlien, howe\er, suppuration has occurred, or if the glands 
 are exposed to pressure or friction, they become adherent not only 
 to neighbouring glands, but also to surrounding structures. In 
 the more chronic cases the fibro-cicatricial tissue tlius formed iiiav 
 be so extensi\e as to firmly fix the mass to the deeper parts, sucii 
 as the main vessels and nerxes, rendering removal by enuclea- 
 tion dangerous and almost impracticable. Important vessels are 
 occasionally eroded by an extension of the suppurati\e process, 
 and this may lead to fatal iKumorrhage. (vi.) Sooner or later the 
 abscess, if left to itself, bursts either at one or several spots, 
 leaving ulcerated openings, through which is seen ojdematous 
 granulation tissue mixed with caseating material. The edges are 
 undermined, thin, and purplish, and the granulations sometimes 
 sufficiently prominent to protrude through the openings as 
 fungating masses. A Aariable amount of pus escapes from these, 
 and the condition may persist for many years if radical treatment 
 is rot undertaken, (vii.) Under suitable local and constitutional 
 measures these sores may, and usually do, heal after a time, 
 giving rise to a pulpy spongy cicatrix, which is often puckered andj 
 more or less keloidal, and may retain its vascularity for a much 
 longer period than would a healthy scar. Lymphatic a'dema in 
 the region drained by the affected glands is sometimes observedj 
 as a late consequence of this affection. 
 
 The usual complications met with in the course of all tuberculousj 
 diseases may also manifest themsehes (p. 109). 
 
 The Treatment of tuberculous glands is palliative or radical. 
 . Palliative Treatment consists mainly in improving the general! 
 
DISEASES OF "HE LYMPHATICS 
 
 293 
 
 health by means of suitable diet and tonics, such as cod-li\er oil 
 and syrup of the iodide of iron, together with residence in a 
 healthy, bracing situation, especially at the seaside, as, for 
 instance, at Margate. All sources of local irritation must be 
 removed so as, if possible, to prevent infection with pyogenic 
 organisms, and counter-irritants, such as iodine paint, are best 
 avoided. Rest of the affected part should be enforced as much as 
 possible ; in some cases the application of splints to restrict move- 
 ment is advisable. 
 
 Radical Treatment.^ — Wherever practicable, glands evidently 
 iuberculous should be completely remo\ ed by dissection, and even 
 amongst the wealthy too much time should not be wasted in 
 ;>alliati\e measures, inasmuch as the longer the glands are left, the 
 nrnier will be the adhesions which they are likely to contract with 
 surrounding tissues. In the later stages, so far may this process 
 have gone that removal by dissection is hopeless. In such cases 
 alVee opening is made down to the diseased tissues, and as large a 
 portion remo\ed as possible, whilst the remaining deeper parts are 
 waped Avith a \'olkmann's spoon. The wound can rarely be en- 
 tirely closed, and must be packed with gauze sor.ked in an iodoform 
 tinulsion (10 per cent.), and allowed to heal by granulation. In 
 I septic cases the same line of treatment must necessarily be 
 I adopted. 
 
 I In the iicck \'ery extensive operations may have to be under- 
 I ;:iken for the remo\al of tubeiculous glands. The incision \aries 
 I with the situation of the mass, but where feasible it is kept well 
 I iehind the sterno-mastoid. When, however, enlarged glands 
 I :xi?t both in front of, behind, and beneath the muscle, it is well 
 |;jinake the incision parallel to the course of the external jugular 
 I v;in, entirely dividing the sterno-mastoid, which may subsequently 
 I X st'tched together. Special care must be taken of the chief 
 I Vessels and ner\'es, particularly of the internal jugular vein, to 
 I which the glands are frequently adherent; in some cases it is 
 I even necessary to divide the vein or '=xcise a segment of it, a 
 icomparatixely unimportant proceodhij 'children. The situation 
 I :t the s(;inal accessory nerw;' as it ciosses the posterior tiiangle 
 l^st also be remembered. ."Sa.arally, adherent glands may be 
 Itoalt with \ery much more freeiy '"n the posterior than in the 
 
 ■ iiUerior portion of the neck. 
 
 I The pvc-anyicidav gland, lying c a the capsule of the parot'd, is 
 
 ■ sinetinies affected, and may cause facial paralysis, either as a 
 
 ■ ;tsult of the sclerosing peri-ade I'tis, or froni injudicious surgery. 
 BAav incisions made with a view to remove the gland or to open 
 ■ill abscess therein should be made in the direction of the fib.res of 
 B-t facial nerve, i.e., horizontally. 
 
 ■ In the groin, tuberculous glandr are often mistcvken fur some 
 Htondition clue to venereal disease. The history of (/usel rjid the 
 ■wreine chronicity should suffice to establish .. dl i^jncsis. The 
 
 T/A 
 
294 
 
 A MANUAL OF SURGERY 
 
 Dl 
 
 iliac glands will often be found similarly affected, and opera- 
 tions in this rejjjion are sometimes very extensive in consetiueiice. 
 Well-marked peri-adenitis is usually present in the iliac fossa, and 
 the glands may be very adherent. Atrophy of the testicle some- 
 times follows, either from division of the spermatic vessels, or 
 from their implication in the cicatrix. 
 
 Tumours of Lymphatic Glands. 
 
 The Primary New Growths occurring in lymphatic glands are 
 lymphadenoma and lympho-sarcoma. A few instances of ajjpar- 
 ently primary epithelioma have been recorded. Amongst others, 
 Sir James Paget mentions some cases of epithelioma of the inguinal 
 glands, following eczema of the scrotum, caused by soot, tar, or 
 paraffin, in which, on the most careful examination, no primary 
 scrotal growth was discovered ; possibly it had disappeared. 
 
 Lymphadenoma is the term given to a new growth occurring 
 in lymphatic glands, corresponding in structure with normal 
 lymphoid tissue — that is to say, it consists of a stroma, more oi 
 less delicate according to the consistency bf the mass, \v th. 
 meshes of which are packed a great number of small round ceP 
 resembling leucocytes. 
 
 There has been much discussion as to the nature of this grew tl 
 and also as to the relation it bears to leukamiia. Nothinjj: 'inal 
 has as yet been made out, but there seems every probahilitv in 
 favour of the view that it is to be looked on as an infective di_-;ea;e, 
 due to some specific micro-organism, and therefore to be placet; 
 midway between tubercle and cancer. Occasionally it develops! 
 as a strictly local affection, and can then be readily eradicated ; 
 sometimes it involves a whole series of lymphatic glands, hut is! 
 limited to one region of the body, both the above types beint,' 
 included below under the term ' benign ' lymphadenoma. On thej 
 other hand, it is sometimes disseminated widely throughout thej 
 system, affecting not only the external lymphoid tissues, but also] 
 the spleen and other internal tissues of a lymphatic nature; it is] 
 then known as Hodgkin's disease, or pseudo-leukaemia. I.euk- 
 aomia (or leucocythamiia) is an affection with special and peculiar] 
 blood features, dependent on changes occurring, in the spleen,! 
 lymphatic glands, or marrow of bones. The spleno-medullaryj 
 type is the connnonest ; lymphatic leuka'mia is much rarer, andl 
 the glands are e\en then seldom larger than walnuts. 
 
 Benign or Localized Lymphadenoma is usually met with in youngi 
 adults, affecting either one gland or a large number. It is mostl 
 often seen in the neck, and though the patient may be slif,ditlyj 
 ana>mic, he never presents any blood changes of the leiilvieniic 
 type. 
 
 W hen a sniffle gland is affected it becomes slowly enlarged. : 
 shows no tendency to caseate or suppurate; it remains frc; ir 
 
 adhesions to adjaci 
 
 J less. It is quite p 
 
 |aature are in real 
 
 enlargement. Th( 
 
 W lien viany glai, 
 
 me region, or se\( 
 
 )f the body ; the 
 
 I often involved, anc 
 
 render the wearing 
 
 I istics of this condil 
 
 [they have no tern 
 
 tiiat there is but li 
 
 [ able one on anothe 
 
 painful nor tender. 
 
 On removal, the 
 
 iometimes firm am 
 
 ' pink and fleshy 
 
 ^raysh and somew 
 
 ■:'' ^lore friable, ai 
 
 rJIk' J nice is obtaii 
 
 ■■'■' not epithelial, 
 
 -ous tumour. T 
 
 I 'k rate of jTrowth, 
 
 j .^Hcroscopically, no 
 
 I :i?sue are observed. 
 
 i.iia'inia present, i 
 
 l.iis affection is 
 
 .,-pecially to the adr 
 
 larsenicalis combine^ 
 
 ^dually increased, 
 
 of the drug, retrogi 
 
 r.ouever, thpv ners 
 
 .■iioval sho'ilM ^ *■ 
 
 I this may in^ ^Jv^ -re 
 
 Hodgk- . Piseasf 
 
 lleiikaein..' I ]<. ,\ ^on 
 
 r.uira-teriicc' 
 
 m 
 
 V 
 
 Itissii.., in thd 1 
 
 [oragminated follicle; 
 are present, consistir 
 ;tes, whilst the rec 
 I" the amount of 
 ■fuka:'m'"a che propoi 
 
 W to ten of the lat 
 leiik^mi;. the prcpo., 
 
 kdaract^, of the leuc 
 
 lalso vv.ic~-. ,o r^nt 
 lat one r .ifferent 
 
DISEASES OF THE LYMPHATICS 
 
 295 
 
 adhesions to adjacent structures, and is hence moveable and pain- 
 less. It is quite possible that many glands thought to be of this 
 lature are in reality tuberculous, in the early stages of fleshy 
 enlargement. The Treatment of such is by removal. 
 When many glands are affected, the disease may be limited to 
 ine region, or several groups may be enlarged in different parts 
 ){ the body ; the neck is a favourite situation, both sides being 
 often invohed, and the disease may here be so extensive as to 
 render the wearing of a collar impossible. The special character- 
 i;tics of this condition are : that many glands are enlarged, that 
 they have no tendency to suppurate, caseate, or ulcerate, and 
 •nat there is but little peri-adenitis ; hence they are freely move- 
 able one on another and on surrounding tissues, .uid are neither 
 painful nor tender. 
 On removal, the glands vary somewhat in consistency, being 
 sometimes firm and elastic, presenting on section with the knife 
 ? pink and fleshy cortical portion, whilst the central part is 
 S? grayish and somewhat indurated ; but in other cases they are soft 
 ■% . /^ iiore friable, and on scraping the cut surface with the knife a 
 mk' J nice is obtained, the cells of which, however, are leucocytes 
 iflL not epithelial, as in the juice obtained by scraping a can- 
 cious tumour. This difference in texture depends mainly on 
 ■he rate of growth, the soft growing rapidly, and the firm slowly. 
 Microscopically, no changes in structure from ordinary lymphoid 
 ;issue are observed. Constitutionally, there is usually a good deal 
 ji.iia'mia present, but no leukpmiia. 
 
 1 .lis affection is sometimes markedly amenable to Treatment, 
 
 ..specially to the administration of arsenic. Small doses of liquor 
 
 isenicalis combined with iron are at first given, but these are 
 
 ;Ta(lually increased, and as the patient comes under the influence 
 
 ot the drug, retrogression of the glands may be ol)served. If, 
 
 owever, thp^ nersist in spite of medicinal treatment, their re- 
 
 3ioval shouJri !L* be delayed. Where many glands are affected, 
 
 ;his may irvjiv^ .tensi.e and repeated operations. 
 
 Hodgk' . Pisease (~s)"i. : General Lymphadenosis or Pseudo- 
 
 ieukaem,.' I i^ ,\ condition usually met with in adults, and is 
 
 ;:;ara' teri/.cd c nn overgrowth of all, or nearly all, the lymphoid 
 
 !i5siK.T in the body, including glands, the spleen, the solitary 
 
 oras^nninated follicles of the intestine, etc. Marked blood changes 
 
 are present, consisting in a great increase in the number of leuco- 
 
 ■tes, whilst the red corpuscles are deficient both in number and 
 
 Ji tlie amount of haemoglobin contained in them. In true 
 
 ieiik;Emia .ihe proportion of white corpuscles to red is enormous, 
 
 jiie to ten of the latter being a common experience ; in pseudo- 
 
 bkami;. the proportion rarely exceeds one to forty or fifty. The 
 
 :haract>.r of the leucocytes and their reaction to staining reagents 
 
 also v',vic~. io I'^^t a microscopical examination of the blood 
 
096 
 
 A MANUAL OF SURGERY 
 
 leukamiia, although the external swellings may be indistinji^uish 
 able. 
 
 The tumours thus produced grow slowly, are painless, and 
 when groups of glands are affected, adhere together, forming 
 lobulated masses, but with no tendency to caseate or suppurate. 
 The skin may become involved in the tumour later on, and super- 
 ficial ulceration follow, but there is no subsequent fungation of 
 the growth. 
 
 The prognosis is exceedingly grave, the disease usually pro- 
 gressing in spite of all treatment to a fatal issue, which is due to 
 exhaustion. 
 
 Treatment. — Arsenic combined with iron may be administered, 
 and, latterly, injection of an emulsion of bone-marrow has been 
 strongly reconmiended, but tne results gained hitherto have not 
 been at all satisfactory. It is useless attempting to '"cnKne the 
 external grc"*^hs, since they are only an evidence of a deep- 
 seated generi' ffection. 
 
 Lympho-sar. I.yiuphatic glands sometimes become the 
 
 seat of a prima ;, rr-omatous growth, the microscopic characters 
 of which have been detailed elsewhere (p. 121). The disease 
 occurs in adults and is met with not uncommonly in the tonsil, 
 sometimes in the glands at the root of the neck, and may occa- 
 sionally originate in the mediastinum or in the testis. When com- | 
 mencing in a region where its development can be followed, it is | 
 seen to form a rapidly growing tumour, which is at first iirm, elastic, | 
 and painless ; later on, howe\er, as it increases in size, it becomes 
 tender, and may cause great pain from pressure on, or implication 
 of, nerves. It early contracts adliesions to svirroundin.i,^ parts, 
 and gi\'es rise to secondary growths in nei^'hbouring glands by 
 direct transmission. The superjacent skin is at first unaltered in 
 colour and texture, but as the tumour increases, it becomes con- 
 gested and shiny, and contains a network of dilated veins.] 
 Finally, it is involved in the growth, and ulcerates, an occurrence 
 usually followed by the sprouting up of a bleeding fungating mass, 
 similar in character to that formed by any other rapidly growing 
 malignant tumour. Dii^semination of the growth throughout the] 
 viscera follows, death resulting from exhaustion and cachexia. 
 
 The Treatment consists in the removal of the mass, where! 
 practicable, without delay. If, however, extensive adhesions! 
 exist, this becomes absolutely impossible. 
 
 Secondary Growths in Lymphatic Glands are a special feature ofl 
 all cancerous tumours. In the sarcomata they are less common, j 
 but are always present in the case of melanotic sarcoma, lympho- 
 sarcoma, and usually in sarcoma of the testis, tonsil and thyroid. 
 The special characteristics of these are noted elsewhere. 
 
CHAPTER XII. 
 
 AFFECTIONS OF NERVES. 
 
 Injuries of Nerves. 
 
 ;;;e simplest and most common form of injury to ivlilch a nerve 
 :iiable is a Contusion, causing a sensation of tingling, or pins and 
 •.rrdles, which usually wears off in the course of a few hours. In 
 ,,ere cases \'ariable degrees of loss of power and sensation may 
 ::.;ue, and in hysterical women more or less neuralgia. In patients 
 leering from gout, syphilis, or rheumatism, a chronic peripheral 
 kiritis is readily induced, often of a somewhat intractable type. 
 Id this even occurs in healthy individuals. Treatment consists 
 |; 'entle friction with stimulating liniments. 
 A nerve may also be Strained by any sudden, unexpected or 
 eptional movement, producing effects identical with those 
 Irang from contusions. 
 
 I Rupture of nerves without an external wound only occurs in 
 :acction with severe injuries, such as dislocations or fractures, 
 :; even then total division is rare, the sheath retaining its 
 b^rity, although the axis cylinders may have given way. Im- 
 pdiate paralysis and loss of sensation usually follow, and may 
 ;jist for a time, although repair not unfrequently occurs, 
 kethe sheath remains intact. The doubt always existing as 
 |;;iie condition of the sheath regulates the treatment which must 
 : followed, viz., one of expectancy. Friction and electricity 
 ::uld be applied to the parts, and only when these have failed 
 Nd operation be undertaken. Secondary nerve suture under 
 p circumstances is not a very successful proceeding. 
 Compression of a nerve is usually due to the growth of tumours 
 ^aneurisms, or to some displacement of bones, as in fractures or 
 piccations ; or, again, the nerve may be included in the callus 
 ped in the repair of a fracture, e.g., the musculo-spiral, owing 
 '^is proximity to the humerus, the symptoms not appearing till 
 Nrfive weeks after the injury ; or it may be met with in the 
 p of c utch palsy, or as a result of splint pressure, as when 
 cexternc;! popliteal nerve is compressed against the neck of the 
 
298 
 
 A MANUAL OF SURGERY 
 
 fibula. Those nerves also which traverse bony canals in the 
 skull are liable to pressure as a result of chronic osteitis and conJ 
 densation of the surrounding osseous tissues. Patients who hav( 
 suffered from syphilis are much more liable to develop chronic 
 neuritis from slight pressure than other individuals. The earl 
 symptoms in such cases are those of irritation, e.g., cramp and 
 spasm of muscles, or neuralgic pain ; whilst the later ones, due td 
 more prolonged compression, are those of paralysis and anasthesial 
 combined sometimes with trophic phenomena. If the compress! 
 ing cause can be removed, recovery, at any rate of a partial 
 character, follows in time under suitable treatment, such a| 
 massage, electricity, and the administration of iodide of potassiur 
 or nerve tonics. 
 
 Puncture of a nerve is associated with severe neuralgic panis 
 especially in neurotic women. Occasionally a chronic form 
 neuritis is started, Avhich travels up the limb, and may cause "rtz 
 suffering or impairment of function. 
 
 Total Division of a Nerve.— The Immediate Effects are : i 
 Paralysis '''' the muscles supplied by the nerve ; {b) complec 
 angesthc.-.; I of the parts supplied by it, which, however, is nc 
 necessarily permanent, since sensation may be conveyed hy cok 
 lateral trunks, t^e anaesthetic area passing through gradual sta^jq 
 of partia: .-.en.-^ation before recovery is complete, [c) \'asomotQ 
 paralysis is also {produced, the limb becoming hypera^mic an 
 warmer for a few days, and then subsequently colder and insuf 
 ciently supplied with blood, (rf) The excito-secretory nerves aijj 
 paralyzed so that glands lose their functions for a time. 
 
 The Secondary Effects \'ary with the character of the ner^ 
 injured, and are much more complicated than the former. \\ 
 must discuss them under five headings : 
 
 I. Changes in the Nerve. — Locally, the two ends retract xei 
 slightly, perhaps not more than the twelfth of an inch, and tlj 
 space thus formed fills Avith blood, which is quickly absorhed aD 
 replaced by granulation tissue, and this in turn by a bulb li| 
 mass of fibro-cicatricial tissue, within which are found spac 
 filled with fine nervous fibrillar coiled up in loops and arising frc 
 overgrowth of the axis cylinders from the upper end {tnmmo\ 
 neuroma). After an amputation, most of the divided nerves 
 found to have developed these typical bulbous ends, whilst 
 nerAes accidentally severed in their continuity the bulbous ma 
 which forms on the upper end is separated by an interval fro 
 the atrophied lower end, though occasionally there is a fibre 
 connection between the two. These bulbs are often the seat! 
 severe neuralgia. In a few rare instances immediate union ofl 
 divided nerve is supposed to have occurred, as indicated by toj 
 and rapid restoration of function. 
 
 Peripherally, the so-called Wallerian degeneration commen(j 
 about the fourth day after the accident, in consequence of 
 
AFFECTIONS OF NERVES 
 
 299 
 
 n of the nerve from its trophic centres. It first shows 
 
 the medullary substance, which undergoes a kind of 
 
 Ltion, becoming broken up into irregular masses of myeline, 
 
 ing entirely in about a month. The axis cylinders also 
 
 te and disappear at a somewhat later period, and finally 
 
 primitive sheath and the perineural connective tissue 
 
 The nuclei of the sheath proliferate and form a fibro- 
 
 uass, which represents the nerve, and has long lost all 
 
 conducting nervous or electric stimuli. 
 
 ally, degeneration of the medullary sheath occurs, similar 
 
 hich is seen in the distal portion, but only extending as 
 
 J next node of Ranvier. It is of but little significance. 
 
 nges in the Muscles. — Complete paralysis of motion 
 
 ly occurs when a motor nerve has been di\ided, and the 
 
 involved slowly atrophy and undergo degeneration. The 
 
 s not noticed at first, and is not so rapid as that arising 
 
 uitile palsy, since it is simply due to separation from the 
 
 entres, and not to their destruction. As a result of the 
 
 and atrophy, deformity may ensue, owing to a disturb- 
 
 the equilibrium normally maintained between opposing 
 
 f muscles. The electrical changes, too, are exceedingly 
 
 t. The faradic current rapidly loses its power over the 
 
 muscles, and its effects totally disappear in two or three 
 
 /liilst the galvanic excitability remains for weeks or 
 
 Lind even then only slowly diminishes, so that a condition 
 
 1 which the galvanic current produces a much greater 
 
 on than the faradic {reaction of degeneration). As long as 
 
 lomenon remains, there is a hope that restoration of the 
 
 y of the nerve may be followed by restoration of function ; 
 
 the muscles react neither to galvanic nor to faradic 
 
 le case may be looked upon as beyond repair. 
 
 ous modifications of Sensation, both special, general, 
 
 ular, may be observed. 
 
 blood supply to a paralyzed part is always diminished, 
 
 looks blue and congested, owing to the weak circulation ; 
 
 itly the temperature falls, and the vitality of the part is 
 
 . This, associated with anaesthesia and the loss of trophic 
 
 of the nerve centres, results in certain conditions which 
 
 considerable importance. Thus the skin becomes thin, 
 
 iluish-red, and shiny ('glossy skin' of Weir-Mitchell), 
 
 be rough and covered with scales, or even oedematous. 
 
 are readily produced, and any exposure to cold or heat 
 
 in vesication or even sloughing. Wounds heal badly, 
 
 ition from slight irritants is very likely to occur, e.g., 
 
 eration after division of the fifth nerve, and perforating 
 
 he foot. The cutaneous appendages are also invohed, 
 
 ailing out, the nails becoming rough, brittle, and scaly, 
 
 )aceous and sweat glands either discharging an abundant 
 
300 
 
 A MANUAL OF SURGERY 
 
 secretion, or remaining absolutely functionless. Atrophy of the 
 smaller bones may follow, and ankylosis of the terminal joints oi 
 the fingers or toes. In a growing child the development of th{ 
 part is always more or less impaired. The more exaggerated 
 forms of trophic trouble just described only occur in irritativ« 
 lesions of nerves, e.g., when a foreign body is left in contact wit^ 
 them ; simple section results merely in simple atrophy. 
 
 5. I'^inally, in a few cases changes have developed in the centra 
 nervous system which are of extreme interest. In the early sta^te 
 reflex spasms or paralyses are sometimes met with as temporarj 
 phenomena ; but at a later date more serious symptoms may resulf 
 Thus, in a glass wound of the median nerve, a healthy man treatej 
 at hospital developed a typical epileptic fit whenever the neuralt^a^ 
 Imlbous end was touched. The bulb was excised, and the nerv 
 cleanly sutured, but without effect, the epilepsy and pain stij 
 remaining. The median nerve was divided in the upper arr 
 and a portion remo\'ed, but no benefit was derived from 
 Finally, the patient passed into a conditinn of chronic dementij 
 and died, no obvious nervous lesions being found on post-niorte| 
 examination. 
 
 Eegeneration of a di\ided nerve must necessarily ensue 
 restoration of function is obtained. Nothing certain is knov 
 as to the exact nature of the change in the few instances 
 immediate union which liave been recorded ; but it appears 
 ha\e occurred in cases where a free collateral comniunicatil 
 existed. In delayed union, especially when a fibro-cicatric 
 bulb has formed, and the lower end has atrophied, it is probaH 
 that after operation the axis cylinders from the upper sej^^ma^ 
 grow downwards into the lower end, and either set up new act! 
 in the sheath of Schwann, whereby new axis cylinders are form^ 
 or they merely extend along the degenerated nerve slieath to 
 periphery, using it as a scaffolding to direct their onward pro<:ra 
 A medullary sheath is subsequently developed, and the procj 
 takes some months to reach completion. It is stated thatr 
 interval of i| inches can be bridged in this way. Clinically, I 
 earliest evidence of regeneration is a slight return of sensati| 
 which may be at first abnormal, and only slowly becomes o| 
 normal type. Motion is generally much later in its restoratj 
 than sensation, and may never be entirely recovered. 
 
 The Treatment of a divided nerve depends upon its size 
 function. If small and of slight importance, no special treatr 
 is required ; but in any of the main nerves of the extremities 1 
 essential to deal with them at once by Primary Nerve Sut 
 This is best accomplished by using a domestic sewing ne 
 without cutting edges, or a fine Hagedorn needle, and the 
 chromicized catgut ; one or more stitches should pass throufjli 
 nerve, and the rest merely through the sheath. Absolute as^ 
 is essential in order to obtain satisfactory results. 
 
 to diminish th 
 
 IDuring the time thj 
 
AFFECTIONS OF NERVES 
 
 301 
 
 I If the wound has been inflicted months before, and a bulb has 
 |j;rnied, Secondary Nerve Suture must be employed. The nerve 
 Is first exposed by a free incision throu<^di the cicatrix, the two 
 leds identified and isolated, and the lil)rous tissue of the bulb 
 Lnioved to a sufficient extent to exjiose healthy ner\-e librilla" ; 
 lie divided ends are then brouf,dit together with as little tension 
 fc possible. To fill -p the gap resulting from removal of the 
 iji). traction upon each end of the ner\e should be employed to 
 fcetch it, and the limb subsequently put up in such a position as 
 fcrelax the parts, e.g., the wrist flexed to a riglit angle, or the 
 ■bow i)ent (except when dealing with the ulnar ner\e above the 
 ■bow, flexion of which increases the tension of the nerve). In 
 lecase we removed an inch or two of the humerus to allow the 
 ■videcl ends of the musculo-spiral nerve to l)e approximated. In 
 Bfiier to diminish the drag on the fine end-to-end sutures, a 
 fcon stitch should be passed through the substance of the 
 ftrve, about | to I an inch from the di\ ided ends. 
 B\'erve grafting, in order to bridge o\er a defect, has not up to 
 ■: present been found of much practical value, although a few 
 Re^of success are reported. A nerve similar in size to that to 
 B: operated on is removed from an animal just pre\iously killed, 
 M; carefully stitched in position. Probably it merely acts as a 
 mrer to the nerve fibrilke from the upper end, and possibly the 
 Me result would be obtained by passing se\eral fine strands of 
 iait from one end to the other. 
 
 jw.'iring the time that the paralysis continues the lind) itself 
 jS.;. be well massaged, the fingers or toes worked daily to keep 
 9:i from getting stiff, and the muscles treated with electricity, 
 |S:preferably by means of the electric bath, one electrode being 
 3i:e[l in a basin of warm saline solution, and the other against 
 MDatient's back, and the affected limb then dipped in the water 
 ^■becomes of a bright red colour. 
 
 ^:many cases where the original wound has been complicated 
 «« spreading septic inflanuiiation the itnpaired mobility is as 
 i3::i due to the inflammatory adhesions of joints and tendons as 
 LjM:aralysis. 
 
 I m Inflammation of Nerves. 
 
 I^liiite Neuritis is not a very common condition. It is usually 
 IjM;) injury, gout, or rheumatism, but is occasionally observed in 
 yRtction with septic wounds. The nerve may sometimes be 
 ^H:o be swollen or tender, whilst se\'ere pain of a neuralgic 
 ^■is often complained of by the patient. On microscopic 
 Iwination the ordinary signs of inflammation are well marked, 
 KS^h mainly evident in the sheath. The Treatment consists of 
 U'.J the limb, together with leeching or dry cupi:)ing over the 
 HBeof the nerve, combined with belladonna fomentations, and 
 ■iBi'le general therapeutic measures. 
 
302 
 
 A MANUAL OF SURGERY 
 
 :.'.i% 
 
 
 'f : X 
 
 Chronic Neuritis, or Perineuritis, is much more comiiDn than 
 the former. It consists patholo<,acally in an increase of all the 
 connective tissue of a nerve, both around it and betweeii the 
 fasciculi, with compression of the vessels and nerve fibres {vv<, 
 80). It may result from injury, such as sprains, strains, or 
 pressure, especially when the patient is suffering from syphnJ!;, 
 rheumatism, or gout, and is met with after influenza and in 
 
 Fig. 80. — Chkoxic NiiuuiTis, showing Increase in the Amount ok C, 
 NECTivE Tissue, and the Nerve Fibres in Section Altered anJ 
 
 COMI'RESSED (A), AS ALSO AN ARTERY WITH THICKENED WaLLS il 
 
 (Putnam.) 
 
 various toxic conditions, e.g., alcoholism, diabetes, malaria, etd 
 It is very common in the fifth nerve, and in the branches of thj 
 brachial plexus. The Symptoms vary a good deal with tb 
 nerve affected. Occasionally it can be felt thickened and tenda 
 on pressure, whilst more or less severe neuralgia is also noticed 
 accompanied perhaps by some loss of power in the musda 
 supplied by it. Trophic lesions may also be induced, such 
 perforating ulcer, or ankylosis of the terminal joints of fingers ( 
 toes. 
 
 The Treatmen 
 
 of anti-diathetic 
 
 or without mere 
 
 rest is needed vvi 
 
 lafer on massage 
 
 the Miuscles mu! 
 
 electric liath. 
 
 hvpodennically n 
 
 Nioiild he adopti 
 
 pas.sed into the si 
 
 a lew nioments ; 
 
 inilanimatory exi 
 
 measures dealt w 
 
 a:;d protracted ca: 
 
 for Tumours ol 
 
 surgeon may be c; 
 jaiid may be one 
 I human frame is su 
 I intermittent pain o 
 [the course of son 
 |irigeminal. In th 
 
 jniay originate, reli 
 Jaliected by them i: 
 land cedematous (tl 
 pdjacent muscles b( 
 Iracted during the a 
 |te lachrymal or s\v 
 limes met with in t 
 
 p., shingles in con] 
 Rnifestations may 
 lie intercostals or 
 Jreast, testis, or the 
 
 n J'le Causes of neu 
 %'s to Jook far afield 
 fyes may be men 
 F' de|)ressing cin 
 I'Aiety and worry ' 
 penza, lead, or 
 
AFFECTIONS OF NERVES 
 
 303 
 
 The Treatment in the early staf,'es consists in the administration 
 of anti-iliathetic rtniiedies, and. indexed, iodide of potassium, with 
 or without mercury, is f^^eneraily appHcal)le. Locally, prolon.t^ed 
 fest is needed with counter-irritation in the form of blisters, and 
 later on massage with suitable liniments. If there is any paresis, 
 ;he muscles must be stimulated daily by the faradic current or 
 electric bath. Excessive pain is c()nd)ated by administering 
 livpodermically morphia or atropine. Failing these, other means 
 ji.ould be adopted, such as acupuncture, in which needles are 
 passed into the substance of the nerve, and allowed to remain for 
 a few moments ; this probably acts by relieving the tension and 
 intlammatory exudation within the sheath. Various operative 
 measures dealt with under neuralgia may be called for in severe 
 
 r-ii protracted cases. 
 lor Tumours of nerves, see p. 131. 
 
 Neuralgia. 
 
 Neuralgia is a condition which either the physician or the 
 Nirs^eon may be cixV 'A upon to Lreat ; it is exceedingly common, 
 x;J may be one of the most terrible afflictions to which the 
 human frame is subject. It is characterized by a paroxysmal or 
 :;uermittent pain of a darting or stabbing character, which follows 
 [the course of some, particular nerve or ner\es, especially the 
 bigeminal. In this nerve the attack commences suddenly, and 
 [•he pain steadily increases, until it reaches a climax, and then 
 L'radually or rapidly subsides. These paroxysms may last 
 [minutes or hours, and may recur at varying intervals, either 
 [a few in a day, or many in an hour; they may be induced by 
 jnitural conditions, or physical phenomena, such as sudden noises, 
 laJraught of air, etc. Moreover, pressure over the affected trunks 
 [niay originate, relieve, or increase the pain, whilst the skin 
 laft'ected by them is often intensely tender, and even hyperaemic 
 [and cedematous (the points doiiloniriix of \'alleix). Occasionally 
 [adjacent muscles become spasmodically and sympathetically con- 
 jtracted during the attack, whilst excessive secretion, such as from 
 Ithe lachrymal or sweat glands, is also induced. Herpes is some- 
 limes met with in the area of distribution of the affected nerve 
 
 '■■!;., shingles in connection with intercostal neuralgia). Neuralgic 
 
 "anifestations may occur in any sensory or mixed nerve, such a- 
 intercostals or sciatic, or in complex bodies, such as the 
 
 [ireast, testis, or the larger joints. 
 The Causes of neuralgia are very diverse, and the surgeon often 
 
 li-asto look far afield in order to find them. Thus, as pvedisposing 
 ir-es may be mentioned the hysterical temperament, anaemia, 
 1(1 depressing circumstances of all kinds, especially mental 
 
 I'Xiety and worry. The direct causes may be toxic, e.g., malaria, 
 
 piluenza, lead, or mercury ; reflex, e.g., ovarian disease, worms, 
 
304 
 
 A MANUAL OF SURGERY 
 
 
 etc.; central, Fnmi disease of tlie spinal corti or brain; radiral, 
 from imssinc on the nerve-roots as tliey enier^'e from the spinal 
 canal or craninm ; or peripheral, owin^^ to lesions ( f the trunks 
 indni cd either by trauma, mllannnati(;n, or new K^rowths. 
 
 Treatment consists primarily in attentif)n to the <j;eneral healtl'. 
 and the local application of counter-irritants and sedati\('s. lr,,i) 
 and arsenic may be f,d\en to ana'inic patients; anti-sjiasniodio, 
 such as valerianate of zinc, to hysterical women ; (|iiiiiiiu' (,r 
 arsenic for malaria; whilst sead)athin},f or chanj^^e of air is often 
 ad\ isable. Iodide of potassiuni and merciu'y are bencf ' i ^ij 
 cases due to syphilis. When the pain is excessi\e, .phi;^ 
 even in lar^^e doses, may be called for. Empirical remedies, surli 
 as antipyrine, phenacetin, menthol, and croton-chloral hydiak^ 
 will sometimes do f^ood. 
 
 When, howe\er, medicinal aj^ents fail, surifical measuri's aa 
 indicated in orrler to allay the patient's sufferinj^s. The followini,' 
 are the more usual methods ado]ited : 
 
 1. In purely Sensory Nerves, such as the trif;eminal, siinpli- 
 di\-ision or iwuiotoniy has often been resorted to, but the relietl 
 j^^ained is of a most temporary nature, since sensory nerves readilvl 
 unite after division, and sensation is rapidly restored e\en wheii I 
 union is incomplete, probably by transmission throuj^Hi collatuial j 
 branches ; hence the operation has fallen into discredit. A iinicli 
 more satisfactory proceedin;^' is neurectomy, or the removal of a pnr 
 tion of the ner\e-trunk, alter which union of the divided eii 's less I 
 likely to occur. Many of these cases, however, are due 'itral 
 disease, and it is an interestinj^ question how the trou.,.. .11 he 
 benefited by such procecnlin.Ljs ; probably the explanation is that 
 the centre is p)laced in a condition of rest by the exclusion of 
 afferent stimuli. Acting on this theory, most surj^eons nowadays! 
 endeavour to remove as lar<re a portion of the affected nerve asj 
 possible, and Thiersch has suf^gested a plan of ncrve-extvaetm inj 
 which the trunk is laid bare at a suitable spot, and then j^^aspec 
 with forceps, and forcibly extracted by torsion. An outline of] 
 the various methods employed on separate nerves is f,nven helow.i 
 
 Finally, if all such measures ha\e failed, the roots of the nerves] 
 may be divided either within the skull or in the spinal canal. 
 
 2. In a Mixed Nerve, conveyinj^ motor as well as sensoryl 
 stinuili, iierve-sinic/iiiig has to be mainly relied upon. The truiikl 
 is laid bare, and traction exercised, both centrally and periphrri 
 ally, by means of a blunt hook if the nerve is small, or of thel 
 finger placed under it if large. The clinical effect is to aholishl 
 the conductivity of the nerve for a time, either completely oij 
 partially ; but since it is not divided, repair and restoration off 
 function follow. The elasticity and extensibility of the nerveJ 
 are considerable, and the pressure needed to cause their rupturej 
 has been accurately estimated. It varies much in different indij 
 viduals, and allowance must be made for this in all operationsi 
 
 The Cranial i; 
 
AFFECTIONS OF NERVES 
 
 J«5 
 
 I'luis, the sciatic m-rx't' will stand ahout as iinich traction as an 
 iiuliiiary man lan make witli his lin^aT and thunih ; it should be 
 iipplicd steadily and continuously, not in a series of jeiks. The 
 i.lTfCt of stretchin^^ is to free the ner\ e from external inflam- 
 !iialui\' adhesions, and to alter the relations between the shi-ath 
 and its contents. 'l"he perineurium has its iilirilla', wiiich are 
 naturally wavy, straij^ditened out, thereby conipressinj,' the lym- 
 nhatic spaces between the rd)res, and possibly rupturing the nri\'i 
 iR'rsorum. The nerve becomes hypera'niic, and the medullary 
 sheath of the tubules may be irregularly broken up. 
 
 Affections of Special Nerves. 
 
 The Cranial Nerves. — The Olfactory Nerve may be invoked in 
 Iractuics extending across the cribriform plate of the ethmoid, or 
 ill severe cases of contusion of the anterior lobes of the brain 
 without fracture, resulting in loss of smell (anosmia). 
 
 The Optic Nerve is sometimes ruptured in fractures of the base 
 (if the skull running into the optic foramen, leading to sudden irre- 
 mediable blindness; or it may be compressed by effused blood 
 or inflammatory exudation, either within or outside of its sheath, 
 causing more or less ctjmplete loss of vision preceded by optic 
 neuritis {i.e., inMannnation of the intraocular te- mination of the 
 nerve, or papillitis) ; but if the haemorrhage has not been \ery 
 extensive, vision may be in measure restored. Orbital cellulitis 
 not unfrequently causes pressure on the nerve, either immediately 
 as a result of the inflannnation, or subsecjuently by cicatricial con- 
 iraction. Syphilitic disease of the sheath or the formation of a 
 i;uninia in its neighbourhood, or intraorbital aneurisms or tumours, 
 niav likewise induce amblyopia from pressure on the trunk. 
 
 rile Third Nerve {motor oculi) being entirely motor, paralytic 
 sviiiptoms are those to be looked for. They may arise from 
 antral causes, such as syphilitic or degenerative changes in the 
 iloor of the third ventricle; or from pcyiphcval lesions, such as 
 aneurisms, tumours, trauma, etc., either in the orbit, sphenoidal 
 rissure, or base of the skull. The Ssrmptoms of complete paralysis 
 are as follows : {a) Ptosis, or drooping of the upper eyelid, from 
 loss of power in the levator palpebrje superioris ; (/;) external 
 .■strabismus, or squint, from paralysis of the inner, upper, or lower 
 recti, the eye being also directed a little downwards from paralysis 
 of the inferior oblique ; {c) mydriasis, or dilatation of the pupil, 
 irom palsy of the iris ; {d) loss of accommodation, from the ciliary 
 nuiscle being paralyzed ; and {c) some slight protrusion of the 
 eyeball (exophthalmos), owing to most of its muscles being 
 t^accid ,:.nd relaxed. In consequence, however, of its close 
 proximity to the fourth, fifth, and sixth nerves in the walls of 
 ihe cavernous sinus and sphenoidal fissure, symptoms referable 
 to these trunks are often associated with the above, as also 
 
 20 
 
3o6 
 
 A MANUAL OF SURGERY 
 
 venous congestion of the eye and orbit from pressure on the 
 sinus. Should the eyeball be totally immobilized from paralysis 
 of all its muscles without venous congestion, the condition is 
 known as ophthalmoplegia externa, and is always due to central 
 disease affecting the floor of the third ventricle, and probahly of 
 syphilitic or tabetic origin. The Treatment in most cases consists 
 in the administration of mercury and iodide of potassium. 
 
 Paralysis of the Fourth Nerve {Pathetic), which supplies the 
 superior obli(|ue muscle, results in defective movement of the 
 eyeball downwards and outwards. 
 
 The Fifth or Trigeminal Nerve is occasionally torn in head 
 injuries, giving rise to anaesthesia, with perhaps ulceration of the 
 cornea; but such cases are exceedingly rare. Much more common 
 is the disease known as trigeminal iiciiyalgia, or tic douloureux, which. 
 is more frequently observed in women than in men. It is to 
 be clearly distinguished from the simpler forms of neuralgia due 
 to some local irritation or general weakness by the paroxysmal 
 character and violence of the pain ; hence the term 'epileptiform 
 tic ' has been applied to it, and not inaptly represents the terrible 
 nature of the affection. As a rule, it commences in the infra- 
 orbital or inferior dental branches, radiating thence to all the other 
 divisions of the nerve. The paroxysms are not very fretjuent at 
 first, but they rapidly increase both in number and severity, until 
 at last the patient becomes utterly prostrate, and may he so 
 depressed as to contemplate or e\-en attempt suicide. The con- 
 dition is often influenced considerably by the general health, and 
 intermissions of varying length occur. The attacks are accom- 
 panied by twitching of the muscles of the face, and even of the 
 neck ; also by unilateral sweating and hypera^mia of the head, 
 and the development of such marked ' points douloureux,' that 
 possibly the patient cannot brush his hair or wash his face on 
 the affected side, which becomes dirty and is often shinv fron; 
 trophic changes. Lachrymation is a marked feature durini^ the 
 attacks, and there may be a considerable increase in the sali\ary 
 secretion, as also in that of nasal mucus. 
 
 As to tlie Cause of tic douloureux, but little can he said for certain, altlnuiiiii 
 many conilitious may contribute to its production, \iz.: (u") C'.v.'."!f/ causes, sucli 
 as changes of a sclerosing type in the deep centres ot the fifth nerve, or in tlit 
 Gasserian ganglion ; (/i) yadicul, or those due to compression or disease nf the 
 roots of the iier\e, reaching from tiie gangl on to the cranial foramina: 
 (c) cranial conditions, such as tliminution in t'".; size of the foramiu.i ot exit 'it 
 the nerves, \>iiich not only vary immensely in different skulls, bemg generally 
 smaller in women, but also may be encroached upon l)y callus, intlainmaic ry 
 swellings, or tumours ; (</) peripheral causes, c.^'., dental caries, narrowing ot tlie 
 walls of the bony canals, etc. ; (e) toxic agents, e.g., malaria, which especially 
 tentls to affect the supra-orbital nerve, constituting the so-called ' brdw ague ; 
 and ( f) rejhx phenomena, e.f;.. ovarian ilisease, errors of refraction, etc 
 
 In the Treatment of tic douloureux, innumerable remedies ha\e been used, 
 with a varyir.g degree of success, e.i;., quinine, where there is a malarial liistniy: 
 iodides and mercury for syphilis; iron and arsenic for anaemic patients; and, 
 
AFFECTIONS OF NERVES 
 
 307 
 
 failing these, croton-chloral, paraldehyde, etc. All sources of reflex irritation 
 should lie removed or treated, .^uch as carious teeth, errors of refractiv)n, intra- 
 nasal trouble, ovaritis, etc. If the pain persists. Operative Measures will, 
 sooner or later, be required. Neurotomy and nerve-stretching may give 
 lemporary relief, but most surgeons have been led by experience to the con- 
 clusion that the greatest measure of success follows neurectomy, and that the 
 larger the portion excised, aiid the nearer hat portion is to the central organs, 
 the better the results attained. Hence much more extensive operations are 
 now undertaken than formerly, even extending to the Gasserian ganglion itself. 
 The operations which have been utilized in dealing with this ner\e are so 
 
 I'iG 81.— (I, lncisif)n for division of supra-orbital nerve ; !>, line indicating 
 position of supra-trochlear nerve, passing from angle of mouth through 
 the inner canthus ; the short cross-line at its upper end is the incision 
 required to expose it ; c, position of infra-orbital nerve and incision ; 
 (/, Carnochan's incision for neurectomy of the second division. 
 
 numerous and often so complicated that we can merely gi\e the briefest 
 (Ifcscription here of those which we usually emplov.* All purely subcutaneous 
 or ruhinucous methods are to be condemned for their inaccuracy and in- 
 tfficiency, as also on account of the bleeding which is likely to result Irom the 
 closely contiguous bloodvessels. 
 
 The biupva-oybital Nerve does not very commonly re(|uire division or extrac- 
 ii"n, since neuralgia of this trunk is certainly more amenable to therapeutic 
 
 ' Owing to necessary limitations of space we must refer readers for further 
 iletails to Rose on ' Trigeminal Neuralgia' (liailliere, Tindall and Cox, 1892). 
 
 20 — 2 
 
3o8 
 
 A MANUAL OF SURGERY 
 
 t 
 a 
 
 measures than other forms. Tlie pain usually recurs about the same time 
 each (lay, and may be treated by givinf( a pill containinj^ ferri sulph., i f,'rain 
 <iuinia^ disulph., 2 f,'rains, and morphina' iiydrochlor., j'.i grain, four JKuirs 
 before the attack is expected, and repeating it every htnir till six ]iills in all 
 Jiave been taken. At the same time attention must be directed to any incal 
 cause of irritation. Should tiie pain persist in spite of treatment, neurecionn- 
 may be undertaken. The nerve emerges from the orbit tlirough the supra- 
 orbital notch, lying at the junction of the inner and middle thirds of the iip]ier 
 margin, and is reached by an incision following the course of the eyebrow 
 through whicli the orbicularis is divided along the line of its fibres (Fig. Si, d}' 
 r>y incising the periosteum and depressing it, together with the orbital fat, 
 the ner\e can be followed back for some distance, and a considerable portion 
 removed . 
 
 The Suh-a-ti'ochlcar Nerve has been stretched (somewhat empiricailv, it is 
 true) f(3r sundry obscure neuralgic affections of the eyeball, and occasionaliv 
 with considerable success. It emerges from the orbit along a line drawn from 
 tile angle of the mouth through tiie inner catithus (Fig. 81, b). An incision is 
 made at right angles to this course just below the eyebrow and the nerve, 
 whicii is found in se\eral filaments, stretched or divided. 
 
 The Infia-ovbital Nerve emerges from the foramen of the sat name at a spot 
 about h inch below the centre of the lower margin of the orbit. It can lie 
 readied and divided by a horizontal or cur\'ed incision placed over tliis site 
 (Mg. <Si, (■) ; but since such an operation is unlikely tcj gi\'e more than temporary 
 relief, the mot of the second division should be at once attacked if opeiative 
 procedures are necessary. It is most desirable to divide the ner\e behind 
 Meckel's ganglion, and hence the operations which are perfornied from t!ie 
 face (either Wagner's, which follows the floor of the orbit, or Carnoclian's. 
 whicli traverses the antrum) are objectionable, whilst they are almost certain 
 to leave ugly cicatrices (Fig. 81, d). 
 
 The //('n'A'o/i/ method, or, as it called, the Braun-Lossen operation, is without 
 d)iibt the best for dealing with the root of the second division. Our experience 
 of tliis proceeding, wiiich is now extensi\e, has induced us to modify tlie 
 original plans considerably, and our usual method of procedure is as follows; 
 The incision commences at the external angular process of the frontal bone, 
 f. )llows the upper border of the zygoma, and curves downwards in front of the 
 ear to reac tiie angle of tiie lower jaw (Fig. 6y, F). The Hap thus marked out, 
 consisting only of skin ami subcutaneous fat, is dissected forwards, temporarilv 
 fixed by a suture \.o the nose, and protected with gauze. The zygoma is 
 e.xposed by a horizontal incision through the periosteum, which is cleaied 
 from the bone by a suitable raspatory, and drilled front and l)ack so as to 
 carry silver wires in the subsequent suturing up (Fig. 82) ; it is tlien sawn 
 tlirough and turned down, together with the masseter. The moutii is slightK 
 opened with a gag, and the temporal tendon pulled well backwards from the 
 front of t!ie temporal fossa by retractors, exposing tliereby the pter\{,'i)- 
 maxillary fissure, although the corf)noid process is sometimes so large as to 
 need removal. The internal maxillary vessels are then looked for, and, if 
 possible, secured by ligatures and divided. The root of the second dixisioii 
 (!f the fifth nerve can tiien be hooked up on an aneurism needle as it eniei<;es 
 from the foramen rotundum, and di\ided — a proceeding much facilitated li\ 
 chiselling away a bony prominence whicli rises from tlie base of tiie great win,;; 
 of the sphenoid, on the pt)sterior aspect of the junction of the two limbs of tlie 
 pterygo-maxillary fissure. By also dividing the nerve as it emerges from the 
 infra-orbital foramen through an ircision in the face, tlie whole trunk is set 
 tree, and can be removed by traction, ail the dental brandies being torn across 
 The displaced structures are then put back in position, tlie zygoma is siitiireil 
 with silver wire, and the incision in the skin closed. The results gained i)y 
 this method have been very satisfactory, scarcely any scar persisting, and the 
 freedom from pain being usually prolonged and complete. 
 
 The third division of the trigeminal nerve has many branches, hut the 
 
 lingual and inferi 
 >evere to call foi 
 be divided sepa 
 epileptiform tic i 
 foramen ovale. 
 
 Tlie Lingual N 
 incision down to 
 thirds of a line d 
 .iiiRle of the jaw ; 
 iiuiccnis membran 
 ii.seless, but dangt 
 T!ie Inferior De 
 pression in its boi 
 
 "trephine the inferi 
 '""•(ier, and remove 1 
 
 plKshed in the follow 
 i-tfltcted forwards fn 
 "! ;'"^ angle of the j 
 «".''.tlie socia paroti 
 i'lcision is kept stric 
 ,»" "ay endangered 
 "flow tlie .soda parot 
 ^f muscle and periost 
 /•','«^l' trephine just 
 
 '^Rsuhsefiuentlyre 
 I'ehind to preserve tl 
 
 
AFFECTIONS OF NERVES 
 
 309 
 
 lingual and inferior dental are those mainly affected with neuralgia sufficiently 
 severe to call for operative interference. For purely local lesions they can 
 he divided separately in the peripheral portions of their course, but for 
 epileptiform tic it is best to deal with them at the same time close to tlie 
 foramen ovale. 
 
 Tlie Li>i,i;iuil Ncirc can be divided from witliin the mouth by a simple 
 incision down to the bone, as it crosses the junction of tlie upper and middle 
 thirds of a line drawn from tlie crown of the last lower molar tooth to the 
 angle of the jaw ; or it may be sought for more carefully after division of tiie 
 mucous membrane. Such methods, however, lack precision, and are not onl}- 
 useless, but dangerous, owing to the necessary occurrence of sepsis. 
 
 T'.ie Inferior Dental Nerve is sometimes the seat of neuralgia, due to com- 
 pression in its bony canal as a result of dental troubles. It may then suffice 
 
 ill.. 82 — Zygoma and Lower Jaw in situ to show Position ok Saw-cuts 
 
 AND DrILL-HOLKS IN THE BrAUN-LoSSEN OTEKATION, AND IN THAT FOR 
 
 Kkmoval of the Gasskrian Ganglion. 
 
 ij trephine the inferior maxilla, making the necessary incision along its lower 
 Imrder, and remove half its thickness, so as to expose the nerve in its canal. 
 
 ,s'(V//()// of the third division of tlie fiftli nerve at the foramen ovale is best accom- 
 plished in the following manner: A flap of skin and subcutaneous tissue is 
 refltcted forwards from the parotid region, extending from the zygoma above 
 to the angle of the jaw below (Fig. 69, F), exposing thus tlie parotid gland 
 with the socia parotidis and the masseter muscle, covered by fascia. If the 
 nicisinii is kept strictly to the subcutaneous tissues, the facial nerve is in 
 iw way endangered. The masseter is then divided transversely immediately 
 i>elo\v tlie socia parotidis, and the vertical ramus of the inferior maxilla cleared 
 if muscle and periosteum to a sufficient extent to allow the application of a 
 jincli trephine just below the sigmoid notch, the remaining bridge of bone 
 JHiing subsequently removed by cutting pliers; enough bone is left in front and 
 i'lhind to preserve the continuity of the jaw with the articular and coronoid 
 
310 
 
 A MANUAL OF SURGERY 
 
 processes. The fibres of the external pterygoid muscle can now be seen cross- 
 ing the upper part of the wound horizontally, and over it the internal maxillarv 
 artery sometimes courses, giving rise to considerable haemorrhage if it js 
 wounded. The lingual and dental nerves are usually found close together, 
 emerging from under the outer pterygoid muscle, and lying between the 
 internal pterygoid and the bone. The peripheral portions should be twisted 
 or pulled up, and divided below as far down as possilile, whilst by drawing 
 the external pterygoid outwards with retractors, the foramen ovale can t)e 
 seen, if electric illumination is employed, and the nerve trunks divided at tiie 
 point of exit. The wound usually heals well, and leaves but little scar, 
 although some impairment in the mobility of the jaw may result, partlv from 
 the cicatrization following disturbance of the muscles and tissues, but mainlv 
 frr)m paralytic atrophy of tiie muscles supplied by the divided nevve. 
 
 In cases where such measures have been adopted and have faihjd, or wiiere 
 the pain is referred to the whole nerve, yevurcul of the Gasscyian f^an^lion has 
 been successfully performed, but should never be undertaken until the extra- 
 cranial proceedings have been very thoroughly carried out. Tlie operations 
 are so elaborate and recondite that we can only give a bare outline of 
 them here. 
 
 Rose's operation approaches the panglion through the pterygoid region, taliing 
 the third division as its guide. An incision (Fig. Cg, F) similar to tliat for 
 exposing the foramen ovale is made through tlie skin, and the flap thus marked 
 out is drawn forwards and stitched out of the way. The zygoma is drilled. 
 divided (Fig. 82), and turned down together with the masseter ; the coronoid 
 process is then divided or removed, and together with the temporal muscle 
 turned upwards ; the internal maxillary artery is, if possible, secured, and the 
 sphenoidal attaciiment of the external pterygoid scraped away so as to allow 
 of the exposure of the foramen ovale, which lies just in front o'' the base of the 
 pterygoid processes. A i-inch trephine is now applied immediately outside 
 the foramen ovale, and the bone around the opening thus made is also 
 remo\ed by forceps or chisel so as to give more space. The trunk of the third 
 division is traced upwards, the slieath of the ganglion opened, the second 
 division cut through by means of a sharp cutting-ho(3k, and the ganglion torn 
 away piecemeal, or, at an\rate, broken up. Tliere is likely to be a good deal 
 ( f l)leeding, especially in the earlier stages of this operation, chiefly derived 
 from veins ; it can, however, be usually restrained by packing the wound for 
 a few moments with sponges wrung out of very hot lotion. Efficient electric 
 illumination is absolutely essential, since the wound is a very deep one. 
 
 The Haithy-Kyause operation was devised independently by the two surgeons 
 whose names are associated with it. An i2-shaped flap is marked out in the 
 temporal region, the base situated just above the zygoma. Through this t:ie 
 subjacent bone is divided by chisel or electric saw, and the whole flap of skin, 
 muscle, and bone is turned down en hloe, exposing tiie dura mater, whicii is 
 gently stripped up from the middle fossa of the skull as far as the cavern<nis 
 sinus. Profuse hacmorriiage is likely to be caused by this proceeding, derived 
 mainly from the middle meningeal trunk or its brandies, and must lie con- 
 trolled by pressure, or possibly by plugging the foramen spinosum witli puri- 
 fied sponge. The second and third divisions of the nerves are readily tound 
 beneath the periosteum, and are traced back to the ganglion as it lies on the 
 apex of the petrous bone. A special cavity in the dura mater (or cavum 
 Meckelii), in which the ganglion lies, has to be opened, whilst liie first division 
 courses along the walls of tlie cavernous sinus, to which it is most intimately 
 adherent. Electric illumination is necessary in order to effect the removal ot 
 these structures, but apparently the wiiole ganglion, together with its branches, 
 l;as been extirpated in tliis way. 
 
 As far as we can see, the freedom from pain is certainly more prolonged 
 tiian after any of the operations upon tiie peripheral portions of the nerve 
 trunks, and may possibly be permanent ; certainly some of the cases on whicli 
 we have operated have remained seven or eight years without recurrence 
 
AFFECTIONS OF NERVES 
 
 3" 
 
 At the same time we cannot but admit tliat, with a mortality wliicli in either 
 ;iiethocl amoimts to alioiit 15 or 20 per cent, it is very desirable to perform the 
 extracranial operations very thoroughly before resorting to such a serious 
 :neasiire. During the last few years we have been working along these lines, 
 •akiiiK the greatest precautions to excise very extensive portions of the 
 nerves, and have been much gratified with the results. 
 
 The Sixth Nerve may be torn or compressed, either in its intra- 
 cranial course in the outer wall of the cavernous sinus, or as it 
 passt'S through the sphenoidal fissure, or in the orbit, as a result 
 of penetrating wounds or blows. Its division causes paralysis of 
 ;he external rectus and consequent internal strabismus. 
 
 The Seventh or Facial Nerve may be paralyzed from a great 
 variety of causes, which may be described under the following 
 headings : 
 
 [a] Intya-cvanial lesions. — If simply coytical, as from pressure, 
 
 luiniorrhage, degeneration, etc., a limited portion of the opposite 
 
 >ide of the face is usually involved. If siib-co"tical, or in the 
 
 corona radiata, or corpus striatum, as from haemorrhage, or 
 
 softening due to carotid thrombosis or embolus, the paralysis 
 
 appears on the opposite side together with hemiplegia, but only 
 
 the lower half of the face is palsied, the associated movements 
 
 I of the eyelids being left. If the lesion is situated in the pons, 
 
 I ;he deep facial centres may be implicated, and then paralysis 
 
 I with rapid atrophy of the facial muscles ensues on the same side 
 
 I a? the lesion, together with loss of power of the opposite arm 
 
 land leg (crossed paralysis). If the root of the nerve between the 
 
 I centres and the internal auditory meatus is involved, the whole 
 
 I of the same side of the face is paralyzed, accompanied, as a rule, 
 
 I i'V deafness. 
 
 I \h) Cranial lesions. — There are two not uncommon causes 
 I grouped vmder this heading, viz., (i.) fracture of the base of tiie 
 I <kull, involving the petrous portion of the temporal bone, the 
 I paralysis supervening either innnediately after the injury from 
 I laceration, a rare phenomenon, or some weeks later from implica- 
 liion in the callus, the usual cause; or (ii.) as a complication of 
 I chronic otorrh(ra, and then due <"o compression or inflammation 
 If the nerve in the atjueductus Fallopii. In both these forms the 
 
 ■ palsy is complete on the side affected, and owing to the com- 
 B;iuinication of the facial with the petrosal nerves in this part of 
 l:ts course there may be unilateral drooping of the velum palati, 
 Bthe uvula being deflected towards the sound side. 
 
 I ii) Extra-cranial lesions from injury, inflammation from exposure 
 ■:icold, or the pressure of a tumour, e.g., malignant disease of the 
 ■rarotid. This variety has been called ' liell's palsy,' and is 
 
 ■ -siially characterized by the whole side of the face being affected, 
 H ut without implication of the palate or uvula. 
 
 I The general Signs of facial paralysis (Fig. 83) are as follows : 
 Hihe side of the face is immobile and expressionless, all the natural 
 
312 
 
 A MANUAL OF SURGERY 
 
 folds and wrinkles being lost ; the eye cannot be completely closed. 
 and on attempting to do so the eyeball is usually seen to roll 
 upwards and outwards ; ulceration, and e\en perforation, of the 
 cornea may result from this exposure. From the droopini,' and 
 relaxation of the lower eyelid, the apposition of the puiiciuni 
 lachrymale to the conjunctiva is imperfect, and thus tears es -ape 
 over the face (epiphora), a condition aggravated by the loss o the 
 suction-like action of the lachrymal sac, owing to the associated 
 paralysis of the tendo oculi and tensor tarsi. On attemptin<,r to 
 move the face, as in laughing or showing the teeth, the muscles 
 
 Fk;. 8j. — 1'acial 1'akalvsis. (I'rom PHOTooRArns.) 
 
 On the left side the face is in a position of rest ; on the rip;ht side an attempt 
 has been made to close the eyes, that on the paralyzed side remainin<; open,! 
 and the eyeball rolling upwards and outwards, wliilst tiie symmetry of tin 
 face becomes more manifest. 
 
 on the non-paralyzed side are alone contracted, and marked 
 asymmetry results from the drawing o\er of the opposite sideJ 
 The lips cannot be closed firmly, and hence whistling and sucl: 
 like actions are prexented. Food collects between the cheek and 
 the teeth, owing to paralysis of the buccinator, and the patieni 
 after a meal has to clear out the debris with a spoon or his lingersj 
 The Treatment of facial paralysis necessarily depends upon \ti 
 cause. In the majcnity of cases medical treatment (including tlid 
 administration of perchloride of mercury and iodide of potassiunij 
 will suffice, together with massage and electricity ; in othersj 
 surgical measures with a \iew to remove some ob\ious cause oj 
 pressure may be necessary. 
 
AFFECTIONS OF NERVES 
 
 3«3 
 
 Facial Tic (or histrionic spasm) consists of a clonic contraction 
 j:|the facial muscles, due to some lesion of the centre in the pons 
 or cortex. The condition causes great discomfort to the patient, 
 Imd may involve the whole side of the face, or merely one part of 
 |:t,siich as the orbicularis oculi. Treatment consists in the admin- 
 |:.;iration of nerve tonics or anti-spasmodics, and, failing that, 
 
 ichiiig, or even in severe cases division, of the facial nerve has 
 Ijieen employed, but is most unsatisfactory. 
 
 Operation. — The nerve is exposed immediately below the ear, its position 
 
 tni; indicated by a horizontal line drawn from the middle of tlie anterior 
 
 Ikder of the mastoid process, and usually corresponding; to the point where 
 
 lie mastoid meets the lobule of the ear. The incision extends from just 
 
 Ikhind the external meatus along the anterior border of the sterno-mastoid 
 
 l^Jicle to the level of the angle of the jaw. The parotid gland is separated 
 
 jm tiie muscle, and both are well retracted, exposing by this means the 
 
 y;terior belly of the digastric. Tlie facial nerve is found abo\e tliis, 
 
 l-nning directly forwards from tiie centre of tiie mastoid process. The great 
 
 luncular nerve is divided in the superficial incision, and tlie posterior auricular 
 
 jMeis will require a ligature. Tlie internal jugular vein is close to the 
 
 (nijterior margin of the wound. The operation is a deep one, and by no 
 
 heans easy in a patient with a thick neck. Tlie cfffct of stretching the 
 
 l:trve is to temporarily paralyze it, but the ultimate results have been by 
 
 • means encouraging, only one case out of twenty collected by Godlee being 
 
 |;;:cessful. 
 
 The Auditory Nerve may be injured in fractures of the base of 
 liiie skull, either one or both sides being involved. Incurable 
 lieatness usually results, often associated with facial palsy. 
 
 It is a little doubtful what effect would be produced by injury 
 
 |}itlie Glosso -pharyngeal Nerve, but in one case in which it was 
 
 supposed to be compressed the patient suffered from difficulty in 
 
 JMllowing and speaking, together with persistent ulceration of 
 
 |ie tongue; death resulted froiu crdema of the glottis. 
 
 .\se\ere injury to the Pneumogastric Nerve may prove rapidly 
 
 fital, but less serious lesions result in palpitation, vomiting, and 
 
 sense of suffocation; such phenomena sometimes manifest 
 
 temselves after head injuries, especially fractures involving the 
 
 Kterior fossa, and indicate that the jugular foramen has been 
 
 Ifficroached on. The nerve is also exposed to injury in operations 
 
 kit the neck, e.g., ligature of the carotid, or removal of tuber- 
 
 fcjus glands. Irritation causes vomiting and temporary inhibition 
 
 |ihe heart's action ; one-sided division sometimes does compara- 
 
 % little harm, but if both ner\es are divided, death results from 
 
 fcjngeal paralysis or from such complications as (rdema or 
 
 p'estion of the lungs. When the vagus is injured in the lower 
 
 : of the neck or compressed by an aneurism, or if the recurrent 
 
 tynsfeal ner\e is dixided or compressed, hoarseness or partial 
 
 I'onia is produced, from paralysis either of all the nmscles on 
 
 side of the larynx, or in slighter cases only of the abductor 
 
 ticD-arytenoideus posticus). 
 
 ]T!:f Spinal Accessory Nerve may be irritated, either at its exit 
 
314 
 
 A MANUAL OF SURGERY 
 
 from the skull by a fracture running through the jugular foramen, 
 or in its peripheral course by inflamed lymphatic glands, etc. 
 Clonic spasm of the sterno-mastoid and trapezius is usually duel 
 to central changes, and it is for this form of spasmodic torticollis} 
 that stretching ov division of the spinal accessovy nerve is employed. 
 
 Operation. — The nerve runs downwards and backwards at rif,'!)! angles to] 
 the centre of a line passing from the anjjle of the jaw to the apex of thel 
 mastoid process ; it enters tlie deep aspect of the sterno-mastoid al)out| 
 j inches below that spot. An incision is made along the anterior border ofl 
 the sterno-mastoid, reaching from the ear to the cornu of the livoid boneJ 
 The fascia is divided, and the muscle tlrawn backwards to expose tlie posteriori 
 belly of the digastric, from under tlie lower border of wiiicli the nerve emerges | 
 passing first in front, and then below the transverse process of the atlasj 
 which can be readily felt. The operation has not given good results, since'l 
 even if the twitching of the head and neck ceases, the spasmodic piienomenal 
 may recur elsewhere. 
 
 The Hypoglossal Nerve may be accidentally divided in anl 
 operation, or compressed by an aneurism of the external carotid,! 
 or by a new growth. Unilateral paralysis or weakness of the 
 tongue results, the organ, when protruded, being directed towards 
 the paralyzed side. 
 
 The Spinal Nerves. 
 
 The nerves constituting the Cervical Plexus are exposed to 
 injury either from blows, dislocations of the cervical spine, peneJ 
 trating wounds, or during operations. No very serious result^ 
 follow, except in the case of the Phrenic Nerve, division of which 
 may cause instant death by paralysis of the diaphragm, althoii;,'li 
 when but one nerve is divided the patient can survi\e. Irritatioq 
 of the nerve gives rise to spasmodic cough or hiccough. 
 
 The Brachial Plexus may be injured from exactly similar caiiseS 
 paralysis or spasm of the muscles of the arm arisinj; frod 
 division or irritation of the motor branches, whilst hypera'Sthesil 
 or anaesthesia may follow from damage to the senst)ry truiiL 
 Thus a blow on the liack of the neck opposite the iifth or si\t| 
 vertebra: caused paralysis of the serratus magnus and rhomboid 
 (winged scapula) ; an old unreduced unilateral dislocation ot thi 
 seventh cerxical \ertebra produced intense neuralgia alonj,' thj 
 course of the ulnar nerve, and many similar instances niif;ht 
 mentioned. 
 
 One special form of injury may be alluded to in which the rool 
 of the fifth and to a less extent of the sixth cervical nerves aif 
 wrenched or torn as a result of a fall on the shoulder, which 
 pressed downwards, whilst the head is forced over to the opposifl 
 side, a type of accident which is liable to follow a spill from ahigj 
 dog-cart. The result is paralysis of Erb's preaxial group 
 muscles, including the biceps, deltoid, and supinator longiis, arisin 
 from the fifth nerve, whilst the extensors of the fingers and wii 
 
 til, winding round 
 
AFFECTIONS OF NERVES 
 
 315 
 
 re involved when the sixth nerve is also injured. Sensory lesions 
 
 L-e usually slight, and recovery, though slow, ensues after a time. 
 
 The Treatment is mainly symptomatic, including the adminis- 
 
 iration of iodide of potassium and the local application of blisters 
 
 rother counter-irritants and of electricity. In cases where there 
 
 <;evere and intractable neuralgia, not referred to any discoverable 
 
 [j;ion, or where clonic spasm of the muscles of the arm and 
 
 Isiioiilder are met with, styetching of the brachial plexus may be 
 
 |:t']uired. 
 
 I Operation. —The patient lies on his back, with the liead directed to tiie 
 l-ju'-ite side, and the arm well drawn down ; a cushion is inserted under the 
 Islioiikier to steady it. An incision is made above the centre of the clavicle, 
 |( r4inclies in length, parallel to the anterior border of tiie trapezius. Tiie 
 ftaivsma and deep fascia are divided, and the deep cellular tissue opened up 
 Ik retracting the margins of the wound. Tlie posterior belly of the omo- 
 pvul is thus e.xposed, and the posterior border of the scalenus anticus 
 Icianed. The cords f)f the plexus are found emerging between the latter 
 IrKleand the medius ; they are carefully isolated by division of the siieath 
 Idcrin^' tliem, and pulled upon by the finger or an aneurism needle passed 
 idcrthem. Special care must be taken of the lf)west cord of the ple.xus, 
 inch passes behind the subcla\ian artery. The nerves are stretched both 
 lempetally and centrifugally. Excellent results have followed this opera- 
 JlT. although in a. few cases the necessary cicatrization which followed led to 
 ■recurrence of the symptoms. 
 
 I The Ciicumflex Nerve is liable to injury from its exposed posi- 
 it.;i, winding round the outer side of the neck of the humerus 
 ■iviiit a finger's breadth above the middle of the deltoid. Blows 
 ■fon the shoulder may in this way cause paralysis ; it is some- 
 Hues torn or compressed in fractures of the surgical neck of the 
 Bcmerus, or in dislocation of the shoulder, or it may be impacted 
 Kthe callus arising from the former injury. Paralysis of the 
 Bcitoid and teres minor follows, evidenced by inability to raise the 
 B-infiom the side, whilst the wasting of the former muscle causes 
 fciie prominence of the acromion. There may be temporary 
 Rijsthesia over the posterior fold of the axilla, but this does not 
 ™long. No operative treatment has been adopted, although we 
 HfcRo reason why it should not be attempted in suitable cases. 
 ■ The Musculo-Spiral Nerve is not unfrequently damaged in 
 ■ictiires and dislocations of the upper extremity of the humerus. 
 Hot is especially exposed to injury in the musculo-spiral groove, 
 Bwe it lies close to the bone. It is implicated with or without 
 B^r nerves in crutch palsy (p. 402), or by lying asleep in bed 
 Hiiii the arm under the body, as so frequently occurs in drunken 
 Bijpie (commonly called ' Saturday-night paralysis '). 
 HThe Symptoms arising from its total division are as follows : 
 Hi .\nasthesia over the front and back of the outer side of the 
 H elbow and fore-arm (external cutaneous branches), 
 
 H over the radial side of the dorsal aspect of the wrist 
 
 H and hand, and over the back of the tluunb, index. 
 
3i6 
 
 A MANUAL OF SURGERY 
 
 middle, and half of the rinj; finj^ers, extendin;,' to tlia 
 base of the last phalanx (radial ner\'e, Fi^^ 85, 15), 
 B. Paralysis of the followinj^^ j^jroups of muscles ; 
 
 (i.) Of the extensor of the forearm (triceps) ; hence thd 
 forearm can only be extended by its own \veij;ht. 
 
 (ii.) Of the lonf( and short supinators; hence the hand ij 
 pronated, the only supinator remaininpf boinj,' the biceps, 
 
 (iii.) Of the radial and ulnar extensors of the wrist ; henc^ 
 wrist-drop (Fif,^ 84), a condition also present in certain 
 lesions of toxic or central orif,dn, e.g., lead palsy, an(| 
 proj^^ressive muscular atrophy. 
 
 (i\-.) Of the extensors of the fingers and thumb, which eithe^ 
 hang limp and motionless, or may be bent up into thJ 
 palm from the unopposed action of the flexor inusclesj 
 If, however, the wrist and proximal phalanj^^es ar^ 
 supported and ex tended, the terminal phalanges caii 
 
 Fig. 84. — Wrist-dkop from Paralysis of the Musculo-Simral \er\r.J 
 
 (TiLLMANNS.) 
 
 be straightened by the action of the interossei anj 
 lumbricales. 
 
 Treatment consists in massage and electricity applied to th 
 muscles, but in some cases an operation is necessary. 
 
 Operation. — The nerve can be exposed on the outer side of the arm after I 
 has traversed the external intermuscular septum, where it lies l)t'tween tlj 
 brachialis anticus and supinator longus. To define this intersection the ton 
 arm is semiflexed and pronated, and an incision made extendin;,' from tij 
 centre of the crease of the elbow upwards and outwards along a line madel 
 prolonging upwards tiie radial border of the forearm, which in this pusiiii 
 corresponds with the supinator longus muscle. The interspace is opened ul 
 and the nerve found together with the termination of the superior proliinq 
 artery. From this point the ner\e may be traced upwards, if neces.sary, 1 
 dividing the intermuscular septum, and retracting or dividing the triced 
 Where there has been considerable loss of substance of the ner\e, .so tlia: tl 
 ends cannot be approximated, an inch or two may be excised from tlieslia 
 of the humerus with advantage, tlie bone being subsequently wired, and tl 
 nerve sutured. We have performed this operation witii a successful result. f 
 
 To expose the upper part of the nerve as it enters the groove, the armj 
 placed over the body, and the posterior border of the deltoid defined 
 oblique incision is made a finger's breadth behind this, and tiie intersectil 
 
 §'■• ^5 DiSTRlUL'TION 
 
AFFECTIONS OF NERVES 
 
 3'7 
 
 ■Awn tlie loiiK and outer heads of tlie triceps found. By openinj,' up this 
 
 lonetlii; fuiger can be passed down to tlie hone, and tl)e nerve, toj,'t;tlier with 
 
 I - -aperior profunda artery, reathly exposed. 
 
 Where the nerve is impacted in tiie calhis arising from a fra' ture of the 
 
 [■uMle of the shaft of the humerus, it is often l)est to expose it by a meihan 
 
 i-isiim clown the back of the arm, splitting,' the triceps, the centre of the 
 
 |, ;;ul heiuK opposite the insertion of the deltoiil 
 
 The Median Nerve may be damaged in fractures and dislocations 
 
 lithe humerus, but is most frequently injured just al)o\e the 
 
 livrist by f,dass wounds, due either to bursting of bottles, etc., or 
 
 thrusting the hand and arm through a window. Paralysis 
 
 jrcassarily results in these cases with the following symptoms : 
 
 \i divided just above the tovist : 
 
 .\, Ana'sthesia over the palmar aspect of the radial side of the 
 hand, over the front of the thumb, index, middle, and 
 half the ring fingers, and over varying portions of the 
 dorsum of the same (Fig. >S5, A, B). 
 
 S5 Distribution ok Sknsorv Nkrvks of Hand from Front and 
 Hack. (Tii.lmanns.) 
 
 H/c, Median nerve ; 11, ulnar ; la, radial. 
 
 H. li.) Paralysis of the outer group of the short muscles of the 
 thumb {i.e., abductor, opponens, and outer half of the 
 tiexor brevis pollicis), so that the thenar eminence 
 wastes, and the mo\ement of ' opposition ' is impaired, 
 ihe thumb remaining extended by the side of the 
 fingers (Duchenne's 'ape-hand'). 
 li.) Paralysis of the outer two lumbrical muscles, causing 
 loss of power of flexion at the metacarpo-phalangeal 
 joints of the index and middle fingers. 
 Ihe great impairment of mobility in the hand and fingers so 
 seen in these cases depends not so nnich on paralysis of 
 Ndes as on the fact that in the majority of cases the synovial 
 
3i8 
 
 A MANUAL OF SURGERY 
 
 shenths of the wrist are also laid open, and involved in senti 
 iiillainniatioii, which leads to tiie formation of diffuse adhesion^. 
 Hence the proj^Miosis is often unsatisfactory, even when the ner\e 
 has been skilfully sutured at a secondary operation. 
 
 // divided at the hcnd of the elhoi.' or in the anii, to the ajuni 
 described symptoms are added : 
 
 (i.) Loss of pronation from paralysis of the two pronators, 
 (ii.) Paralysis of the de\or carpi radialis, causinj,' defecti\i;| 
 wrist flexion (jn the radial side, and im[)airL'{l radiij 
 abduction. 
 (iii.) Paralysis of the flexor lonj^ais polHcis, of the ileNi-rl 
 sublimis, and the outer half of the flexor ])rofiincliisj 
 digitorum, leading to loss of power in the haml-j,a;isji,j 
 especially on the radial side, and perhaps hypu- 
 extension of the wrist. 
 (i\.) Paralysis of the palnuiris longus. 
 
 Operations. When tlie nerve lias been divided, primary or secondary ner, J 
 suture sliouid always be undertaken. In the latter case incisions are madsl 
 thr<iu(,di tiu' old scars, which may be removed with advantage, tiie ends of the 
 iu'r\e clearly defined, and tiie bulb removed Suture is ()ften vlt}- ditlimltl 
 b-om lack ui material, and to assist in the apjiositioii of the sef,niicnts tlie hand 
 
 is flexed to a rif,dit angle, and also the elbdwi 
 and maintained in that position hvaporoJ 
 plastic or plaster ot I'aris splint 
 
 In order to stretch the nerve, it mav Da 
 
 exposed in the arm by an incision similar iq 
 
 that for ligature.of the brachial artery, ural 
 
 the wrist by an incision placed to tlie ulnal 
 
 ie^M's "%. 5^ side of the flexor carpi radialis tendon, hej 
 
 r^^^ ^ *A tween that structure and the palmaris longu 
 
 LiL^^L m- "^ or flexor suhliniis tendons, 
 
 ^.m. ^*r.Vl The Ulnar Nerve is exposed td 
 
 injury at the wrist, as also in thd 
 hollow between the olecranon and 
 the inner condyle of the humerus, and 
 paralysis may be caused by wounds 
 fractures, blows, implication in callu^ 
 etc. The symptoms are very cliaraq 
 teristic. 
 
 // divided at the elbow : 
 A. Anaesthesia of fhr ;nar..iati 
 the f u-e wn?t ar 
 
 palm iuar ciiian; 
 
 branc. . over the baci\ 
 the hand, and 'i the littl 
 and half the ,111 : fingerj 
 back and front (^Fig. S| 
 A, B). 
 B. (i.) Paralysis of the flexor carpi ulnaris, causing weaknej 
 in flexion and in ulnar adduction of the wrist. 
 
 Fir.. 
 
 EN 
 
 86. — Claw-hand (Main- 
 • Griffe) from Ulnar 
 
 Paralysis. (After Bvrom 
 
 i>ramwell.) 
 
 fii.) Paraly.s; 
 weake 
 'iiigerj 
 (iii.) I'aralysi 
 intcros 
 the finj 
 each f 
 phalauj 
 The ii 
 from at 
 (iv.) Paralysis 
 inner 
 transve 
 Hexor I) 
 // divided just abi 
 Ipalniar aspect and 
 Iparalysis merely aff( 
 jinipairment of movt 
 Iration of the long 1 
 Treatment. — If di 
 |to the rides already 
 
 To expose the nerve f 
 liffnllnwing methods 1 
 jiiJeMmilar to that for 
 I :Atllieeli)ow, cut (lo\ 
 |M:nd the internal inte 
 
 'liistahine the wrist 
 IKtween the tendon and 
 loision. 
 
 1 iie Intercostal Ne 
 icier from a chronic 
 |bMon by tumour 
 ^ 1 injury or pressi 
 p the spine, hh 
 ^fltk to such paij 
 F'Sthesia. 
 
 (Sciatica, or neura 
 
 p til affection, and 
 
 -' tlie following 
 
 i''!e or chronic), t' 
 
 fpliilis, and many 
 
 f'"c portion of the 
 
 [aJing dislocations 
 
 simi'-ir pressi 
 
 Kes thiough the, 
 
 pia of the pelvic 
 
 ps, c; uterine fib 
 
AFFECTIONS OF NllRVES 
 
 319 
 
 (li.) Paralysis of the inner half of the flexor profundus, with 
 weakened hand-grasp, especially in the ring and little 
 fingers. 
 (iii.) Paralysis of the two inner lunibricales and of all the 
 interossei ; hence, loss of adduction and abduction of 
 the fingers, with flexion of the two last phalanges in 
 each linger and hyper-extension at the metacarpo- 
 phalangeal joint (main-en-griffe or claw-hand, Fig. 86). 
 The interosseous spaces also become very evident 
 from atrophy of these muscles. 
 (IV.) Paralysis of the short muscles of the little finger, of the 
 inner group of short thumb muscles (adductor 
 transversus, adductor oblicpuis and deep portion of 
 flexor brevis), and of the palmaris brevis. 
 Ij divided just above the i.'vist, the ana-sthesia only involves the 
 halniiir aspect and back of the terminal phalanges, whilst the 
 paralysis merely affects the shc^rt muscles of the hand. Additional 
 Inipairment of movement may, however, arise from septic inilam- 
 Imation of the long tendons and their sheaths. 
 
 Treatment. — If dixided, the nerve must be dealt with (according 
 |iothe rules already given) at the injured spot. 
 
 Tcexpnse tlie nerve for tlie purpose of stretching for nenr.ilgia, or suturing, 
 
 lielnliowinji metiuxls may hi: adopteil : (a) In tlie upper arm an incision is 
 
 :aJe similar to that for tyin^' tiie brachial artery, hut half an inch behind it. 
 
 Auhe elbow, cut down just behind the internal condyle, and find the nerve 
 
 liehmd the internal inter-muscular septum with the inferior profunda artery. 
 
 1 lust alime the wrist it lies to the radial side of tlie flexor carpi ulnaris 
 
 I'wueen the tendon and the ulnar vessels ; the skin and deep fascia alone need 
 
 Icivision. 
 
 The Intercostal Nerves are frequently the seat of severe neuralgia, 
 jetherfrom a chronic neuritis, probably of toxic origin, from com- 
 Bfession by tumours, or inflammatory lesions of the ribs, or 
 loni injury or pressure directed to the nerve roots as they emerge 
 \m the spine. Herpes zoster or shingles is a very frequent 
 ^juela to such pain, and may be followed by some amount of 
 jsthesia. 
 
 S atica, or neuralgia of the great sciatic nerve, is a most 
 
 ;1 affection, and often exceedingly intractable. It may arise 
 
 the following Causes : {a) Inflammation of the neurilemma 
 
 > or chronic), the result of cold, injury, gout, rheumatism, 
 
 :nlis. and many toxic agents ; {b) pressure upon the extra- 
 
 jeivic portion of the nerve, as by aneurisms, tumours, or old- 
 
 pding dislocations of the head of the femur on the dorsum 
 
 ) siini'ir pressure upon the nerve in the pelvis, or as it 
 
 Eerg;es thiough the sacro-sciatic notch, as from sarcoma or 
 
 Isieoma of the pelvic bones, rectal or uterine cancer, a pregnant 
 
 kus, ( uterine fibroids ; {d) pressure upon the nerve-roots in 
 
320 
 
 A MANUAL OF SURGERY 
 
 the spinal canal, as tVoni caries or sarcoma ; (e) chronic diseasts 
 of the spinal cord, such as tabes. 
 
 The Symptoms are very evident, the pain shootinjf down tlit- 
 hack of the thij^di and often referred to the toes. It is of a 
 paroxysmal nature, and may he hrouj^dit on by pressure o\er 
 almost any part of the nerve or by movements of tlie thij,di, and 
 hence the patient's j:,'ait is stifif and shamhlin}^^ Tenderness in 
 the line of the nerve is felt when the cause is a peripheral 
 neuritis, and the trunk may sometimes be detected on pa'.pation 
 as a thickened cord. The limb is often kept slif^htly llexed, Imt | 
 complete flexion of the thij^di on the pehis is an impossibility 
 and if, when the patient is standing aj^^ainst a wall, the linil) can 
 be raised to a rif^ht aufj^le with the knee extended, it is certain! 
 that sciatica is not present. 
 
 The Treatment necessarily \aries with the cause. If due to] 
 neuritis or perineuritis, f^eneral anti-syphilitic or anti-rheumatic 
 measures may he adopted, and blisters or sedati\e remedies in the 
 more acute cases applied to the back of the thij^h. Hypodermic 
 injections of morphia and atropine may also be useful ; hut if 
 the usual anti-neuralj,'ic ''emedies have been exhausted without] 
 benefit, stretching of the ner'.e may be employed. 
 
 Sti'dchin^ of the sciaticnct'vc nvAy he. required for: (i.) neutai;,'ia| 
 of an intractable type ; (ii.) paralysis or spasm of muscles supplied 
 by it, owing to adhesions contracted between it and surroundini,' 
 parts, the residt of injury, cellulitis, or perineuritis ; (iii.) in 
 paralysis or spasm due to some forms of tabes. The ner\e inayl 
 also l)e exposed in order to suture it after it has been divided, 
 Nerve-stretching may be accomplished without operation byi 
 Hexing the thigh upon the abdomen and then extendinj,' thel 
 knee ; in cases of sciatica an anaesthetic will be retjuired for this,! 
 but it may be attempted before undertaking further measures. 
 
 The nerve is best exposed for stretcliing at the point wiiere it emerfjes frcral 
 under cover of tlie f,'hiteus m;i\imus, midway between tlie tuber ischii and liiel 
 f^reat trochanter. 'l"iie patient lies in the prone position with tlieliinli s]ij;htlyl 
 flexed, and a 4 or 3 inch incision is made \ertically downwards from tiit^ yliitfalj 
 fold in tile middle lineof tlie tiiif,'h. The lower border of the <,diiteus maximuij 
 is first exposed, and its fibres seen runninj,' downwards and outwards Iliel 
 hamstrinji muscles emerj^'ing from under it are drawn inwards, and the nervej 
 is found eiisheathed in loose connective tissue ; it is stretched, by a finj,'cr| 
 hooked under it, both peripherally and proxinially. 
 
 The Anterior Crural Nerve may be paralyzed as a result 
 injury or pressure, and may be the seat of neuralgia or spasi 
 Its di\ision causes paralysis of the (piadriceps extensor, pectineiijJ 
 and sartorius, and the most marked effect will be secondarij 
 fiexion of the knee-joint from the imopposed action ol the hami 
 strings ; anaesthesia extends iner the front of the thigh and aldit^ 
 the inner side of the leg and foot as far as the ball of the i,'ic;it| 
 toe. The nerve may be exposed on the outer side of the leinoii^ 
 
AFFECTIONS OF NERVES 
 
 vessels, just below Poupart's Ii<^^iinent, by a vertical incision half 
 an inch outside the line of the artery. 
 
 The External Popliteal Nerve may he divided durinf; a sub- 
 cutaneous tenotomy of the biceps, to which it lies immediately 
 internal ; or compressed, as it winds round the neck of the fibula, 
 hv stnippinff, bandages, or splints ; or it may be injured in 
 fractures of the neck of the fibula. Total division causes 
 aiucstliesia over the dorsum of the foot, toj^ether with paralysis 
 of the extensor and peroneal j^roups of muscles ; and from the 
 contraction of the unbalanced opposinj:; <j[roups, the paralytic 
 form ot talipes erpiino-varus results. The nerve may be ex- 
 Diised by makin<f an incision ih inches long to the inner side of 
 the hiceps tendon, terminating at the neck of the fibula. The 
 knee is then fiexed, and the nerve is readily found embedded in 
 tlie loose cellular tissue of the popliteal space. 
 
 The Internal Popliteal Nerve is much less expensed to injury 
 owinjf to its more sheltered position. Division results in anaes- 
 thesia of the back of the calf and sole of the foot, and in paralysis 
 of the calf muscles, flexors of the foot and toes, and of the short 
 muscles of the sole. Paralytic talipes calcaneo-valgus is very 
 likelv to ensue. The nerve is laid bare by a vertical incision in 
 the middle of the popliteal space, which should a\oid the short 
 saphena vein. After dixision of the deep fascia, the ner\'e is the 
 most siuxM'ficial structure. 
 
 If the Tibial Nerves are divided, the resulting effects are more 
 limited; thus, [)aralysis of the extensors of the foot and paralytic 
 uiipes er^uinus result from division of the anterior tibial ; and 
 paralysis of the short and long-flexors of the foot and of the inter- 
 ObSei, with resulting talipes calcaneo-N'algus, follow lesions of the 
 'fWsterior tibial. The nerves may be expensed in the same way as 
 the accompanying arteries 'p. 267). 
 
 The Sympathetic Nerve Trunk in the neck is occasionally com- 
 pressed bv aneurisms or ti.mours. If merely irritated, dilatation 
 of the pupil on the same side and unilateral sweating of th.e head 
 and face are produced ; but, if dixided, the pupil is contracted 
 ironi inihalanced action of the third nerve. It has also been 
 mtentionallv divided and portions excised in the treatment of 
 Graves' disease, glaucoma, and epilepsy ; but such practice is still 
 Illy in the experimental stage. 
 
 ai 
 
CHAPTER XIII, 
 
 SURGICAL DISEASES OF THE SKIN AND OF THE 
 CUTANEOUS APPENDAGES. 
 
 A Boil or Furuncle is a limited form of infective f,'anj^a-ene invoI\ in^ 
 merely a small portion of skin and subcutaneous tissue, usuallv 
 round a hair follicle. Ivxperimentally, ;i plentiful crop of boils caii 
 be produced by rubbinj; a culture of staphyU)Cocci into the skin, 
 and clinically it is supposed that a similar infection throuj;h ilit 
 hair follicles is the most conuuon cause of this condition. Thr 
 secondary boils around a ("tiimary one are without iloubt due to 
 the friction upon the healthy intej^amient of dressings, covered 
 with pus and microbes. 
 
 People with a coarse skin and a tendency to comedcMies an 
 sp,ecially liab.le to the occurrence of boils. A <,fangrenous inllain- 
 niation ensues after infection, resultin.i,^ in the death of tlu' hair 
 follicle, or of the sweat or sebaceous gland involved, and of the 
 surnnmding connectix e tissue, and the slough thus formed is cast 
 off by a process of suppuration. A matured or ripe boil, therefore, 
 consists of a central slough or core, a zone of pus around it, and 
 external t(j this granulation tissue merging into healthy skin and 
 connectixe tissue. Although infection from without is the local 
 exciting cause, there is freciuently present some depression of the 
 vital powers, which may lead to crops of boils recurring a,t;aiii 
 and again. 
 
 Signs. — A boil commences as a small red irritable pimi)le, from 
 which a hair may often be seen to protrude, which increases! 
 gradually in size, becoming more and more i)ainful, until it form 
 a conical tumour, deep red in colour and exciuisitel}- tender. .' 
 small whitish spot appears in the centre, and around this so-calle 
 core yellow pus can be seen. Finally it bursts, dischaiginj; tl 
 pus, and subserjuently the core or slough comes away. Tl 
 pn^cess is then at an end, and the wound rapidly heals by granii 
 lation. Occasionally the inllanunation extends more deeply int 
 the subcutaneous tissues, constituting a ' carbuncular boil.' 1 
 neighbouring lymphatic glands become sympathetically enlan,'e 
 and painful, but rarely suppurate. A boil sometimes siihsii' 
 
SURGICAL DISEASES OF THE SKIN 
 
 323 
 
 without suppuration, lea\in<.j the parts thickened and inhhrated, 
 .instituting,' what is known as a ' hhnd l)oil.' 
 
 Treatment. — Locally, many boils may he left to hurst naturally, 
 :.io,i,L;h possibly the process may be checked by surrounding^ 
 ;ht:in with a piece of ordinary adhesive plaster, with a hole o\er 
 hf apex of the swellin},'. Poultices are generally applied, and 
 he boil is incised when mature. The pus should be recei\ed 
 11 portions of wool soaked in carbolic lotion (i in 20), and the 
 jvitv li,i,ditly swabbed out with pure carbolic acid. A small 
 Miilodion dressing is then applied. Constitutionally, tonics, such 
 ,, iron and (luinine, are usually required, except in plethoric indi- 
 viduals, in whom a spare diet and abstinence from stimulants may 
 it' recommended. A change of air to a bracing seaside place is 
 .-I'tcii achisable, especially when a succession of boils has appeared 
 -1:11 tune to time for weeks or months. 
 
 .V Carbuncle is a more extensi\e infecti\'e gangrene of the subcu- 
 
 uiieous tissues, due to a local imasion with pyogenic microbes, 
 
 ;he commonest being the StapJiv/ococciis pyoi^cncs aiiveus. It occurs 
 
 in individuals run down by any general debilitating condition, such 
 
 ,b ;illiuininuria or diabetes, in whom the germicidal powers of 
 
 r.c lissuch are much depreciated ; it is also occasionally met with 
 
 |.i> ;i Sfiiuela of acute fe\ers. The exciting cause may be some 
 
 j!!o\vor siiueexe, resulting in extra\-asation of blood or some local 
 
 Nimimition of vitality; into this area cocci are implanted either 
 
 iviinto-infection, or more usually through the sweat-glands or 
 
 I i:;iir follicles, or through some slight superficird abrasion. 
 
 Signs. — A carbuncle conunences as a hard, painful infdtration 
 
 10' the subcutaneous tissues, the skin o\er which becomes red and 
 
 cjsky. The swelling gradually increases in size in all directions, 
 
 ;inil even a diameter of six or more inches is reached. .\s it ex- 
 
 li-nds peripherally, the central jiarts, which were formerly brawny, 
 
 litcome soft and boggy, and the overlying skin shows evidences 
 
 Yielding to the pressure within. \'esicles form on the surface, 
 
 |i::d filially pustules; these in turn burst, and allow a tardy exit 
 
 the ashy-grey sloughs and purulent discharge accumulated 
 
 litlow. Fresh t)penings graduall)- de\ elop, leading to a cribrif(;rin 
 
 Icoiidition of the cutis, due probably to the passage of the pus 
 
 liion},' the lines of least resistance, \iz., the perforations of the 
 
 pis at tlie sites of the sebaceous glands and hair follicles. Some 
 
 tthese apertures enlarge and run into one another, producing a 
 
 fcntral irregular crateriform opening, at the bottom of which lies 
 
 lie necrotic tissue. As the violence of the inflammation subsides, 
 
 ifcf sloughs gradually separate, leaving a clean granulating wound. 
 
 tarlmncles most fre(]uently occur on the back, the nape of the 
 
 fcak, the slu)ulders, and nates, where the \itality of the tissues is 
 
 per very active ; when they form on more vascular parts, such 
 
 pthe face and lips, the consefjuences may be even more serious, 
 
 21 — 2 
 
324 
 
 A MANUAL OF SURGERY 
 
 since infecti\e thrombosis of the large veins may follow, and 
 this may (luickly spread up to the cavernous sinus. The soft 
 and sponj^^y tissue of the check is a very favourable place for the 
 extension of the necrotic process, and there may be a wide area ot 
 mischief under an apparently insignificant superficial lesion. A 
 carbuncle is usually single, and may be accompanied by a painful 
 enlargement of the nearest lymphatic glands. 
 
 There is often considerable constitutional disturbance of an 
 asthenic type, although the temperature is not necessarily nuicli 
 raised. Sometimes the gravest symptoms of blood-poisoning.,' 
 (pyaMnia or septicaMiiia) may supervene. 
 
 Diagnosis. — i. From Boils. — PatJwlof^ically, a boil is an infective 
 gangrene of a small portion of the skin. A carbuncle affects the 
 sid)cutaneous tissues primarily, and the skin secondarily. CUni- 
 cally, boils are multiple, conical in shape, more localized, and 
 when suppuration has occurred the process is terminated by the 
 discharge of the pus and slough through a single openin-^. 
 Carbuncles, on the other hand, are usually single, much lari,'er. 
 flatter, and the sloughing process may continue peripherallv, 
 whilst the central part is discharging its sloughs through severa! 
 openings. 2. Fvoni Gimuitata. — Cutaneous gummata are frcfiuentlv 
 nmltiple, occurring in patients with a distinct syphilitic histurv. 
 They are not \ery painful, and do not as a rule attain any 
 great size. The> usually ulcerate early, leaving circular sores, 
 or if multi[)lc and confluent, sores with serpiginous outlines: 
 there is generally but little definite sloughing. The cieener 
 gunmiata are also less painful, have Init one opening, and leave 
 excavated sores, in the bases of which are yellowish slouj.,dis like 
 wet wash-leather. The discharge is not distinctly purulent, imi 
 more like bloodstained gum, imless the sore IteccMues sej^tic. 
 
 'fhe Prognosis of a carbuncle iiainly depends upon the c(jnditi()P 
 of the internal organs. If the [patient is a confirmed sufferer Um\ 
 diabetes or albuminuria, there is always considerable risk of his 
 sinking from exhaustion. The vascularity of the parts also influ- 
 ences the result, as although there is more reparative power about 
 a vascular region like the face, yet the implication of large veins 
 may lead to endiolic pya'mia. 
 
 Treatment must always be of a tonic, supporting character. 
 Cu)od food, iron, (juinine, and alcohol according to judgment. 
 must be administered, whilst appropriate medicine (f.(S,^, codeia or 
 opium) and limitation of diet are necessary in diabetic patients. 
 Locally, many different forms of treatment have been suggested. 
 The most thorough and satisfactory is to lay the carbuncle freely 
 open under an ana'sthetic, and scrape with a sharp spoon or cut 
 away all sloughs until healthy tissue is reached, and then t' 
 tiioroughly disinfect the cavity with pure carbolic acid or pero.xiiie 
 of hydrogen (lo volumes). The hollow thus formed is stutW 
 with antiseptic dressings, such as gauze soaked in an iodotorni 
 
 emulsion (ic 
 .Vnotlier less 
 and allow thi 
 antiseptic poi 
 In the earl 
 in);,' tissues vv 
 orj^'anisms, an 
 of cases this ^ 
 the organisms 
 
 A Corn {d 
 
 i.iyer of the j 
 iiorny plug, w 
 J.\ing papilla", 
 surrounding p 
 this central p] 
 corn and a sim 
 Any abnormal 
 ,;'iantiiig that : 
 ulceraticju ; bui 
 chief cause is 
 bribed, viz., tli 
 The hard cor 
 of the metatars 
 'iist plialanges c 
 lo hannner-toe. 
 'l^irk, dry, cent 
 ^viien rain is thr 
 ;i corn, and the 
 I'^inng the corn 
 with salicylic ac 
 suhition of salic 
 plaster may sul . 
 to the boots, ant 
 where the toe is 
 A soft corn oc 
 '"'" t'f sweat t 
 fMreinely painfu 
 'i'ticle after the 
 !""v cleansed nii 
 
 ' The f(;l lowing,' i: 
 
 ^'K : ' '!"( 
 
SURGICAL DISEASES OF THE SKIN 
 
 32s 
 
 eimilsion (10 per cent.), find tlie case will then probably do well. 
 Another less radical proceeding,' is to make a free crucial incision, 
 and allow the slou^dis to separate naturally, assisting' matters by 
 antiseptic poultices. 
 
 In the early sta^'es, it lias been proposed to inject the surround- 
 inj,' tissues with pure carbolic acid in the hope of destroyiu},' the 
 iirfianisnis, and thus preventing suppuration. In a certain number 
 lit' cases this object will be successfully accomplished, but where 
 the or-^^'uiisms are at all \irul' nt, it will probably fail. 
 
 A Corn (iiaviis) is a localized outgrowth of the epidermic 
 layer of the skin, together with a central ingrowth of a hard, 
 •lornv plug, which compresses and causes atrophy of the under- 
 ivin^' papilhe, constituting a cup-shaped hollow, whilst the 
 >urruunding papilla; are hypertrophied. It is the presence of 
 this central plug that constitutes the difference between a true 
 corn and a simple callosity or diffuse o\ergrowth of the epidermis. 
 Am abnormal pressure is capable of producing either condition, 
 i,'ianting that it is not suffi -iently severe or intense to lead to 
 ulceration ; but it is rare to lind corns except on the feet, and the 
 chief cause is badly-fitting boots. Two kinds of corns are de- 
 scribed, \ i/.., the hard and the soft. 
 
 The hard corn usually occurs on the little toe, or over the head 
 lit the metatarsal bone of the great toe, or over the heads of the 
 liist phalanges of the other toes, especially if there is any tendency 
 it/ hammer-toe. They form nuMe or less conical swellings, with a 
 (lark, dry, central plug, and are often \ery painful, especially 
 wlien rain is threatening. Suppuration sometimes occurs beneath 
 icorn, and the pain then becomes a ute. Treatment consists in 
 paiin;,^ the corn down, after softening with h(jt water or treating 
 with salicylic acid plaster (10 or 20 per cent.), or painting with a 
 i^uliition of salicylic acid in collodion.* A circular ring of felt 
 plaster may subse(iuently be worn, but attention nnist be directed 
 to the boots, and the cause of the trouble remo\ed. Occasionally, 
 where the toe is deformed, it is necessary to perform amputation. 
 
 A soft corn occurs between the toes, and owing to the absorp- 
 tiiin of sweat the surftue looks white and sodden ; it is often 
 cNtienielv painfid. Treatment consists in remoxing the thickened 
 cuticle Jifter the use of salicylic acid. The parts are very care- 
 tullv cleansed night and morning, ard spirits of camphor painted 
 
 ' The following is a useful foruiula : 
 
 1^. Acidi salicylici, gr. xv. 
 ICxt. cannabis inch, gr. viii. 
 Sp. vini rect , iilxv. 
 .-ICtheris, iiixl. 
 Colloilion riexile, iiilxxv. 
 M. l''t pigni 
 Sig. ; ' To be painted on with a brush three times a day for 
 a week ' — K Crockkk. 
 
326 
 
 // MANUAL OF SURGERY 
 
 on at ni<4iit, whilst cotton-wool is worn I'.etwecn the toes (lurinL: 
 tile (lay. 
 
 Perforating Ulcer of the Foot forms on some part of the sole 
 and i)ro,L,nesses deeply so as to in\ol\e sooner or later the liniu> 
 and joints. It is usually due to two main factors, \iz., auirstlusi,' 
 of the soles, and more or less persistent imiiiiiatisiii, such as aiisi. 
 from \\earin<,f a tis^ht hoot or from the presence of a nail, wiiicli i> 
 not noticed owinj; to the concurrent anasthesia. It is tliercfoiv 
 likely to be met with; (i) In certain central nervous diseases, (.■,,. 
 tabes dorsalis, syrinj^omyelia, spina bihda, etc.; (2) in diseases such 
 as diahetes, syphilis, alcoholism, etc., which lead to peripheral 
 neuritis ; and (3) as a setpience of traumatic lesions of the ner\es 
 affecting;' an\- portion of their course from the spinal cord ddwn 
 wards. Thus, a short time hack one of us amputated a loi 1 
 which was painful and deformed as tlie result of a healed pd 
 foratin^ idcer which had inxohed hones and joints, and was ilwr 
 to a se\ere lesion of the lower lumhar rej^ion, invoKinj; tlic 
 Cauda etpiina, recei\ed thirty years pre\ iously. (4) PerforatiiiL; 
 idcer is occasionally due to pure plantar lesions, apart from ;ui\ 
 ner\()us iiilluence, r./r., a suppuratinj;' wart or corn, or even a 
 chionic epitlielioma. The skin under the lieatl of the first metatai>al 
 is tlie part most fre(]uently affected, hut any spot to which iindiir 
 pressure is directed may iiecome in\oKed, and not unconmionlv 
 sexeral such sores may he seen on the same foot. A corn or 
 callosity first forms, and under this a hursa, in whicli su})purati(.ii 
 takes place, the pus tendin,L,^ to tra\el not only to the surl'acL, hvA 
 also decpl}', so as to inxohe hones and joints. A typical per- 
 ibratin^' ulcer presents the ai")pearance of a sinus passini; dowii 
 to the deeper parts of the foot, the (Milice of which is surruuiidtd 
 by heai;ed-up and thickened cuticle. There is usually hut littK- 
 discharge and often no pain. If allowed to proiLfress without 
 treatment, the hones and joints of the foot may he extensively 
 destroyed, or may he welded together into a solid jxiinl'ul nias;-. 
 in either case necessitatinj; amputation ; hut if taken in liaiu! 
 early, a cure can in some cases he estahlislied hy carefully parin- 
 awa\' the thickened mass of cuticle, purifying the sinus, and pn 
 tecting the parts from pressure. 
 
 .\ Wart [vcnuca) is a pajiillary o\ergrowth of the skin, wiiidi 
 may manifest itself in many different appearances. The connm i; 
 wart is a lujrny projection about the size of a split pea, usually 
 seen on the hands of young people; its surface may he sniootli 
 or irregidarly (ilif(.)rm, and its colour \aries with the amount o 
 dirt ingrained on the surface. When smooth-topped, they ait 
 sometimes e.\tremely niunerous, and niav he a little difficult to 
 distinguish from lichen planus. In parts where there is a certanir 
 amount of moisture warts heccme soft in character, and luiiai 
 
 h\r<i,c vasculai 
 The best nietl 
 i^jacial acetic ; 
 alter softening 
 Verruca Nee 
 
 Tuberculous . 
 
 •lupus ■ is usu; 
 (it the' skin, v( 
 chronic intlain 
 results in repl 
 cicatricial tissi 
 shall deal with 
 acknowledged c: 
 It is met will 
 ..Iter the age of 
 usually starting 
 hut fairly frequi 
 iiieinhiane of tl 
 cases the disease 
 syninirtrical. e.\( 
 Clinical Featu 
 in the lormaticjii 
 layers of the skii 
 and iniiltration. 
 touch, hut wlicr 
 hrownish -yellow 
 ^lass slide, appe; 
 Gradually the pi 
 special direction, 
 "^ame time the ir 
 into granulation ( 
 epithelium, and ( 
 !""liilcs, or to a 
 tlie vessels bv the 
 wy liable u] foil, 
 i"itre<]uently tak( 
 'anatomical wart 
 '""ft''m porters. 
 
 A Lupoid Ulcer 
 ''leotiirr. and hci 
 crescentic in sha| 
 ''y various causes 
 '"tt-'n of a protubc 
 "■'ited, and scattei 
 "tending into the 
 tested. A consid, 
 •ins hy drying forn 
 
SURGICAL DISEASES OF THE SKIN 
 
 227 
 
 \i\riic vascular masses, c./j^., venereal warts (Chapter XXXIX.). 
 Tlie best nietliotl ot treatin}^^ ordinary warts is to paint tlu-in with 
 cdacial acetic acid, (jr scjnie other caustic, e\ery two or three days, 
 after softeninj^ and reinovinj^ the horny crust with salicylic acid. 
 Verruca Necrogenica (see ]i. 169). 
 
 Tuberculous Affections of the Skin. — Lupus. — Although the term 
 •lupus' is usually and correctly applied to a tuberculous affection 
 (li the skin, yet it is also sometimes employed to indicate any 
 chnjuic intlammation of the skin which tends to spread, and 
 results in replacement ot" the cutaneous structures by hbro- 
 (icatricial tissue with or without ulceration. In this place we 
 shall deal with the ordinary Lupus Vulgaris, which is universally 
 ;icknii\vledj,fed at the present day to be of tuberculous origin. 
 
 It is met will) in children and younj^ adults, rarely commencing 
 citlci" the age of thirty. Its most conunon situation is the face, 
 usuallv starting on the nose or clieek. It is rare on the scalji, 
 Imt fairly freciuent on the trunk and extremities. 'J'he mucous 
 iiienihrane of the nose and mouth is also attacked, but in such 
 cases the; disease usually spreads to it from the skin. It is rarely 
 ^-viiiiiictrical, except when connnencing on the nose. 
 
 Clinical Features. — The earliest manifestation of lupus consists 
 in the iormation of one or more shot-like notlules in the deeper 
 lavers of the; skin, which are siu'rounded by a zone of hypera.'mia 
 and infiltration. These nodules are not particularl\' hard to the 
 touch, but when of any size can be demonstrated to be of a 
 liiownish-yellow tint, especially if they are compressed bv a 
 :;'lass slide, appearing then somewhat of the c(jlour of ai)ple jelly. 
 Gradually the process extends, and usually more rai)idly in one 
 special direction, following the course of the \essels. At the 
 same time the integmnent becomes infiltrated and transtV)rmed 
 into "granulation or cicatricial tissue, co\'ered by a layer or two of 
 epithelium, and owing either to degeneration of the tuberculous 
 nodules, or to a lack of vitality, arising from compression of 
 the vessels by the contraction of this new formation, ulceration is 
 verv liable to follow. In the extremities the lupoid growth not 
 unfrequeiitly takes on a warty aspect, somewhat similar to the 
 'anatomical wart ' occasionally seen on the knuckles of post- 
 mortem porters. 
 
 A Lupoid Ulcer usually spreads at one margin as it heals at 
 tlie other, and hence under typical circumstances is more or less 
 crescentic in shape, although this is fretiuently interfered with 
 liy various causes. The surface is covered with granulations, 
 "tten of a protuberant nature. The edges are raised and infil- 
 trated, and scattered lupoid tubercles are readily distinguishable, 
 (.■\tendiiig into the healthy tissues, which are usually red and con- 
 sisted. A considerable amount of sero-pus is often secreted, and 
 ibis by drying forms thick scabs. Any cicatrix which results from 
 
328 
 
 A MANUAL OF SURGERY 
 
 natviral processes of inire is tliin aiul \ascular, easily bri'iikini,' 
 down from any slif^dit irritation. The process extends p^raduailv, 
 with or W'ithout intermissions, from the seat of its first app^'araiic'e. 
 bein},', as a rule, distinctly Hmited to the cutaneous tissues; hut 
 when it attacks the nose, the cartilaj:;es are often invoKed and 
 destroyed, whilst if it extends to the palate or septum nasi, 
 perforation is \ery likely to ensue. The disease is i)racti(allv 
 painless, and does not at lu'st allect the <;eneral health. Ni.ii,'h- 
 bourin}^' lymphatic j^dands may become inllamed, and in sonic leu- 
 instances are the seat of a tuberculous deposit. Even if left td 
 itself, it tends sooner or later to come to an end, the ulcerated 
 parts cicatrizinj^f, but lea\in}^ indelible traces of its ravages in the 
 shape of ob\ious scars, with often considerable loss of substance. 
 Occasionally it persists, in spite of treatment, and then an 
 epithelioma may in time de\elop on the site of the miscliiei', 
 running a rapid course owing to the \ascularity of the part. 
 
 Pathological Anatomy. — ^The characteristic microscopical feature 
 of lupus lies in the formation of nodules around the smaller vessels 
 of the skin, consisting chieHy of a mass of round cells, within 
 which may perhaps be oiiserved a giant cell and epithelioid c(ll>, 
 arranged in the same way as in tubercle. The structures around 
 are inliltrated and hypera-mic, and as the disease progresses, ihe 
 original tissue of the part disappears, and is replaced by {granula- 
 tion or iibro-cicatricial tissue. The bacilli are by no iiuiub 
 readily found, and are always few in number (Fig. 87). 
 
 The Diagnosis oi lupus from syphilitic anil other dest.uctivc 
 affections of the skin turns on the presence of outlying nodules 
 beyond the spreading edge of the lesion, togetht!r with tlu' apple- 
 jelly-like granulations, and the thir., congested cluuacter of anv 
 cicatricial tissue present, whilst the slow, though continuous, 
 progress, and the tendency to heal at one part as it spreads at 
 another, are also suggeslix e of its presence. The age and con- 
 stitution of the individual, and the persistence of the disease in 
 spite of treatment, must also be taken into account. 
 
 The Treatment of lupus is often a matter of consideraMe 
 difficulty. Theoretically, it consists in the free removal of all 
 the diseased tissue, either by the knife, sharp spoon, or causties. 
 \Vhere\er possible, excision of the whole mass should he per- 
 formed, the wound being either closed by sutures, or rdlowed tn 
 heal by granulation, or co\ ered by skin-grafts. The last is the 
 best plan to adopt, if practicable, when dealing with the lace. 
 More commonly one has to depend on scraping and the use 0! 
 caustics. This nuist be undertaken with a free hand if the \vh.>le 
 disease is to be eradicated, since the growth extends beneath the; 
 layer of fibro-cicatricial tissue exposed by the spoon. Htiue 
 scraping should always be accompanied by the subse(pien' appli- 
 cation of caustics, <•.^^, solid nitrate of siher, a paste coinposidj 
 of chloride of zinc, pyrogallic acid (5 to 10 per cent.), or even| 
 
SURGICAL DISEASES OF THE SKIN 
 
 329 
 
 the actual cautery. The wound thus produced should be dressed 
 ,vith an ointment containin.Lj iodototni, and allowed to heal by 
 jiiniilalion. Outlying' nodules may be reiuo\ed with a sharp 
 iiipus-spoon, and the little ca\ ity formed in this way covered with 
 hloridc of zinc paste ; or they may be du<,f out with the shari)ened 
 riid i)f a match dipped in acid nitrate of mercury. Kecently 
 rMLJleiit results ha\e been obtained by exposing' lupus patients 
 :o concentrated electric- or sun-lif,dit from which the heat rays 
 avc been eliminated (I'insen lif^ht cure). Inflanuuatory pheno- 
 
 ina sii|)ervene, and tiie lupoid tissue disappears. 
 
 Lupus Erythematosus is a disease the nature of which is not yet 
 ...I'lbtactorily determined. The appearance of the affection is 
 hliiahly characteristic ; it is usually situated on the face, and in 
 
 ^^- 
 
 Ik,. 87— Si-KKADiNT, Margin of a Tatch of Lui-us. (Zieglicr. 
 
 : \ rmal epidermis ; h, normal coriiim uitli sweat gland (/) ; c, focus of 
 lupoid tissue; </, vascular nt)dule surrounded by diffuse cellular inliltra- 
 tion ; i, non-vascular nodule : /, strings of cells in course of lymphatics ; 
 .lupoid ulcer; A, prijliferating epithelium. 
 
 most typical cases symmetrical patches are formed over the 
 
 t of the nose and cheeks, correspondin},^ in appearance to a 
 
 berfly with outspread wind's. There is a considerable tendency 
 
 pit to invade the forehead, ears, and scalp, and it occasionally 
 
 purs on the trtmk, and may then be unilateral. It appears 
 
 fasniooth hypera-mic surface, covered with a braimy descjuama- 
 
 h; the scales consist of inspissated sebimi, and are continuous 
 
 pdeep ph'gs, which can be traced into the mouths of enlarj^ed 
 
 toceoiis follicles. As the disease spreads peripherally, the older 
 
 1 central portions are transformed into cicatricial tissue of a 
 
 fethin and white type, in marked contrast to the hyperamic 
 
 pition (;f the advancing margin. It is usually seen in adults, 
 
330 
 
 A MANUAL OF SURGERY 
 
 SUh 
 
 and more frcqiu-ntly in wonion than men. Prot,aess is e\- 
 CL'L'diii^l) sli)\v, and ulcciation unconnnon, except when tlii- earsi 
 or scalp are in\()l\('d ; in tiie latter rej,M()n tin; hair is often lust 
 Ivpilhcliotna lias also been known to follow this affection. 
 
 The Treatment consists in attention to thi; f,a'neral lualtll 
 tof^^ether with the Icx-al application of weak tarry and nuicnn,] 
 preparations. 
 
 The so-called Tuberculous Ulcers differ from the lujioid in tliul 
 fact that they al\\a\s result fiom tlu' bri'akin^^ down of a suli-f 
 cutaneous focus, and hence may l>e i-onnected with diseases uf] 
 
 Imi; SS " 'rcBKNCci.ocs ri.ci-.KATioN OK Lak(,i-: Intkstixi. X ]0 
 
 (ZlKlil.KK.) 
 
 i(, Mucosa ; /'. sulmuicosa; c, inner transverse mustiilar coat; il. luitcr long 
 tiulinal niiisi ular coat: c, serosa; /, tiil)eritiloiis locus in soiiiarv ;'l:in(l 
 ^', mucosa inlihrated with cells; //, tubi'rciiloiis ulcer; /(,, focus i it sniteJ 
 ing or tul)erculous abscess ; /, early tubercle, with giant cell in cciurq 
 /,, caseous tul)ercie. 
 
 bones, j(;ints, lymphatic <,dands, or simply of thi' conncdiv 
 tissues. A similar condition is foimd in connection with niiK'iii 
 mend)ianes, the tid)ercul()us foci staitiu}.,' in the suhniucosa. ;ii| 
 sid)se(piently iiurstin.y; throuffh the mucous membrane (Fi.u- 
 W'hatexer their location, tlu- ulcers are characterized by the s;iiij 
 features, \i/., an irre^ailar and rajf^'ed marf^nn with luuUiini 
 and couf^^ested ed},fes ; the base is formed by pul[)y ^nunuhitid 
 tissue containing caseous masses of tubercle (jj). 
 
 'J"he Treatment necessarily consists in the remo\al both nl tl 
 unhealthy and undermined skin, and of the tubercuhnis giaiiul 
 
 Inon tissue beneati 
 
 ;nti.sc[)tic, and thci 
 
 Other cutaneou.^ 
 
 vij scarce! \' \,r ni 
 
 Onychia is almost 
 |,![icr (irL;anisms of 
 ':.iil u!)(lt'r the semii 
 Onychia Purul 
 |aiia'tiiin of the mall 
 Iiiiich suppuration 
 jlixi>eiR'cl ; the indi\ i 
 loinlition usually st^ 
 }k semilunar fold ; 
 Hav he affected. \\ 
 the diseased poi 
 tissue. The p 
 Itriiiui^. The only li 
 ;;: tine scissors, po 
 ):!inn of the nail, ;i 
 rAiiitrati' of sihcr 
 lit doubt linse( 
 :!'!ilic loiion ( r in 
 iifthe ,L;cneral heal 
 .'.Onychia Malignr 
 iiiilinii int-t with il 
 Miilitie. The \\h, 
 ;>a', whilst the dii 
 !;t consists in a\ u 
 b of antiseptic font 
 Ingrowing Toenail 
 OUT the sid 
 bt toe), and due 
 pi: boots, or to 11 
 
 lis thus pres.sed 
 
 frpatient walks, an 
 
 pad thereby, he o 
 
 ■imt leaves a dee 
 
 "^ riceration en 
 
 -^"iiiiuli pain as 
 
 \''''\''\ the nail m.M 
 
 ■■^ earliest sta,i.^e 
 
 • '■'■'■till attention to 
 
 f-:< easily, and b' 
 
 [rrcss hack the o\ei 
 
 ily present, the 
 
SURGICAL DlSi:ASh:S OF Till-: SKIN 
 
 ii^ 
 
 II tissue bcni'ath it, the wound \)v\n<^ purified hy sonie stronj; 
 itj^fptic, and then dressed witii j,Muze coxered with iodoform. 
 ()tlu'r cutaneous manilestalions ol tubercle are recognized, but 
 ,j scarcely be mentioned hen-. 
 
 AflFections of the Nails. 
 
 Cnychia is almost always due to tlu' int'eclion with |iyof,n'nic or 
 
 -..(irnanisnis of the matrix, startint,^ at the side or base of the 
 
 .,,'n::nlcr till' semilunar fold. Two \arieties are described : 
 
 • Onychia Punilenta (Pcii-oiiyc/iia, oi Ungual Whitlow) is an 
 
 Ij^ctiiin of tlie matrix commonly Sf ii in sui',L;('ons and nurses, in 
 
 Ir.icli supjHiration occurs beneath thi- nail, which is theri'by 
 
 ,„iuil : tlie indi\idual attacked is {.generally out oi sorts. The 
 
 ■cordilicn usually starts on one side, and f^Madually extends round 
 
 ^tf semilunar fold and beneath the nail, until the whole matrix 
 
 [Uj\ lie affected. When the loosened nail is cut away, it is found 
 
 fc; the diseased portii n of the matrix is converted into j^'ranula- 
 
 joii tissue. The process is extremely painful and somewhat 
 
 lf(i,iinis. The oidy hope of checl<in,i; its pro-^ress lies in remo\ in^^ 
 
 t:i:; tine scissors, possibly under an ana'Sthetic, all the loosened 
 
 jKirtmn of the nail, and then touching' the exposed },n'anulations 
 
 irih nitrate of siher. whilst the most comfortint^ applications are 
 
 llmut tloubt linseed-meal jioultices, possibi)' made with hot 
 
 iMic lotion (i in 40), and he(iuently repeated. At the same 
 
 if tlic ueneial lit alth must be attended to. 
 
 ;, Onychia Maligna is the term applied toa somewhat sinilar 
 
 TAiitiiiii nut witli in badl\' nourished children, who are jierhaps 
 
 fphilitic. The whole matrix is transformed into },a'anulation 
 
 ;m, whilst tlu' di.uit becomes swollen and club-shapi-d. Ticat- 
 
 :.:i consists in a\ ulsion of tlu" nail hom its bed, and theappiica- 
 
 bot antiseptic fomentations or jioultices, to}.jether with iodoform. 
 
 Ingrowing Toenail is an ulcerative condition of the soft jiarts 
 
 fuiii; o\er the side of one of the toenails (usually that of the 
 
 beat toe), and due either to the pressure of pointed or badly- 
 
 !tiii;,' hoots, or to nei,dect in triniminj^f the nails. The fold of 
 
 t" is thus pressed bv the boot oxer and a^'ainsl tlie nail when 
 
 tpatienl walks, and in order to diminish tlu' pain and irritation 
 
 p»l thereby, he often cuts away the projectin<4 an,t,'le of the 
 
 pLluit leaves a deep corner w'hich still further irritates the soft 
 
 l>. Ulceration ensues, accompanied by an ofTensi\e dischar^fe 
 
 cjonnuh jxiin as to prevent the patient hdm walkin.i;. The 
 
 latnx e'f the nail may also become inflamed, and onychia result. 
 
 he earliest staj^a-s, further profjjress can often be pre\ented 
 
 fairoful attention to the nails, by the use of Sfjuare toed b.oots 
 
 ini; easily, and by introduciii}^ small pluj.js of aseptic wool 
 
 fprcss hack the (nerhan<,Mn}; fold of skin. When ulceration is 
 
 lly present, the best plan to adopt is the removal of the 
 
33» 
 
 A MANUAL or SUHGEIiY 
 
 afTfCtcd half of the nail under local or j^'fncral annr'stlu-sia. ;;ivi;ir 
 special attention to the extraction of tin- piojectinf,' an>;lf, |f 
 there is much clischar^'e, it is also wise to cut away tin- ovtrl 
 han^^'in;^' fold of skin with scissors, and sirape away any ur-'UHila 
 tions present. The parts are then dressed antisepticalK , aiul \A 
 a few days the patieni is able to walk about. 
 
 The term Onychogryphosis is applied to a hypertrophic ((ind:.| 
 tion of the nails, which beconu' distorted and bent, or twistnl uri 
 perha[)S simulating' a ram's horn. It is usually liiniteil Ut \\]A 
 ^'reat toes of elderly j)e()ple, and is due to nej^dect. The nails are! 
 very rou^di, and often coxered with }^M"oo\es or ridj^^es, wlnlstj 
 beneath them is an accumulation of soft, offensiNc ei)ithilim"] 
 The only treatment is remcnal. 
 
 AflFections of the Sebaceous Olands. 
 
 Sebaceous Cysts occur on any part of the surface of the liudyj 
 but esj)ecially the scalp, and are due to obsliuction of tlicdiutij 
 a sebaceous f^dand. I'liey are rounded swellin/^s, lirm and fl,isti(j 
 to tlu' tt)uch, mo\eable on the deeper structures, and alwavj 
 attached at one spot to the skin. On careful examination, tiij 
 t)bstructed mouth of a sebact-ous follicle can usually be sccii, and 
 possibly some of the contents of the sac S(piee/.ed tlnoii;,'!! m 
 (jpeninjf. The cyst wall is formed by several layers of ej)itlK'liuin 
 suiromuled by dense fibro-cicatricial tissue, and if expostd 
 irritation or pressure, as when situated on the back or slimiide^ 
 and rubbed by the braces, becomes \ery firudy adherent to tti 
 surrounding parts. The material contained within is of acluojj 
 pultaceous consistency, with a peculiar stale odour, yclldwiJ 
 white in colour, and under the microscope is seen to \)v conipobfl 
 of fatty and j,'ranular debris, epithelial cells, and cholesterinl 
 Sometimes a distinctly adenomatous element is [)resent, st: [\\i 
 the cyst walls are thick and hrm. Left to themselves, the tvsl 
 may attain considerable dimensions, the walls even hecoiniij 
 calcified. Occasionally the exudation oozes throuj^di the dud 
 and ilries on the surface, with just sufficient ct)hesion to [)R'\e| 
 it from fallinj; off; la}er after layer of this tlesiccated material 
 deposited from below, fmally j^iving rise to what is known as| 
 Sebaceous Horn. These become dark in colour frou) adiiiixtu 
 with dirt, and are always mo*e or less fibrillated in texture, whil 
 the base to which they are lirndy adherent is infiltrated and hvpd 
 aeniic. Sebaceous cysts sometimes inflame and suppurate. Whj 
 the skin has f^'iven way o\er them, the contents are only [lar 
 dischaif^a-d, and the remainder undergoes putrefacti\e ch;ui,i,'j 
 giving rise to an offensive ulcerated surface, which may read 
 l)e mistaken for epithelioma, and spreads rapidly. True mall 
 nant disease (jf an epitheliomatous nature is said soinetiniesj 
 supervene. 
 
SURGICAL DISEASES OF I HE SKIN 
 
 Hi 
 
 Diagnosis. From .'i dcrwoiti cyst it is known by th«! facts that 
 
 • 1^. lU'iiiiiiid is ronj^^cnital in ori},Mn, th.'it it is limited to ccrtJiin 
 
 ',Gilitii.'S, whilst it is liarcily cvi-r diifctly attaclu-d to the skin, r'rom 
 
 if(i//i tiiiiioiii' it is recojfnisi'd hy the absence of lobulation, and by 
 
 Miiorc solid character, whilst a lipoma is softer and more mo\e- 
 
 M,., iMom a chronic ahsccss it is distiiif^uished by the existence of 
 
 , liilaied orilice, by its firmer consistency, and l)y the history, 
 
 |i ; It IS sometimes impossible to be certain as to its nature before 
 
 iibini; it. 
 
 Treatment. — A sebaceous cyst should be entirely and completely 
 |feiiio\t(l if K'^''"K '"'^^ ^" ^"y incon\ enience or pain. In the scalp 
 that is needed is to transfix t!ie tumour, sipu^e/.e out the cheesy 
 |r iiU'iits, and then the cyst wall can be readily removed by 
 L,;isnini; it with dissectinj,' forceps and pulling' it away. In other 
 Isitiiatinns the cyst wall may re(|uire to be dissected out ; but e\en 
 ItSi; it is advisable to open it by transfixion, and to deal with, the 
 troiii below rather than fiom aboxe. Horns and funjfatin<( 
 ii'ifHrs should be excised with the surroundin<jj skin. 
 Molhiscum Contagiosum.- This affection shows itself in the 
 itm of a number of firm hemispherical nodules, a little larj^er 
 Mil a Sj>lit pea, usually of a yellosvish-whit(! colour, and \ery 
 littinitelv umbilicated. The depression in the centre may be 
 mipieci by dry debris, and from the lar<;i'r ones a waxy mass 
 Da\ be expressed. They arc usually seen on the face, but may 
 involve any part of the surface of the body. There seems no 
 bubt as to their contaj^nous properties, this bein.^j j)erhaps best 
 Itffl in the de\elopment of j^^'owths of this nature on a mother's 
 delist, secondary to those on the face of her baby. The cause 
 [the contagion is by no means certain, whilst the exact nature 
 |it;he affection is also more or less in dispute, since, aithoiij^h 
 pe authorities consider it sebaceous in (n'ijfin, others are efpially 
 Wtent that it commences in the hair fol'icles or ileep layers of 
 ^erete. Fatholo<:fically, the tumours consist of numennis wedge- 
 jiapeil Idbules of polyj^'onal, nucleated, epithelial cells, supported 
 lyatihrous stroma. The cells towards the centre under^^o a 
 m or hyaline dej^^eneration, and in them are seen numerous 
 bailed bodies, which ha\e been supposed to resemble psoro- 
 Miiis. Treatment consists in cuttinj.,' or pullinj,' them away, or 
 anting them across, and scjueezing the contents out from the 
 kfildetined capsule. 
 
CHAPTICR \1\'. 
 
 AFFECTIONS OF MUSCLES, TENDONS, AND BURS^. 
 
 Injuries of Muscles and Tendons. 
 
 Contusion. —Muscles arc hruiseil as a ii-sull of blows uv fall>. j 
 iradiii;;- to more or less oxtraxasatioii, with possibly some ruptan- 
 of the libres. The part becomes tender and swoPen, aiul a!i< 
 acti\( e(tntraction },M\eH rise to pain ; passi\c in()\eiiient, howLnt-r. 
 is tolerati'd, if the injured libres aie not thereb)' put on the strctrh, 
 I'onu ntations and rest may be needed tor a lew days; luit trictiun. 
 witli stinndatin.s,^ embrocations and liniments, and rej^nilar nias^a^v 
 ol" tin- parts, are subseipieniiy necessary. 
 
 Sprains and Strains, due to violent efforts or falls, result in t;itj 
 tearin.L; or stretehiii;^' of some of tlu' id)res. Considerable siilfiif; 
 follows, especiall\ in rheumatic and j^'outy patients. Rest and! 
 either hot or cold apjilications may lu; used at Inst ; but iVictin'.ij 
 with liniments and passive movements will bi; needed later. Inj 
 indi\iduals jMedisposed t') the development of tuberculous discaM.', 
 special precautions must be taken to ensure comi)lete re( n\iiv. 
 
 Rupture of the Sheath of a nmscle is an accitlent occasiniialiyl 
 met with, especially in ! . biceps cubiti or rectus feinoiis. Thi;| 
 belly of the muscle, when contracted, protrudes throu;,di the openi 
 in<; as a hernia, constitutinj,' a soft semi-tluctuatinj^' swrlliui,'. ln| 
 treatin*^ this condition the lind) must be kept at rest in siul 
 positi(jn as to relax the nuiscular libres and allow the rent in the 
 fascia to heal. In old-standin;,^ cases it is justifiable to cut cliiwnj 
 and expose the (>penin,L,f in the nmscular sheath, the eiij,'es d! '\\iiic!il| 
 are sutured toi^ctiier. 
 
 Displacement of Tendons rarely occius, excej)t in parts \vhcr<| 
 these structures pass throuf^h osseo-fibrous canals, and particular!) 
 in those where the line of action is therebv ( hant^ed. Prii im,'si)iiiej 
 violent effort the i)-ttient feels a sudden localized pain, full owi'illifl 
 a certain amount of limitation of mobilit)-. This accident is pnpiij 
 larl)' known as a ' rick.' In superficial parts the displaci'd tendtif 
 can sometimes be distinctly felt in an abnormal positii.n, ami th 
 becomes more e\ iilent on attempting to mo\e it. Thus the lod 
 
 
AFFECTIONS OF MUSCLES, TENDONS, AND BURSM 335 
 
 ana I 
 
 •ti<i',:| 
 
 i 
 
 SCilH'.l 
 
 V. 
 
 )jX'!>l 
 
 (HI 
 
 which 
 
 when 
 ■ular!; 
 < soiiii 
 
 'a \i 
 
 pupil' 
 
 er.i 
 
 ti'. 
 
 U'lulon of the biceps may be dislocated from the bicipital j^aoove ; 
 ;,,id various tendons about the wrist or luiklc, especially that 
 I the i^eroneus l(jn<,ais, may similarly suifer. If left alone, the 
 ..(Its settle down more or less comfortably, but some permanent 
 \\eakness may persist ; whilst recurrence is \ery likely to ensue 
 . niiAcment is permitted before the newly-formed connections 
 ■i\c had tin)e to consolidate. 
 
 Treatment consists in fully relaxing,' the nuiscles an<l replacin*,' 
 ihe tcMulon, if possible, by manipulation. The parts are tlien 
 ■•.Diohilized and well siip|)orted, as by a plaster of Paris splint or 
 -u.ippiii;,', and this should be maintained for six or ei,L,dit weeks. 
 It tiie displacement recurs, as is connnonly the case where such 
 tieatmenl has not been adoi)ted, it is sometimes ad\ isable to cnt 
 (iuwn, exjiose the tendon, and stitch il biuk into position, usinj^ 
 farlv passi\e movement to prexent tiie forniai! )n of troublesome 
 adht'sions. This is recpiired most fri'(]uem!y in tin; case of 
 the peroncus lonj^us tendon, which slips forwards from its Ljrooxe 
 iitrhiiul the external malleolus. The external annular litjament is 
 theifhv ruptured, and the operation consists either in suturinj^ 
 thi' ciividecl se.ijments, or in more a,L;",i;ra\ ated cases it may be 
 ntcessary to turn down a ilap of perii)steuni from the malleolus 
 and l)V stitchin^j^ its apex to the outer side tjf the os calcis secure 
 the tfiuloii in place. 
 
 Rupture of Muscles and Tendons is by no means an uncoiumon 
 iuxidcnt, ii'sullin,L,f from any iv\cessi\e \ iolence of a sudden and 
 unexpecti'd nature. Ahjst fretjuently the tendon f,n\-es \\a\ at its 
 iiinioii with the muscular belly; K'ss often the belh' itself yields, 
 whilst occasionally the tendon may sua)), or the point of bone to 
 which it is attached may be torn off. 
 Signs. The patient at the moment of the accident experiences 
 -Harp and se\ere pain, as if he liatl been "struck with a whiji; he 
 lii.av also feel or hear a snap. Loss of function follows, tOL;ether 
 uitli a certain amount of ^:wellin^f ani! bniisinji^, which is mort- 
 jevidt'iit if the muscular !;b. 'S ha\e been torn across than if tlu' 
 ttiidon has alone been lacerated. On altemptiui.' to contract the 
 alifcted muscle, the l^eiiy rises up as a soft, I'uuuled. semi- 
 liKtualiii}; tumour, drawn towai'ds the uninjiued a'.achment, if 
 liif union b(>tween tlu> t(>ndon and belh' has nivcn w..v; whilst if 
 Ithf lesion has been throuj^h the nuis( alar substance, .'",■ di\ided 
 alvL'sof the belly become similarly prominent, and a disinu t ;;ap 
 pr>ul(iis can be felt between them. 
 
 Repair is established in the usual way alri'ady described (p. lyr), 
 li/!.. a {(llido-plastic efl'usion is first poured out, takin;,; the place 
 )! the hlood-ciot, which is absorbed: this becomes vascularized 
 tit k'ramilation tissue, and fin.div cicatricial tissue is ilexcloped. 
 "hi'iua nuiscular belly is iiuoKed ,uid tlu' ends much sej)araled, 
 H!,' and weak l)ond of union i\ likeby to form; but when they 
 »rt closed y apposed, the cicatrix may be a short one, and may 
 
336 
 
 A MANUAL OF SURGERY 
 
 sooner or later l>e replaceil by true imiscular tissue. When a 
 tc'ndon has been dixicleii or torn, the c:oiniectin<,' niecUum is ;it 
 first attaclied to the sheath, and if tliis atlliesion persists, it mav 
 lead to much pain antl wi'akness. It is an e.\ceechni,d\- imprest. 
 in.L( tact to note iiow rapidl\' this tissue attains a loiisidcralile 
 ih';^ree ot strenijth ; a rabi)it's tendon ten days after tii\isi,,ii 
 rcMjuii-es a wei^'ht of 5r) lbs. to break it (I'ajjfet). 
 
 Treatment. — It is essential to relax the parts fully so as tin 
 prevent sejiaration of the diviiled ends, and to maintain them in 
 this position for two or thrive wi-eks. .Vny residLin;; stiffiiis^ i^ 
 
 cond)ated by passi\e movements and mas. 
 san'e, whilst, if need be, adhesions arel 
 broken down under an anaesthetic. Tenddiisl 
 actitlentally di\ idetl in open wounds should! 
 be sutured toj,a'ther by catgut, spt'cial ami 
 septic i)recautions beinj^j adopted to picvcntl 
 suppuration alon>,^ the temlon shratiisJ 
 Where there has been actual loss of suhj 
 stance in a tendon, it is possible to remnl' 
 the defect by i,M"aftinj,^ a jiortion of tendon 
 from another patient, or from an aninialj 
 between the two ends; or, a^ain. ont' ind 
 may be split lonj^itudinally in such a wav :J 
 to leave a thin flap attached perijihcralU, 
 that the free end ((f) can be turned down .tiid 
 united to thi' other se<,Mnent (Fif.^. S((). W Ik'^ 
 nuiscular bcliii-s ha\e been divided, ii 
 not dilHcult to secuic tluMU, if the librcs havl 
 been severed loni,otudinally or obli(iU('l\ ; liu 
 Imo S() Mi:tiioi> ni. when the si'ction is transverse, tlierc i> 
 
 f^reat tendenc\' for the stitches to cut dul 
 In such a case it is advisable to enciioj 
 with a lij^ature a bundle of muscular fil)r( 
 on eitlu-r side of the incision, and then 
 the two threads to^^ctiier. This must _ 
 done at several spots in the cross-section, and the musculai (.iid 
 can tluis be safely approximated. 
 
 The loiiu; iciidon of the biceps is not unfnvpietitly torn from tl 
 musiular belly, which, on attemptini,^ to bend the arm, is diav 
 ilown tow.irds the elbow, constitutiufj^ a soft tumour, soinew.. 
 reseniblinj.: a lipoma. No special treatment is needed hfym 
 keepinj; the forearm flexed for a time. If the tcndo Arlnllis 
 ruptured, union may be attained bv keepinj; the knee bent ; 
 the heel raised, a*^ by securing; a stra[) to the i)ack ot a slip, 
 below, and to a dof,'-collar passed round the knee above. A lut 
 result, however, woidd follow an aseptic incision and sutu 
 Similarly, if the ii^aiiinitinii ptUe/Lr j,Mves way, suture tlnou,i,'h 
 open wound is more satisfactory than mere elevation ot tlu' 
 
 S() Mi:tiioI) oi. 
 
 rNiriM. I IXDON 
 
 A !•■ r \:K I - o S S () 1- 
 
 'I'lsscK r,v Tlknim. 
 Down a I'oRTioN or 
 
 IT AS A Im.AP. 
 
AFFECTIONS OF MUSCLES, TENDONS AND BURS.E 337 
 
 ^iiul list; hut no such open methods must W\ ;uloptetl unless the 
 surj;e<)ii is (]uite conlidcnt in hi- abihty to maintain al>sohito 
 ,isepsi>.. The inney luad of the f^astioinemiiis is sometimes torn in 
 urenclies or shps, as at lawn tenni>, and the plantai'is is similarly 
 aPected. T\\v addiutoi lon^us may be lacerated in violent attempts 
 :> maintain a seat on horseback, and constitute ■ one form of 
 ridi is' sprain : it is treateil by rest and llie application of a linn 
 jp ii bandajfe. 
 
 Diseases of Muscles. 
 
 Inflammation of Muscles (Myositis) may arise hom a \ariety ot 
 
 (ircumslances, but the chiet results are alike, \vhate\er tlu; cause, 
 
 ,iz., a more or less painful inhltration of the muscle, with in- 
 
 reased discomfort on altt iiiptinjf movement. The part feels 
 
 :,,iril and rif^id, and ma\- be tender to the tuich. If suppura- 
 
 ;.tn ensues, the ordinary sij^Mis of an abscess subscMpicnlly make 
 
 ;;tiiisel\es e\ ident. A certain amount of contractile tissue is 
 
 iht'P'hy destroyed, and tlu' cicatricial chanj^es induced will 
 
 :h>ssi1)1\ lead t(; di'formity. 
 
 Variet'.<?s. — i. Simple Traumatic Myositis results from contusion 
 
 r laceration of tiie libres, and is merely a jjlastic inllammation, 
 
 with or without ha'iuorrhajjje, runnin.i,^ on to resolution, with 
 
 .dhaps a little fibroid thick(!nin;,f of the part. It is liable in some 
 
 ■■ to become chronii', the imisile substance becomin<,f shorli'iied 
 
 i placed by tibrous tissue {M . jihivsd). The induration of the 
 
 riioniastoid muscle met with in c hiklren is of this type. In 
 
 :lk'r cases ossilication of a limited portion of the muscle 01 
 
 -ndoii may occur from lonf^-continued aiul frecpieiitly-repeated 
 
 ntatioii ; thus, in riders the upper portion of the adductor 
 
 I cnilons may in this way become bony, constituting,' the so-called 
 
 riders' bone.' 
 
 :. Rheumatic Myositis usuaby results hom exposure to cold, 
 
 ..,\vi\ neck hom sitting; in a drauj^lit. It is treated by lopienta- 
 
 |;:ons, and ordinarx' saline anti-rheumatic remedies, whilst later 
 
 onlri'tidn with stimulatiiiij embrocations is needed. 
 
 3. Acute Suppurative Myositis is the outcome of infection with 
 
 i^tnic orj^anisms, either from without, as after operation 
 
 amis, punctures, j^un-shot injuries, f^fanj^rene, etc.. the pus in 
 
 skIi (Tist's spreadini,' wiilelv up and down tlu' muscular plani-s ; 
 
 |::tniiii within the bod\, as in pva'inia ; or by extension from 
 
 JMiilihoiirinf.; suppuiatixc foci, as from sub-periostcal abscesses; 
 
 |::nia\ also arise after a contusion or sprain by auto-infection. 
 
 Great (iratricial deformity is likely to follow. 
 
 f Chronic Tuberculous Myositis, with the formation of a chronic 
 
 >sct'ss, is not an uncommon si-coiulary consivpience of a similar 
 
 fetion of neii^ddxmrin^ bones or joints — r.^'.. a psoas abscess. 
 
 3. Syphilitic Disease is usually met with in the tertiary perio'l, 
 
 cd takes the form either of a dilVuse sclerosis or of a localized 
 
 22 
 
.138 
 
 A MANUAL OF SUHGERY 
 
 AFFECTI 
 
 ^umiiia. Any muscle may he aflectecl, but perhaps the toni^'iu 
 and sterno-mastoid are those most fretpiently insoKed. Care i< 
 ■ leeded in niakin<f a dia^mosis, since these conditions rc^ciiiMf 
 tumours in their method of onset ; but the presi-nce ot" a sxphilitji 
 history, the slow f/rowth, the iiardness witii suhse(]uent central 
 softenin^^ and the rapid disapjH-arance alter the administration of 
 iodide ot potassium, should sullice Vo determine their nature. 
 
 h. Parasitic Myositis, arisinj^' from the presence of eitiur tlu 
 rriililiid spirtilis or of hydatiils, need not be described here. 
 
 7. Myositis OFsiflcans is a \ery rare disease, (tf wliich I nil little 
 is known beyond the fact that \arious nuiscles, especially tlms;- 
 of the back, are transformed into bony plates or rods, which mav 
 lead to e\tensi\(' ankylosis. The process seems to be one of dssi- 
 lication of the conneclixe tissue associated with atroplu of th- 
 muscular ld)res, and is sometimes extremely painful. It is ukiv! 
 commonly seen in younp mali's, and is possibly rheiuuatic in 
 origin. In a bo\ recently undi'r observation the arms Wfa- 
 inuuobili/.ed by ossification of the Lalissinuis dcjrsi nuiscles on 
 either side, whilst the Pectoralis major was also ossified on tin- 
 v'v^ht side. The ICrector spina' was inxoK'cd, the back beinif thus 
 rendered ri}^id, and the rifj^ht I'rapezius was under'^oin^^ the sanu- 
 ihau}^a'. The proci-ss in this case had been ipiite painK-ss. No 
 treatment has proved of any value. 
 
 Tumours of Muscles are not very common, rrimaiy i,'rovvth> 
 consist of angioma, fibroma, chondroma, myxoma, or -.arcoiiia, 
 and of tiu'Si' the majority start in the fibrous sheaiiis >'.\ thej 
 inter -fdirillar comiective tissue. Secondary ileposits of Ixith 
 carcinoma and sarcoma occur, but there is nothin}^ spec ial u< W-\ 
 noted about them. 
 
 Treatment must be determined on ordinary surj,d( al princij^lis.! 
 If sarcomatous, the whole thickness of the muscle slioiild. ifl 
 possible, be excised for some distance' from the j,M<)Wth,the sheathj 
 forminf,' a natural limit not early ovei stepped. Amputation of 
 the limb max, however, be required. 
 
 Diseases of Sheaths of Tendons. 
 
 The synovial membranes which, line the sheaths oi leiulnna 
 may become inflamed as a result of injury or infection. 
 
 1. Acute Simple Teno- Synovitis often follows sprains and 
 strains, and is most (ommonlv seen in connection with tlifl 
 extensor muscles of the thumb. A puffy swi'lliuf^; in the ( oiirsi ol 
 the tendons is produced, j)ainful on movemeiU and perhaps tt iicief 
 to the touch, j,'iv in^' a characteristic- fme crejiitiis w henev cr lln' [)ail 
 are movc;d. All that is needed lor its Treatment is to imniohili/i 
 the limb for a few days, and apply fomentations. As soon as ilij 
 more acute symptoms have disappeared, friction with stiiinilaiinf 
 
 tiiil'/rocations a 
 ! the fluid : wl 
 ;i|"''\<'"t tile f 
 .'. Acute Sup 
 :iire(] wound ol 
 vpread to it fro 
 •iliitlow (p. i;o) 
 up and clown tl 
 -litiitional symp 
 iriujon will slo 
 :iti,i,'hliourin<^r p.^ 
 .iinction follows, 
 irticiilations, lea 
 !•;'' <if the tcndoi 
 ,v Chronic Sim] 
 :rii/ed by a pas 
 -irovia, soiiicwha 
 ■'lited in extent, 
 '^l^i^f- An flast 
 >iiiliin, usually a 
 Milcrness, but th 
 "'onnter-irritatio 
 N the part may 
 fstrecl he, the ea\ it 
 w suffice to puiK 
 K'liitents, pressure 
 4' Chronic Tube] 
 p tlu- slieath is 
 hme tliiekness, eoi 
 Imic swelling,' ; 
 •iuwiy in size, aiu 
 J"'" niay follow, 
 jfreatment < onsists 
 |?"U'iIient of the 
 phlished, a fVee 
 pile removed. 
 '■'f "ther fori,, 
 ">i"n into the sy 
 "Ills tliickened' 
 r tlu- same time tli( 
 p'inl mvloii-sct'd Iwd 
 p'liapscontainin;,' tr 
 pcroi-s thev ^Mve 
 l>pitus. 'I'liat they 
 F'H I'ViiioculatioV 
 •^'•"'■•t'e not, how.. 
 ' Treatment by ii 
 ■"'" "' Scotfs ch 
 
AFFECTIONS OF MUSCLES, TENDONS, AND BUIiS.'E 339 
 
 .nl'.riirations .'ind pressure ari- employed to hasten the absorption 
 ,,i the thiid : whilst acti\e and passi\ e luoxeiacnts are vuiderlaken 
 , I prevent the formation of adhesions. 
 
 .'. Acute Suppurative Teno-Synovitis may result from a punc- 
 
 MiL'd wound of the syno\ ial sheath, or the innaiuniation mav 
 
 -plead to it from neij^dd touring; tissues. The thecal variety of 
 
 whitlow (p. 170) is of this nature. Suppuration may extend both 
 
 ;; and down the sheath, and ijives rise to both local and con- 
 
 <iUitional symptoms. I'nless promptly treated by incision, the 
 
 :tnclon will slouf^di, or may contract extensive adhesions to 
 
 ;itii;lihourinf,' parts; in either case considerable im[)airment of 
 
 uK'tion follows. The suppuration m;iy extend to nei^hbourin<i[ 
 
 irticulalions, leadinj; to their disor^'anization, especiall)' in the 
 
 ise of the tendon sheaths around the wrist-joint. 
 
 ^ Chronic Simple Teno Synovitis is a common affection, charac- 
 
 •ii/cd by a passive elhision iiUo the tendon sheath of j^lairy 
 
 -vrovia, somewhat resend)ling uncooked white of e<,'f^^ It may be 
 
 iiitcd in extent, constituting,' one of the varieties of ^'anj^'lion, or 
 
 i.lfuse. An elastic lUictuatint,' swelling' forms in the course of a 
 
 ■didun, usually associated with creakinj^. There is no i)ain or 
 
 ;eiultrness, but the affected part feels weak. Treatment consists 
 
 oiinter-irritation and pressure, as by Scott's dressing; failing 
 
 ^, the part may be freely im ised, the synovia removed, and, if 
 
 lr.cc(l he, the cav ity washed t)ut. In the more localized forms it 
 
 pia\ suffice to puncture the cyst-like swelling and sijueeze out the 
 
 ntfiils, pressure beint; sid)sci piiiitlv applied. 
 
 4. Chronic Tuberculous Teno Synovitis is of two types. In 
 
 iHf the sheath is lined by (edematous granulation tissue of 
 
 Inime thickness, containing tuberculous foci, giving rise to a soft 
 
 lactic swelling along the course of a tendon, which increases 
 
 -uly ill size, and is but slightly painhd or tender. Suppura- 
 
 iMii Miuy follow, and subjacent bones or joints be involved. 
 
 iTreatment (onsists in immobilizing the part, pressure, and iiu- 
 
 .: .(iiitnt of the general health. If a cure is not ipiickly 
 
 |'5!;il»lished, a free incision should bv made and the diseased 
 
 >-iie removed. 
 
 T!ie other form of tuberculous disease consists in a passive 
 |t!iusion into the synovial space, the lining membiane of which 
 lines thickened by the dejiosit thereon of fibrinous material. 
 the same time there is usually a large development of the so- 
 il uuloii-sct'd IhhUcs, which are laminated masses of hbrin, 
 i.ipNc ontaining traces of tuberculous giant-cell systems. When 
 ;;iier()i's they give rise to a curious and characteristic form of 
 i>itus. That thev are of a tubeiculous nature c;in be demoii- 
 Mlfd by inoculation (-xperiments ; the spores ux bacilli contained 
 [>rein are not, however, in a very active state. 
 (Treatment by innnobili/ation .ciu pressure (as by the appli- 
 ■'iii of Scott's dressing) fails, the part should be laid open, 
 
 22 — 2 
 
340 
 
 A MANUAL OF SURG Eli Y 
 
 ;iii(l the cniisfd I'lbiin and nu-loii-seed hodit's rt-movril, lo.i^cilict 
 witli as imuh of the lhi( ktucd nicnd)raiu' as possil)le. 
 
 A Ganglion is the term j^mvcii to a localized ryst-like swi'IIjum 
 forniin},^ in c oiiiuTtion with a tendon sheath. It is most connnoiiK 
 met with at the hack of the wrist, arisinj^ from the tendons of ih",. 
 thmnl) of iiu!e\(inL'''r, hut it sometimes orriirs on the front of the 
 wiist or in the foot. It \aries in sixe considerahly, and conta-iis 
 a clear, transparent ,t,a'latinous or colloid substance, like wliitc. 
 currant jelly. A rounded fnin elastic swellin^^ is jiroduced, usiiaii\ 
 somewhat moNcahle. and neither painful nor tender at tirst. 
 althou.uh some painful weakness of the part may be experieiiciHl 
 as it increases in size. It is due to one of se\eral causes : thus, 
 it max result frf)in a chronic localizi'd teno-synov itis, or from 
 a hernial piotrusion of the s\no\ iai mendnani' ihrouj^h an opcniiii; 
 in the tendon sheath. Otiiers seem to ori^nnate in a colloid df- 
 f,'eneration of the cells linin;^ the syno\ ial space; whilst certaiiiK 
 some few arise in connection with subjacent articulations, in thf 
 same way as a Maker's cyst. Little difriculty arises in the 
 diaj^Miosis. althoujj^h, when situated ileeply and lyiii;; over a liiiiic. 
 llie\' ha\i' been mistaken fot exostoses. 
 
 Treatment. — A ^ant^iion may often be rupturetl by manipulaiim; 
 and pressuic with the thumbs, or by a forcible blow with a I'liok, 
 but it is apt to fdl ai,Min. I-'aiiiuf^ this, ;i rapid cure is n-^ualh 
 obtained b\' an ase])tic puncture of the cavity, and tlu" subsi(|ucm 
 application of firm pressure. In souk- cases it may be a(l\i>al)lc 
 to lav the pait open and remo\ e the cyst wall; such ticaliiitiii 
 re(]uires absoluti- asepsis, since, if infection occurs, most serimiv 
 conse(|uences ma\- ensue. 
 
 A Compound Palmar Ganglion consists in a tubeiculous aflcctiuii 
 of the common synoxial membrane sinroundin'; the flexor tendoib 
 of the wrist, the ca\it\' beini; distended with svno\ia, usiiallv 
 containiuf;' many melon-seed bodies. It forms a lar;;e swelling; 
 extendinj,,^ above and below the wrist, fluctuation beinf,^ rcatlilv 
 transmitted from one part to the other beneath the aiiniilai 
 lij^ament ; it also extends anh)nj;sl the muscles of the lluiiar 
 eminence alon^^ the tendon of the flexor lonj^us pollicis. In ihc 
 treatment rest and pressure, as by Scott's dressiiif^s toj,'ether witli 
 suitable constitutional remedies, mav first be tried ; and tailing.' 
 this, an incision shocdd i)e made both above and below the 
 annular lit,^mient, tlu' cavity beinj^ well washed out, and all 
 melon-seed bodies and fibrinous debris removed with a sharp 
 spoon ; a drainajL^e-tube is subse(]ueutly inserted. In a few i ases 
 it may be necessary to divide tlu' amiidar li},,^ament in onler ti^ 
 efficiently deal with the trouble. The results, however, aiv mt 
 very t,'ood, as the tendons j^'et matted tojLjether and adhcinil U 
 the skin, and the movement of the liiif^ers is thereby haniperal. 
 
 ■ ipi'd or subciit 
 >()me deformitv 
 'Uraenu to rec 
 ilitis. the tendc 
 .vi,' in Older to 
 l'i\ ision of t 
 utancous or o 
 ;i^f of where 
 .-imctures. Tli 
 liic character < 
 ahscnce of diaii 
 'i!;'ai)isms, if i. 
 ^viiovial tendon 
 i"'i septic in (Ian 
 iii'i .i,'i\e rise to 
 "'i^ists in in.ser 
 iiiwn to the tenc 
 Aiiife p.-i.ssed aloi 
 i'tiieath (he tend 
 tile tendon dividt 
 :-i!iictiue is put c 
 I'f entertained a 
 "I liflow the ten 
 I'M! tliere is no 
 ■'"■sKin, and th, 
 ^-iictures if (he 
 '.ind. if the k„,|, 
 -iiiii subjacent si 
 '' 'i matter of c, 
 ■''>"'i".k' impoitai 
 n tiMotoniv of 
 I method, lii this 
 
AFFECTIONS OF MUSCLES, TEX DONS, AND DURS.E ,541 
 
 Operations on Tendons. 
 
 ;, 1 ly Tenotomy is ine;iiu the dixisioii of ;i leiulon llirou^h an 
 ,,ptn or suhcutiincous wuuiul with tlic oi)j(.Ht cither uf leineclyiii}^ 
 -oint' (lefonnity, such as tahpes or torticollis, or of assistin<f the 
 viiifieon to reduce some displacement, as in settiuf^f a fracture; 
 iliiis, the tendo Achillis may re(|uire division in fractures of the 
 \X in order to overcome nuiscular contraction. 
 
 i)i\ision of tendons is accomplished in two ways, viz., by sul)- 
 ulaiu'ous or open incision. 'The subcutaneous method is made 
 :k' of where there is little hUelihood of injuiin;,' important 
 .inictures. The strictest attention to asepsis is desirable, since 
 the ciiaracter of tlie wound, \i/.., a puncture, and the cnitire 
 iiliscnce of drainaj^e, are most faxourable to the (le\'elopnu>nt of 
 ,ip,'iinisms, if entrance is once ijiven to them. Moreo\er, the 
 <vii()vial tendon sheath is often, thouj^h undesif^nedly, wounded, 
 ,i!id septic inllannnatioii woukl rapidly spread aloiiLj this structure, 
 ,111(1 Ki\e rise to the most serious ct)nse(piences. The ()peratit)n 
 Miiisists in insertin},,^ a sharp-pointed tenotome throu^di the skin 
 
 wii lo till' tendon. This is then wit'ulrawn, and a blunt-pointed 
 ■ iiile j)asse(l alonj,^ the tiack thus maile, either superficial to or 
 i.t;iieath the ti'iidon. 'J'he cutlinj^^ edf^e is turned towaids it, antl 
 ;l.i tendon divided by a sawin<; or rockin.tj mo\ement, whilst the 
 -liiiclure is put on the stretch by an assistant. N'arious ()|)inions 
 ,iiv ciilertained as to whether it is better to pass the knife al)o\e 
 u\ lic'luw the tendon ; the acKantaj^es of the former nu^thod are 
 that there is no likelihood of makinij an uiululy lari^i- wound in 
 ihfskin, and that there is less risk of ilixidiiii; the Icix subjacent 
 -liiictines if the knife is tinned towaids them. On thi' other 
 laiul. if the knife is at once |iassed below the tendon, and any 
 >iiiii subjacent structures ari' by mistake includ(!il, their di\ision 
 
 - a matter of certaintx'. Where, however, there is any risk of 
 M'vulin^ important structures, such as the external popliteal ner\e 
 :n tiiiutomy of the biceps cruris, it is wiser to ailopt the open 
 method. In this an incision about i inch in len^^tb is made o\-er 
 :;: uuclon, wliich can thereb\' be e\[)oseil, lifted on an aneurism 
 nmlle, and severed without dauLji-r. IMieie is no ha-morrhaj^e 
 |Hi)rl!i nienti(.)nin}.j, and the wound is closed by a point 01 two of 
 
 aUiie, dressed antisepticallv. and lirmh' banda^'cd to prevent 
 Itxlravusation. The malposition is at once (oiiecied, and the 
 l;iin iinmobili/.ed at the time, or in the course of forty -eij,; lit hours, 
 
 in plaster of Paris. 
 hnotoiiiy of the 1 eiido AiliH/is. — The foot is placed on its outer 
 
 >iik'. and the tendon relaxed by pointinj; the toes downwards. 
 
 Hit tc'i,.)tonie is introducx-d about 1 inch al)o\e its insertion 
 
 li;;. 7J, [•') at liie inner marj^^dn of the tendon, eitliei sui)erru-ial 
 1 lifiieath it, and it is readiK divided when the foot is dorsi- 
 
34^ 
 
 A MANUAL OF SURGERY 
 
 flexed. If tho surr^^'on cuts towards the skin, he inust he ( arcful 
 not to di\ide the last tew lihfes too rapidly, otiierwise a con 
 sidcralile external wound may he indicted by the sudtlciiK 
 liberated knife. We certaiidy preft^r to di\ide the tendon fron, 
 without inwards. 
 
 The 'iibialis Antiius is usually divided about i inch above \\^ 
 insertion, as it crosses the s<aplioiil (Fi^' 75. C). There is heir 
 no synovial sheath, and the arteria dorsalis pedis is separated 
 from it by the tendon of tiie extensor proprius hallucis. it is 
 first relaxed so as to allow of the introduction from the outer side 
 of the sharp tenotome beneath it ; this is then replaceil hv a 
 blunt-pointed instrument, and the seilion is readily acconiplis'lie ! 
 wiien tin; foot is abductetl. The open method may hv. adopttd ii; 
 sonu! cases. 
 
 The Tihialis Posticus is usually divided to{,'ether with the Hcxui 
 lon}j[us di^atorum just above the base of the iiiuei !llallc()iu^, at a 
 spot about a finj^'er's breadth from the tip of that process in an 
 infant, and about i\ inches from it in an adult (Fi{^'. 73, IC). A 
 small tubercle can usually i)e felt at this spot, and the sectinn 
 nuisl be made just above. The knife is inserted verticallv 
 between the tibia and the tendon, and is kept as near tlic Imn, 
 as possible. If correctlv placed, it remains fixed without tlu 
 support of the hand, beinj,' ^aasped betwi-eii the tendon aiul tin 
 bone. The blunt-pointed tenotome is then introduced, and thi' 
 ed{,^e beiiifj^ turned towards the tendon, the latter structure is 
 di\ ided when the foot is dorsillexed. The posterior tibial vessel^ 
 may be wounded if the tendons are too suddeidy severed, hut 
 even should this occur, a little well-adjusted pressure will suifia 
 to prevent any serious consecpiences. 
 
 The Peronei tendons are divided just above the base of the ouit' 
 malleolus, at a spot where the syno\ial sheath is usually ahsen; 
 ( b'ig. 74, 1)). The tenotome is inserted close to the fihiila. 
 between the tendons and the bone, 
 
 The Hiicps Cruris tendon is best di\ided by an open operation, 
 on account of the close propin(|uity of the external popliten' 
 nerve, which has often been wounded in the subciitaneou- 
 operation. An incision is made in the direction of the tiiuinn 
 just above its insertion into the (ibula. It is then lifted upon an 
 aneurism needle and divided; nuiscular libies will probably bi 
 iound (]uite close to its lower end. 
 
 The Sfmiiiumbnitwsus and the Scmitemiimsus tendons are dcah 
 with just above the knee-joint, and the subcutaneous operation 
 may be conveniently adopted when they are proiuinent and tcns>. 
 
 b'or division of the Sterno-mastoid, see C'hapter W . 
 
 2. Lengthening a Tendon is sometimes, thouf,di rarely, re(|iiire(l. 
 in order to overcome the deformity which results from a con 
 tracted tendon. It may be possible to utilize the method su^ 
 j,,'ested on p. 336 for the union of a tendon where there has heeii 
 
AFFFXTIOSS OF Ml'SCLFS, TENDONS, AND liURS.'E 343 
 
 loss of substance, \iz., by bridf^inj:? the interval by a flap turned 
 down from one end. Perhaps a more efficient method is the 
 so-callcd Z op'-ration ( I'ij^'. \)o). The tendon is spHt \o\v^\- 
 tadiii.dly into two halves {he), which are separated one from the 
 other by cross cuts made on opposite sides, one at each end {ah 
 and (■(/). The two flaps are tlien drawn ajiart for a distance 
 corresponding,' to tiie increase in len^'th recpiired, and sutured 
 together ; the resulting bond of union will be as represented in 
 1%. >,i. 
 J. Shortening a Tendon is undertaken in some forms of paralytic 
 
 ff 
 
 ■HP 
 
 I'K 
 
 90 
 
 l'"i(; fji 
 
 Fk; fj2. 
 
 lli.S <)0, IJI AM) (JJ. -Ol'KKATION KOK I -i:\( .TIIEMNl . OK SHORTENINO OK 
 
 Tendons. 
 
 In l"ig ()i) tl\e nu'llioii of (li\ iditi); the tendon is shown In I'iy. (ji tlie flaps 
 are slipped downwards, one on tlie otlier, so as to len|,'then the tendon. 
 Ill i-if,' (j2 e(|uai portions have l)een cut away from each half, and the 
 remainders sntured, so as to shorten it. 
 
 talipes. The Z method may also be employed here, the two 
 halves, after they have been separated, being shortened to the 
 required amoimt, and then stitched together (l"Mg. 92). This 
 iiptralion will probably give a more solid bond of imion than the 
 Minpler proceedings in which either a transverse or an obliiiue 
 section is removed, and the ends sutured together ; in such the 
 sutures are nuich more likely to cut out. 
 
 4. Tenoplasty, or the incorporation of a strong tendon into a 
 we.ikti one in (jrtlcr to strengthen it, is rarely imdertaken except 
 ill talipes, and more particularly in order to reinforce a weak 
 ■'endo Aciiiilis in paralytic talipes ecjuinus, by joining to it a strong 
 and healthy percMieus longus. In order to make an etlectiNe bond 
 
344 
 
 A MANUAL or SURGERY 
 
 ot imioti, the licuilliy iciulon imisi \)v tlirciulctl tliroii^'h the we.ik 
 arul iitrophic one, and lixed hy sutures in several plaies. 
 
 .U'FRCIIO} 
 
 Diseases of Bursae. 
 
 Bursaj exist as normal structures in many parts of the Imdv 
 exposed to pressure, their ol)je( t hein^' to cUminisli iVictinn aiul 
 permit of a j^didinj^f iiioNemmi. Similai casilies, Unown ;is 
 ahnorm.d or Adventitious Bursa}, are developt'd in re^doiis wlitn 
 exceptional pressure is hrouj^iit to bear on some pioiniiunt 
 structure ; tlu-v consist of a Idirous wall lined by a smjiis 
 mend)ianc, ((jutain a small (|uantity of serum, and iuc f'lnnt'd 
 either by dilatation o' lymphatic spaces, or as a rtsuit dt ,i 
 localized cflusion into the tissues. I'lxamples of this arc met 
 with in men followin;^' special occupations: c.^'., o\cr the vcitclua 
 promincns of Co\ent Ciardi-n porleis, and then known as a 
 •hmnmy'; r>iliin;,fsffale lish-carriers occasionally lia\e luirs,i 
 under the centre ot the scalp; and deal runners often prcM iit 
 one on the uppei part of the shoulder. They occur omm hom 
 prominences arising' Irom malformation or displacement, c .;,'., ovd 
 the cuboid, in talipes cquino-varus ; oxer the internal coiidylcs nf 
 the femora, in bad cases of '^vuu \al.i,uun; whilst the laisc joiiil 
 or pseudarthrosis which occurs in unreduced dislocations oi 
 imunited fractures is practically of this naluie. 
 
 Wounds of burs;r may be caused b\ penetratinj^' injuries, c: 
 somclnncs by the skin o\er them splitliiiLj, as, c.^., in a iail m; 
 the |)oint of the olecranon. The escape of bursal thiid wliid 
 residts often prexents healinj^\ and then it will be necessary citlu'i 
 to excise the bursa, or to ojjen it freely so that it can be stiillni 
 and made to },Mamdate from the bottom. 
 
 The followiiif.; are the morbid conditions which arise in ad 
 veiititious as well as normal bursa: 
 
 1. Acute Simple Bursitis max result from a non-pcm iratiiiL: 
 injury, or liom piolouLtcil irritation, espe( iaIK in ^outv or liu'u- 
 matic indi\ idnals. Thi' part bec-omes swolleii, painful, and tciidci, 
 and if superlicial the skin over it may be hyperainic. iJliisiuii 
 into the caxity (|uickly occurs, the fluid beinj,' spontancoiislx 
 coaj^'ulable in the early sta.tjes, and, if resultinj,^ from iramnatiMi!, 
 mixed with blood. Lvmph is deposited on the serous sin lace, 
 and in many cases results in the formation of adhesions, ami 
 possibly obliteration of the cavity. Treatment consists in keeping' 
 the part at rest, and applyin;,' fomentations, wlnlst suitable con- 
 stitutional remedies are ailministered. If the elhision persists, 
 aspiration, or remoxal with trocar and cannula under strict 
 .isepsis, may be em[)loyed, or e\en the whole cavity excised. 
 
 2. Acute Suppurative Bursitis arises from infection oc( urriiiL; 
 either from without or within; it not uncommonly tolldws.ij 
 subcutaneous injury of a chronicilly inllamed bursa, leading,' tol 
 
Arri'lCtlONS OF muscles, tendons, and niJRS.'E J45 
 
 ;> distension with Mood. All the phenomena, local and constitii- 
 
 oniii, usually associated with the foiniation of a supct licial or 
 
 ,;tp altsci'ss arc piestiil. The pus, toinicd at first witliin the 
 
 >i:si, may tra\el dirt't lly to the surface, or hurstin;; liirou}^ii the 
 
 ipsuit', is diffustul tiiroufj^h the tissues. Where this occurs, the 
 
 unuicristic Icaturcs suf^'j^^estinj,' a bursal oiij^'iii of the ahscess 
 
 i,i\ be mask(;(l. Tluis, in suppuration of the bursa pati-iia', the 
 
 jsoftrii tinds its way to the lateral aspects of the liinli, allowinj^ 
 
 ...patella to he distinctly felt thr()u<^di the skin ; the case is then 
 
 I .ilijf to I )(■ mistaken for suppuration within the knee-joint, hom 
 
 hdiicli, li<)we\cr, it is easily (listin^;ui.shed l»y the alisence of the 
 
 "loreiKUte arthritic symptoms. Implication of suhjacent hones 
 
 ,-j juiiils sometimes occurs ; tinis, the |>alella or olet ranoii may 
 
 n line carious, or necrose. The Treatment of suppurative bursitis 
 
 |::vilves itself into an early free incision, and drainage. 
 
 ;. Chronic Bursitis with Effnsiofl is, perhaps, the most connnon 
 |Vi;:iiil();;ical (oiulilion met with in comiection with burs.e. The 
 :.i\U\ hecomes distended with a seious effusion of varyinj^ 
 liTui'.nt, ui\i"f.( 'i^f to a fhictuatinif tumour, 'ilie walls iliffer in 
 Ir/kiu'ss according' to circumstances ; if the condition is one of 
 ?.; staiuliu},', or if tVeipient recuricnces have been present, the 
 :;ni1 wall is usualK' reticulated and dense, and adhesions or 
 jjkouscords are often produced. Suba« uie exacerbations are fre- 
 :itly ,i(rafled on the more chronic variety. Treatment (<in- 
 L;>iiiresl and counti-r-irrilation, as by blisleiini; or ioiline paint, 
 iraiftliis fails, the bursa should be dissected out. Special care has 
 |t-il't' taken in dealing,' with bursa- comunniicatinj^ with joints, such 
 !;i;it under the semimend)ranosus tendon ; the tumour should 
 iMiicopcned into, if possible, but its neck nuisl be isolated, an<l its 
 l:"iiiu!nication with the joint shut off bv a catL^ut or silk lij^'ature. 
 Chronic Fibroid Bursitis. In this variety the walls of the 
 |..:m Income c hroiiically thickened, as a result of proloiii^'ed irrita 
 p.andalso probably fr(jm the effect of syphilis. There is but 
 petViision; conseipiently a hard fibroid tumour is met with in 
 prieijioii of the binsa, and in the centre of this is a small ca\ itv. 
 only Treatment is lompleie removal. 
 
 Chronic Tuberculous Bursitis occurs either in the form of 
 i;:iirin()iis ileposit on the inner wall, toj,'ethe|- with effusion and 
 \^ presence of melon-seeil bodii-s ; or the lininj; membrane 
 truoes a chanj^'e analoj^ous to that described as pulpy de- 
 lation of a joint, and perhaps leailin}; to the formation of a 
 prnic abscess. ICither condition mav be secondaiv to a tuber- 
 tiou^ ailhnlis, or may i^wv. rise to it, when the bursa com- 
 plicates with a joint. If total removal is nupracticabk-, the 
 atment consists in layin;; the part freely opi-n, scra[iin^' away 
 "li'L'iculous tissue, and sluffinj,' the cavity with <;au/e impref,'- 
 fitfil witli iodoform. 
 Syphilitic Changes may also occur in burs;r, in the shape 
 
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 (716) 872-4503 
 
 
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345 
 
 A MANUAL OF SURGERY 
 
 either of a symmetrical bursitis in the early stages, or later on as 
 a gummatous peri-synovial development. 
 
 Occasionally Gouty Deposits are observed in the walls of bursa 
 constituting tophi, the irritation of which may predispose to 
 abscess formation, pus mixed with urate of soda crystals l^einfj 
 discharged. The bursa over the olecranon is said to lie mosi 
 frefjuently affected in this way. 
 
 Special Bursse. 
 
 The bursa patella (Fig. 93), which lies over the lower half of the, 
 bone and not over its centre, is exceedingly liable to injury and 
 
 ^^^B^^ -M 
 
 :. : ] 
 
 W 1 
 
 
 •V ■■■*•■'.■, 
 
 
 n 
 
 
 wPf ' 
 
 Fig. 93. — Enlarged Bursa Patell.e. (From a Photograph, 
 
 inflammation from its exposed situation, and especially in tho^ 
 who kneel much, giving rise to the condition known as ' housi 
 maid's knee.' Any of the above-mentioned varieties of Imrsitj 
 may be met with, and their signs are so evident that it is unnece 
 sary to again mention them in detail. The relation of the burJ 
 to the patella explains the fact that acute suppuration sometimj 
 gives rise to caries or superficial necrosis of that bone, whilj 
 chronic and subacute inflammations may lead to thickenin^^ 
 the bone from osteoplastic periostitis. 
 
 Tlie bursa beneath the ligamentum patella', between it and the 
 of the tibia, when distended with fluid, gives rise to a fluctuatij 
 swelling felt on either side of the tendon, more especially wl 
 the limb is extended ; when the leg is flexed, the swellij 
 diminishes. Chronic enlargement of this bursa may cause 
 ligamenta alaria to be pushed backwards into the joint, so til 
 they are nipped between the bones whenever the patient attemj 
 to stand with the leg extended ; the pain thereby induced is son 
 
 AFFECTIi 
 
 tthat similar to 
 
 in a loose forei^ 
 
 i a'straight leg, a 
 
 cient, however, 1 
 
 The bursa' in tl 
 
 I retween the in: 
 
 [ meinbranosus, le 
 
 iiited on its o 
 
 I wards the inne. 
 
 [according to the 
 
 dmsion and flact 
 
 J articular bursas. 
 
 pulsation is occn 
 
 expansile, in cha 
 
 ■liiinicates with ti 
 
 lireatment ; it sh 
 
 Icoiiimunication \ 
 
 liuture. 
 
 The bursa beneat, 
 Isometiiiies inflam 
 [periostitis of the si 
 
 The bursa benea 
 Iktuating swellir 
 liiiuilating disease 
 le posterior aspec 
 f the pressure of I 
 
 Distension of th 
 
 ' swelling whic 
 
 ber side of Scarp 
 
 Vthe thigh, and tb 
 
 lit disease or of a 
 
 liiis bursa often coi 
 
 J The bursa over the 
 
 ftion known as ' w 
 
 .. 'ind is ofte: 
 Wd be removed. 
 [Enlargement of tl 
 ' l^nown as ' nii 
 
 l'-^ not uncommon, 
 |e elbow-joint is hx 
 Ulie large niuJti.U 
 
 feids to proniin 
 Hder. (For dia 
 
 ; Chapter XIX.) 
 
 ' fails, the cavity 
 
AFFECTIONS OF MUSCLES, TENDONS, AND BURS/E 347 
 
 jviiat similar to that caused by a displaced semilunar cartilaj^e, or 
 l,v a loose foreif^n body in the joint. The inability to stand witli 
 a'straight lej^, and the presence of the enlarged bursa, are suffi- 
 cient, however, to guide the surgeon to a correct diagnosis. 
 
 ]'h( bursiT in the popliteal space are often enlarged, especially that 
 
 jetween the inner head of the gastrocnemius and the semi- 
 
 i nieinbranosus, leading to a rounded fluctuating swelling, sharply 
 
 iiiiiited on its outer aspect, and more fixed and less defined 
 
 towards the inner. The sensation imparted to the fingers varies 
 
 according to the position of the limb, the swelling being tense in 
 
 atnision iiiid flaccid in flexion, as occurs in most of these peri- 
 
 larticular burss. Owing to the proximity of the popliteal vessels, 
 
 Iriilsation is occasionally detected ; but it is only heaving, not 
 
 [expansile, in character. The fact that the bursa usually com- 
 
 jnranicates with the joint necessitates considerable caution in its 
 
 lirtatment ; it should l)e removed by a careful dissection, the 
 
 [communication with the joint being closed by ligature or 
 
 liuture. 
 
 The huvsa beneath the insertion of the semitendinosus and gracilis is 
 Isometinies inflamed, and is very liable to cause osteoplastic 
 [periostitis of the subjacent inner surface of the tibia. 
 
 The bursa beneath the tendo Achillis, if enlarged, presents a 
 [fluctuating swelling on either side of that structure, somewhat 
 Isiinulating disease of the ankle-joint, but necessarily limited to 
 |t!ie posterior aspect of the joint. The enlargement is usually dvie 
 jthe pressure of badly-fitting boots. 
 
 Distension of the bursa beneath the psoas tendon gives rise to a 
 iiid swelling which usually projects anteriorly, presenting on the 
 jnnerside of Scarpa's triangle! If painful, it necessitates flexion 
 (the thigh, and thus leads to symptoms resembling those of hip- 
 joint disease or of a psoas abscess. It must not be forgotten that 
 jtiis bursa often communicates with the joint. 
 ,T\\e bursa over the tuber ischii, if inflamed, gi\'es rise to the con- 
 litioii known aa ' weavers' bottom ' ; it causes great discomfort in 
 (itting, and is often solid and symmetrical. If troublesome, it 
 
 lid he removed. 
 [Enlargement of the bursa over the olecranon constitutes the condi- 
 p known as ' miners' or students' elbow ' ; suppuration within 
 jisnot unconmion, leading to necrosis of the underlying bone; 
 p elbow-joint is but rarely affected. 
 
 iThe large nuUtilocular subdeltoid bursa is occasionally enlarged; 
 
 leads to prominence of the deltoid, and expansion of the 
 
 pilder. (For diagnosis from effusion into the shoulder-joint 
 
 Chapter XIX.) Where treatment by counter-irritation and 
 
 : fails, the cavity should be incised and drained. 
 
CHAPTER XV. 
 
 DEFORMITIES. 
 
 Torticollis. 
 
 Torticollis, or wry-neck, is a defonnity produced hy a contrac- 
 tion of tlie sterno-mastoid muscle, the trapezius and deep tasci; 
 being also freciuently affected, and occasionally the short muse! 
 
 at the l)ack of th( 
 
 neck. It is characi 
 terized hy theaffectec 
 side of the head beiiif 
 drawn down towardS 
 the shoulder, whili 
 the face is turne( 
 towards the souni 
 side, as shown ii 
 Fig. 94. When thij 
 has lasted for som| 
 time, especially 
 congenital cases ai 
 those conimencin;,' 
 childhood, the al 
 fected side of tl 
 head and face H 
 comes atrophic, 
 measurement froi 
 the external canthi 
 to the angle of tl 
 mouth is smaller, tl 
 eyebrow is lei 
 arched, the nose 
 fiected, and the cht 
 less full than on t| 
 sound side. No v 
 
 Fig. 94. — Torticollis. 
 
 he ri<,'ht sterno-mastoid is contracted, and tlie corre- 
 sponding half of the face atrophic. 
 
 satisfactory explanation of these phenomena is forthcoming, 
 they are probably due to imperfect vascular supply. T| 
 
 I cervical spine b 
 hfected side, an 
 jin the dorsal rep 
 Ion a level. 
 
 The Causes a 
 yhws : 
 I. Conr;cnital I 
 ion in utero, or 
 jjervous lesion. 
 
 Muscular tor 
 linastoid, apart frc 
 latter intramuscul 
 Mm the congen 
 [due to laceration 
 juith as a tempoi 
 |ijvo?itis, or stiff- r 
 3. Torticollis a 
 jpanlysis. Spasun 
 Itrom the direct ii 
 liiitiamed cervical 
 jte!le.\ irritation, 
 li;i;>chief: and (c) f 
 jliiis latter variety 
 |!!e posterior must 
 most frequently, tf 
 Jearsofage, and tl 
 ph as epilepsy, 
 jlivays iinfavourab 
 ^v appropriate op 
 bcDiiie affected 
 plysis of one mi 
 pother side, or fi 
 f Hysteria is alsi 
 •^lost commonly 
 |e clavicular ha 
 ptricial cases the 
 [scess of fibrous ti 
 pst entirely a 
 F he well de\elo 
 ^na always becoti 
 [tlie deformity has 
 [milady affected, 
 Falso be indue 
 Nest towards th 
 pile Diagnosis of 
 Nounded with ci 
 (Juiving burns, or 
 an acute deep -5 
 
 
DEFORMITIES 
 
 349 
 
 Itervical spine becomes laterally curved, with its concavity to the 
 
 ,i^ectecl side, and a secondary compensatory cur\e is also present 
 
 -[he dorsal region, so as to maintain the eyes as far as possible 
 
 ;:n;ilevel. 
 
 The Causes and Varieties of torticollis may be classified as 
 
 ;:!lows : 
 
 i, Coi!,<^'ciiital torticollis, the result of malformation or malposi- 
 •jon in utero, or of some intra-uterine muscular contraction or 
 Ijervoiis lesion. 
 
 :, Mnsciilar torticollis, due to intrinsic contraction of the sterno- 
 [na^toid, apart from nervous influences, as in cicatricial shortening 
 lalter intramuscular abscess or gumma. In children it is said to 
 |;Mlo\v the congenital induration of the muscle so often seen, and 
 [cue to laceration during birth, whilst it is not unfrecjuently met 
 luiih as a temporary deformity resulting from cold (rheumatic 
 lir.vositis, or stiff-neck). 
 
 ']. Torticollis arising from nervous causes, including spasm and 
 Ipanlysis. Spasmodic torticollis (tonic or clonic) may result (a) 
 the direct irritation of the nerve trunk or its roots, as by 
 jinllamed cervical glands or cervical caries ; (h) possibly from 
 jietiex irritation, as by carious teeth, and worms or ovarian 
 [unschief: and (c) from irritation of the deep or cortical centres. 
 iTiiis latter variety is usually of the clonic type, and often involves 
 re posterior muscles as well as the sterno-mastoid. It occurs 
 \m frequently, though not exclusively, in women of about thirty 
 jjearsof age, and there is often a family history of nervous diseases, 
 pifh as epilepsy, etc. The prognosis in these cases is almost 
 ilivay^ unfavourable, since, even if the localized spasm is cured 
 v appropriate operative treatment, other parts are likely to 
 MDine affected. Panilytic torticollis arises either from infantile 
 jaralysis of one muscle, leading to unbalanced action of that i,n 
 mother side, or from some peripheral nerve lesion. 
 f Hysteria is also responsible for a certain number of cases. 
 Most commonly the sternal portion is mainly affected, whilst 
 Ise davicular half may be quite relaxed. In congenital and 
 Ibtricial cases the muscle stands out as a hard tense band, an 
 |\cess of fibrous tissue being present, or the muscular substance 
 most entirely absent ; but in spasmodic cases the muscle 
 [.ay he well de\eloped and not specially prominent. The deep 
 Kia always becomes secondarily contracted and shortened, and 
 [the deformity has lasted long the posterior cervical muscles are 
 pilady affected, whilst changes in the shape of the vertebra.^ 
 [ay also be induced, the bodies becoming wedge-shaped and 
 lickest towards the con\-exity of the curve. 
 
 I The Diagnosis of torticollis is readily made. It must not be 
 
 pnlounded with cicatricial contraction of the skin of the neck 
 
 wing burns, or the attitude temporarily assumed by a patient 
 
 1 an acute deep-seated abscess of the neck, or with tuberculous 
 
350 
 
 A MANUAL OF SURGERY 
 
 caries of the spine associated with hiteral deviation. The ri<fi(litv| 
 of tlie neck in the latter case, together with the pain caused li'vl 
 mo\ement of or pressure over tlie xertebrae, should suffice to inakel 
 the diagnosis clear. Rheumatic contraction of the deeper li";i.[ 
 nients and muscles of the cer\ ical spine (rheumatic spoiulylitislj 
 may also be mistaken for torticollis, but it comes on lapidly, andl 
 is associated with tenderness on deep pressure. The fact that inl 
 tonic cases the muscle is evidently contracted, and stands out asl 
 a tense band in the neck, is sufficiently cliaracteristic. Spasmodicl 
 torticollis, again, cannot well be mistaken for any other condition I 
 but it may be difficult to distinguish its cause or to localizf the 
 affected muscles. 
 
 The Treatment of torticollis necessarily varies with the cause] 
 and thus either anti-phlogistic, anti-neurotic, anti-rheuiiiatic, ori 
 anti-syphilitic remedies may be required. When, however, it ij 
 due to congenital or tonic contraction of the muscle or its tendon] 
 massage and manipulation may be first tried, or even some foim 
 of mechanical apparatus ; but in the majority of cases tenotomv 
 or myotomy will give a more satisfactory result, and is much les^ 
 tedious and troublesome. 
 
 Two methods of dividing the sterno-mastoid have been ein| 
 ployed : (i) The suhciitaneous operation is a somewhat undesirab 
 proceeding, on account of the important structures placed 
 immediately beneath it. There is but little danger or difiicultj 
 in dealing with the sternal head, a tenotome being p 
 down to it beneath the skin, and the incision made from befor^ 
 backwards ; the tension to which it is exposed suffices to draw- 
 well forwards out of harm's way. In dealing with the clavicula 
 portion, it has been recommended to introduce a sharp-, andafteij 
 wards a blunt-pointed, tenotome beneath the muscle, and thej 
 divide it from v/ithin outwards, whilst others suggest that a directo 
 should first be passed beneath it, and then the muscle dividecj 
 (2) The open method is far preferable to any of these plans,; 
 thereby all danger is obviated. The skin is freely incised acrosi 
 the muscle, its anterior and posterior borders defined, anj 
 its fibres carefully and fully divided. No attempt should 
 made to deal with the portion of deep cervical fascia whicl 
 passes beneath it and securely covers in the important undea 
 lying structures. Any part of the lower half of the nniscff 
 may be selected, but the best spot is about h inch above th 
 clavicle. The position of the head is then rectified, and fixed 
 plaster of Paris or some other suitable apparatus. A sinip| 
 and satisfactory arrangement consists of a padded leather stia 
 passed round the forehead and occiput, and another undj 
 the axillae. A chain or elastic band is secured to the forehei 
 strap abo\e the mastoid process of the side which is not afTecte| 
 and traction made by fixing it to the front of the lower belt 
 the opposite side of the body. Thus, if the left sterno-mastoid I 
 
DEFORMITIES 
 
 351 
 
 Icontracted and has been divided, the chain is attached over the 
 
 -ffht mastoid process above, and below o\er the front of the left 
 
 laxill'i) tracti(>n being thus made in the direction of the right or 
 
 weakened sterno-niastoid muscle. Where, however, osseous 
 
 Ranges are present, the deformity may persist to a great extent, 
 
 lie spite of combined operative and mechanical treatment. 
 
 In cases of clonic torticollis it maybe necessary to cut down on, 
 [jnd stretch or excise, the spinal accessory nerve (p. 314). This 
 I j; not attempted until suitable hygienic and tonic treatment has 
 jiailed. Where the cause is peripheral, good results may follow ; 
 Ihitwhen due to central lesions, as is usually the case, we have 
 liiready stated that failure is not uncommon. In such, division 
 [the posterior cervical nerves, as they lie on the semispinalis 
 )ili, will occasionally bring about a cure ; should this fail, it may 
 Ik justifiable to deal with the cortical centres. 
 
 A Cervical Rib is a deformity of somewhat unusual occurrence. 
 11; arises most frecjuently from the anterior transverse process of 
 lie seventh cervical \ertebra, but a similar outgrowth sometimes 
 [xfiirs from the sixth. It is mainly composed of cartilage, but 
 liitli perhaps some bone in its interior. It passes down behind 
 
 nerves to unite witii the central portion of the first rib, and 
 kasionally consists of two portions, an upper and a lower, united 
 Kther by a synchondrosis. No symptoms are produced until 
 jtlieinass by its growth compresses the brachial plexus, or pushes 
 I'jie subclavian vessels forwards, thus leading to trophic and 
 fascular disturbances, as well as to neuralgia and some weakness 
 
 loss of power in the arm. Ni I'.ing should be done to this 
 bndition unless pressure symptoms are present, when removal 
 py be required. An incision is made parallel to the anterior 
 pder of the lower portion of the trapezius ; the nerves and 
 psels are separated from the mass of cartilage and drawn aside, 
 
 the growth carefully excised with gouge, chisel, or cutting 
 filers. 
 
 Deformities of the Spine. 
 
 j Scoliosis. — By scoliosis is meant a lateral curvature of the 
 bine accompanied by rotation of the xertebra;. Conditions are 
 m with in which the spine becomes deflected laterally as an 
 psional result of Pott's disease, or in fractures ; such, however, 
 p not generally considered to be genuine scoliosis. 
 [Etiology.— The following are the chief causes of scoliosis : 
 
 It is said to occur very rarely as a congenital deformity, owing 
 
 pnialformation of the vertebras. 2. It may commence in children 
 
 early period of life as a result of rickets, owing partly to the 
 
 [ittened and rarefied condition of the bones, partly to their irregular 
 
 'uneven growth. It is probably often induced by the method 
 Mlways carrying children on the same arm in vogue with nurse- 
 
352 
 
 A MANUAL OF SURGERY 
 
 maids. A similar chanj^'e, due to the so-called * delayed rickets,' 
 may also t;crur later on in children who are able to run about. Tliel 
 primary curve in this type is usually one directed towards the left! 
 in the dorsi-lumbar rej,non. 3. Any condition of asymmetry ofl 
 the body may lead to what is known as statical scoliosis, c.<r,^ con-f 
 genital shortness of one leg, unilateral dislocation of the hipJ 
 contractions of the knee or hip joints, genu valgum, falling in ofi 
 the chest wall as a result of empyema, and even old-standin"! 
 torticollis. If the cause exists in one of the lower extremities I 
 the pelvis is tilted down on the shorter side, producing a luinharj 
 curve with the convexity towards the side of ihe shortened le<^| 
 whilst a compensatory dorsal curve in the opposite direction is 
 subsequently added in order to maintain the general axis of the 
 body. When due to empyema, a primary dorsal curxature is 
 produced, with its con\exity towards the sound side. In torti-j 
 collis the cervical curve is primary, and a compensatory curve in 
 the opposite direction in the dorsal region usually follows. 4. Thd 
 most common form of scoliosis, however, is that known as 
 scoliosis of adolescents, met with in young people about thea.tjeol 
 puberty, or a little older, who are in a weak and asthenic coii'l 
 dition, often as a result of rapid growth, combined possibly witli 
 improper food, defective hygienic surroundings, or exposure tq 
 hard work, whereby muscular fatigue is induced. Young women 
 of an anasmic type who suffer from amenorrhoea, and who ,1^ 
 housemaids or factory hands have to undertake a good deal oi 
 lifting, are especially liable to this condition. It is due to 
 relaxed state of the ligaments and muscles, which have noi 
 deweXo-pcd pai'i passu with the weight and length of the skeleton! 
 it is therefore not unfretiuently associated with flat foot and ^^eni] 
 valgum. Prolonged standing in a position of ease or rest, iij 
 which the weight is mainly carried on one leg, may determine itj 
 occurrence, as also faulty positions occupied by children at schoolf 
 owing to low desks and want of support to the feet. The luniba 
 curve usually forms first, its convexity being to the left side, ; 
 compensatory dorsal curve, with its convexity to the right, heing 
 subsequently developed. 
 
 The Phenomena resulting from lateral curvature of the spine maj 
 be most readily considered by describing the usual form met witi 
 — that is, where the dorsal convexity is to the right, and thi 
 lumbar to the left (Fig. 95). In the opposite condition all thai 
 is necessary is to transpose the words ' right ' and ' left ' in th 
 following description. 
 
 In addition to the lateral displacement, rotation of the bodies oftl 
 vcvtchvec (Fig. 96) towards the convexity of the curves is al\va)[ 
 present. This is probably a pure mechanical act, and due 
 the more firm support given to, and the interlocking of, til 
 posterior parts of the vertebra\ As a result, the spinoJ 
 processes are directed towards the concavity, and hence \\1 
 
DEFORMITIES 
 
 353 
 
 ahvavs indicate a smaller amount of distortion than really exists. 
 Occasionally there may be some backward projection of the 
 jpines at the junction of the two curves. 
 
 The thoracic walls necessarily participate in the process. The 
 
 ribs on the rif^ht side become to some extent separated from one 
 
 another, and project posteriorly on account of the rotation of the 
 
 vertebra? ; the amount of cur\ature at the angle is consecjuently 
 
 [increased, whilst the front of the chest on this side of the body 
 
 95. —Scoliosis see\ kuo.m 
 
 BkIIIND. (TlLI.MANNS.) 
 
 Fig. gf). — Spine in Scoliosis seen 
 FROM IN Front. (Tillmanns.) 
 
 Ikcomes flattened. On the left side the ribs are huddled together, 
 
 land the curve at the angle diminished, the ribs being thereby 
 
 ipened out ; consequently the thorax is flattened posteriorly on 
 
 side, but projects in front ; the left breast may thus be 
 
 lendered prominent (Fig. 97). In fact, the thorax becomes 
 
 pore or less rhomboidal in shape. The sternum also is somewhat 
 
 liisplaced or twisted, the anterior surface looking towards the 
 
 . The capacity of the thorax is not as a rule affected at 
 
 23 
 
354 
 
 A MANUAL OF SURGENY 
 
 first, hut in tlie hiter stages it is considerably diminished, and the 
 ahdoniinal siscera may e\en be disphicecL The scapula follow 
 the thoracic wall, and hence the ri^ht shovdder is pushed up- 
 wards and outwards, and this, it is said, in tlie worst cases niav 
 projLjress to such an extent as to cause the sternal end f)f the 
 cla\icle to be spontaneously dislocated backwards, h is for this 
 
 'growing out of the 
 •jJL shoulder' in ymingj 
 
 Ij^^V^ women that the inajorityj 
 
 of cases come under! 
 observation. The let'tl 
 scapula is generallyj 
 somewhat lower than! 
 the right. The eHectj 
 on the nuiist also \aries; 
 on the right side thel 
 true w£ust becomes more 
 marked than usual, cor- 
 responding to the hum 
 bar concavity, and 
 advanced cases a distinctj 
 sulcus may be presentj 
 between the lower ril 
 and the crest of the ilium] 
 which is also thought td 
 be ' growing out.' On th^ 
 
 Fig. g-. -Skctiox ok Thorax in Scoliosis. 
 (Aft!;k Iloi.Mics AND Hclkk.) 
 
 left side the true waist becomes flattened, owing to the projection 
 of the limdiar vertebra>, whilst the dorsal concavity higher up niaj 
 simulate a false waist. In addition to the above phenomena, thd 
 buttocks may be noticed to be asymmetrical, if the scoliosis is ol 
 statical origin. The erector spiucr nuiscle stands out unduly oq 
 the left, owing to the rotation of the vertebra, whilst the tn 
 
 ans 
 
 verse processes on this side may be unusually evident. 
 
 In the early stages the characteristic deformity disappears oj 
 extension of the trunk, as by hanging from a trapeze, or on bend 
 ing forwards; but as it progresses, the spine becomes more anj 
 more fixed, and but little alteration is produced by suspension 
 the patient. In the worst cases the deformity becomes st) niarkej 
 as to simulate the ' hump ' formed in Pott's disease, especial' 
 when associated with kyphosis, and the patient's stature becom^ 
 dwarfed and stunted. 
 
 Subjective symptoms, such as neuralgic pain and weakness, ad 
 .also present, but they are not very prominent features. 
 
 Anatomical Changes. — The structure of the spinal column isi 
 first not manifestly altered, but as soon as the deformity becomd 
 chronic, the individual vertebrae become mis-shapen. The bodi^ 
 are somewhat wedge-like on section, being thicker on the convf 
 than on the concave side. The intervertebral discs are similar! 
 
 kin^'ed, whilst tl: 
 |;;econca\-e side, 
 'liie transverse ai 
 lae another on tin 
 ;,:mcnts, which in 
 iktened on the 
 yiesof the \-erte 
 ilected, being rel 
 irmse]\-es afterwji 
 b contracted on t 
 It is most essent 
 ;.->ihle. since so m 
 kiamination should 
 [wist, so that the \' 
 vniade to sit strai 
 e surgeon stands 
 ted, and then tin 
 jther with a spot 
 :r thorax, the cu 
 iDulae, are also as 
 liiian.i; from a bar, 
 tspecti\e mo\-emei 
 kained of the extei 
 ';: little risk of mis 
 ftormity, and local 
 t'lose cases of sco 
 :t spinous processe 
 pa careless exam 
 The Prognosis nee 
 "lias reached. Ir 
 t.and when it disa 
 pin to be entire 
 pron it can be in 
 fcjhat can be ex pec 
 1= the Treatment c 
 [overlooked, since i 
 Vit any rate pre\'e 
 hi._ inequality in t 
 Kofa high-heeled 
 p should, if pos 
 prs in N'oung peor 
 pi health must I- 
 Pnistration of toi 
 bated rest and e. 
 pve the muscular 
 ■f patient; for a si 
 feticial. All error: 
 h forms, and ch; 
 
 c 
 
DEFORMITIES 
 
 355 
 
 litanged, whilst the articular processes are unduly pressed tof^ether on 
 
 lie concave side, and separated from one another on the con\e.\. 
 
 Ilhe U'ansverse and spinous processes are also approximated to 
 
 locanollier on the side of the concavity, and often cur\ed. The 
 
 ..jm/z/s, which in the early stages are relaxed, become secondarily 
 
 Ijiortened on the concave side, and may, indeed, disappear, the 
 
 liodiesof the \erlel)ra' beinjj^ ankylosed. The muscles are similarly 
 
 kected, being relaxed in the early stages, but acconmiodating 
 
 li^nisehes afterwards to the altered curves of the spine, and hence 
 
 li:- contracted on the concave side, and stretched on the convex. 
 
 It is most essential tliat a correct Diagnosis be made as soon as 
 
 |))«ible, since so much depends upon early treatment. A thorough 
 
 Ivamination should be made with the clothes stripped to below the 
 
 r.ai>t, so that the whole back can be seen. The patient should 
 
 Lniade to sit straight up on a stool or chair placed sideways, and 
 
 It >ur<(eon stands behind her. The general appearance is lirst 
 
 ■;ed, and then the spinous processes are marked out one after 
 
 jther with a spot of ink or with a flesh pencil. The shape of 
 
 lie thorax, the cur\ ature of the ribs, and the position of the 
 
 ;apula?, are also ascertained. The patient is then made to stand, 
 
 ihant; from a bar, and to bend forwards, and the effects of these 
 
 kpecti\ e mo\'ements noted ; by this means some idea can be 
 
 [t'ined of the extent and nature of the deformity. There can be 
 
 I:; little risk of mistaking it for Pott's disease, since the rigidity, 
 
 feormity, and localized pain of the latter are so characteristic ; 
 
 tthose cases of scoliosis, however, where there is a projection of 
 
 te spinous processes backwards, a mistake might easily arise if 
 
 pa careless examination were made. 
 
 tile Prognosis necessarily \aries with the stage whicli the affec- 
 
 plias reached. In early days, before the deformity has become 
 
 ,and wlien it disappears on extension of the spine, it is almost 
 
 \:.\m to be entirely cured, if suitable precautions are taken. 
 
 Later on it can be improved to some extent, but in very bad cases 
 
 [lihat can be expected is to pre\ent it from getting worse. 
 
 Is the Treatment of scoliosis, the cause of the trouble must not 
 
 ioverlooked, since in many cases the deformity may be remedied, 
 
 tat any rate prevented from increasing, by attending to this. 
 
 p, inequality in the length of the limbs necessitates the wear- 
 
 Kof a high-heeled boot, whilst contractions of the knee or hip 
 
 lilts should, if possible, be remedied. In that \ariety wdiich 
 
 lairs in young people from constitutional or local debility, the 
 
 leral health must be improved by a visit to the seaside, or the 
 
 tiinistration of tonics, such as iron and arsenic. Carefully 
 
 pated rest and exercise must also be recommended, so as to 
 
 ?rove the muscular tone of the back without unduly fatiguing 
 
 : patient; for a similar reason massage and cold baths are 
 
 Mcial. All errors of position must be corrected, and suitable 
 
 In the slighter cases it often 
 23—2 
 
 J- 
 
 jlar^ftiis, forms, and chairs utilized. 
 
356 
 
 A MANUAL OF SURGERY 
 
 suffices to order the patient to rest in the supine position on ;|., 
 inclined board for an liour or two daily, tlie heail hcin- tins 
 raised and the spine extended. Cahsthenic movements and 
 gymnastic exercises, especially on the horizontal bar and trapeze, 
 are also valuable. Of course, these must be arran<,fed so as tol 
 exercise the weak nuiscles and counteract the defo..uity. Space 
 forbids us describinj^^ them here, and we must refer readers tol 
 special textbooks. A spinal support is often useful, bui shoulai 
 not be worn continuously, except in bad cases, as it renders the] 
 muscles of the back weak from disuse. All that is needed in ihej 
 early stages is the support of a firm, carefully-fitted corset: hiitl 
 should the deformity increase, stronger steel instruments may bel 
 em[)loyed in which springs are incorporated, wlierehvi 
 it is hoped that correction of the curvature may lieJ 
 brought about. In the more severe cases, which are 
 often associated with considerable pain, such a con-i 
 trixance with axillary crutches is absolutely essential 
 Plaster of Paris, applied according to Sayre's niethodj 
 is certainly objectionable, since it is irremo\al)le, and 
 all other local treatment to the back is thus prevented] 
 
 Kyphosis. — By this term is meant a condition oi 
 increased dorsal convexity of the back (V\ii. (,s)| 
 which is often associated with loss of the lumbar con 
 cavity, so that the whole spine is arched backward! 
 Occasionally, however, a marked lumbar lordosis i| 
 present as a compensatory condition. 
 
 The chief varieties of kyphosis are as follows : 
 I. Kyphosis from defective growth or habit. T 
 may occur (n) in children under the age of four, rj 
 suiting from rickets ; (b) in adolescents up to the ag 
 of sixteen (round shoulders), from a continuous hai 
 of stooping, as in reading or writing, and is not ui] 
 common in those suffering from myopia ; (c) various forms 
 occupation, in\ol\ing the carrying of heavy weights, or stoopin 
 over w^ork, will lead to its appearance in adults, as in porters aii 
 cobblers, whilst the use of bicycles which necessitate the ridel 
 stooping forwards in order to grasp the handles is becomingj 
 frequent source jf this deformity ; (d) in old men it results tro 
 senile atrophy. 
 
 2. Kyphosis from general diseases of the spine is a niarkj 
 feature in osteo-arthritis, osteitis deformans, osteo-malacia, hypj 
 trophic pulmonary osteo-arthropathy, and acromegaly. In 
 latter disease the condition is limited to the dorsal region. 
 
 3. Kyphosis from localized disease of the spine is sometiiil 
 described, although it is more commonly known by the contrad 
 tory term ' angular curvature.' It results from fractures, Poj 
 disease, gumma, or cancer (q.v.). 
 
 Fif., 98.- 
 K V miosis. 
 (A K T !■: u 
 Kkichsen.) 
 
 Treatment is 
 -lioiildersof yoii 
 nf the surgeon 
 I needed. 
 Round Should* 
 ;,!()idly, and pet 
 often due to dale 
 ! • liool, and may 
 iher intrinsic c( 
 he primarily resp 
 cer\ ico-dorsal re 
 [onected, but no 
 Treatment. — A 
 ■j'liestion of cans; 
 ilie essential poi 
 :i;e power of the 1 
 apezii, the erec 
 |:iieserrati. 'llns 
 j electricity, and 
 blirected 'towards 
 hiimild never he a 
 land must rest on 
 I (or half an hour. 
 i'.ick. without a •■ 
 liiiecurve. The g 
 \iko he attended 
 prescribed. 
 
 
 
 ( 
 
 Lordosis (]<ig. gc 
 
 iivature of the s 
 
 ■'■"'iliy produced 
 
 |«';ether due to 
 
 fniiiced dislocatio. 
 
 |f.te it is irremedi, 
 
 '-mur can be corre 
 
 't is seen as a te 
 
 pstant phenomei 
 
 ■'•^creased weiglit o. 
 
 ml displacement 
 
 FJiist correctly the 
 
 I* "oticed in persoj' 
 
 , /t 's occasional 
 
 P^re die lumba 
 
 ally in pseudo- 
 
 P,?astrocnemii a 
 
 y^« posture. In 
 
 '^placed forwards, 
 
 ■'fw and shoulders 
 
DEFORMITIES 
 
 357 
 
 Ireatment is impossible in the majority of rases, but the round 
 -hmiKU'rsof yourif^ |)(.'()|)lecoine so commonly under the observation 
 (if the surj^^eon that a little more notice ot' the condition is 
 needed. 
 
 Round Shoulders occur most fre(|uently in ,t(irls who ha\e j^rovvn 
 
 ;,midly, and periiaps developed precociously. The condition is 
 
 j often tlue to defective habits of sittin<( and standinj^, especially at 
 
 ji'hool and may be induced by faulty desks and chairs, whilst 
 
 ,ther intrinsic conditions, such as luyopia or adenoids, may also 
 
 i,e primarily resptjusible. The spine becomes bent forwards in the 
 
 [cervico-dorsal ref,don ; at first the deformity can be \'oluntarily 
 
 [curectcd, but not so later on. 
 
 Treatment. — A thorough investigation must be made into the 
 
 jiiestion of causation, and all removable conditions dealt with. 
 I The essential point in the treatment is to increase 
 [the power of the nuiscles of the back, especially the 
 
 irapezii, the erectores spinet, the rhomboidei, and 
 
 •jieserrati. 'J'his maybe accomplished by massage, 
 
 tlectricitv, and exercises, the latter necessarily 
 lilirected towards extension of the back. The girl 
 hhiiuld never be allowed to fatigue herself uiiuuly, 
 
 acd must rest on her b ;< ' wo or three times a day 
 m half an hour. At night the c'lild lies on her 
 liiack. without a !■■ Ister, and with a pillow beneath 
 
 ihe curve. The general nutrition and health muse 
 |,il>o be attended to, and a course of suitable tonics 
 
 prescribed. 
 
 Lordosis (Fig. 99) consists in an increased anterior 
 uiiviiture of the spine in the lumbar region. It is 
 I'JHially produced by continued flexion of the hip, 
 l»hether due to congenital displacement, to un- p,^. ,,„ ,_ Lor- 
 Itcduced dislocation, or to hip disease, and in such misis. (Aktek 
 leases it is irremediable unless the malposition of the Ekichsen.) 
 lieinur can be corrected. 
 
 h is seen as a temporary condition in pregnancy, and as a more 
 jfonstant phenomenon in bad cases of uterine fibroids, owing to the 
 jiOTeased weight of the uterus or its contents, necessitating back- 
 ward displacement of the upper part of the spine in order to 
 kliist correctly the centre of gravity of the body. The same may 
 |lt noticed in persons with large, fat, and pendulous abdomens. 
 
 It is occasionally present in progressive muscular atrophy 
 pare the lumbar and abdominal muscles are weakened, and 
 jsiiaily in pseudo-hypertrophic paralysis from loss of power in 
 liie |,^astrocnemii and other muscles engaged in mumtaining the 
 pet posture. In both cases the centre of gravity of the body is 
 pplaced forwards, necessitating the throwing backwards of the 
 'Kidand shoulders in order to maintain the ecjuilibrium. 
 
 •;■ ■'] 
 
358 
 
 A MANUAL OF SUKGERY 
 
 Spondylo-listhesis is the term applied to a curious and some- 
 what uncommon deformity, in which the lumbar vertelira- slip 
 forwards and downwarus from the top of the sacnun. It arises 
 from fracture of the articular processes of the lumho-sacral 
 synchondrosis, or from imperfect development of the lamina- or 
 pedicles of the lowest lumbar vertebra, as a result of which the 
 pressure of loads carried on the shoulders or the weit^ht of ;;. 
 pregnant uterus brings about the displacement. In tlie latter 
 instance the enforced lordosis aggravates this tendenc}-. The 
 effects produced are shortening of the stature, together with the 
 formation of a marked hollow above the sacrum, whilst the 
 lumbar vertebra: are unduly prominent anteriorly. The condition 
 is accompanied by neuralgic pain and weakness. The only fnat-. 
 incut is p'-olonged rest in the recumbent posture, and possihlv 
 the application of a well-fitting leather jacket, closely moulded U)\ 
 the pelvis, and supplied with cru^ches, so as to carry part of thei 
 weight downwards from the axilla' to the pelvic support without j 
 utilizing the spine. 
 
 Deformities of the Upper Extremity. 
 
 Many different forms of congenital defect of the arms aiidi 
 hands have been noted, but the majority are so unconnnon that] 
 no particular mention of them is needed. Various types cfl 
 Club-hand occur, in which the hand is deflected to one or thej 
 other side, or is hyper-extended or flexed. Perhaps the niostj 
 frequent cause is a congenital absence of the radius, under wliichi 
 circiunstances the hand is radially abducted to a marked degree, 
 the ulna is shortened and curved, and its lower epiphysis nuicli 
 altered in shape. In any of these deformities skiagraphy shoiildi 
 be employed, so as to ascertain the exact relation of the hones toj 
 each other. 
 
 Congenital Deformities of the Finger are much more comnionJ 
 and the account here given of such defects of the upper extreniitv] 
 applies with ecjual force to those which occur in the lower. Tl; 
 following varieties may be alluded to : 
 
 Polydactylism consists in the presence of supernumerary finger^ 
 and toes, and is often seen. There may be from one to seven 
 additional digits, and the condition is usually symmetrical. Ond 
 case is on record Avith twelve and thirteen fingers on the bands] 
 and twelve toes on each foot. The accessory digits are often 
 stunted, and smaller in size than the normal, but may he < 
 average dimensions. Usually they are separated from the trua 
 digits, but now and then may be blended with them. The correci 
 number of metacarpal and metatarsal bones may be present, oj 
 they also may be multiplied. In one of our cases there were si.f 
 digits and six metatarsal bones; but the last two digits were sup 
 ported by an accessory metatarsal apparently springing from th^ 
 outer side of the fourth. The condition is frequently inlierited 
 
DEFORMITIES 
 
 359 
 
 The U'catmcnt consists in removing the supernumerary digits, if 
 useless, obtrusive, or troublesome. Sometimes the patients are 
 proud of their abnormality, and refuse to part with it. A patient 
 with two weak tluuubs may sometimes be benefited by uniting 
 iheni latendly into a single broad one. 
 Ectrodactylism, ox the absence of one or more of the digits, is 
 
 
 ^ , 
 
 J 
 
 
 ]|^^ 
 
 
 i\< ■-■..*.■ 
 
 
 / 
 
 1 
 
 JsP't. 
 
 I 
 
 Vm 
 
 
 
 ^H 
 
 yf 
 
 ^'A 
 
 \i^m 
 
 
 
 I^^^HI 
 
 HJH 
 
 dt' •^Mr 
 
 1 
 
 Lm 
 
 
 1 
 
 1 
 
 ^ 
 
 
 
 JpP^M 
 
 H 
 
 f 
 
 
 ^ 
 
 1 
 
 w^ 
 
 mk 
 
 ■ 
 
 €>A.S>- 
 
 Fl(i. 100. -MACROnACTVLV AND SYNDACTYLY. 
 
 In this case a child, aged two and a lialf years, had the ring and middle fingers 
 united laterally into a large mass which projected far beyond the otheis. 
 Tlie middle finger was normal in size, the ring finger was hyper- 
 tropiiic. A frnitless attempt was irade to sa\e the middle finger, but 
 both iiad finally to be amputated. 
 
 occasiorally seen, as also partial nrrests of development of fingers 
 or toes. 
 Macrodactyly (Fig. loo) consists in a congenital overgrowth of 
 '■neor more lingers or toes. The structure^ are perfectly normal 
 in character, and merely gigantic in size for the age of the 
 individual. Amputation may be needed in these cases, as the 
 Jetornied parts grow out of all proportion to tlie neighbouring 
 
36o 
 
 A MANUAL OF SURGERY 
 
 tissues. Thus, an infant with enormous overgrowth of the second 
 toe of the riglit foot was successfully treated by excision of the 
 digit, together with a \'-shaped portion of the foot, whicli was bv 
 this means reduced to normal shape and size. 
 
 Syndactylism, or webbed fingers, is a condition in which two or 
 more fingers are joined together laterally, either by a thin web 
 consisting mainly of skin, or by a thick fleshy bond of union. In 
 the foot no tveatment is required, but in the hand the fingers must 
 be separated. If there is merely a thin web, this may be divided 
 by scissors ; but to prevent its re-forniation from below upwards, 
 as healing proceeds, a flap of skin must be transplanted into 
 the angle between the fingers, or an opening in the base of the 
 web may be made and maintained, and the edges allowed to 
 cicatrize before the web itself is divided. Where the union, how- 
 ever, is thick and fleshy, a more extensive operation is needed. 
 Two flaps of skin as long as the web, and half the width of a 
 finger, are respectively raised from the dorsal aspect of one finger 
 and from the palmar aspect of the other, in such a manner that, 
 after the web has been divided, the denuded surfaces can be 
 covered by wrapping the flaps round the lateral aspects of the 
 hngers and suturing them in position. An additional flap of skin 
 must also l)e fixed in the angle between the separated digits, unless 
 the preliminary measure just described has been undertaken. 
 
 Of the Acquired Deformities of the Hand, Dupuytrens con 
 traction is the most important, but a few others are occasionally 
 seen. Thus, after burns the hand may be contracted into a 
 useless mass in w^hich the fingers are drawn into the palm and 
 united i)y cicatricial tissue to the palmar structures, so that all 
 treatment is hopeless. 
 
 Again, after injury or separation of one of the epiphyses of] 
 either radius or ulna, the uninjured bone may continue its growth, 
 whilst the other remains stationary, so that considerable lateral] 
 deviation of the hand is thereby brought about. 
 
 The term Mallet Finger has been applied to a condition in] 
 which the terminal phalanx is maintiuned in a state of flexion] 
 owing to some damage to the extensor aponeurosis. It usuallyj 
 follows slight injuries, which lead either to a separation of the! 
 tendon from the bone, or to a thinning of its texture, wherehy thej 
 flexor tendon attached anteriorly to its base is able to act withl 
 undue power. The tveatment consists in the application of anj 
 anterior finger-splint in the early stages, but later on, when thej 
 deformity is persistent, an incision is made on the posterior aspect! 
 of the joint, and the weak tendon isolated and stitched down in| 
 such a way as to give it a better attachment to the bone. 
 
 Contraction of the Palmar Fascia (Dupuytren's Contraction). - 
 This condition is usually met with in middle-aged individuals ot ; 
 gouty temperament, more often in men than women, and not] 
 
DEFORMITIES 
 
 361 
 
 Fig 
 
 loi. — Dui'uvtren's Contrac- 
 tion OK THE Hand. 
 
 •jnfreiiuently on both sides of the body. It may or may not be 
 associated with direct irritation of the palm, as by leaning 
 much on a round-headed cane, or from the constant use of some 
 instrument, such as an awl, whilst heredity is an important 
 causative factor. Pathologically, it is due to a chronic over- 
 j-rowth and contraction of the fascia, inflammatory in nature, and 
 cirrhotic or sclerosing in type. It commences as a:n indurated 
 subcutaneous nodule in the palm of the hand, about the situa- 
 tion of the most marked transverse crease, and affects most 
 commonly the ring and little fingers first, the other fingers and 
 thumb being less often involved. The induration spreads slowly 
 both up and down the fascial 
 bands into the fingers, which, as 
 ; increases, are gradually drawn 
 into the palm and fixed, so that 
 extension becomes impossible 
 Fis;. loi). The flexion is 
 limited to the first and second 
 phalanges, the thiid remaining 
 extended, and, indeed, sometimes 
 assuming a position of hyper-ex- 
 tension, owing to the injudicious 
 application of a splint. The skin 
 over the indurated masses is sooner or later incorporated with them. 
 
 The Diagnosis of Dupuytren's contraction is exceedingly easy, 
 liieonly condition for which it is likely to be mistaken being flexion 
 o'the finger due to contraction of the long tendons. In the latter 
 case there is, as a rule, no palmar induration, and on attempting to 
 straighten the finger the tendons may be felt to become tense above 
 ;he wrist ; the terminal phalanx is also flexed in many instances. 
 
 The only satisfactory Treatment is by operation, and the follow- 
 iRs; methods are those which are most successful : (a) Adams' sub- 
 cutaneous section of the fascia and its prolongations consists in 
 dividing the indurated bands by a tenotome in several places, 
 I where they can be felt tense. One puncture and division must be 
 mde in the centre of the palm ; a second divides the same band 
 asnear the finger as possible, whilst the third and fourth deal with 
 the lateral prolongations at the sides of the finger; if other 
 bauds still exist, they are treated similarly, the tenotome, if 
 possible, in all cases being inserted between the skin and the 
 Mascia. The improvement thus produced must be maintained and 
 increased by the subsequent use of suitable apparatus and passive 
 |nio\ements, but the final results are not very satisfactory. 
 
 'i Kocher's method consists in the total extirpation of the 
 
 I'iiiickened bands and their prolongations through longitudinal 
 
 :r.cisions. The fingers are at once straightened, and subse- 
 
 |;iiient contraction is prevented by mechanical appliances. We 
 
 ave had many excellent and lasting cures by the latter operation. 
 
362 
 
 A MANUAL OF SURGERY 
 
 :s 
 
 Deformities of the Lower Extremity. 
 
 Coxa Vara, or incurvation of the neck of the femur {Vv^. 102.) 
 
 is a condition to which attention 
 has l)een called only of lecen; 
 _\'ears. The neck of the hone, 
 instead of passin^^ obliciuely up- 
 wards, is horizontal, or r\en m 
 bad cases directed downwards, 
 whilst shortening from inter- 
 stitial absorption also occurs. 
 and the head becomes mush- 
 room-shaped (Plate \'1II.). At 
 first the osseous tissue is 
 softened, but after a while 
 sclerosis supervenes. It is met 
 with usually in adolescents, 
 although occasionally it occurs 
 in young children. It is sup- 
 posed to be due to a lute mani- 
 festaticMi of rickets, but, since it 
 is often unaccompanied In- 
 other exidences of the disease, 
 ihis hypothesis is a little diffi- 
 cult to accept. Certainly it is 
 seen most frecjuently in those 
 who ha\e to do much walkinf( 
 or carrying of heavy wei,i(hts. 
 Possibly it is in some cases 
 due to a gradual slipping down of the epiphysis, which consti- 
 tutes the head of the bone, as suggested by the late Mr. Davies j 
 Colley. 
 
 The Symptoms commence with pain in the region of the hip, 
 followed l:)y a distinct limp. As the neck of the bone becomes 
 absorbed or curved, the trochanter rises above Nelaton's line, 
 and real shortening of the limb occurs, even up to i^- inches, 
 The limb is also exerted and the trochanter increasingly pro- i 
 minent, especially on flexing the thighs. The movements of the | 
 joint are limited, particularl}- in the direction of internal rotation; 
 and abduction, the latter being practically impossible in the i 
 more severe cases, owing to the base of the trochanter hitching 
 against the lip of the acetabulum. (Jn Hexing the limb, the! 
 thigh sometimes lies across the sound one, whilst in the later 
 stages the adduction may be so marked that a scissor-lej^^gedj 
 condition occurs if both sides are affected. As distinguishiiiij 
 features may lie mentioned : the absence of local swelling or] 
 tenderness on pressure, as also of the up-and-down movement 011 ' 
 
 I"i(i. 102. — Coxa \'.\u.\. 
 
 Tlie dotted line represents the 
 normal neck of tlie lemur. 
 
PLATK \I1I. 
 
 < 
 
 
 
 < 
 
 X 
 
 
 si 
 
traction, so w 
 tion never fc 
 ohser\-ed. 
 
 Treatment. - 
 thereby any i 
 vented ; local 
 the later stages 
 is perhaps the 
 recommend m( 
 sequent shorte 
 to the under si 
 
 Genu Valgui 
 
 knees are alio- 
 
 the malleoli an 
 
 condition of al 
 
 some external 
 
 affected, but if 
 
 common. Occi 
 
 the other is in a 
 
 There are tv 
 
 rachitic genu v£ 
 
 occurring in ado 
 
 The genu valg, 
 
 I mkets, a disease 
 
 tissue on either ; 
 
 I lerence with the 
 
 as to whether tli 
 
 I in the internal co 
 
 truth proba 
 
 jatlairs is often s 
 
 authorities maint 
 
 land that operati- 
 
 I possibly this idea 
 
 I cases arise from 
 
 I femur, especially 
 
 jahout too early. 
 
 The genu valgu 
 [most commonly ii 
 Itution, and partic 
 jheavy weights. ' 
 jmaids, and young 
 |cit, There are 
 ft is produced : s( 
 to a delayed 
 % at fault, b( 
 f?ain, maintain th, 
 I'ossibly several 
 
DEFORMITIES 
 
 363 
 
 traction, so well marked in congenital dislocation, whilst suppura- 
 tion never follows, and thickening of the trochanter is not 
 observed. 
 
 Treatment. — In the early stages rest is the essential, and 
 thereby any increase in the deformity already existing is pre- 
 vented ; local massage and manipulation are also advisable. In 
 the later stages, excision of the head, or subtrochanteric osteotomy, 
 is perhaps the best measure to undertake, although some surgeons 
 recommend merely a cuneiform osteotomy of the neck. The sub- 
 sequent shortrening may be dealt with by means of a thick sole 
 to the under surface of the boot. 
 
 Genu Valgum, or knock-knee, is a deformity in which, if the 
 Knees are allowed to touch with the patella^ looking forwards, 
 the malleoli are separated one from the other — i.e., it is a fixed 
 condition of abduction of the legs from the middle line, with 
 some external rotation (Fig. 103). One or both limbs may be 
 affected, but if due to general causes the double form is more 
 common. Occasionally genu valgum occurs in one leg, whilst 
 the other is in a condition of genu varum. 
 
 There are two main varieties of the disease, viz. : (i) The 
 rachitic genu valgum of young children, and (2) the static form 
 occurring in adolescents. 
 
 The genu valgum of young children is practically always due to 
 n:/.Y/s, a disease associated with a softened condition of the bony 
 tissue on either side of the epiphyses, which results in an inter- 
 ference with the normal development. It is still an open question 
 as to whether this deformity is primarily due to increased growth 
 in the internal condyle, or to arrest of development in the external ; 
 the truth probably lies between the two. A similar state of 
 ailairs is often seen in the tibial tuberosities, and indeed some 
 ; authorities maintain that the chief mischief is located in the tibia, 
 [and that operative treatment should always be directed to it; 
 possibly this idea is true in some instances, but not in all. Other 
 leases arise from a rachitic curvature of the diaphy^'s of the 
 ieniur, especially when the child has been allowed to walk or run 
 [about too early. 
 
 Ih genu valgum of adolescents, or static genu valgum, occurs 
 liiiost commonly in young people under twenty, of relaxed consti- 
 Itution, and particularly in those who, in addition, have to carry 
 jlieavy weights. Thus, anaemic young women who act as nurse- 
 Imaids, and young bricklayers, smiths, and porters, are very liable 
 [to it, There are many different opinions as to the way in which 
 jit is produced : some maintain that it is primarily osseous, and 
 Idue to a delayed rickets ; some believe that the ligaments are 
 piefly at fault, being relaxed on the inner side ; whilst others, 
 p?ain. maintain that it is primarily a nmscular phenomenon. 
 
 Possibly several 01 these causes may be conjoined in any par- 
 
364 
 
 A MANUAL OF SURGERY 
 
 ticular case, but the most likely explanation is a purely mechanical 
 one. When a person stands in the erect posture, the pcrpen- 
 dicular line which represents the direction in which the weif^lu 
 is transmitted downwards from the head of the femur passes 
 through the outer rather than tlie inner condyle, whilst tlie latter 
 structure is lengthened in order to maintain the horizontal position 
 of the articular surfaces of tlie knee-joint. A certain amount of 
 strain is thus normally cast upon the internal lateral ligament 
 even in a healthy person, and this is increased as the natural 
 position of rest — i.e., with the feet separated and slightly abducted 
 — is adopted. A long continuance of this posture tires those 
 muscles on the inner side of the limb which tend to counterbalance 
 
 this strain, especiall)' if a 
 certain amcjunt of additional 
 weight has to be carried, and 
 particularly in those whose 
 bones have rapidly increased 
 in length and weight withom 
 any coincident increase in 
 power of muscles or liga- 
 ments. Hence the internal 
 lateral ligament becomes more 
 and more stretched, and not 
 unfrequently a certain amount 
 of lateral mobility of the knee 
 is noticed in the early sta^^es, 
 Subsequently the outer con- 
 dyle becomes atrophied from 
 more weight being trans- 
 mitted through it, and tlie 
 inner condyle becomes 
 lengthened from overgrowth. 
 It is also important to note 
 that flat-^foot and lateral cur- 
 vature of the spine often 
 accompany this form of genu 
 valgum, the former beini,' 
 also usually due to ligamentous relaxation, whilst the latter may 
 be merely associated with it, or be compensatory if the deformity 
 in the knee is unilateral. 
 
 Occasionally genu valgum is due to tnvnnatic causes, such as 
 fracture of the tibia or femur close to the joint, or lateral (lis 
 location of the knee ; whilst, again, it may be caused by atrophy 
 consequent on interference with the epiphysis from local injiuy 
 or diseases other than rickets. It is sometimes observed, as a | 
 result of riding, in those with long legs, as in cavalry soldiers; 
 short-legged individuals, such as jockeys, are more lii ble to '. 
 <levelop a condition of genu varum. 
 
 Fk; 
 
 103. — (jKNV Valol'm. 
 
 MANNS.) 
 
 (Till- 
 
DEFORMITIES 
 
 365 
 
 The Physical Condition of the parts about the knee may be 
 
 suiiini;iri/.ed as follows : 
 
 [a] The inner condyle of the femur forms a marked and obvious 
 subcutaneous projection ; the increase in size is mainly in the 
 vertical and transverse directions, and but very little antero- 
 posteriorly, so that, on flexion of the joint, the deformity to a 
 large extent disappears. 
 
 (/)) In rachitic cases a locali.''ied bony outgrowth can usually be 
 detected on the inner surface of the tibia about 2 or 3 inches 
 from tlie joint, and probably due to a localized periostitis at the 
 point of attachment of the internal lateral ligament. 
 
 ((•) Impaired growth and atrophy is observed in the outer 
 femoral condyle and tibial tuberosity, conditions supposed to be 
 due to the weight of the body being transmitted more directly 
 throuf^h these structures. 
 
 ((/) Relaxation of the ligamentous and muscular tissues takes 
 place on the inner side of the joint. This, however, is not con- 
 stant, especially in the later stages or in cases which are stationary. 
 
 [c) The tendons and ligaments on the outer aspect of the joint 
 are contracted and shortened, especially the external lateral liga- 
 ment, the ilio-tibial band, and the tendon of the biceps. 
 
 (/) The patella tends to be thrown outwards from the angular 
 deformity existing at the knee-joint. Occasionally the bone is 
 actually dislocated, and when this has once happened the dis- 
 placement is very likely to recur from time to time. 
 
 The following secondary conditions may be met with resulting 
 from genu valgum, viz. : The feet are displaced outwards, or 
 occasionally inwards, as best suits the convenience of the patient 
 in obtaining as good a footing as possible ; the bones of the legs 
 and of the thighs are often bent ; whilst, if unilateral, the pelvis 
 is tilted downwards on the affected side, and the spine laterally 
 curved on account of the unnatural shortness of the limb. 
 
 In well-marked cases the gait of the patient is very charac- 
 teristic, since the knees tend to get in the way of each other ; 
 hence the term ' knock-knee.' The legs are kept partially fl.exed, 
 and as the condyles touch or overlap, they have to be separated 
 at each step to allow of progression, and thus a curious rolling 
 sort of walk results. Occasionally bursa form over the points 
 wliere the friction is most marked. 
 
 Treatment. — The surgeon must study each particular case in 
 order to ascertain, not only the cause of the trouble, but also 
 whether or not it has advanced to such a stage as to render treat- 
 ment other than operative useless. In the early stages of a 
 rachitic knock-knee, the bones are still soft and vascular, so that 
 ^vith care and patience the deformity may be remedied without 
 having recourse to the knife, and the same statement is true of 
 the early stages of the static variety. 
 
 In rachitic infants, the general condition must be dealt with in 
 
366 
 
 A MANUAL OF SURGERY 
 
 accordance witli the rules given elsewhere (Chapter X\'I1.). \ 
 suitable diet should be ordered, cleaiiHness attended to, ami plcntv 
 of fresh air allowed. Parrish's food is perhaps the best drug to 
 administer, whilst cod-liver oil is rarely needed, since it tends to 
 increase the body-weight, and so may do harm rather than good. 
 Absolute rest in bed is enforced ; the limbs are well rubbed (laijy, 
 and such manipulation and pressure employed as will tend to 
 remedy the deformity and straighten, if possible, the limb. Xo 
 pain should be caused, and by perseverance slow but appreciable 
 progress may be made until the limbs are straight. In older 
 children, especially when there is some difficulty in keeping them 
 off their feet, it is better to apply splints on the outer side of the 
 limbs, reaching from the pelvis down to the outer malleoli, or, it 
 need be, beyond them. These are retained in position by water- 
 glass bandages, put on firmly enough to draw the knees out- 
 wards. Such an arrangement is often sufficient in early cases 
 to bring about a cure in the course of a few months. Some 
 authorities ha\e recommended forcible correction of the deforniitv. 
 and subse(juent fixation in plaster of Paris, but the condition of 
 the epiphyses, and the ease with which they are detached, are 
 good reasons against adopting any such method. 
 
 In the static cases the administration of tonics, such as iron and 
 arsenic, combined with rest, massage, iind possibly a change of 
 air, will frefjuently suffice to determine a cure in the early stages. 
 
 When the deformity is somewhat more advanced, more efficient 
 apparatus is needed ; that usually employed consists of an outside 
 iron stem, jointed at the knee, fi.xed below into a slot in the heel 
 of a well-made boot, and attached above to a pelvic band. From 
 it several well -padded straps pass round the limb, and at the 
 knee itself a much broader one covers the projecting inner 
 condyle ; by tightening these, the limb is drawn out towards 
 the rod. The apparatus is somewhat heavy, but if carefully 
 applied for some months may effect a cure. It is possible that 
 division of the tense structures on the outer side of the joint may 
 considerably assist the process. 
 
 When, however, the osseous deformity is marked, and the patient 
 of such an age as to preclude the hope of a cure by mechanical 
 means, osteotomy must be resorted to. Amongst the many plans 
 which have been suggested, only two need be mentioned here, 
 viz., those devised by Ogston and Macewen. Ogstoifs opcvation 
 consists in sawing off the enlarged inner condyle through an 
 incision made by inserting a narrow finger-knife obliquely above 
 the condyle, and pushing it downwards in front of the bone to the 
 level of the articulation. The objections to the plan are the 
 necessary implication of the joint and of the epiphyseal cartilage, 
 so that ankylosis may occur on the one hand, or such interference 
 with the growth of the inner condyle, on the other, as leads later 
 on to genu \aruni. The immediate result is very satisfactory. 
 
DEFONMITIES 
 
 367 
 
 ;indit may be used with success in adults where no more fjfrowth 
 IS expected. M(!ie7iicii's opcnition is, howex'er, that most generally 
 applicable, and has practically superseded all others. It consists 
 ;i) the division of the fenuir transversely about a (in^fer's breadth 
 ;ibove the upper border of the external condyle, so as to be well 
 ,i\vay horn tiie epiphyseal cartilage. Macewen himself uses an 
 osteotome''' for the purpose, introducing it through an incision 
 made i inch in front of the tendon of the adductor magnus, and 
 iiirninf,^ it so as to lie at right angles to the long axis of the shaft ; 
 ",e divides the bone for three-quarters of its diameter, and breaks 
 the remainder. A similar method may be employed from the 
 outer side, the force used in breaking the inner layer of compact 
 hone comminuting and com[)ressing that portion, and so diminish- 
 ini^tlie deformity. Many surgeons, however, prefer to divide the 
 hone with a saw, pre\iously making a track for it along the front 
 of the femur, and we certainly consider that such an operation is 
 simpler, and e<iually efficacious. The Umh, having been straight- 
 ened, is either put up at once in plaster of Paris, or, perhaps, at 
 lirst in a (iooch's splint, which allows the wound to be looked at 
 and dressed, and subseriuently in plaster. Union is complete 
 in six weeks, but an immovable apparatus should be kept on for 
 three months. 
 
 !n a few cases due to rickets it may be necessary to divide the 
 tibia just below the tubercle in addition to dealing with the femur. 
 This is best accomplished as a first step, and if necessary the 
 lihula may also be divided. When these wounds have con- 
 solidated, the femur is dealt with. 
 
 Genu Varum (one form of hov-lcg) is a less common condition, 
 
 the exact opposite of genu valgum, and what has been said above 
 
 j of the one is true of the other, if the word ' internal ' be substituted 
 
 for ' external ' and vice veysa. Treatment is only required in bad 
 
 cases. 
 
 Genu Recurvatum, or Back-hncc, is a deformity occasionally met 
 
 jwith in which the joint is hyper-extended, the limb describing a 
 
 curve with the conca\'ity forwards; it is necessarily associated 
 
 with relaxation or stretching of the crucial ligaments, and is usually 
 
 due to a congenital displacement, possibly the result of the lind:)S 
 
 I being flexed in iitet'o, but extended with the feet under the 
 
 n. It is sometimes the result of paralysis of the flexor muscles 
 
 of the knee and of the popliteus, or may arise from irregular 
 
 growth along the epiphyseal line, possibly as a sequela of tuber- 
 
 [culoiis or other disease of limited extent in that region. It has also 
 
 been known to occur as an accjuired accomplishment in fakirs and 
 
 ' An ostcctioiie differs from a cliiscl in the fact that the formrr is bevelled on 
 "ill sides, whilst the latter is merelj' bevelled on one side. 
 
368 
 
 A MANUAL OF SURGERY 
 
 contortionists. If treatment is necessary, it must be suited to the 
 special reriuirements of the incli\idual case. 
 
 Contractions of the Knee may arise from many different causes, 
 whicli may be either intra- or extra-articuhu" in character. Tht.' 
 cxti'(i-iuiici(/ai' c'MXHL'S of this altection maybe situated (i) in thf 
 5/1/;/ and subcutaneous tissue, as a result of the contiariion of 
 cicatrices of burns or ulcers ; or (2) in the flexor inusiics, which 
 may become contracted in consequencce of dilluse suppuration 
 within their sheaths, or of infantile paralysis of the extensors, 01 
 as a secondary result of inflammatory troubles in the knee-joint, 
 (3) The contraction is in some cases hysterical in ov\\(\x\, the Joint 
 bein<,f fixed by muscular action, but remainiuf;; healtliy, ultliou','li 
 much local pain and superficial tenderness are complained of. 
 The diagnosis of such a condition is readily made by indiicini; 
 anasthesia, or taking the patient imawares, when the linih is 
 found freely moveable and can easily be straightened. The 
 treatment of the preceding conditions is conducted on gtMieral 
 principles. 
 
 The ciiticiilcw causes of contracted knee are as follows : ( i ) Wheiei 
 the capsule and ligaments are affected as well as the nuiscles. tlie| 
 causati\e inflanuuation having been usually of a rheumatic 
 gonorrho-al nature. The limb is fixed, but there is no actiia 
 displacement of the head of the tibia. (2) Fibrous adliesionsul 
 greater or less density may pass between the articular surface^, 
 as a result either ,of acute synovitis, or of tuberculous or acut 
 arthritis. In the former case some mobility may be present, hii 
 in the latter the mo\'ements may be very defective. (3) Ossroii 
 ankylosis may exist, the position of the limb depending on tli 
 prexious treatment of the case. If care has not been taken 
 prexent deformity, the leg may be found at right angles to tlii 
 thigh, and more or less exerted. This rectangular deformity is 
 not uncommon consequence of tuberculous disease of the kn 
 which has been treated early in life by partial excision. Tl 
 epiphyses are here only slightly interfered with, and hence ;;ro\v 
 continues, but not equally in all directions. Where the anteri 
 portion of the bo'-.e develops more than the posterior, ilexio 
 necessarily occurs ; but if the growth is mainly in tlie opposil 
 direction, genu recurxatum may be induced. (4) As an occasion 
 result of tuberculous arthritis, the tibia is flexed on the feiii 
 whilst its upper articular surface is displaced horizontally bac 
 wards, and the lower limb rotated outwards, constituting wiiat 
 known as the tyiple displacement. If the limb has been allowed 
 lie on its outer side whilst disorganization was proceeding,', thei 
 may be an additional lateral displacement of the head of the ti 
 outwards. 
 
 The Treatment of these conditions necessarily depends on tli 
 nature. Where adhesions exist within the joint, or the ligaiiie 
 
 alone are co 
 under an an; 
 traction is a; 
 ^llape(l piece 
 I'le triple dis| 
 ■i i.s often a d 
 'f the tibia. 
 ly silver- wire 
 
 Rachitic Tib 
 
 liie ti|)ia and 
 wrtion in the c 
 to rin -ihout. 
 and sonic amoi 
 toits, too, are 
 
 '■'''"■P edge, and 
 |anty; they ba 
 '"r reniedyin|[r 
 'itiiall acti\-e s 
 ;''«i he i)erform 
 Mril}- \ary with 
 'iie fjuidance of 
 tot prominent 
 '^edge-sliaped 
 ctions should i 
 '»er segments c 
 '^fe t'lan simp] 
 •parate incision. 
 ^"'ie tibia and / 
 isteriorjy as tJK 
 ^scase is pure 
 '"'st the subcuf 
 '"rp as in ricket 
 'ntre of the slia 
 
 ne 
 
 filler 
 
 Frefore, 
 
 'ndition^ 
 
 ir the k 
 
 to 
 
 De 
 
 and 
 
 •^ase should 
 
 ?iiosis. 
 
 md 
 
 ')■ tal 
 
 'pes, or ell 
 
 ;';;|scular, Jigar 
 ainJy 
 
 urnn 
 
 m 
 
 'auses.--TaJip 
 
 ™?enient 
 
 'siiitr 
 
 in tl 
 
 « ^'I'oups ol 
 
DEFORMITIES 
 
 369 
 
 .iloiic are contracted, it may be possible io straif,'hteii the limb 
 aiiiler an ana'sthetic by forcible manipulation. \\'liere the con- 
 traction is associated witii osseous ankylosis, a suitable wedj^'e- 
 ^ha^)e{l piece of bone {iiuuiform osteotomy) should be removed. In 
 the triple displacement ordinary excision may be undertaken, but 
 it is often a dilliiult matter to remedy the backward displacement 
 f the tibia. The bones should subsecpiently be kept in position 
 ,i\ silvt'i-wire sutures, or other means. 
 
 ^Vhevej 
 
 OS. the] 
 atic orl 
 actvKill 
 sit)ns oJ 
 wface<] 
 iv acute 
 _>nt. bul 
 
 (in H 
 .akeii \\ 
 to tlij 
 nitvi^i 
 
 (rvoWtj 
 
 anteric 
 , Ik'xii' 
 [opposil 
 :casionj 
 feinu 
 
 Illy \yA 
 Vwiuitl 
 
 lowefJ 
 UK, tbei 
 the ti^ 
 
 Rachitic Tibia and Fibula. — It will be hereafter pointed out that 
 
 i:ie tibia and hbula are liable to a considerable amount of dis- 
 
 lOition in the course of an attack of rickets if the child is allowed 
 
 to run 'd)Out. As a rule, the antero-posterior curve is increased, 
 
 .mil snine amount of ab- or ad-duction may also be present. The 
 
 boiici', too, are usually llattened from side to side, presentin;^^ a 
 
 [sharp edf(e, and with a buttress-like support reaching along thecon- 
 
 Icavity; tliey become exceed^ ,dy dense and sclerosed. Operations 
 
 t r reitu'dying the defect Si «uld never be undertaken, liowe\er, 
 
 until all actixe signs of rickets have disappeared. ( )steotomy may 
 
 linen be performed, and the character of the operation will neces- 
 
 birilv vary with the amount of deformity. The general rule for 
 
 liiic f;iiidance of the surgeon is either to divide the bones at their 
 
 lost prominent part, or, if it is considered necessary, to remove 
 
 wedge-shaped portion from the tibia [cnncifoym osteotomy) ; the 
 
 tctions should always be made at right angles to the upper and 
 
 lower segments of the bone respectively. The filnda never needs 
 
 jore than simple division, and this is accomplished through a 
 
 ;parate incision. 
 
 The tibia and fibula also become distorted and curved antero- 
 jsteriorly as the result of inherited syphilis. The deformity in 
 liis case is purely antero-posterior, without lateral deviation, 
 the subcutaneous margin of the tibia is rounded, and not 
 :arp as in rickets. Moreover, the curve is mainly placed in the 
 entre of the shaft, whilst in rickets the chief deformity occurs 
 per near the knee or a little above the ankle. There ought, 
 ^trefore, to be but little difficulty in distinguishing these two 
 Editions, and a careful inc^uiry as to the previous history of 
 case should materially assist tne surgeon in forming a correct 
 
 m 
 
 [cfcWW^ 
 
 on 
 
 gnosis. 
 
 Talipes. 
 
 ijy talipes, or club-foot, is meant a deformity of the foot due 
 [muscular, ligamentous, or osseous causes, the displacement 
 
 Jiring mainly at the ankle and mid-tarsal joints. 
 pauses. — Talipes may generally be said to result from some 
 langement in the equilibrium normally maintained between 
 
 osing groups of muscles, in consequence of which the more 
 
 24 
 
370 
 
 A MANUAL OF SURGERY 
 
 powerful group draws the foot into an abnormal position. Con- 
 sidered more in detail, it is well to study the aetiology of the 
 acquired and congenital forms separately. 
 
 Coiifrenital malformation or malposition is responsible for a 
 certain percentage of the cases. Such may result from imperfect 
 development of the bones of the foot or leg, or from intra-uterine j 
 paralysis of central origin. Other cases seem to be due to a 
 deficient amount of liquor amnii, as a result of which the feet I 
 are abnormally compressed, and held in one position. It must 
 be remembered in this connection that in the foetus the legs are 
 naturally in a state of flexion, and the feet usually in the 
 position corresponding to that of talipes varus ; it is easy then to 
 understand that in an unusually small uterus this tendency may 
 be exaggerated. Spina bifida in the lumbar region is occasionallv 
 associated with congenital talipes, which is then probably due to 
 impairment of nervous control. The congenital variety is often! 
 hereditary, and may occur in several members of the same familvj 
 or be transmitted through many generations. 
 
 The acqui/ed varieties are somewhat easier to understand than) 
 the congenital, since they arise from definite pathological lesion? 
 such as : {a) Paralysis of central origin, one of the commonestj 
 causes of talipes ; in young children it is usually due to infantilej 
 palsy (anterior polio-myelitis), whilst a similar affection isl 
 occasionally seen in adults, (b) Contraction of muscles, tliej 
 result of diffuse suppuration, arising from burns or disease of| 
 neighbouring bones ; thus, necrosis, or caries, of ihe tibia ma 
 lead to the formation of an abscess in the sheaths of the tibialis] 
 anticus or posticus, and contraction of one or both of thesa 
 muscles may cause talipes varus, {c) Essential shrinking, reJ 
 suiting from a transformation of the muscle substance into iibroJ 
 cicatricial tissue, is occasionally met with in elderly people ; it ia 
 due to a chronic inflammation (myositis fibrosa), the nature oi 
 which is but little understood, {d) Affections of the niaiij 
 peripheral nerve trunks of the leg also result in talipes ; thus, 
 nerve may be divided in an accident or operation, or torn in 
 fracture or dislocation, or compressed by callus or splints, ol 
 inflamed (peripheral neuritis). If the internal popliteal nerve if 
 involved, talipes calcaneo-valgus will ensue, whilst a lesion of thi 
 external popliteal nerve produces talipes equino-varus. {e) Dee| 
 spinal mischief of a sclerosing type occasionally leads to spasm ( 
 some group of muscles and talipes of a spastic type. (/) Shorten! 
 ing of the leg from hip or knee mischief often causes a compenj 
 satory talipes equinus, whilst injuries or diseases of one of th 
 epiphyses of the leg-bones may stop its growth, and then i\ 
 continued development of the other bone forces the foot to oa 
 side or the other, {g) It is a qiiestion whether the conditioj 
 known as flat-foot, arising from prolonged standing, is to 
 classed as a form of talipes ; some surgeons draw but \m 
 
DEFORMITIES 
 
 371 
 
 difference between it and talipes valgus, {h) Finally, prolonged 
 maintenance of the foot in a bad position may lead to permanent 
 deformity, as in the variety known as talipes decubitus. The 
 barbarous custom still practised by the Chinese of forcibly com- 
 I pressinf:f the feet of female children brings about a similar result. 
 
 Varieties. — In considering the different forms of club-foot, it 
 
 j must be remembered that the ankle is a hinge joint only allowing 
 
 of flexion and extension, although when fully plantar-flexed a little 
 
 j lateral mobility is also possible. The movements of abduction 
 
 and adduction of the foot take place chiefly below the astragalus 
 
 and at the mid-tarsal articulation. Four primary varieties of 
 
 [talipes are hence described, viz. : T. Equinus, in which the heel 
 
 lis drawn up, the patient walking on the toes (plantar-flexion) ; 
 
 A B C 
 
 Fig. 104. — Various Forms ok Talipes Equinus. 
 
 I. Calcaneus, in which the toes are raised from the ground (dorsi- 
 
 pion) ; T. Varus, in which ;he anterior half of the foot is 
 
 lidducted, and the inner side of the foot is raised, the patient 
 
 Valking on the outer ; and T. Valgus, due to abduction and 
 
 [version of the anterior half of the foot, or to yielding of the 
 
 Witudinal arch on the inner side. Not unfrequently mixed 
 
 bms occur, due to the association cf two of the above, e.g.y 
 
 [.equino- varus, or T. equino-valgus or T. calcaneo-valgus. 
 
 As to tlie relative frequency of chese different forms, tliere is not 
 
 iie:lig;htest question that T. equino-varus is by far the commonest. 
 
 , however, we exclude congenital cases and flat-foot, T. equinus 
 
 fin all probability the variety most frequently observed. 
 
 [Talipes Ectuinus (Fig. 104, A, B,and C) is almost always acquired ; 
 
 pas been known to occur congenitally, but this is exceedingly 
 
 re, It is usually due to paralysis of the extensor Hurdles, 
 
 24 — 2 
 
 ^ 
 
372 
 
 A MANUAL OF SURGERY 
 
 either from infantile palsy or injury to the anterior tibial nerve 
 secondary contraction of the calf muscles follows, the tendo 
 AchilUs being specially tense and rigid. It also occurs as a com- 
 pensatory manifestation where the limb has been shortened as 
 after hip disease, and a variety known as T. decubitus results] 
 from the bed-clothes pressing for some length of time on the I 
 dorsum of the foot of a bed-ridden patient. 
 
 In the slightest cases all that is noticed is that the foot cannot i 
 be dorsi-flexed beyond a right angle (right-angled contraction of 
 the ankle). When the condition is more marked, the lieel is 
 actually drawn up, and the patient walks on the heads of the! 
 metatarsal bones and on the toes, which are usually hyper- 
 cxtended. Occasionally, however, in neglected cases due to I 
 paralysis, the toes, instead of being extended, become flexed, the! 
 
 Fig. 105. — Congenital Talipes 
 Varus. 
 
 iMci. 106. — Paralytic Form ok 
 Talu'es EguiNO-vAias. 
 
 patient walking on their upper surface (Fig. 104, C) ; if sucl; 
 condition is allowed to persist, the whole dorsum of the foot majj 
 in time be turned downwards. The astragalus is somewhat disJ 
 placed from under the malleolar arch, only the posterior part ol 
 the articular surface being in contact with the tibia. In easel 
 due to paralysis the deformity is always associated witH 
 dropping of the anterior segment of the foot at the mid-tars 
 joint, so that the head of the astragalus and scaphoid constitute 
 a marked prominence beneath the skin. In all cases the solei 
 ihe foot is shortened by contraction of the plantar fascia, and 
 tlie short plantar muscles, a condition we shall shortly refer tl 
 under the name of pes cavus. In old-standing cases a certai^ 
 amount of varus is almost always present. In this, as in all form 
 of talipes, callosities, and perhaps bursas beneath them, form ov« 
 points of pressure, viz., under the heads of all the iiietatars^ 
 bones. 
 
DEFORMITIES 
 
 373 
 
 Talipes Varus, or, as it is most frequently termed, Equino-varus, 
 
 .is the commonest variety of congenital club-foot, but is not a 
 jverv unusual result of infantile palsy of the extensor and peroneal 
 j muscles, with secondary shortening of the tibialis anticus and 
 Iposticus, the flexor longus digitorum, and of the tendo Achillis. 
 lOther cases are due to a primary spastic contraction of these 
 *!iiuscles. 
 The heel is drawn up, and the anterior half of the foot adducted 
 ind drawn inwards (Fig. 105). The inner border of the foot is 
 Iconcave, and a well-marked transverse crease crosses the sole on 
 jalevel with the mid-tarsal joint ; the outer border is convex, and 
 liii adults who have walked a thick bursal formation is usually 
 jpresent over the cuboid. In neglected cases the patient may even 
 l;;andon the dorsal aspect of the latter bone (Fig. 107, A). The 
 
 A 15 
 
 Fig. 107. — Nkglixtkd Case of Talipes Varus. 
 
 jole of the foot is arched from secondary contraction of the 
 
 itar fascia and short muscles of the sole, especially the abductor 
 ailiicis, and a longitudinal crease may run down the centre of 
 le sole, owing to doubling over of the outer metatarsal bones 
 fe 107, 1-5). 
 
 I The most marked Anatomical Changes are found in the astra- 
 lu infants the head and neck are normally set at an angle 
 1 the body of the bone, being directed slightly inwards ; as 
 
 wtl. proceeds, this diminishes from about 35° to 10°, so that 
 jithe adult there is but little obliquity of the neck. In Talipes 
 psthis angle is increased, often amounting to 50" or more, the 
 J:katthe same time being longer than usual, a condition simu- 
 
 ni,^ that found in some of the higher apes. The bone also 
 lojects forwards from under the tibio-fibular arch, the posterior 
 |rtion of the upper articular facet alone remaining in contact 
 
 I it. The scaphoid is displaced to the inner side of the head 
 I the astragalus, so that only the inner portion of the latter 
 lucture articulates with it ; the tuberosity is usually in close 
 
374 
 
 A MANUAL OF SURGERY 
 
 proximity to, or may even touch, the inner malleolus. The o^ 
 calcis and other tarsal bones are also modified to some t xtent in 
 position and shape to correspond with these changes. 'Jhc dorsa 
 tendons are displaced slightly inwards, usually occup\ing thi 
 centre of the concavity between the foot and the leg. The H<'ai 
 ments on the inner side of the foot are contracted, especially th( 
 anterior portion of the deltoid, the inferior calcaneo-scaphoid, anj 
 to a less extent the long and short plantar ligaments. 
 
 The following table (slightly modified from Mr. Tubby's excellen 
 work on Deformities*) Avill suffice to indicate the chief diagnosli^ 
 points between congenital and paralytic T. equino-varus : 
 
 Congenital. Paralytic. 
 
 History Affection has existed Affection not de\tloped tii 
 
 from birth. the second or third veal 
 
 and usiiered in by cuiui 
 
 sions, fever, etc. 
 
 Feet AFFECTED Usually bilateral. More often unilalural. 
 
 Circulation Good. Feeble ; limb is culd, blm 
 
 and clammy. 
 
 Muscles But little wasting. Extreme wasting. 
 
 Electrical Reactions Not much impaired. Almost entirely absent 
 
 paralyzed muscles. 
 
 Growth of Bones. . . . Much as usual. Considerably diminished. ' 
 
 Furrows in Sole .... Present. Absent. 
 
 Talipes Calcaneus (Fig. io8) is an unusual variety of tlj 
 deformity, and may be either congenital or acquired. In til 
 
 congenital form the toes are drawn ul 
 wards, so that the heel alone conies in| 
 contact with the ground, the sole poin 
 ing forwards. The extensor tendons ; 
 contracted, but the toes may be ile.\| 
 owing to the tension of the fiexor loiisji 
 digitorum. It is sometimes associatj 
 I^M with deviation of the foot inwards 
 0{ -^MB outwards, constituting a condition 
 t '^feW T- calcaneo - varus or -valirus. 
 u.^t^^ acquired variety is generally due 
 
 infantile palsy of the calf muscles, 
 occasionally results from over stretcliy 
 of the tendo Achillis after tenoton 
 
 J. „ „ The longitudinal arch of the footj 
 
 riG. io8. — Paralytic . ? ,i r .^i i i i 
 
 Talipes Calcaneus. increased, partly from the developmj 
 
 of a large pad of fat over the calcan 
 tuberosities, but mainly from the toes not being drawn uptowa 
 the leg as in the preceding variety. The anterior half of 
 foot appears to drop forwards from the niid-tarsal joint owing 
 secondary contraction of the plantar fascia and short muscle 
 the sole. 
 
 * Macmillan, 1896, p. 398. 
 
 M^:' 
 
T"!- 
 
 DEFORMITIES 
 
 2,1s 
 
 Talipes Valgus is a condition seldom met with as a congenital 
 lieformity, except in association with T. equinus. In it the outer 
 Ljdeof the foot is abducted and everted, owing to contraction of 
 
 liieperonei muscles. The sole becomes flattened, and the inner 
 border of the foot comes in contact with the ground (Fig. 109). 
 
 Considerable pain is usually experienced after walking a short 
 histance. The scaphoid is displaced outwards, so that the inner 
 hcrtion of the head of the astragalus projects into the sole of the 
 
 iwt, the cartilage being uncovered. This deformity is occasionally 
 1 to absence of the fibula. The acquivcd variety, which is not 
 linconinion (Fig. no), is produced as a result of paralysis of the 
 Itibial muscles, or from spastic contraction of the peronei, the 
 
 ;ondition in these cases closely simulating the deformity known 
 Iss flat-foot. 
 The Diagnosis ">f the different varieties of talipes is, as a rule> 
 
 a S 
 
 In, 109. — Talipes Valgus (Congenital), 
 jsiiH A Little Tendency to Calcaneus. 
 
 Fig. 1 10. — Acquired Talipes 
 Valgus. 
 
 Ii41v made, although the cause of the deformity is not always 
 
 |j) readily ascertained. In paralytic cases the limb is alwp/s 
 
 liirophied, bluish in colour, and feels cold and clammy. Trophic 
 
 Isions are not uncommon in the shape of recurrent ulceration, 
 
 IdJ even ulcers of the perforating type may develop, especially in 
 
 pes due to nerve lesions, whether central or peripheral. The 
 
 liiouble is often unilateral, and the muscles are wasted and 
 
 labby. In congenital cases the condition is usually symmetrical, 
 
 lof coui 3 present from birth ; considerable resistance is felt 
 
 Ion an;/ attempt being made to correct the deformity, and the 
 
 pjs are well nourished, at any rate at first. In spastic cases 
 
 «inDst frecjuently T. equinus) spasm or contraction of other parts 
 
 susually present, which renders the diagnosis obvious ; one or 
 
 limbs may be affected ; the muscles, at first firmly con- 
 
 fracted, may finally atrophy. 
 
 Ihe Treatment of talipes is always somewhat tedious, demand- 
 
 te care and patience on the part of all concerned. In the con- 
 
 pital variety no time should be lost in correcting the deformity, 
 
376 
 
 A MANUAL OF SURGERY 
 
 and, in fact, treatment should commence as soon after birth as 
 p^^ssible. The nurse must be instructed to manipulate the foot 
 inio a good position, holding it there for some time daily. At 
 the same time the muscles on the offending side of the limb 
 should be rubbed and stimulated. In the early stages of the 
 paralytic variety friction and faradization of the paralyzed muscles 
 must be regularly undertaken. At a somewhat later date treat- 
 ment by the application of suitable mechanical apparatus may 
 suffice to restore the foot to its normal position. If this is un- 
 successful, division of the contracted tendons, ligaments, and 
 fasciae will be necessary, whilst in severe and neglected cases 
 more extensive operations in the shape of tarsectomy or tarsotomy 
 may have to be performed. 
 
 Talipes eqtiiniis, if secondary to hip disease, should not, as a rule. 
 be interfered with. In other early cases, it may be remedied by 
 
 Fig. III. — Savre'.s Apparatus for Talu'es Equinus. 
 Tlie upper figure shews how the strapping is fixed to the plantar splint. 
 
 what is known as Sayre's apparatus (Fig. iii). This consists in 
 the application of a plantar splint which projects slightly beyond 
 the toes, and from the anterior end of which a piece of adhesive 
 strapping is carried to just below the knee, to which it is applied 
 and fixed by a firm bandage. Each day the bandage is carried 
 a little lower down the iimb, and as the traction of the strapping 
 is thereby increased, the foot is gradually extended. In the more 
 serious varieties tenotomy of the tendo Achillis may be required, 
 accompanied, if necessary, by division of the plantar fascia, whilst 
 in neglected cases, or where tenotomy has failed, excision of the 
 astragalus gives most excellent results, the patient being able to j 
 walk subsequently with a plantigrade foot. 
 
 Talipes equino-varus may be treated in the early stages by apply- 1 
 i;it4 to the foot a carefully-fitted malleable splint (Fig. 112), the 
 sliapo of which is gradually altered so as to bring it in time to a 
 normal position, or by a series of casings of plaster of Paris, a 
 little improvement being obtained at each change. By care and 
 
 Fig. 112.— Malle 
 
DEFORMITIES 
 
 377 
 
 patience many a cure will thus be obtained, but if time is of 
 value, or if the deformity cannot be overcome, or improvement 
 ceases, tenotomy is required. The tibial tendons are usually 
 divided first, and the tendo Achillis subsequently, although some 
 surgeons, and especially Mr. Edmund Owen, recommend that the 
 latter structure should always be first dealt with, as this will 
 occasionally suffice alone. The limb is at once restored to a good 
 position, and put up in plaster of Paris. In the more marked 
 cases division of the tense ligaments on the inner side of the foot 
 isvndesmotomy) may be necessary, particularly the anterior 
 portion of the internal lateral ligament of the ankle-joint. The 
 abductor hallucis muscle may also require section. 
 
 In neglected cases where the patient walks on the outer aspect 
 of the foot, two chief forms of operative treatment have been 
 advocated, viz., tarsectomy, and Phelps' operation, i . In tarsectomy, 
 ,1 wedge-shaped portion of bone is removed from the outer 
 
 Ik,. 112.— Malleable Spli.'IT for Treatment of Congenital Talipes 
 
 Equino-varus. 
 
 1 consists of two plates of metal, shaped to fit the sole of the foot and the 
 lower part of the leg respectively ; these are united by a malleable curved 
 bar of copper. The foot-piece is first fixed, and then the foot brought 
 into as good a position as possible, and the leg-piece bandaged on. Each 
 week the foot-piece is bent a little more towards the normal position. 
 
 [aspect of the foot. This is accomplished through an incision 
 
 jtound the outer border on a level with the cuboid. The thick 
 
 Subcutaneous structures, including the bursa, are removed, and 
 
 |tlie tendons stripped up from the bones both on the dorsal and 
 
 plaiitar aspects by the aid of a raspatory, and held aside by 
 
 Iretractors. The extensor tendons are already displaced some- 
 
 phat inwards, and hence are not injured by this proceeding. The 
 
 jtarsus is now divided by a chisel in two places in such a way 
 
 Itat a wedge of bone can be removed, the base being on the 
 
 pter aspect, and the apex on the inner. The position of the 
 
 lointsneed not be taken into consideration, and as far as possible 
 
 pe sections are made at right angles to the anterior and posterior 
 
 '*gments of the foot respectively. The wound is closed, and the. 
 
378 
 
 A MANUAL OF SURGERY 
 
 foot placed in a good position, in which it is maintained by plaster 
 of Paris. The after-treatment is likely to be prolonged, hut 
 otherwise the results are excellent, the foot, although a little 
 shortened, being firm and plantigrade. 2. Phelps' operation con- 
 sists in dividing all the structures on the inner aspect of the foot 
 through a vertical incision, starting above just in front of the 
 internal malleolus. Joints are, if need be, opened, tendons and 
 ligaments divided, and the foot put up in a good position with 
 the wound gaping. Healing may be accelerated by skin graftinf,', 
 The results are at first quite as good as those attained by tarsec- 
 tomy, and the operation has the advantage of not shortening the 
 foot ; but there is a decided tendency for the deformity to recur 
 as cicatrization advances. 
 
 In talipes calcaneus all that may be needed is division of the 
 extensor tendons ; but in the paralytic variety some form of 
 apparatus must always be worn. Where the tendo Achillis is 
 thin and attenuated, a portion of it may be excised, and the ends 
 united by suture ; or the healthy peroneus longus tendon may he 
 grafted into the tendo Achillis ; or the tubercle of the os calcis 
 into which the latter is inserted may be sawn off and reattached i 
 by a nail or peg to the bone at a lower level (Walsham) ; but the! 
 prognosis in all forms due to paralysis is somewhat unsatisfactory, 
 
 Talipes valgus, if unrelieved by the application of suitable boots, 
 may need division of the peroneal tendons, or in severer cases] 
 wrenching the foot into position, and fixation in plaster of Paris. 
 Removal of a wedge-shaped portion of bone from the inner aspect! 
 of the loot may be undertaken, but is not very successful. 
 
 Flat-foot {syn. : Splay-foot or Spurious Valgus) is a condition! 
 frequently seen in young adults whose occupation exposes themj 
 to long standing, over-fatigue, or the carrying of heavy weights;! 
 hence it is commonly met with in nurse-girls and shop-boys whoj 
 have only recently left school, any general deterioration of thej 
 health also assisting in the production of the deformity. It occursj 
 as a natural condition in many of the negro races, and is morel 
 often seen in long than in short feet. 
 
 Mechanism. — As already stated, there is some difference o^ 
 opinion amongst surgeons as to the primary causative factor in 
 the production of this deformity. The most generally accepted 
 idea is that it is in the majority of cases due to a relaxation of tha 
 inferior calcaneo-scaphoid ligament, which extends between tlia 
 adjacent surfaces of the os calcis and scaphoid, supporting thj 
 under surface of the head of the astragalus, and thus keeping up t 
 inner portion of the longitudinal arch of the foot. This in its turJ 
 is braced up by the tendon of the tibialis posticus and an expan| 
 sion backwards therefrom to the os calcis, as also by the planta 
 fascia and ligaments, and by the short muscles of the sole. \\ m 
 the weight of the body increases rapidly, and out of all proportio 
 
DEFORMITIES 
 
 379 
 
 to the muscular development, this important ligament is likely to 
 vield, and then the head of the astragalus is displaced downwards 
 into the foot, causing obliteration of the instep. Possibly paresis, 
 if not [)aralysis, of the tibialis anticus assists in this process, allow- 
 ing the peronei tendons to abduct the front of the foot from the 
 inid-tarsal joint, and in the later stages these tendons are often 
 found tense and rigid. By the majority of authorities, this con- 
 traction of the peronei is considered to be secondary to the liga- 
 mentous lesion, and quite independent of any weakening of the 
 jibial muscles. However produced, the deformity is tolerably 
 characteristic (Fig. 113). The sole of the foot is flat, and in well- 
 marked cases comes in contact with the ground throughout the 
 whole of its extent. The inner border is convex and somewhat 
 
 Fig. 113. — Flat-foot. 
 
 lengthened, whilst there is a tendency to eversion of its anterior 
 
 portion : the outer border may be slightly raised from the ground. 
 
 The head of the astragalus is distinctly felt a little in front of and 
 
 below the internal malleolus, whilst the sustentaculum tali, which is 
 
 normally to be distinguished about three-quarters of an inch below 
 
 the malleolus, is buried by this displacement. The tubercle of 
 
 the scaphoid is less evident than usual, being situated below and 
 
 in front of the head of the astragalus. The gait becomes some- 
 
 j what shuffling, and severe pain is experienced, not only in the sole, 
 
 but also about the heads of the metatarsal bones and in the toes. 
 
 I Sometimes it is extremely marked in the metatarso-phalangeal 
 
 joint of the great toe, which may be enlarged and rigid, owing to 
 
 1 an associated osteo-arthritis. 
 
 Treatment. — In the earliest stages, when the deformity, though 
 
 [threatening, has not yet actually developed, all that is required 
 
 I in many cases is rest, so as to allow the overstrained muscles and 
 
 ligaments to recover themselves ; at the same time the parts 
 
 [should be well rubbed with stimulating embrocations, and tonics 
 
 \'\ 
 
38o 
 
 A MANUAL OF SURG Eli Y 
 
 administered to improve the p^eneral tone of the system. In the 
 next stage, where the deformity, though present on stancHii", can 
 be made to disappear by manipulation, or on making the patient 
 stand on tiptoe, some slight support is advisable, and prol)al)lv 
 an indiarubber or cork instep pad worn inside the sock or stock- 
 ing will be all that is necessary. In addition to this, square-toed 
 boots must be used, so as to prevent any tendency to an increase 
 in the valgoid position of the anterior segment of the foot. It is 
 also wise to make the patient walk with the toes turned inwards, 
 and in some cases assistance may be obtained by ordering him 
 to sit cross-kneed, in the tailor position, so as to exercise a certain 
 amount of constant pressure inwards upon the front of the feet, 
 Regular exercises ought to be instituted, such as raising the hodv 
 on tiptoe with the feet inverted ; such can only be undertaken fiir 
 a short time at first, but as the muscles regain their tone a lonfer 
 
 Fig. 114. — Thomas's Wrench. (Down Bros.) 
 
 The two cross-bars are protected by thick indiarubber, and can be approxi- 
 mated or separated by rotation of the handle. The anterior portion < f 
 the foot is firmly grasped between them, ^ne being placed on the dorsal 
 and one on the plantar aspect, and forcible wrenching movements can 
 then be carried out. 
 
 period can be tolerated. In still worse cases a metal sprinjj or 
 instep pad may be required ; but frequently the tenderness of the 
 sole is so great that it cannot be borne. 
 
 When the affection has reached a later stage, and the deformity 
 cannot be remedied by ordinary manipulation, forcible rectiiicatioii 
 under an anaesthetic may be employed. The foot is firmly grasped 
 in the two hands or in a Thomas's wrench (Fig. 114), and the 
 anterior portion is forced inwards and backwards in such a way 
 as to draw the scaphoid round the head of the astragalus as a 
 fulcrum, and thus restore the arch. Probably a numher of 
 adhesions in the astragalo-scaphoid and other joints will be felt to 
 give way during this manipulation. Tenotomy of the peronei is 
 sometimes required before rectification of the position is possible. 
 The foot is then put up in plaster of Paris and kept at rest for 
 some weeks. The results of this method of treatment have been j 
 satisfactory. 
 
 In advanced cases that have been entirely neglected, operative j 
 
DEFORMITIES 
 
 381 
 
 proceedings are necessary, and probably the best of the many 
 that have been sugfjested consists in removal of a wedge-shaped 
 portion of bone from the inner side. Ogston advises that this 
 should be taken from the neck of the astragalus, but others have 
 advised either removal of the scaphoid or of a wedge-shaped 
 section of the foot without respect to joints (Stokes). 
 
 Pes Cavus (Hollow or Claw Foot) is a condition characterized by 
 increased concavity of the plantar arch, so that when the indi- 
 vidual stands there is a greater interspace than usual, if not an 
 absolute break, between the impressions produced by the anterior 
 and posterior segments of the foot. It is almost always an 
 acquired deformity, although a few cases of congenital cavus have 
 been reported. Corresponding to the increased concavity in the 
 sole, there is a marked convexity on the dorsal aspect of the 
 foot, whilst the toes are generally in the condition to be immedi- 
 ately described as hammer-toe ; the heads of the metatarsal bones 
 are unduly prominent below, and callosities often form beneath 
 tiiem. Considerable pain and inconvenience are occasioned by 
 these associated deformities. 
 
 Causation. — Duchenne originally maintained that it arose from 
 paralysis of the interossei and lumbricales in a manner similar to 
 tiiat which leads to the main-en-gyiffe after paralysis of the ulnar 
 r.erve, and it is quite possible that this accounts for a certain small 
 proportion of the cases. Others rightly associate it with a slight 
 Jefjree of talipes ecjuinus (right-angled contraction), and Parkin 
 let Hull has worked out its method of production from this cause. 
 The weight is normally carried to the ground mainly through the 
 lieel, hut also partly through the toes ; in these cases it is, how- 
 ever, only transmitted through the toes and front of the foot, and 
 since the anterior extensor muscles are supposed to be weak and 
 [paretic, the short flexors are able to act at an advantage, and by 
 ; contracting draw the heel downwards so as to reach the ground, 
 [and thus the arch is increased. 
 
 The Treatment in the early stages consists in friction applied 
 Ito the weakened muscles of the leg, together, possibly, with the 
 lapplication of a splint to the sole. In more marked cases division 
 jofthe tendo Achillis is needed, together with subcutaneous section 
 [of the tense plantar fascia. The deformity of the toes usually 
 jdisappears when the equinus is corrected, but may require further 
 lattention. 
 
 Hallux Valgus. — This condition consists in a displacement out- 
 ivardsof the great toe from the median line of the body, as a result 
 
 which the other toes are huddled together, and in extreme 
 ^ases the hallux is placed over or under them (Fig. 115). It is 
 
 resent in the majority of people in some measure, owing to the 
 Nual shape in which boots are made ; but in its severer forms it 
 
383 
 
 A MANUAL OF SURGERY 
 
 generally occurs in elderly people, and is often associated with 
 osteoarthritis of the metatarsophalangeal joint of the liallii\, 
 the greater power of the adductor group of tnuscles explainin' 
 the deff)rmity. The cartilaginous surface of the head of llie first 
 metatarsal hone becomes exposed beneath the skin, and by the 
 constant irritation of the boot it becomes inflamed, its structure 
 and shape altered, and the joint more or less disorganized. Two 
 other conditions are also met with arising from this deformitv 
 viz., bunion and hammer-toe. 
 
 A bunion consists in the formation of a bursa over the lieadof 
 the first metatarsal bone, which becomes inflamed from cold or 
 injury, and may e\'en suppurate, the abscess usually communi- 
 cating with the joint, and leading to its disorganization. .\ 
 marked bony outgrowth is usually found under the bursa, 
 springing from the inner side of the head of the bone, and due to 
 a localized chronic periostitis. 
 
 The Treatment of hallux valgus in its earliest stages consists 
 
 Fig. 115. — Hallux Valgus. 
 
 in the use of correctly-shaped boots, with the inner border straight! 
 from toe to heel. In worse cases an apparatus may be worn, 
 consisting of a band around the dorsum of the foot, to which isj 
 attached a support running along its inner border, towards whicli 
 the great toe can be drawn by elastic tension. In tlie niostl 
 severe types excision of the projecting head of the metatarsal bonej 
 through an incision made on its inner aspect, with replacement olj 
 the toe to a normal position, gives admirable results. Under 
 circumstances ought the second loe t r be removed for this con I 
 dition, as the lateral support of <.(ie great toe is thus weakened, 
 and the deformity is very probably aggravated. An inflmd\ 
 bunion is treated by removing all local pressure, and applyinjj 
 fomentations. If the joint Js involved in suppurative disease,! 
 excision of the head of the bone, or amputation of the toe, niavj 
 be required. In less serious cases it may suffice merely to removej 
 the thickened bursa. 
 
 Hammer-toe. — This deformity is constituted by hyper-extensionj 
 of the first phalanx, marked flexion to an acute angle of the! 
 second, and either flexion or extension of the terminal phalanx, sol 
 
DEFORMITIES 
 
 383 
 
 thiit tlui first interph.'il.'ingoal joint projects under the upper 
 
 leather of tlie hoot, whilst the patient walks on the extremity of 
 
 ttheiin.u^ual phalanx, or even on the nail (I'Mf^. 116). Corns form 
 
 up<iii tlii= points of pressure (i, 2, and 3), especially on the dorsal 
 
 j aspect, and a subcutaneous bursa over the head of the first 
 
 !i;il:inx (4), Riving rise to great pain and inconvenience. The 
 
 uecDii'l •-oe is that most frequently affected, with or without the 
 
 lothers, but it is uncoiumon for the halluK to be thus defonucd. 
 
 The Causes are numerous. It is occasionally congenital, but 
 Iniore often acquired, and then (a) it may be secondary to hallux 
 i valgus: (b) it may result from wearing short and pointed boots, 
 or very high heels; in either case the toes are crowded together 
 and dnnvn up out of the way of pressure : (c) it follows contrac- 
 tim of the plantar fascia, and is then associated with pes 
 cavusand perhaps a slight degree of talipes ecjuinus : (d) paralysis 
 
 Fig. 116. — Hammer-toe. (After Keen and White.) 
 
 li.Callnsity over liead of metatarsal bone in sole ; 2, callosity over end of toe ; 
 j, callosity or corn over head of first phalanx ; 4, adventitious bursa over 
 the same bony point. 
 
 lof the interossei and lumbricales may also lead to this condition 
 [ill the same way that the main-en-griffe follows paralysis of the 
 luliiar nerve. 
 
 However caused, the hyper-extension of the first phalanx is 
 lassociated with a contracted state of the extensor tendons, which 
 tod out very evidently beneath the skin. The flexion of the 
 second phalanx on the first is carried to such a degree that the 
 Hormer bone is semi-dislocated. The prolongations of the plantar 
 Bascia on either side are much shortened, and the lower portions 
 fthe lateral ligaments of these articulations are also contracted. 
 Treatment may be commenced by the use of correctly-shaped 
 boots, but the case has usually progressed to such an extent when 
 Blie patient is first seen that no palliative measures are of any 
 Jvail. Operation is then necessary, and this may in the first place 
 j)e directed to the contracted tendo Achillis and plantar fascia, if 
 Inch conditions are present, or to division of the lateral ligaments 
 M the first inter-phalangeal articulation. Division of the extensor 
 
384 
 
 A MANUAL OF SURGERY 
 
 tendons may also be tried, but probably the displacement of thei 
 base of the second phalanx is such that nothing short of removal! 
 of the head ot the first phalanx holds out any prospect of perma- 
 nent relief. \n incision is made longitudinally over the joint, tliej 
 extensor tendon being split down the middle ; the head (jf thel 
 l)one is then cleared by the raspatory, and nipped off by cuttiii"-. 
 pliers. The foot is put up on a splint, and care taken to main- 
 tain the toes in a good position by the use of some suitable! 
 
 appliance (Fig. 117). There aitj 
 / however, cases of hanimer-toej 
 
 affecting merely one digit that aref 
 
 perhaps best treated by amputa-i 
 
 tion. 
 
 Metatarsalgia, or Mortonsj 
 Disease, is characterized by seveieJ 
 pain of a neuralgic type locatedl 
 primarily about the head of one or| 
 more of the metatarsal bones, hut| 
 
 also radiating thence up and dowi 
 ViG^ 117.-T-SHAPEU Splint fok ^j^g ij,^^i^_ j^ ^^^^^^ ^^^^^^^ j,^ 
 
 Hammer-toe, which can he used , ^. . . , o ' .'■ 
 
 IN Slight Cases, or after ^^ rheumatic subjects, and may In 
 Operation in Bad Cases, attributed to some form of injuiv;! 
 
 it is frequently associated witli aj 
 slight degree of flat-foot, and may be due to the wearing of tiglitf 
 boots. Morton's explanation is that, as a result of the jMessure 
 of badly-fitting boots, the metatarsal bones and phalanges ar 
 laterally displaced, and the digital nerves compressed eithen 
 between the third and fourth or between the fourth and fifth. 
 That this displacement does occur in some cases has bet 
 demonstrated by skiagraphy, but it is doubtful whether tl 
 nerves are in reality compressed hehncen the bones, as Mortocj 
 belie\'es. R. Jones, of Liverpool, has recently adduced soiiia 
 weighty reasons for believing that the pain is rather to 
 explained by compression of the nerves between the boiie^ 
 and the ground. In other cases a simple peripheral neurida 
 may explain the manifestations. The foot is usually found to m 
 broader tb".n usual, and marked callosities or corns are found unj 
 the under surface close to the heads of the bones, one or moreoj 
 which may be unduly prominent. In a few cases small bonf 
 enlargements ha\e been found projecting from the heads of tha 
 metatarsal bones, and in others definite fibrous growths lia\i 
 been found in the subcutaneous tissues. The pain is genera 
 induced by walking, and comes on in characteristic paroxysnisj 
 Lateral pressure over the metatarsal bones sometimes relievel 
 the pain. Occasionally evidences of osteo-arthritis are found in 
 one of the neighbouring joints. 
 
 Tieatment consists in allowing the foot to rest for some tin 
 
DEFORMITIES 
 
 385 
 
 hhilst suitable diet and drugs are ordered to combat any gouty or 
 I'jeutnatic tendency. At the end of a few weeks the patient may 
 U alloXved to walk again, but only with suitable boots, which 
 {;!-iOul(l be broad anteriorly, and with an instep pad if flat-foot is 
 |5tesent. Morton's recommendation — viz., excision of the head 
 J the fourth metatarsal bone — may be reserved for the more 
 |jjgra\ated and serious forms of the affection. 
 
 ii' 
 
 filthJ 
 
 M 
 ,ovtoi^ 
 SDiiiei 
 to pa 
 boiicSj 
 iieuriti^ 
 [0 H 
 nd on 
 iioie I 
 1 boiijl 
 of m 
 IS \m 
 
 ;ner-i 
 )\ysms| 
 reiifvtl 
 juiul ill 
 
 le im 
 
 -J 
 
CHAPTER XVI. 
 INJURIES OF BONES— FRACTURES. 
 
 Contusion of a Bone and of its i^eriosteum is usually a matter 
 of no great naonient, although the part becomes painful, aiidj 
 swollen. Occasionally a subacute periostitis is caused in people! 
 liable to rheumatism or gout, or in the subjects of syphilis; 
 whilst in those who are thoroughly out of health, and with l(j\v: 
 •germicidal power, acute infective periostitis or osteoniyehtis,] 
 resulting in necrosis, may be lighted up. The Treatment i^f aaj 
 uncomplicated case consists merely in the application of coolin;,') 
 lotions or a bandage, whilst if periosteal thickening results, iodidej 
 of potassium may be given, and iodine paint applied locally. 
 
 Bending of Bone may or may not be associated with fracture.} 
 Bending without fracture occurs mainly in children, and in adultsj 
 is only the result of some local disease. More connnonlya partial! 
 or green-stick fracture is produced (p. 388). The deformity caul 
 generally be remedied by the application of a little force. 
 
 Fractures. 
 
 A fracture may be defined as a sudden solution of continuity iq 
 a bone, usually resulting from external violence. 
 
 Predisposing Causes of Fracture. ^ — Age has a considerabli 
 influence in the deternunation of fractures, and for two reasons j 
 firstly, because the strength and elasticity of l)ones vary consider 
 ably at difTerent periods of life ; and, secondly, because the liahilitJ 
 to injury is likewise variable. Fiom two to four fractures ar^ 
 not unconnnon, owing to th6 unsteady gait and frequent falls 
 which little children are exposed ; from four to six they are les 
 common, the bones often bending so as to cause green-stick fraci 
 tures, whilst injuries near joints induce separation of epiphysesf 
 from six years onwards fractures are fre(iuent enou.Ljh, and 
 increase steadily with the age, old people being peculiarly liablj 
 to this form of accident, owing to the bfSttleness of their hones. 
 
 Sex. — As might be expected, fractures are more common in t 
 male sex during boyhood and adult life ; but up to the age 
 
 r^^ties are jiserte 
 
INyURIES OF BONES— FRACTURES 
 
 3S7 
 
 ■;,ur or five they are equally frequent in the two sexes, whilst 
 ;;:ter forty-five they are more common in women, owing to their 
 real liability to intracapsular fracture of the cervix femoris and 
 ; Colles's fracture. 
 
 ]}oyhid Conditions of the Bones predispose to fracture in a marked 
 I manner, very slight force occasionally sufficing to bring it about. 
 Under this heading may be included: (i) Atrophy of bone, from 
 wiiatever cause it arises. Thus, it may be of the senile type, as 
 manifested especially in the cervix femoris ; or it niay be due 
 ;j want of use, as in a paralyzed limb or from an ankylosed 
 I loint. <^?rtain ner\ous affections, such as general paralysis and 
 I ither foiins of insanity, and even tabes dorsalis, are oft'-n asso- 
 I ciated with atrophic conditions of the bones, which lead to 
 I iracture without any apparent cause. (2) Fragilitas ossium or 
 I ..jteo-psathyrosis consists in an inherited tendency to spontaneous 
 iTacture. It results in a multiplicity of fractures, occurring even 
 [ :! chi'd'-e'i ; thus, a girl, aged twelve and a half years, had 
 I j'l'riied . m forty-one fractures since the second year of life. 
 |.\/ eM"'i;r"'atu ■ of this condition is known; the lesions often 
 IjiiitL I :^rfec^'y, though sometimes with a good deal of deformity. 
 I ]iG'..-'ral bone diseases, such as rickets and osteo-malacia, also 
 [.redispose to fracti re ; in those due to the latter affection there is 
 Ik:'.!:}' "o attempt at repair. (4) Local bone disease may also 
 lu'i:;titute an "mr >rtant predisposing factor by so weakening the 
 1,1011 'ar> to lead to its fiacture from a very slight injury. Thus, 
 i,-ircona and secondary cancer of bone are often first recognised 
 liiy causing a spontaneous fracture, whilst manipulation of a limb 
 ■ivhich is the seat of caries or necrosis may lead to a similar 
 |:r>ult. 
 
 ■ Till' Exciting Causes of Fracture are threefold : (i) Direct violence, 
 ■■...e fracture occurring at the spot struck. The direction of such 
 ■iftions is often trans. 'le. and they are not unfrecjuently com- 
 minuted, or complicaif:' vv '1 injuries to the adjacent soft parts. 
 ■oiWhen due to vr' red iiuunrc, the bone gives way at a distance 
 ■:rom the point to \n'i:'\} ♦'he force is applied. The accident is 
 ■:>ually produced mv Ui- impression or bending of the bone with 
 Mch force as t ^ exceed luc liiuits of its natural elasticity, so that 
 ■t yields at the weakest spot. Thus, when a person jumps from a 
 ■teijjht, the leg bones are compressed between the weight of the 
 ■I'jily and the resistance of tlie ground, and, if the violence is 
 Bscessive, a fracture occurs at some point of mechanical dis- 
 Bdvautage; if a person jumps from a carriage or train in motion, 
 ■Tie same conditions obtain. Fractures produced in this way are 
 Btten obli(|ue or spiral in direction, and as the displacement may 
 Bf considerable, ^here is great risk of them becoming compound. 
 Jil 3//;sch/(i;' actioii is ■■. ■ Ft connnonly the cause of fracture of 
 
 ieous prominences into which powerful 
 The pattella and olecranon are not unfre- 
 ■ 25-2 
 
 ' hor.f's, or o"' ■■ 
 Piscies are insertea.. 
 
388 
 
 A MANUAL OF SURGERY 
 
 quently broken in this way, the former often occurrinj:^ from 
 sudden and vigorous efforts to avert a fall. Occasionally one 
 of the lonf:f bones, such as the humerus or clavicle, has heen 
 broken by violent muscular exertion, as by throwing a cricket- 
 ball. 
 
 Intra-uterine Fractures may be caused by blows upon the 
 mother's abdomen, or by abnormal or violent uterine contractions, 
 especially if the liquor amnii is deficient in amount ; when 
 multiple, they are usually due to fcftal syphilis. They mav 
 present any type of deformity at birth, and may be partially or 
 completely united. They must be clearly distinguished from 
 malformations resulting from impt^rfect development. 
 
 Congenital Fractures are produced during birth by violence 
 used by the accoucheur, or from excessive uterine contractions. 
 They are most c(. non in the thighs if due to traction, or in the 
 skull if due to the -.---yy ,,£ forceps. 
 
 Varieties of Fi-a.^ r —Many terms are used to describe t'ne 
 
 multiplicity of condituu ■ 'vhich may be met with in connection 
 with a broken bone. The following are the more important : A 
 Simple Fracture is one in which the skin is unbroken, or, at anv 
 rate, where the external air has no admission to the site of injurv, 
 A Compound Fracture is present when the skin or mucous mem- 
 brane over the injured spot is lacerated, so that there is direct 
 communication between the fracture and the external air. In tlk- 
 base of the skull, however, a fracture may open up one of the 
 deeper air-sinuses, and thus cause it to become compound without 
 any apparent external lesion. These terms, though sanctioned 
 by the approval of centuries, are neither of ihem good, sw- 
 cutaneous and open being preferable. A subcutaneous fracture is 
 often anything but a simple injury, and may result in the most 
 disastrous consequences, whilst an open fracture may be a matter 
 of comparati\ely little importance. Indeed, with our present 
 appliances and methods of treatment open fractures often give 
 better results than those that are called simple. 
 
 Fractures are complete or incomplete., according to whether ot 
 not the continuity of the bone is entirely interrupted, ^'aril)ll^ | 
 forms of Incomplete Fracture are described, and since the introduc- 
 tion of skiagraphy their presence has frequently been deterininaj 
 in cases which would otherwise have been overlooked. Thus. 
 the green-stick fracture is one which only occurs in young children. I 
 and most often in those that are rickety; curved bones, such an 
 the clavicle, are usually affected, and the fracture merely involve- 1 
 the convexity of the curve, whilst the concave half is bent, jus: 
 as when a green bough or twig is partially broken. Dcprcsno'A 
 of the skull may be similarly incomplete when the outer table is 
 driven in without fracture and the inner table alone splintereJj 
 Fissured fractures also are often only partial. 
 
 Complete Fractures may be transverse, though this is not ver)j 
 
'^ flTJlll 
 lly one 
 s been 
 cricket- 
 on the 
 actions, 
 ; when 
 !y mav 
 :iallv iir 
 d from 
 
 /iolence 
 actions, 
 • in the 
 
 :ibe the 
 mection 
 tant: A 
 ', at anv 
 f injury, 
 IS nieni- 
 s direct 
 In tlk 
 e of the 
 
 withoii; 
 nctionei! 
 
 od, m- 
 .cture i? 
 
 le nios; 
 a rnattt"; 
 
 present 
 ten give 
 
 letlier or 
 Variou? 
 ntrochic- 
 tfrininei i 
 ThiiN I 
 childivtt 
 , such a; j 
 invohe.-| 
 lent. JUN 
 ;('y)ir5.<;;'--| 
 r t;ible:-| 
 plinteiu 
 
 not very I 
 
PLATE IX. 
 
 'EP 
 
 OBLiguE Fracture ok Thua, showing the ends ok the fragments shap 
 
 I'll bcc (If flute. 
 
 The skiagram was taken from the front through a casing of plaster of Paris, tiie 
 irregular outline of which can he seen on the inner side of the limb. 
 
 common ; o 
 uhen the fi 
 t!ie same ti 
 most fVeque 
 iil'ten has a 
 •ippeanince 
 htc : see PI, 
 ur splitting 
 niilitat'}' siir^ 
 inj,' joints iiic' 
 transverse fii 
 term used to 
 more than tv 
 the other ; ;, 
 tlicatcd, when 
 <Iaiiia,i(e(l as v 
 Tlie Separa 
 in people unci 
 iir violence di: 
 "Hire or less 
 epiphysis or ( 
 inherited syp} 
 The ends of t 
 afTected. TIk 
 spongy l)one (i 
 IS cartila^^e wi 
 the other. T 
 tpipliyses are i 
 (haphyses heii 
 epiphysis is ei 
 'il^rays a pure 
 iater date it is 
 adjacent end ol 
 in all these Jes 
 ''"^"Pli loosely 
 I ciiildren, is firn 
 I connection wit 
 i'"\rever, the fo 
 ""e side hy th 
 I which thus in v(| 
 displacement is 
 I <i dislocation. 
 
 ' tile longitud 
 h'-^was at one ti 
 jance where one 
 jdefdnnities of t 
 l^'wwth of the u 
 •'' sequela in un 
 
 To face f- .i?9- 
 
INJURIES OF BONES— FRACTURES 
 
 389 
 
 comiiKjn ; oblique, arising usually from indirect violence ; spival, 
 when the fracture is due tu a force acting longitudinally, but at 
 the same time with a rotary movement superadded ; it occurs 
 most frequently in the tihia or femur, and the lower fragment 
 often has a sharp triangular upper end, giving it somewhat the 
 appearance of the mouthpiece of a clarionet (fracture en bee de 
 Mc ; see Plate IX.). A longitudinal fracture is one due to Assuring 
 ',,r splitting of the bone in its long axis ; it is most conuiion in 
 military surgery, as the result of gunshot injuries; the neighbour- 
 ini; joints may or may not be involved. If it is combined with a 
 transverse fissure, it is often termed T-shaped. Comminuted is a 
 term used to describe the condition when the bone is broken into 
 more than two pieces ; impacted, when one fragment is driven into 
 the other ; multiple, when more than one fracture exists ; com- 
 tlkntcd, when important structures, such as an artery or joint, are 
 (lainaj^^ed as well as the bone. 
 
 The Separation of an Epiphysis is not an unconunon occurrence 
 in people under twenty-two years of age. It results from injury 
 (ir violence directed to the ends of the bones, but occasionally is 
 more or less spontaneous, or predisposed to by disease of the 
 epiphysis or of the adjacent portion of the diaphysis {cf:;., from 
 inherited syphilis, or acute infectixe or tuberculous epiphysitis). 
 The ends of the femur, humerus, or radius are those most often 
 affected. The line of cleavage usually runs through the soft 
 spongy bone on the diaphyseal side of the cartilage, so that there 
 !j cartilage with spicules of bone on one side, and spongy bone on 
 the other. The direction taken is in the main transverse, but most 
 epiphyses are more or less conca\e or cup-shaped, the ends of the 
 diaphyses being convex. In very young children, where the 
 epiphysis is entirely or mainly cartilaginous, the lesion is almost 
 ahvays a pure separation of the epiphysis from the shaft ; but at a 
 later date it is not unusual for the fracture also to implicate the 
 adjacent end of the diaphysis (Fig. 137). A very marked feature 
 in all these lesions is tlie stripping up of the periosteum, which, 
 though loosely attached to the shaft and easily detached from it in 
 children, is firndy adherent to the cartilage, and hence retains its 
 connection with it, thus frefjuently limiting displacement. If, 
 however, the force is sufficient, the periosteum is torn through on 
 one side by the edge of the bone, and the periosteal ' sleeve ' 
 which thus invests it may to some extent hinder reduction. The 
 
 ■^placement is mainly lateral, and may somewhat resemble that of 
 [.-dislocation. Union usually occurs by lueans of bone, and arrest 
 't the longitudinal growth may follow, though not so frecjuently 
 • > was at one time supposed. This is a matter of special import- 
 ance where one of the bones of the leg or forearm is affected, since 
 jdeformities of the hand or foot often result from the continued 
 growth of the uninjured bone. Suppuration sometimes occurs as 
 Y sequela in unhealthy children, or when the accident is due to 
 
TT;r:' I 
 
 390 
 
 A MANUAL OF SURGERY 
 
 preceding disease of the epipliysis, and may result in an aciii,. 
 arthritis, possibly necessitating amputation. 
 
 Partial detachment of an epiphysis {the jiixta-epiphysecil siyain i,\ 
 Oilier) often occurs, giving rise to phenomena similar to those i)f 
 a sprain ; if o\erlooked and neglected, it is likely to pro\e a t'crlilc 
 source of tuberculous disease, or may interfere with the grow tli of 
 the limb. The essential feature is a more or less tender hut 
 \ery distinct swelling the bone close to the epiphysis, but thu 
 neighbouring joint remains unaffected. Treatment consists in 
 immobilization in plaster of Paris. 
 
 Signs of Fracture. — The history usually given by the patient is 
 that, as the result of some accident, he felt, or perha])s heard, 
 something give way with a snap and experienced sharj) pain, 
 which became much intensified on attempting to move the limli. 
 On examining the injured part and contrasting it with the opposite 
 side, the following points are usually noticed : 
 
 1. The 5/^''//5 of a local trauma, viz., pain, bruising, and swelling,'. 
 as a result of the effusion of blood from the tc^-n and lacerated 
 structures. The amount of this may be so great -s to obliterate 
 all the ordinary bony prominences and landmarks. IMehs and 
 bullae sometimes form over the surface in the course of a dav or 
 two, and these should be carefully protected from infection. The 
 discoloration continues for some time, and may spread to parts 
 far removed from the original mischief. This infiltration ot ihe 
 parts with blood often leads to considerable subse(]uent thicken 
 ing, and possibly to serious adhesions and limitation of move- 
 ment ; this fact is correctly utilized as an argument in favour ot 
 the treatment of fractures by an open operation. It is unusual for 
 suppuration to occur after a simple fracture, but if the patient i> 
 \ery debilitated, and his germicidal powers diminished, auto- 
 infection and abscess may result. 
 
 2. Pretcvuatnral mobility in the continuity of the hone may be 
 demonstrated by manipulation, but never unnecessarily. Im- 
 paction of the fragments prevents its occurrence. 
 
 3. Partial or complete loss of function also follows. 
 
 4. Crepitus is obtained by moving the limb and rubbins,' the 
 rough ends against one another. It can only be felt when the 
 fragments are moveable and can be brought into contact, but not 
 when there is wide separation or impaction. When an epiphysis 
 has been detached, it is softer in character. 
 
 5. Change in shape of the limb or deformity from displacements 
 almost always present. There are three chief factors at work in 
 producing deformity, \iz., the direction of the violence, the weii^ht 
 of the limb, and the contraction of muscles, whilst injudicioib 
 movement or rough handling may aggra\ate it. It is alway,^ 
 more marked in oblique than in transverse fractures, and hence is 
 usually greater in those due to indirect violence. \'arious types 
 of displacement are described, viz.: Angular, usually due to an 
 
INJURIES OF BONES— FRACTURES 
 
 39« 
 
 ncreasrd curvature of the bone from the unbahincecl action of 
 luwerful muscles, es{)eciully wlieu the hne of fracture is not far 
 ■roin the end of the shaft, as in fracture of the upper third of tlie 
 tlii'^h ; Intend, where the displacement is merely to one or the 
 other side, and most conmion in transverse fractures; l()ii<,'ifiidiiial, 
 when one fra^Muent overlaps the other or is forcibly driven into it, 
 causing,' shorteninj^^ of the limb; it may also occur in the form 
 of wide separation of the traj^nnents, as from contraction of the 
 luadriceps in fractiu'e of the patella ; yotatory, when one fraf,niient 
 b twisted on the other, as in fractures of the fennir, where the 
 weight of the lind) causes e\ersion of the lower end. In flat 
 hones — e.g., the skul' — deforiuity may exist in the shape of 
 Un'ssioit or elevation. 
 
 Such are the typical sij:(ns of a fracture, but it goes without 
 Niving that all of them are not present in every case, and that it 
 is not always easy to ascertain the existence or not of such a 
 lesion. Comparison with the op]X)site limb, and gentle manipula- 
 tion to demonstrate abnormal mobility or crepitus, must be under- 
 taken to settle this point, but no undue violence should be used. 
 
 The X rays have proved of the greatest value in these cases, 
 and where there is any doubt as to the existence or not of a 
 iiacture, the limb slunild be at once skiagraphed. 
 
 General or Constitutional Effects. — These may be divided into 
 :wi) i,M'()ups : 
 
 1. Immediate Effects, consisting of shock and haemorrhage. 
 Skxk is greater or L^ss according to the amount of violence 
 and the seat of injury. It varies from a mere passing faintness 
 •lO the severest prostration. If the bones of the head or spine are 
 injured, special symptoms due to concussion of the brain or 
 injury to the spinal cord may also be produced. Hanwrvhage 
 always occurs either in simple or compound fractures, and it may 
 progress to a considerable degree from laceration of important 
 vessels or even of the main artery of a limb. 
 
 2. Secondary or Remote Effects. — Fvaduvc fever is met with in 
 ;;:e majority of cases, conuuencing twenty-four hours after the 
 uccident and lasting two or three days. As a rule, it is not 
 H'vere, the temperature rarely rising above ioo° F. in uncom- 
 plicated cases. It is a form of aseptic traumatic fever, probably 
 iiue to the absorption of fibrin ferment. In compound fractures 
 where asepsis is not attained, any form of wound infection may 
 risuit, and even general septicaemia or pyaemia. 
 
 Ddii'iuin fyemens is a not unusual complication of fractures 
 "t the leg in debilitated individuals or habitual drinkers. The 
 ;'t.nend characters and treatment of the disease are dealt with 
 elsewhere (p. 189). As regards local treatment, the limb must be 
 iixed by splints or encased in plaster of Paris, and suspended in a 
 Salter's swing so as to prevent the patient from moving the upper 
 Iragment independently of the lower. 
 
392 
 
 A MANUAL OF SURGERY 
 
 Fat embolism is a condition resulting from the absorption (jf 
 lir()l<en-up fat globules after any injury which results in the con. 
 tusion or laceration of fatty tissue. If at the same time niucli 
 hajmorrhage and local tension exist, as in fractures where the 
 medullary fat is involved, this process is more likely to occur. 
 As a general rule, no harm results, since the great mass of the 
 tat is liltered off by the lungs or eliminated by the kidneys (as 
 can be demonstrated after death by staining with osmic lujdi. 
 The pulmonary obstruction may, howe\er, become so great as to 
 lead to a fatal issue from dyspno'a ; whilst if the cerebral vessels 
 are also blocked, syncope, or e\en coma, may be induced. The 
 symptoms, which are gradual in their onset, usually commence 
 about the third day, but may not be evident for a week or more. 
 
 Complicated Fractures. 
 
 1. Comminution of one or both fragments is due to excessive 
 violence, or perhaps to exceptional brittleness of tlie bones. .As 
 long as the skin remains unbroken, sound union is usuallv ob- 
 tained, though witli an increased amount of callus. Occasit)nall\ 
 comminution may be a cause of non-union, a small detached 
 portion of dense compact tissue being wedged cross-wise l)et\veen 
 the fragments, especially in the case of the tibia or femur. In a 
 compound fracture serious mischief may result from sepsis. 
 
 2. Fracture implicating a Joint. — In healthy indixiduais no 
 untoward result is met with ; the joint is for the time filled 
 with blood, which, however, is soon absorbed, and the hssure in 
 the cartilage closed by plastic lymph. Adhesions are, however, 
 very liable to form, as also new bony deposits, leading to defective | 
 mobility or e\en locking of the joint. Early passive movement | 
 and the breaking down of adhesions under chloroform may 
 impiove matters. If the patient has a tuberculous tendency, I 
 arthritis will possibly be lighted up, whilst osteo-arthritis is often 
 induced by an accident of this nature. 
 
 3. The same violence that causes the fracture may at tlie samel 
 time produce a Dislocation in a neighbouring joint. Treatment 
 should be undertaken inunediately ; the limb is firmly fixed 
 in splints commanding both fragments, and reduction attempted 
 under chloroform. Failing this, consolidation must be allowe' 
 to proceed, and then the case dealt with as one of old-standingj 
 dislocation (p. 510). If the fracture involves, or is close to, the 
 articular end of the bone, as is not unfrequent at the elbow and! 
 shoulder, it may be advisable to operate at once, opening thej 
 joint, reducing the dislocation, and wiring the fragments ; or itj 
 may be better to remove the small detached articular portion. 
 
 4. The Main Artery of a limb may be compressed, contused,] 
 punctured, or ruptured. Thrombosis results, with or without suchj 
 an extravasation of blood as may impede the venous return. 
 
INJURIES OF BONES—FRACTURES 
 
 393 
 
 ,;,L. peripheral vessels are healthy, no permanent harm need follow, 
 unless tlie \ein is also implicated, and then moist f^'anf^n'enc is 
 lil^ely to supervene. If the terminal vessels are calcarecnis and 
 riijid, so that there has been a preceding condition of chronic 
 amiTiia, dry gangrene will probably ensue, in the slighter cases 
 an neurism may subser|uently develop. I'^or furtlier details, 
 see Chapters I\'. and \'I1I. The Treatment must necessarily 
 \aryin cliOerent cases. The ideal practice would be to cut down 
 in every case where a large artery is punctured or ruptured, remove 
 clots, and tie above and below the injuty in the vessel ; but, 
 owing to the extensive laceration and displacement of the parts, 
 it is not always advisable to do so, and, indeed, it should never 
 be undertaken without the most rigid asepsis. If it is considered 
 unwise to lay the parts open, the main artery may be compressed 
 or tied above the fracture, but only where the distal circulation 
 has been re-established ; in the absence of this condition, gangrene 
 would be certain to ensue. If neither of the abo\e-mentioned 
 expedients can be adopted, an expectant plan of treatment must 
 jie followed. The limb is thoroughly purified, wrapped in aseptic 
 wool, placed on appropriate ."■ plints, and slightly elevated. Should 
 pini,Tene supervene, amputation is the only resource ; it need not 
 It undertaken for a few days if the limb is aseptic, so as to allow 
 a distinct line of separation to form ; but if septic, early removal 
 dirou^di or above the line of fracture is essential. 
 3. Laceration of the Veins of a limb results in extravasation of 
 blood, which is not so extensive as when an artery is wounded, 
 from the fact that thrombosis is more easily determined owing to 
 e lesser blood-pressure, but the congestion and (jedema of the 
 ;(listal part of the limb which follow constitute serious additional 
 lements predisposing to gangrene. Simple compression of the 
 eins produces oedema, which, even in favourable cases, may 
 ipersist for some time, needing for its removal firm bandaging, 
 lussage, and cold douching. 
 
 0. The Nerves of a limb may be injured at two different periods. 
 |i!) Immediate injury is due to laceration or rupture, either of the 
 lole trunk, or, as is more common, of the ner\e fibrilla?, without 
 loss of continuity of the sheath. Paralytic and anaesthetic pheno- 
 "iCna follow, but are usually recovered from. {b) Secondary 
 vniptoms result from inclusion and compression of the nerve 
 the callus, or from injudicious splint pressure. Irritative 
 iymptoms in the shape of neuralgia and muscular spasms are 
 St manifested, followed by paralysis and anaesthesia. This 
 ually occurs about three or four weeks after the accident, 
 nd may diLappear in a month or two, or persist. Treatment is 
 iHvays for a time of the expectant type, even when the paralysis 
 immediate,, since total rupture of a nerve is rare, and restoration 
 function ihe lule rather than the exception. When, however, 
 e symptoms persist, the parts must be laid open, the nerve freed 
 
.594 
 
 A MANUAL or SURGERY 
 
 from adhesions, or exuberant callus removed, and such moasuro^ 
 taken as will best secure the nerve from furlher compression. 
 
 Union of Fractures. 
 
 The union of fractures is brought about by a series of chants 
 analogous to those which we ha\e already seen occur in other 
 wounds, except that they do not terminate in the fortnation n 
 cicatricial tissue, but go on to the further developmcMU of hone, 
 
 When a fracture has occurred, the broken ends of the bone arc 
 left rough, spiculatetl, and more or less separated one From the 
 other; the periosteum is torn, but, according to Oilier, the 
 rupture is not always complete all round, a ' periosteal bridge' 
 perhaps persisting, and playing an important part in the repara- 
 tive process, especially if the fracture is not accurately set. The 
 nuiscles and neighbouring tissues are also lacerated, and a varying; 
 amount of blood is e.xtravasated, occupying the interstices of the! 
 wound. In the course of a few hours after the parts ha\e been 
 imiuobilized, the process of repair is inaugurated by the blood-clot 
 becoming in\aded by leucocytes, and after a time it is absorbed,! 
 the haemoglobin j)assing through various stages of degeneration, 
 and thereby staining the surrounding tissues. At the same time.l 
 a rarefying inilammation occurs in all the injured and laceratedl 
 structures, as a result of which an exudation of plasma occursl 
 into their substance, whilst the connectixe tissue cells proliferate 
 actively, and thus a cellulo-plastic exudation forms around anr 
 between the lacerated tissues and broken ends of the bone, whichj 
 is transformed into granulation tissue by vascularization froml 
 circumjacent \essels. Calcification of this material follows, pre-[ 
 ceded or not by a cartilaginous or fibrous change, and this calcifiedj 
 material is in its turn replaced by bone, which, at first soft andj 
 spongy, becomes after a time firm and sclerosed. Of course,[ 
 these changes do not occur simultaneous!} in all the tissiiesl 
 involved, and we must refer to them as they affect the periosteum,[ 
 the medulla, and the bony substance itself. 
 
 The periosteum becomes thickened and more vascular, and iti 
 connection with the bone is loosened for a short distance byaa 
 exudation of plasma, which is soon followed by a new deposit oS 
 spongy bone on the surface, as a result of the irritation. Tl 
 space beneath the periosteum is quickly occupied by granulatiod 
 tissue, which unites with that developed from surrounflin^^ torn 
 structures and with that coming from the bone itself, and thisovoi(| 
 mass binding the fractured ends together is known as the /w 
 visional or cnshcatJiing callus. The transformation of this callus intd 
 bone starts from the periosteum ; if it has been totally lacerated! 
 ossification commences at the furthest point from the fractiirl 
 where the irritation caused thereby is felt, and gradually spreadj 
 
 u% If a perios 
 
 ander surface, ; 
 
 lormed bone ca 
 
 .uid evidently d 
 
 new licne deri\ 
 
 ceded hy cartii,' 
 
 Aciiirtiice of c 
 
 hinm was forme 
 
 I where absolute 
 
 Ttures of the 
 
 .lie changes 
 
 jhvpera'inic for' 
 
 |iransfurniation 
 
 sprinfjing up fr 
 
 loiniitiences in tl 
 
 .<yi, from whic 
 
 liTanulation niai 
 
 timid callus, oi 
 
 Ifjrmation of can 
 
 Naturally, the 
 
 J !o engage in the; 
 
 llliey are in beiiij^ 
 
 Ijiiiic, and practi 
 
 jtl'.c hone c:ells pn 
 
 ^'an canals increj 
 
 ig absorbed, 
 
 'th and co\ 
 
 |witli tile niedull, 
 
 las an extensi 
 
 )\ver, since all 
 
 Ikne nuist be ei 
 
 liie annular bone 
 
 lie, to which w; 
 
 s probably of pe 
 
 llractured surface. 
 
 It will thus be 
 
 h'i before the ; 
 
 llepends on the 
 
 lapidity of this 
 
 laceration, but in 
 
 of gentle pa 
 
 Piree or tour weeL 
 
 p bone with tht 
 
 t first soft and s 
 
 walled definitiv 
 
 us disa[)pears, 
 
 flay vanish entir 
 
 My renio\-ed. 
 
INyUh'lES OF HONES— FH ACT LRUS 
 
 395 
 
 1 ,5, If ;i periosteal l)ri{l<;(^ is l(!ft, ossification commences on its 
 
 jnder surface, and not imtVefiucntly in skiagrams a line of ncnviy- 
 
 iformetl l)one can he seen passin-^ from one fraj^ment to the other, 
 
 I uul eviilently due to this cause. Some authorities maintain llial 
 
 Liewl'i'iie deri\'ed fiom jieriosteum in this maimer is always jire- 
 
 ceded bv cartilaf^e, hut this is prohahly not tile case, althou;;li the 
 
 xcurreiice of cartilage; in the re|>air of fractures is more conunon 
 
 hiiaiiwas formerly supc)osed. It is most liUely to occur in cases 
 
 I where absolute inmiohili/ation hiisnot hecn obtained — f.^., after 
 
 ' ictures of the ribs and in children. 
 
 il)e changes oi)taining in tlu; medulla consist in its becoming 
 |'nvper>Tinic for some distance Ircjm the seat of fracture and its 
 hranstoiination into granulation tissue, which unites with that 
 b;irint,'ing up from the opposite fractured surface. Ossification 
 joiiiimeiices in this, probably from the inner aspect of the compact 
 .jicll. from which fine spicules of bone gradually permeate the 
 granulation mass until the whole is ossified, constituting the 
 liiita// callus, t)r, better, the medullary pluf^. There is here no 
 liorniation of cartilage. 
 
 Xiiturally, the bony tissue involved in the fracture is the last 
 
 [ioeiif,';ige in these changes, and the denser the i)one, the longer 
 
 |tliev;ire in being completed. The fractured end becomes hyper- 
 
 Ijiiiic, and practically passes into a condition of rarefying u teitis, 
 
 Itiiehoiu' cells prohlerating, the medullary contents of the iia\er- 
 
 '4n canals increasing in amount, and the actual osseous substance 
 
 i;; absorbed, until the rough and spiculated surface becomes 
 
 th and covered witii granulations. These quickly unite 
 
 iwith the medullary j^lug, of which they may indeed be looked 
 
 |o:i as an extension ; but the union with the periosteal callus is 
 
 lliwer, since all the blood-clot and the damaged surfac v, of the 
 
 Ikne must be entirely removed before this is possible ; indeed, 
 
 p annular bond of union between the two layers of compact 
 
 one, to which was originally applied the name ' definitive callus,' 
 
 probably of periosteal origin, and not derived at all from the 
 
 ^tactured surface. 
 
 It will thus be obvious that the continuity of a bone is restored 
 
 luiii: before the act of repair is completed, and that such union 
 
 ttpends on the ossification of the ensheathing callus. The 
 
 rapidity of this process varies with the amount of periosteal 
 
 laceration, but in many cases the callus is sufficiently firm to 
 
 V of gentle passive movement in ten to twehe days, and in 
 
 liree or tour weeks it may be so firm that it is difficult to bend 
 
 ne bone with the fingers. The newly-formed osseous tissue is 
 
 t first soft and spongy, but gradually becomes denser. As the 
 
 )called definitivv: callus becomes stronger, the ensheathing 
 
 alius disappears, and finally, if the ends are in good position, 
 
 pay vanish entirely, whilst the raedullary plug may also be 
 
 Ctally removed. Thus it is possible for the l)one, under these 
 
396 
 
 A MANUAL OF SURGERY 
 
 circumstances, to be so absolutely restored as to show no sif(ris 
 of its having been fractured. 
 
 Thus far we have been supposing that the broken ends are 
 accurately apposed and the limb immobilized; but little rallus is 
 formed (Fig. ii8, A), and that equally and evenly all mund the 
 site of the fracture. Where, however, movement is possible, tlic 
 amount of callus is much increased. 
 
 Where the ends of the bones partially overlap (Fig. ii.S, B). 
 the amount of ensheathing callus (c) is correspondingly increased, 
 and fills up all the spaces left by the overlapping of the fraj;. 
 ments. The projecting margins of bone are rounded off, and tbe 
 
 Fig. ii8. — Diagram to kkprksknt Union of Fractures: A, whkn iiq 
 Ends are in Close Apposition ; B, when the Ends are onlv I'l 
 TiALLV Apposed; and C, when the Fractured Surfaces ark not 
 Contact at ale. 
 
 ii, True or definitive callus, /;, internal or medullary callus; c, external i 
 
 provisional callus. 
 
 medullary ca\ ities closed by plates or plugs (b) ; the amount ol 
 definitive callus (a) is usually small, but varies with the actu/ 
 conditions present. The main bond of union is the ensheathinl 
 mass, a considerable portion of which persists. Some deformitj 
 is sure to remain after such an accident, and it is unusual tor tli 
 medullary canal to be restored ; frequently one or more plates ( 
 br'ue are found crossing it. 
 
 If the fractured ends are not placed in contact at all (Fig. ii8,Cj 
 the medullary cavity of each fragment is closed by a plate 
 internal callus (b), and union is secured by a large mass of 
 sheathing callus (c). 
 
 Where conuninution has occurred, the splintered fragments; 
 matted together by an abundant formation of granulation tissw 
 which is subsequently transformed into callus. 
 
INJURIES OF BONES— FRACTURES 
 
 397 
 
 The soft tissues around — muscles, tendons, etc. — are repaired in 
 the usual way, but one cannot overlook the fact that such repair 
 is often \ery imperfect, owing to the infiltration of the parts with 
 Wood and the subsequent adhesions that form. In fact, although 
 the bones may unite perfectly, the functional result may be most 
 disappointing. 
 
 The removal of the clot and the formation ^i granulation tissue 
 usually take about a week or ten days, and new bone formation 
 commences about the end of the first w^eek. By the fourth or 
 sixth week, according to the size and vascularity of the bone and 
 tlie recuperative power of the individual, the fracture will be con- 
 solidated, but in the lower limb it is often eight weeks before the 
 patient can bear any weight upon it. Months may, however, pass 
 hefore the final stage of complete repair is attained. 
 
 In conclusion, one must allude to the fact that a sarcoma some- 
 times develops at the site of fracture within a comparatively 
 siiDii time of the accident, and is presumably derived from an 
 
 ergrowth of the callus. 
 
 The Treatment of simple fractures is sometimes a matter of but 
 
 little difficulty, although when the bones are much displaced or 
 
 c mminuted, it may not be easy to correct the deformity or to 
 
 I maintain the fragments in position. Constitutionally, all that is 
 
 iveiled is to restrict the diet, eliminating all stimulating and 
 
 ..necessary articles, at the same time attending to the state of 
 
 •i.e bowels. This is especially needed in fractures of the lower 
 
 |;\treniitv, where the patient must be confined to bed for some 
 
 me, In elderly people the general health is very likely to suffer, 
 
 [partly from the shock of the accident, partly from the enforced 
 
 laRcl sudden change of habit, necessitating a somewhat generous 
 
 idietand the administration of a certain amount of stimulant. 
 
 be Local Treatment of a simple fracture consists, first, in setting 
 Hmb— that is, in reducing the deformity and restoring the 
 IlLictured ends to a normal position- and then \r\ fixing it. 
 
 First Aid. — In moving the patient from the spot where the 
 Occident happened, it is necessary to temporarily secure the limb 
 as good a position as possible ; splints have often to be im- 
 brovised from sticks, umbrellas, newspapers, and so forth. In a 
 laiKvay accident the splintered debris of the carriages may be 
 |niployed for this purpose, and the upholstery f)f the seats as 
 adding. A broken leg may also be firmly tied to the other limb, 
 Jliifh is thus converted into a temporary splint. 
 Reduction of a fracture is usually accomplished by a combination 
 (traction or extension applied to the lower segment of the limb, 
 manipulation of the fractured ends, counter-extension being 
 Idle same time maintained by an assistant. In some cases it is 
 Itcessary to relax certain muscles in order to facilitate reduction ; 
 pus, in fractures of the leg, the lower fragment is liable to be 
 
398 
 
 A MANUAL OF SURGERY 
 
 drawn up by tlie muscles attached to tlie tendo Achillis, and to 
 obviate this tlie knee should always be flexed by an assistant 
 who holds up the leg and makes counter-extension, whilst the 
 surgeon reduces the deformity by traction on the lower part of 
 the limb ; section of this tendon is sometimes required in these 
 cases. The manipulation is painful, but, if possible, an anu'sthetic 
 should be dispensed with, as one can never be certain whether 
 or not the patient will struggle during its administration. It is 
 unwise to use too much force in order to correct decided shorten- 
 ing from muscular contraction ; it is better to relax the muscles 
 by the adoption of a suitable position, or to apply continuous 
 extension. I'here can be no (juestion that in bygone days patients 
 were subjected to a great deal of unnecessary pain from misguided 
 ofiforts to ' set ' the fracture. 
 
 The maintenance of the limb in a good position is pro^' 'i for 
 by the application of suitable splints. These consist of n trials, 
 such as wood, leather, zinc, poroplastic, etc., according to the 
 recjuisites of the case. If of wood, zinc, or tin, they are usually 
 made according to some general pattern, and fitted to the patient 
 by means of pads ; if formed of leather or poroplastic, they should ; 
 be shaped so as to meet any peculiarities of the part. A paper! 
 pattern is first fitted to the opposite limb, and the splint is then 
 cut to the desired shape ; it is softened by immersion in hot or I 
 cold water, moulded to the part, and allowed to dry. Where 
 leather is employed, the addition of a little vinegar to the water 
 assists in rendering it soft and supple. The edges and corners 
 are finally rounded, and the interior padded with wool or lint. 
 The general rules relating to the application of splints are as 
 follows: (i.) The joints both above and below the site of fracture] 
 should always be immobilized ; (ii.) the splints must be sufficientlv 
 large to firmly encase the part, or if flat, to project a little heyondl 
 it, so that the limb may be fixed by the splint, and not the splint 
 by the limb; (iii.) careful attention must be given to the paddini;- 
 so as to prevent irritation or sloughing of the skin. In out- 
 patient pra'"tice, where the patients are not too careful as to 
 personal cleanliness, it is advisable to pad the splint with soniel 
 imtiseptic material, such as boracic lint, in order to prevent the 
 development of vermin. It is better not to apply a roller bandage 
 under the splint in the situation of the fracture. The s))lints mayl 
 often with ad\antage be first fixed to the limb by one or two turns j 
 of strapping, and then secured by ordinary calico bandages;! 
 these must not be applied too tightly, since the swellin^f of the! 
 limb not unfre(]uently increases afterwards, and undue constric- 
 tion resulting in gangrene may ensue. Moreoxer, a lind) en- 
 sheathed in bandage must never be flexed, but the flexion should 
 always be made first ; if this is not attended to, the bandafi;e mavl 
 cut into the soft tissues, and by compression of the vessels causel 
 gangrene. It is sometimes advisable to bandage the whole of tliej 
 
r\y':"ir.jr 
 
 INJURIES OF BONES-FRACTURES 
 
 399 
 
 iinib from the fingers or toes upwards, so as to prevent oedema 
 from the pressure of the apparatus obstructing the venous return. 
 fhe patient should always be seen on the day following the 
 application of the splints, and the condition of the fingers or toes 
 carefully examined ; if they look at all blue, or feel numb and 
 cold, the bandages must be slightly relaxed. 
 
 \ arious forms of Fixed Apparatus arc occasionally used in the 
 
 ueatment of fractures, especially in the later stages when the 
 
 ^uellinF has disappeared, and in children. The materials most 
 
 commonly employed are starch, water-glass, and plaster of Paris. 
 
 The stiiych bandage is utilized only in cases where great 
 
 btreni,^th and rigidity are not required. The limb is carefully 
 
 padded with cotton wool, and over this are applied thin strips of 
 
 cardboard soaked in starch so as to fit the limb. These are secured 
 
 ova bandage, the meshes of which are well impregnated with a 
 
 jtarch solution, and over all may be placed another bandage, the 
 
 •jnder surface of which is also rubbed with starch. When this 
 
 i dries, it produces a firm mass, sufficient to immobilize the limb. 
 
 't should be put on fairly tight, the wool padding, if thick enough, 
 
 Uuflicing to prevent injurious constriction. If employed in the 
 
 j early stages of fractures, it becomes loose when the swelling of 
 
 ihehnih diminishes, and must then be readjusted by slitting up 
 
 I and paring away a portion on one or both sides. 
 
 The watci'-glass bandage is applied by first swathing the limb 
 
 nvithathick padding of cotton wool, or bandaging it with boracic 
 
 lint; around this a coarse canvas bandage soaked in a solution of 
 
 hilicate of soda, strong enough to be of the consistency of treacle, 
 
 Is applied ; several thicknesses of the bandage are required in 
 
 irder to give it the necessary strength. The great advantage of 
 
 I jis material is that it is light, easily applied, and makes but little 
 
 jniess; the chief objection is that it dries but slowly, taking fully 
 
 jnventy-four hours to become tlioroughly hard and firm. 
 
 Phnkr of Paris, though rather messy and increasing con- 
 jsiderably the weight of the limb, is one of the best means of 
 jsfcuring prolonged immobilization. It may be applied directly 
 Ito the outside of a layer of cotton wool or boracic bandage ; but 
 |trei]uently a coarse canvas bandage or a suitable piece of house- 
 Itlannel is employed as a foundation on which to place it. (a) The 
 Idned plaster may be rubbed into a coarse canvas bandage, which 
 ior to use is soaked for a few minutes in cold water, to which 
 little salt or alum may be added in order to hasten its 
 setting; it is then wound round the limb, which has been 
 breviously padded with boric lint or wool, and on the exterior of 
 [this fresh plaster of the consistency of cream is applied. To 
 mke this cream of the right strength, the dried powder is cast in 
 onfuls into a bowl of cold water until it no longer sinks im- 
 mediately, but a portion remains fioating on the surface. The 
 nixture is then stirred with an iron spoon, and is ready for use. 
 
400 
 
 A MANUAL OF SURGERY 
 
 (b) It may also he fitted to any part of the body accordinj,' to a I 
 method introduced by Mr. Croft, of St. Thomas's Hospital. If 
 recjuired for a limb, pieces of fiannel are cut into the shape ofl 
 lateral splints, two for each side, and sufficiently large to encase it I 
 comfortably. After protecting the limb with wool or lint, one of 
 the lateral segments, the outer side of which is well soaked with! 
 plaster, is placed in position, and the second portion, which has 
 been totally immersed in the plaster, is then placed over it, a little 
 extra plaster being perhaps rubbed in ; the two are now secured 
 by a muslin bandage. After this has set, the opposite side ofl 
 the limb is dealt with in exactly the same way, and when the' 
 whole is solid, the muslin bandage is cut through in front, but is 
 left untouched behind so as to form a hinge. If it is considered 
 necessary, thin strips of wood or tin may be incorporated in any 
 of these arrangements, so as to add to their strength. 
 
 Early immobilization by means of plaster of Paris has been I 
 advocated by certain Continental aad American authorities, and so 
 much confidence have they in it that even fractures of the femurj 
 are dealt with in this way within a few days of the accident, and 
 the patient allowed to walk about. Such amhulatoiy treatment has! 
 not received much support in this country, although surgeons are 
 beginning to realize that the old conservative plan of prolonged! 
 immobilization in splints is not always desirable. The practice 
 followed is to secure the limb on both sides of the fracture fijrj 
 some considerable distance, incorporating metal supports in the 
 plaster casing. To allow for the shrinking and atrophy of thel 
 muscles which necessarily follow, the splint is early divided so as to) 
 allow of its frequent removal, and it can then be pared down andl 
 refitted to the limb ; if this is not attended to, the ends of thel 
 fragments become loose, and are likely to move one on the other,! 
 possibly giN'ing rise to non-union. 
 
 Another modification which has been recently advocated- 
 especially by Lucas-Championniere — is the treatment of fractures] 
 by Massage. It has long been recognised that after an accidentj 
 of this nature the limb is likely to remain for some considerablej 
 period weak and stiff, owing partly to atrophy of muscles, partlyl 
 to cicatricial adhesions between various divided structures, andl 
 in part to contraction of ligaments in neighbouring joints. Tol 
 prevent this, it has been proposed that splints should Ix; entirely 
 discarded, except in cases where displacement of the fraf,anents 
 cannot be otherwise prevented. The limb is allowed to lie on ; 
 soft sand-bag or pillow, or, in the case of the upper extremity, iS 
 supported in a suitable sling. Massage is commenced within aj 
 few days of the accident, being at first limited to mere rubhin* 
 movements, but subsequently including more forcible manipulationJ 
 and also passive exercise to the neighbouring joints : the rubbings 
 are repeated daily, and for a longer time. A certain amount 0| 
 pain is noticed at first, but this rapidly disappears, and, indeed, 
 
 sensation of cc 
 I inat by this nit 
 iliat there is n 
 I ;nast not be fc 
 lijood-clot is St 
 ,vin,i( in a larg 
 [ reported from tl 
 iif used during 
 I :reatment is not 
 of long bones, 
 Lirticular ends t 
 I fracture of the a 
 'racture, and for 
 i eiliow, it has be 
 In one case of 
 ;reated by this r 
 I t!ie limb was me 
 luithin three day 
 MS able to raise 
 [ivent out subseq 
 (ainiost perfect. 
 all that is needed 
 strapping; in thi 
 ilie help of a stic 
 During the la| 
 to the Early Opa 
 [complete fixation 
 as short a space 
 utilized for such 
 results which fol 
 antiseptic methoc 
 [opening up a so-c 
 the ends of the I 
 pee sepsis had 
 
 'ed compour 
 Ijiinple fractures 
 'iiii;ation, especic 
 [Tlie reason for th 
 i> almost inipract 
 'issues with bloo 
 My adhesions ; 
 results in greater 
 lence the com me 
 W thigh or leg . 
 >ersistent deformi 
 the joints beii 
 Foned by mont^ 
 "Ptrated on, the b 
 
.^iv-^^ 
 
 INJURIES OF BONES— FRACTURES 
 
 401 
 
 itiisation of comfort is induced by the exercises. It is claimed 
 
 .■•lat by this means tlie period of treatment is much reduced, and 
 
 ihat there is much less subsecjuent stiffness and disability. It 
 
 ;^ust not be forfj^otten, however, that in the early stages, where 
 
 blood-clot is still present, it is possible to dislodge a thrombus 
 
 ,vin,ff in a large vein, and certainly one fatal result has been 
 
 reported from this cause ; the greatest gentleness must therefore 
 
 jieiised during the first week or ten days. Of course this plan ox 
 
 :reatment is not advisable in dealing with fractures of the shafts 
 
 ;][ lon^' bones, but as to its value in fractures involving the 
 
 I articular ends there can be no question. For such injuries as 
 
 iracture of the anatomical neck of the humerus, CoUes's or Pott's 
 
 ■racture, and for fracture-dislocations in the neighbourhood of the 
 
 j elbow, it has been already proved to be of the greatest service. 
 
 one case of the first mentioned of these lesions, which we 
 
 |;reated by this means at hospital, the result was most gratifying; 
 
 the limb was merely kept in a sling, and massage was commenced 
 
 •AJthin three days of the accident ; within a fortnight the patient 
 
 MS able to raise his arm without help to a right angle, and he 
 
 wntoiit subsequently with a limb the movements of which were 
 
 I almost perfect. Similarly, in the simpler cases of Pott's fracture, 
 
 all that is needed is daily massage and the fixation of the foot by 
 
 Utrapping; in three W'eeks the patient can usually get about with 
 
 j the help of a stick. 
 
 During the last few years considerable impetus has been given 
 
 lathe Early Operative Treatment of fractures in order to secure 
 
 omplete fixation and the restoration to health and usefulness in 
 
 las short a space of time as possible. At first this plan was only 
 
 jutilized for such bones as the patella or olecranon, but the excellent 
 
 lesults which followed, and the increased confidence with which 
 
 liiitiseptic methods were employed, soon removed all the fears of 
 
 |openint( up a so-called simple fracture in order to deal directly with 
 
 he ends of the bone. Moreover, it soon became obvious, when 
 
 loace sepsis had been excluded, how much better results often 
 
 (oliowed compound fractures which had been operated upon than 
 
 liiinple fractures which had been treated by the routine immo- 
 
 jfcation, especially after oblique fractures of the larger bones. 
 
 ■The reason for this was that accurate apposition of the fragments 
 
 Is almost impracticable in such cases, whilst the infiltration of the 
 
 pues with blood leads to much fibrosis and the formation of 
 
 Miiy adhesions ; moreover, the more lengthy immobilization 
 
 bulls in greater atrophy of muscles and stiffness of joints, and 
 
 Jience the commercial value of a working man after a fracture of 
 
 jlie thi^di or leg is very considerably depreciated, owing partly to 
 
 Jetsistent deformity, the limb being often short and weak, partly 
 
 |o the joints being stiff, whilst the period of convalescence is 
 
 leckoned by months rather than weeks. Should such a case be 
 
 fperated on, the blood being removed, and the ends of the bones 
 
 26 
 
402 
 
 A MANUAL OF SURGERY 
 
 freed from intervening tissues and securely united by wires, screws 
 or pegs, convalescence may be anticipated in a comparatively short 
 time ; the bone retains its normal length ; early massage of the 
 muscles and joints above and below becomes practicable, owin" 
 to the fixity of the limb, and thus atrophy on the one hand, and 
 stiffness on the other, are avoided. 
 
 At the same time one must emphasize the gravity of these 
 operations, which are only justifiable when complete asepsis can be 
 maintained, whilst, moreover, the manipulative dexterity required 
 in order to bring them to a successful issue is such that, in our 
 opinion, the ordinary general practitioner, who undertakes but 
 little operative work in the year, is not justified in undertakintf 
 them. 
 
 In the actual performance of the operation, the incision to 
 expose the bone should be extensive, so as to give plenty of room 
 and allow exit to as much of the extravasated blood as possible. 
 The ends 'of the fragments are cleared, and care taken that no 
 tissue is interposed between tliem. They are then brought into 
 position, attention being directed to make certain that there is 
 no abnormal rotation, and fixed by suitable forceps with a larn;e 
 grasp, e.g., Peters'. The fragments are then drilled in one or tw 
 places, and silver wire or plated screws introduced ; the ends of 
 the wires are twisted up, cut short, and the knot hammered down 
 into the periosteum. \'arious encircling contrivances of the collar 
 type have been suggested in order to help in the fixation of the 
 bone, and may prove useful under certain circumstances. It is a 
 general rule in all these operations to interfere as little as possible 
 with the periosteum. 
 
 Complications arising during Treatment. — (i) If an elderiv 
 patient is kept in bed for any length of time in the recumbent 
 posture, hypostatic pneumonia is likely to ensue. It occurs most 
 commonly after intracapsular fractures of the cervix femoris, and 
 non-union often results, since the patients must be allowed to get 
 about on crutches at an early date, the limb being merely fixed | 
 in a Thomas's splint. (2) Bedsores are very liable to supervene in 
 old people with fractures which need treatment in the recumbent j 
 posture. (3) Crutch palsy is the result of compression of the 
 brachial nerves between the head of the humerus and the pad of 
 a crutch. It may affect all the nerves of the upper extremity, or J 
 may pick out any one of them, and then most commonly the] 
 musculo-spiral. It can usually be prevented by the use of spring-j 
 padded crutches with cross-pieces for the hands, so as to alloivj 
 the patient to partially relieve the axillary pressure by supporting! 
 the weight of the body by means of the arms. When it hasj 
 occurred, the use of crutches must be discontinued, and faradisral 
 and massage employed to the affected muscles. (4) Gangrene mayj 
 arise from fractures in a variety of ways : (i.) From the immediatej 
 effects of the injury, either by its direct action on the tissues, cri 
 
INJURIES OF BONES—FRACTURES 
 
 403 
 
 bv causing a""*^erial thrombosis in a limb with atheromatous vessels, 
 or from rupture of the artery with consequent venous thrombosis, 
 owing to the pressure of the extravasation ; (ii.) by the super- 
 vention of spreading gangrene in a compound fracture ; (iii.) from 
 errors in the course of treatment, as by bandaging the limb too 
 tjf^htly, so as to constrict the vessels ; or by the bandage becoming 
 unduly tight, owing to the subsequent swelling of the limb ; or by 
 j]exing a joint after bandaging it, the bandage cutting into the 
 soft tissues ; or by the localized pressure of a splint which has 
 been insufficiently padded. Moist gangrene is the type met with 
 in all cases, except when the limb has been previously drained of 
 its fluids by an atheromatous condition of its vessels. (For rules 
 of treatment, see Chapter IV.) 
 
 Compound Fractures. 
 
 A compound fracture is one in which there is a communication 
 between the external air and the site of injury. It is produced by 
 direct or indirect violence, and any of the complications or modifi- 
 cations met with in simple fractures can be present. The bones 
 may be but little displaced, or protrude through the opening in 
 tlie skin, and under such circumstances may be much bruised or 
 comminuted, and even contaminated with dirt or mud. 
 
 The chief dangers of compound fractures are, firstly, hcsmovvhage, 
 
 which, instead of collecting within the tissues of the limb, is able 
 
 to escape externally, although subcutaneous extravasation is not 
 
 uncommon ; and secondly, the advent of sepsis. The latter is the 
 
 more important, and may lead to the most serious consequences. 
 
 Portions of muscle and periosteum, which in a simple fracture 
 
 would be removed or incorporated in the new formation of 
 
 I callus, become inflamed in septic cases, and even slough. Small 
 
 I isolated fragments of bone are almost certain to necrose if sup- 
 
 [puration ensues, whilst the severest forms of septic osteomyelitis 
 
 [may occur, endangering the patient's life by pyaemia. Such 
 
 [results are more likely to follow when the external wound is 
 
 [small and insufficient provision has been made for drainage. 
 
 [immense advances in the treatment of these conditions have 
 
 ibeen made since the introduction of antiseptic surgery, and 
 
 [where such is regularly and efficiently practised, these dangerous 
 
 |complications are rarely seen. 
 
 The Method of Union of a compound fracture is practically the 
 [same as that occurring in simple fractures. If the wound can be 
 Rendered aseptic, and there is not much bruising, it may be 
 |:!osed by suture except at the spot where a drainage-tube is in- 
 
 CTted. Primary union may thus be obtained, and then repair 
 bccording to the details already described will follow. If, however, 
 kuppuration occurs, it is probably attended with a greater or less 
 pount of necrosis, and possibly diffuse suppuration in the soft 
 
 26 — 2 
 
404 
 
 A MANUAL OF SURGERY 
 
 parts ; the wound will therefore remain open for a tine, varyjnf 
 with the acuteness of the local phenomena. It is gradually closed 
 by granulations, which extend upwards from below, and the 
 deepest part of this granulation tissue, which is derived from the 
 bone and periosteum, and contains osteoblastic elements, will lie 
 transformed into callus, and finally into true osseous tissue. 
 Repair is probably much slower under these circumstances than 
 in a simple fracture, since the suppuration may have interfered 
 with the osteogenetic powers of the periosteum, and thus the new- 
 bone formation is dependent solely on the osseous tissue itself, 
 which is always slow to react. 
 
 The Constitutional Ssrmptoms following compound fractures are 
 much more marked than in simple cases. Even where sepsis 
 is prevented by efficient treatment, some amount of aseptic 
 traumatic fever is certain to supervene for a few days, whilst 
 if infection occurs, there is a period of marked febrile disturbance 
 for a week or ten days, similar to that which is seen in all septic 
 lacerated wounds (p. i6o). 
 
 In the Treatment of compound fractures, the main object is to 
 render the wound aseptic and to give efficient exit to tlie dis- 
 charges. For this purpose the patient should in most cases lie 
 anaesthetized, the wound enlarged and thoroughly washed out 
 and even scrubbed with some potent antiseptic, such as carbolic 
 lotion (i in 20). Loose fragments of bone are removed, and 
 portions denuded of their periosteum may be taken away lest 
 necrosis should ensue ; where fragments retain any considerable 
 connection with the soft parts, they may be left without fear, and 
 of course as little periosteum should be removed as possible. 
 When a sharp end of one of the fragments is protruding throuf;hj 
 a small opening in the skin, it is first thoroughly purified before 
 attempting its reduction, and then replaced, after enlarging tliel 
 wound in the skin, or a portion is sawn off. Haemorrhage ii 
 dealt with in the usual way, and the fragments are placed asnearl; 
 as possible in their normal position. If there is no comminiitioi 
 and the fragments can be brought accurately into position, it ii 
 well to fix them by the insertion of silver wire, or of ivory pej 
 or plated screws ; but where the ends of the bones are comj 
 minuted, the small portions must be arranged in position as wel 
 as possible, and no attempt made to wire them. A good-sizi 
 drainage-tube Ts inserted, and, if need "T")eV counter-openings a] 
 made ; the limb is then placed on appropriate splints, and t 
 external wound closed or not according to circumstances. Undi 
 such a regime the majority of uncomplicated cases will do wel 
 Immoveable apparatus maybe applied after a time, windows beii 
 left in the plaster casing to allow wounds to be dressed. 
 
 In compound fractures which have been attended with coi 
 plications directed to vessels, nerves, and neighbouring soft pai 
 or joints, the prognosis and course of the case may be considi 
 
 \ 
 
 "9— Cn-c-n 
 
 '3 very debilitate 
 limb. (2) Fibiv 
 f s firm mass o 
 lllieends of the 1 
 ''"'n P'ate of b 
 Nted. (3) j\ 
 'vin'ch the ends 
 f '';i^^e, and n^ 
 fa'iou- ball -and 
 "e surroundintr 
 
INJURIES OF BONES— FRACTURES 
 
 405 
 
 ably modified ; treatment suitable to each of these conditions must 
 be adopted (p. 392). 
 
 The fiuestion of Amputation will necessarily be raised in the 
 more serious cases ; but it is unnecessary to add anything here to 
 what has already been stated in Chapter VII. (p. 161). 
 
 Ununited Fractures. 
 
 Three varieties of ununited fracture have been descril^ed : 
 (i) Absolute Hon-uuion is said to be present when no attempt at 
 repair is made. This rarely occurs except when some definite 
 bone disease exists, such as sarcoma or osteo-malacia, or when in 
 
 Fig. iiq. — Uncniticd Fractcrk with False Joint. (From College of 
 
 Surgeons' Museum.) 
 
 [a very debilitated patient there has been no attempt to fix the 
 
 lb, (2) Fibrous union consists in the development of a more or 
 
 lless firm mass of connective tissue as the bond of union between 
 
 Ithe ends of the bones, which are either rounded off" and closed by 
 
 la thin piate of bone or cartilage, or are sometimes atrophic and 
 
 ipointed. (3) A false joint, or pseiidartlwosis, is a condition in 
 
 bich the ends of the bones are covered either by bone or 
 
 jcartilajfe, and more or less altered in shape, so as to form a 
 
 pllow ball-and-socket joint, the capsule being represented by 
 
 lie surrounding fibrous tissue, and the synovial cavity by an 
 
'51' 
 
 4o6 
 
 A MANUAL OF SURGERY 
 
 adventitious bursa, which results from the friction of the two ends 
 (Fig. 119). 
 
 The most common situations for ununited fractures are project- 
 ing processes of bone to which powerful muscles are attached, 
 such as the patella, olecranon, coracoid process, posterior half of 
 the OS calcis, etc. ; whilst in long bones the middle of the shaft of 
 the humerus and the upper and lower thirds of the femur are the 
 favourite sites. 
 
 Many different Causes may be associated in determinin<,' the 
 defective union of fractures, but the following are the more 
 important : (i) Want of apposition of the bony ends, o\viii<,' to 
 muscular action — e.g., in the patella, when the two fragments 
 are widely separated, or in the femur, where they may over- 
 lap ; (2) the interpositioix of fluid or such substances as muscular 
 or aponeurotic tissue, or detached fragments of compact hone; 
 (3) want of rest, one of the most common causes, as in the 
 middle of the shaft of the humerus, where, unless the elbow is 
 well supported, complete immobility cannot be obtained, and 
 non-union is likely to result ; (4) defective blood-supply to one or 
 both fragments, as by injury to the nutrient artery, or as in intra- 
 capsular fracture of the cervix femoris, where the only source of 
 supply to the upper fragment is a small twig derived from the 
 obturator artery running along the ligamentum teres ; (5) local 
 affections of the bone, such as malignant tumours, destruction of 
 the periosteum by inflammation, or the undue pressure of pads 
 upon the newly-formed callus ; (6) general bone disease, as osteo- 
 malacia ; and (7) general constitutional weakness or debility, 
 sometimes due to definite diseases, such as scurvy or severe 
 syphilis, sometimes to general asthenia or alcoholism. It has 
 been proved that senility, pregnancy, and the cancerous cachexia 
 do not, as used formerly to be stated, predispose to this condition, 
 
 The Signs of an ununited fracture are usually obvious, mobility 
 between the fragments being easily obtained, although without 
 crepitus. 
 
 The Prognosis is good if suitable treatment is adopted. In 
 children, however, the condition is often maintained even after 
 operation, and, in fact, may be aggravated by it, the ends of the 
 bone becoming atrophic, rounded, and covered by cartilage; in 
 such the final resource is not unfrecjuently amputation. 
 
 Thf^ Treatment of ununited fractures is now conducted on per- 
 fectly definite lines, (i) The parts are refixed in an immoveable 
 apparatus, preferably plaster of Paris, for six weeks, whilst means 
 are adopted to improve the general health, as by a stay at the 
 seaside and the administration of tonics. (2) Failing this, the 
 ends of the bones may be well rubbed together, so as to excite 
 local action, and the parts again fixed. Regular massage is also 
 useful, and enforced congestion of the limb by an elastic tourniquet 
 applied for an hour or two daily has also been recommended. 
 
INJURIES OF BONES— FRACTURES 
 
 407 
 
 ij) Should this he unsuccessful, operative measures must be 
 undertaken. If the hone is tolerably superficial, and the ends 
 not very far apart, they should be exposed, sawn into shape, 
 titted t(i{j;cther (preferably by a dove-tailing process), and secured 
 In stout silver wire, whicli maybe left in situ permanently, and 
 if aseptic, becomes encapsuled. If, however, the bones are deeply 
 placed, so that the operation to expose the ends and fit them 
 tofjether becomes a very severe one, it is often better practice to 
 leave them in their bad position, and merely 
 tix them by the insertion of ivory pegs or 
 nickel-plated screws. Thus, in the upper end 
 of the femur non-union is usually associated 
 with overlapping of the ends of the bone to 
 a considerable extent. To expose and fit 
 these together would necessitate a very ex- 
 tensive dissection ; it is wiser in such cases 
 merely to cut down in front upon the upper 
 anterior fragment, drill two holes in different 
 directions through both fragments, and into 
 these insert suitable ivory pegs. Two holes 
 .-hould always be employed, to prevent slip- 
 pin;,' of the fragments during the many neces- 
 sary manipulations ; whilst one drill is 
 removed for the insertion of the peg, the 
 other holds the bone steady. As a rule, the 
 pe.^'s may bt allowed to remain permanently, 
 iait occasion dly they become loose in three 
 iir four weeks, and need removal. Their 
 presence causes the formation of a large 
 amount of callus, and by this means the frac- 
 ture is consolidated. It is well to examine the 
 fracture by the X rays from time to time to 
 ■^^ee that the bones are still in position, and 
 for this purpose the dressings need not be 
 removed, if metal splints are not used. 
 
 Disunited Fracture is the term applied to Fig. 120 — OLul•KAc- 
 a rare condition, in which a fracture which '^ure of Femuk 
 had been firmly united becomes separated Union. 
 again. It is only met with when the indi- 
 vidual develops some extremely debilitating disease, such as 
 scurvy, and may be recovered from under suitable treatment 
 directed to the cause, and by fixation of the parts- 
 Vicious Union (Fig. 120) of fractures results either from imper- 
 fect readjustment of the ends of the bone prior to placing the limb 
 on an immoveable apparatus, or from the parts not being kept at 
 rest, and hence becoming subsequently displaced. Various kinds 
 «t deformity and disfigurement, accompanied or not by loss of 
 function, may result from this accident. In some cases it may 
 
4oS 
 
 A MANUAL OF SURGERY 
 
 he advisable to leave thinpjs alone, but where tlie deformity or 
 functional disturbance is serious, means must be taken to rcinedv 
 matters, if observed early, it is not difficult to readjust the parts 
 by simple pressure under an ana'sthetic, if necessary re-frat lurini,' 
 the bone ; but this should only be undertaken whilst the ciillu-, 
 is soft, uc, within three or four weeks of the accident. Some 
 surj^feons apply this method of osteoclasia even when consolidation 
 has been accomplished, usinj; for the purpose levers and powerful 
 clamps ; but in our opinion such treatment is most untk'sirahlt 
 and hi}^dily unscientific, since it is diflicult to accurately ^(au>,'e the 
 amount of daniaf^e concurrently inflicted on the soft parts. \\e 
 much prefer the open method, cutting down on the bone, re-divid- 
 ing it, remo\ing redundant callus, and fixing the fragments bv 
 silver wires, pegs, or screws. 
 
 Special Fractures. 
 
 Bones of the Face. — The Nasal bones are broken as a result of 
 direct \ iolence, by the fist, a cricket-ball, stick, etc. The fracture 
 is generally trans\erse, and situated just above their free mari^'ins; 
 occasionally, when greater force is used, it occurs close to tlie root 
 of the nose, and may then be associated with fracture of the frontal 
 bone or base of the skull. In young people the cartilages aloiit 
 may be separated. There is usually considerable deformity from 
 depression or lateral displacement of the fragment, althouLfh it 
 may at first be masked by the amount of bruising. Severe 
 epistaxis, surgical emphysema, and cerebral symptoms, are some- 
 times met with as complications. The fracture very readilv 
 becomes consolidated, and the deformity is thus often irremediaMv 
 fixed. It is most important, therefore, to determine the presence 
 or not of a fracture at once, and this can only be made out, when 
 much swelling is present, by grasping the organ and moving it 
 from side to side to elicit crepitus. The Septum is sometimes 
 broken and depressed in association with the above injury, but it 
 may occur alone in other instances, giving rise to lateral displace- 
 ment. This need not result in obvious deformity, but may lead 
 to considerable nasal obstruction and discomfort. The Treatment 
 of these cases consists in immediate replacement of the bones, 
 ad\isably under an anaesthetic ; this may be accomplished by tbf 
 pressure of some blunt instrument, such as a pair < * pa(' 
 dressing forceps, the blades of which are introduce ' , :e 
 
 nostril, or by distension of a suitable indiarubber ba . air or 
 
 water. A pad of lint or gauze soaked in carbolizeti I is then 
 inserted to maintain the position, and a guttapercha or /n ■ sp!' 
 moulded to fit the bridge. In old-stancling cases, where ther 
 much depression, but little can be done, although the deformity 
 has been remedied by bone-grafting. Lateral displacement can 
 usually be remedied by mechanical appliances or operation. 
 
 The Lachrymal bone has been broken by direct violence, the 
 
INJURIES OF liONES—I'RACTUHES 
 
 409 
 
 fracture usually exteiuliiiff from the nasal hone to the lateral mass 
 of the cthmoicl. Interference witli the flow of tears and surj^'ical 
 e:ii|ihys<'Mia are the two most marked symptoms. 
 
 The Malar bone is but rarely fractured without the other bones 
 of the face beinj,' involved. When it does occur, it is almost always 
 associated with daniaf^e to the anterior wall of the antrum and con- 
 siderable depression of the fragments. An attempt should be 
 made to replace the parts by pressure from within the mouth. 
 
 The Zygoma is fractured by direct violence applied from with- 
 iiut; the broken portion may be depressed below the surface, 
 but vertical displacement is limited by the attachment of the mas- 
 seter below and of the temporal fascia above. Reposition, either 
 hy manipulation from within the mouth, or even by operation, is 
 essential in order to prevent interference with the subsefjuent 
 mobility of the jaw. Perhaps the simplest plan to adopt is to 
 encircle the zygoma subcutaneously with a loop of silver wire 
 and lira;,' it up to its natural level. 
 
 The Superior Maxilla is invariably broken as a result of direct 
 injury, such as a gunshot wound or a blow; it is almost always com- 
 pound, and often bilateral. The alveolar portion is either partially 
 or entirely detached, or a transverse fissure, extending as far as 
 the pterygoid processes on each side, may render the whoie palate 
 and lower part of the facial skeleton moveable. Not unfrequently 
 all the bones of the face are smashed and comminuted, se\ere 
 iiapmorrhage sometimes 
 resulting from wounds of the 
 internal maxillary artery or 
 its terminal branches. As 
 a rule, Treatment consists in 
 merely keeping the patient 
 quiet and applying cooling 
 j lotions; union occurs with 
 great readiness, but is some- 
 j times associated with sup- 
 |puration and necrosis. The 
 [patient must be fed by a 
 jtnbe, and a carefully fitted 
 '' pi; le should be ap- 
 ) a ,)roken alveolus. 
 
 1 Inferior Maxilla is usually fractured by direct violence, but 
 |occ .ally by force applied indirectly, as when a carriage passes 
 jovei . le hone, laterally compressing the two sides, and leading to 
 la fracture in the middle line. Most frequently the lesion is a 
 jlittlein front of the mental foramen (Fig. 121), this being a weak 
 [spot at the junct- n of two strong parts, viz., the symphysis menti 
 land the aheolar process carrying the molar teeth ; the bone is 
 jiurther weakened by the long narrow alveolus which lodges the 
 prune tooth. This fracture may sometimes be double when great 
 
 Fig. 121. — LowiiR Jaw, indicatincv thk 
 Most Common Sitks ok Fracture. 
 
4IO 
 
 A MANUAL OF SURGERY 
 
 violence has been applied to the symphysis. A solutioi. of con- 
 tinuity also occurs close to the an^de behind the molar teeth 
 whilst the coronoid process and condyle have occasionally been 
 broken, the former only as a result of great force, e.g., a gunshot 
 wound, the latter from either direct or indirect violence. 
 
 The Signs of fracture are very evident if the lesion is situated 
 anteriorly ; but when behind the teeth, diagnosis may be much 
 more difficult. The usual variety is almost always compound, 
 owing to the firm attachment of the muco-periosteum to the 
 alveolar border. Laceration of the gums, the blood-stained 
 saliva soon becoming foetid, the irregularity in the line of the 
 teeth, and the easily elicited crepitus, all constitute a typical 
 picture. There is often considerable pain, owing mainly to the 
 tearing of the mucous membrane, but possibly due to implication 
 
 of the inferior dental nerve. The 
 m a i n t r u n k, however, genei ahy 
 escapes, owing to the position of the 
 fracture in front of the mental fora- 
 men, whilst in those behind there 
 is but little displacement. Smart 
 haemorrhage sometimes occurs from 
 laceration of the accompanyin<; 
 artery. The posterior fragment isi 
 often somewhat raised, wliilst thej 
 anterior portion is depressed liy tht 
 action of the hyoid muscles, and may 
 override the other, owing to the I 
 direction of the fracture, the anterior 
 fragment including more of the outer 
 surface of the bone than the pos- 
 terior. The direction of the displace- 1 
 ment is reversed in some cases. 
 When situated at the angle or in the vertical ramus, there is such 
 ecpial nmscular support on the two sides that but little displacement 
 results. When the fracture passes through the neck of the condyk' 
 that process is drawn forwards and inwards by the external 
 pterygoid, whilst the body of the bone is freely moveable antero- 
 posteriorly, and displaced towards the fractured side. When the] 
 coronoid process is detached, it is dragged upwards by the temporal 
 tendon, but no great displacement can occur, owing to the exten- 
 sive attachment of the tendinous fibres. 
 
 In those cases of fracture which are compound (and this includes! 
 the great majority), septic inflammation of the ends of the lioiiej 
 often ensues, leading to localized necrosis, and sometimes to| 
 septic pneumonia, or even to general pya^^mia. 
 
 The Treatment of a fractured mandible is frecpiently a matterl 
 of difficulty, owing partly to the septic element, and partly toj 
 the difficulty of (being the jaw without interfering with thej 
 
 Fic;. 122. Al'I'LICATION OF 
 
 FoUK-TaILKD HaNDAOK K(JK 
 
 Fkacture of Lower Jaw. 
 
INJURIES OF BONES— FRACTURES 
 
 411 
 
 hatient's nutrition ; hence the co-operation of a skilled dentist 
 Ishould always he secured. 
 
 I. As a temporary measure, and indeed as a permanent appli- 
 
 hncein simple cases, without nmch displacement of the fragments, 
 
 jaBii where dental assistance is not to hand, all that is needed is 
 
 Ian efficient four-tailed bandage. This is made by taking a piece 
 
 1)1 calico 4 inches wide and i yard in length, and splitting each 
 
 Fig 123. — Leather Splint 
 FOR Lower Jaw. 
 
 Fi(i. 124.— Leather Si'lint 
 
 APPLIED. 
 
 lend into two, leaving about 8 inches undivided, and in the centre 
 lot this a small longitudinal cut is made, into which the point of 
 Itbechin is inserted. The two lower tails are then drawn up and 
 jiied over the vertex, whilst the two upper ends are secured 
 phind the occiput, and then, to prevent slipping, are knotted to 
 [the ends of the former (Fig. 122). If the lower knot is brought 
 llielow the protuberance, backward die ;)lacement of the anterior 
 IfraL'ment may be produced, and subsetiuent deformity. This 
 Japparatus is maintained firmly in position for three weeks, the 
 [patient being fed on fluids passed between the teeth or through 
 [the ;(ap behind the last molar, and all mo\ement of the jaw 
 kohihited. The mouth should be frequently washed out with 
 koine antiseptic lotion. Ihiion is usually secured in fi\e weeks. 
 2. If patients are unruly, or if the abo\e apparatus fails to 
 
 mintaiii the fragments in position, a moulded guttapercha or 
 [eatlier splint may be applied, made in the shape indicated in 
 
 is;. 123, tiie upper portion being folded back, and the lower 
 
 ortion drawn up around the bone. It is lined with lint, and 
 
 «ciired by bandages or tapes passed through holes, and tied as 
 
 ^hown in l-'ig. 124. 
 ]• Where there is much displacement, the fragments must be 
 
 M. Wire sutures passed around or between the teeth and tied 
 : distinctly objectionable, causing the teeth to become loose and 
 
 *^diaps diseased. Hammond's wire splint is the best apparatus to 
 
412 
 
 A MANUAL OF SURGERY 
 
 employ. It consists of a firm wire collar or framework (Fifr. 12- 
 which encircles the whole series of teeth in the lower jaw. It jsj 
 accurately fitted by a dentist, firstly, to a cast of the jaw, sub-l 
 se(]uently to the jaw itself, and is fixed by several wires passinfj 
 from one half to the other between the teeth. '^j 
 
 4. In cases where a Hammond's splint fails in remedyinj; the dis-l 
 placement, or where the teeth are defective, a Kingsley's apparatus! 
 (Fij;. 126) maybe used with advantage. It consists of a ^•ulca^ite| 
 splint fitted over the teeth or alveolar process of the mandible } 
 
 Fig. 125. — Hammon'h's Si'lint kor Fracture ok Lowi;r Jaw 
 
 and extending for a sufficient distance on each side of the fracture 
 to steady the fragments. To the front of this are attached curved 
 metal bars, which extend sideways from the angles of the moutli 
 over the cheeks. It is kept in position by passing a bandage over the) 
 bars and under the chin (Fig. 127), and secures thereby exceller.tf 
 immobilization of the fragments, even when the mouth is openedJ 
 
 5. Wiyiiif* of the fraj^mcnts together may be required in a few] 
 cases. The wires nmst be passed either through the bone l)elou| 
 the teeth — a task not easy to accomplish without an external 
 wound— or through the empty alveoli of neighbouring tcetlij 
 which are extracted for the purpose. 
 
 When septic inflammation occurs of such severity as to lead toj 
 necrosis, it is often best to delay all operative treatment until thei 
 se(]uestrum has been detached, and the parts are more healthyj 
 the patient's mouth in the meantime being frequently clean^ef 
 with antiseptic lotions. Wiring of the fragments may tlieii, i| 
 necessary, be undertaken with good hope of success. 
 
 Fracture of the Hyoid Bone is uncommon, arising usually froii 
 direct violence, such as a forcible grasp or the constriction ol M 
 
INJURIES OF BONES— FRACTURES 
 
 4«3 
 
 jjck in hanj^ing. Either the body may be broken, or one of the 
 I cornua separated. The symptoms produced are : Pain on attempt- 
 
 ijc to move the tongue, jaw, or neck; a husky voice; and de- 
 
 iormity, which can sometimes be detected from without. Occa- 
 sionally the mucous membrane is perforated, and bleeding into the 
 
 pbarnyx may occur, whilst axlema ot the glottis may subsequently 
 b'jpervene. The fragments should be approximated as well as 
 
 Fig. 12G. 
 IKint.sley's Splint for Fracture 
 OK Lower Jaw. 
 
 Fk;. 127. 
 
 KiNGSLEY'S SI'LINT Al'l'LUU). 
 
 [possible hy manipulation between one finger in the mouth and the 
 [hand outside, and the neck then fixed by a poroplastic collar. 
 
 Fracture of the Ribs may arise in two distinct ways: (i) By 
 
 Idirect violence, as by blows or stabs, the fragments being driven 
 
 Inwards, and damage to the underlying pleura, lungs, liver, or 
 
 l&iphragni, being very likely to occur ; or (2) much more fre- 
 
 IliidUly hy indirect violence, as when the chest is compressed 
 
 ptween 11 cart-wheel and the ground, or between a wall and the 
 
 Itiackof a waggon. The ends of the ribs are then approximated 
 
 Ibeyimd the limits of natural ijlasticity, and they gi\e way at the 
 
 Host convex part — i.e., near the angle. The viscera may be con- 
 
 Itused, luit less often than in the former class, although luemo- 
 
 porax from rupture of the parietal pleura is not uncommon. 
 
 Jneor several ribs may be broken, but the displacement is rarely 
 
 'larked, except in cases due to direct violence where several ribs 
 
 tave been 'staved in.' The fifth to the eighth ribs are those 
 
414 
 
 A MANUAL OF SURGERY 
 
 visually injured, being more prominent and fixed at both ends' 
 the first and second ribs are so well protected by the clavicle a'. 
 to be seldom broken by direct injury, although great violence 
 from above downwards to the outer end of the clavicle may lead 
 to such an accident ; the lower ribs often escape on account of 
 their greater mobility. Elderly women and persons sufferini' 
 from general paralysis of the insane are specially prone to thi^ 
 fracture. 
 
 The Symptoms are tolerably obvious, viz., a sensation of some- 
 thing snapping or giving way, a sharp localized catching pain at 
 the site of the injury, increased on deep breathing and coughinj; 
 and possibly some local extravasation and swelling. Pain is also 
 elicited by conjoined pressure upon the sternum and spinal column, 
 whilst the fracture may be evident on palpation, or crepitus 
 detected when the patient coughs or on auscultation. When 
 
 several ribs are driven in, a marked 
 depression results, but if a sinHe 
 bone is broken in a fat individual, the 
 diagnosis may be extremely obscure, 
 For the clinical history of lesions of the 
 lungs or pleurae, see Chapter XXIX. 
 Treatment. — The affected side 
 should be firmly strapped with broad 
 strips of adhesive plaster, so as to 
 limit its movements. The strips, 
 i^ to 2 inches wide, should extend 
 beyond the middle line, both front 
 and back, and are applied from below 
 upwards whilst the chest is in a state 
 of forcible expiration, each strip over- 
 lapping the preceding one and cross- 
 ing the direction of the ribs (Fig. 128], 
 A firm woollen bandage should then 
 be applied over all. If the ends of 
 the bone are driven inwards, strapping can rarely be borne, as it j 
 tends still further to irritate or compress the lung. Under such 
 circumstances all constriction of the chest must be avoided, but 
 the patient is confined to bed with a sandbag between the 
 shoulders, and ihe arm bound to the side. When the lower ribs 
 are broken, tight applications are generally contra-indicated, since 
 the diaphragm is likely to be irritated, and troublesome hiccough 
 may result. Ribs unite readily, but a considerable amount of 
 callus is formed owing to the difficulty of satisfactorily fixing thc[ 
 broken ends. 
 
 Separation of a Costal Cartilage sometimes occurs, giving rise to I 
 the same symptoms and reijuiring the same treatment as a brokeaj 
 rib. Occasionally the cartilage itself may be fractured. Ineachj 
 case the resulting bond of union is osseous. 
 
 rif.. 
 
 128. — Mkthop ok stkap 
 I'iNG Bkokkn Kilts. 
 
INJURIES OF BONES— FRACTURES 
 
 415 
 
 Fracture of the Sternum is almost always due to direct \'iolence, 
 althouj^h it has been known to yield from excessive flexion of 
 the body after fracture of the spine, or from muscular strain 
 during parturition. The line of fracture is usually transverse, the 
 bone giving way either between the manubrium and gladiolus 
 or a little below this level. The fragments may remain /// situ or 
 ihe upper portion be displaced backwards, the deformity in such 
 cases being very evident, and great dyspncL'a resulting. As a late 
 effect, aneurism of the arch of the aorta may occur. 
 
 Treatment. — The patient should be Kept in bed with a pillow 
 between the shoulders, and the chest strapped as for fractured 
 ribs. If the patient cannot bear this position, he should be 
 allowed to sit up with the body leaning forwards. Reposition 
 can sometimes be effected by manipulation and extension of the 
 spine. 
 
 r 
 
 Fractures of the Upper Extremity. 
 
 Fracture of the Clavicle. — No bone in the body, wit h the ex- 
 ception of the radius, is brokerriu6fe*1requ(?nTl)^fTmn~tTi^'c^avTcre; 
 this is chTE3~rts*;«3!;i}asel iJ0SJtiQ:J-,aB4; it§.-^T?ittress^lJke ACtl^^ in 
 keeping out tTie point of the shoulder, so that every shocT: to the 
 arm is transmitted through it to the trunk. Hence, although 
 fractures from direct violence do occur, it is more usually broken 
 as the result of force directed to the hand or shoulder, such as a 
 fall from a horse. The injury is \ery common in children, being 
 then often of a greenstick nature, and more frecjuent in men 
 than in women. The bone may yield in four different spots, viz. : 
 
 1. At the Sternal End, an imusual occurrfce, due to direct 
 or indirect violence. The disphxement varies with the Ime of 
 fracture ; if transverse, it is slight, but if oblicpie, and this is most 
 usual, the outer fragment is drawn downwards and forwards as 
 in the next variety, though to a less degree. 
 
 2. Through the Greater Convexity, the conmionest situation. 
 The bone yields about its centre, or a little external to it, and the 
 line of fracture is slightly obliciue, running from before backwards 
 ami inwards. The displacement is fjuite characteristic, and is 
 present in any fracture situated between the rhomboid ligament 
 on the inner side and the coraco-clax'icular ligaments on the outer, 
 I'eing less marked, however, when the frarcure is nearer the 
 
 j extremities than in the centre of this space. The patient presents 
 iself with a history of injury and se\ere pain, supporting the 
 
 I elbow with the other hand, the head |>ei_n^bent^\er t o the affecte d 
 side, so as to relax the nuiscTes'of the necIc7n"n7TR'e arm being 
 P'lwerless. On closer examination, one finds that the point of the 
 shoulder is less prominent than usual, being approximated to the 
 middle line, and on a lower level than the other, whilst at the seat 
 of fracture is a slight bony projection. This deformity is accounted 
 
4i6 
 
 A MANUAL OF SURGERY 
 
 for by a displacement of the whole outer fragment downwards 
 forwards, and inwards (I'^ig. 129); the outer end, however is 
 more displaced than the inner, so tliat the fractured surface of the 
 outer fragment looks upwards, inwards, and backwards, althouwh 
 
 it is placed iniiiu'diately 
 below the inner frai,Miient, 
 The deformity is mainly due 
 to the weight of tlie' arm 
 acting upon the outer fra^'- 
 ment when the buttress-like 
 action of the bone is gone 
 allowing the scapula, to 
 which it is firmly united bv 
 ligaments, to embrace tl/e 
 cur\ed thoracic wall, from 
 which it is usually separated. 
 'The action of the muscles 
 passing from the trunk to 
 the upper arm may have 
 some effect, but can only 
 be looked on as an accessory, 
 and not the main cause of 
 this displacement. The posi- 
 tion of the inner fraj,'ment 
 is probably but little altered, 
 since it is held in place by 
 the rhomboid ligament ; the 
 apparent projection of its outer end is due rather to the depression 
 of the outer fragment than to elevation of the inner by the sterno- 
 mastoid. 
 
 3. Between the Coraco-clavicular Ligaments, usually arising from 
 direct \iolence, and with but little displacement, owing to the 
 tension of the ligaments and to the fact that the periosteum is not 
 torn across. The signs of local trauma and crepitus are, how- 
 ever, present, tiiough not very olnious. 
 
 4. At the Acromial End, external to the trapezoid ligament, and, 
 again, usually prt)ducecl by direct violence. The inner fragment 
 retains its position unaltered, but the outer fragment is dragged; 
 down by the weight of the arm, and forwards by the action of the 
 iriuscles, so that it lies at right angles to the rest of the bone. 
 
 Complications arise most frecjuently in cases produced by direct! 
 violence. 'J'he subclaxian vein may be injured, or the brachial 
 plexus; and e\en the dome of the pleura and the subjacent hind 
 have been wounded. Gangrene of tfce arm has resulted from [ 
 obstruction to the vessels. 
 
 Treatment. — Where there is little or no displacement, all that! 
 is needed is to immobilize the arm in a sling and to keep thej 
 patient (juiet. 
 
 I'k;. 129. — Fkacti'kk ok t'LAvici.i: 
 
 THROUCIH GrEATKK CoN VKXITV. (TlI.L- 
 MANNS.) 
 
 St, Sterno-mastoid : S, suhclavius ; 1* mi, 
 pectoralis minor; S m.serratus magnus. 
 
INJURIES OF BONES-FRACTURES 
 
 417 
 
 l/or fractures with displacement many cUfTerent plans of treat- 
 ment have been adopted. In order to replace the fraf,Mnents, tlio 
 sur;,'eon should stand behind the patient, who is seated, with 
 his knei; between the scapulae; traction is then made upon the 
 shiuilclcis, and the point of the acromion is drawn upwards and 
 !)ack\vards. To maintain the fractured ends in apposition the 
 following; methods have been reconimended : (a) The simplest, 
 which can always be applied on an emerj^^ency, and perhaps the 
 liest even for a permanent application, is that known as the tlinc- 
 iMulkcrdncf plan. Two lar^e handkerchiefs, folded double and 
 rolled into bands, are placed vertically, one over each shoulder 
 and uiulrr each axilla; each is lif^htly knotted behind, and the 
 nnds tinnly tied to the opposite handkerchief across the middle 
 
 111 thai I 
 lep t 
 
 Fig 130 -Savkk's Mktiiod ok Stk.vi'1'in(; k<m< I'^ract 
 
 UKKI) Cl.AVlCLK. yf'^' 
 
 line. I'y this means the point of the shoulder is kept outwards 
 
 land hack wards. The third handkerchief is now folded crosswise 
 
 land used as a slinff to support the elbow, which is drawn well 
 
 Iforwards, the hand beinj^^ placed o\er the sound clavicle. If this 
 
 [apparatus is employed permanently, the knots nuist be examined 
 
 [every few days, especially at first, as the handkerchiefs always 
 
 >tretch a little, and require occasional tighteniuff. (/;) Sayvc's method 
 
 |i^ very useful, especially in treating children. A long strip of 
 
 (ihcsi\o plaster, 3^- inches wide or less, according to the size of 
 
 |tlif patient, is passed round the arm a little below the axilla, as 
 
 loop, with the sticky side out, and then around the body with 
 
 tie adhesi\e side inwards, the arm being drawn well back, and 
 
 [lie loop -i.nd ends secured by stitches (Fig. 130). If tiiis has 
 
 peen tirndy applied, it may now be used as a fulcrum, so that as 
 
 elhow is drawn forwards, the point of the shoulder is directed 
 
 pckwards and outwards, and thus the main deformity iso\ercome. 
 
 j^nother strip of a similar width is applied o\er the elbow (a small 
 
 27 
 
 t .^ 
 
4i8 
 
 .'! MANUAL OF SURGERY 
 
 hole being cut to receive the point of the olecranon), and l.v tln^ 
 means the arm is raised and drawn forwards and the hand jJlactd 
 on the opposite shoulder, and the desired position is tluis main- 
 tained. In children more than one strip of plaster will lu 
 needed in order to secure the arm, whilst an additional l)and;t"e 
 is also useful. Excellent results follow this plan of treauiient. 
 (c) In ladies, where even the slightest deformity is undi'siiiihle^ it 
 is better to confine them to bed; the head is kept low without a 
 pillow, and a sandbag placed between the scapula-, the arm heint: 
 JKUidaged to the side. This position must be maintained for 
 three weeks, and even then only \ery limited movement allowed. 
 {d) The old-fashioned plan of treatment I)y means of an axillary 
 |)ad, a figure-of-tS bandage crossing behind the shoulders, and aii 
 elbow sling, has been to a large extent superseded by Sa\ re's and 
 other methods. Union is probably attained in four weiks, but 
 the movements of the arm should be restricted for some time 
 longer. A considerable amount of callus is usually formed, and 
 there is very likely to be some slight persistent deformity. 
 
 Fractures of the Scapula. — i. The Acromion Process may he 
 broT^tMTT^'^Tir'S^^Wfl^tfc'e" 'applied to the point of the shoulder. 
 The arm hangs powerless at the side, supported by the other 
 iiand, and the shoulder is flattened. The irregularity of the bone 
 can be readily detected, and crepitus can be elicited bv raising 
 the elbow and rotating the arm. Occasionally merely the tipisj 
 detached, and then the above signs will not be present. Thei 
 Treatment consists in raising the elbow, and bandaging the arm 
 to the side. 
 
 2. The Coracoid Process is rarely fractured, and only from direct 
 \iolence. There is but little displacement, op account of the manv 
 powerful ligaments attached to it, and the only treatment needed] 
 is to raise the arm by a sling, and to keep it at rest by the side. 
 
 3. The Body of the scapula is broken as a result of considerable! 
 direct \'iolence, which is often primarily received by the spine,! 
 and also bruises the thick inuscles above and below it. There 
 is but little displacement, if, as is usually the case, the fracture 
 is transverse just below the spine. A longitudinal fracture may, 
 however, result in the inner or \ertebral fragment bein.i,' drawi 
 upwards and outwards in front of the axillary portion by the 
 serratus magnus and levator anguli scapula?. The diagnosis i^ 
 made by grasping the bone firmly, and moving one fragment on 
 the other; crepitus may thus be obtained. The Treatment cmij 
 sists in bandaging the arm to the side, and possibly applyint 
 strapping to support the fragments. 
 
 4. Fracture of the Neck of the bone is usually due to fjrea 
 \ iolence directed to the shoulder, but it is a rare accident. 
 portion of the articular surface is broken ofl" and displaced down 
 wards in some few cases of dislocated shoulder (iMg. i ]i- A): oj 
 
 I Fractures ox t 
 
 Y Of the An 
 jM, the so-ca 
 iiracapsiiJar p 
 iPlate X.). rh 
 "■ays cine to I) 
 iilisonthe shoul 
 m of a severe 
 "le head of the 
 Kwiinatic^n fron 
 Nistinctly felt. 
 I'^iefe is some sii'. 
 most cases l 
 pains connecte 
 p^i'le, and thus 
 
 Z ""'''" "PPer 
 deformity of the I 
 
INyURIHS OF BONES— FRACTURES 
 
 419 
 
 ;lie fnifture has been known to run through the anatomical neck 
 il'ijr. 131, 1)), either condition ca usnig sli;(ht lengtheniiuf of the 
 arm. and displacement down waul?? Uf" Tlie fiWtTTTlOlie'tiummis. 
 Tfgatmenl.— Tfre rtrm'Tmtgfhfe-'JrerpfW tR6' slrte'lffid 'tUFsedr*^ 
 
 More commonly, however, the fracture involves the Surgical 
 Neck (I'^if,'- 13I) C), extending from the suprascapular notch 
 above to just below the 
 ,)ri>,'in of the triceps 
 nuiscle, so that the de- 
 tached fragment includes 
 the coracoid process. 
 Flattening of the 
 shoulder results, with 
 prominence of the acro- 
 mion, lengthening of the 
 .irm as measured from 
 the acromion to the 
 external condyle, and 
 crepitus on raising and 
 rotating the limb. Treat- 
 ment.- Ihe bone is re- 
 jptsced by p|ressure in 
 I the axilla, if necessary 
 [under chloroform, and 
 j tixed by an axillary pad 
 or the p -shaped leather 
 Kplint recommended by 
 Erlchsen, whilst the arm 
 I is kept to the side. 
 
 Fractures of t he U pp gr 
 
 11. Of the Anatomical 
 Neck, the so-called ' In- 
 |;racapsular Fracture ' 
 iPlate X.). This is al- 
 lays due to blows or 
 
 jialison the shoulder, never to indirect violence. It is exidenced by 
 jijins of a severe local trauma, with loss of mobility of the arm. 
 iThe head of the humerus is found to be irregular in shape on 
 lexamination from the axilla, and the fragment, if detached, may 
 jK; distinctly felt. Crepitus is obtained on moving the arm, and 
 jihere is some slight shortening, but not more than half an inch. 
 most cases the upper fragment is not totally detached, but 
 lemains connected with the rest of the bone by a few shreds of 
 jcapsule, and thus necrosis is prevented. Should impaction occur, 
 m small upper fragment is driven into the lower, and marked 
 Wormity of the head of the bone results. 1'h e arromior) bercm^f^j;^ 
 
 27 — -2 
 
 iMC. 13 1. 
 
 -Fkactures ok Till-; Xi;ck ok tiuc 
 
 SCAI'ULA. 
 
 A, Tlirougli the f,'lenoid fossa ; H, tlirou^h the 
 anatomical neck; C, throuK'li the surgical 
 neck. 
 
420 
 
 A MANUAL OF SURGERY 
 
 uhily pronn .iient, and tlie ro undecl projection of the deltoid i^ 
 TTrtTltSncU", iiiuess, as~oTten happens, tTTe s\veTTTffis!f'' d"ire To v\\t;\- 
 
 un( 
 
 vasation is considerable. Repair takes place mainly frf)iii ih,, 
 lower vni\, and, owinfj; to the difticuity of apposing and inuiid. 
 hilizing the fraj^aiients, a considerable mass of callus is iisualK 
 formed. Examination must be conducted with great can! lest 
 impaction be disturbed, or any capsular attachments hrokm 
 through. 'Hie Treatment usually recommended is to bind ih,. 
 arm to the side, and apply evaporating lotion for a few days if 
 great ecchymosis exists. A pad or p|-sliaped splint is then placed 
 in the axilla, and retained in position by a soft bandage or luinil 
 kerchief passing over the top of the shoulder, and tied under the 
 opposite axilla ; this assists in raising the arm, which is alsD 
 supported by an elbow-sling. l''inally, a comfortable i)oroplastK 
 or leather cap is fitted over the shoulder and buckled on. liiion 
 generally occurs in about six weeks, but often results in n^rtat 
 stiffness, for the removal of which massage and even manipulation 
 under chloroform are required. To obviate these sequeL-r, it is 
 well to treat the case by earl)- massage and manipulation, the limh 
 being merely supported in a sling ; the massage should comiiieiicr 
 about the third day (see p. 400). 
 
 2. Of the Surgical Neck, the ' 1 Extracapsular l-'racture' (PlatiXl.j. 
 
 The bone yields in this case below 
 the muscles attached to the tuhei 
 osities, but above the insertions intu 
 the bicipital groove and its niarf,Mn> 
 of the latissimus dorsi, pectorali- 
 major, and teres major. It usuallv 
 results from violence applied 
 directly below the point of the 
 shoulder, but also from falls on the 
 hand or elbow. The fracture is more 
 or less transverse, and the displace- 
 ment a double one: the upper frag- 
 ment is rotated outwards, and 
 generally adducted by the muscles 
 inserted into the tuberosities, espe- 
 cially the subscapularis ; whilst the 
 lower fragment is drawn inwards 
 by those attached to the liicipitai 
 groove, and upwards by the deltoid, 
 coraco-brachialis, biceps, and tricep- 
 (I'Tg. 132). The appearance ot the 
 patient is sufficiently characteristic:! 
 the head of the bone is still in the 
 glenoid cavity, so that there is no loss of the fulness of the) 
 shoulder (Fig. 133, C), although there is a depression just below. 
 unless it is obliterated by the extensive luemorrhagic effusio:;. 
 
 I'lG. 132. — Fkactckh ok Slk- 
 GicAL Neck ok Humkius. 
 
 b, Subscapularis; f-.l), latissi- 
 mus dorsi ; ]), deltdic! ; I'M, 
 pectoralis major. 
 
Ill i< 
 
 Ihr 
 
 imo 
 
 iialK 
 lesi 
 okci! 
 1 the 
 .ys if 
 laced 
 laml- 
 r ilif 
 
 .'iIn) 
 
 lastii. 
 .'nion 
 'Arm 
 lation 
 , it is 
 i limli 
 iiLiiCf 
 
 :)l 
 
 .XL), 
 below 
 tulier- 
 s into 
 ar},Mib 
 torali> 
 suallv 
 ieil 
 the 
 jii the 
 more 
 )lace- 
 fra- 
 and 
 uscles 
 espe- 
 St the 
 wards 
 cipitai 
 eltoid. 
 riceps 
 of the I 
 ristic ; ! 
 11 thej 
 f the; 
 )elo\v, 
 'usior.. 
 
 u 
 
PLAI'I'- X. 
 
 Imi'actkd I'kactl'ki: of Anatomical Nkck ok IIimi;ul's 
 
 To/acc I'tatc XL, l'it:><icii pp. \iii diui i^n.^ 
 
 ^'^""^'I'latcX., !,,!,„, 
 
rLATIC XI. 
 
 FkACTL'RK of SL'KCICAL NliCK OF I IlMICKLS. 
 Y'"<i,- /'/,!/,■ X., bct'vccit pp. 420 and \2\.\ 
 
fhe elbow i 
 
 •wer iv'd<fm 
 
 iitained by ( 
 
 :) incli or m^ 
 
 ; the ui)pei 
 
 •rves. If i 
 
 ,1(1, indeed, n 
 
 ,!iivcn into tli 
 
 'IV be prese 
 
 Coniplicatic 
 
 (i more conn 
 
 / 
 
 \iirnial slunilc 
 
 t.'iecireunitlex, 
 
 tnr site (if lilt; 
 
 'nil- Treatrn' 
 
 'lii^iy, \ iz., tb 
 
 'ip, whilst the 
 
 !;}■ ;i slin-. Tl 
 
 tiiesliorteiiiiicr. 
 
 |>ix weeks, witi 
 
 ""i'^-"tf,a' and I 
 
 !'f'"ii the third 
 
 "'■ purpose and 
 
 .!• Separation 
 's'litecn to t\\( 
 i;il«T()sities. T 
 '■'\^k[pv, the a 
 ■iH'ldleolthe ep 
 
 Rr:^ra'#j 
 
INJURIES OF BONES— FRACTURES 
 
 421 
 
 Ihe elbow is directed away from the side, and the axis of the 
 lower fra<;ni('nt is upwards and inwards. Oepilus can be 
 ,)!)tained by extendin;^' and rotatinj^' the arm, which is shortened 
 in incli or more. This fracture is often very painful from pressure 
 t!i<' upper end of the lower fra<^ment af^ainst the brachial 
 
 • ivcs. If impaction occurs, the signs are much less evidi-nt, 
 ..lid, indeed, may be very ecjuivocal ; the lower fraf,mient is usually 
 driven into the upper, and only slif^ht shortening or displacement 
 iiiiv he present. 
 
 Complications. 
 r. more, conunonj 
 
 5. — The axillary vessels may be seriously d^i, ma^ ed. 
 inly "^me oF the nerves sustain injury, especially 
 
 l"li;. I 5J. — OCTI.INICS ()!•■ Sllori.DKK. 
 
 Normal shoulder ; I!, disloc.-ition ol shoulder ; C, Iractiire of suri^'ical nccl 
 
 of luimerus. 
 
 !■ circumllex, which winds round tl"' n2ck of the bone close to 
 site ot the fracture. 
 
 riic Treatment is mucli t'K; simg as for tiic intracapsular 
 !i(ly, \iz., the application o'^ r 1 axillary pad and a shoukler- 
 :. whilst the arm is kept to tne side, and tlii> hand supported 
 ii sling. The elbow should be allowed to lumg to overconiv' 
 ■' shorlen'.ng. I'irm union usually results in four and a half to 
 \ weeks, with the formation of a goc^d deal of callus; but 
 ivNige and passive ni;uii|)ulatioiis should be daily cmidoycd 
 111 tile third week onwanls, the apparatus being taken off for 
 ■purpose and reapplieil, if necessary. 
 
 Separation of the Upper Epiphysis occurs up to the uge of 
 
 ^:iI^■t 11 U) twenty years and in\oKes the h.ead and both the 
 
 '"losities. The upper end of the shaft i*^ somewhat conical 
 
 >h;ipe, the apex of the cone fitting intc a depression in the 
 
 ■'Mle ol the epiphysis (I'ig. 134). The lesion usually follows the 
 
422 
 
 A MANUAL OF SURGERY 
 
 line of the cartilap;e ; but the displacement is often incomplete, 
 partly from the conical projection hitchin',^ a{;(ainsl the inner edf;c 
 of the epiphysis (a doubtful occurrence), but mainly from tliH" 
 persistence of a well-marked periosteal slee\e or bridf^e on the 
 outer side. The shaft usually travels forwards and inwards, aiu; 
 thus its ujiper' end' may project under the coi^acoid ^Moces-. 
 (Tausin.y; the condition to somewhat resend)le a subcoracc^d dislo- 
 cation. The presence of the head of the bone in the glenoid (avitv 
 should prevent this mistake, whilst the softness of the cicpltu's 
 tlistinpjuislu's it from a fracture. 
 
 Treatment. It is most important to reduce this displacement. 
 sin7tMT[TienAise interference with the growth of the limb is alnios; 
 certain to i-nsuc. This may l>e effected by traction upon llir aiii; 
 under an anajslhetic, assisted perhaps by slight rotary mo\emtiu> 
 
 ^ 
 
 fl^^^^HMI^^^HH|||P!^i ' V ^ 
 
 w 
 
 ^^^^^jL^Ht • t*™'NB||*-" 
 
 // 
 
 
 VU,. IJ4. Slil'AKATlON OK Till-: I'lTICK I'". I'l I'll V-IS OK Till- lllMIKlS 
 
 or abducticMi ; but shoidd these manoiu res not be successful, 'it i- 
 quite permissible to open the joint antiscptically, and restore thf 
 parts to their correct position. After reduction the limh i- 
 treated as for a fracture of the neck. 
 
 XTN Xhe Great Tu berosity is occa sionally lor n off as a rcsii ii 
 of direct or inus(nn!M"^toTcilu^"oi' 'i^ a coi'lTpli(.'fltlon"or l'fy,tlll' 
 ^'llI^iStLJil/!^- ■ If "tlK" whole iTTT/ei'A.'iilty fi 'g^|JcTraTe3',"t1uii' i- 
 maiked dei'oi'nii'ty, resulting in a great increase in the breadth i! 
 the shoulder. The fragment is displaced upwards and back\varil> 
 by the unopposed .iction of the supra-and infra-spinatus, whilst ihf 
 shaft of the liumerus is drawn forwards and partially dislocain! 
 (or subluxated) by the subscapularis and other muscles. A ili> 
 tinct sulcus is felt between the two bony masses, and it tl'' 
 can be brought together, crepitus is obtained. Treatment. A| 
 
INJURIES OF BONES^FRACTURES 
 
 423 
 
 pad i s placed in the axillci^ and the elbow kept to the side so 
 ;is"to throw tTie"uppef""end of the bone outwards, whilst the 
 
 tuberosity is drawn down to this as far as is possible by the 
 pressure of a pad strapped on, the elbow beinjj also supported by 
 ,1 slin^'. Another plan su^'gested is to elexate and extend the 
 arm above the he?' 1, keepinj^ it supported by pillows, t;'' union 
 has occurred — a most uncomfortable and tedious proceedinff. A 
 much UK <i efiicacious method, and one that need not be feared 
 where asepsis is maintained, is to cut down on the fragment, and 
 wire or peg it in position. 
 
 Fract^s^ jbhe ,^|^ . q;^ thft..awiieru^.may_^y4^ 4^^^^ 
 foffii of violence, whether direct oi" maiti;ct» wIilIsliL is TTie 
 I'SiTTnioiiest site for fracture of the shaft of a long bone ironi 
 mn^ciltai' '"(^^iTce, asT^-^-. i'n thfr.uTng a cricket-ball. Xiie.jjiiios 
 of the injuiy are very obvious, and most typical. The displace- 
 ment depends largely on the position of the fracture. If it occurs 
 above the in.^ertion of the deltoid, but below that of the muscles 
 inserted into or aiound the bicipital groo\e, the upper fragment is 
 drawn inwards, and the lower upwards and outwards. If, how- 
 ever, it is belov. the deltoid, the upper fragment is drawn outwards., 
 ;in(l ttu' lower upwards and inwards. .\s the line of fracture ap- 
 proaches t!ie elbow, the displacement tends to become more antero- 
 posterior than lateral, following the change in direction of the bone. 
 The r. '-i '^ommon complication is injury to the musculo-spira! 
 nrrve ', ' ' *i winds round the shaft close to its centre. 
 
 Treatment. An internal angular splint re:vrluiigJ[tiiil]J.he axilla 
 to the wrist must be applied, together with three small lateral 
 splints to fix the fragments, or a piece of Cioocli or kettle-holder 
 >plint ; the limb is kept to the side in a sling. Union is usually 
 ioiiiplfte in hve weeks. 
 
 It is not at all uncommon to meet with an ununited fracture of 
 the shaft of this bone; this is probably due, not to any anatomical 
 reasons, but simply to the fact tiiat the necessity for Jixing ajid 
 -upportiiig the elbow-joint has not been appreciated, the forearm 
 !ifin<,' allowetl to hang loose on th.e false plea of tending to 
 I'.iminish tlu> shtirteiiing. 
 
 Fractures of tlie Lower End of .the Humexus. — In dealing witii 
 ally injury in the vicinity of the elbow, it is absolutely essential 
 that the relatixe position of the bony points, whicii can there 
 I'L' felt, shouUl be accurately established, and a comparison made 
 with those of the opposite side. Hoth arms are stripped a\\(\ 
 examined in similar positions, a good plan being to place (if 
 possible) the liands on the top of the head, so that the elbows 
 look forvvartls. Normally foilr bony prominences can be made 
 out, viz., the two condyles, the olecranon, and the head of the 
 radius. The relation of the olecranon to the condyles varies witii- 
 the i^osition of the elbow. If the forearm is extended, the tip ol 
 tile ole( ranon just touches the intercondyloid hnc, but is placeil 
 
424 
 
 A MANUAL OF SURGERY 
 
 nearer the inner than the outer condyle, whilst in flexion of 
 the forearm it lies below that line. The head of the radius in all 
 positions of the arm is inuiiediately below the outer condyle, and 
 can be felt rotatinj'^ beneath a dimple in the skin which api^ar-. 
 at that spot. When the arm is Hexed to a rij^ht an;^de, the tip of 
 the olecranon is a little in front of the posterior surface ot the 
 upper arm, so that a ruler placed alon-,' that surface misses the 
 olecranon ; this is a useful <,ande in ascertainin<,f if the bones of the 
 forearm ha\e been displaced backwards or lor wards. 
 
 Another important feature depends on the fact that the axis ut 
 the forearm does not correspond with that of the arm, the formci 
 beinj^f in a position of slif^ht abduction (about 15'), constituliiij^ 
 
 \'\r, I 55. - ( )iitliiu's of I'l))!!'!- I'"streniity ti) slio w A. Xnniial cariyiiif,' ;ii!i;r 
 (ti = 13 ), li, t iiliiliis varus; C, cubitus \al;,'iis. 
 
 what is known as the ' carryinj,' anf,de ' (Im.l^. 135, A). Lattiai 
 de\iation follow in;^^ fractures m the nei}^dibourliood of the flbov, 
 lesults in niodilications of this an^de, and if these are allowed I' 
 lersist, conditions of cubitus \arus or valj,ms {\'\\*. 133, b. ( 
 ensue, which much interfere with the utility of the limb. 
 
 1. Transvfirsfi Sn|^rarnnrij[]Awl Fracture, i il_\ ol\ ili^^ the >lul; 
 
 J Vli^UUCi_ill' .^..JilUiL'L- 'i.ll9}~^', -•; ' ^ '- J * 'iiiJ^'' ^ ^^^ '■■'UJier^to a faTl on liif 
 hand with the arm Iient, when the lower fra.L;ment*'Ts usuallv tli^- 
 })laced backwards, or much less conunonly to a tall on or \ iok'iuf 
 tlirected to the point of the elbow, when the displacement is either 
 forwards or backwards. When the lower fraj^jment is displaail 
 backwards, it is also drawn up b) the action cjf the triceps iipor 
 the olecranon, a cei tain amount of angular as well as \erlicai 
 
INJURIES OF BONES— FRACTURES 
 
 425 
 
 deformity beinj:^ tluis produced ; wlieii displaced forwanis, ap- 
 parent lengthening' of the forearm results, with a loss of pron\inence 
 iit tlie olecranon. The former of these conditions is likely to he 
 mistaken for a dislocation of both hones backwards at the elbow 
 uf. Fig. 13^), A and J>), but may be recognised by the following 
 hicts : ((j) Ihe relative position of the bony points at the elbow is 
 unimpaired ; in a dislocation they are necessarily disturbed. 
 ,/) Tlie upper arm measured from a tubercle which can be easily 
 hit at the back ot the acromion to the outer condyle is shortened 
 
 w a fracture, but remains the same length in a dislocation. 
 
 I The projection of the upper fragment forwards is felt beneath 
 
 •:;e skin above the crease of the joint, whilst in a dislocation it 
 
 iiesponds with it. (d) The def(jrmity is easily reduced with 
 
 A B 
 
 . IJd 1'kACTCRK of LoWKK I'.M) (IK HlMi:KlS (H) COMPAKKI) WITH DlS- 
 tATlnN (>|. KaUIL'S AM) I'i.NA IIACKUAKDS AT l'',l.i;cl\V (A). (Tl I.I.MAN N •^ ) 
 
 luipiiu;, hut readilv reappears ; in a dislocation tin- bones are 
 il.iced with ilifliculty, but after replacemeiu they usually remain 
 [ill position. It maybe diflicult and at times almost impossible to 
 Ir. M>i;iiise this condition at once, owing to the amount of swe'ling 
 land eccliyniosis present ; the application of n cooling Idliun tor a 
 |ft\vuays will so reduce this as to permit a thorough exanunation, 
 ar.il this is most essential, as a w long diagnosis probably leails to 
 jl>al ticalment and much subse(|uent im|)airm nt of function of 
 ■• liiiih. Skiatirau hy will a t._ont;e detertnine tlie naturi' of the 
 i')n. l.ateral deviation sctnietniies occuis. luul the resiiitation ()l 
 I'' normal '^carrvTii'g angle" must always lie .-iimed at. 
 Murh ca'c is neecleo in the Treatment orTlie'se* cases in order to 
 ^iiit ankylosis or deformity, and the stereotyped a|)plication of 
 
426 
 
 A MANUAL OF SURGERY 
 
 an internal angular splint is by no means sufficient. To currect 
 the backward deforniity the elbow must be flexed, and traction 
 made upon the forearm, which is placed in a position of full 
 supination. It may then suffice to apply an anterior an^'ular 
 splint in the bend of the elbow, and a straight posterior splint 
 reaching below the tip of the olecranon, so as to keep ii well 
 forwards ; or perhaps it would be better to apply a carefulK. 
 
 Fl'i. IjS.^SACilTTAI. SKCTION CI 
 
 LowKR End ok Himkkis (i 
 
 A YolTH OF FlFTKKN VllAK- 
 SHOWING THAT THK I';i'iril\ >;~ 
 
 KOR THic Intkrnai. CoNliM i: in- 
 
 liV THIS TIMK I»I:KN SKI'AKATI 
 
 KKOM THE Main ECimi'iivsisiskm; 
 
 ,, ,, niAClRAMMATIC). 
 
 iM'i IJ7 - S li I'AK AT ION OK Tllli 
 
 LowKR lu'ii'HYsisoKTHK Hi-MKRUs TIk! liollow al)ove the epipluMV 
 IN AN Inkantunijkk TiiRKi; Ykars. Ii»e is the olecranon lossa ci. 
 
 (MUSKL'M OF KoVAI- COLLEGK OK aCfOSS. 
 
 SURGKONS.) 
 
 A, Epipliysis, incliHlinK' l)oth con- 
 Jyles ; B, small portion of the 
 diaphysis detacheil with epiphysis ; 
 C, (liapiiNsis ; D, loose periosteal 
 bridge. 
 
 moulded gutter-sha|)ed posterior splint reaching well al)o\e aiitl 
 below tlie elbow, and a shorter anterior splint fitting down to tlif 
 bend of the joint. If there is any dilhculty in keeping' ilu' 
 bones in position, a pad may be placed cner the lower ciul ol the 
 upper fragment in front, and another over the tip of the olecranon 
 behind, and a ligure-of-S band.'ige will efficiently press the latur 
 process of bone dow nwards and forwards ; splints are then applien 
 as indicated above. In these fractures the elbow-joint is not as a 
 
rrect 
 :tion 
 
 fui; 
 
 ;ular 
 
 plin' 
 
 well 
 
 ■iillv- 
 
 OS 111 
 
 fS OK 
 
 k'l-AR^ 
 
 I'llVsl- 
 
 I.K H\~ 
 
 iW.ATl 1' 
 
 , Iskm: 
 
 )h\M'al 
 
 isa cii! 
 
 to the 
 1^^ l!u- 
 of tlif 
 •raium 
 liitii' 
 ipplii'il 
 ot as ii i 
 
1 'LA lie XII, 
 
 Separation ov thi-: I.h\vi:k Mni'iivsis ok tiii-: I Iimkkis, with 1 )im'i.aci:mi\^ 
 
 OL'TUAKDS, in a YoTNO I'ICKSON, a LITTLK oVKK TllK .\(;K Ol- I'lllKKTV 
 
 'I"he outer (condyle li;is been l)r()k<;n oft', as well rts the epiphysis, and cii'^jluefl 
 iipwanls and outwards ; ai)o\i' this (rrif,'ineiU is seen a shadow caused h\ 
 strippiu;,' up ol the periosteum. Tiie nhia and radius accompany tlie I'tl 
 epipliysis of the hiuiierus outwards. 
 
 Iraf,'mt'iit of 
 
 To /(ice p. 4-7d 
 
INJURIES OF DOMES— FRACTURES 
 
 427 
 
 rule involved, and therefc-e passive movement is not commenced 
 too early, for fear of deformity owing to yielding of the callus. 
 In dis|)lacements of the bone forwards an anterior angular splmt 
 >hoiil(i be employed, antl possibly a short posterior one in 
 
 addition. , 
 
 J. SeparalJop_ of the Lower Epiphysis. oC-tlVB-JBUuufirm-i5.J6L,\:£ry 
 
 comniDn iicci^lent in children . At b.irth and for some yea rs 
 
 .iFterwards the epiphysis consists of .ji single, mass of cartila^^je. 
 
 inrliicling "tTie two c()n(TyT^s"as "\velT as the articular surface.lind 
 
 these are all involved in any separation, together possibly with u 
 
 fragment of the diaphysis (Fig. 137). As, liowever, growth and 
 
 ossiticution proceed, the shaft encroaches rapidly upon the inner 
 
 portion of the epiphysis, so that the epiphyseal line becomes almost 
 
 tctanj^ular (I'ig. ij*^), the internal condyle being isolated from 
 
 ;he rest of the epi[)hysis. As a result of this, separations of the 
 
 rpiphysis after puberty do not usually include the internal 
 
 ondyle; the accident at this period is situated much nearer the 
 
 joint than in infants, and conseciuently is more likely to be 
 
 iollowcd by impairment of movement. The displacement is 
 
 ;'enerally backwards, with some amount of lateral deviation 
 
 I'lati' Xll.). Treatment.- -Reduction can usiiall)- be accomplished 
 
 by flexion, and the application of antero-posterior splints may 
 
 suffice to maintain the fragment in position ; but it is an open 
 
 ']uestion whi'lher it is not wiser, at any 
 
 r;ite in small children, to avoid splints and 
 
 iriisi to full and complete flexion alone, 
 
 liu' hand being bandaged down to the 
 
 -boulder on the same side. Passive move- 
 
 nents should commence from about the 
 
 'lijbtli day. 
 
 3. The Condyles .bsiye been broken 9ff 
 l'"thby direct and indirect violence, though 
 more commonly by the former. Tliis par- 
 ;icularly applies to the inner condyle, 
 -ince the outer is sometimes broken l)y 
 indirect violence, such as a fall on the 
 land, owing to the laxity of the elbow- 
 lomt on this side allowing considerable 
 niojiility between the radial head and the 
 apitelhun of the humerus, iliacture of 
 "f external condyle always .iivvoIvestTlie 
 'l^i'w joint, and is more common than 
 
 '!al of tte innerT^^nielme of fracture runs from the condylar 
 ■i>i?e dnwn-wards and inwards so as to separate the capitellum, 
 ' ^ven encroach upon the trochlear surface. The fragment is 
 I'lii little displaced, and can be felt to move on the rest^ of the 
 l^onewith crepitus, which may also be produced by rotation of 
 the hand and radius. The accident is associated with much pain 
 
 Imo. 139. - Kkactukks 
 OK Intkrnal Con- 
 
 DVLK AM) IClMCONUVLK 
 OK HCMERUS. (TlLL- 
 MANNS.) 
 
428 
 
 A MANUAL OF SURGERY 
 
 and ecchymosis. Fracture of the internal condyle may he intra- 
 or e.\tra-( apsiilar. 'J'he cxlni-ar/iiitlay variet) (Fiff. i^yi-ujusiMtv 
 of a mere clisplacenieTTt of iTie tip oTfEe co'ncIyT6''(orTpicoii7IyltM, 
 proT)ably a separation of tlie epiphysis, since it occurs mainly ii 
 children. The small fraf^meni is drawn a little downwanls hv 
 the nniscles attached to it, and the fracture is readily detected li'v 
 the usual si^ms ; it may be associated with injury of the ulnar 
 nerve. The inti'a-ai'tuular form is tiie more common, and extends 
 from the condylar rid<,^e to the trochlear s'uface, implicaliiij; the 
 coronoid and olecranon fossa*. The fragment is displaced a little 
 upwards and backwards, the ulna usually accompanying it, sn 
 that on extending the elbow the olecranon appears uiiJuh 
 promineiit, the lower end of the humerus projects anteriorly, anrt 
 the. forearm is slightly adducted" Xcubitus' varus). Tlic uln.u 
 ner\e may also be injured in this case. 
 
 Treatment. — Flex the f orear n\ yj^i.! place, it. on an angular splint, 
 using a pad and strapping to maintain the fragments in position. 
 If the joint has been involved, there is a great tendency to 
 impairment of its usefulness, and passive movement should U. 
 started early. Possibly in these cases it would be wiser to a[)plv 
 no splints, and treat the fracture by early massage, or per!ia[)- 
 even better to operate and fix the fragment by wire or screw. 
 
 4- Jt-flT y.TSliaped EtacJiUre, Xisually occurs as the result of direct 
 injury. A fissure extencls into the joint between the condyles, 
 and may either bifurcate to either side in a Y-shaped manner, 
 detaching partially or completely the two condyles, or it may be 
 conncjcted with a transverse supracondyloid iissure, constituiiii',' 
 the T-shaped variety, if the fragments are not totally detatliei. 
 there will be much bruising and i)ain, but no crepitus ; but if the 
 fragments are separated, the condyles will move on each other 
 with crepitus, and the elbow will be widened with much deformity, 
 In these cases the joint is very likely to become stiff, o\vin.i,Mi(ii 
 only to adhesions within it, but als(j to the filling up oi the tossi 
 ■ n the lower end of the humerus with callus. ICxcess of xioKnu 
 leads to comminution, and luxation of the bones of the fortarm 
 may also occur. A marked feature of these cases is tlic rapiditv 
 with whicli swelling supervenes, owing to luemorrhagi' into aii^l 
 around the joint, rendering accurate diagnosis difficult. Treat 
 ment nmst be directed towards reducing the swelling, and then. 
 after manipulating the fragments into as good a position a:- 
 possible, antero-posterior angular splints are applied, and jiassm' 
 motion started early. Possibly an antiseptic incision antl wiriiK 
 or pegging of the fragments would gi\e better results, wliil>t i" 
 some cases excision of the ends of the bones may be required. ^^ 
 
 Fractures of the Ulna. — i. The Olecranon is freciuenthj^ijiii 
 by direct violerice, the paticmt (Tilling on the l)enf 'eluu^W-li*' 
 occasionally by muscular action. The displacement is olti" 
 
ntra- 
 
 ily i',, 
 Is hv 
 ■d liy 
 ulnar 
 U'lul.- 
 \U, tile 
 . little 
 it, SI I 
 luiuly 
 ,', and 
 ulnar 
 
 >plinl, 
 sition. 
 icy Id 
 lid lie 
 apply 
 ;rha(b 
 ,v. 
 
 direct 
 idyle>. 
 aiiiier, 
 lay be 
 tiitiii'4 
 uhe'l. 
 
 if the 
 
 other 
 rniity. 
 lit; III)' 
 
 t)s^ie 
 oiciKe 
 )reariii 
 ipiditv 
 to aiul 
 Treat 
 
 llu-n. 
 ion a- 
 )assi\e 
 wiriiK 
 lilst 1" 
 ed. ^ 
 
 broke;' 
 
 often 
 
IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 1.0 
 
 I.I 
 
 ' itt IIIII2.2 
 
 ■ 40 
 
 2,0 
 
 1.8 
 
 
 1.25 
 
 1.4 
 
 1.6 
 
 
 ^ 6" — 
 
 
 ► 
 
 Photographic 
 
 Sciences 
 Corporation 
 
 33 WEST M/ IN STRtiET 
 
 WEBSTER, NY. I4S!30 
 
 (716) 872-4503 
 
<" C^x 
 
 
 % 
 
 .^ 
 
 L<?/ 
 
 "m 
 
 cp- 
 
 C/j 
 
 o 
 
 ^ 
 
 
 w 
 
PLATE XIII. 
 
 Fracture ok Olijcranon before Operation. 
 
 To/ace I'liitc A'/ 1 '., /•ctwec i //. 428 an / 429. 
 
PLATE XIV. 
 
 Fractuke of Olecranon after Operation. 
 From the same patient as I'late XIII. 
 
 [ ?■•' 'ic* Plate All I., betwicn pp. 428 and 429.] 
 
very considt 
 
 ,Flate XIII 
 
 tendon to tl 
 
 little separat 
 
 displaced for 
 
 usually runs 
 
 the shaft, an( 
 
 and around t 
 
 fragment car 
 
 shaft a sulci 
 
 extending th 
 
 amount of se 
 
 If the fragn 
 
 tibrous union 
 
 tissue may st: 
 
 in some cases 
 
 and a false jo 
 
 are brought 
 
 some impairr 
 
 encroaching ( 
 
 In all cases tl 
 
 Treat ment . - 
 
 ireely"'open, 
 
 e.\udatto^*rei 
 
 I k placed bet 
 
 the \vire'j"ust"e'; 
 
 The same pre 
 
 lealing with t 
 
 [compound ca; 
 
 occurred with 
 
 [instance the i 
 
 and the bony 
 
 I taken, the arn: 
 
 bgment bein 
 
 I of a pad and fi 
 
 [ massage shoul 
 
 2, ThejCorc 
 
 I tected that fra( 
 
 I as an acconipa 
 
 I signs rellej or 
 
 ^location is e 
 
 Ithatthedeforn 
 
 ppposing the 1 
 
 I I^ony union' is, 
 
 i'^ow, awd-tiic 
 
 J. The 'Shafl 
 
 jof direct viol 
 
 ipeciiliarly liab 
 
INJURIES OF BONES— FRACTURES 
 
 429 
 
 very considerable, the fragment being drawn up by the triceps 
 Plate XIII.); but if the ligamentous fibres passing from the 
 tendon to the fascia of the forearm remain intact, there is but 
 little separation. When complete, the bones of the forearm are 
 displaced forwards, "arid TJrfibst disTocat'edr " ThS"H"irer of fractwre 
 usually runs through fKe base of the'process at its attachment to 
 the shaft, and is for the most part transverse. Great swelling in 
 and around the joint comes on early ; on examination, the detached 
 fragment can be readily distinguished, and between it and the 
 shaft a sulcus, which increases on flexion and diminishes on 
 extending the forearm. The nature of the union depends on the 
 amount of separation of the fragments, and the treatment adopted. 
 If the fragments are not brought accurately into apposition, 
 librous union is likely to occur, and although the new cicatricial 
 tissue may stretch considerably, a useful elbow sometimes results ; 
 m some cases the fragment is drawn up and fixed to the humerus, 
 and a false joint is developed below it. If, however, the fragments 
 are brought in contact, bony union follows, though even then 
 some impairment of function may ensue owing to the callus 
 tncroaching on the articular surface, which is always involved. 
 In all cases the ulnar nerve is exposed to injury. 
 Treat men t. — The most, ^^tti'ifartnry plj\iiji,s_io.Jav the parts 
 freelf^pen, to Jhorouffh]x^clear_the^j^^^^ 
 exudatfdn. 'remove snreds 01 tendon 
 
 and ligaments which may 
 
 ' ' » T*rl«s*;*i M(*teK»«Mi»«K'j:.***<^i 
 
 k placed between the fragments, and then _wir e them t ogether, 
 the wiFe JusrexlendmgBmvn loTTTe artTcular ca r f iTage ( J:Tai!G^'I V . ) . 
 The same precautions and after-treatment must be followed as in 
 dealing with the patella. A similar plan should be adopted in all 
 
 j compound cases, and in those where loose fibrous union has 
 occurred with a resulting weak and relaxed elbow ; in the latter 
 instance the new fibrous tissue must be entirely dissected away 
 
 I and llie bony surfaces freshened. If an operation is^ not ^under- 
 taken, the arm should be put up on a straight anterior splint , the 
 
 I fragment being drawn into position as well as possible "Dyineans 
 ofapad and figure-of-8 bandage. Gentle passive movement and 
 
 I massage should commence at the end of a fortnight. 
 
 ThgJgprgnQid PrQCfiSa is so . degpJy.^acedL^and ^ ^ w a l i - pfe - 
 
 hected that fractures must necessarily be very uncooinion, ej^cept 
 
 as an acconiganiment of dislocation pf.tUe^ulna-backiviirds. The 
 
 [sifjns relieJ on in niaHng a diagnosis are that reduction of tKe 
 
 fclocation is easier than usual and associated with crepitus, and 
 
 I that the deformity is likely to recur. The Treatment^con^igts. ill 
 
 apposing the bony surfaces, if possible, by flexing the f or eacrp. 
 
 Bony union is, h'6v»%ver, less important than a 'freely'^ rjjoveable 
 
 lbo\v,aHfhth«Tefore passive movement is commenced early. 
 
 j. The Shaft of the Ulna is often fractured by itself as a result 
 |of direct violence, to which its exposed position renders it 
 jpeculiarly Hable. Fracture also occurs as a complication of 
 
430 
 
 A MANUAL OF SURGERY 
 
 fsw 
 
 J 
 
 S5l 
 
 several of the forms of dislocation of the radius alone (Plate XX 11.), 
 The superficial position of the posterior border renders examina- 
 tion of the bone easy ; if displacement or a breach of substance 
 occurs, it is readily detected, but when merely a fissure exists, it 
 is not so easy to make out. The constant pain referred to one 
 spot, the sHejit niQbJi ^tY^jtnd possibly crepitus,, indicate tlie char- 
 acter oJ^FHeJesionT l^o long^^ ctrspTacemen^ caH"occuF iT the 
 
 radius'^feiiiains intact, and under such circumstances the only 
 deformity consists in a slight drawing forwards of the upper frag- 
 ment by the brachialis anticus, whilst the lower fraVnnent is 
 approxiriiated to the radius by the pronator quadratus. Treat- 
 raent.— ^The arm is placed midway between p r_onation ami supina- 
 tion, the defor mity correcte d, and the limb kepF aT "r esT T)e!\v5?Ti 
 anterior and posterior splints, or in plaster of Paris. 
 
 4. The Styloid Proneq ^ niav be detached by direct violence, or 
 as a complication of fracture of the lower end of the radius. The 
 displacement may be considerable and very evident, being go\ erned 
 by the direction of the violence. Treatment consists in replacing 
 the fragment by manipulation, and fixing it by adhesive plaster: 
 an anterior splint is applied with the hand adducted. 
 
 . TVafitiirAs nf tk JfifV^— ^ ^ he Head of the Radius is rarely 
 
 broken alone, such an accident being usually associated "wTRi 
 other injuries to the elbow, as, for instance, fracture of die outer 
 condyle or some form of dislocation. The upper epiphysis may 
 be separated, or there may be merely a tran^werse or \ertical 
 fissure ; but under any circumstances the displacement is slight if 
 the orbicular ligament remains intact. In complete separation 
 the head is immoveable, and crepitus is produced when tlie arm 
 is rotated ; bony union usually follows with more or less im- 
 pairment of function, but sometimes the head, or a portion of it, 
 remains detached as a loose body in the joint. All that is needed 
 is the application of a splint, the limb being kept midway between 
 pronation and supination, and early passive movement instituted. 
 Excision of 
 fixation of tJie 
 
 i the biceps tu 
 
 2. 
 and tfie biceps tuberosity, is occasional lv broken. The low gr frag- 
 "^tJ.^...^^.^.^f?.,yfi>XajPda-aii^ fGr..iiytatds.J,)jt.- tiia^bieeps, causing. al 
 Bony"proJection^qn_the pf jtbfi .eihow, especially, -evident o" 
 
 atteinptin^ to flex the jou ^U whilst the forearm is pronated with 
 log's oTfTTepoweiT of irotation, and the head of the bone does not 
 accompany the shaft on passively rotating it. Treatment.— X!ln 
 arm Js flexed to, relax.. tbe-biofips, and the limb placed on aj 
 posterior "angular splint, with a pad oyer the front of the lowerl 
 Tragnient. Passive movement should not be commenced too early,| 
 as the lesion is extra-articular, and the biceps may produce per-j 
 manent deformity if allowed to act upon unconsolidated callus. 
 
INyURIES OF BONES— FRACTURES 
 
 431 
 
 slight if 
 
 LVJ-~ 
 
 ligament 
 
 or by falls 
 
 fib 
 
 aft 
 
 A 
 
 on 
 
 the palm ; the latter 
 
 .site J?J. ,4'rect.vi9i§ftl^ 
 accident, however, rarely 
 
 cauS5?'fRrcttrre*except'^t'the lower end. The signs are sufficiently 
 evident, owing to the superficial position of the bone, consisting 
 of Igcfl lized pa in, loss of power of active rotation, whilst passive 
 rotary movements are'ac^orfipamed'T^rxieBr^s, the head of the 
 bone and upper fragment remaining immobile below the outer 
 condyle unless impaction is present. 
 
 The displacement is somewhat characteristic. If the fracture is 
 imX^A aSoveJIie insertion of the pronator teres, the upper fragment is 
 
 ilexed ^ " dJiiU ^ '^n p' n atf d. J?X.tl]^,-^.^t'."." "f-t^\^-! ^j^.^r^ ^^^4 supiriattQr 
 bfeus, whilst the lower fragment is (Jrawn towards the ulna and fully 
 pfonated by the unopposed action of the two pronator muscles. 
 Treatment. — Inasmuch as it is practically impossible to command 
 the small upper fragment, the lower must be brought into apposi 
 tion with it by fully supinating the forearm and hand after flexing 
 the elbow, and applying a posterior splint, the patient being pre- 
 ferably kept in bed for a time and the arm laid on pillows. It 
 may afterwards be supported in a hollow leather splint carried 
 across the body, and with the palm directed upwards. 
 
 When the fracture is placed heloiv the insertion of the pronator teres, 
 the upper fragment is drawn forwards by the action of the biceps, 
 and inwards by the pronator, assuming a position midway between 
 pronation and supination ; the lower fragment is approximated to 
 the ulna partly by the direct action of the pronator quadratus, partly 
 hvthe supinator longus tilting the upper end inwards; the hand is 
 fully pronated looking downwards. Union to the ulna by callus 
 thrown across the interosseous space is not unlikely to occur, treat- 
 ment by anterior and posterior splints ma y h^re, be. adopted, wjib^a 
 gHMaQsg£fluspadj,nJLea;>og.e.d,bptw.ee^^^ 
 
 the arm being placed midway between pronation arid .supination, 
 and the hand full^^ddijcli^d. 
 
 4- The LQXey;„BftJL.Qf thg Ba4ips,^is broken wjth^^xt^^^^^ fre 
 E.cy, constitutmfiL^wML-is .knQwn as. CoUepi^ ^ap are. 
 injury occurs most commonly in women ot aov^nced years, 
 although it may happen at any age or to either sex. iLi^jJinost 
 invariably due .tO-fa.U& upon the outstretched palm, wlien,th^e hand 
 is completely pronated andl'exlti^firedT The line of fracture**is 
 placed- abo'ul'jLjyasll.J^Qi)^ rather under than 
 
 over this. It is by no means purely transverse, being usually 
 oblique in an antero-posterior direction, sloping from above down- 
 wards and forwards, so that the fracture is nearer the wrist-joint 
 in front than it is behind, and also not uncommonly oblique later- 
 ally, slanting from without downwards and inwards (Plate XV.). 
 
 The displacement is somewhat comDlicated. [a) The_ lower 
 fltis-xaifcfi£!^33.tloL^(ts' and^ a uttle upwards, a condilioif 
 
 ig from the direction"^ fne_3olen£ej_.\Tz^7'a*'fan*'o^ 
 
 'm of thFtrotstretChed "tiand, tTie radius being thus compressed 
 
 V/ 
 
 5> 
 
 "ty 
 
 Vv ,^' 
 
 XX 
 
 [resuitin 
 piii 
 
43a 
 
 A MANUAL OF SURGERY 
 
 9IM' 
 
 ■ams^iK^.-M-'m 
 
 between the ground and the weight of the body, and yieldiriff at 
 what is evidently a weak spot; tli is deformity is maintai_ngi]„ij^ 
 the action of the radial JS-^i.lensor'^muscIes of the wrist, and often 
 by impaction of the fragments, (b) From' the fact that the main 
 violence is received by Ae'ban of the thumb, owing to the extreme 
 pronation of the hand, the outer side of the lower fragment is 
 displaced more than the inner, which, moreover, remains fixed to 
 the ulna by the strong inferior radio-ulnar ligaments. Tnis 
 position is in part kept up by the tension of the extensors of the 
 thumb and the supinator longus, but mainly by impaction of the 
 fragments. TheJ]aa4^mdj:a^i^s_ahva^^^ 
 
 mejntj and hence the former becomes markedly abducted, causin;,' 
 t'Ke s^ivloiS orocess'oftlie ulna to become' unduly profninent.iind 
 lower than that of the radiuSK^ whereas Jt4§^nQja&ieyii.£w^ 
 slightly higher level. Occasionally the styloid process of the'ulna ■ 
 is actually torn off, or the internal lateral ligament ruptured, 
 
 Fig. 140. — CoLLEs's Fracture : 
 Lateral View. 
 
 Fig. 141. — CoLLEs's Fractlrk; 
 Palmar View. (Tillm.ans.) 
 
 allowing displacement outwards of the whole hand (Plate X\'I.), 
 (c) The lower fragment is also rotated around a transverse axis, 
 so that the lower articular surface looks backwards as well as! 
 downwards, a displacement due to the fact that in falling the 
 force is directed, through the carpus, more to the posterior than 
 to the anterior aspect of the bone, (d) The upper fragment is 
 pronated and approximated to the ulna by the pronator quadratus 
 muscle. The,j^^i;>/i!J/xj^r£diipfid..t?y, the fracture is therefqrej.mj 
 charac-tfiriiillcrxjiehai^^ 
 
 usually_£»r;QjQi^4* w^th the iingQf.s.„.somewhat flexed- (dinneL-forkJ 
 deformity). Three abnormal osseou^ projections are present: 
 (i^^The ' ■ — ' "-"' "■ ■ - - 
 
 radiaTaE „......, ^ . , ■ . , -^ —^ ~ 
 
 wrist is a prorriinence' which terminates abruptly abcve, caused 
 by the projection of the lower fragment (r ig. 140) ; and (ni.) cor- 
 responding to this dorsal projection there is a well-marked depres- 
 sion on the palmar surface, and above it a less sharply-defined 
 swelUng, which gradually shelves into the forearm, due to the 
 upper fragment. Eronation ft^H gnpinatinn arp Inst, and.j^a 
 ru le, there is neither crepitus nqr pre ternatural moBHity, owing to 
 impaction of ffie ^ iragni e n t s . In douKTiircasesTielp'in" dIagnosis| 
 
^:: 
 
 y .X-.' 
 
 yi» :!"■ 
 
 >»■ 
 
 ■•."...■^,i»: -■: 
 
l^LATJ-: x\ 
 
 m*' 
 
 CoLLEs's Fracture : a Simi'le Case, without much Lateral Displaceme.'^P'CUes's Fkact 
 
 OF Hanp. H torn 
 
 To/acc Plate .\7V., hctvccn //. \yi and ^^-.^.^ 
 
 ''■'•/'/«/,. .\7- 
 
I'LATIC X\l, 
 
 piLEs's Fkacture : A Bad Case, with the Styloid Process ok the Ulna 
 
 TORN OFF AND MUCH OUTWARD DISPLACEMENT OF HaND, 
 
may be 
 styloid p 
 of the 111 
 
 tliat_of tl; 
 
 As air 
 
 ■pi^iir fra 
 
 the lovvei 
 
 ften at 
 
 Cnion is 
 
 he warnec 
 
 urist, as 
 
 mobility c 
 
 joint, pan 
 
 fi.\in<,f the 
 
 Treatme 
 
 ticm are Ik 
 
 and the SI 
 
 iisFfi'if"tf]e 1 
 
 for tliose o; 
 
 14^. 
 
 |ell)ou:, and 
 Idisimpactiol 
 
 iiables the 
 Many pja 
 
 hi.s fractun 
 pimple and 
 jfnmt and ba 
 pearly from 
 
 lit' index an 
 (lorseshoe n 
 Metacarpal t 
 (laged on 
 
 Oi^ition of £ 
 
 pi'Venients ( 
 
 lar conti 
 
 fting the fr 
 
 liilstto the 
 
 ' the lingen 
 
 f>sition of ai 
 
 'i'lie Pistc^ 
 
 f^nt of the fc 
 
INyUIiJES 01 BONES— FRACTURES 
 
 433 
 
 may 1h' obtained l)y observing tlie relative position of the two 
 stvli'i'l processes ; normally, that of the radius is well below that 
 ,(f'tlu' ulna, but in cases of fracture the ulnar projection is belgw 
 that of the radiilS" 
 
 "\s "already slated, the fracture is commonly impacted, the 
 " [/cr fr.'if^mient being firmly driven into the cancellous tissue of 
 tlie lower end ; excess of violence may, however, disimpact, but 
 ften at the expense of comminution of the lower fragment. 
 I'nion is effected without difficulty, but the patient should always 
 lie warned at an early date to expect some deformity about the 
 wrist, as well as ccjnsiderable impairment in the subsecjuent 
 mobility of the fingers and hand, owing partly to adhesions in the 
 joint, partly to blood trickling down the tendon sheaths and 
 tixinj; the tendons. 
 
 Treatment. -Tp.rje.duce .the defprmity, exter^siqn, and. rnzuiipijla- 
 tioii'are iVo'th needed. The patient s hould be seated on a chair. 
 
 inc the surgeon, standing m front, should grasp the hand nrmlv, 
 iisinj,' the right hand for fractures on the., r.ight, side, ^i)Q.. toe left 
 foffiiose on that side. Counter-exten.sion is made from the Hexed 
 
 ""^^'"n iitiifriii' iiirr"^"iTriiT i ■^ 
 
 "J^'-^-l 
 
 L^ 
 
 F 
 
 Ik;. 142.— Cark's Splint for Colles's Fractcre ok Left Hand. 
 
 (Down Brothers.) 
 
 lelbow, and th e hand is then for cibly extended and adducted ; 
 
 |disinipaction is thus brought ahouf,"" ana a rirne-mmnpinrnTOn 
 
 enables the fragments to be moulded into position. 
 
 Many plans have been adopted in the application of splints for 
 
 bis fracture : (i) A piece of Gooch splint is perhaps the most 
 
 feimple and efficacious. It is shaped so as to cover the radius 
 
 Iront and back as far as the middle line of the arm, and extends 
 
 pady from the elbow to the front and back of the knuckles of 
 
 Ihe index and middle fingers ; its lower end is hollowed out in a 
 
 lorseshoe manner, so as not to reach beyond the end of the 
 
 netacarpal bone of the thumb. This is well padded and firmly 
 
 andaged on ; it grasps the radius and steadies the hand in a 
 
 sition of adduction, without in any way interfering with the 
 
 povements of the fingers. (2) Cavvs splint (Fig. 142) is_a very 
 
 Imilar contrivance, consisting ~ot two shaped ^ITSC'fi?' "6T*'^f OtfU" 
 
 ting the front'lLW;^^^!^"'^^ tii"e;Tat|ial' slffe" oT^^ 
 
 Vilst to the palniar one is alfache'd an oBlique rod to Ke grasped 
 
 the hngers, and thus the hand and wrist are maintained in a 
 
 bsition of adduction, whilst the fingers can be freely moved. 
 
 The Pistol splint consists of a straight portion fitted to the 
 
 N of the forearm, whilst the handpiece is bent at an angle like 
 
 28 
 
434 
 
 A MANUAL OF SURGERY 
 
 the butt-end of a pistol. It may also be applied to the hack (;f 
 the forearm, together with a short straight splint on the palni,ir 
 aspect reaching to the wrist. It keeps the hand and ami ia 
 excellent position, but is objecti mable because the hnger.s are 
 also restrained. If, however, it is shortened at the end of fdiirnr 
 five days so as not to extend beyond the knuckles, it may iie 
 used without doing harm. (4) Two straight splints may le 
 applied to the front and back of the forearm, which is kept niidwav 
 
 between pronation and supination ; neither should extend hey 
 the knuckles, so that the fingers are free. The weight of the 
 when the arm is slung, keeps it in a position of adduction. 
 
 
 
 
 
 5^-- 
 
 t 
 
 A_ .-^.MfcA . 
 
 
 
 ^r--m,M 
 
 ■:.x ■ 
 
 
 
 pCS 
 
 ••■;-.,;iat*fe 
 
 ^i^^^^iiii 
 
 W^'^'^-M'" 
 
 
 "'.'■, 
 
 
 h 
 
 «f5 ,' .V:.'?:;i 
 
 "'. ''X'-V^'v, 
 
 » 
 
 
 , ■■■■■■■ 
 
 
 
 
 
 
 
 
 ■;^# 
 
 
 ' "" 
 
 
 .'^■:^y# SiLwiMl^^l 
 
 
 
 U:,: 
 
 
 
 i' - 
 
 W^-' 
 
 
 ■^^ 
 
 /f^^^'X^ 
 
 F^IPI 
 
 Fig. 143. — Skiagram of Displacement of Lower Epiphysis of Kaiih- 
 
 AND OF THE HaNO OUTWARDS. 
 
 Union is usually firm enough in a fortnight to permit tlii 
 removal of the splints, the arm being kept in a leather or guttaj 
 percha support for some time longer. M.aft8afi(j..„.'>n(l-,.paaavj 
 
 5. 'Sepai'ation of the Lower Epiphysis of the radius occurs in yoiinj 
 people under twenty, and, when the lower fragment is displace 
 backwards, simulates somewhat closely a CoUes's fracture. Tli 
 lower end of the diaphysis projects anteriorly to a much ,t(reatd 
 extent, and, indeed, may protrude through the skin of the wrisj 
 causing the fracture to become compound. The lower end of th 
 ulna may also be involved in the accident, either the epipliysl 
 
iis OF K.\iur\ 
 
 to permit t'nJ 
 ither or guttaj 
 
 
 ccurs in youn| 
 it is displace 
 racture. 
 
 much greatd 
 of the wrisj 
 wer end of 
 
 the epipliys 
 
 1 
 
PLATE XVII. 
 
 Fracture of both Bones of the Forearm, with Disflacemeni outward^ 
 
 To/ace /: 43S-] 
 
i^Z!!^fi^lff^;ff-F«^cr.-;,« 
 
 being separated, or the shafr hr. i , -— 
 
 tion ma\' also be mistaJ-^,, f i^roken a little above Th,- 
 
 posmon of the styloid prcSe ?„^',^ ""^^"""g the re t' 
 Jisplacement also occur.; ,„ '° "><= carpal bonp= ™'y'™ 
 
 or indirect \iolencel^r?r^^'*S^^->.'-,S^^J"i may re^iMlf fr^_ j- 
 
 o".hepah/ofthehand p" ,XW?,*?^.'° 'h^ -y^^^^^ 
 «-s ally drawn together and prJn.tLV' J''' "PP« fragmems are 
 laims IS drawn ud hv tl,„ P™™'™, whilst the lowpr .„j r , 
 
 "■»"«. i-eing due*^fdiS'vf°r ""«' ^'■^"'"'fr^^ are not „„ 
 
 « r Fractures of thA Pai«- -^— 
 
 '■ractures of the "" i •■ ,- --^ "®Ms. 
 
 «y Slfe^^^^ of .he crista ilil 
 
 '«'c to such"' ;," ."'<= '«"'« produced Xt ^'j:';'"". ^'=p'-"---"«i. 
 
 pain IS always produced 
 
 ' 28—2 
 
436 
 
 A MANUAL OF SURGERY 
 
 by these conditions, especially on any vigorous respiratory movt. 
 ments. Union occurs readily, all the treatment required beintrto 
 keep the patient quiet in bed with the shoulders raised, and tin 
 legs supported to relax the muscles. A flannel bandage rounc 
 the pelvis gives comfort and support. 
 
 2. Fracture,.ol-tilie..JCrjfteJ?.ei]49.i§ a much more serious acci4cm. 
 The Ime of fracture usually runs intothegbturator. foramen, and 
 may detach both the horizontal ramus of the pubes and tht 
 ascending ramus of the ischium from the rest of the innoininatt 
 bone (Fig. 144). This is frequently conjoined with a fracture 
 through the sacro-iliac synchondrosis eitaer on the same or 
 
 opposite side, but moit 
 frequently the latter: 
 whilst a double fracture, 
 front and back, mayalj. 
 occur at these, the weakest 
 points. The cause of the { 
 posterior fracture is that. 
 when the pelvic ring has j 
 yielded anteriorly from 
 the violence, the con- 
 tinued strain, whether di- 
 rected from the front or I 
 from the sides, must! 
 necessarily fall on the 
 part where the ilium i- 
 most closely connecttaj 
 with the sacrum, and the bones then give way rather than tiiej 
 unyielding and powerful sacro-iliac ligaments. The Symptomsj 
 are those of shock and pain in and around the petvis, especiallyf 
 "on 'movements of the legs or on coughing. There maybeJ_oca!J 
 ecchyraosis, and tenderness. aver. the pubic ramus, and the patient! 
 either cannot stand, or feels as if he were falling to pieces oiil 
 attempting to do so. There is rarely any deformity, although! 
 occasionaliy stich' an occurrence is noted. Crepitus may bej 
 elicited on grasping the iliac bones, and moving them one on the 
 other ; but such a method of investigation must be very sparinj,'!] 
 indulged in. Complications frequently arise from iniury to tlid 
 internal Viscera, especialTy the bladder, rectum, urethra, or vatjinaJ 
 as indicated by haemorrhage into or from these organs. An aseptid 
 catheter 's!roul(f,''ifpCfgStbte:'i7e passed "as-a^-r^ 
 if fne unne IS, blood-stained, It is tied in. 1 
 
 Treatmejit. — The patient should be inQyjed-with.-the greattsj 
 care, for fear of producing or increasing \isceral complication^ 
 He is put to bed, and any obviously displaced fragments reduced 
 if practicable, possibly under an ana?stl),etic. A brocicl.Jannd 
 Imndage should__be^^glied, the knees tied together, and a leatlia 
 o*r'"poroplastic splint nK)iir3ed'"t6tTie "pelvis.' Visceral coniplica 
 
 Fig. 144. — Fracture of the Pelvis. 
 (Bryant.) 
 
INJURIES OF BONES— FRACTURES 
 
 437 
 
 ;ions must receive att ention, as incl icated^gJ§,Q wh firti?- Union n iay 
 t ig (;.tpt> fet"6tl ill tibunt six weeks, buf the patient should be kept ni' 
 btd for at least eight, and even then only allowed to get about on 
 crutches, wearing a padded belt. 
 
 A Fracture of the Acetabulum is pf tvo^tjjjig^: eithe£,4Jie 
 
 notferior liR.i^. JbxokeR off .as a result of violenqe cliiefctfeil .^jiaiflst 
 
 ffbvthe head of the femur, which is dislocated bnck wa rdK by the 
 
 sime acciqejit ; or a tall on tne trocnanTer may cause a simple 
 
 fTsTure extending into or across the cavity, or may resolve it into 
 
 its three constituent elements, or may even drive the head of 
 
 the bone into the pelvis. In the former case, the limb is in the 
 
 i}isition of a dorsal dislocation ; this can be reduced without 
 
 jifiiculty, and possibly with crepitus, but manifests a great 
 
 tendency to recur. Prolonged extension with a long splint is 
 
 needed in such cases. In the latter class of injury a mere fissure 
 
 I of the acetabulum produces but few symptoms beyond a little 
 
 I pain and impairment of movement ; but if the head of the bone 
 
 ' is driven into the pelvic cavity, the symptoms are much more 
 
 I serious, on account of the associated injuries to the viscera and 
 
 he <,Teater amount of violence employed. The case will resemble 
 
 tone of fracture of the neck of the femur, but there is usually only 
 
 very slight mobility, and the head of the bone may be felt within 
 
 [the pelvis on rectal examination. An attemptshould be nmde to 
 
 I free .the.kead,. P.L lliSJ^SGg » apd. tllfe!fipOSf^iBrii5He3TS"w^e 
 
 otjlije^ neck of the femur ; but a fatal issue is very Ij^eJly^toioJJ.QAV. 
 
 4. Fracture of the* Tuber Ischii results from falls in the sitting 
 [po?ition. The diagnosis is often obscure. 
 
 Fracture of tihe Sacrum is always due to direct violence of 
 [considerable severity, such as kicks, blows, or gunshot^^wounds. 
 jit is not unfrequently comminufedV anJ," fl'6m tlieassocialied mjuiy 
 [to the lower sacral nerves, may result in. loss, of power, pf the 
 Ibladder and rectum. In a transverse fracture^ thq lower fragment 
 |i? usually displaced forwards, and may cause pressure upon the 
 itectum; irregularity in the, shape of the bone may be detected 
 [from within (per rectum) or from without. Treatment. — The 
 
 wer fragment should be replaced, if possible ; but considerable 
 Idifficulty may be experienced in keeping it in position. P). well- 
 r^S P£l\i?,J!i9Jjdj, \vith regtia, la&d,.i&p£ohablyaU ,t}iat.is.necessary. 
 IToAFractures of the doccyx are by no means uncommon as^a 
 leWt of falls or blows, although its mobility often protects it 
 
 oughing, defaecatipn, etc., since the coccygeus muscle wh i c n is 
 Attached to this bone forms '|jarl:"ljr3!ljejpw^ 
 sMomen. A rectal examination reveals preteriiaturaT "mobility 
 pTflie lower fragment, angular deformity, and perhaps crepitus. 
 "lie Treatment consists in keeping the patient at restjy,ntil_ union 
 ps occurred ; it is impossible to a'pply any apparatus to correct 
 
438 
 
 A MANUAL OF SURGERY 
 
 the deformity. Sometimes the bone unites at an angle, causing 
 much pain and discomfort, whilst difficulty in parturition may also 
 arise from this cause. Excision of the bone is th^n X£.Qui^e( ^ | . The 
 patient lies semi-prone with the legs slightly fiexea or in the 
 lithotomy position, and a longitudinal incision is made in the 
 middle line. The apex and lateral margins of the hone are 
 cleared, and the ligamentous tissues uniting it to the sacrum 
 divided by the knife ; the bone is now laid hold of by sefiuestrum 
 forceps, and its remaining attachments severed, due precautions 
 being taken not to encroach on the rectum. Two or three stitches 
 are inserted, and also a drainage-tube for a few hours; the dressiii" 
 is secured in position by a T-bandage, but it is not common to 
 obtain heahng by first intention. The bowels should be confined 
 for some days aftcjr the operation. 
 
 Falls upon the coccyx, unaccompanied by fracture, sometimes 
 giv e ^ iiiUJ tu H iinj.gt bl!V e ie"ain;t""i»liwe t nt"ih!) ' t y{W ' «rf" « »n«w» fttyiH, 
 kiicVw-n-as cdcCyayniarA^^Tch„;Tn^.(luit.^. iirgxiini^^^yienriTOii 
 fblta\\TTlw-+rrS"aT'OCaTions.* If all the usual sedatives tail in <;ivin;'| 
 relief, the bone must'be excise 
 
 Fractures of the Upper End of the F emur . 
 
 I. Fractures of the Neck of the Femur are commonly di\'ide(l iuti 
 intra- arid extra-capsular varieties, and, although this is by no nieanj 
 free from objections, yet it constitutes a useful working l)asis, 
 
 The Intracapsular Fracture, or fracture near the head (Fig. 145), 
 met with__m^ persons in advanced life, and especially in females 
 only about i per cent, of the cases occurring in individuals iinde 
 fifty. Tills is explained by the atrophic changes whicTi' take plad 
 
 in the cervix femoris of elderly people. Tl 
 spaces between the bony cancelli are 
 larged, and loaded with soft fat, whilst [\\ 
 ensheathing compact tissue is thinned, aq 
 the ' calcar femorale ' of Merkel {i.e., til 
 process of thick cortical substance runniq 
 from the lesser trochanter to the undi 
 part of the head) is atrophied. The nefl 
 of the bone is sometimes more horizontj 
 than usual, emd the head sinks helow 
 usual position. Under such circunistancd 
 it requires but little violence to producej 
 fracture, the direction of. which varies 
 cording to the force applied. As a ru 
 the accident is due tojiome slighlstuinB 
 o r fall , such as_sli£ping„.a2LiJae-kerbJ 
 tripping upstairs ; the bone jdejds i" cd 
 secjuence, and the patieiit mils rtp Ihe groun d. The linel 
 fracture may t)e transverse or oblique, and is mainly 
 
 Fig. 145. — Intracapsu- 
 lar Fracture of the 
 Cervix Femoris 
 
 inq 
 
INJURIES OF BONES— FRACTURES 
 
 439 
 
 .;msul;ir. Some of the fibres reflected from the under surface of 
 ;he capsule to the head of the hone may remahi untorn at first, 
 but later on they give way from inflammatory softening or inju- 
 dicious manipulation or attempts to use the limb. The fracture 
 ;^ not usually impacted; if, however, this condition should occur, 
 the upper end of the neck is driven into the loose cancellous tissue 
 iiitlie head. The dispj_acement is necessarily limited entirely to the 
 inyerjVagment, which is drawn upwards by the glii'tei, recti, and 
 hanistringuuiscl^S, and rotated outwards aiid S(5nie\vKal' backwards, 
 is) that the fractured surface looks almost directly forwards. 
 
 ^J'Ti^ ^'^-^I (S^uLimlJmL ^ " these cases depends to a large extent 
 ' ral condition of the individual. 'TT of a healthy 
 
 •jpon 
 
 tlie general 
 
 leiiiperanient,. iind without any chronic pulmonary affectionj^,.so 
 
 iivided inid 
 )v no niean| 
 basis. 
 
 in feiiialeg 
 uals uiuk 
 h'take plad 
 leople. Tli^ 
 lelli are eti 
 ^ whilst til 
 [binned, an 
 :el (i.(. tH 
 ce runniti 
 the undl 
 The neJ 
 \t hoi'izontj 
 :s below 
 :unistancd 
 produce! 
 [\ varies 
 
 As a ru 
 
 luUi-Stuml 
 
 tie-ketM 
 
 lekls in cj 
 
 iThe line 
 
 lainly inl 
 
 A B 
 
 I'lG. 146. EXTRACAl'SULAR FkACTURE OF CeRVIX FeMORIS. 
 
 From behind, showing detaciiment of both trochanters ; B, (jn section, 
 showing impaction of liead and neck into base of trochanter, which also is 
 
 detached. 
 
 m he can be kept in the recumbent posture for six or eight 
 
 leeks, bony union may certainly occur, in spite of the fact that 
 
 l!irst synox'ial fluid finds its way between the fractured surfaces. 
 
 ce main process of repair takes place from the^jowe r end, no 
 
 illiis being fornied froni the head of the borie, the vascular supply 
 
 ni; only Just sufficient to maintain its vitality. If, however, 
 
 patient is feeble and weakly, and especially if the subject of 
 
 [tonic bronchitis and emphysema, Jlie progno.sjs is by no means 
 
 jince hypostatic pneumonia and extensive bedsores inay 
 
 FT him off during the short" stay in bed^ which" is always 
 
 jcessary, in order to relieve the more urgent' sympf6nTs"oT"pain. 
 
 IT' union is never, under these circuiiistances," to be expected, 
 
 i a loose fibrous union, or even a false joint, is the best that 
 
440 
 
 A MANUAL OF SURGERY 
 
 can be looked for, the patient henceforth walking with the assist- 
 ance of a stick or crutch. 
 
 FiXtTair.fl,Pflll1air rrafitilire o_f die cervix^_fenioris^j/mr///;'£ mujl,c 
 trochanter) is an absolute riiisriorner, since tTTe capsule extends 
 to"ni'e~sBaft of the bone" along tKe'anterior intertrochanteric,- Jin,, 
 and leaves no portion of the neck uncovered in this situation, 
 The line of fracture is placed in front, either along the atlachnient 
 of the capsule or within it, and is really only extracapsular i 
 behind ; sometimes, moreover, the shaft itself is considiTahlv 
 encroached on. The great trochanter is often involved in the 
 fracture, being splintered or detached, and the lesser trochanter! 
 may be split off with a portion of the shaft, so that the Ixme is 
 broken into at least three different fragments (Fig. 146). 
 
 Mechanism. — This fracture is usually the result of directviolcncej 
 actTn g"~trahsversely upon the trocljajiter",n,:^gji)r, as from a Ik aw 
 iall upofrTRe'Tit]5r' 1 lie posterior part of the neck, being wcllkeri 
 than the anterior, first gives way, being more or less crushed ami) 
 comminuted ; the whole neck then yields, and the severed head 
 and neck are forcibly impacted into the junction of the trocliantcr 
 and shaft (Fig. 146, B). The majority of these cases are thus 
 primarily impacted, continuation of the violence producing dis| 
 impaction, coupled either with detachment of one or both tro- 
 chanters, or witli comminution of the great trochanter. A siniilarl 
 result may follow from the inflannuatory exudation causing a hitc 
 separation of the impacted parts, or from injudicious manipulation,] 
 
 The displacement is much the same as in the former variety 
 the Tipper fragment remains in statu quo, whilst the lower iij 
 drawn up and everted, only to a greater extent. Shortenin;^ 
 may at first be slight, but is likely io increase at the end (ifl 
 a few days, as a result of disimpaction of the fragments, rrj 
 from the yielding of the reflected fibres of the capsule, or fronil 
 the tonic action of the nmscles. Later on, moreover, the shQrter-j 
 ing_iiiay again increase frorn_a rapid absorption of 'the_ neck, which 
 occasTonaTly follows this accident, or is possibly due to the'sunerJ 
 \'^fntTorr of ostep-artnntis. 
 
 rhe^Signa ..an d Symptoms of these two fractures may well hj 
 corisideredtogetfier, tlie pomts of similarity and contrast heinf^ in! 
 this way more effectually emphasized. 
 
 {a) The signs of local trauma, viz., pain, brmsing, and swejHD^'J 
 majr^be'presen'f inlVotH'; but whilst slight Tn 'the inTni-capsulaJ 
 \ariety, they are very marked in the extracapsular. It must noj 
 be overlooked, however, that eveh' in the former the patient iiia}^ 
 fall on the affected hip after the fracture has occurred, and thuj 
 cause a considerable amount of bruising. 
 
 {b) Crepitus, is evident in the unimpacted forms of each ; hut i| 
 is unnecessary and, indeed, unwise to elicit it by forcible manipuj 
 lation, especially in the intracapsular variety. 
 
 (r) Loss of power of the limb exists to a variable extent, ;'.ndi| 
 
INJURIES OF BONES— FRACTURES 
 
 441 
 
 ijerhaps more marked in the extracapsular form than in the 
 Intracapsular. Cases of the latter in which the patient was able 
 ;,,\valk into hospital some days after the accident are not unknown, 
 
 I ind are probably due to impaction. 
 ((f) ^iioaiflU-is-a nios^t characteristic feajiurgijijipt^^^^ the 
 
 ■lib lying absolutely helpless on its outer sjde. This displace- 
 
 I fent isjvccredijtej:! to the natural weight of the limlvto the greater 
 S^iility of the back of the cervix, causing it to be more com- 
 
 Uiinufed than the antisrior surface, arid, Jastlj^. ..tQ,.tTb'e "^eater 
 pver of the external rotator muscles. Iiivcnion has been met 
 intli in a few rare cases, but is probably due to the violence in 
 •> particular instance being directed from behind forwards, and 
 
 I to impaction of the fragments. 
 i() Shoytcning is slight in the early stage of. intracapsular, and 
 ranch .^feaiter m the. .e.xtracapsulajr, fracjtures. In tlie latter case 
 
 |Fig 147.— Nklaton's Line and Bryant's Measurement for ascertaining 
 Position of Great Trochanter. 
 
 the shortening usually attains its maximum —viz., i^^ to_2^ or 
 |e\W3 inches — at once ; but such is not always the case Ji_n the 
 Itormer. ItlsTnclicated by displacenient ortlie 'trocH"aii^er upwarHs, 
 I due allowance being inade for. the position of. the limb as regards 
 latxluction or adduction. 
 
 "(f) The position of the f{yc(it t yoc hanter \soi t he greatest irn^ 
 I portance. It is raised above its ordinary lever aTid e verted 
 
 approximated to the miH^'TiKe^QtlTi'fe! 
 
 superior iliac spTfieVan<3^ rotates. in the arc of a smaller, ci.rc^eman 
 
 usual,, the radius .l)eipg the thicko^.s&...Q£.ibe..t;.Qcbaflt§J~aK"^> 
 [Instead of including also the length of the neck. The demonstra- 
 
 ' of fhls' position is riitistimporta and, amongst others, the 
 |follo\ving tests are employed : 
 
 }[clatoifs line (Fig. 147) is one drawn from the aritejior-superior 
 hpine to the most prominent point of the tuber ischii. The_.centre 
 loftTiis cortesporias Yo thetop of the great ti'dchanter, if the limb 
 
442 
 
 A MANUAL OF SURGERY 
 
 is placed in the axis of the l)()cly ; hut if either ahduction or iuldiu . 
 tion is present, the top is situated sh^htly above or l)elo\v the line, 
 Definite elevation of the bone above the line indicates shui teniny 
 of the limb due to dislocation l)ackvvards, fracture of the iirck, di 
 absorption of the neck from disease, 
 
 " BrYau r.Llcd Lhic (FiiL ir?).— In this the patient lies ilat on a 
 horizontal couch, and a vertical line is let fall from the anterior 
 superior spine. The perpendicular distance of the top of the <freat 
 trochanter from the line is compared with a similar measurement 
 on the opposite side ; definite shortening may thus be discovered. 
 
 Morris's hityochantcric test indicates the amount, of inw^nd dis- 
 placement. It is conducted by measuring the distance between 
 the outer surfaces of the trochanters and the middle line of the 
 body by means of a rod graduated from the centre, alon;.,' which 
 two pointers work outwards. Shortening in this direction will 
 also be observed in most dislocations of the hip-joint. 
 
 One other chjinge in the great trochanter may be noted in the 
 extracapsular Joringjf.frkcture, wliich can be utilized as a useful 
 diagnostic feature between it and the intracapsular variety, nIa. 
 tKe gxfidii iCmkiuni oi'thicJictiing of the process which is always pro 
 duced, owing to the excessi\e development of callus. In thei 
 intracapsular variety it is rarely fissured or injured, and therefore 
 no thickening occurs. 
 
 {g) Lastly, relaxation of the fascia between the crest of the iliuni j 
 and the great trochanter (that is, of the upper part of the ilioi 
 tibial band) is given as a characteristic feature of these fracturesV 
 
 Diagnosis . — Simple iinimpacted iracturesa.re readily detected, and ] 
 th^re can' be but httle difficulty in distinguishing the two form- 
 either from one another or from other injuries. The fact that an i 
 impacted fracture has occurred can also be easily made out as a 
 rule, the pain, eversion, and shortening sufficing to indicate its 
 existence; but it is often very difficult to say which of the two 
 forms of fracture is present, especially if the surgeon is not called 
 till late in the case. The character of the accident and the age I 
 of the patient must be taken into account, whilst the existence of j 
 fissuring or thickening of the trochanter, or an excessive amount f 
 of shortening, may indicate that the lesion has been extracapsular. 
 A severe contusion of the hip, which may be associated with marked! 
 eversion, is known from a fracture by the absence of shorteninjj 
 and crepitus ; there is no displacement of the trochanter, whi 
 rotates in a normal manner. The shortening which sonietimesj 
 follows, owing to subsequent atrophy of the neck, may, howeverj 
 complicate matters. In a dislocation the head of the bone canbel 
 felt in an abnormal position, and hence no difficulty should beexj 
 perienced in its recognition. In chronic osteo-arthritis of the hipj 
 with antecedent shortening and marked bony crepitus, there mayj 
 be no history of accident, and no acute eversion, pain, or lossofj 
 power ; possibly the existence of similar disease in other jointsi 
 
INJURIES OF BONES— FRACTURES 
 
 443 
 
 may assist the surgeon, whilst osteo-arthritis of the hip usually 
 results in prominence of the trochanter, and not in flattening, as 
 occurs after fracture. Moreover, the fascia aho\e the trochanter 
 is never relaxed in osteo-arthritis, always in fractures. It must 
 nut be forgotten that, after an intracapsular fracture, the patient 
 mav fall, not on the injured side, but on the sound thigh, and cases 
 liavf heen known where the surgeon's attention was directed to 
 ;he wrong limb owing to the amount of bruising there manifested. 
 
 iTjl'illP'i '"^ ^iri^^dy ^ililtHiJT"^" the mdiyidual. ( 
 
 If old, weakly, and witTTTi tencIency'"fo cTiirbiiic bronchitis, loner 
 I coatofiiiinnL ta ,l.)ert„.^a]iaa..)ii^.V^ .a. njpst deleterious, if not , tol, 
 |e^^ In such cases the limb is put at rest for a few ciays 
 [lieween sandbags, and cooling lotions applied. A Thomas's 
 Uolint should be fitted as early as possible, and the patient 
 Lncouraged to get about on crutches. 
 
 Fig. 148. — Liston's Splint padded and applied. 
 a, Perineal band. 
 
 In a healthy individual with good physique, where bony union 
 
 iniay be expected, the patient is kept at rest in bed for six or 
 
 (ti^'iit weeks, by means of Liston's splint (Fig. 148). This needs 
 
 icareful adjustment, but is satisfactory in its results when properly 
 
 IBpplied. It should reach from the axilla to about 6 inches below 
 
 he ankle, and is fixed to the leg and body either by bandages, or 
 
 niicli better by two broad sheets, which first firmly envelop the 
 
 ilint, and are then passed round the body, and finally secured by 
 
 |pins to the portion surrounding the splint. Carefully padded 
 
 [loroplastic foot-pieces are placed on either side of the ankle so as 
 
 I dififuse the pressure, and a handkerchief passed round the foot, 
 
 iJ through the prongs at the end of the splint, fixes it in the 
 
 Jesired position. A well-padded perineal band is next applied, 
 
 aking its purchase from the tuber ischii, and with its free ends 
 
 assed through the two holes at the upper extremity of the splint ; 
 
 1 tightening and tying these two together, the upper end of the 
 
 plint is steadied. Extension of the limb is obtained by an elastic 
 
444 
 
 A MANUAL OF SURGEliY 
 
 .'icruimilator, or by wciffht and pulley artinj^' from the knee in tli. 
 usual way. I'inally, the sheets or handa^'es are adjusted, and the 
 lower end prevented from mo\inf; laterally or rotatinj; by slippjivr 
 it into a slot between two rectan^ailar plates of metal screut-d to 
 a substantial wooden base, which rests on the bed. The h;ui(lk(r. 
 chief and perineal band will need occasional tif^hteninj,' to niainiain 
 the re^iuired extension, and the latter must be renewed from time 
 to time for purposes of cleanliness, and the parts well powdfrd 
 with boric acid. At the end of six weeks or so the peKis should 1,,. 
 encased in poroplastic material or plaster of Paris, and the patiint 
 allowed to f^'et about on crutches, or a Thomas's splint applied. 
 
 No attempt should be made to disimpact fractures in old people; 
 rest and (piiet are maintained by applying,' a long splint wiihuut 
 extension, and bony union usually follows. 
 
 In other cases it may suffice to simply lay tbe limb on a \H 
 between sandba<;s, and to make extension from the foot. The le;' 
 is first swathed with a borr'cic lint bandage, and then a piece of 
 broad adhesive plaster is applied on either side of the limb, reach- 
 ing nearly as high as or above the knee, and with a loose stirnij: 
 4 or 5 inches long below the foot ; the pilaster is secured bv one or 
 two strips of strapping :| inch wide wound obli(]uely round the 
 limb above and below, and by a calico bandage. In the stirrnp;i| 
 cross-piece of wood, rather broader than the ankle, is insertcvl, and 
 a knotted cord carried through a hole in it. The cord is p,assed 
 over a pulley fixed to the end of the bed, and to its end is attached 
 a weight, varying with the requirements of the case; the lower 
 portion of the bed is usually raised by placing the legs on blocks, 
 so as to utilize the weight of the body as a counter-extending force, 
 It must be borne in mind that the continuous application of a 
 hea\'y weight may stretch the ligaments of the knee joint; it is 
 ad\isable therefore to distribute a part of the traction above the 
 knee. Hodgen's splint, as described below, may also be used in 
 these cases. 
 
 treat ment of Extracapsu lar Fracture , — The long splint with] 
 exTflTSlWl'l ulll HUiiiLlilllLtf J^Uffliie loi this condition, good lionv 
 union usually occurring, tbougb with some shortening. In some] 
 cases it may be advisable to make extension from the knee, and 
 to keep the limb slightly flexed, as on a double inclined plant, I 
 Probably treatment is best carried out by the use of the splintl 
 introduced by Dr. Hodgen, of St. Louis, U.S.A., the \ahie (ij 
 which was first demonstrated in this country in the theatre oil 
 Guy's Hospital by the inventor in 1879, and which has since been! 
 largely utilized in that institution. For our description of it wej 
 are indebted to Mr. Golding Bird, k is made of stout iroi3^:ia;e.f 
 quite rigid, and is in the form of {Tie"'TetFer"tJrtKe oute r limbj 
 reacKTngTro ni'TTi'S" ant enof "^ItTperibT'SpW! e''To"'3'^i nches^^fiela 
 in-sliEprand-th'einnwrfrom- the nridttttor T^^^ 
 SpoTr'where the two' TiiiiBg'" unite in a crossbar 3 inches; in widt 
 
INJURIES 01' HONES— FRACTURES 
 
 445 
 
 Tlif sidt's tiiper with the liiiil), and should be ',' inch furtluT apart 
 [iiiin the diameter of the Hiiib at any point. At the upper end the 
 i.trsare uniteil by an arch of the same material, whicli is phici-d 
 „n the slant, and should correspond to Poupart's ligament; two 
 -iniilar arches are placed at ecpial points lower down. The splint 
 sliLiit at the knee to about an angle of 130 . 
 
 jicfore applying the splint, an ordinary extension stirrup should 
 Iv attached to the limb, and a piece of wood introduced therein wide 
 tndu^di to take any pressure off the malleoli ; to the wood is t' ;d a 
 pica' of stout cord. Strips of house llannel, about 7 inches wide, 
 aretlien cut and arranged beneath the limb at right angles to its 
 direction, each one overlapping the next ; the length of the strips 
 shiiuld be rather more than the circumference of the limb at the 
 
 Fig. 149. — Hodgen's Splint api-liep. 
 
 spot to which each is to be applied. The splint is then adjusted, 
 
 jthe top of the outer bar resting against the anterior superior 
 
 I spine, and the inner bar against the adductor tendon, whilst the 
 
 crossbar below is supported so as to be on a level with the instep. 
 
 Tile strips of flannel are then raised in succession, and, being 
 
 lapped over the bar, are pinned or stitched there, so that when 
 
 completed the limb lies in a flannel trough, from which only 
 
 the upper surface projects, and there should be an interval of 
 
 fully an inch between Poupart's ligament and the upper crossbar. 
 
 [The short cord already mentioned as being attached to the stirrup 
 
 [is tlien securely tied to the lower end of the splint. Cords are 
 
 [now fixed to the hooks, two of which are soldered to each side of 
 
 fthe splint, the lengths of the cords being such that, if they were 
 
446 
 
 A MANUAL OF SURGERY 
 
 raised and made taut with the finger, the finger would be about 
 8 inches above the splint. The two cords are then broui'ht 
 together over the limb, and to them is tied another stout cord 
 which passes over a pulley attached to a vertical post at the 
 end of the bed, and is weighted to a sufficient extent. The an^le 
 required to make satisfactory extension is determined partly In 
 the position of the limb, partly by the sensations of the [)atient. 
 The limb when the weight is applied should lie free of the bed. 
 even to its extreme upper limit, and at the lower end should lie 
 lo inches above it. No bandages are required ; the limb lies in 
 the obliquely-set flannel trough, which is maintained in position 
 by its friction against the limb ; the splint itself is pulled upon hv 
 the extending force, and this is transmitted to the limb tbroii;,'li 
 the stirrup cord attached to the lower end of the splint, li 
 correctly applied, this stirrup cord is taut 'like a harp strinj;': 
 any slipping of the extension or of the apparatus is indicated hv 
 laxity of this cord, and involves readjustment. 
 
 When impaction has occurred in_younff and active individual 
 
 down, so as to pfeyept s.i;i?s^e/juent .shortening. 
 
 2. Fracture of the Great Trochanter is very rare, and alwav^ 
 due to direct violence ; in the young it occurs as an epiphyseal 
 lesion. The trochanter, or a portion of it, is entirely separated 
 from the rest of the bone without any loss of the continuity of the 
 shaft. Independent movement of the fragment with crepitus ij 
 usually obtainable; and if the displacement is at all marked. an j 
 operation to fix it by means of a plated screw or ivory peg shoiwj 
 be undertaken. 
 
 3. Fracture through the Great Trochanter (the pev-tvochanUn] 
 fracture of Kocher) closely resembles the extracapsular fracture, 
 the lesion running from the inner and under part of the nectj 
 obliquely upwards and forwards through the base of the trochanter j 
 The lower fragment, including the lesser trochanter, is drawcj 
 upwards and backwards towards the sciatic notch, and forms ij 
 projecting mass behind, somewhat simulating a dislocation : 
 tip of the trochanter can, however, be felt separately, not movinJ 
 with the shaft. Such cases may be treated by extension witij 
 the long splint, or perhaps better by Hodgen's apparatus. 
 
 4. Separation of the Upper Epiphysis of the Femur. — Tlie uppeJ 
 cartilaginous end of the femur in infants includes not only til 
 head, but also both trochanters, and there is no case on record 
 complete detachment of this portion. Ossific centres early appeij 
 for each of these three projections, and by the rapid grottii] 
 upwards of the shaft, they are separated from each other by 
 fourth year, the neck thus being really constituted as an outgrod 
 of the shaft. The epiphysis of the head has been CGniplete| 
 detached in a considerable number of cases, but the accident isa 
 so common as in the humerus, owing to the protection given i 
 
myURIES OF BONES— FRACTURES 
 
 447 
 
 the depth of the acetabulum. The phenomena closely simulate 
 those of an intracapsular fracture, but are less obvious. Impair- 
 ment of f;rowth may follow, and possibly the shape of the head 
 and neck may be so altered subsequently as to simulate the con- 
 dition known as coxa vara. Treatment of the lesion is by exten- 
 sion, and possibly the use of the long splint. 
 
 ve individuals, 
 
 •e, and always 
 an epip^iyseal 
 irely separated 
 jntinuity of tlie I 
 vith crepitus is 
 all marked, an] 
 
 ?ory peg ^^lO"'^ 
 
 • per-tvochanUn: 
 psular fracture,! 
 art of the nedl 
 ,f the trochantei,! 
 anter, is dra\vtl 
 'h, and forms il 
 dislocation ; M 
 tely, not movinsl 
 r extension witJ 
 
 iparatus. I 
 
 TuL-The uppej 
 ^es not only t..| 
 Ease on recotdi 
 kres early appefl 
 
 le rapid gro*l 
 Vach other by t* 
 
 as an outgw*! 
 been complete! 
 he accident is«f 
 
 ,tection given' 
 
 i 
 
 Fic. 151. — Fracture of Lower Third 
 OF, Femur, showing Displacement 
 OF Lower Fragment Backwards. 
 (From Gray's ' Anatomy.') 
 
 150. —Fracture of Upper Third 
 pF Femur, showing Displacement 
 JifBone. (From Gray's ' Anatomy.') 
 
 fel^' 'n spite of J,|^^gj3il^i^ Any.part 
 
 ^?..inmyea,..paxticjularly,iije^qe.ntre, whilst, they occu^ at the 
 
 ^r end more freque;itJly.„,);b;^^t,tUe .i^per. In the I'atter'situa- 
 
 they are usually due to indirect violence, whilst at the low-r 
 
 [they f^enerally result from direct injury ; either form of violence 
 
 lead to a fracture about the middle of the bone. 
 
448 
 
 A MANUAL OF SURGERY 
 
 I 
 
 In almost everv case displacement occuxs, the direction and 
 amount or winch depends not onlv on the line of fracture. Tnt 
 also on file situation. | In the uppey third (Fig. 150), the smali 
 
 H]E?H:^g!^'f r^M^Jf.^^^^^ k>m^^ li)^ |J^^.iUO;psQas, and 
 
 abmictecT , and .jbyerted^ Jl^ Itjie gluteus . minimus-, a«d. external 
 mtatbisv whilst the lower fragment is drawn up\va4:ds .^nd to the 
 inner side oTTBe' tipper Idj llie'harhst rings' and adductor muscles, 
 marked eversion also resulting partly from the weight of the foot, 
 and partly from the action of the adductors ; but such a com- 
 plicated displacement is not always present. 
 i>««» YjxJ^.Vii^d.l^ thkd^'^i due to direct violence, the line of fracture 
 slants from above down'wards and backwards, causing a simple 
 over-riding oTf he fragments, or an angular deformity. The lower 
 fragment is drawn upwards and inwards, either in front of or 
 behind the upper fragment, and is usually everted. The upper 
 fragment is sometimes tilted forwards. If due to direct violence, 
 the fracture is more often transverse, and any form of displace- 
 ment may then occur. 
 
 Ill the lower third.„t,he fractures often arise from direct force, and 
 are transverse ; the lo\yer fragment inay then be tilteci bacl<\vards 
 by^e-gastrocnemii muscles, and conipress or rupture the po|)liteal 
 vessels, perhaps caiisirig gangrene (Fig. 151). Oblique 'fractures 
 from indirect violence, sloping from above downwards and for- 
 wards, are also met with ; the upper fragment is driven into the 
 substance of the quadriceps muscle and may become fixed in it, 
 projecting immediately beneath the skin, whilst the lower fra;;- 
 ment is drawn up behind. If such a case is left unreduced, 
 ununited fracture is likely to ensue ; the knee-joint is generally 
 pgBi,etr:iited-4iy the lower end of the upper fragment. 
 ( XCfi§!liffl-,§al,-— In the upper third, where the upper fragment is 
 tik-ed forwards, constituting a projection under the skin, and when 
 it is too short to be controlled by any splint, reduction of 
 deformity is accomplished by flexing the thigh, and niakin»j 
 extension from the knee, the lower fragment being thus broii,s;iit 
 into the same axis as the upper. Manipulation will usually 
 correct any lateral displacement. The limb must be confiikJ 
 in this position by some form of inclined plane, such as a Mac 
 intyre's splint, with a long thigh-piece, and with small straigli 
 wooden splints or a piece of Gooch's splinting fixed, if necessary 
 to the front and outer sides of the limb, over the seat of fracture, 
 The spUnt is slung at the knee, the foot-piece being fixed to hlock! 
 of wood, a little lower than the level of the knee. If these pre' 
 cautions are not taken, an ununited fracture, with the upper fra: 
 ment in front of the lower, is likely to occur. Hodgen's a 
 also a nswers admir ably in these cases. """"""—"•■■' "' 
 
 ""Tn the middle i7;«j^&ht"htr"thTg4*y»^here the upper fragment csil 
 be controlled by splints, shortening is prevented by simple extenj 
 sion (p. 444), the thigh being surrounded by pieces of Gooclif 
 
INJURIES OF BONES— FRACTURES 
 
 449 
 
 iction Mjl 
 
 the smali 
 psQas, and 
 i. external 
 ^nd.to tilt 
 or muscles, 
 of the fouul 
 ich a com- 
 
 of fracture 
 
 ifT a simple I 
 
 The lower 
 
 front of 
 
 Tlie uppril 
 ect violence,! 
 
 of displace- 
 
 ;ct force, and! 
 4 backwardi] 
 the pc)iiliteal 
 :iue" fractures I 
 ards and tor- 
 Lven into the) 
 ,e fixed in itj 
 
 lower fva'j;- 
 ;t unreduced,! 
 
 is generally] 
 
 fragment isl 
 cin, and Avhenj 
 bction of tliel 
 and makin'l 
 Ithus brouj;iit| 
 will usual 
 be conhnedl 
 [h as a M^c-I 
 Imall straig 
 
 if necessaryj 
 
 It of fracture] 
 
 Ixed to blockJ 
 
 If these pre) 
 
 tras 
 
 le upper 
 
 tragnient cai 
 simple extenj 
 IS of Gooc!i( 
 
 splinting, which grasp the muscles and keep the parts at rest. 
 The linib is then placed between sandbags, or secured on a 
 Listen's splint. Where the fracture is oblicjue, with a good deal 
 of tendency to overlap, Hodgen's apparatus should be utilized. 
 
 In the loicev third, if there is any tendency to displacement of 
 the lower fragment backwards, a Macintyre's splint, with the 
 knee well flexed, should be employed, on the principle of the 
 double-inclined plane, together with a short anterior thigh-piece 
 of Gooch's splinting. When the upper fragment projects anteriorly 
 beneath the skin through the quadriceps, operation alone holds 
 out any prospect of bringing the parts into apposition, the mus- 
 cular fibres being divided sufficiently to allow the projecting end 
 of the hone to be replaced, and if necessary wired or pegged. 
 
 Other forms of treatment are in use besides those we ha\-e 
 mentioned, but the above are those most generally adopted. 
 Thus, Thomas's knee-splint can be adopted if accompanied with 
 tour short splints to grasp the limb. In children, Bryant's plan 
 of treatment is most excellent ; it consists in slinging the limb at 
 riijht angles to the body after applying a back-splint from the heel 
 to the nates and short lateral splints, thus obtaining extension by 
 utilizing the weight of the body. By this means the bandages, 
 etc., are kept from being soiled. If a long splint is used for 
 children, a double one {e.g., Hamilton's splint) with a crossbar 
 below is the best. Plaster of Paris or starch bandages may be 
 early applied in adults, but only in the later stages in young 
 children, as they are difficult to keep clean. 
 
 Fractures of the Lower End of the Femur. 
 
 1. Transverse Supracondyloid Fracture is practically identical 
 with that invoking the lower third of the femur ; the lower frag- 
 
 ( iiient is rotated backwards by the action of the gastrocnemii, thus 
 endangering the integrity of the popliteal vessels, and predisposing 
 to non-union, if the deformity is overlooked. 
 
 2. T- or Y-shaped Fracture of the Condyles. — In this a trans- 
 |verse fracture is complicated by a fissure, which runs into the 
 [joint, separating the two condyles. The symptoms are much 
 [the same as the above, but the joint is distended with blood, the 
 ;lione may feel broader than usual, and crepitus may be detected. 
 jThe Treatment is the same as for transverse fracture. 
 
 3. Separation of either Condyle always results from direct 
 lyiolence, the line of fracture being oblique. There is no shorten- 
 In;,', but the leg may be deflected towards the side injured ; the 
 
 fioint is distended with blood, and the fragment displaced upwards. 
 
 Jt may ino\e separately from the shaft, and give rise to crepitus. 
 
 reatment. — Reposition is easily effected when the limb is slightly 
 Pexed, and it is best put up in this position. 
 
 Occasionally a small portion of the condyle may be detached 
 wd lie loose in the knee-joint ; when the immediate symptoms 
 
 29 
 
450 
 
 A MANUAL OF SURGERY 
 
 due to the injury have subsided, the signs of a foreign body in the 
 joint may become evident. 
 
 4. The Lower Epiphysis of the Femur is separated from the 
 shaft in young people ; it is not a very rare accident, and closelv 
 simulates in its signs those of a transverse fracture, even occasion- 
 ing gangrene in some cases. The epiphysis is generally displaced 
 forwards by the traction of the quadriceps on the tibia, and the 
 vessels may be compressed by the lower end of the femur. Suppura- 
 tion occurs in a fair proportion of the cases. This condition has bet 
 mistaken for disease of the knee-joint. Treatment. — Reduction is 
 effected by an assistant making traction on the tibia in the line of j 
 the limb so as to stretch the quadriceps ; then the thigh is graduallv 
 flexed by the surgeon, standing above and with both hands clasped | 
 beneath it. The epiphysis is by this means restored to its normal 
 position, and the limb is kept flexed by a bandage at about an 
 angle of 60°, and laid on its outer side with an icebag applied. 
 Passive movement is carefully commenced in a fortnight. 
 
 5. Longitudinal and Spiral Fissures are met with in the femur, 
 running down to the knee-joint, but causing no characteristic! 
 symptoms beyond pain and haemarthrosis. Early paosive move- 
 ment is necessary to prevent impairment of the functions of the] 
 joint. 
 
 Fractures of the Patella. 
 
 t>««f«MamnPMtta 
 
 ■Wil l MM wqiWMifWH^ W 
 
 The patella is broken in two distinct ways, viz., by muscularj 
 force 'ancr"^*^r^t*violeh"cerand" the produced are sol 
 
 "clifferent that a separate description is necessary. 
 
 1. Fractures by direc t v i 9 ,^e ft 9e may traverse the bone in aiiyi 
 direction, but are rhost o7ten vertical or star-shaped, and possiblyl 
 comminuted. They are frequently incomplete, i.e., mere fissuresj 
 of the front of the bone, and as a rule the fibrous aponeurosis orj 
 capsule covering it is uninjured, thereby preventing any displace-f 
 ment of fragments. There is a good deal of subcutaneous bruising;! 
 and perhaps some effusion into the joint, whilst on careful palpaT 
 tion the fissure may be detected. Crepitus can be obtained if 
 the fracture is complete. Treatment consists in keeping tha 
 limb at rest on a back-splint, and perhaps applying evaporating 
 lotions. P'assive movements must be commenced early wher^ 
 there has been much effusion into the joint. 
 
 2. Fract ures due to muscula r force constitute a very differenj 
 class "Of itijury, smce they ai'^'UlWHy!, transverse, usually completq 
 and also involve the fibrous aponeurosis, so that considerable di 
 placement occurs. 
 
 Mechanism. — When the knee is semi- flexed, the patella 
 poised upon the front of the condyles of the femur, resting upoj 
 the middle of its articular surface ; in this position any suddej 
 and violent contraction of the quadriceps, as in attempting j 
 recover one's equilibrium after having slipped, takes the bone 
 
INJURIES OF BONES—FRACTURES 
 
 4SI 
 
 a disadvantage, and may succeed in saapping it. Possibly in 
 some people there is a predisposing weakness, as cases are 
 not rare in which the other bone yields subsequently, although 
 nerfect functional repair has been obtained in that first broken. 
 The fragments are often almost equal in size (Fig. 152), but 
 mav vary widely ; and either of them may be again divided 
 vertically, or comminuted. 
 The Signs o f this fracture are very^ evident, consisting of lQsg.Qf 
 po ger in ine limb , pain^^stensiQ£.Qtl|3ue!^4Qiji„^ 
 separation ot the tragments, w hich can be readil y fplt nnd 9,nmp. 
 
 _ i ll I m i n i II I _ I I I -■■■ > !■ I ' I ■— ^ • I . ^ • . / T-* • J \ 
 
 times hrougnt into apposition with crepitus (rigs. 152 and 153). 
 This displacement, at first due to muscular action, is maintained 
 by the eflfusion of blood, as also later by synovial exudation. 
 
 |Fio 152 —Fracture of Patella, 
 AND Separation of Fragments. 
 iFrom Gray's ' Anatomy,') 
 
 Fig. 153. — Appearance of 
 Knee after Fracture 
 OF Patella. 
 
 aiact explained partly by the separation of th( 
 
 Ipartly^fjylli e carryi: 
 |or capsuTerwnicn y\ 
 
 SB fa 
 
 gs or the 
 itjevel to. 
 
 yielas at a ditterent level to mertbone 
 I result, and when this is short anc 
 
 :a«&^ae2as.w«si* 
 
 ^ -»-.-. - - Fibrous 
 
 InTIiOTnrTRe'usuaTTesinfTa^^^ short and strong, it 
 
 may be quite satisfactory ; but more commonly the bond of union 
 
 plds when the limb is used, so that the two fragments are once 
 
 gain separated, merely a bridge of fibrous tissue intervening, the 
 
 Joint being often very weak in consequence. 
 
 The Treatment of these cases has been a matter of much 
 piscussion, and many plans have been adopted, which may 
 grouped under three headings, viz., treatment by retentive 
 ^pparatus, by subcutaneous operation, or by the open method. 
 
 29 — 2 
 
452 
 
 A MANUAL OF SURGERY 
 
 1. Simple retentive apparatus may be^ eniployed jn . ca^es where 
 the fragm en"l s~~are'~npf ," wijjeiy separate37 and caii, }D^§,j^adij\, 
 
 ^Tfrbiight into contact and maintained in apposition. 
 
 Some surgfons depend mainly upon plaster of^Pans to effect 
 this. If thfic is but little effusion, THe'TimlSis'extencred, swathed 
 in cotton -v/ool and a flannel bandage, and over this the plaster 
 casing jr. applied. As the apparatus becomes looseTrom muscular 
 atrophy, it will need readjustment. The patient is kept in bed 
 for three or four weeks, but the plaster is retained for as manv 
 months, and after that a knee support, such as the Middlesex j 
 splint (vide infra), is kept on till twelve months have elapsed. 
 Where there is much effusion after the accident, the limb is | 
 placed on a back-splint and kept cool by ice or evaporating lotion, 
 until the fluid has been absorbed ; or the joint may be aspirated j 
 in order to hasten matters. The plaster is then applied, and the 
 same routine followed. In all these cases massage of the knee 
 and of the quadriceps should be early instituted so as to hasten 
 consolidation and prevent muscular wasting. 
 
 In the so-called Middlesex plan of treatment a large piece of I 
 moleskin plaster is placed over the front and sides of the extensor 
 surface of the thigh, reaching halfway up to the groin, and terminat-j 
 ing below in two lateral elongated ends or tags, to which elastic] 
 traction is applied. The limb is put on a back-splint, with a foot- 
 piece, beneath which the elastic accumulator is firmly tied, 
 Removal of the effusion in the joint may be hastened hy the 
 use of the aspirator. At the end of about six weeks the patient is I 
 allowed to get about in a plaster of Paris casing, and then, aboiit] 
 three months after the accident, a special knee-splint is substituted, 
 which allows of only a small amount of mobility at first, hut, In} 
 filing away a stop, this can be gradually increased, until a fuilj 
 range of movement is permitted. In this method of treatment it| 
 is probable that only fibrous union is obtained. 
 
 2. To insure more accurate apposition and a firmer union, amii 
 3^et to avoid the risks necessarily associated with laying the jointi 
 open, x'arious subcutaneous operations ha\'e been adopted, (a) Barker! 
 recommends aHferd'-posieriov" suture of the bone (Fig. 154). AnI 
 opening is made't^ith''5*'Teiio'ESomy''I.nife into the joint just belowj 
 the lower segment, through which any effused blood or synovia cani 
 be squeezed, and along which a curved hernia needle is passed! 
 traversing the articulation from below upwards, and emer|,'ina 
 through the skin above the upper fragment. A piece of sterilized 
 silvLi wire is then carried back under the bone. The needle ia 
 ;; ' V' ;scrted at the same spot below, and carried in front of tha 
 '■' ; : T.ider the skin, emerging at the same point above. Tlij 
 r.p.Ki. ( Ad cf the wire is threaded through it, and by this meanj 
 brou<:,'1i^ out at the lower opening. The bone is thus encircieiii 
 and by tightening and twisting the wire the fragments are brouf! 
 into apposition. The ends are cut off and pushed back under thj 
 
INJURIES OF BONES— FRACTURES 
 
 453 
 
 [skin. The punctures are treated antiseptically, and the Hmh 
 placed on a back-splint for a week or so, when passive movement 
 
 [is commenced, the patient being allowed to walk about at the end 
 nt thes econd, 3Yfifik» ^^"^ i]\^rnrA\ncf all apparatus at the end of 
 ivTweeks. [b) Circumferential 5///«>'_^ "(mtroduced originally, by 
 butcher, of Liv erpo ol) is"also practised (Fig. 155), the wire in this 
 
 1 5se' passing '^rounH the bone from side to side. A somewhat 
 longer period of after-treatment is needed in these cases, {c) Mayo 
 Robson, of Leeds, inserts knitting needles through the muscle 
 and tendon above and below the fragments, and draws them 
 together by elastic bands passed over the ends (Fig. 156). 
 Necessarily, a certain element of risk is admitted in any of 
 
 [these subcutaneous operations, and the surgeon has to ask himself 
 whether he is doing the best for his patient by utilizing such 
 proceedings, granting that it is advisable to interfere at all. 
 
 [Personally, we are of opinion that, if it be justifiable to incur any 
 risk, it is best to proceed by the open method, since in none of 
 
 |FiG. 154.— Barker's 
 Method of Sub- 
 cutaneous Suture 
 aftekFkactureof 
 
 Patella. 
 
 Fig. 155. — Circumferen- 
 tial Suture for Frac- 
 ture OF Patella. 
 
 Fig. 156. — Mayo Roii- 
 son's Method of 
 dealing with Frac- 
 tured Patella. 
 
 |the others can the fragments be brought into accurate apposition, 
 Owing to the impossibility of removing the interposed portion of 
 fibrous capsule, Avhich is always curled in over one of the broken 
 Surfaces, whilst the joint cavity cannot be cleared of the blood- 
 pot which may have collected within it. Impressed by the 
 tonlidence derived from a thorough and efficient application of 
 peptic principles, we cannot but conclude that, if it is desirable 
 |o do more in a case of fractured patella than apply mere retentive 
 jpparatus, the patient's welfare is best consulted by adopting — 
 3. The open plan of treatmenty advocated and perfected by Lord 
 Listerr - IlT ' m fa i g yWF ige^ y'^^ the interior of the^^icwla- 
 
 |22j cleannj^tHejoint of alflSIood-cIbt, removing all tags of fascia 
 p aponeurosis, and wiring ttie fragments securely togetlier. 
 ' '^''6 surgeon sHolild' attempt this operation unless well assisted 
 
454 
 
 A MANUAL OF SURGERY 
 
 and thoroughly an fait with the details of antiseptic work, as the 
 risks run are considerable, although the benefits to be derived are 
 correspondingly great. At King's College Hospital this practice 
 is now almost exclusively followed, and the results, at any rate m 
 the more recent cases, are most satisfactory, no instance of serious 
 mischief from the operation having arisen for the last fifteen years 
 or more. A longitudinal incision is sometimes adopted, althoui; 
 
 a horseshoe -sh aped fl ap is more frequendy^dissected tip^orllown 
 e^xposing tlTe"Tion'e. All blobd'^rof is'i^moTeJramTmeTni^^^ 
 
 n, 
 
 .. _^^_^ ^ ._ .. _ ured" 
 
 snrfttCG^^qJgafrefl' of all cloV an3*lit)rous' shfeils, which are verv 
 oTten adherent. Tracks' lor "the ^ire'siiFiires are nCw^'made by a 1 
 brapdarcdr extending from the upper or lower end through the 
 centre of the bone, so as to emerge on the fractured surface just j 
 in front of the articular cartilage (Fig. 157) ; should the awl 
 emerge at different levels on the faces of the fragments, cartilage j 
 or bone must be chipped away to make a channel in which the 
 wire may lie, so that the two fragments are exactly level, with 
 no inequality of the articular cartilage. A sterilized silver wire 
 of suitable thickness is then passed; the bones are brought into 
 
 apposition, and the wire twisted into a knot 
 or loop, which is hammered or pressed down 
 into the periosteum, so as to keep it from I 
 projecting under the skin and causing irri- 
 tation. A second wire is sometimes needed! 
 in order to prevent rotation of the fragments,; 
 The wound is closed, and the limb kept 
 a Gooch 's splint for eight days, when passivel 
 mo^'^WSffl^is commenced, and by the end ofj 
 a fortnight the patient is allowed to wa 
 Some surgeons keep the limb im mobilized! 
 for a longer period, and such a practice isj 
 certainly desirable in complicated cases, wherej 
 several fragments have to be dealt with. 
 
 It is perhaps advisable not to undertake! 
 this operation immediately after the accident, 
 The limb should be kept at rest on a back-splint, and an icebagf 
 applied for a week or ten days, so as to allow the joint to recoven 
 from the effects of the injury it has sustained ; there is then niuchj 
 less risk of septic complications. 
 
 In old cases, where the fibrous union has stretched and the utiiit)! 
 of the limb is seriously impaired, the open operation holds out tli^ 
 only hope of helping the patient, although it is always a matter ( 
 considerable difficulty. The fibrous tissue must be dissecteJ 
 away, and the ends of the bones freshened, if need be, with m 
 saw. To obtain apposition, the upper fragment must be freeli 
 detached from the femoral condyles, to which it is very ofteij 
 adherent, and the rectus muscle, which is secondarily contracted 
 may need to be partially divided. The limb should be well raisei 
 
 Fig. 157. — Position 
 OF Silver Wire in 
 Open Operation 
 FOR Fractured 
 Patella. 
 
INJURIES OF BONES— FRACTURES 
 
 455 
 
 to relax the quadriceps and thus diminish tension on the bond of 
 union, and lowered inch by inch on succeeding days. The muscle 
 i; thus stretched to accommodate itself to the altered conditions. 
 
 If the fragments cannot be absolutely brought together, the 
 same treatment may be adopted, and the patient allowed to get 
 about with silver wires between the fragments ; the quadriceps is 
 stretched by this means, and a subsequent operation may pro\e 
 successful in gaining bony union. 
 
 Fractures of th e Leg. 
 
 and may involve eith.qjr.thfi tibia or fibula alone,, or both bones. i 
 Tractures o^ the Tibia alone. — Several varieties are described. /, 
 (d) Tlie uMerejid^^^^M&UJsdiy broken as a'fesuTt^ of direct^y.iQlence, 
 the ITne oriracture being_ transverse ; it is by no mej3,ns a common'-''.*^. 
 acCid^jp-t. The cTiaracteristic features are not always very evident 
 at first, since considerable swelling and ecchymosis are produced. 
 Occasionally as a result of falls on the heel a T-shapecl fracture 
 occurs, the tuberosities being broken off and the upper end of the 
 shaft impacted into one or both of them. A few cases of vertical 
 separation of one of the tuberosities alone are also on record. 
 Treatment consists in placing the limb upon a back-splint, e.g., 
 Macintyre's, with the knee bent, and, as a rule, satisfactory union 
 ensues, though possibly with some distortion, (b) Fracture of the 
 shaft of the tibia, apart from the fibula, is usually caused by direct 
 violence. It is transverse in the upper part of the bone, and 
 ol)lique below (Plate IX.). The fracture is diagnosed by feeling 
 an inequality on running the fingers along the shin, together with 
 pain at this spot on firmly grasping the bones above and below. 
 There is often but little displacement, since the fibula acts as a 
 splint, hut tlie lower end of the upper fragment, which is usually 
 pointed, is tilted forwards by the action of the quadriceps and 
 may pierce the skin. Xhe.treatment consists in the agpU^ 
 ba ck or. ^idg..splints (Cline's) for ^a few. . days. ilaBl the. s^veU.ing has 
 gone down, and . theri jHSel^imS maj^.be.,P!4i.,WR..A'3,,.P.l?^§ter. l£ the 
 l)ofie"lias been comminuted, treatment will,,.t)g.. fflorQ,pj;qtr3.cted. 
 (iJThe intcrii'dtDtdlteolus is occasionally separated as the resmt of 
 direcTffi'JQT^'^Tl'flaFr TWfff^any other osseous lesions, constituting 
 what is known as ' Wagstaffe's fracture.' There is comparatively 
 httle displacement, but the malleolus is loose, and crepitus can 
 usually be obtained on moving it backwards and forwards. Union 
 [bylibrous or osseous tissue ensues, but usually in a more or less 
 ^almonnal position, in consequence of which the integrity of the 
 [ankle-joint is disturbed, and weakness or lameness may follow. 
 [Treatment consists in the application of lateral splints. If there 
 I IS any difficulty in keeping the parts in apposition', an incision 
 should be made, and the malleolus wired or peggeSTtoTKe tibia. 
 
 t- 
 
 ■^^1 
 
4S6 
 
 A MANUAL OF SURGERY 
 
 II: :' 
 
 Fractures of 
 
 usiuilly ouuirrn' 
 
 the Fibula alone are by no means uncommon, 
 — il*. c'l resifh'^frf" direct violence. There is tin 
 
 ^ 
 
 displacement or deformity, hut the patient complains of pain 
 localized to some particular spot, and this can usually be eliciim 
 by graspinf^f the bones above and below, and compressing,' then; 
 laterally {' springinj,' ' the fibula). Sometimes the diagnosis is 
 extremely imcertain, and then the X rays prove useful. Treat- 
 ment consists in immobilizing the limJxi.n.H plag.ier.case. ' 
 
 Tfacture of bp^i JJibjia. and Fibula is a \' ery common accident, 
 due to both direct and indirect violence ; if "to direct xToTence'a'nv 
 part may be injured, both bones yielding at the same le\ el ; l)ut 
 if in consequence of an indirect injury, t he tib ia usually gives wav 
 at i ts weakest part, \iz., at the junction oT'itsniiddle'^^^^a^^ 
 TnrfcTs, and the fibula at a slightly higher .level. ^The fractures an 
 often oblique, running in any direction according to the character 
 of the violence, although the obliquity is most frequently directed 
 downwards, forwards, and inwards. The lower fragment is gener 
 ally drawn upwards on account of the contraction of the powetti! 
 calf muscles, and often rotated outwards from the weight of the 
 foot ; hence there is well-marked shortening, which can usualK 
 be overcome by traction. The ordinary characteristics of ;•. 
 fracture are very e\ ident, and but little difficulty can ever be 
 experienced in making a diagnosis. The fracture is likely to 
 become compound when due to indirect violence, owing to the 
 sharp end of the oblitjue fragment of the tibia, usually the upper. 
 piercing the skin. Skiagraphy is exceedingly useful in enablin;; 
 one to decide as to the character of the lesion, and the skiagrams 
 should be taken both from the front and from the side, as the 
 appearances are often very different (compare Plates X\'III. and 
 XIX.). 
 
 Tli^e fracture of the tibia has been proved by skiagraphy to ne 
 frequently of the hcc-dc-flutc type, and is then probably always clue 
 as much to forcible torsion of the limb as to vertical strain. The 
 rotation is a very important element in these cases, and the lower 
 end of the upper fragment rides prominently forwards (the ' ridiii;' 
 fragment '). The shortening is sometimes less marked than in 
 simple oblique fractures, but there is much greater difficulty in 
 getting satisfactory approximation of the fragments, e\en after 
 freeing the ends of the tibia by operation. This difficulty i> 
 probably in most cases due to the broken ends of the fibula be- 
 coming engaged in the fibro-muscular tissues around it, and will 
 necessitate an incision over this bone in order to free them. 
 
 Treatment. — In the simpler cases reduction is accoinplished hy 
 fl^'^T^'*airT11'xmJ-'nie*1<ffee^ iiiuscTes'bf the call, 
 
 anHTlien' imping 'f inaction' oiTtliy fUUt and mampuTatTng "the parts 
 .'Tnto'posrfTon. *The tendo ^AjchjUis.niay, if necessary, Joe divided, 
 It will usually silffice'to put up the limb in a pair of side-splints, 
 su"c1i'a?Ome'g: ttife" t6ngeT''dne wiW the tw 
 
nconimon, 
 lere is n, 
 !S of pain 
 be elicilLii 
 sin^^ tlicn; 
 iaf,'n()sis i> 
 il. Treat- 
 
 i^ accident, 
 olenceTiHv 
 level ; but 
 gives way 
 and lower 
 ictures an 
 i characte; 
 ly directed 
 it is ,<fener- 
 e powcrti:' 
 ight of the 
 an usuallv 
 istics of :i 
 m ever l)e 
 3 likely to 
 ino- to the 
 the upper, 
 n enabliii;' 
 skiagrams 
 ide, as the 
 :VIII. ami 
 
 aphy to lie 
 always due 
 rain. Ih: 
 1 the lower 
 the ' riding 
 ed than in 
 lifficulty in 
 e\'en after 
 lifficulty i> 
 ; fibula bt- 
 it, and wii! 
 hem. 
 
 iplished by 
 of the calf, 
 g "the parts j 
 be divided, 
 ;ide-splints. 
 ig In tended j 
 
rLATi: \\ III. 
 
 Fracture of both Bones of the Leg, seen fuom in front. 
 
 To/ace Plate -\7.\'., bet-iwcn />/<. 436 a»(f 4S7-1 
 
I'LATi: XIX. 
 
 The same Fracture as in Plate XVIII., seen from the inner sioe. 
 
 rrom a study of tlie two skiagrams it will he noticed that both lower fragments 
 have l)een displaced outwards, with but little alteration in their antero- 
 posterior axes. 
 
mnti line 
 (jiiiticient 
 cithe lin 
 i::i>t anc 
 liikelyto 
 In obli 
 jin i^'ettin,!. 
 lihem in ,t. 
 anci 
 s 
 
 Idouht tha 
 Itl'.i:' tra,<,nn 
 ls'iiri,'eoiis. 
 linclude ar 
 Fractur 
 
 inmarlly" 
 ieciiiuIaVy 
 JFracture-d 
 :. Displ 
 Rriety, cc 
 ts fro 
 lcffli1verl)s 
 ler . 
 : portio 
 il)ula, 
 3 in( 
 'ie~lower'' 
 
 Btact, the 
 Rotated out 
 Tlie aiiK 
 «! the foot, 
 '■■'Htures, t 
 1^ correctl} 
 llaifral !i<ra 
 
 itlati 
 
INJURIES OF BONES— FRACTURES 
 
 457 
 
 tor 
 
 the outer side . In other cases it may be better to apply a 
 
 |!^natrpp^t^^-12I--.?P^i'^l with a rectanijulai', ..iaaL-.piece, e.g., Mat.- 
 
 ;:,tvre's, anJ two uiteral spfipts. Some surgeons recommend an 
 
 llnierior wire splint, extending from above the knee to the foot, 
 
 l:he leg being subsequently slung in the flexed position. This 
 
 ;ii;iy be advantageously modified by combining it with an addi- 
 
 jtional casing of plaster of Paris. Whatever treatment is cidopted, 
 
 i;i? necessary to see that the length of the limb is as far as possible 
 
 Imaintained, and that no rotation of the lower fragment is present. 
 
 Il'jensure a!)sence ofrotation, all that Is needed Is to iiofe iKa'f the 
 
 'r.nt-r aspect of tlie great toe, the subcutaneous surface of the 
 
 jnicinal malleolus, and the inner border of the patella, are in the 
 
 ;,-iiiie line, and correspond with the opposite limb. Union will be 
 
 ;ii!liciently advanced in two or three weeks at the latest to allow 
 
 ihe linil) being put up in plaster, which must be retained for at 
 
 [.■:\-i another ifionth, and even then a good deal of lameness is 
 
 ;ik''!v to persist, which will need subsequent massage.- 
 
 In ohlique and spiral fractures there is often very great difficulty 
 insetting the fragments together, and even more in maintaining 
 hhcin in good position. Taking into consideration the degree of 
 D.rnuinent depreciation that a man (especially if of the labouring 
 iL.bses) suffers from \icious union of these bones, we ha\e no 
 I'Jit that tlie suggestion to cut down on, and wire, screw, or peg 
 |;>. fragments together, is fully justifiable in the hands of skilled 
 aixt'ons. In the spiral cases the operation may also ha\e to 
 include an incision to free and fix the fibula. 
 
 Fractures in the neighbourhood of the Ankle-joint are usually 
 Jprodnced by _ indjrg(;f. 'yAuIeficej' ' 'tlie ..'Toipt slipping, and ' leading 
 inmarily to a disghicement of the ankle, the fracture bein 
 rsiconclary result. They would therefore be better" d5scrib(?d 
 |rracture-dislocations at the Attkle-joint 
 
 1. Dhplaceniait of the Foot outwards is by far the most comu'ion 
 ivariety, constituting what is known ix^ Pott's Fn id uve. It^iu-.uaUy 
 Iresults from the patient slipping^ on the, inside ot.tne fogtj_,_v!>:','cnt 
 |cf^'1<erl)stone. ' "THe as't'fagaTus is therelw forcibly drlvyu^i^jitiiisi 
 ItneiiTner aspect p0.bG...^>;ternal malleolus, and teiKJs o displace 
 jtliai portion of bone outwards. The force is thence transferred up 
 tie lihula, which bends and breaks at its weakest !sp'-'i- -Jthat is, 
 Kiu't 3 inches alwve t:liQ,,tip,p£,.^i.^,u),§L|k9Jus— -the up.per end of 
 Vlhwer fragment being displaced inwards to\v'TnT."?:Th'L''"Tibia. 
 lere the ihrerior interosseous tiDio-nDuTar hgam.n-t remains 
 intact, the foot itself cannot be displaced upwards, b it is merely 
 it'tated (^utwards. 
 
 I lie amount of injury inflicted on the tissue, to the inner side 
 ('the toot, or on the tibia, warrants us in describing foi'r distinct 
 ''"^^tuies, to the first two only of which the name Pott's fracture 
 ^ correctly applied: {a) In the first degree, merely the KUernul 
 '^tfral ligament is torn through (Fig. 158) ; the intact Tnaireolus 
 
 ling . 
 
458 
 
 A MANUAL OF SURGERY 
 
 can then be felt projecting beneath the skin, (b) In the second 
 degreerthTi 1iialTeoTus''it'seTr IS torn pff, and a distirjct sur^ys"^^^3> 
 felt between it and'tKelbw'eFend of the tibial shaft, (fj^^ i:j,:, 
 (c) The third degree is a much more serious lesion, constituting; 
 what is sometimes known as Dupiiytvcns Fracture. The inter- 
 osseous^tibjq-fibular ligament yterd's^ ot fhfe_ flake bfl^oi^e'tcj^vliich 
 ir~Is attachedjs torn off"; the foot, ciarrying with it tlie lower 
 portion of the fibula, and the superficial flake of the tibia, whith 
 has been detached, is displaced firstly outwards, and tlien when 
 the astragalus has cleared the lower end of the tibia, upwards, and 
 
 Fig. 158. — Dhdinarv Pott's Fracture 
 WITH Rupture of internal Lateral 
 Ligament. 
 
 Fig. 159. — Pott's Fractlhe 
 WITH Internal Malleoli's 
 
 TORN OFF. 
 
 to a less degree backwards. On the inner side either the ligament I 
 or the malleolus may yield (Fig. 160). {d) The fourth degree 
 consists in the usual type of fracture of the fibula, associated with 
 an aln ost transverse fracture of the tibia, just above tlie haseof 
 the inner malleolus (Fig. 161). In this variety, the lower end of 
 the shaft of the tibia projects beneath the skin, and is likely to lie 
 mistaken for the tip of the malleolus; if this error is conuniltai. [ 
 and the fracture allowed to unite without proper rectification, cor 
 siderable deformity results. 
 
 In rare instances, the lower end of the tibia may project througii 
 the skin, thus rendering the fracture compound. 
 
PLA'I'IC \X. 
 
 hlALLKOLVS 
 
 '''IIVTKKNS l',<ACTrKK, WITH VI '.-MAUKED I ^ISI'IAC ICMKNT ( )l TWA K I )S OK 
 THE J'mot, ,\s WKLL as ok Tlllv LOWKU l'".<A(iMi;NT OK Till-; l"ir,L-LA AND 
 
 TMK i\iiiK-,AL Malleolus. ^oKIAuKam taken from in kkont.) 
 
 ^ 
 
HBI 
 
 In al 
 and thii 
 tendon 
 associat( 
 of these 
 occur wi 
 of callus 
 2. Dh 
 tfie oute 
 against t 
 
 into it. Tl 
 and owing 
 wliTcn'actsI 
 ^'ott's fract 
 
 t^l'giitly bad 
 > Dispfac: 
 
 I 'dipping fon 
 
 pnti fibula ii] 
 ot the foot 
 
 |P'532). 
 Treatment 
 
INJURIES OF BONES— FRACTURES 
 
 459 
 
 In almost all of these varieties the ankle joint itself is opened, 
 ^nd this, combined with the amount of bleeding that occurs into 
 tendon sheaths and muscles around, and the difficulties often 
 associated with fixation of the fragments, explains why the results 
 of these cases are frequently so unsatisfactory. Should union 
 occur with the foot in a false (i.e., everted) position, a large mass 
 of callus develops between the shaft of the tibia and the malleolus. 
 
 2. Displacemen t of the Fo ot inwards. — When the patient slips on 
 the outer aspect of the'Toot7''tTre' astragalus "is" TorcnolydlrtVen 
 ai;ainst the inner ma,lleolus, which may be broken off or impacted 
 
 ■iG. i6o.— Dupuytren's 
 Fracture. 
 
 Fig. i6i. — Fracture of Lower End of 
 Fibula and Tibia simulating Pott's 
 Fracture. 
 
 iinto it. The outer malleolus is dragged Jjnwajds,,^iy^„the foot, 
 ■and o\vint{ to" the 'integrity of the inTenor tibio-?ibular ligament. 
 
 [wlTicH'acts as aTiilcrum, tnelibula yields at the same spot as in 
 ! Pott's fracture. The foot io displaced inwards, and perhaDS 
 iliglitly backwards. 
 
 3. hisflacemeni of the Foot backwards, by catching the heel and 
 
 tripping forwards, is usually fissociated with fractures of the tibia 
 
 [and fibula in the same position as in Pott's fracture, but eversion 
 
 I of the foot is absent (see allocation of the ankle i)ackwards, 
 
 IP' 532). 
 
 Treatment. — In reducing these fractures, traction should be 
 
 - .♦/r ■*.' «»..■ 
 
 ( ^v ^T P n y fiHrynl»f»i^« 1. 1 
 
460 
 
 A MANUAL OF SURGERY 
 
 made upon the foot after the tension of the calf muscles has heen 
 Jlll^^^lt^i!^ ^^^™S^ 't'^t^^T^^e, or by tenotomy of the terido" AcTiiTIis ; 
 the position of the internal malleolus must be accurateiy defined. 
 Before applying the splints, careful attention must be given to the 
 following points : (a) The foot must be maintained at right an;,'les 
 te-the jeg ; (b) J\\eJjisd'^xioM^^^ 'uncTuJyrMCfetat'ds '; ' and 
 
 (fj the foot nitist not,be^rotat!e,d.pn...tUe leg — i.e., the imier surfaces 
 of the great toe, intexoal malleolus, and patella niuiit be in the 
 sam£ line. A pair of Cline's jjpljjjts is generally sufficient to 
 sfeady the parts. Some cases are better treated, however, hy a 
 Dupuytren's splint (Fig. 162), wdiich is really a Liston's splint on 
 a small scale. It reaches from the knee to below the sole of the 
 foot, and is placed on the inner side of the limb, the patient Ivin;,' 
 on the sound side during its application. A firm pad extends 
 down as far as the base of the internal malleolus, and o\er this 
 as a fulcrum the foot is drawn inwards by a handkerchief applied 
 around the ankle, and tied to the notches at the end of the splint. 
 The foot being thus fixed, the upper end of the splint is bandaged 
 
 Fig, 162. — Dupuytken'.s Splint applied for Pott's Fr.^ctuke. 
 
 (TiLLMANNS.) 
 
 to the limb. Any tendency to backward displacement of the heel 
 may be counteracted by the use of a Macintyre's back-splint, or 
 b- the application of a Syme's anterior"lTfTI^esTioe"sp'ITivf7"whicli 
 ca.'i be used in combination with a Dupuytren. It consists of a 
 flat piece of wood, well padded, extending from the knee to the 
 ankle along the crest of the tibia ; the lower end is shaped like a 1 
 horseshoe, the two limbs passing one on either side of the foot. 
 A handkerchief or piece of bandage is then applied, with its centre 
 over the point of the heel ; it passes up on either side between thei 
 splint and the foot, winds over the former structure, and is tied 
 behind the heel, which is thus lifted forwards. As soon as I 
 possible, the limb should be put up in water-glass or plaster of j 
 Paris. 
 
 In the siiiipler forms, early massage may be employed, and then! 
 ffTTthe retentive apparatus necessary is some adhesive plaster! 
 applied so as to cover in and encase the foot and ankle. In the] 
 more difficult cases, where there is considerable displacement ami 
 much difhculty in keeping the fragments together, operation tofixl 
 them is quite justifiable. 
 
INJURIES OF BONES—FRACTURES 
 
 461 
 
 In cases of vicious union after Pott's fracture, it is usually 
 necessary to re-divide the fibula, and to excist a V-shaped portion 
 ,,f bone from the tibia extending into the ankle joint, so as to 
 enable the malleolus to be brought in contact with the shaft of 
 the tihia. 
 Fracture of the Os Calcis may result from direct violence, such 
 ;i5 a blow on the heel, or possibly from muscular action, the 
 epiphysis being then separated, or the shell of bone into which 
 the tendo Achillis is inserted being torn off. The fragment thus 
 separated is displaced upwards by the contraction of the calf 
 muscles, and the resulting deformity is very evident. If the line 
 of fracture passes through the body of the bone, there is usually 
 no displacement, owing to the attachment of the interosseous and 
 lateral ligaments ; crepitus can sometimes be obtained on firmly 
 ''rasping and moving the fragments. Treatment consists in im- 
 mobilizing the foot in a plaster case if there is no dispkicement ; 
 hut where the posterior part of the bone is drawn upwards, it 
 must be approximated to the rest of the bone after flexing the 
 le^', in order to relax the calf muscles, or possibly after tenotomy. 
 A more satisfactory result may, however, be obtained by cutting 
 down, and wiring or pegging. 
 Fracture of the Astragalus is usually due to falls on the foot 
 j from a height, or from direct violence applied to the foot, as by a 
 weight falHng upon it. The lesion is often a severe comminuted 
 I one, and portions of the bone may be displaced forwards or back- 
 wards, making a marked projection beneath the skin. In a case 
 recently under our care at hospital, the patient had fallen down a 
 lift, alighting on his feet ; both astragali were smashed, and this 
 jprobahly saved his life. Such accidents are often associated with 
 sions of the tibia or fibula, and possibly even of the femur. 
 [The whole region of the ankle becomes infiltrated with blood, 
 land an exact diagnosis is sometimes difficult. Treatment 
 consists either in immobilization, which is likely to be followed by 
 stiffness of the ankle, or in bad cases by excision of the bone or of 
 I projecting fragments. 
 
 Occasionally in less severe accidents the bone merely splits 
 [across, the lesion being usually situated about the neck. Such is 
 [due either to the weight of the body flattening out the arch of the 
 I Done beyond the limits of elasticity, or if the foot is dorsi-flexed to 
 penetration of the bone by the anterior edge of the tibia, impac- 
 tion being even produced in this way. Massage and early 
 I mobilization should be employed in such cases. 
 Other bones of the tarsus are occasionally fractured, l)ut these 
 lesions require no detailed description, y 
 
CHAPTER XVII. 
 
 Inflammation of Bone. 
 
 In order to assist our readers to correctly understand the subject 
 of inflammation in bone, we must call to mind a few facts relative | 
 to its constitution and growth. 
 
 Bones are divided into the long, the short, and the flat, each of i 
 these consisting of compact and cancellous tissue in varying 
 amounts. In the shc5rr"bt)Ttes there" Is b'iit a tliih layer of compact 
 tissue surrounding a cancellous central mass, the meshes of which I 
 are filled with medullary fat and connective tissue. In the flat] 
 bones the compact tissue forms two limiting plates, separated by 
 a layer of cancellous tissue of varying thickness (known in the 
 skull as the diploe). In long bones the shaft consists of a peri- 
 pheral tube of compact structure, surrounding a space which isj 
 normally filled with medulla, and known as the medullary canal ;[ 
 at each end it gradually merges into a larger mass of loose 
 cancellous tissue, the interstices of which are similarly packed 
 with vascular fatty medulla, which apparently performs the! 
 function not only of maintaining the nutrition of the bone, but] 
 also of elaborating the blood. Prolongations from the medulla, 
 moreover, extend into the Haversian canals, and are thence con- 
 tinuous with the periosteum, so that the mineral skeleton hasj 
 incorporated within it a vascular fibro-cellular mass which I 
 permeates its whole structure. It must be clearly remembered I 
 that there is normally no open hollow space, and therefore noj 
 endosteum or internal lining membrane (except in bones con- 
 taining cavities, such as the mastoid cells or frontal sinuses). 
 
 The vascular supply of a bone is derived {a) from the nutrientl 
 artery which passes into the medullary space, and there breaksj 
 up into branches which ramify through the whole of the medullaryj 
 tissue, and thence extend into the Haversian canals ; and {h) fromj 
 the periosteum, an exceedingly vascular ensheathing membrane,! 
 from which smail vessels pass perpendicularly into the Haversianl 
 canals, and thus establish a communication between the twoj 
 
DISEASES OF BONE 
 
 463 
 
 ly packed ■^ceis' 
 
 Ijvsteins. These latter vessels are especially numerous and large 
 IJose to the epiphyses. Large veins ? ^^}^S '" ^the medy[lar^ 
 and cancen p us^ j.nterior, ami, are frequency jHrmn]^^ in. iii,-,>. 
 jSnimatory mischieT.; if the thrombus becomes infected, and. j&o 
 ijgttlTE^raf ed, gy aenua is yerj^Jikel^ Jo e.n§uj, 
 
 '"The gyoivth or bone manifests Itself in three different ways : (i.) \^ 
 BcreaseaJ«„,l^ngthfr2mJj-|e. shaft ,si^p .of. tlip epjphy ^4 cartilage, 
 ite epiphysis. itsdr.gaiiViJag..bui..iittle. In the japper limb the 
 ilief increase in length occurs at the 9hdJiHd££"iSiaVwirsT/w1iT[st 
 glBeteg'lt'ts'WamTy evident on either side of thaliijee-joint, and 
 iliis in. spi^'iSETtEe fact that the so-called nutrient ^rterjeii are 
 |ected away from these points ; this_wo-ld tend to indicate, th^it 
 iiie im^ortance^gf. these vessels in suppfying nutrition to the bones 
 liasbeen much over-rated, (ii.) Increase in breadth is produced 
 bvnew formatinn -pf bone from the, deeper layer of the periosteum, 
 j-hich contains many yellow elastic fibres, and a large number of 
 angular nucleated cells, or osteoblasts, which are presumably the 
 [loneforming agents; (iii.) A l)one increases in density by a new 
 deposit of osseous tissue around the Haversian canals and cancel- 
 lous spaces. 
 In considering the inflammatory affections of bones, it must 
 always be kept in mind that the essential pathological phenomena 
 (viz., hypersemia, exudation, and tissue changes, active or passive) 
 are similar to those manifested in any other vascular structure, 
 but that the resulting effects are modified by the limited space in 
 ivliich the vessels lie, and the resisting character of the surround- 
 inj; osseous tissue. _Heiice_^any acute inflammation, resulting in 
 rapid vascular engorgement and considerable exudatibh ' cjUi^kfy 
 
 pressure within the unyielding bony canals. If, however, the 
 '_ia!. j?i^fl£Mif^, so that the tissue-liquefying pfbpertres'ortlie 
 exudation an^ the tissue^absorbing activity gf.. the. jeucocytes can 
 come.mia4ilay, then osteoporosis or: mvefac.tion.ol th^hoxx^ iQ^nli^^'A 
 condition sometirnes_termed caries. On the other hand, if the 
 iiiflainmatioh '{s'clironic, and due to causes other than tubercle or 
 tlie pressure of tumours, then new formation occurs, and osteo- 
 iilimis, or condensatiorij^ js^niost likely to result. Tul5ercTe 'ifi 
 kffl^'as~'ersewliere7 causes prTmafiTy Vafefaifition of the tissue 
 attacked, though sclerosis may be associated with or follow it, 
 and the chronic pressure of tumours or aneurisms leads to rarefac- 
 
 in and atrophy locally, although a certain amount of sclerosis 
 
 ly be induced around. 
 
 One more general fact must be noted, viz., that it is very rare 
 br any inflammatory process to affect solely one element of a 
 ibone. The continuity of the vascular supply explains why a 
 periostitis is usually or almost invariably associated with inflam- 
 [niation of the subjacent bone, and why an osteomyelitis is never 
 limited to the medullary cavity. 
 
464 
 
 A MANUAL OF SURGERY 
 
 Terminolp frv. — Many difTercnt terms ha\e been applied to these 
 [)atlu)loj,Mcal processes, and much needless confusion introdiKvd 
 thereby into a subject at all times somewhat complicatd. 
 ICspecially is this the case in inflammatory affections of cancellous i 
 or compact bone, the terms ' osteitis ' and 'osteomyelitis' heinir 
 used with very little precision. All inflammation of bone occurs 
 in connection witli the \ascular tissue permeating its structure. 
 and hence, as this is everywhere connected with the medulla, 
 all such processes might be described as forms of osteomvelitis, 
 This term is, however, limited to the affections of the medulla 1 
 of long bones, whilst the term 'osteitis' is applied to those 
 occurring in the compact tissue of the shaft of long bones, or in 
 the cancellous tissue at the ends of long bones, or in the interior I 
 of short bones, and with such limitations we shall comply here, 
 Then, moreo\er, the results of disease have been often confounded | 
 with the pathological processes leading to them, and the clinical 
 conditions — canes, necrosis, and sclerosis — are described as distinct I 
 diseases ; we shall endeavour to avoid this source of error by pre- 
 facing our description of the diseases with a few remarks on eaclij 
 of these clinical conditions. 
 
 JTecros is.^r death of bone, may occur in a variety of forms,} 
 and froirirmany dififerent causes, e.g. : (a) From acute Jg^yJijii^dj 
 suppurati\e periostitis, the seciuestrum, or deacfm assTTicin.r rlun i 
 !?imply a superncial plate or Hake of tlie compact exterior (i'lis. i6ii:| 
 (o) Tmni rtCTi _tu "ITTTOj^al m c imective osteomyelitis (acute panostitisl 
 ()f licTiTeniecf osis), tifie s'enue^sfritirft T^eH'Sfti^^vblvrng" tTie'wholel 
 tTnclTng'SS' bf 'tTielione^ ahcf iinaclmg more or less of the length ufj 
 the diaphysis, so that a .greater extent of the superficial tissue is] 
 destroyed than of the cancellous interior (Figs. 164 and 165) ;j 
 (c) from acute septic osteomyelitis, usually traumatic in ori<;in,j 
 the sec}uestruni being a'nhularin shape, and involving more of tliej 
 interior of the bone than of the exterior (Fig. 166) ; (d) fromaciitej 
 or subacute septic osteitis of cancellous l)one, the sec]u^fra beinijl 
 sTnTll1'S|3'idiilafS(!''!Pagiiients of the bony cancelli which ha\e escaped! 
 al)Sorption by the granulation tissue ?lways forming in sucliaj 
 process ; (e) from tuberculous disease of cancellous tissue, tliel 
 sequestrum being light and porous, often infiltrated with curdyl 
 material, and rarely separated completely from surrounding parts;| 
 (/) from syphilitic disease of cancellous or compact tissue, usua 
 resulting from excessive sclerosis, or gummatous disease of tlid 
 periosteum which has become septic ; (g) from the action of local 
 irritants, e.g., mercury, or phosphorus fumes gaining access to tha 
 interior of the teeth ; {h) occasionally as a simple senile loss ol 
 nutrition, as in senile gangrene ; and (i) a variety, described by Sin 
 James Paget under the name of ' quiet necrosis,' occurs as a resiill 
 of direct injury, the sequestrum separating without suppurationf 
 it is one of the causes of loose bodies in joints, and especially thj 
 knee, following a blow on one of the condyles. 
 
h) 
 
 DISEASES Of hone 
 
 465 
 
 The separation of sequestra is always broufrlit about by a process 
 ijnati5?^iTf?~t0-th'c'Tr"bv ificatji?, yf >Vhicl) slougTis' and gangrenous 
 I irateri.'ils are cast oil from the body, viz., b^ cpnipletcixb.svrp- 
 jon if small, aseptic, and surrounded by sufficiently vascular 
 |55ue; l>y absorption >.,f as much as possible, in larger aseptic 
 IniSses, j,aanulation tissue invading and replacing the dead mass, 
 landii liiit^' "f separation forming as a result of defective nutrition 
 of the most advanced layer ; or, if septic, an active rarefying 
 |intl;iminution occurs in the neighbouring living tissue, which in 
 jiime breaks down, and so sets free the dead mass. (See in more 
 1 at p. 55.) From the eroding action of the granulation 
 [tissue, the under surface of the sequestrum is always hollowed 
 it, and, as it were, worm-eaten in appearance. Where sepsis is 
 Ipresent, the process is more active, and is completed more rapidly, 
 Ithough with greater risk to the patient. 
 
 Caries, or, as it is sometimes called, osteoporosis, or rarefaction of 
 Ifciif. is a clinical condition resulting from inflammation, and con- 
 IsistinK in a soft and spongy state of the bone, which, if it can be 
 Ireached, readily breaks down on pressure with a probe. It may 
 Iresult from the following conditions : {a) A simple subacute in- 
 lllaiiimatory process, f.^^, during the early stage of repair in a 
 Itracture; {h) from acute or subacute septic or infective inflamma- 
 of cancellous tissue ; [c) from tuberculous affections of the 
 Icaiicellous tissue or periosteum ; [d) from syphilitic disease of the 
 [raedulla or of the under surface of the periosteum. 
 
 Pathologically, it is characterized by the replacement of the 
 
 Imedulla by granulation tissue, which usually contains some large 
 
 Imiilti-nucleat ed ceH s, or osteoclasts, and these seem to be closely 
 
 [connected with the removal of tlie bone, though we are at present in 
 
 Jignorance of the manner in which this is effected. The cancellous 
 
 (tissue becomes hollowed out to accommodate these granulations, 
 
 the osteoclasts are usually found occupying shallow depres- 
 
 kions known as ' Howship's lacuna\' In tuberculous and syphilitic 
 
 sions the bone corpuscles undergo fatty degeneration. 
 
 Certain terms are used to indicate the characteristics observed 
 
 |ii particular cases. By Caries sicca is meant that the process 
 
 iccurs without suppuration ; in C. suppurativa pus is always 
 
 liresent ; in C.fungosa the granulation tissue is exceedingly abun- 
 
 6ani, especially in tuberculous disease of the articular ends of 
 
 pnes ; in C. necrotica necrosis is associated with caries, the 
 
 lequestra consisting either of spiculated fragments, or in tuber- 
 
 lulous disease of larger masses. 
 
 If caries is recovered from, a subsequent condition of sclerosis 
 ksually follows, with loss of substance and often deformity. 
 
 Sclerosis of bone (osteosclerosis) is invariably the result of some 
 Ihronic inflammatory affection, e.g., (a) chronic .peripstiti§«.3YJiether 
 liniple or syphilitic ; {h) chronic osteomyelitis, simple, tuber- 
 pous, or syphilitic ; or [c) chronic osteitis of the compact bone, 
 
466 
 
 A MANUAL OF SURGERY 
 
 which is always scconchiry to one of the former. In all cases 
 the condition is due to a slow formation of new honi; within the 
 Haversian canals or cancellous spaces, thus diminishin;; ili(irj 
 lumen ; in syphilis this may prof^ress to such an extent as tf) lead 
 to their total occlusion, and e\en to localized necrosis from lack nfl 
 blood-supply, especially when sepsis has occurred. In tuhtTculousf 
 bones the sclerosed tissue is always at some distance from the 
 focus of mischief, and may be looked on as Nature's attempt to 
 limit the spread of the disease ; it forms also the final tissue orl 
 bone-scar in the process of repair in those cases where a curej 
 has been obtained by natural or surgical means. 
 
 II. 
 
 III. 
 
 Classification of Inllammatory Affections of Bone. 
 
 I . Periostitis : 
 
 (a) Acute localized, with or without suppuration. 
 (h) .'^cute diffuse, always associated with or secondary tc 
 .icute infectixe osteomyelitis. 
 
 (c) Chronic simple, or hyperplastic. 
 
 (d) Chronic tuberculous. 
 
 (c) Chronic syphilitic. 
 Osteitis, or inflammation of compact bone, which is alwavsj 
 
 associated with and secondary to either periostitis orl 
 pstepmyelitis, and so will not be described separately,! 
 The acute form results in necrosis; th'e subacute inl 
 osteoporosis, and tlie chronic in sclerosis, e.xcept iiij 
 
 tubercidous disease." ' " 
 
 Osteomyelitis, or inflammation of the medulla of jdiii; 
 bones : 
 
 (a) Acute septic (traumatic). 
 
 (b) Acute infective (idiopathic == acute panostitis). 
 (r) Subacute simple or infective, e.g., after fractures, ors 
 
 during the separation of secjuestra, resulting primuiilyj 
 in rarefaction, but finally in sclerosis. 
 
 (d) Chronic simple, tuberculous or syphilitic, usually causin J 
 general enlargement and sclerosis of the bone, ev(:ii| 
 if locally some rarefaction is present. 
 
 Inflammation of , the CancellP-HS _ Tl9§^e ....(P^jJi^l, mm 
 
 similarly be : ' 
 (^) -l.?iJte septic or traumatic. 
 (/)) Acutejnfegtive. 
 
 (c) Subacute simple or septic. 
 
 (d) Chronic simple, syphilitic, or tuberculous. 
 When limited to the articular end of a bone in a young person^ 
 
 this is sometimes termed Epiphysitis. 
 
 It is unnecessary to describe in detail all these conditions, sincd 
 many of the divisions overlap, and hence we shall group togethet] 
 
 I\" 
 
DISEASES OF BONE 
 
 4»9 
 
 -htNarioiis acute and chronic afTections in order to indicate the 
 
 clinical signs and symptoms. 
 
 /AcuTK Inflammations oi- lioNE. i 
 
 1, Acute Localized Periostitis usually arises as a result of 
 traumatism applied directly to the bone, with or without an open 
 wound ; it may a) ' ^ determined by general conditions, such as 
 rhi'Uinatism, gout vi pyaimia, or by an extension of inflam- 
 matory tnischief, as in an alveolar abscess. 
 
 Pathologically, the process consists of hypera'iiiia of and exuda- 
 [luii into the periosteum, which becomes swollen, turgid, and 
 ihickencd. Tliis may be followed in due course by resolution, or 
 niav leave the bone thickened and in a condition of chronic inflam- 
 mation; or suppuration may ensue, and with it usually a limited 
 
 [fir, ir.j.—supekficial necrosis resulting from a localized periostitis 
 
 (Diagrammatic). 
 
 A represents the necrosed tissue lying in continuity with the surrounding Hving 
 bone; the periosteum is stripped up from it, and has an opening through 
 which the pus has been discharged. H shows a later stage, in which the 
 seiiuestrum is being separated by a process of rarefying osteitis in the 
 immediately contiguous living bone, whilst an in%olucrum, or sheath of 
 new bone, is formed from the under surface of the periosteum ; a cloacal 
 aperture remains in the involucrum for the escape of discharges. C shows 
 the condition of affairs after the sequestrum has been removed. 
 
 buperticial necrosis. In the last event pyogenic organisms must 
 tind an entrance to the area of mischief, and probably in cases 
 jdiie to trauma through the abrade'l or injured skin ; in other 
 jmstances they may come from neighbouring foci of inflanmiation, 
 jor possibly auto-infection may occur. Whatever their origin, 
 Ithese organisms are not usually very virulent, or, at any rate, 
 r'ley rarely give rise to serious mischief. The inflammatory 
 Iprocess e.\ tends to the small vessels entering the bone from the 
 
 30—2 
 
468 
 
 A MANUAL OF SURGERY 
 
 under surface of the periosteum ; these become dilated, next 
 throiiibojied and strangled by the TJffe^Sufe of* the exuJat'on 
 around them, and finally pulled out 'from the osseous canals by 
 the tension of the subperiosteal efTusion and by the peptonizini; i 
 power of the bacterial products. Consequently, the vitality of the] 
 superficial layer of bone is destroyed for an area corresponding,' 
 almost exactly to that from which the periosteum has Ijccp 
 stripped (iMg. 163, A). 
 
 As soon as tension has been relieved by the escape of the pus, 
 repair commences. Where the mischief is very slight and super- 1 
 ficial, the involved bone may entirely recover, or even smal 
 necrotic portions be absorbed. If the dead portion of bone is] 
 more extensive, it will be separated from the subjacent livjuf; 
 tissues by one of the processes already described (p. 465), whilst 
 frorn the under surface of the stripped-up periosteum a casfiig of 
 "hew b6ne*"irnevMoped,''c6ii's{itutin^ ap!'yV^^^ at 
 
 fTTfSt ' spon'gy and ' ca'hcellousm texture, but finally hard and] 
 
 SetefOsed; in the centre of this new formation are found one nr I 
 
 more openings or cloiiar through which the discharge passes, and! 
 corresponding in position to th(? openings in the periosteum and! 
 skin made by Nature or the knife (Fig. 163, B). 
 ■ Clinically, the symptoms oF acute localized periostitis consist inl 
 the ordinary phenomena of acute inflammation, the pain heing of] 
 an intense aching character, worse at night, and increased hy[ 
 lowering the limb or by any kind of pressure. If a subcutaneous 
 portion of bone is involved, a painful swelling develops, at firsti 
 brawny in character, but, when suppuration has occurred, t!ie| 
 centre softenS; whilst the skin over it becomes red and oedeniatous.i 
 When an abscess has burst or been opened, bare bone is feltj 
 beneath the periosteum, and the greater part of this denudedf 
 structure usually dies, and must then be either absorhed orj 
 separated, in any case a sinus remaining for a time coniiminij 
 eating witlT''trTtC^'tJ^;j^tf llre^ ' Trbtn this ei'tireFpurorl 
 
 "'felMSTVi'WiTr'be discharged, according to whether the wound liasj 
 become septic or not. In about five or six weeks' time thej 
 secjuestrum is loose, and this may be ascertained by moving itl 
 with a probe within the osseous ca\ ity, which is now lined oiij 
 the inner aspect with granulation tissue. 
 
 Treatment. — l^e§t, elevation of the. limb, leeches, and fomeii'.ij 
 tioiis are "usual fy reliecfon locally in the early stages, whilst ;ij 
 good purge a?.d specific anti-diathetic remedies may he usedl 
 generally. If, however, the affection is not readily gheckedj 
 and suppuratton threatens, a free "aseptic incision down to tli 
 bone is file best means of preventing necrosis. Should an ahsces^ 
 form, it must be opened early, and possibly by this means dexM 
 of the bone may be obviated or limited. When necrosis \ui 
 occurred, the parts must be carefully dressed and kept aseptic] 
 until the sequestrum is oetacnea. An incision is tlien made ouil 
 
DISEASES OF JiONE 
 
 469 
 
 liieinvolucruni, the periosteuin stripped from it, one of the cloacae 
 ft l' il i ya t,'tlTK^ th e dead Tione removed. Ttie cavity will now rapidly 
 iilt ap with' graniiratiohs, find heal completely. In many cases 
 recovery may be expedited by chisellinjf away those portions of 
 (iend"hone" which must ultimately be separated without waiting 
 tor the tardy process of Nature; this should not be und'-: taken 
 tnitil' the destructi\e changes have ceased, and then only to a 
 ijiiiited extent. The dead bone is recognised from the living by 
 ;;> white appearance and by not bleeding when cut. 
 
 .'. Acute Infective Osteomyelitis (Syii. : Acute Necrosis, Acute 
 Muse or Infective Periostitis, Acute Diaphysitis, Acute Panostitis). 
 -This disease usually occurs in children, often of a tuberculous 
 inheritance, and not unfrequently follows one of the exanthemata 
 i(,g^, measles or scarlet fever). It generally commences l)efore 
 the age of puberty, and is an affection of the gravest import. 
 
 Pathology. — The patients are always in a state, pf .depressed ^i)^-*^ 
 ,'eneral health', so that tfieir' germicidal powers are coijsiderc<.bly 
 diminished. Moreover,, spotj; of localized ulceration are often 
 present'ln the throat, mouth, or intestines, which give a ready 
 entrance for micro-organisms into the system. Evidently some 
 oftliese must be circulatincrwithin the blood, ready'to'af fact ally 
 area of dimmished tissue^ resistance. A slight mjur^, which is 
 bfterrenfii'ely 'overlooked or forgotten, may suffice to determine 
 ttieXomTnetTceTn'ent of an inflammatory process which rapidly 
 spreadrby coritifiuity of tissue, until the; Whole, structure of the 
 bone may' be affected. ' 
 
 Tlie^ disease almost always starts in the soft vascular tissue 
 on the shaft side of the epiphyseal cartilage, but it may be pre- 
 ceded by a patch of localized periostitis in the diaphysis. The 
 inedulla is intensely hypera^mic ; the veins become thrombosed ; 
 localized foci of suppuration and gangrene appear ; and, in 
 consequence of the increased pressure, infective emboli are 
 ''''^'y. .^° l^^~.4?^£ll.^4}. 9:"-4 py.sEmicV .to. follow. Even if the latter 
 does not occur, the general condition is profoundly affected by 
 fKe ahsorptipn_o.f_ toxins. Suppuration also occurs beneath the 
 periosteum, which is rapidly stripped up from the diaphysis, 
 and this may even spread to' such an extent as to involve 'tlie 
 »!ioie length and circumference of the shaft._ Unless proihpt 
 nieasures are taken to limit the progress of the disease, necrosis 
 is certain to follow, usually implicating the whole thickness of the 
 diaphysis, and sometimes extending along its whole length. 
 
 The oyganism generally found in this disease is the StaJ>lty- 
 ^''^'ocm pjogdics ..aureus, but occasionally others are responsible 
 for it, and the symptoms vary somewhat witlx tlie causative 
 microbe. Thus, if due to the Staph, pyog. albiis, the process is 
 less acute ; a good deal of brawny infiltration of the periosteum 
 ensues, and necrosis is more easily prevented by early treatment ; 
 this variety is sometimes termed ' periostitis albuminosa.' The 
 
 ^ 
 
470 
 
 A MANUAL OF SURGERY 
 
 Styej>iococciisJ>yogenes, if present at all, is only found „in youn" 
 "cliildren, and the ' rissulfiiig necrosis is often less extensi\e. The! 
 Pnenmococais has a:lso b'^eti^ distdvered in this disease, as well 
 as the Bac. typhosus, but with each the inflammatory process! 
 is subacute in nature. One special characteristic of typhdidj 
 necrosis is the length of time the organism may lie latent in 
 the medulla before leading to suppuration. The Bac. coli commnwA 
 
 Fig. 164. — Diagram of Massive Necrosis after Acute Osteomvelitis 
 . (Billroth.) 
 
 In A (early) the necrosed tissue, though continuous above and below with thej 
 healthy bone, is surrounded by a cavity formed by the stripping up ofj 
 the periosteum, and from it two sinuses pass to the e.xterior; in B (late) I 
 the sequestrum is supposed to have been loosened and removed, and the! 
 cavity remaining is lined by granulation tissue, and surrounded by a thickj 
 involucrum of new bone, in which two cloaca:! exist, 
 
 has only been demonstrated in association with other organisms;] 
 the resulting pus is very foul. I 
 
 Clinical History. — The disease usually (:oriiuieA9,es . abf.uptl) J 
 ^Yi^!Lili|9r» fonowgd^.^ZM^ I'eyef and severe. £ain in the limhl 
 wmch soon becomes swollen, brawny, and congeste^^J. It mayatj 
 first tre -riri-l§tc1'R'etr"ft5r^Wf ^'^Cilf e ' attacK' orfKeuniatism, althou)jh I 
 the fact that the interarticular portion is affected, and not thej 
 articulation, should readily prevent this error. The periosteuml 
 
DISEASES OF BONE 
 
 471 
 
 TEOMVELITIS. 
 
 I yearly stripped from the bone, and an abscess forms beneath 
 ; which may extend along the whole length and around the 
 
 I t'Dole circumference of the diaphysis, being 
 jjually, however, limited by the close 
 
 Liachinent of the periosteum to the 
 tpiphvseal cartilages. Owing to this, 
 
 heii'hbouring joints escape without being 
 involved in the suppurative process, unless 
 (jsin the hip-joint) thvj epiphyseal junction 
 
 Isintra-articular, or the disease attacks 
 ieepipliysis and burrows through it [vide 
 
 I epiphysitis), or unless the suppurative 
 process spreads along the soft tissues out- 
 
 I side the bone, as along the bicipital groove 
 I i' houlder-joint. A serous effusion 
 ) I. joints is, however, often present. 
 
 I Occasionally in the most severe cases both 
 
 I epiphyses are detached, and the whole 
 
 Uiaphysis may l,e found lying free in an 
 abscess cavity formed by the stripped-up 
 periosteum. Moreover, the process may 
 at times be so acute as to cause actual 
 sloughing or disintegration of the perios- 
 teum, so that subsequent repair is im- 
 possible. The formation of the abscess 
 is always accompanied by severe con- 
 stitutional disturbance of a toxic or 
 pvsemic nature, and the patient's life may 
 be destroyed in this way. 
 Sooner or later the subperiosteal abscess, 
 
 [which may have transgressed its periosteal 
 
 [boundary and burrowed under fascial or 
 uiscular planes, is opened or bursts ex- 
 
 [lernaily, giving exit to a larger or smaller 
 
 lainount of pus, and the subjacent bone is 
 
 jfound hare and apparently dead. Possibly 
 
 Ithe relief of tension may suffice in such 
 
 leases to limit the mischief, the periosteum 
 
 lagain becoming adherent to the bone, and 
 
 Itlius a cure is established without ex- 
 
 jtensive necrosis. More frequently a con- 
 
 lsidera[)le portion of the shaft loses its 
 
 jvitahty. and has to be separated in the manner already detailed, 
 
 Iwhilst an involucrum forms around it from the periosteum 
 
 iFigs. 164 and 165). If sepsis has been excluded, no fever or bad 
 
 pnstitutional symptoms need be expected during this stage. 
 The Prognosis is always somewhat grave. Life may be 
 
 threatened by pyaemia or toxaemia in the early stages, whilst 
 
 Fig. 165.— Necrosis fol- 
 lowing Acute Osteo- 
 myelitis. (From Speci- 
 men IN College of 
 Surgeons' Museum.) 
 
 The irregular new bone of 
 the involucrum is well 
 seen, and within it por- 
 tions of the sequestrum. 
 
472 
 
 A MANUAL OF SURGERY 
 
 *^; 
 
 t 
 
 later on hectic, amyloid disease of the viscera, and exhaustion 
 may terminate the case if sepsis has been admitted. 
 
 The utility of the limb may be unimpaired if the disease has 
 not been too extensive, and if prompt treatment has been adopted; 
 but if neighbouring joints are affected by a suppurative arthritis 
 or if the osteogenetic powers of the periosteum ha\e been 
 destroyed by the acuteness of the process, amputation may he 
 required. In cases which have recovered, excessive growth of the 
 bones sometimes follows, owing to the long-standing hypera;miaof 
 the part ; but if the epiphyseal cartilage has been much affected 
 the limb may be stunted in its subsequent development. 
 
 Treatment. — Prompt surgical interference must be adopted in 
 order, if p ssible, to cut short the malady. As soon as the local 
 pain and high fever give evidence that this affection is present, 
 a free incision should be made in the long axis of the limh 
 through the periosteum, whether suppuration exists or not. The 
 surgeon will then proceed to carefully invest-gate the condition 
 of the bones by inspection and the use of the finger and probe, 
 and his further proceedings will to a large extent depend upon 
 what is thus found. 
 
 If the suspicions as to the existence of osteomyelitis are thereby 
 confirmed, the most vigorous surgical treatment is demanded, for 
 if the teachings of pathology are to be depended on, it is certain 
 that no good can follow any half measures which stop short of 
 the medullary canal. As a rule, the surgeon will find himself in 
 the neighbourhood of the epiphyseal cartilage, and if the case has 
 been taken in hand early, it is possible that the mischief will he I 
 (juite limited ; all that is then required is to scrape or gouge 
 away the softened and hyperaemic bone at the end of the diaphysis, 
 together with any necrotic tissue which may be present. The i 
 cavity thus formed is thoroughly washed with an antiseptic, 
 and perhaps swabbed out with pure carbolic acid ; a drain-tube i 
 is inserted, and in all probability recovery will rapidly ensue. 
 
 If the case has gone further, the periosteum will be found! 
 stripped from the bone for a varying distance, and possibly the 
 epiphysis partially or completely separated. Under these circum- 
 stances it is always necessary to open up the medullary canal] 
 by removal of part of the compact bone, so as to allow 
 hyperaemic and gangrenous fatty tissue contained therein to be I 
 scraped out. Whether or not it is advisable to remo\'e a porticnj 
 of the whole thickness of the shaft must depend on the exact 
 condition of affairs in the particular case. Certainly when tl.e| 
 lower end of the femur is attacked, and grave constitutio 
 phenomena are associated with loosening of the lower epiphysis,! 
 it will often be found expedient to amputate, since resection, 
 even if successful, may leave a shortened and useless linikl 
 for it is a well-known fact that in necrosis of the posteriori 
 aspect of the lower end of the femur there is scarcely any attempt| 
 
DISEASES OF BONE 
 
 473 
 
 at the formation of an involucrum, owing to tlie tenuity of the 
 periosteum in that locality. 
 
 If the periosteum has been more extensively invohed, and a 
 liirgr'ain'oiInTr"pT'*1)one, ' possib the whole cliapiiysis,' denuded, 
 f(vonf6iiVses' 'are .open ^ .surgeon: either to remove the 
 
 \vl3ftle.,nejciX)Sfid area at once, or simply to relieve tension and 
 ait for an involucrum tp'forxia before 4akinjfavvay't'Heseque^^^^ 
 The gfeat 'iffvantage of the former plan consists in the immediate 
 extirpation of the infective focus, thereby diminishing the risks 
 of pvsemia or toxaemia, and pre\enting the necessity for further 
 operative proceedings. On the other hand, it is claimed that the 
 contliiucil .presence of the sequestrum is beneficial, in that it 
 stimulates the periosteum to ne>v formation, of. bone,, and hence it 
 s1iDuld''hot' be removed until a sufficient involucrum has formed. 
 The' practice usually adopted is as follows: For tl^e.^ femur and 
 humerus sequestrotomy should be delayed; irnmediate_r§.iT3joval 
 \VOHldtead to hop.eIess shortening and' crippling of the limb. For 
 the hones of the forearm or leg, immediate removal' is perfectly 
 justifiable, since there is always a second bone present to main- 
 tain the length of the limb. Some surgeons have recommended 
 that a hone-graft or suitable rod of celluloid or ivory should be 
 inserted to take the place of the resected diaphysis and stimulate 
 : the osteogenetic powers of the periosteum ; there is no objection 
 to such an attempt being made, provided that asepsis is main- 
 I tained, but it is very questionable whether much good will follow. 
 When there is any doubt as to the actual condition of the bone, 
 jits immediate removal is undesirable ; the pus is allowed to 
 escape through a free incision, the cavity is well irrigated, and 
 [the stripped-up periosteum allowed to fall back upon the bone, 
 [and regain adhesions to it, if possible. Drainage is provided for, 
 [strict asepsis maintained, and the discharge soon becomes merely 
 [serous. A portion of the bone dies, and during its separation 
 [from neighbouring parts becomes incased in a newly formed 
 linvolucrum. When the sequestrum is free — that is, in about five 
 |)r six weeks — sequestrotomy will be required ; it consists in refiect- 
 Bng the periostgU'iti frtfili ' the ne\y casir^ and m enlarging _o.r \ i /D 
 bniting one or more of tlie'. f [oacffi, so as to allow tTie sequestrum r ^'/o 
 16 be'Trirhd'ir'awn ; it sometimes expedites matters to divide the 
 Rquestruin Tnto^two portions, and then to deal with each 
 feparately. The ,cavjtx ,thps left is well irrigated^ and either 
 irained or packed with gauze, so as to allow it to lieal„from..-the 
 otrom by granuTation. Occasionally the operation for removal 
 f the seqitestTTrm is exceedingly difficult and dangerous, owing 
 |o the situation of the sinuses, and in some places, e.g., the 
 losterior aspect of the lower end of the femur, it is almost im- 
 iracticable to reach it ; under such circumstances amputation may 
 preferable. This summary proceeding may also be needed 
 the course of this disease on account of pyaemia, defective 
 
 .# 
 
 
474 
 
 A MANUAL OF SURGERY 
 
 repair, exhaustion from chronic sepsis, or suppuration in a neiffh. 
 bouring joint. 
 
 3. Acute Epiphysitis is the term applied to an infecti\e in- 
 flammation of an epiphysis, simihir in nature and orij^in to the 
 acute osteomyehtis just described, and most often afft'ctinj,^ the 
 upper end of the humerus, or one or other end of the femur. This 
 disease is almost entirely limited to infants and very voun" 
 children, and is said to occur more frequently in the subjects 
 of inherited syphilis. It generally commences on the shaft side 
 of the epiphyseal cartilage, but its effects are mainly limited 
 to the epiphysis, which may become eroded, carious, or even 
 necrosed, whilst the shaft is but slightly involved. Suppurative 
 arthritis may be caused, especially if, as in the hip-joint, the 
 epiphyseal cartilage lies within the cavity of the articulation ; or 1 
 an abscess may form and burst through the articular cartilage 
 into the joint. In some of these cases the articular structures, 
 especially the ligaments, are so destroyed that a loose flail-joint 
 results. The local and general phenomena are identical with 
 those described as characteristic of the former disease, and the 
 treatment consists in free incision, if possible before suppuration 
 occurs, removal of the infected tissue, and drainage. Death from 
 exhaustion and pyaemia is very likely to ensue. 
 
 A subacute or chronic variety of this affection is also met with in 
 young adults (constituting one form of ' growing pain '), in which 
 the same symptoms present themselves, but by suitable treatment 
 resolution is obtained without suppuration or necrosis. In such 
 cases, however, the subsequent growth of the bone at the epiphysis 
 may be impaired or even arrested. 
 
 4. Acute Septic Osteomyelitis arises as a result of infection 
 from without, e.g., in cases of compound fracture, and after 
 amputation, excision, or even osteotomy. The organisms present 
 are usually staphylo- or strepto - cocci, together with various 
 non-pathogenic forms. The clinical history of a case involvingl 
 the shaft of a long bone is as follows : The patient during an] 
 attack of septic traumatic fever due to an injury or operation 
 has one or more rigors, which suggest the existence of pyaemia, 
 and is suddenly seized with severe pain in the limb, whichj 
 becomes intensely sensitive. On examining the wound, the soti 
 parts are found to be unhealthy and infiltrated, the lower end 
 the bone is bare and yellow, and from the interior projects 
 stinking mass of gangrenous medullary tissue. Should early anJj 
 efficient treatment not be undertaken, the patient runs a consider 
 able risk of succumbing to pyaemia or septic intoxication, wbilsi 
 a varying amount of the interior of the bone dies {central I'l 
 tubular necrosis), and a small segment of its whole thickness below, 
 so that the sequestrum which ultimately separates is annular an 
 conical (Fig. 166). Should the patient survive, the necrotic tissui 
 gradually separates, and during this process a mass of new hone ii 
 
DISEASES OF BONE 
 
 475 
 
 formed from the under surface of the periosteum, so that the shaft 
 becomes much thickened externally. Hectic fever may supervene 
 whilst this is occurring. 
 
 The Treatment of this condition has been somewhat modified 
 of late years. Formerly, the only plan 
 adopted was am- utation of the limb through ,i 
 
 ttie next joint. At the present time one 
 would freely open up the wound as early 
 as possible, flush it out, and then thoroughly 
 scrape away the sloughing medullary tissue 
 from the interior of the bone, subsequently 
 disinfecting the cavity with pure carbolic fftlf jf j 
 
 I acid, and placing a drain-tube or gauze wick ^■ijR..'§ 
 
 in it for a few days. A certain amount of Jl4L''tv! 
 
 necrosis follows, but without high fever or 
 i toxaemia. Should this treatment fail, ampu- 
 I tation may still be resorted to. 
 
 A similar process may also invade the short 
 
 f\ 
 
 M^ 
 
 M 
 
 M 
 
 m 
 
 /; 
 
 ms, and the cancellous extremities of long 
 
 I bones, being often secondary to septic ar- 
 thritis, or to a compound fracture involving 
 such parts. The local and general pheno- 
 mena are very similar to those detailed 
 above, except that no large sequestra are 
 formed, the dead bone coming away in small 
 
 [spicules (one form of cayies necvotica), whilst 
 the pain and fever are less severe, and there 
 
 lis less Hkelihood of the development of 
 
 jpya.Miiia. Treatment consists in free drainage, 
 
 Iremoval of the septic tissue and efficient 
 
 Ipurification of the wound. 
 We have also seen one or two cases of 
 
 \iimitc septic osteomyelitis, involving the shaft 
 
 lof long hones after operation, in which the 
 
 Iniedulla became profoundly al^;Ted in texture, being transformed 
 
 Into granulation tissue, with rarefaction of the bony cancelli ; the 
 
 [process was associated with considerable pain and some amount 
 constitutional disturbance. No necrosis followed, but amputa- 
 tion was necessary on account of the extent of the disease and the 
 
 fain. 
 
 Fig. i66.— Tubular or 
 Conical SEguEs- 
 
 TRUM FROM SePTIC 
 
 Osteomyelitis 
 AFTER Amputation. 
 
 Chronic Inflammation of Bone. 
 
 Chronic Osteo-periostitis. — By this disease is meant a chronic 
 nflammatory condition of the bone, which results in overgrowth, 
 [liickening, and condensation. 
 
 Varieties. — [a) It may arise as a localized chronic periostitis, 
 traumatic, rheumatic, or syphilitic in origin, or due to the close 
 
476 
 
 A MANUAL OF SURGERY 
 
 proximity of a chronic ulcer ; it is characterized by a forinationl 
 of new bone lieneath the periosteum, the so-called mdc (Vv. [h- 
 The cancelli are arranged at right angles to the surface, in con- 
 sequence of the new tissue forming around the small vessels L 
 
 which enter the bone from the under surface! 
 of the periosteum. At first this new iiiateriall 
 is soft and spongy, but it rapidly hecomtsj 
 hard and sclerosed, and a similar conditionl 
 affects the subjacent compact structure I 
 which is thickened and indurated by a ikwl 
 formation around the Haversian canals, 
 the irritation persists, as in the case of al 
 chronic ulcer, this condition may run on into! 
 the following variety. 
 
 {b) The diffuse form of chronic osteol 
 periostitis usually originates in some deep- 
 seated or central affection, tuberculous otj 
 syphilitic in nature, and tends to involve tli 
 whole bone, although it is sometimes limited 
 to one or other end. If tuberculous, there 
 may be a small abscess or some central! 
 necrosis, and around this focus of prolonged 
 irritation the bone becomes thick and inj 
 durated. In the later stages a considerable 
 new formation may occur beneath tlia 
 periosteum, and even the medullary cara 
 become entirely obliterated. If syphilitic i 
 origin, it may be due to a central gumma 
 or a general condition of sclerosis ma)l 
 supervene without any special focus. 
 
 The Symptoms consist of deep aching paiij 
 in the limb, worse at night, with perhao 
 tenderness over some particular spot. Tl 
 latter condition is especially evident in casej 
 where a localized abscess exists in the liea 
 of a bone, such as the tibia. On examinaj 
 tion the bone is felt to be thickened, and it^ 
 surface more or less nodulated. If the diseasj 
 is localized and superficial, a distinct nodi 
 may be felt, consisting of a hard, fusiform 
 and tender swelling. Where the enlargement is more generaj 
 there is less tenderness, though the pain is constant. 
 
 The Diagnosis of such cases is not always easy, the enlargj 
 ment of the bone being sometimes mistaken for the early sM 
 of a malignant tumour. The rate of growth will be of littl 
 assistance, since it is very variable ; but a tumour may have nioif 
 defined limits, and its tension is often not the same throughoul 
 Skiagraphy is valuable in this direction, since in simple clironj 
 
 Fig. 167. — Chronic 
 osteo - periostitis 
 OF Tibia, showing 
 THE Fusiform 
 Swelling on the 
 Front of the 
 Bone, consisting 
 OF Dense Osseous 
 Tissue, and the 
 Medullary Cavity 
 
 ENCROACHED UPCiJ. 
 
DISEASES OF BONE 
 
 All 
 
 eriostitis the bone is solid and throws a continuous and well- 
 Jelinecl sluidow, while in malignant disease a certain amount of 
 (oft tissue is sure to be present, either centrally or peripherally, 
 easily penetrated by the rays, and hence leaving gaps in the shadow. 
 
 , in spite of such assistance, the case is still doubtful, an exploratory 
 Incision will be required. 
 
 The Treatment at first consists in resting the limb, applying 
 icounter-irritation {e.g., iodine paint or the actual cautery), and 
 I'iving iodide of potassium internally. If relief is not thereby 
 obtained, an operation will be necessary. An incision is made over 
 Itlie whole length of the thickened bone, right through the peri- 
 osteum. This membrane is now stripped aside with periosteal 
 detachers, raspatories, etc., and if merely a nodular enlargement 
 1:5 present, the new formation is chiselled away. When the v.'hole 
 [thickness of the bone is involved, a gutter or trench must be made 
 iKfjouge and mallet, extending into the medullary cavity through 
 Itlie whole length of the enlargement. The soft parts are then 
 Ipartially drawn together and the wound dressed. It is advisable 
 [to cover it with protective, so that the hollow made by the surgeon 
 [may fill with blood-clot, and this is then allowed to organize 
 |(p. 176). If this operation is carefully performed under antiseptic 
 Iprecautions, and enough bone is remoxed, the most satisfactory 
 [results may be expected. In some of the most aggravated condi- 
 Itions, which have lasted for many years, amputation may be 
 Required. 
 
 Tuberculous Diseases of Bone. 
 
 Hone may be affected in two ways by tubercle, either the 
 periosteum or the cancellous tissue being primarily involved. 
 
 I, In Tuberculous Periostitis a specific infiltration of the 
 leriosteum is met with, consisting of a deposit, partly in that 
 Minbrane and partly under it, of pulpy granulation tissue contain- 
 iit[the characteristic miliary tubercles, which are chiefly developed 
 kround the vessels passing from the periosteum into the bone. As 
 
 tuberculous disease elsewhere, caseation and suppuration are 
 tkely to follow, leading to the formation of abscesses which are 
 Irimarily subperiosteal, and filled with curdy pus ; these in time 
 W their way to the surface, either directly or by more or less 
 prtuous channels, and leave sinuses, extending down to the bone. 
 [he final effect of such a condition depends largely on whether 
 pe subjacent bone consists of thick or thin compact tissue. If the 
 onipact bone is thick, the disease is usually localized to the part 
 Irst affected, the surface of the bone escaping entirely, except some 
 liRht superficial erosion. Occasionally, however, the disease may 
 pad along the periosteum for some distance, and even involve 
 [neighbouring epiphysis or joint. If the compact bone is thin, as 
 
 I the bodies of the vertebrae, the underlying cancellous tissue is 
 
478 
 
 A MANUAL OF SURGERY 
 
 almost certain to be secondarily affected, and the chanj,'es to Ik 
 immediately described are produced. 
 
 Clinical History. — In the early stages a somewhat diffuse elastii 
 or pulpy swelling forms over the bone, which is tender and as^i 
 ciated with characteristic bone pain, worse at night. It takes ^();!| 
 weeks or months to develop, iin^ on skiagraphy the underlying 
 osseous tissue may appear quite normal in texture. In thehici 
 stages, when caseation or suppuration is present, the swell in^'oUti 
 becomes more defined and its surface nodulated ; it then some 
 wliat resembles an ordinary node, but is usually more irre<,'iil: 
 in sliape, of somewhat unequal consistency, and on firm pressurJ 
 small portions may be felt to give way. If an abscess forms, thJ 
 pain becomes greater, but it diminishes as soon as tension i| 
 relieved i)y discharge of the pus. The admission of sepsis, howl 
 ever, increases the trouble. 
 
 Treatment. — In the early stages, constitutional treatment iiial 
 suffice, together with rest and carefully adjusted pressure, ;is 
 strapping with Scott's dressing. The condition, however, fie 
 quently demands incision, whether suppuration has occurred 
 not, together with free removal of all the granulation tissue anJ 
 softened bone with a Volkmann's spoon, disinfection of the cavi 
 with pure carbolic acid, and stuffing it with gauze soaked in ; 
 emulsion of glycerine and purified iodoform (lo per cent.), till 
 wound being allowed to granulate from the bottom. The exttn 
 to which the bone should be scraped away may be indicated !| 
 the fact that the nearest layer of unaffected bone is hard ;i;i| 
 sclerosed. 
 
 2. Tuberculous Osteitis always arises in cancellous tissue, ami 
 affects~nie"sTi(Trrif6nesi or the shafts or ends of long oaes.'*"' ■ 
 ■" (fl) The shoyt bones of the hands and feet are very liable to tlij 
 condition. It occurs in weakly children with a tuberculous i 
 heritance, or in those whose general health has been depressed 1 
 one of the exanthemata, or sometimes in those otherwise heal 
 Some slight injury may determine the onset of the attack, whid 
 frequently involves several bones simultaneously. When 
 phalanges are involved, the disease is known as Tuberculij 
 Dactylitis (a condition formerly described under the meanini,'lt 
 title of ' spina ventosa '). 
 
 Clinical History. — Tlie affected bone becomes slowly enlari.! 
 expanded, and painful, the pain being, however, slight in anud 
 though generally worse at night. This continues for some tiiij 
 until finally one spot rapidly increases in size, becoming red al 
 tender, and finally an abscess forms, which bursts or is openj 
 leaving a sinus, down which a probe can be passed into 
 carious interior of the bone. Occasionally contiguous joint^i 
 involved in this process, whilst the tendon sheaths are also Hal 
 to be affected ; a large portion of the swelling is often duej 
 periosteal infiltration. 
 
im 
 
 langes to In 
 
 liffvise elastid 
 er and ass) 
 [t takes soiiid 
 e underlyiiiii 
 In the I'a.fc 
 swelling,' oftf 
 t then soiiiel 
 ore irrei;uI:J 
 firm pressiirl 
 iss forms, ilj 
 as tension 
 : sepsis, \\m 
 
 ■eatment iiial 
 ressure, as ! 
 however, frd 
 5 occurred 
 on tissue ani 
 of the caviti 
 soaked in 
 er cent.), till 
 . The exurt 
 e indicated 'J 
 ; is hard a;il 
 
 5 tissue, and j 
 
 one'sP 
 
 liable to t 
 iberculous 
 L depressed J 
 irwise healthj 
 
 attack, whi| 
 ■. When 
 s Tuberculij 
 e nieanin.iilt 
 
 Dwly enlarj;e| 
 [rht in amoiiii 
 "or some tn 
 
 )min'r 
 
 red aJ 
 
 s or is openij 
 issed into !| 
 uous joints i 
 , are also liatj 
 s often dutj 
 
I'f.ATi': xxr. 
 
 TUHKRCULOUS I )lSK.\Sl-; OK K'adils. 
 
 The patient was a lads- over fifty years of a,?e, who had suffered for sdiiie moiithil 
 from pain and swellinsi of this lione, The site and extent of the disease lij 
 indicated by the light area in the shadow of the bone. Eventually amputa-| 
 tion was required. 
 
 To face p. 479.] 
 
DJSEASHS or HONE 
 
 479 
 
 Pathology.- -A deposit of tubercle bacilli occurs in or around 
 l|,(. bloocK essels in the interior of the bone, which may have been 
 ipreviously rendered somewhat hypera.'mic as the result of an 
 liniury. I'he orj^anisms prochice their usual effect, vi/., trans- 
 TJorniatiiJii of the nt)rmal mecUillary tissue into pulpy ^granulation 
 Itissue containinj; tubercles, the bony cancelli becomin}; meanwhile 
 Eroded and rarefied, and the bone corpuscles under^'oinf^ fatty 
 (ie"enenition [vide Caries, p. 4^)5). Se(|uestra occasionally form, 
 Ibut more often in adults than in children, owinj^^ to the f^'n^ater 
 density of the bone in the former. They are due to a cuttinff-off 
 the blood-supply of a definite portion of the boiiy tissue, either 
 |as a result of tuberculous endarteritis, or frotn early caseation 
 [within the cancelli of the whole of the {granulation tissue. The 
 Isfiiuestra are usually yellowish white in colour from the presence 
 I the caseating tissue in their substance, and are seldom com- 
 lely separated from the surrounding bone ; thus, they are often 
 ijuite clear superficially and laterally, but adherent on the deeper 
 kide. When the tuberculous disease does not involve the whole 
 Bwne, the nearest healthy tissue may become sclerosed, and thus 
 Wnot unfre(iuently finds a central se(iuestrutn surrounded by 
 Lrefied bone which merges into an area of sclerosed tissue. 
 jWhen a tuberculous focus becomes septic, the destructive process 
 tncivases in rapidity, and minute spiculated secpiestra often come 
 pway in the discharge. The term expansion of bone used above is 
 perhaps scarcely correct, inasmucli as the enlargement is due to 
 pbsorption on the inner aspect, whilst there is a new^ formation of 
 joiie under the periosteum. Skiagraphy is a useful adjunct in 
 Estimating the amount of disease present, since the affectetl bone 
 Is less dense, and consequently light areas appear in the midst of 
 lliedark shadow cast by the bone (see Plate XXL). 
 
 The Treatment of tuberculous dactylitis in the early stages 
 jconsists in attention to the general health, together with rest 
 locally, and perhaps strapping the parts with Scott's dressing. 
 liuuld the disease progress in spite of such measures operation 
 bust not be unduly delayed, since neighbouring joints and tendon 
 heaths are very likely to bt attacked. An incision is made down 
 jlo the bone at some siiitalle spot where tendons or other im- 
 portant structures Ai' ' in injured; the periosteum is divided, 
 find the o'ter ayer lA compact bone removed by gouge or 
 pphii^ .0 allow tlv- diseased medulla to be scraped away 
 
 ivitli a .ann's spoo When all the tuberculous tissue has 
 
 been ell, lated, the cavity thus produced is swabbed out with 
 pure carl Jul 1. aci'. and stuffed with gauze soaked in an iodoform 
 buision, in ordt 1 id ensure healing by granulation. Unless this 
 papiiifr is thoroughly performed, ecurrence is very likely to 
 pile, but the integrity of "epiphyses and of articular cartilages 
 luist be respected. When an abscess or a sinus exists, the same 
 ■easures must also be adopted. Not unfrequently the growth of 
 
48o 
 
 A MANUAL OF SURGERY 
 
 the bone is \ery considerably hindered either by the disease or In 
 the treatment requisite in order to eradicate it, and the pan 
 becomes stunted or deformed in consequence. 
 
 (b) Any of the bones of the tarsus may be involved in exactly 
 the same manner, the clinical history and treatment hein" 
 identical, although possibly articular lesions are somewhat mon- 
 common than when the disease is limited to the phalanges. The 
 whole foot becomes swollen, shiny and pulpy, since the overlvin;: 
 periosteum is often involved in the process ; and it is fre(]uentiv 
 impossible to determine whether the lesion is limited to the hont> 
 or also involves the joints. In the early stages one part of the 
 foot may be more swollen than another, according to the location 
 of the trouble. Thus, it frecjuently starts in the astragalus, tht 
 swelling then occurring below the level of the ankle-joint in troii; 
 of or behind the malleoli, whilst pressure over the head of thi 
 bone gives rise to pain. An examination of the accompanviiii, 
 illustration (Fig. i68) will explain the fact that tuberculous distasi 
 starting in the astragalus is very likely to involve the ankle-joint. 
 or to spread to the os calcis or scaphoid. Disease of the os calcic 
 leads to more limited swelling of the back of the foot on one or 
 both sides of the heel ; the movements of the ankle will not 1r 
 impaired, although walking is painful, and hence the patii-nt 
 limps, treading only on the toes. Further forwards tuberculous 
 disease is most likely to start in or around the scaphoid, tht 
 bulbous swelling of the foot being then shifted anteriorly, and thc 
 movements of the ankle remaining unimpaired. Tlie prognosis 
 is much worse when the disease attacks the inner half of the foot. 
 comprising the astragalus, scaphoid, cuneiform, and three iniit.: 
 metatarsal bones, owing to the arrangement of the synovial 
 membranes, than when it affects the outer segment consisting; ( : 
 the cuboid and two outer metatarsals, which are excluded tioni 
 the general synovial membrane, and are thus more anienahlf ^ 
 treatment. 
 
 Sooner or later suppuration occurs with increased pain, aiici, 
 should the sinus which results from opening the abscess hecomfl 
 septic, the trouble is sure to spread much more rapidly, and tlit[ 
 prognosis becomes increasingly gra\ e. 
 
 Treatment is conducted according to the rules which al\vay>j 
 guide us in that of tuberculous disease. In the early stages the 
 foot is immobilized, and preferably in plaster of Paris or wattrj 
 glass, the ankle also being included. The chdd is sent to thel 
 seaside, and plenty of good food administered, and it is not! 
 allowed to walk until all pain has ceased ; e\ en then the plasterj 
 case uuist be retained until the swelling has entirely disappeared.! 
 It is wise to remove the plaster every month or two for inspectir-ni 
 and readjustment. 
 
 Should the disease persist in spite of such treatment, or should 
 suppuration occur, removal of the ttibercidous tissue by opeiatiiaj 
 
DISEASES OF BONE 
 
 481 
 
 sease or hx 
 id the pan 
 
 in exactly 
 nent beirii; 
 jwhat more 
 ingcs. The 
 le overlying 
 s frtHiutntiy 
 to the bones 
 
 part of thf 
 
 tlie location 
 tragalus, the 
 joint in from 
 
 head of tlv 
 :conipanyin':^ 
 ulous disease 
 e ankle-joint, 
 i the OS calci> 
 )ot on one or 
 e will not ht 
 i the patient 
 s tuberculoib 
 scaphoid, the 
 •iorly, and the 
 .'he prognose 
 alf of the foot, 
 ,d three inner 
 the synovia! 
 consisting' ": 
 
 xcluded from 
 amenable i" 
 
 Led pain. anc. 
 Lscess becoir.t I 
 hidly. and tin- 
 
 kvhich always I 
 l-ly stages the 
 jaris or water- 
 lis sent to the 
 luid it is m 
 Icn the plaster 
 disappeared I 
 for inspection] 
 
 lent, or shouWi 
 l)y operaii'' 
 
 mav be required. If the os calcis alone is involved, it will usually 
 suffice to open well into it either from one or both sides, to scrape 
 cut its interior and then pack it with iodoform and gauze after 
 disinfectinjjf it with liquefied carbolic acid. Decalcified bone chips 
 mixed witli iodoform have been packed into the cavity in order 
 111 hasten bony consolidation, but not with much success ; in any 
 case the interior of the bone becomes occupied by fibrous tissue, 
 with perhaps a few bony spicules, and a marked permanent 
 depression always remains at the site of operation. Excision of the 
 lis calcis was formerly practised, but is not to be recommended, 
 since even if performed subperiosteally, the power of repair 
 that remains is very slight. If the disease mainly affects the 
 dra^dub, it may suffice to remove it entirely, neighbouring 
 articulations being curetted, if need be ; but probably the disease 
 
 Fk;. 16S -Arrancrment ok Synovial Membranes of Foot. 
 
 [will have spread so far that amputation will be required, and then 
 jSyme's operation is better than methods such as Pirogoff's, which 
 [retain any portion of the tarsus. Disease of the cuboid and outer 
 of the foot in front of the os calcis can often be dealt with 
 lefticiently by scraping, but when the common synovial membrane 
 tin the inner side is involved, amputation will probably be required, 
 lailinjf success i)y conservative measures. 
 
 If the tuberculous disease affects the ends of long bones, it most 
 
 fcommonly starts in the epiphysis, or under the articular cartilage, 
 
 Ihou^di sometimes on the shaft side of the epiphyseal cartilage. 
 
 Tlie changes already described take place, and lead to early 
 
 jje^truction of the latter cartilage, so that the adjacent parts of 
 
 Xith epiphysis and diaphysis become invoked (tuberculous epi- 
 
 hysitis). The general signs are similar to those present when 
 
 Hf smaller bones are affected, but the results produced may 
 
 lary considerably, (i.) In the slighter forms, where efficient 
 
 ^1 
 
482 
 
 A MANUAL OF SURGERY 
 
 treatment is adopted, the tuberculous tissue may he totally ah. 
 sorbed, and the process thus comes to an end, though the afffc. 
 tion of the epiphyseal cartilage may lead to subsequent impair.! 
 ment of growth, (ii.) In others it may be circumscribed hythel 
 bone becoming sclerosed around a caseating focus, and then, ifl 
 suppuration ensues, a deep abscess in the end of the bone may |ie[ 
 produced (Fig. i6g. A). Such is rarely of large size, (•ontainin'rl 
 at most I or 2 drachms of curdy pus, and is lined by a definiiel 
 pyogenic membrane of the usual tuberculous type. The eftectsl 
 produced by this condition are similar to those of chronic osteij.f 
 periostitis, viz., a deep aching or boring pain in the hone, worsel 
 at night, together with enlargement of the affected part, whilstl 
 
 »'.i«4iiiiiiiill!l'ii'llllliiiniyitt*./"'^ 
 
 A 
 
 Fig. 169- Diagrammatic Kepresentation ok the Kesllts of 
 Tuberculous Eimphysiti.s. 
 
 In .\ the focus has become encapsuled, a chronic abscess in tlie interior 1 if thJ 
 bone resulting : in B the process has tracl<ed along the epiphy.seal linel 
 opening externally without involving the joint ; a .se(}uestrum has 
 formed : in C the epiphysis has been invaded and destroyed, ami ih^ 
 joint freely opened ; two sequestra are indicated. 
 
 one spot is often very tender on palpation. If it has e.xisted 
 any length of time, the whole shaft may become enlarj^'ed as 
 result of chronic osteo-periostitis (p. 476). (iii.) The disease nia^ 
 burrow along the epiphyseal line, and find its way into the iitij; 
 bouring joint, if the epiphysis is intra-articular, as in the Iiid 
 but if the epiphyseal cartilage is placed beyond the limits 
 the capsule, a subperiosteal extra-articular abscess will resiil 
 (Fig. 169, B). Should the disease spread e(}ually in all directioiii 
 the epiphysis may actually be separated, (iv.) A more coiiiiiwl 
 result is for the whole or part of the cancellous tis.sue of tlif 
 epiphysis to become involved, and the joint to be secoiulaiilj 
 affected with tuberculous arthritis, either by perforation, ero.sioii.c 
 necrosis of the articular cartilage, or by extension to the synoviJ 
 membrane around its margins (Fig. 169, C). (v.) The piocej 
 may sometimes extend upwards along the medulla into the slial 
 causing a diffuse osteo-periostitis with or witiiout a niedullai[ 
 abscess (I'ig. 170). 
 
DISEASES OF BONE 
 
 483 
 
 ]01 
 
 The Treatment of tuberculous epiphysitis is conducted in the 
 nrst place by absolute ini- 
 n,,bi!ization and hygienic 
 measures ; but the surgeon 
 iiuist not be tempted to 
 trust too long to such a 
 regime, for fear of the 
 
 ,nt beconiing also af- 
 fected. As soon as pos- 
 sible, an opening should 
 be made into the interior 
 of the epiphysis, and all 
 the pulpy granulation 
 ti-sue, caseous debris, or 
 diseased bone removed 
 with a sharp spoon, the 
 icjivity being subsequently 
 Iflisinfected, and stuffed 
 inth gauze infiltrated with 
 orni. Of course, the 
 utmost care must be taken 
 n ; to open the joint by 
 
 Iscrapinj. 
 
 : through the arti- 
 
 ''-X^-'m^r^ 
 
 Icuiar cartilage. Where a Fio. 170.- 
 jiiroiiic abscess exists in 
 [he end of a bone, a tre- 
 
 -LOCALIZEI) AhSCESS IN THE LOWER 
 
 End of the Femur, extenuing from 
 
 THE KPIPHYSEAL LINE UPWARDS INTO THE 
 
 Medulla. (From Specimen in the 
 liine should be applied College of Surgeons' Museum.) 
 [iver the tender spot, and, 
 the cavity is not at first opened, the bone may be drilled in 
 [iiierent directions to ascertain whether or not pus exists.\ 
 ((/) The medullary canal of the shaft of a long bone sometimes 
 lecoines the seat of tuberculous disease ; this, as also the abscess 
 hone described above, is more common in adults than in 
 hiidren. The part thus affected becomes carious, with or with- 
 ut the formation of seciuestra or pus ; but the most marked 
 atiire of this deep-seated central trouble is that the whole bone 
 ia.<ses into a state of chronic infiamnuition, which we have 
 Escrihed, as well as the treatment necessary for it, under the 
 tleof chronic diff"use osteo-periostitis (p. 476). y) 
 
 Syphilitic Diseases of Bone. 
 
 [The osseous tissues may be involved in acfpiired syphilis in 
 
 her the secondary or the tertiary periods. 
 
 In the Secondary Stage flying pains about the bones (sometimes 
 bed ostcocopic) are often complained of; they are, however, 
 jlmt little importance, and disappear rapidly as the patient gets 
 Ider the infiuence of mercury. In the late secondary or early 
 
 31—2 
 
 t*. 
 
484 
 
 A MANUAL OF SURGERY 
 
 tertiary periods, a periosteal node is often met with, as a re-iilj 
 of chronic periostitis. It usually affects only one hone, and niosi 
 commonly the tibia, and consists of an infiltration and lliickenini 
 of the periosteum, which may entirely disappear, hut later om i| 
 accompanied by a formation of new bone. This is at lirsi spon4 
 and soft in character, but after a while becomes hard anj 
 sclerosed; the Haversian canals are always placed at ri<flit an"l( 
 to the subjacent osseous tissues. When such has once occurred 
 absorption of the newly formed lione does not readily follou 
 even under treatment, the part perhaps remaininjf perinarit^ntll 
 thickened. It is recofifnised clinically as a fusiform swtllin/ 
 a little tender on pressure, and the seat of deep achiriL; paid 
 
 
 Fig. 171. — DiFFUsi-: (icMMATous Diskase and Caries ok thk SkullJ 
 {1'"kom King's Cullicge Museum.) 
 
 usually worse at night. It must be understood that tiie pa 
 is not so much associated with the onset of night as witii tl 
 increased warmth of the limbs when in bed; indeed, patient^ wl 
 syphilitic tibia; freciuently sleep with their legs exposed. Xi;'lr 
 watchmen and others, on the contrary, complain of pain diiril 
 the day, when they take their rest. Suppuration does not ofU 
 occur, and constitutional rather than local treatment is required 
 In the Tertiary Period the bones may participate in thechand 
 which involve any and e\ery tissue or the body. These ami 
 in an infiltration and overgrowth of the connective tissues, uhj 
 if diffused through an organ produce sclerosis, if localized to 
 
DISEASES OF BONE 
 
 48s 
 
 !•• riiE Skl'll.I 
 
 ot lead to the formation of a gumma. Hence the following 
 
 jjjions are met with : 
 
 (ii) The formation of suhpcyiosteal f^iiiiiiiiata, either localized or 
 
 Lfuse, probably resulting in cayics of the suiijacent bone ; if the 
 
 jfection is limited, only a small portion may be thus involved ; but 
 
 there it is widely diffused, an extensive surface of the bone may 
 
 xome eroded and irregular. This process is sometimes accom- 
 
 anied by a development of new bone under the adjacent peri- 
 
 0-m, and is very often complicated by sclerosis and necrosis. 
 
 The calvarium is the part most fretiuently involved in this change, 
 
 tut, owing to the osteogenetic powers of the pericra. ium being 
 
 ;niall, there is rarely any new formation of bone in the neigh- 
 
 iirhood, and thus the skull may present a curious worm-eaten 
 
 Lpptarance (Fig. 171)- Frequently the gummata break down and 
 
 fotroy the superficial scalp 
 
 iKiies, leaving deep and 
 
 ktensive wounds, discharg- 
 
 Ids; an abundance of foul 
 
 ;;>,at the bottom of which 
 
 are and even dead bone 
 
 nav be felt. 
 
 ifii Al the same time a 
 
 Hklition of scleyosis may be 
 
 Ldiiced in the underlying 
 
 \i: surrounding parts, and 
 
 lis may progress to such 
 
 (ie^'ree as to seriously 
 
 onipress and constrict the 
 
 hssels in the Haversian 
 
 ?nals. Moreover, an ob- 
 
 literative endarteritis is 
 
 llmost always present, and 
 
 Ihese factors, combined 
 
 pth the separation of the 
 
 lerinsteuni by the above- 
 
 jceniioned g u m m a t o u s 
 
 pnges, so interfere with 
 
 [lie vitality of the bone, that should sepsis occur in the broken- 
 
 lown gummata, necrosis is almost certain to ensue, especiallv in 
 
 fce skull. 
 
 I'iG. 172 
 
 SVIMIIMTIC XllCKDSIS OV 
 
 Skull. 
 
 Tiir; 
 
 The sequestrum is hecomiug separated, and 
 a ring ot caries is fdruiiiig annmd it. 
 
 The effects produced vary considerably in different cases, and 
 ^peciiiily with the situation. When the caiviwiiini k attacked, 
 jeinic phenomena are commonly present, and necrosis is a usual 
 [cciimpaninient of the gummatous changes. The process in such 
 V;ise, as is represented in Fig. 172, would probably be as follows : 
 [lie pericranium corresponding to the necrotic area became 
 lummatous, and at the same time the imderlying bone under- 
 
486 
 
 A MANUAL OF SURGERY 
 
 went sclerosis. Sooner or later the gvimmata burst or were I 
 opened ; septic changes supervened, and the scalp tissues wtrej 
 stripped off the calvarium to the limits of the disease, necrosis! 
 resulting in the sclerosed area of bone. A line of caries siihse. 
 (juently formed around the sequestrum in consequence ol Nature si 
 attempts to separate it. The disease is then marked by itsj 
 extreme chronicity, the sequestrum lying bare in the woundl 
 perhaps for years without being separated, owing to the sli"htl 
 degree of vascularity and the extreme condensation of the sur- 
 rounding parts. Moreover, as explained above, there is an entirel 
 absence of an in\olucruin. In the shafts of long bones, where the! 
 compact tissue is thick and resistant, there may be extensi\e peri- 
 osteal disease, with but little affection of the underlying parts;! 
 but if this compact layer is thin, and especially when the cancellousl 
 ends are involved, a considerable amount of destruction from caries! 
 may result, though if sepsis is not admitted there will he an entire! 
 absence of necrosis. 
 
 In the Treatment constitutional remedies, in the form of iodidel 
 of potassium and mercury, should, if possible, be depended onJ 
 Gummiita should never be opened without the strictest attention! 
 to ivsepsis. If sepsis has occurred, the wounds may be treated hyl 
 applying iodoform and dressing with lint steeped in lotio ni},'ra,| 
 or covered with mercurial ointment. Counter-openings are often| 
 refjuired for purposes of drainage, especially in the scalp. Necrosed 
 portions, when separated, are to be remoxed, carious tissue iiiavi 
 be scraped away with a sharp spoon, and the surface powderedj 
 with iodoform and dressed antiseptically. In the calvarium no 
 attempt must be made to chisel away the dead bone. 
 
 (c) Occasionally a gummatous osteomyelitis is met with, in whiclij 
 a gumma forms in the interior of a bone. It results in tha 
 so-called expansion of bone and secondary thickening and enlar^'e-j 
 rnent of its whole structure, i.e., a diffuse osteo-periostitis. Tl 
 symptoms are the same as those described for the latter affection] 
 and if it resists the administration of anti-syphilitic remedies, i| 
 must be treated in the same way, viz., by separation of tha 
 periosteum, freely opening the medullary cavity, and reniovini,' all 
 diseased tissue. These cases when affecting the long bones havj 
 often been mistaken for malignant growths ; necessarily, it is 
 matter of the most vital importance to come to a right conclusioa 
 as to their nature. The greater rapidity of growth in the syphilitid 
 cases, and the evidences of syphilis elsewhere, or of a sypliilitil 
 history, will often guide the surgeon to a right conclusion ; but 
 there is any doubt an exploratory incision should always he underj 
 taken before amputation is resorted to. 
 
 In Inherited Syphilis any of the above manifestations may 
 seen, but with more or less special features added, and, in additio^ 
 
DISEASES OF BONE 
 
 487 
 
 It) these, certain forms which do not occur in the acquired type of 
 
 jthe disease have been described. 
 I. A new formation of bone beneath tlie periosteum is perhaps 
 
 line most frequent result, and this occurs with but httle pain. 
 
 iFerhaps tlie most common situation of this lesion in infants is the 
 
 [ailvariuin, where bony masses known as Parrot's nodes form around 
 
 liiie anterior fontanelle, causing the top of the skull to resemble a 
 ■ hot cross bun' in shape. In the early stages the bone is soft and 
 
 Lp)iigy, and on post-mortem examination is dark red or maroon 
 
 lincolour. If the process is not checked by suitable anti-syphilitic 
 treatment, the newly-formed osseous tissue becomes dense and 
 sclerosed, and the deformity may then persist through life. Any 
 part of the calvarium may, however, be affected, and the change 
 
 lis not necessarily limited to the first years of life. 
 
 . A similar condition is met with in the shafts of long bones, 
 
 [due to the deposition of alternating lamella? of soft and hard bone, 
 
 loitside the ordinary compact tissue. 
 
 3. Syphilitic epiphysitis (or, as it is termed, syphilitic osteo- 
 mulritis) is a lesion met with in infants, somewhat simulating 
 
 [rickets, in that the epiphyses become enlarged as a result of 
 the overgrowth of the cartilage. It also involves the adjacent 
 portions of the shafts, which become expanded and spread out 
 50 as to fit into the enlarged epiphyses. The zone of calcified 
 Icartilage is friable, opaque, and irregular, and as the condition 
 jprofjresses it may become atrophied, and replaced by granula- 
 tion tissue, so that separation of the epiphysis follows. This 
 im turn often results in suppuration and possibly acute arthritis, 
 lor the limb hangs powerless in a condition known as syphilitic 
 hmb-paralysis. The disease is sometimes widely diffused through- 
 out the body, and in much the same positions as the true rachitic 
 |allections, the lower end of the humerus and the wrist being 
 perhaps most often affected. 
 
 The diagnosis from rickets is made by observing the fact that 
 Ithe syphilitic lesion extends further up the shaft, and is not so 
 Istrictly limited to the articular ends of the bones. Moreover, the 
 Iconcurrent phenomena are not those characteristic of rickets, but 
 lare of a syphilitic nature. 
 
 4. A symmetrical overgrowth of the tibiae, perhaps combined 
 Iwith an anterior curvature, also occurs in syphilitic children, 
 Iresiiltinf,' in permanent elongation of the legs (p. 369). 
 
 3. Cnviiotahcs is also occasionally met with in Congenital 
 
 isyphilis. It consists in a localized absorption of the osseous 
 
 tissue of the cranium, leaving small areas where the bone is 
 
 Ithinned ur absent, imparting a sensation of parchment to the 
 
 |lini;er. It is usually seen in the occipital region, and is also 
 
 rtind in rickets. 
 
 The Treatment of syphilitic lesions in cliildren must be carried 
 
488 
 
 A MANUAL OF SURGERY 
 
 out in accordance with general principles, and mainly by the 
 administration of suitable druj,^s. 
 
 Rickets. 
 
 Rickets is a general disease of malnutrition, occunincf jni 
 children, and manifesting itself mainly in lesions connected with] 
 the bones. It usually commences within the first three years ofi 
 life, but sometimes appears later. 
 
 Causes.^ — Any and every fault in the hygienic and dietetic treat- 
 ment of a child seems capable of inducing rickets ; but the niostl 
 important factors in its aetiology are insufficient or improper food, 
 especially the too early administration of starchy materials;! 
 whilst uncleanliness and want of air and light also predispose to 
 it. Prolonged lactation is not necessarily a cause, if the mother 
 is healthy and capable of feeding the child ; but amonj^'st poor 
 patients this habit is frecjuently responsible for its appearance, 
 although in Japan, where the children are suckled for two or 
 three years, the disease is unknown. Rickets is especially comnion 
 in the poorer classes, who are herded together in small and badly 
 ventilated rooms, and is so peculiarly frequent in this country 
 as to be known in Germany as the ' English disease' (J'Jt^lisik(\ 
 krankheit). 
 
 The Symptoms may be divided into the early or general, and the! 
 later or osseous. The general symptoms are mainly referable ton 
 state of irritability of the gastro-intestinal mucous membrane. The 
 child may be fat and flabby, or thin and emaciated; the nuicousj 
 membranes are pale, and vomiting and diarrhoea are constantly 
 present, the motions being often green, slimy, and very offensive. 
 The spleen is enlarged, the abdomen tumid, and profuse s\veatin{;| 
 of the head is very characteristic. 
 
 The commencement of the osseous changes is usually indicated by 
 increasing irritability and restlessness, the child tossing off his i 
 bed-clothes at night, and crying out when handled or touched. 
 The articular ends of the long bones become enlarged, as also the 
 junction of the costal cartilages with the ribs. Sooner or later 
 the shafts of the long bones soften, and may bend in variou;; 
 directions, and thus many deformities may be produced. 
 
 The head usually becomes flattened antero-posteriorly, so that 
 the forehead appears square in shape and enlarged, whilst frontal 
 bosses may develop on either side, due probably to new formatinn 
 of bone under the periosteum. The fontanelles remain open 
 much longer than usual, and craniotabes may be observed in the | 
 occipital region. The teeth do not erupt till late, and are j 
 stunted, defective in enamel, and easily eroded, so that the ends 
 of the incisors are often concave ; they must not be mistaken 
 for syphilitic teeth, since the concavity is a small arc ot a lart;e 
 circle, whilst the typical notch of syphilis is a large segment ot a 
 small circle. 
 
DISEASF.S OF BONE 
 
 489 
 
 Xhn^piMC mnyhe affected by kyphosis (p. 356), or less frequently 
 
 V scoliosis (p. 351) ; the Ryphotlc curve resuTTs nhen the 
 Ijjtientis allowed to lie too much 
 
 '"iiecTu'ttir'the Iiead on a high 
 Inillow, or if it is carried about 
 
 ^ith a curved back ; scoliosis 
 jaiore often occurs when the 
 
 [iititnt is able to walk. Occa- 
 
 lioiiiilly the two conditions are 
 lajsociated in the same child, a 
 
 iivphd-scoliosis resulting, which 
 
 !siisu;illy due to its being carried 
 
 about sitting on a nurse's arm 
 'with the pelvis tilted. 
 
 Changes in the thorax are pro- 
 Ijuced hy enlargement of the 
 
 costo-cbondra.1 junctions {headed 
 
 r;fj), whidij when present on 
 
 eithfiL-akle of the sternum^^jDro- 
 
 iiuce__\yhat is known as the 
 
 nikd)' rosary . TT Ttiere is any 
 
 r.lKtriirtinn to tHe entrance o f 
 
 airiiiIo~"the lungs, as from a 
 
 inicheitis or bronchitis, the atmo- 
 spheric pressure may cause the 
 hoftened heme and cartilage to 
 
 sink inwards, and as a result of 
 
 •Jiis the sternum may be pushed 
 honvards i bi'jeon breast ), \ v:hn st 
 
 ;be ciir\ature of the ribs at TTiS 
 \m<\c. i s increased . A vei_, char- 
 acteristic feature of the rickety 
 
 change consists in the lateral 
 groove thus produced on each 
 [side of the sternum, which may 
 
 aieet with a transverse depression 
 
 below, caused by the projection 
 lot the lower ribs by the tumid 
 [.ibdomen. 
 
 The pdvis is flattened antero- 
 I posteriorly, or more rarely tri- 
 
 radiate, the former condition being produced when the patient 
 
 lies hahitually on his back, the latter only occurring when he is 
 
 allowed to walk about, the acetabula being thus pressed inwards 
 
 and backwards by the heads of the femora. 
 
 The deformity of Xhe loug hone s (Fig, 173) usually consists in an 
 |inci;;e ase in their natural cur\ e s. especially at points where power- 
 jtul nuiscTes are attached. The femora are curved antero-pos- 
 
 FiG. 173. -Pklvis anm) I,k(;-H()NES 
 
 IN RiCKKTS. (FkUM C0I.LKGK OK 
 
 Surgeons' Museum.) 
 
490 
 
 A MANUAL OF SURGERY 
 
 teriorly, and the tibia in a similar direction, altliouf^'li tlicre i> 
 often some lateral displacement superadded, (ienu \;il;,'uiii or 
 varum may also result from the epiphyseal chanf,fes. 
 
 When the acute staj^^e of rickets has passetl away, ;iny d, 
 forniities present become fixed by the complete ossification of th( 
 softened bony tissues. As a rule, the density of such deformed 
 bones is increased, whilst their natural shape is altered by deposits 
 
 I'K. 174. -SkCTION THKOIC.H 
 
 LowKK I'"m) ()i-- Kickktv 
 Kadics, showing E.\A<j(ii;K- 
 
 Al EI) DlCI'TH AND IRRKGILAK 
 BoRDKRS OF THK PrOI.IFKR- 
 AllNC. I'll'll'HV.SEAI. CaKTI- 
 
 i.A(;i:. 
 
 (I'rom Ashby and Wright's ' Diseases of Cliildren ) 
 
 I'll,. 175.-- TrANSVKRSK SkCTION THKor,. 
 
 THE-: Shaft of thi: I'i.na ikum \ 
 RicKirrv Chu,i) of Thirtkkn Momh^ 
 
 ( X 10), SHOWING SrONGY TlSSCK BKNKATH 
 THK PkKIOSTKCM INSTEAD OF Tllh CoM 
 FACT TiSSLE OF NoRMAL ]50Ni; 
 
 of new subperiosteal bone or struts in the concaxities, so that on 
 section they are usuall)- more or less flattened from side to side. 
 Growth is often checked by this disease, so that the individuai 
 bt'comes stunted and dwarf-like. , 
 
 t pathologically^, the chiel changes in rickets are IquiuI in the 
 iieijfhbourliood of the^ epiphyses. Ordinariiy^Jthe-.J:p.ipliyseai j 
 cartdage is a lamell a abou t a^Hne^iiLlhickntiSS, bounded on either 
 side by a zone oT calcified tissue, containing regular alveolar 
 spaces filled with vascular medulla, and Hned l)y osteohlaitb, 
 shelving gradually into normal cancellous bone. In rickets the 
 
DISEASES OF DONE 
 
 491 
 
 (piphystal cartilage is not only circumfcrc nti nlly rnlartred. hut a lso 
 thimiiit'cljinti irregular (I'^ij,'. 174), outgrowths of cartilage project- 
 ing on either side into the calcified tissue, which is murt' cibundant 
 and more open in texture than usual, whilst it pjiaaeiLirregularly 
 into the cancellous bone. Tluis, there is an increase in the 
 material which Nature prepares for the formation of b(jne, but the 
 ussifying process is inefficiently carried out. In addition to this, 
 the Haversian canal systems and the medullary spares in the 
 Jiaphyscs are enlarged, so that the bones become weaker and 
 kss ri^,nd from the insuflicient amount of lime salts present, and 
 thus readily bend under the weif^^ht of tiie body or from muscular 
 ution. Somewhat less frequently the subperiosteal compact 
 lioiTe hecomes similarly rarefied (Fig. 175), or a new formation of 
 oft vascular tissue forms beneath it, which later on becomes 
 
 ^ndensed, thus increasing the thickness and sectional area of 
 iliel)oiu'., 
 
 ^iKe Treatment ol Jackets the most essential feature iu the 
 earlv staf^es is the correction of all errors in the personal hygiene. 
 The (lift should consist of good cow's niiUk, diluted if need be, 
 and with lime-water added ; whilst the juice expressed from raw 
 ll^ or one of the ijiany meat j.u ices ng_\y sold, may also be 
 administered. ' Tlie condition of the bowels must be attended to, 
 iiml the chilcTplacedin as j^ood suriQundiugs^as possible. PiuxislLS 
 tood (syr. ferri pjios.jCQ.) may be gi\en by itself^^hui if the infant is 
 :hin and emaciate d, cod-li\er oil sho uld 1^'- nrldnd Deformities 
 musti if possfl^Te, Tie prevented by keeping the child in the va.- 
 1 u.UibeiU posture, and not allowing it to crayvl pi^run about. The 
 early stages of deformity can often be corrected by dally manipu- 
 lation of the affected bones, and in the later stages they may be 
 improved by suitable apparatus for immobilizing the limb, com- 
 hined with pressure. Osteotomy, or e\en resection of portions 
 of hone, is required in the severer cases where the deformity 
 persists (see p. 369). 
 
 Scurvy Rickets {Syn. : Acute^Bicketa, Hsemorrhagic Rickets 1. Coiisulcniblf 
 attention liasTiel'ii direc ted of rece nt years, n(<[nj)ly hy t^r Hnrlow , toacuno iis 
 ( mcTmoti met uitli j^ti ~cliiltlren , which seems to combine som e of the m ost 
 :n:ii^lie(l feat ures of rickets and scurvy, but m wliTcL eitilJSlLDne ()r the otlier set 
 'fjilienonien a may predomin ate. Ttls usually seen in the children of well-to- 
 ii'l^eople, and apparently arises from deftJCtiveniitrition, especially from the 
 
 pnji imtjed administration or~peptonized or preparetl foods, toj^the^ with an 
 
 ah: ■ ' . . ^ - .. . - . . , 
 
 ■ence^pf frt'.s ii meat and \ e^etables . In the slighter cases there may be but 
 ""T-nrt,- gf [!)>» srnilintiti. x.-/in,lifi()p b eyoiu l the_Jai.'l tha t in a ricTtet y 
 
 i^liiid tjiere is somej^^ylenry fo r fli e t^ni m s to blee d or a little lurmaturia ; but 
 inlhcise tliat are more marked the rickety signs are of little importance 
 ompaied with those due to ha^morrhagic extravasations. The disease often 
 tmie.son siuUIenly with some amount of pyrexia, rarely e.\ceeding 102 F., but 
 ilie child is evidently ill, and perhaps complains of tenderness of the limbs, 
 which may be kept so quiet as to suggest that they are paralyzed. This is 
 lollnwt'cl l)y the appearance of swellings of some size, due to subperiosteal 
 fMravasations, the skin over the affected parts being at first shiny and 
 'I lematous, but subsequently becoming stained by the blood pigment. The 
 
49* 
 
 A MANUAL OF SUHGEh'Y 
 
 femur and tihi.i jire most often aff(!ct«!(l in this way, and tlie epiphvMs mav 
 (Hcasioiialiy Ix'inmt! (ictaciuHl, or i'\en spoiitani'oiis fractiiri'socnir IHiedin' 
 may also takt- place liencatii tlu- loiijuiutixa or iiitu th»; ()ri)it, Ifjidini; t' 
 protrusion of tlu- t-yidiali. wiiilst tluTc may Ix' hiood-staiiicd diarrlma 
 hirmatiiria, or cpistaxis 
 
 Tiu! (iist;ase, wiien recoj^nisfd. is readily amenai)l(! to tii\iliiuiit, hut sIkhiIi) 
 its nature be overlooked, the child is likely to become emaciated and die 
 Attention to the diet is the main jioint to be attended to, for when froh tniH 
 lime-jiiire, or \e},'etal>les arc ),'i\''n, tlu- symptoms soon disajipear '{■jic .illcdeii 
 lindis must be ki'pt at rest, and cooling,' lotions applied, whilst splint!^ urc 
 employed for scp.irated epiphyses or fractures 
 
 Achondroplasia is thi' nauie uiven tuaiare and curious conf,'enital((iruiitii,ii 
 somt;wliat resembling riikets, in which the growth of osseous tihsuc; uiLlJji; 
 sh;ift sidi- of tile epiphyses of the long bones of both arms and legs is dtlti- 
 ti\e, so that the limbs are slu)rt and stunted, and tlie stature correspinuliiii;!' 
 diminished, rdthough the epiphyses are normal. The bones generalK are nii; 
 bent or curved abnormally, though tiiere is probably some change id tlie neLk 
 or shaft of the femur, residting in lordosis, whicii is very marked wiien the 
 patient stands The fingers taper to their tips, and are separated one from 
 another in ' spokedike ' fashion. The bones at the base of the skull, l)i-inn "' 
 cai tilaginous origin, undergo premature synostosis, whilst the ujipcr iiali di 
 the skidl, being tierised froui membrane, and therefore deseloping naluiallv 
 looks unusually large; the face is small and the bridge of the nose deprcssaj 
 as iix cuji^fMiital syphilid.- The children, if they live, are usually efliciem in 
 their mental (le\ elopment, and the thyroid body normal. No known trfatment 
 is of any value 
 
 Simple Atrophy of Bone . . 
 
 This results from a variety of c onditions ouit e indei^endent of rarufyin:; 
 inn\mmation[ in which it is afw.'iysa mark ed feature. (</) It may be Tv/i^'i »//,(. , 
 perhaps iinoKinij bones and soft tissues alike, (h) It in ay" result from iiiier- 
 ference with the epiphyses, asTn rickets, or after injuries, or as a se(|iR'la in 
 tid)ercidons or other intlammations involving the juncticm cartilage (i) it 
 ma\ be due to injury or disease of the ct-ntral nerxous system or ot peripiicral 
 ner\es, as in tabes dorsalis, syringomyelia, leprosy, etc. iil) It may be caused 
 by want of use, as in a paralysed or aidiylosed lind). (c) Local pressure, as it 
 a tuinour growing within or outside the bone, or of an aneurism, may lit'ter- 
 mine its existence, and possibly to such a degree as to result in sponlaneoui 
 fracture. (/) It may be a senile change, as seen in the lower jaw, cervi.v 
 femoris, or cranium 
 
 The t\pe of atroplu" \ aries with the cause. Sometimes it merely consist- 
 in an arrest of longitudinal development ; at others the bones arc n >; 
 only short, but smaller in all directions, and in leprosy may imdergo alnuM 
 total absorption. IJ the cause is localize(l, and act s fro nj %Yi thoiit. tliecompaa 
 bone is more or less cle anly ero decj; wdiilst if the cause is general, absorpiii :: 
 niay occur e itlierlToii'i wit fun , the m ed uTIary^caTTnt "t)ec? )rn i n g^e n 1 a rj^ed and tl'.i 
 compact tissue thinned, or from witlTmiTrnie cross-secTTonljf the bone gradiial'v 
 dwindling- ~' ~ ^ ~ """" 
 
 The possible presence of atrophy mnst always be kept in miiul whin 
 dealing with ankylosed or paralysed limbs, since very little forct- may siiltin' 
 to produce a fracture. 
 
 MoUities Ossium {Syn. : Osteo-malacia) . 
 
 This disease is one of somewhat unusual occurrence, characterized 1)\ the 
 absorption of the osseous substance of the bones, as a result of whicli soitii!- 
 ing and rarefaction are produced, followed by bending or spontaneo.;^ 
 fracture. 
 
 The complaint is almost limited to the female sex, and usually commences 
 
DISEASES OF HONE 
 
 493 
 
 lurinu' prfK'i'i"''y : it i^ ^''li'l t<> J"' somt^tiiTK-s connecttMl witli a rheiini.itic 
 ti-nilt'iH V Any part of llic skfli-ton may lie attcctnl, but most lri'(|iifiitly tlie 
 iiflvi^. spinal column anil ribs, altiiouKli the limbs arr otcasionally iiivolvi'd 
 
 Pftjthologically, tliu change consists in a replacement of the medullary 
 ^iib^l;uii (■ by a soft ribr;)-cellular tissue, which is ex ceecllngly vasc ular, and 
 intii wliiih li.'cmorrha^e o(ttMi_uixurs ; the resultinj,' material looks in the fresh 
 ,tati' siinu'thing like splenic pulp, Tlit? bony cancelli are absorbed, as also the 
 ■Teattr part of the compact tissue, svith the exception of a thin layer situated 
 lienealli 'he perioste ini ; in a well-marked case the mineral salts may be 
 .liminislu'd to about uuc-idxlli of tlu:ir normal amount, but the relative propor- 
 tioti of ]>h()sphate of lime to llig ciirLuuiUc-w nol clmn^ril Part of the bone 
 ^iibstaiu' remains Tor a time in adecalcifuMl state, with the corpuscles evident, 
 hut in a condition of fatty dtt,'ent; ration . i I'robably sonu? acid, c ^'., l;ictic aciil, 
 IS the active agent in disso'-. in{^ tlie e;irthy salts, which es cape partly in the 
 urine, partlv in th'; fa-ces. It is possible tTiat TTie 2L"^*il'^^,.i ^ t"""*^^'^ tt"l ^^ i^h 
 the absorption of some internal secreTion, nor mal or v itiated i^nrti<iii:>riy thnt 
 fnim the ovarj', an idea suKKcsfecrtJynTie fact that the removal of the uterine 
 .ipiHiid.iKt'^ has in a few cases stayed the disease 
 
 Clinically, the onset is usually somewhat indefinite, the only complaint 
 beiliR of a rheumatic type of pain in various parts of the body, whilst th e 
 patient becomes emaciated .'indexTTau sted . Sooner or later skeletal cnanges 
 ■miiiiTTest themselves , arid demonstrate the character of the disease. The limbs 
 m;iv either ■.. bend or brea k ; in the latter case there is often no attempt at 
 repair. The pelv is becomes tri- rad i a t e i ri sTi ape" ow i li k" t ( 7 the aceT itbula bein g 
 pressed invvarus and back ward sTTy- the weigiit of tlie body, aniTin pregnant 
 women this may cause so much ileformity as to call for C'a'sarian section or 
 I'orro's operation. Death may result from exhaustion, or from ol)s{ructron to 
 parturrtinii, Of TTie patient may live more or less bedridden for years. 
 
 As to Treatmyjt^nj^tjhinj^ ver^satis_fact()r^' c.an be accom^ilislied. Opiates 
 mayT)e administered to relieve pain, and various drugs, such as alum, anil 
 phosphate or liypupUii^Hllitc of lime, have been rec omme nded In cases not 
 assoiiiUeii with parturition or~pregriarricyr<x)pIi()rectomy is said to have been 
 employei l with benef it. The induction of jTremat ui'e lilboiir is consicTeret! by 
 some to lie beneticiAl, not only for the sake of obviating the necessity for 
 such operations as Cicsarian section, but also on the chance of checking the 
 disease. 
 
 H ypertroph y of Bone. 
 
 It is always a ma tter_oL_clifficulty to draw a definite line between a true 
 nypert nipliy an d inilaji|n atory or other overg rowt hs, and especially is this tlie 
 £ase in cuimedion with bones where chronic inflammation is always associalecT 
 with new bone formation. Two or three conditions to which the term 
 hypertrophy is perhaps more correctly attached may, however, be mentioned. 
 1)1 It is .sometimes congenital ; if involving a whole liml) or any large portion 
 nf the l)oily, it is known as Gif^antism : if merely affecting the fingers or toes, 
 ;t IS termed macrodactyly (p. J5o). (b) It may follow inflammatory affections 
 It l)()nes, which are thereby left with an increased blood supply, c.f;., after 
 acute osteomyelitis, which has not destroyed the epiphyseal cartilages ; in such 
 casys the overgrowth is mainly longitudinal, (i) Increased growth of bones is 
 assiciateil with several diseases to be described immediately, \iz., osteitis I'cfvtr- 
 mans, acromegaly, etc., and in these it is possibly due to the effect of some 
 internal secretion. 
 
 Osteitis Deformans. 
 
 Osteitis deformans is an inflammatory disease of the osseous skeleton, first 
 descrilied by Sir James Paget in 1876. The onset is insidious, and the progress 
 very slow It is characterized by a painful overgrowth of the long bones, 
 spine, cranium, and pelvis, which are also softened, so that those which bear 
 the weigiit of the bocly become curved. It may commence in one bone alone, 
 
494 
 
 A MANUAL OF SURGERY 
 
 and then usually the tibia or femur, but more often iiiany bones are affectwi 
 at the same time. Attention may be drawn to the :(mdiiion, either in tlu- 
 pain, whicii tiie patient at first considers to be rheumatic, or by the yeiieral 
 enlarj^cment ami bending of tlie liones, or by the increased size of tlie hta,! 
 necessitating the use of larger hats. The cranial overgrowtii is eccentric m 
 ciiaracter, ami tlie caKarium may become very thick ; the facial slieiftim 
 however, is not much aflected. The spine becomes markedly kyplieiu 
 (Fig. lyC)), the dorsal curve being increased, anc' the lumbar c<mcavi;\ 
 obliterated ; it is nearly rigid from ankylosis of the vertebr;r, am! mav \k- 
 very painful. The head is carried forwards by the btnd of tin; ; inne' the 
 height is diminished, the shouiiiers are round, and the cl.est sunken tnwnriK 
 the pelvis : the gaii is slow and awkward The disea^e usuallv nttncl,. 
 
 I''i<.. 176. OsTKiTis Dkkokmans. (Hkv.wt ) 
 
 middle-aged men ; its progress is exceedingly slow, the patient often li\inj;ii 
 an advanced age, or dying from some intercurrt;nt ni.'ilady Some ca.'^cs ii;ui 
 terminated in inulti])le sarcomata ot the bones The str are of the nssenib 
 tissue is suggestive (.f inflammatory rather than degt.i'jrative changes It 
 is softer and more uniform in structure than usual, the tliffereuce hetwftn 
 the cancellous and compact tissue being less dehned : the Ha\ersi;ui laiiai- 
 are large, and arranged irregularly, whilst the bony sul)st.uice is i liaik\ 
 looking. 
 
 Differential Diagnosis. I'Voin mtlnitis (/cf(iniiii>i.\ winch it reseinhles In ilu 
 attitude and gait of the patient, it is known by the absence of articular li'sion>, 
 especially in the fingers, and the enlargement of the bones, notably nf tlu' 
 cranium, I'rom iicy«mci;al\ it is distinguished iiy the .absence of enlar.m'miii! 
 of tile I'aiids, feet, and lower jaw 
 
 Treatment is most unsatisfactory, no reined) at present known Iia\ iii);! an\ 
 control over the disease. 
 
 Acromegaly. 
 
 Acromegaly is a rare condition the characteristics of which were fir-: 
 described by Dr. I'ierre Marie in 1MS5. It is a general affection iinolMiii, 
 mainly the osseous system, commencing usually in young adults, and, alltr 
 
DISE/ISES OF BONE 
 
 495 
 
 istinK f'T ^ 1""K time, killing the patient by syncope i^r cerebral compression, 
 isiinie intercurrent mal.idj- does not destroy liim. 
 It is characterized i)y a very dffinite enlarfjement of tlie liands and leet, 
 aIucIi arr, iiowever, not li'nf,'tliened, so that the iiands have been compared 
 10 battlcdoP's, and tlie linf,'ers to sausaj^es. Tlie iiones tiu-msflves are 
 dilarjifil. and tlie soft structures on tlie pahnar aspects jiroject as jiads. The 
 •lails and skin are unchanged, whilst the otiier segments, both of the upper 
 jjiil lower limbs, are usually unaffected, though sometimes considerable over- 
 ■riiwth ill lenf,'tli occurs ; in fact, many of the so-called };iants who have been 
 rtiiibitt'd are typical illustrations of acromegaly l'.otli the iqiper and lower 
 lawsare tliickened and prominent, whilst the lower liji is enlar^'ed and ()\er- 
 iianKinfi 'he orbital ridges project, and the forehead is usually low ; the 
 mise and up of the tiinj,'ue are also more or less unlar),'ed. 'ilie spine is 
 
 Ft, 1-7 
 
 // 
 
 Mkai) ok Woman wirii AcKoMKtiAi.v. 
 AM) iKoM nil: SiDi;.* 
 
 SliKN FKOM Till-; 1'KON I 
 
 'k\iini)tic in the dorsal region, with a slight lumbar lordosis Ihe ribs and 
 <'pnuim project anteriorly 
 
 The patient usually suffers from headache, lassitude, ;ind great fatigue, 
 A.inikTMig pains about the b'xly, and excessivi ^ppc-tite and thirst ; 
 aiiienorrlura is a marked symptom in women, whil.-ii m. n suffer from a loss 
 "t virile power The urine is abundant, but of a low specific gravity. Vision 
 ;-iisii,il!\ diminished, and optic neuritis has Ivmi -ibserved in s(/me cases 
 
 Morbid Anatomy. Hut little is known as \> .In cause or ]iathological 
 cliiiiini's ncciirring in this disease, beyond the fact 'hat the anterior glandular 
 :i:ilf 111 the pituita'A- boly is hypertropiiied, and the sella turcica expanded 
 riuthaiigis in the bon» s are merely those of overgrowth 
 
 Diapiosis. The di.v.ase has been mistaken for niyxnilcnui. but there is not 
 mucli ilittutilty in distinguishing the two if it be rememi .-red tliat, in the 
 latter cnndiiinii, the skin is not moiiile o\er the thickened siilicutaneous tissue, 
 iiiat tile tact! is bro.nd, pasty, and putty, and th.at m.isses ot gel.atinous tissue 
 are found a!>cive the clavicle, whilst in acromegaly the face is elongated, and 
 -'■skin an 1 subcutane(ais tissues normal The mental condition and speech 
 
 Repniduced from ihr Ii,linljHii;'i Mulinil JkiiiiuiI, 1)\ kind pirmiNsion of 
 "r <; \ (;ih;;on. 
 
496 
 
 A MANUAL OF SURGERY 
 
 of a patient siiflerinj^ from myxccdema are widely tiifferent frciin tlio^^t; m 
 acromcf^'aly ; wiiilst in tin; former tlie tiiyroici body is eitlier alwdnt or 
 diseased, and in tiie latter skeletal clian^es are present. I-'roin chioinc dj/;, 
 arthiitis aiiectm^; the hands, tlie iliagnosis is easy, in tluat there are usually p 
 sif,'iis of articular disease, and much less pain, i'rom osteitis i/ffm nuuh, \\\, 
 distinfiiusliinf,' features ha\e already i)een indicated. 
 
 Treatment is merely symptomatic, antipyrine lieinj,' useful in relic\in>,' ;h 
 headache, as also valerianate of caffeine. Possibly hyroid extract iniiv In- ^^ 
 some use in combatinj^ the functional phenomena, tlough it will nut nitlipjio 
 the skeletal chanj;;es. 
 
 Another iiirious affection which has bc-en recently descril)ed is tli.u ku< w, 
 by the formidable title of Hypertrophic Pulmonar^ Osteo-arthropathy, i 
 has been Ion;,' known tliat clubbinf,' of the teniiiivii phalaiiK'-''' was a CDmmn' 
 accompaniment of chronic pulmonary ilisease ; but this new affeclinn is min 
 extensi\e. 'i'he terminal plialanges of the finj^ers and toes are (•iil;ir},'L'(l m- 
 l)ull>ous, with the nails curved over them towards the palm or sole; tlierc i-. 
 also a considenible swellin}.; of the bones just above the wrists and ankles, ami 
 possibly a similar condition around other joints. The spine is kypliotic in thf 
 upper dorsal region, but with well-marked lordosis below. It is ttnis seen 
 that tlu! changes are somewhat like those of acromegaly, from whicli thev are i 
 distinguished by {a) the implication only of the terminal phalanges; (/;') the 
 swellings above the wrists and ankles ; and (c) tlv absence of the characteristic I 
 deformities in the skull and head These phenomena probably result fr.mi 
 a chronic osteitis, due to toxic absorption, since the condition arises in siidi 
 diseases as chronic bronchitis, bronchiectasis, and chronic empyema, where 
 suppuration has existed for some time. Little can be done in t!ie wayoti 
 treatment, except to remoM' the cause. 
 
 Tum ours of Bon e. 
 
 Many difVercnt types of tumours grow from bone. Tlu. 
 characters of the osteomata, chondromata, uiul fihroinala li.ivi 
 been described in Chapter \'l., and various sohd ami c\stiij 
 tiunours connectt;d \vitli tlie teetli are dealt with clsewlicre. 
 
 Sarcomr. is the most important primary tumour of bones, and! 
 ahnost any form may occiu'. The microscopical characters iiave I 
 been detailed in the chapter on tiunours, and we siiall iicre oiilv 
 refer to their cliniral charactcyhtiii. They may be divitled into Iwm 
 main j^roups — the endosteal or central, and the neriosteal. 
 
 Endosteal or Central Sarcoma (I'iK- '7^"^) (>f bone coinmciiccsin 
 the medullarv cavity or cancellous tissue, and results in the so 
 called ' expansion of bone,' which consists in absorption of \\\k 
 bone from within, whilst at tlie same time new osseous tissue i.- 
 being deposited from the mulcr side of the perioste.nun. thou.i^'hinj 
 these cases only to a hmited degree. The Symptoms iit lir>: 
 resemble those of chronic osteo-periostitis, althougii in most casesi 
 of tumoiu' there is rather less pain. The growth usually com- 
 mences near the end of a long bone ; it seldom encroaclics on thfl 
 articular cartilage, so that tlie joint escapes, although it inav 
 contain an excess of serous tUiid ; occasionally, Iiowcmt, tlifj 
 growth may extend laterally beyond the level of tlu; cartilage, am! 
 thus imade the articular ca\ity. Sporii.ineous fracture is iii>t aiil 
 unfre'iuent complication, and owing to the expansion of lii' himv] 
 
DISEASES OF BONE 
 
 497 
 
 im those m 
 r ahsent iir 
 
 chionii i)s;.M- 
 V usiiallv n.' 
 f/drwMus, tin 
 
 relieving thi 
 ct may hv ol 
 not infliujncc 
 
 ^ thai kiiiivw: 
 iropathy. 1; 
 IS a cumniii' 
 ctiiin is nvTi 
 cnlarf^cd uri'! 
 ^nlc ; tlierc i-, 
 (1 ankles, anil I 
 .'pliotic inth;' 
 is thus seen I 
 liich they are i 
 iif^cs ; {h] the j 
 characteristic 
 y rt'sult ffiim I 
 arises in such 
 [)yt;ina. wht-re ] 
 in till' wavoll 
 
 )onv. The 
 mala liavi 
 and cystic 
 
 KTC. 
 
 lones, and 
 utcrs liavi' 
 lere only 
 cd into t\v.' 
 fid. 
 
 nniences in 
 s in the so- 
 il ion of the 
 us tissue is 
 . tlioii!,''' '" 
 )ni3 at tir>'. 
 niDSt i-ast.> 
 iially com- 
 .(■lies on the 
 frh it may 
 iwever, the 
 irlila.i,'(.',am! 
 IV is not an 
 if ill'.' how 
 
 I framework ' ef^f^shell crackling ' is sometimes met with. After a 
 
 ,vhile, the growth may extend beyond the osseous limits into the 
 
 I soft parts, and then the chances of general dissemination are con- 
 
 sideraiily increased. The chief varieties of sarcoma growing from 
 
 jihe interior of long bones are the round or spindle-celled, ;ind the 
 
 inivtloid. The two former early diffuse themselves throughout 
 
 I the medti'ilary cavity, and infect ;;eighbouring tissues and the 
 
 svsteni generally. Not unfrequently cartilaginous nodules may 
 
 Ih; found scattered throug!- the mass. Myeloid tumours are almost 
 
 !benif,'n in character, never giving rise to secondary deposits, either 
 
 jinlvniphatic glands or viscera, and their growth within the bone 
 
 --/ 
 
 I 
 
 
 1 
 
 
 1 
 
 
 Fill. lyS.— ICndostkai. Sakcoma. 
 
 KiN( S ("jLl-KdlC HOSI'ITAI. MfSKLM.) 
 
 Fk;. 179, — rKKIOSTKAL SaK- 
 COMA. (BkVANT ) 
 
 iimited to the region from which they originated ; sometimes a 
 aver of condensed bone forms a definite barrier to check any 
 dvance along the medullary canal. The sites of election for 
 nyeloid tumours are the lower ends of the fenuu' and radius, ami 
 lie upper ends of the tibia and humerus — that is, where the 
 |re\vth of the limbs is greatest ; ihey also grow within the hori- 
 ontal ramus of the lower jaw and the diploe. Not unconmionly 
 l?ilirosarcomatous epulis is myeloid in nature. 
 
 liuunsideri'.ig the nature ui an endosteal sarcoma, it should be 
 kii'.einbeted that myeloid tumours grow more slowly than the 
 piiiid- or spindle-celled, and are more likely to cU-xclop cysts 
 
 *in^: to ha-morrhiige into their substance. In all of ihem a 
 ^r'uiin aitioimt of bony skeleton may pervade the growlii. 
 
498 
 
 A MANUAL OF SURGERY 
 
 The Periosteal Sarcomata (Fi^'. 179) are round- or spindle- 
 celled in nature,. They often grow very rapidly, without n'mivl 
 rise to much pain, unless causinff erosion of the hone. Tht-y 
 usually start on one side of the hone, but later on may surrouiicij 
 its whole circumference. They spread rapidly along its exttiinr 
 and are highly malignant in nature, giving rise to socoiuiarv 
 growths in the neighbouring lymphatic glands or in the visma, 
 They frequently become ossified, with or without the devclopmLntl 
 of cartilage, and in such cases the subjacent bone becomes sclerosed 
 and thick. The bony skeleton of such a growth is very characterl 
 istic, consisting of fine spiculated trabecular, radiating more url 
 less regularly from the surface, and looking in the dried statel 
 somewhat like asbestos. \N'hen a periosteal sarcoma does iiijtj 
 become ossified, the growth usually erodes the underlying,' honej 
 and may lead to spontaneous fracture ; the tumour in such c;im> 
 is softer and more elastic than in the former variety. All ossmisi 
 sarcomata are exceedingly vascular, and may even pulsate, whilsti 
 the superficial veins are olniously dilated beneath the stretched 
 integument, giving rise to a blue network. 
 
 The Diagnosis of osteo-sarcoma in the early stages is often 
 matter of the greatest difficulty. The endosteal form may e;isil\^ 
 be mistaken for chronic osteo-periostitis, medullary gumma, or 
 deep abscess of the bone, and can sometimes only be distin!,fuisht(| 
 from them by an exploratory incision, which should ulwav,- 
 undertaken in doubtful cases prior to radical operations, such 4 
 amputation. In the later stages, the presence of ' etij^'shelj 
 crackling' or cystic change will help to make evident the natiiri 
 of the disease. The periosteal form may at first be looked \\\xi 
 as a perii)steal node, or a deeply placed abscess. The niiiiKJti 
 and definite edge of the growth, its irregular consistency, aiul tiij 
 history of the case, will assist in the determination of its naturrl 
 but in the early stages an exploratory operation is not unfre(|iui!tir 
 necessary. For the diagnosis of a pulsating sarcoma from a 
 aneurism, see p. 230. \\ hen either iorm involves the articuial 
 end of a bone, especially the lower end of the femur, it inaj 
 simulate tuberculous disease of the adjacent joint. It will, hu\<f 
 ever, be noted that the centre of the swelling corresponds toj 
 point well above or below the joint, that a certain amount 
 movement is possible, and even without pain, whilst the staitin| 
 pains at night characteristic of joint mischief are absent, 
 age of the j)atient, and the presence or not of cacliexy, are 
 important features which have to be taken into considcnuicJ 
 Skiagraphy serves in some cases as an important dia^'nojtj 
 adjuvant (p. 47<.>). 
 
 The Treatment of osteo-sarccMiui must always be of .1 laiiici 
 nature, antl, remembering the highly malignant character ol ma 
 of these growths, we would strongly urge ihe importaiicv' 0! 
 early exploratory o|)eration in doubtful "ases ; if under! 
 
DISEASES OF HONE 
 
 499 
 
 iwith antiseptic precautions no harm can ensue, and a definite 
 |(lia"nosis is thereby possible. If the case is left until increased 
 Iffrowth reveals the true state of affairs, it is more than likely that, 
 lexcept in myeloid sarcomata, it will be too late for successful 
 operative interference. In every form of the disease except the 
 nyeloid, tlie affected limb should be remo\ed high abo\e the 
 [tumour. Thus, if growiiiLj from the lower end of the tibia, dis- 
 articulation at the knee-joint should be performed ; if at the upper 
 indof the tibia, amputation through the middle or lower third of 
 Ihethi^^li; if from the lower end of the femur, amputation through 
 Ihe upper third of the bone, if not at the hip-joint. I"\)r sarcoma 
 pi the head of the humerus, disarticulation through the shoulder- 
 pint may suffice, but if there is any doubt as to this, it is wiser 
 remove the scapula and greater part of the clavicle as well 
 jjinterscapulo- thoracic amputation). The results of the latter 
 |)ruceedinf,^ as regards final cure, have been much more satis- 
 lactory than those of the former. When muscular bellies have 
 leeii invaded, it is desirable, though not always practicable, to 
 Delude the whole of them in the scope of the operation. 
 Mveioid sarcomata being jiractically non-malignant, except 
 qIIv, are dealt with in a much more conservati\e manner. 
 Imputation through healthy tissue just above the growth being 
 that is necessary. It is advisable that the medulla at the 
 omt of se( tion of the bone should be examined microscopically 
 lefcre the wound is closed, to make certain that it has not been 
 hvaded. When affecting the lower end of the radius, an attempt 
 Bav he made t.; save the limb by excising the diseased portion of 
 pne; if a portion of the ulna is also taken away at the same time, 
 pre is less chance of the hand being drawn up and abducted, 
 ^d hence it if likely to become more useful. Central sarcoma of 
 lower jaw, if myeloid in nature, may be treated by making a 
 opening in the bone, scraping the diseased tissue away, and 
 kai)hin<,f cut the cavity with pure carbolic acid. The continuity 
 he jaw niav thus l>e maintained, even if the teeth are lost. 
 JEveral successful cases treated according to this plan have been 
 (iirded. 
 
 [Secondary Sarcoma of bone is by no means uncommon. It is 
 plly endosteal in character, and, except in the most unusual 
 tcunistances, will not demand treatment, owing to the general 
 lection of tlie system. I'ossibly where it has led to spontaneous 
 Icture. and there is much pain owing to the difficulty of lixati>)n, 
 hvould he justifiable to remove the limb. 
 
 ICarcinoma of bone is always secondary in nature, although it 
 
 V he iii'.ohed i)y direct extension in a i)rimary growth, it may 
 
 :asionally lead to spontaneous fracture. 
 
 rare form of secondary carcinoma of bone is that known as 
 
 Toid Cancer. The primary growth is in the thyroid body, 
 
 32 — 2 
 
500 
 
 A MANUAL OF SURGERY 
 
 whilst the secondary deposits in the bone are exactly similar mi 
 structure to it, and usually pulsate strongly. 
 
 Pulsating Tumours of Bone, or Osteo-aneurism. — Not ,i fewcas.. 
 of sarcoma of bone, whether central or peripheral in character 
 have an evident pulsation, owing to their extreme vascularity 
 the thin-walled vessels in their substance being even dilated and! 
 aneurismal. Apart from these, two other conditions are mot with 
 the nature of which cannot be considered as yet settled, in wiiic 
 distinct pulsation is also noticeable. 
 
 In the first of tliese the medullary cavity is occupied hv 
 non-malignant vascular tissue, practically identical with what w 
 have already described as an aneurism by anastomosis. A lar" 
 number of small arterioles open into spaces without the intervene 
 tion of capillaries, so that an erectile tissue similar in natiirt ti 
 the corpus cavernosum penis results. Such tumours arc situat 
 most frecjuently in the cranial bones, and may be multiple, im 
 medullary tissue being in consecjuence atrophied, and the coiiipa 
 tissue thinned, so that ' eggshell crackling ' may be obtained. 
 
 The second form is found most commonly in the up|)er end 
 the tibia, or some such cancellous mass. It consists of a hollo' 
 cavity formed in the cancellated tissue, and filled with hloi 
 Several distinct arterial twigs may open into it, and llic overlvj 
 bone is thinned and absorbed. It is probable that the nuijoritv 
 such cases are in reality due to the breaking down of surcoiiiai 
 of extreme tenuitv. 
 
 The Diagnosis of these conditions from an ordinary aneurism 
 alluded to elsewhere (p. 476) ; but it is often impossible to distil 
 guish one form of pulsating tumour of bone from another witlioi 
 an exploratory incision. 
 
 The Treatment of these cases necessarily varies with the coi 
 dition found after tlie preliminary incision into its suhstan 
 which should always be made after rendering the limb hldtHJli 
 Where it seems probable that the condition is not associated \\\\ 
 malignant disease, or is merely due to a myeloid tumour. ; 
 cavity should be well i-craped, swabbed out with pure carM 
 acid, and then firmly stuffed with gauze, so as to ol)tuin lieaii 
 by granuliiiion from the bottom. In other cases amputate;; 
 the only treatment. 
 
 Hydatid Disease of Bone. — The cancellous tissue of bones ^n 
 sionally becomes the site of hydatid deNelopment, any partiitlj 
 of the medullary cavity or of the ends being in\olved. The 
 becomes expanded, with all the symptoms of an endosteal f,'ri)wi 
 Considerable deformity may occur, and when tlie compact l.i| 
 has become sufficiently a!)sorbed, spontaneous fracture may loll 
 \ peculiar cliaracteristic of this affection is that there is no lin 
 ing cyst wall, the small daughter cysts being diffused wii 
 
DISEASES or DONE 
 
 SOI 
 
 |tfcroiif,'hont the affected area. A clia{:?nosis is little likely to he 
 Iniade (at any rate, in this country, where hydatid disease is so 
 Itiirel prior to an exploratory incision. Treatment. — If all the 
 Icvstscan be removed without interfering with the integrity of the 
 Lhaft, a recovery, with good suhseciuent utility of the limb, should 
 jtollow. NN'here, however, the disease has encroached widely on 
 (the bonv tissue, whether spontaneous friicture has occurred or 
 Irot. amputation holds out the only prospect of cure. \J 
 
CHAPTER XVIII. 
 INJURIES OF JOINTS— DISLOCATIONS. 
 
 Sprains and Strains. — When some of the Hfjjamentoiis ni.rt! 
 around a joint are ruptured or stretched, as the result of smMe 
 violence, the joint is said to be sprained or strained. The arrii 
 dent itself is associated with severe pain, and is iinniediatcl' 
 followed by more or less haemorrhage into the surrouiKiinj 
 tissues, or into the articular cavity. An attack of synovitii 
 varying in se\erity, generally ensues, and may lead to persisten 
 weakness and pain in the joint, either from the formation 
 adhesions, or from imperfect repair of the ligaments. If this coil 
 dition is neglected, it may originate tuberculous disease in tliosl 
 who are so predisposed, whilst osteo-arthritis is a by no nitaii 
 uncommon sequela. If the patient is in a bad state of health 
 the time of the injury, it is possible that an attack of aciiii 
 infective arthritis may be lighted up. Treatment. — The joiij 
 should be firmly supported by a bandage as soon after 
 accident as possible, and cold or evaporating lotions applied. 
 tlie slighter cases, all that is needed is to strap the joint oral 
 elastic pressure, the patient being allowed to use the limb at iH 
 end of a day or two ; but in severe sprains it is better to keeptJ 
 part absolutely at rest for some days, since neglect in the m 
 stages may give rise to as much, if not more, trouble than if 
 limb had been fractured. I'riction with stinuilating liniintiiii 
 massage, and douching the joint alternately with hot and ca 
 water, are subsecjuently useful in restoring the limb to fnll 
 tional activity. When synovitis supervenes, the treatment ;.ii 
 able for that condition must be adopted. 
 
 Penetrating Wounds of Joints are often accompanied by 
 escape of synovia, which is recognised as a gkiiiy, oily 
 floating perhaps on the surface of the blood ; if, however, t| 
 aperture is small, this may not occur. It is always followed 1' 
 certain amount of inflammation, the severity and e.xtcnt of wli 
 depend on whether the joint is infected and the character of \i 
 infection. If no infection has taken place, and the joint is maf 
 
INJURIES OF JOINTS -DISLOCATIONS 
 
 50.1 
 
 surroundini 
 
 •ained in an aseptic condition, a simple synovitis ensues, and soon 
 passes »»'f; it» liowe\er, micro-organisms have entered, acute 
 arthritis probably supervenes, leading; to destruction and dis- 
 intt'iiration of the joint. (I'^or symptoms and treatment, see 
 Chapter XIX.) A penetratin;^ wound, ^,'ven if untreated, does 
 not necessarily become septic ; thus, if the lesion is ptoduced by 
 a small clean instrument, and especially if this is inserted in a 
 sliintin^^ direction, so tiiat the wound is valvular, or if the incision 
 ijaliir^'c one, allowing free vent to all discharges, recovery with- 
 out septic inflammation is possible. 
 
 Considerable difterence of opinion has been expressed as to the 
 ntiessity for accurately determining whether or not the synovial 
 meml'nuu: has been involved. Speaking generally, one would 
 recommend that if the wound is small, and the surgeon has 
 reason to believe that the instrument inflicting it has been aseptic, 
 the external skin should be thoroughly purified, and an antiseptic 
 dressing applied. A careful watch must be kept upon the con- 
 liiiion of tiie joint, and upon Llie temperature of the patient ; as 
 >oon as any signs of acute arthritis manifest themselves, free 
 incisions are made into the joint, so as to relieve tension and allow 
 the cavity to be irrigated. If, however, the wound is inflicted by 
 a dirt V instrument, and there is but little doubt that the joint 
 has been penetrated, it is most important to make certain oi 
 this fact. For this purpose the wound should be enlarged, so 
 [that its depths may be purified, and then carefully examined. 
 I !f it is found that the cavity has been opened, the aperture 
 j should be increased in size so as to allow it to be washed out and 
 a drainage-tube inserted; if acute arthritis supervenes, it must 
 lie treated in the usual way. 
 
 Dislocations. 
 
 Although the term ' dislocation ' is most commonly applied to a 
 [forcible displacement of one of the bones entering intoanarticula- 
 Ition, as the result of an injury, it nuist not be forgotten that con- 
 Ii;inital and pathological displacements also exist. 
 
 Congenital Dislocation.— This term is applied generally to any 
 {defect of a joint present at birth, but is really a misnomer, since 
 [the condition is almost always due to an error of development, as 
 la result of which a normal location of the bony constituents has 
 jnevLT been present, and hence a ^//slocation cannot have taken 
 place. The hip-joint is most freciuently affected ; but similar 
 ImalfornKitions have occurred in the shoulder, wrist, and jaw, 
 Vhilst tile patella may be congenitally absent or displaced. 
 
 Congenital Dislocation of the Hip is by no means rare, although 
 fits causation is still (jiiite uncertain ; probably it is due in some 
 tases to malposition of the f(jetus in the uterus or to some irregu- 
 larity in the shape of the uterine wall, e.g., such as results from 
 
5<H 
 
 A MANUAL OF SURGERY 
 
 the presence of fibroids. The malformation is frequently bilateral 
 more commonly unilateral. It often passes unnoticed muil th.. 
 cluld begins to walk, and then the characteristic signs heconic 
 evident. The limb is shortened and flexed on the pelvis, owiri" 
 to the traction of the ilio-psoas muscle, necessitating a consider 
 able amount of lordosis to maintain the body in a vertical |)osition 
 (Fig. i<So), whilst scoliosis is well marked in one-sided cases. 
 Since the head of the femur is displaced from the middle line, a 
 
 Fig. i8o. — Congenital Dislocation of the Hip 
 
 gap is usually noticed between the thighs close to the perineu 
 Considerable adduction of the lower end of the femur may lesiiit I 
 from muscular contraction (adductors), and in bilateral cases a 
 scissor- leg deformity may ensue. The patient's gait is of a curioii> 
 waddling character, which becomes very marked if one side alone | 
 is affected. Since the head of the bone is only maintained in 
 position by its ligamentous and muscular attachments, it can ofter j 
 be draw. J down at first, and the leg thus lengthened to the exteni| 
 of _.:. mch or two ; moreover, it is often easy to reduce the &>■ 
 
' bilateral. 
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PLATE XXII. 
 
INJURIES OF JOINTS— DISLOCATIONS 
 
 50s 
 
 placement and put the head of the bone in the acetabulum in 
 children that have not walked much. It is sometimes necessary 
 to invert, sometimes to evert the limb, as well as make traction, 
 in order to accomplish this, the head of the bone not being always 
 in the same place. At a subsequent date strains to the limb are 
 almost entirely borne by the ligamentous tissues, and hence attacks 
 of synovitis are common. 
 
 The Pathological Anatomy varies considerably according to 
 whether or not the child has walked. At birth the head and neck 
 are sometimes nearly normal, although the head is often rather 
 small and perhaps flattened at the spot where it rests against the 
 innominate bone, and the neck is short and stunted. The liga- 
 nientum teres is long, thin and usually somewhat flattened. The 
 acetabulum is smaller and more shallow than usual, but can 
 usually receive the head of the bone, though it cannot retain it ; 
 this is stated by Lockwood to be due to the absence of the carti- 
 laginous rim, but this explanation is certainly not true in all cases. 
 The capsule is large and roomy. After the child has walked, sundry 
 modifications make themselves evident. The head of the bone 
 becomes more and more displaced, so that it may finally lie well 
 above the acetabulum on the dorsum ilii (Plate XXII.). The 
 capsule becomes stretched over the displaced head, and much 
 thicker than usual ; the ligamentum teres is flat and band-like. 
 The head of the bone is considerably altered in shape ; the 
 defective development of the acetabulum is more obvious, since 
 it becomes triangular in shape, owing chiefly to want of growth of 
 the iliac portion, whilst the muscles are necessarily modified as 
 to their length. A new, but very imperfect, acetabulum forms on 
 the spot where the head of the bone usually rests. 
 
 Treatment. — Should a diagnosis be made before the child has 
 commenced to walk, there is no reason why treatment should not 
 be instituted at once. The head of the bone can usually be placed 
 in its socket, and is kept there by fixing the limb in a position of 
 abduction, whilst inward pressure is made over the trochanter 
 with a screw apparatus. Schede has by this means converted 
 the unstable articulation into a stable one. Such treatment will 
 last from six to twelve months. Others have effected the same 
 result by "prolonged traction. 
 
 At a later age (up to five or six years) Lofenz's bloodless 
 mtJiod of treatment may be employed with good hopes of a 
 successful issue in unilateral cases, (i) The head of the bone is 
 first drawn down to the level of the acetabulum. Some surgeons 
 recommend this to be effected by gradual extension ; others do it 
 at one sitting under an anaesthetic. The adductor muscles are 
 the chief hindrance, and will require a good deal of kneading, 
 or even possibly section with a tenotome. (2) The head of the 
 bone is to be replaced in the acetabulum, and as this cavity is 
 small and chink-like, and sometimes covered in by the front of 
 
5o6 
 
 A MANUALOF SURGERY 
 
 the capsule, a good deal of difificulty may be here experienced, 
 The limb is fully flexed and then forcibly abducted, extended 
 and everted, no undue violence being permissible, or the bone 
 may be fractured. The head of the bone can sometimes be felt 
 to slip into the acetabulum, and the manoeuvre should be repeated 
 several times, as it were, grinding the head of the femur into the 
 acetabulum. (3) The limb is then put up in plaster of Paris from 
 the pelvis to the knee in a position of abduction and slight eversion, 
 and with the leg flexed. It is maintained in this position for 
 ten or twelve weeks, and it is well to ascertain by skiagraphy 
 that the bone has not slipped. At the end of that period it will 
 probably be found that a less degree of abduction will suffice in 
 order to keep the bone in place, and a fresh case of plaster is 
 applied with the limb in this new position, the extension and out- 
 ward rotation being maintained. As soon as possible the child is 
 encouraged to walk on the limb in this position of abduction, so 
 as to force the head of the bone still deeper into the acetabulum; 
 crutches are required at first, but he will soon do without them, 
 The plaster casing is usually needed for six months. 
 
 In older children (from five to ten years) operative treatmmi 
 can be undertaken with some prospect of success. Hoffa and 
 Lorenz have been the great exponents of this proceeding, though 
 . for children under five years they both admit the value of the 
 bloodless method. Their operations consist in opening the joint 
 from the back and front respectively, shaping up the head of the 
 bone, enlarging the acetabulum so that the head can be replaced 
 in it, and dividing any tense structures which prevent reduction. 
 The limb is subsequently immobilized in a position of eversion 
 and abduction, but for as short a time as possible. Even if anky- 
 losis results, the patient's gait is considerably improved. 
 
 Pathological Dislocations are produced as the result of some 
 intra-articular affection, e.g., tuberculous disease, osteo-arthritis, 
 Charcot's disease, etc. It is unnecessary to describe them here. 
 
 Traumatic Dislocations. 
 
 Causes. — These are divided into the predisposing and exciting. 
 Under the former head may be included some anatomical pecu- 
 liarity of the joint, such as the shallow socket of the glenoid cavity, 
 or some weakness of the muscles or ligaments which control the 
 movements of the articulation. Dislocations are rare in children, 
 since any violence directed to a joint or its neighbourhood is more 
 likely to lead to an epiphyseal separation. Moreover, in old 
 people the bones become brittle, and thus fractures, rather than 
 dislocations, are produced ; hence the later lesions are almost 
 limited to adults, and, owing to their greater exposure to injury, 
 occur in men rather than in women. 
 
 The Exciting Causes are the application of external violence and 
 
INJURIES OF JOINTS— DISLOCATIONS 
 
 507 
 
 muscular force, acting alone or in combination. The former may 
 be direct, but is more commonly indirect, the force being applied 
 at a distance from the joint. Muscular action by itself can only 
 produce dislocation in certain joints, which by their peculiar con- 
 formation are predisposed to it ; the head of the humerus, the 
 patella and condyle of the jaw are the bones most often affected 
 in this way. If, however, the ligaments of a joint have been 
 stretched by previous disease or displacement, recurrent disloca- 
 tions, the result of muscular action, are not unusual. 
 
 Tlie term complete dislocation, or lnxatio:i, is applied to that con- 
 dition in which the articular surfaces of the bones are completely 
 separated from one another. An incomplete dislocation, or subluxa- 
 tion, is one in which the surfaces are only partially separated. 
 
 A compound dislocation is one in which the skin has been ruptured 
 and a communication established with the external air. A com- 
 plicated dislocation is one in which there has been some associated 
 injury of vessels, nerves, or viscera. The term fracture-dislocation 
 is one applied to a condition in which a dislocation is complicated 
 by fracture of one or both bones involved. 
 
 The Signs of a dislocation are as follows : (i) Thejevidences of 
 a local trauma, e.g., pain, bruising, and swelling oFTt[e~5Cfft 
 tissues, due to their laceFatiOn arid the "'effusTofT'of blood" into 
 tliem ; the amount of this varies in different cases : (2) deformity 
 of the limb due to the articular end of the displaced bone being in 
 some abnormal position, where it can often be felt and sometimes 
 seen : and (3) restricted mobility of the affected joint, and hence 
 impairment of function of the limb. The degree to which this 
 obtains is necessarily variable, but, as a rule, it is very marked ; 
 if, however, fracture is also present, passive movements may be 
 possihle, though associated with pain and crepitus. 
 
 The Effects produced by a dislocation extend to all the struc- 
 tures entering into and surrounding the site of injury. The liga- 
 ments are partially or completely torn ; the bony surfaces are not 
 unfrequently fractured, especially in closely-fitting hinge joints, 
 such as the elbow and ankle ; the cartilages may be bruised, 
 or portions of them detached, and neighbouring muscles and 
 tendons lacerated and displaced ; adjacent vessels and nerves are 
 often contused or compressed. Considerable effusion of blood is 
 always present, infiltrating the whole area involved. 
 
 The character of the injury explains the difficulties that are 
 met with in its reduction. These arise from two main causes : 
 (a) The anatomical structure of the joint and its ligaments, re- 
 sulting in the hitching of bony prominences against one another, 
 whilst the head of the bone does not always lie opposite the hole 
 in the capsule through which it originally passed. In a few cases 
 the end of the bone may be grasped by neighbouring ligaments 
 and muscles in such a way as to render its replacement a matter 
 of the greatest difficulty, (b) Muscular contraction also con- 
 
5o8 
 
 A MANUAL OF SURGERY 
 
 stitutes an obstacle, which, though formerly difficult to counter- 
 act, is now readily overcome by the use of anaesthetics. Kot 
 only does the patient maintain the limb in a condition of rest 
 by a voluntary tonic contraction, but it becomes fixed by the 
 involuntary passive tension of the displaced muscles. Moreover 
 clonic spasms may arise from the direct or reflex irritation of 
 nerves, and these the patient ij. quite incapable of controllint^. 
 
 When once reduced, Nature soon restores the part, so that in many 
 cases no permanent lesion remains, although in some the rent in 
 the capsule does not heal firmly, leaving the joint weak and liable 
 to a recurrence of the displacement, while intra-articular ad- 
 
 Fig. i8i. — Old-standing Subcoracoid Dislocation of the Shoulder, show- 
 ing Atrophy of True Glenoid Cavity, together with Formation of 
 New Joint and Alteration in Shape of Head of Bone. A, View krom 
 the Front ; B, from the Outer Side. (From College of Surgeons' 
 Museum.) 
 
 hesions, or the cicatricial contraction of the injured ligaments and 
 muscles, may cause some loss of mobility. 
 
 If a dislocation is alloived to remain unreduced, the true articular 
 cavity becomes shallow and partly filled up by a transformation 
 of its cartilage into fibrous tissue, whilst the displaced head of 
 the bone becomes adherent to the structures amongst which it 
 lies ; as the result of a plastic inflammation, either dense fibrous 
 adhesions are formed, or a new false joint {pseudarthrosis). The 
 articular cartilage is eroded, and the exposed bone eburnated and 
 sclerosed, whilst, owing to chronic periostitis, the end of the shaft 
 may be considerably deformed. The portion of bone upon which 
 
INJURIES OF JOINTS—DISLOCATIONS 
 
 509 
 
 the displaced head rests undergoes changes, partly atrophic (from 
 pressure), partly hypertrophic (as a result of chronic periostitis), 
 whereby a new socket is produced (F'ig. 181). Neighbouring 
 niuscles are secondarily shortened, and accommodate themselves 
 to the abnormal position of the limb, and tendons which have 
 been torn gain fresh attachments. These changes necessarily 
 interfere more or less seriously with the power of the limb and 
 the movements of the joint. 
 
 Treatment. — The treatment of dislocations consists in the re- 
 duction of the displaced bone with as little delay as possible. 
 There are two chief methods of gaining this end, viz., manipula- 
 tion and extension. 
 
 Man ipula tion is always the best means to employ where 
 praHIcable; less injury being sustained by the surrounding tissues. 
 It consists in moving the limb in such directions as shall cause 
 the displaced end to retrace the course that it has ah-eady taken, 
 through the rent in the capsule to its normal position. The 
 shoulder and hip joints are more amenable to this method of treat- 
 ment than hinge joints. Anaesthesia will be required in difficult 
 cases. The special manipulations needed in any particular 
 instance are detailed under the various joints. 
 
 Extension is employed to overcome muscular and other forms of 
 resistance, so as to draw the bone back into its original position. 
 In order to make this effectual, the parts above the dislocation 
 are steadied by some counter-extending force applied either by the 
 hands of an assistant, or by a belt or towel, or by the knee or foot 
 of the surgeon. Extension may be made by the hands, or a 
 firmer grip may be maintained, and greater force used, by apply- 
 ing a bandage or a jack-towel to the limb by means of a clove- 
 hitch. In a few cases, the force may be exerted through some 
 form of multiplying pulley, fixed at one end to a hook or staple, 
 and at the other end to the loop of a towel or bandage attached 
 to the limb. When any such contrivance is employed, precau- 
 tions must be taken to prevent the soft tissues from being injured. 
 A useful plan consists in applying a damp bandage iX the point 
 from which traction is to be made, and over this a thick skein of 
 worsted in the form of a clove-hitch, the loop being attached to 
 the hook of the pulley. The extension must be made continu- 
 ously ; no jolting or jerking action is allowable, or considerable 
 mischief may ensue. Since the introduction of anaesthetics, how- 
 ever, pulleys have been very rarely required, except in dealing 
 with old-standing cases. 
 
 Reduction, however produced, is usually accompanied by a 
 sudden and distinct snap or suction sound, due to the contraction 
 of muscles, unless the patient is deeply under an anaesthetic, and 
 the muscles are absolutely relaxed. The limb is subsequently 
 kept at rest for some days, to allow the rent in the capsule to heal. 
 Cooling lotions are appHed to reduce the swelling, and at the end 
 
510 
 
 A MANUAL OF SURGERY 
 
 of ten days or a fortnif:jht passive movements commence, tofether 
 with friction and massage of the soft parts. 
 
 The treatment of unreduced dislocations is often a matter of con- 
 siderable difficulty. Attempts to reduce them may be undertaken 
 up to two or three months, but no undue violence is permissible, 
 owing to the fact that adhesions to neighbouring parts may thereby 
 be ruptured, and the main vessels or nerves endangered. The 
 use of pulleys has been sometimes recommended, Init so ?iianv 
 accidents have been reported, varying in severity from laceration 
 of the skin io actual avulsion of the limb, that it is better to dis- 
 continue such treatment if it has failed on its first application. 
 
 The amount of mobility possible in .in unreduced dislocation 
 varies a good deal in different cases, and the character of the 
 treatment is mainly governed by this. If movement is toleral)lv 
 free, and not particularly painful, massage and manipvdation may 
 be undertaken, and a very useful limb result. Where, liowever. 
 movement is both painful and limited, operative treatment should 
 be undertaken ; subcutaneous section of muscles and tendons has 
 been practised, but without much success, and the risk, o\vin<f to 
 the fact that the peri-articular structures are displaced and dis- 
 torted, is so great as to render such a procedure unad\isahle. 
 Two chief methods of operative treatment are applicable : (i.) Re- 
 duction by an open operation. The head of the bone is cut down on, 
 and freed from its adhesions to surrounding structures, the capsule 
 of the joint being also opened, and the cavity cleared ; reduction 
 may then be possible by means of manipulation or extension. 
 A few cases of successful treatment of old-standing dislocations 
 of the shoulder by this means have been recorded ; but, as a rule, 
 the gain derived thereby is not commensurate with the risks and 
 di Acuities of the operation, especially if a considerable interval 
 has elapsed since the accident, (ii.) Excision of the displaced head 
 of the bone will give the best result in most cases. In the elbow- 
 joint it is often the only practicable treatment, and in the shoulder 
 and hip it is usually better than attempting open reduction. 
 
 Compound dislocations are almost always serious lesions, for not 
 only is the skin lacerated, and the joint exposed to the risk of 
 septic contamination, but adjacent vessels and nerves are liable 
 to injury. Unless efficient treatment is adopted, suppurative 
 arthritis ensues, leading to disorganization of the articulation with 
 subsequent ankylosis, or, in the case of larger joints, possibly to 
 death from pyaemia and septic poisoning. The treatment consists of 
 the application of the principles of antisepsis already enunciated for 
 the treatment of lacerated wounds, together with reduction of the 
 dislocation. If necessary, the wound in the skin must be enlarged. 
 in order to allow of the replacement of the bone, and, should the 
 latter structure be much bruised or injured, it may be advisable to 
 resect it at once. If, however, vessels and nerves are also injured, 
 or if the patient is old or debilitated, amputation may be required. 
 
INJURIES OF JOINTS—DISLOCATIONS 
 
 S«' 
 
 Special Dislocations. 
 
 Dislocatio n of the LggflL-JaJlf fflny»r><lB is not a very common 
 acciSe'nf ,'" and usually results either from muscular action, or from 
 a blow on the chin when the mouth is widely open, as in gaping, 
 lau'^hing, or attempting to take a large bite. It has also been 
 produced in dentistry by a violent strain during tooth-drawing, or 
 from digging out roots with an elevator. In some persons the 
 accident happens with the greatest ease, and constantly recurs, 
 owing probably to laxity of the capsule or insufficient develop- 
 ment of the eminentia articularis. 
 
 The mechanism of the dislocation is as follows : When the 
 mouth is opened, the condyle of the jaw slips forwards on to the 
 eminentia articularis, and it requires very little force to displace 
 it still further into the zygomatic fossa (Fig. 182). The inter- 
 articular cartilage sometimes follows the condyle, and the attach- 
 ment of the external Dt£LV£oid. iiiusdQ-tQ^hat..strtrcture and to 
 Hie bone explains the occurrence of dislocation from muscular 
 action. 
 
 The displacement may be unilateral or bilateral, more frequently 
 the latter. The mouth remains widely open, the teeth and the 
 jaws being separated by an 
 interval of about an inch. 
 The lower jaw projects un- 
 duly, and is fixed, saliva 
 dribbling over the lip ; 
 speech and deglutition are im- 
 paired, the pronunciation of 
 the labial consonants being 
 especially difficult. A hollow 
 can be detected immediately 
 in front of the tragus, where 
 the condyle is normally 
 lodged, and in front of this 
 holiow the condyle can be 
 felt, being recognised by the 
 slight amount of passive 
 movement still possible. A finger inserted into the mouth may 
 be able to make out the coronoid process in an abnormal position 
 beneath the zygoma. 
 
 When the dislocation is unilateral, the symptoms are much less 
 marked. Some amount of movement of the jaw still remains, 
 whilst the chin is displaced towards the sound side. 
 
 Treatment. — The reduction of the bone is in most cases easily 
 eftected. All that is needed is to depress the condyle below the 
 level of the eminentia articularis, when the masseter, temporal 
 and internal pterygoid muscles speedily draw it back into the 
 
 Fig. 182. — Dislocation of Jaw. 
 
S«2 
 
 A MANUAL OF SURGERY 
 
 glenoid cavity. The patient is seated in a chair ; the surgeon 
 standing in front f^uards his thumbs with thick napkins to prevent 
 being bitten, and introduces them into che mouth, pressin;,' upon 
 the lower molar teeth. Pressure is continued in a downward and 
 backward direction until the condyle is free, and then the chin is 
 raised by the fingers on either side. The jaw is kept at rest for ;i 
 few days by means of a four-tailed bandage. 
 
 . A few cases are on record of displacement of the condyle of 
 the jaw backwards, associated with fracture of the tympanic plate 
 and tearing or separation of the cartilage of the auricle, leadin" 
 to bleeding from the ear. Displacement upwards into the cranial 
 cavity through the roof of the glenoid fossa hjis also been described, 
 the patient in one case dying of meningitis. ^ / 
 
 Dislocation of the Sternal End of the Clavicle. — It ini<:;ht be 
 supposed that displacement at this joint would not be uncommon, 
 when the shape and relative sizes of its articular surfaces are con- 
 sidered, together with the great strains to which it is subjected, 
 Owing, however, to the strength of the ligaments surrounding it, 
 particularly of the rhomboid, this is not the case, the clavicle being 
 broken rather than displaced. The cause of such displacements is 
 violence directed to the acromial end of the clavicle. If the force 
 acts from in front, the bone may be thrown forwards ; if from 
 above, downwards and inwards, the upward dislocation mav 
 occur ; if the shoulder is driven forwards and inwards, the head 
 of the bone may pass backwards. Three varieties are described 
 according to whether the head of the bone tra\'els fonvards, hacl 
 wards, or iipuiards. 
 V In the forward dislocation the end of the bone lies on the 
 anterior surface of the manubrium, where it can be easily de- 
 tected ; all the ligaments of the joint are torn, except, perhaps, 
 the interclavicular. The point of the shoulder is approximated 
 to the middle line. Treatment. — Reduction is eflfected by placing 
 the knee against the spine between the scapulae, and drawing the 
 shoulders backwards, the elbow on the affected side being kept in 
 front of the mid-axillary line. The displacement is very likely to 
 recur, and to prevent this a pad is kept over the end of the bone 
 by a figure-of-8 bandage, whilst the point of the shoulder is 
 pushed outwards by placing a pad on the axilla, and binding the 
 arm to the side. It is advisable to keep the patient in bed for a 
 few days, so as to give the ligaments a better chance of reuniting, 
 but some amount of forward displacement is very likely to! 
 persist. No bad result follows, even should the dislocation] 
 remain unreduced. 
 
 The backward dislocation is not often met with. The head of 
 the bone lies behind the upper part of the sternum, close to the 
 origin of the sterno-hyoid and sterno-thyroid muscles. All the 
 ligaments are ruptured, including the rhomboid. A depression is 
 
INyURIES OF JOINTS— DISLOCATIONS 
 
 SI3 
 
 lie surgeon 
 to prevent 
 
 ssiii^ upon 
 
 mward and 
 the chin is 
 
 it rest for a 
 
 condyle of 
 ipanic plate 
 icle, leadini; 
 
 the cranial 
 ;n described, 
 
 It mi^ht be 
 uncommon, 
 ices are con- 
 is subjected, 
 rrounding it, 
 lavicle being 
 )lacements is 
 If the force 
 irds ; if from 
 ocation may 
 ds, the head 
 ire described 
 hyii'ards, huh 
 
 lies on the 
 be easily de- 
 apt, perhaps, 
 pproximated 
 d by placing 
 drawing the 
 Lieing kept in 
 cry likely to 
 of the bone 
 shoulder is 
 binding the 
 in bed for a 
 of reuniting, I 
 ry likely to | 
 dislocation 
 
 I The head of 
 
 close to the 
 
 Hes. All the 
 
 depression is 
 
 tilt in the usual position of th(3 head of the bone, which may he 
 Miiiietiines detected lyinj,' deejily in the superior mediastinum. 
 The shoulder is thrown forwards, and situated nearer the middle 
 line of the body than usual, whilst the movements of the head 
 and neck are painful and limited. Pressure of the bone upon the 
 trachea, (rsopha^^us, and vessels of the neck gives rise to diffi- 
 (ultv in breathing and swallowing, whilst the consetiuent conges- 
 tion of the head may even cause semi-coma. Reduction by exten- 
 sion of the shoulders backwards is usually accomplished without 
 nmcli trouble. In cases of difficidty, a firm pad can be placed in 
 the axilla, and the shoulder levered outwards by using it as a ful- 
 crum, the elbow l)eing pressed to the side. It is retained in position 
 |iv keeping the shoulders well extended by the use of two hand- 
 kerchiefs, as suggested in the treatment of fractured clavicle. If 
 the condition cannot be reduced, and serious symptoms of pressure 
 risiilt, the head of the bone should be excised. 
 The upward dislocation is one of extreme rarity. The liead 
 ! the bone is felt in front of the trachea, in which situation 
 !t may compress both windpipe and oesophagus, especially when 
 the patient sits up or leans forwards. To effect reduction, a pad 
 is placed in the axilla, and the arm pressed inwards over it ; the 
 I'lhow is subsequently bandaged to the side and well elevated. A 
 pad is at the same time kept o\er the end of the bone, but it is 
 very probable that some amount of displacement will persist. 
 
 Dislocation at the Acromio- clavicular Joint consists in the 
 acromion being forced either abo\e or below the outer end of the 
 
 iclavicle, more commonly the latter. The displacement is easily 
 rico;,'nised by the abnormal prominence 
 ot one or other of the bones (Fig. 183). 
 It usually results from violence directed 
 
 ito the scapula. No difficulty is ex- 
 
 Iperienced in reduction, but the displace- 
 
 jment is very liable to recur, especially in 
 
 [the more conunon form. The elbow is 
 
 [then flexed to a right angle, and pads of 
 [lint or small towels placed o\er the 
 
 lacromion and beneath the elbow ; a 
 bandage or strap is then applied over 
 |lie shoulder and under the elbow, and 
 ^uthces to maintain the bone in position. 
 is kept from slipping by passing a 
 bandage under the strap round the oppo- 
 site side of the chest. Should the displacement persist, and give 
 N to pain or impair the movements of the arm, the bones may 
 wired together after removing the cartilaginous surfaces. 
 A condition is sometimes met with, described as a Dislocation of 
 he Lower Angle of the Scapula, or, better. Winged Scapula. It is 
 
 33 
 
 Fig. 183. — Dislocation 
 Downwards of Acromion 
 FROM THE End of the 
 Clavicle. (Tillmanns.) 
 
SM 
 
 A MANUAL OF SURGERY 
 
 characterized by projection backwards of that part of the 11,^,,^. 
 when the arms are tlirust forwards ; and is due ratlier to [laralysN 
 of the serratus niaj^Mius and rhomboids than to shppiii^' of (|„. 
 fibres of the hitissimus dorsi from the lower anf^de, as was formt'riv 
 supposed. In several cases we have noticed pain and tciujcrnes 
 over the roots of the 5th and 6th ner\ es in the neck, suij;<;estin" 
 its dependence on a chronic neuritis of these trunks. A siiniliK 
 condition is sometimes noted in progress'^': muscular iitruphv. 
 The Treatment consists in the administration of strychnine, and 
 the use of massaj^'e and of the faradic current, whilst, if p^. 
 sistent, a properly applied apparatus may correct the deforniitv, 
 
 Dislocation of Jlift^.Sh5.ulder occurs almost as fretjuently as all 
 the otTier dislocations of tlie body put together._ The shallowness 
 of the f^denoid cavity, the size of the head of the hunurus, the 
 laxity of the capsule, the extent and force of the movements 
 possible, and the exposed position of the shoulder, e\|)lain the 
 f^reat frequency of the accident. It usually results from falls i 
 upon the hand or elbow, the arm at the time of the accident 
 being widely outstretched, to enable the individual if possihle to 
 save himself. The weak lower and inner part of the capsule 
 receives the chief portion of the shock, and yields, the liead of the 
 bone being primarily displaced downwards into the axilla (sub | 
 glenoid variety), and then, according to the direction of the force, 
 or the character of the subsequent manipulations, the head tra\el>| 
 either forwards (gubcoracoid or subclavicular dislocation) or ba.ck J 
 wards (subspinous). Falfs ori" the ettiOW'O'f "sHoulder may, howl 
 evSV,"c'auS'e "a" dtl^'CT' forward or backward displacement. 
 
 The Signs of a dislocation of the shoulder are suflicientlyi 
 obvious, and certain characteristic features are met with in almostl 
 all \arieties. (i) The shoulder looks flattened, owning to displace! 
 ment of the head inwards (Figs. 133, B and 186), and as a resuiij 
 of this the acromion process is unduly prominent, and a hollow felt [ 
 below it, occupied by the tense deltoid. (2) The head of the Iwiiej 
 lies in some al)normal position, and the glenoid cavity is emptyl 
 (3) The elbow is displaced away from the side, and it is iiiij 
 possible to make it touch the chest wall at the same time than 
 the hand is placed on the opposite shoulder (Dugas' test) ; tlii| 
 does not always obtain in the subcoracoid type. ' (4) The vertical 
 measurement round the axilla is increased in all the varieties (Callj 
 away's test) ; whilst inspection reveals a lowering of the anterioJ 
 or posterior axillary fold (Bryant's test). (5) A ruler or straight! 
 edge can be made to touch both the acromion process and the oiitel 
 condyle of the elbow in most cases of dislocation (Hamilton's rulel 
 test) ; this is impossible when the head of the bone is in its noniiaT 
 position, but can also occur in fractures of the anatomical neq 
 At the same time, the usual signs of a dislocation, viz., rigiditj 
 and local bruising, are also present. 
 
INJURIES OF JOINTS DISLOCATIONS 
 
 S>5 
 
 Subglenoid Dislocation (I'l^- ^^■\) is the primary condition met 
 
 \vali ill nil cases where the accident is due to a fall upon the out- 
 
 i stretched arm, hut is not commonly seen, since the head of the 
 
 [vine usually slips up under the coracoid, as before stated. The 
 
 l,(;,i(l of the hone passes downwards into the axilla, restinj^^ 
 
 against the outer border of the scapula below the fjflenoid cavity, 
 
 lietween the subscapularis above and the teres minor below, 
 
 I whilst tlu' long head of the triceps is placed behind. The capsular 
 
 ligament and muscles passinj,^ to the tuberosities are lacerated, 
 
 I whilst the axillary vessels and nerves may be seriously com- 
 
 I pressed. The head of the bone is detected in the axilla, and 
 
 the anterior axillary fold is much lowered; the elbow is directed 
 
 (awav from the side and slightly backwards; the arm is 
 
 [leni,'thene(l, perhaps to the extent of i inch, whilst the forearm 
 
 [is usually llexed, and the fingers may be numbed from pressure 
 
 Ion the nerves. 
 
 ^ir, 184.— Subglenoid Dislocation Fig. 185. — Subcoracoid Dislocation 
 OF Shoulder. (Tillmanns.) of Shoulder. (Tillmanns.) 
 
 .\ few cases have been recorded in which the arm was abducted 
 hi displaced vertically upwards, although the head of the bone 
 ps in the usual position of a subglenoid dislocation. This 
 [ariety is known as the luxatio evecta. 
 
 Subcoracoid Dislocation (Figs. 185 and 186) is, without doubt, 
 he most common form. In it the head of the bone lies under 
 pe coracoid process on the anterior part of the neck of the 
 bpula, immediately in front of the glenoid cavity, the anato- 
 mical neck impinging on its anterior border. In this position it 
 I above the tendon of the subscapularis, which is either torn or 
 Iretched over the neck as a tense band, and may considerably 
 npede reduction. Two forms of this displac;ement are described 
 
 Malgaigne, according to whether the muscles attached to the 
 
 33—2 
 
S«6 
 
 A MANUAL OF SUh'Cnh'Y 
 
 ^veai tuberosity ;iro intact, R'snltiiif; in marked external roiaim,, 
 of the linil) (subcoraioicl variety), or whether they are la( oiaicd, 
 or even the j^reat tuberosity itself pulled off, the hunicnis Iihuj 
 then rotated inwards (intracoraioid \ariety). in both tyiics ih,. 
 elbow is ilisj^laced backwards and outwards, and the head of the 
 bone can be usually felt with ease, especially on rotation of ilie 
 arm, under the outer third of the cla\icle, except in stout people 
 or wlu>re the muscles are f;r(>atly developed. C'omparativ cly liiiie 
 alteration in tin* length of the arm is produced. 
 ,_^'rh(> Subclavicular variety is very uncommon, and nicidv ,iii 
 
 
 
 
 
 
 
 ^_^ 
 
 ^ 
 
 Bi^*»^^ 
 
 
 m 
 
 s*.* 
 
 
 SbES 
 
 
 \ k 
 
 1 
 
 V ■ "- " '-'T^ 
 
 1 ''T^K 
 
 
 4, 
 
 1 -■-^^?;?-*-'" 
 
 iL * j^^l 
 
 
 I'-Ki. iSG. — Slucoracou) Dislocation ov thk Ruiiit Siioii.dkk. 
 
 vxa<:jij;eration of the subcoracoid. The head of the luunerml 
 passes further inwards, and lies deeply under the pectoralis majorj 
 •on the second and third ribs. The capsule and surrounding 
 muscles are much lacerated, or perhaps the jj^reat tidierosity torn! 
 ■olT; the elbow is markedly separated from the side and directedj 
 a, little backwards, whilst distinct shortening is present. 
 
 The Subspinous Dislocation (Fig. i^Sy) is not freciuentiy meJ 
 with. The head of the bone lies in the infraspinous fossa, ini-j 
 mediately behind the glenoid cavity, between the infraspinatus! 
 and teres minor muscles, the subscapularis being usually tornJ 
 
INJirh'll'lS Oh JOINTS DISI.OCAI IONS 
 
 517 
 
 srnal \\)Va\h\ 
 ari! l;i(X' rated, 
 lunuTus liciiiji 
 lolh types ihc 
 e licail of till. 
 rotation of the 
 n stout people 
 larati^ dy liltle 
 
 lul nicu'lv ail 
 
 'll 
 
 Siiori.iiKK. 
 
 the hunu'insl 
 
 Ic-toralis majorJ 
 
 Icl siuroundinJ 
 
 Ituberosity tornj 
 
 and clirecte 
 
 kent. 
 
 [reciuently mei 
 
 lous fossa, inij 
 
 inffaspinatiisl 
 
 usually torn! 
 
 Mal'^'iif,'"^^ states tliat the head of tlic hmiu;nis is most ccmmonly 
 
 foiiml it'stiii^ on th<' posterior edf^e of tlic glenoid cavity iniinedi- 
 
 iiloiy lu'low llic! acromion process (suh- 
 
 aiiomial variety). Tiie elbow is displaced 
 
 considerably forwards, hut can be made 
 
 to toiuli the chi'st wall ; the arm is 
 
 rotated inwards, so that the hand is 
 
 thrown across the front of the body. 
 
 There i^ 
 
 usually a marked hollow Ik; 
 til tiu! coracoid process, whilst a dis- 
 t iMoininence is laused by the h(;ad 
 
 nca 
 
 tiiict pr 
 
 of the hone in its false positif 
 
 )n. 
 
 T 
 
 Iciii 
 
 ;tli of the lind) is frecjuently un- 
 
 alTectc 
 
 if 
 
 •h 
 
 It, 
 
 l'"iii. 187. Sciisi'iNors I )is- 
 
 l.OCATION OK SlIOCI.DlCK. 
 ('I II. I, MANNS ) 
 
 fe IS present 
 the arm is slifj;htly lenf^thened. 
 
 Tlire(! or four cases have been de- 
 scribed of what is known as a Supra- 
 coracoid. Dislocation. Tlu; head of the 
 lione is here displaced upwards, and 
 either the coracoid or acromion process 
 
 is broken, more connnonly the former. keplacemeiit willi 
 crepitus is easily obtained, but the dislocation is liable to recur. 
 
 The Treatment of Dislocation of the Shoulder consists in reduc- 
 tion by manipulation or extension. 
 
 1. For miiiiiioii I)y titdiii/ idiilioii an ana'sthetjc is adviaiil)lc!,.thpuf,di 
 notnlm(^hil(dy (isseptid l.and preferably chloroform, aUhou},di when; 
 the patient is in a bad state for the administration, i.e., with his 
 stomach full of food, ether may be preferable, it is only rif^ht to 
 I draw attention to the fact that a lar^^e number of fatal cases of 
 chloroform administration have been reported as occurrin*^ in the 
 treatment of shoulder dislocations; this is due mainly to two 
 I causes, viz., the deep ana'sthesia retjuired, and the want of pre- 
 paration of the patient. The jj;reatest care must therefore be 
 [exercised in {giving the ana'sthetic. 
 
 Many different methods of manipulation have been suf^gested, 
 [of which the following are the more important. Not unfrecpiently, 
 where the muscles are relaxed, any slight rotary movement suffices 
 jto' put the bone in.' 
 
 Koclin''s Method. — The surgeon standing in front of his patient, 
 Iwho is seated or reclining, grasps the elbow after flexion of the 
 [forearm, and presses it to the side. The arm is now rotated firmly 
 [and steadily outwards until the forearm is at right angles to the 
 [body, when distinct r;!sistance will be felt. This causes the head 
 [of the humerus to roll out beneath the acromion, and is often 
 [sutificient to effect reduction ; but if the limb is still displaced, the 
 [elbow should be drawn forwards to the median line and elevated, 
 kith the hand still abducted and everted, whilst finally the arm 
 lis rotated inwards so as to carry the hand towards the opposite 
 
Si8 
 
 A MANUAL OF SURGERY 
 
 shoulder, and the elbow lowered. This plan is most useful in 
 subcoracoid dislocations, and the explanation given by Kocher of 
 this method turns on the fact that the posterior part of the capsule 
 and the scapular tendons inserted therein are usually untorn and 
 stretched tightly across the glenoid fossa. Rotation outwanls 
 relaxes this structure and removes it from the fossa, whilst the 
 rent in the capsule gapes, but owing to the fact that the upper 
 and lower margins of the opening are still tight, the head of the 
 humerus remains fixed against the neck of the scapula until the 
 elbow is carried forwards and raised. The upper part of the 
 capsule then relaxes, and the lower part which remains tense 
 guides the head of the bone into the joint. 
 
 Smith's Method varies somewhat in its application, according to 
 whether the head of the bone is displaced anteriorly or posteriorlv. 
 For anterior displacements the surgeon stands in front of the 
 patient, and grasps the shoulder, using the right hand for the 
 right shoulder and the left for the left, so that the thumb rests on 
 the head of the bone, and the fingers grasp and steady the scapula. 
 With the other hand he seizes the arm near the elbow which has 
 been flexed, and raises it from the side, extending and everting it. 
 Having thus raised it to a right angle, the limb is steadily and 
 continuously circumducted inwards, the thumb following the head 
 of the bone and assisting it to reach the lower and under side of | 
 the capsule, and thus enter the socket through the rent. For the 
 subspinous dislocation, the surgeon stands behind the patient and 
 grasps the shoulder with one hand, raising the arm with the 
 other, and making extension backwards combined with external 
 rotation ; i.e., the limb is circumducted outwards, and finally 
 brought to the side. 
 
 2. Extension may be made in different ways, the object of all 
 however, being to overcome the tension of surrounding ligaments I 
 and muscles. It may be applied directly downwards by the 
 surgeon grasping and pulling on the arm, whilst his unbooted 
 foot is used as a counter-extending force in the axilla, the patient 
 lying flat on a mattress placed on the ground, and the surgeon 
 sitting by the side. Another plan consists in using the knee as a | 
 fulcrum instead of the heel, the patient sitting in a chair. Occa- 
 sionally the foot has been placed against the thoracic wall, and I 
 extension made directly outwards at right angles to the body, as 
 recommended by Sir Astley Cooper. White of ^Manchester 
 suggests vertical traction, the arm being pulled directly upwards, 
 the surgeon's foot having been placed over the acromion, the 
 patient being in the recumbent posture. The only objection to 
 this last method, which may succeed where other plans fail, isj 
 that the axillary vessels are somewhat exposed to injury. 
 
 Dislocations of the Elbow-Joint are not very uncommon, occur 
 ring particularly in young people, and are due to either director! 
 
INJURIES OF JOINTS— DISLOCATIONS 
 
 519 
 
 indirect violence. The diagnosis is often difficult from the amount 
 of swelling that quickly follows. A careful investigation of the 
 relative position of the bony points (p. 423), and of the degree 
 of mobility of the different parts on each other, is essential in 
 order to arrive at a definite conclusion as to the exact nature of 
 the lesion. In cases of doubt, a skiagram should, if possible, be 
 taken. 
 
 A considerable variety of displacements is met with, involving 
 either one or both bones. 
 
 1. Dislocation of Both Bones may occur either hachvavds, for- 
 ■ards, or laterally. 
 
 The backward variety (Fig. 136 A) is that most often met with ; 
 .it usually occurs without either the coronoid process or the 
 olecranon being fractured, although occasionally the former is 
 detached. If the coronoid remains intact, it sometimes becomes 
 locked in the olecranon fossa, and renders the arm immobile ; if, 
 however, it is broken, considerable mobility of both bones occurs, 
 with crepitus. The forearm is semi-flexed, the hand held midway 
 between pronation and supination, 
 and the displaced bones form a con- 
 siderable swelling at the back of the 
 
 joint, ibove which is a marked liollow, 
 crossed by the triceps. The lower 
 end of the humerus projects in front, 
 and the artery and the soft parts are 
 displaced forwards. The measure- 
 ment from the acromion process to 
 the external condyle remains un- 
 altered, but that from the condyle to 
 the styloid process of the radius is 
 distinctly shortened, and the distance 
 between the condyles and the ole- 
 cranon process is increased. 
 
 Dislocation forwards of both bones 
 rarely occurs without fracture of the 
 olecranon process, although a few 
 cases of this unusual accident are on 
 record. The displacement is readily 
 detected, the forearm being length- 
 ened perhaps to the extent of an 
 inch. The arm is in a condition of 
 tiexion, and, indeed, the accident can 
 only take place from falling back- 
 wards on the point of the elbow when 
 in this position. The triceps muscle 
 may be considerably lacerated. 
 
 Lateral dislocations of the forearm are almost always incom- 
 plete and are not very frequent ; the bones may be displaced either 
 
 Fig. 188. — Redl'ction of B.\ck- 
 WARD Dislocations at the 
 Elbow. 
 
520 
 
 A MANUAL OF SURGERY 
 
 inwards or outwards, the latter hcinj^^ tlie more common. Tl,^.y 
 are recognised by a careful examination of the relative i)()piti()ii 
 of the bony prominences. 
 
 2. Dislocation of the Ulna alone occurs only in a Imckworii 
 direction. It is an occurrence of the greatest rarity, owiiif,' i, 
 the position and strength of the orbicular and ol)lique lig;uiiem> 
 and of the interosseous meiubrane. If, howe\er, the Ixjiies oi 
 the forearm are rotated backwards upon the head of the radius as 
 a fulcrum, and tlien the forearm adducted, this disphueineni 
 can occur without extensive ligamentous lacerations, am! as a 
 point of fact they ha\e not been noted in any of the few casts 
 observed. 
 
 The Treatment of the above dislocations is carried out alon.; 
 the same lines, all that is necessary being to unhitch the inter 
 locking bony prominences, so as to allow the bones to return in 
 their normal positions by muscular contraction. This is usually 
 accomplished by the method described originally by Sir Astiev 
 Cooper. The patient being in a sitting position, the surffeoii 
 presses backwards, with his knee in the bend of the ell)o\v, 
 against the lower end of the humerus ; at the same time he 
 grasps the patient's wrist, and slowly and forcil)ly bends the 
 forearm (Fig. i88). 
 
 3. Dislocations of the Radius alone may occur either fovwani^. 
 hach'i'ards, or out7i.m'ds. 
 
 The forward dislocation (Fig. 189) is that usually seen, and 
 results from falls on the haiid when tlie forearm is in a stated 
 extreme pronation. The head of the radius rests against tlu 
 
 lower end of the humerus in thr 
 hollow above the capiteliuni, and 
 the most characteristic feature 
 consists in the inal)ility of the 
 patient to flex his forearm, owini: 
 to the bone impinging against tlif 
 lower end of the humerus. It 
 can be readily detected in tlii> 
 situation, rotating with the move- 
 ments of the forearm, whilst a 
 deep hollow is felt behind, imim- 
 diately below^ the external condyle. 
 Fic. 189.— DisLocATiox OF THE Tlic foreami is somewhat flexed, 
 Radius Forwards. (Pick.) ^nd midway between pronation 
 
 and supination ; the former act can 
 be satisfactorily accomplished, but supination cannot he carried 
 hirther than half-way. A marked fulness exists on the anterior 
 aspect of the limb when the arm is extended. Fracture of the , 
 upper third of the ulna sometimes accompanies this accident. 
 especially when produced by direct violence (Plate XXIII.). If tlii-; 
 luxation is not reduced, \ery great impairment of the niohilityot 
 
PLATE XXII 1, 
 
 I'ISLOCATION ()!<• KaUIL'S FOKWAKUS, AMJ FkXCTUKE OF Hl'l'EK ThIKD OK UlNA. 
 
 To/acf/: 520.] 
 
;lie liii 
 
 iiiipossi 
 
 troin th 
 
 with prf 
 
 the orb 
 
 til recti 
 
 mterdic 
 
 .Ulterior 
 
 ,1 splint. 
 
 Disloc 
 
 die exte 
 
 can be c 
 
 dexed, a 
 
 hut littb 
 
 Disloc 
 
 (iisplacec 
 
 easily b( 
 
 moveine 
 
 out diffic 
 
 Occas 
 
 ulna pas 
 
 deformity 
 
 A \'er; 
 
 tion of 1 
 
 lif,^iiiient, 
 
 jietween 
 
 of the ha 
 
 as pulled 
 
 comes fix 
 
 tie \ ion, a 
 
 with the ] 
 
 by comp! 
 
 and subs 
 
 and leave 
 
 It mus 
 
 we have 
 
 the pure 
 
 practice c 
 
 nature ar 
 
 the shape 
 
 both con 
 
 much di 
 
 These fra 
 
 I rise to so 
 
 '^ is fre(]i 
 
 ; the nature 
 
 I It is doul) 
 
 the nature 
 
INJURIES OF JOINTS— DISLOCATIONS 
 
 fftl 
 
 the limb results, flexion beyond an obtuse angle becoming' 
 impossible. Treatment. — Reduction is accomplished by traction 
 from the wrist, with the forearm flexed to a right angle, combined 
 with pressure over the head of the bone. Owing to the fact that 
 the orbicular ligament is ruptured, the deformity is very likely 
 to recur, and hence active movements of the limb must be 
 interdicted for three or four weeks ; a pad may be placed 
 anteriorly over ihe head of the bone, and the limb kept flexed on 
 a splint. 
 
 Dislocation backwards is less connnon. The head lies behind 
 the external condyle on the outer side of the olecranon, where it 
 can be detected on rotating the limb (Fig. igo). The forearm is 
 flexed, and the limb pronated. Even if left unreduced, it leads to 
 but little inconvenience. 
 
 Dislocation outwards is also rare, the head of the l)one being 
 displaced to the outer side of the external condyle, where it can 
 easily be felt, causing considerable impairment of the natural 
 movements. Reduction of these conditions is accomplished with- 
 out difficulty. 
 
 Occasionally a rare form of dislocation is met with in which the 
 ulna passes backwards and the radius forwards, resulting in great 
 deformity. 
 
 A very common accident in children consists of a subluxa- 
 tion of the bead of the radius downwards within the orbicular 
 hfjament, so that a portion of it sHps up and becomes nipped 
 between the head and capitellum. It results from forcible traction. 
 of the hand, and is a common nursery accident, popularly known 
 as pulled elbow. The limb be- 
 comes fixed in a position of semi- 
 flexion, and the child cries out 
 with the pain ; it is readily treated 
 bv completely flexing the limb, 
 and subsequently extending it, 
 and leaves no bad results. 
 
 It must not be forgotten that 
 we have here merely described 
 the pure dislocations. In actual 
 practice complications of a serious 
 nature are frequently present in 
 the shape of fracture of one or 
 both condyles, which lead to 
 much difficulty in diagnosis. 
 These fracture -dislocations give 
 rise to so much haemorrhage that 
 
 " is frequently impossible to come to a correct conclusion as to 
 the nature of the case without the assistance of the Rontgen rays. 
 It is doubtful, however, whether even an accurate knowledge of 
 ilie nature and extent of the lesion will enable us to improve on 
 
 Fig. 190. 
 Radius 
 
 MATIC). 
 
 - Dislocation of the 
 Backwards (Diagram- 
 
522 
 
 A MANUAL OF SURGERY 
 
 the results hitherto gained, apart from operation. So much callus 
 is likely to be forniecl, and fibrous adhesions of such stren^ifth are 
 often developed, that considerable impairment of function is 
 almost certain to ensue. Probably the best line of practice is to 
 keep the elbow at rest on a rectangular splint for a week or ten 
 days, so as to allow the immediate effects of the accident to pass 
 off, and then to make an aseptic incision, dealing with tlu' condi- 
 tion of affairs in the way best suited to the requirements of the 
 particular case. 
 
 Dislocation of the Wrist is a xery uncommon accident, and mav 
 occur fovwayds or backwards. The lower ends of the radius anil 
 ulna become prominent under the skin, and especially the styloid 
 processes. By this means it is easily distinguished from a fracture 
 of the lower ends of the bones. 
 
 Occasionally the radius, carrying with it the hand, is dislocated 
 from the lower end of the ulna, as a result of forcible pronation. 
 This is usually described as a hachmrd dislocation of the ulna, and 
 is easily reduced by manipulation. 
 
 Dislocations of various Carpal Bones have been described, but 
 
 the only one which is at all 
 common is a displacement of 
 the OS magnum backwards. It 
 forms a rounded prominence 
 under the skin in the usual 
 situation of the bone, which 
 becomes more prominent on 
 flexion, and may disappear on 
 extension. As a rule, it is 
 readily reduced, but is very 
 likely to recur. 
 
 Dislocations of the Meta 
 carpal Bones and Phalanges 
 are not unfrequent, but need 
 no special mention, except in 
 the case of Dislocation Back- 
 wards of the First Phalanx of 
 the Thumb. The chief inte- 
 rest in this case lies in the 
 Fig. 191. — Dislocation of Thumb, difficulty that has been e.\- 
 sHowiNG Head of the Metacarpal pgrienced in reduction, and! 
 NG Forwards BETWEEN ^,. , 1., ^h^, I 
 
 Bone protrudi 
 
 THE Heads of the Short Flexor 
 
 Muscle. (Pick.) 
 
 which was erroneously attri- 
 buted to the head slipping 
 between the two portions of 
 the flexor brevis pollicis and being grasped by them, as a button 
 in a buttonhole. It has now been shown that there are two 
 
INJURIES OF JOINTS- DISLOCATIONS 
 
 523 
 
 much more important factors, viz., the tension of the lonj^ flexor 
 tendon, which hitches round the neck (Fi^. 191), and the arrange- 
 ment of the glenoid ligament. Tliis structure passes between the 
 two heads of insertion of the short flexor, and is thus incor- 
 porated between the two sesamoid bones ; it consists of fibro- 
 cartilage, and, whilst firmly attached to the base of the phalanx, 
 is but loosely connected with the head of the metacarpal 
 bone, so that it accompanies the phalanx in its disloca- 
 tion. It thus comes to be situated immediately behind tlie head 
 of the metacarpal, and opposes any attempts at reduction. 
 Treatment. — Traction and manipulation should always be at- 
 tempted in the first instance. The thumb is grasped by a suit- 
 able apparatus and hyper-extended to a right angle, thus making 
 the head of the metacarpal project still further through the nms- 
 cular interspace, and, as it were, enlarging the buttonhole. Still 
 keeping up the extension, the thumb is rapidly flexed into the 
 palm, the metacarpal bone being at the same time pressed in- 
 wards. Should this fail, as it often will, a purified tenotome 
 should be inserted in the middle line of the thumb behind, imme- 
 diately above the base of the phalanx, and should be pushed on 
 till it reaches the glenoid fibro-cartilage, which is divided by it 
 between the sesamoid bones ; this little manoeuvre will at once 
 render replacement simple (J. Hutchinson, jun.). 
 
 Dislocation of the Hip, though not very common, is a condition 
 of extreme gravity. The depth of the socket in which the femur 
 rests, and the strength of the muscles and ligaments surround- 
 ing the articulation, explain the comparative infrequency of the 
 accident. It is never produced by direct violence, but always 
 results from a force applied to the feet or knees, or, if the legs be 
 tixed, to the back. It is rarely met with except in young people 
 or adults, since after the age of forty-five fractures of the neck of 
 the bone are much more likely to occur. 
 
 In considering these dislocations, the relative strength or weak- 
 ness of the different parts of the capsule and its surrounding 
 structures must be remembered. Thus, the weakest part of the 
 capsule is placed below and behind^ and the fibres here are easily 
 lacerated ; indeed, it is through a rent in this part of the capsule 
 that the head of the bone most frequently escapes from the 
 articulation. In front, the ilio-femoral or Y-shaped ligament of 
 Bigelow, extending from the anterior inferior iliac spine to the 
 I anterior intertrochanteric line, is a structure of much strength, 
 I on the integrity of which depends the fact whether the displaced 
 ; head of the bone shall occupy some definite position or be freely 
 'moveable. Hence Bigelow, to whom we owe so much in the 
 elucidation of the mechanism of these dislocations, has divided 
 them into two great classes — the regular and the irregular — accord- 
 ling to whether this ligament is intact or completely lacerated. 
 
iH 
 
 A MANUAL OF SURGERY 
 
 Posteriorly, the tendon of the obturator internus muscle, consist- 
 ing of a mass of plicated tendinous tissue, is the most iiiii)ortan; 
 structure to be considered, and according to whether it is rupiuiei! 
 or not depend in some measure the position and level of tlie boni 
 on the dorsum ilii. It must also be remembered that the Hj^m. 
 mentum teres is relaxed when the thigh is forcibly abducted, and 
 is made tense by adduction. 
 
 Four chief varieties of dislocation are described, in two of 
 which the head of the bone is displaced posteriorly, and in two 
 anteriorly. The two former are known as the Dorsal and the 
 Sciatic varieties, although Dorsal belorv the tendon, as orif,finallv 
 suggested by Sir iVstley Cooper, is the better appellation for the 
 latter variety. The two anterior dislocations are known as the 
 Obturator or Thyroid, and the Puhic ; in the former the head 
 of the bone is located in the obturator notch, and in the latter 
 upon the pubic ramus. The relative frequency of these disloca- 
 tions is as follows : About 50 to 55 per cent, of the cases art 
 of the dorsal type, 20 to 25 per cent, sciatic, 10 to 15 percent. 
 obturator, and 5 to 10 per cent, pubic. In addition to these four 
 varieties, many other slight modifications have been described, 
 which it will be unnecessary to further particularize. 
 
 The exact Mechanism of dislocations of the hip is still more or 
 less a matter open to discussion. Some surgeons strongly main- 
 tain the opinion that the limb is always in a position of abduction 
 at the moment of dislocation, the head of the bone escaping from 
 the capsule through a rent in the lower and back part of the 
 ligament, and thus being primarily displaced downwards. ^The 
 type of accident responsible for this is when the patient falls with 
 the legs widely separated, or when the limbs are drawn forcibly 
 apart, as, for instance, when one leg is placed on a boat just 
 moving away from a pier on which the other is fixed. The direc- 
 tion of the violence, or the subsequent manipulations performed 
 by willing but ignorant friends, or the voluntary movements of 
 the individual, determine what form of dislocation is to be sub- 
 sequently produced. If the limb is externally rotated and ex- 
 tended, the head travels forwards, and either the pubic or obtura- 
 tor variety results. If, however, the leg is inverted and flexed, 
 the head of the bone passes backwards, and either the dorsal or 
 sciatic form is produced. Again, in the posterior dislocations, if 
 the obturator internus tendon remains intact, it may hitch across 
 the front of the neck, and prevent any further upward displace- 
 ment of the bone, thus giving rise to the so-called sciatic variety: 
 but if the tendon is ruptured, or if the head of the bone slips in 
 front of it, there is no obstacle to its upward displacement on the 
 dorsum ilii. 
 
 Bigelow, however, and with him many other surgeons, main- 
 tain that dislocation of the hip does not only occur with the Hmb 
 in a position of abduction. Under certain circumstances, it may 
 
INJURIES OF JOINTS DISLOCATIONS 
 
 525 
 
 also result when the hmb is in a position of adduction, a diyect 
 iloml dislocation hein^' thus produced, the head of the hone escaping,' 
 (i-oin the capsule abo\e the tendon of the obturator internus ; such 
 an accident is sometimes, but not always, associated with fracture 
 of tlie posterior lip of the acetabulum. The type of violence 
 leadin},' to this occurrence is when a heavy weif^ht falls on the 
 lack of a person whilst kneeling, or when, his knee being fixed, 
 the hody is thrust forwards, so that the limb is forcibly in\erted. 
 It, however, the thigh is in a position of extreme flexion, the head 
 may he displaced below the tendon of the 
 obturator internus, ^nd the sciatic variety 
 ttijl then result. \/ 
 
 I. Dorsal Dislocation (Fig. 192). — The 
 head of the bone in this form is found 
 Ivinj: on the dorsum ilii, a \'ariable dis- 
 tance ahove and behind the acetabulum, 
 and always above the obturator internus 
 tendon. It maybe detected on manipula- 
 tion of the limb, although in muscidar 
 subjects this is difficult. The ligamentum 
 teres is necessarily ruptured, as also the 
 capsule, the rent being situated either 
 l)elow or above the obturator tendon 
 according to whether the dislocation is 
 due to forcible abduction or adduction. 
 The small external rotator muscles are 
 usually lacerated, and perhaps even the 
 i;lutei and the pectineus. The ilio-femoral 
 ht,'ainent usually remains intact. The 
 !,'reat sciatic nerve is sometimes com- 
 pressed or contused. The trochanter is 
 raised al)o\e Nelaton's line (p. 441), and 
 approximated to the anterior superior 
 spine ; the ilio-tibial band of fascia is 
 therefore relaxed, and there is consider- 
 able shortening of the limb, amounting 
 often to 2 or 3 inches. The leg is in a 
 position of flexion, adduction, and in- 
 version, so that the axis of the femur 
 crosses the lower third of the sound thigh. 
 The knee is semi-flexed, and the ball 
 of the great toe rests against the opposite 
 instep ; the heel is somewhat raised. A marked hollow is felt in 
 the upper part of Scarpa's triangle, and the main vessels of the 
 limb appear to be unsupported. 
 
 Tlie Diagnosis should be easy, the only difficulty being ex- 
 perienced in distinguishing it from an impacted extra-capsular 
 tracture. The character of the accident, the presence of adduction 
 
 Fig. 192. — Dorsal Dislo- 
 cation OF THE Hip. 
 
 (TiLLMANNS.) 
 
526 
 
 A MANUAL OF SURG FRY 
 
 and inversion, the increased breadth of the trochanter in the case 
 of fracture, and the abnormally pl;;ced head of the bone in dlslo. 
 cation, are the points to wincli attention must be directed in 
 makinf^f a diaf^nosis. 
 
 2. Sciatic Dislocation, or dorsal below the tendon, is ono in 
 which the head of the bone is prevented from travellinjij upwards 
 to the dorsum ilii by the intej^M'ity of the obturator inteinns 
 tendon, as already described. It may occur either from torctd 
 abduction of the limb, or from extreme Hexion in the adducteil 
 position. The lesions of nuiscles and lif,'aments are practically 
 the same as for the dorsal variety. The ilio-femoral lij^'anicnt b 
 uninjured. 
 
 The Signs resemble those of a dorsal dislocation, bat are less 
 marked. There is less shortening,', often not more than \ to i inch : 
 the limb is flexed, adducted, and inverted, but the axis of iIr 
 fenuir is directed across the opposite knee, and the great toe rests 
 against the ball of the great toe of the opposite side. The head 
 of the bone is often much less distinct, owing to the greater thick 
 ness of the glutei muscles at that level. 
 
 Treatment of the Two Backward Dislocations is effected in nuich 
 the same way, whether the dorsal or sciatic variety is present, 
 
 The most usual method is that of imwi- 
 pnlation and rotation, so accurately worked 
 out by Bigelow. The patient is anasthe 
 tized, preferal)ly on a mattress placed on 
 the floor. The leg is hrst flexed on the 
 thigh, and the thigh on the abdomen, tht- 
 position of adduction being still maintained, 
 so tha*^ the knee extends beyond the middle 
 line of the body (Fig. 193). This position 
 is maintained for some moments, and then 
 the limb is freely circumducted outwards. 
 and brouglit rapidly down into a position 
 of extension parallel with the other. By 
 this manoeuvre the tense structures in front 
 of the joint are relaxed, and then the head 
 of the bone is made to retrace its course 
 towards the rent in the capsule, and finally 
 directed upwards into the acetabular cavity. 
 These movements are tersely summarized in Bigelow's words- 
 ' Lift up, bend out, roll out.' 
 
 If this plan does not succeed, the following method of tracim 
 may be employed. The patient, lying on his back, is firmly fi.ved 
 by a bandage or towel passed over the pelvis and secured to two 
 or three hooks or staples driven into the floor. The surgeon 
 stands over the patient, whose thigh is flexed to a right angle on 
 the abdomen, as also the knee upon the thigh. The surgeon's 
 arms are passed under the knee sufficiently far to enable him to I 
 
 Fig. 193. — Reduction of 
 Dorsal Dislocation 
 OF Hip. (Bryant.) 
 
INyURlES OF JOINTS DISLOCATIONS 
 
 527 
 
 ((Hisp hi? own elbows, .ind the front of th(' leff is steadied ar^ainr^t 
 the opt'iator's perineum. Direct and foreihie traction iipwartls can 
 iiiiw be made, and this is often sufficient in itself to lift the head 
 i)t the bone into the acetabulum. If tiiis is unsuccessful, the move- 
 imnts described above can be enerf^^etically repeated in this posi- 
 tiiin, The above plans, combined with the use of an anu'sthetic-, 
 rarely tail in reducinfj; a backward dislocation of tiie hip, and hence 
 (\taisioii liy means of pulleys '\i^ rarely recpiired. If, howe\er, it is 
 lUL'dcd, traction should always be made in the direction of the 
 
 liG. 194.— Dislocation of the Hii> : 
 Obturator Variety. (Tillmanns.) 
 
 Fig. 195. — Dislocation ok the 
 Hip Forwards: Fubic Varietv. 
 (Tillmanns.) 
 
 [displaced limb, /.^., across the other thigh, counter-extension beinj^ 
 
 obtained by a jack-towel passed between the injured thigh and 
 
 the perineum, and fixed to a staple in the floor, close to the head 
 
 of the patient, and on the side of the dislocation. When sufficient 
 
 force has been applied, the surgeon rotates the limb outwards, 
 
 [SO as to allow the head of the bone to once more slip into its socket. 
 
 3. Thyroid or Obturator Dislocation (Fig. 194). — The head of 
 
 jthe hone in this case passes downwards through a rent in the 
 
 jlower part of the capsule, and its position is subsequently but 
 
 jlittle altered, a slight forward and upward movement being alone 
 
52S 
 
 A MANUAL OF SURGERY 
 
 superadded. The ilio- femoral ligament is untorn, hut the pectineus 
 and adductors are very tense, or may even be lacerated ; the 
 ligamentuni teres is, of course, ruptured. The head lies on the 
 ol)turator externus muscle, and can be detected in the perineum, 
 The trochanter is less prominent than usual, and, indeed, its 
 normal position may be represented by a depression. The limb 
 is slightly abducted and everted, as well as lengthened, perhaps 
 to the extent of 2 inches, though this is more apparent than real. 
 It is also flexed, owing to the tension of the ilio-psoas muscle, and 
 advanced before the other, with the toes pointing outwards. The 
 adductor longus tendon stands out prominently, and much pain 
 may be experienced from pressure on the obturator nerve. If the 
 patient stands, the body is bent forwards, whilst it is interestinf; 
 to note that if the dislocation remains unreduced the patient niav 
 be able to walk Avithout much pain or inconvenience, thouj^^h in a 
 more or less stooping position. 
 
 4. Pubic Dislocation (Fig. 195). — In this variety the head of 
 the bone lies on the horizontal ramus of the pubes, just internal 
 to the anterior inferior spinous process of the ilium, where it can 
 be felt rolling under the finger on any movement of the liiiih. 
 The vessels are pushed inwards, and considerable pain may be 
 felt down the limb from pressure on the anterior crural nerve. 
 The ilio-femoral ligament is untorn, whilst the ligamentuni teres 
 and capsular ligament are ruptured ; the small external rotator 
 muscles, with the exception of the obturator internus, are usually 
 torn. There is marked flattening of the hip, the trochanter heint: 
 
 approximated to the middle line and 
 raised. The limb is shortened to the 
 extent of i inch, and there is con- 
 siderable abduction and eversion, so 
 that the inner aspect of the limb looks 
 forwards. The thigh is slightly fle.xed 
 to relax the ilio-psoas muscle. 
 
 Treatment of the thyroid and pubic 
 dislocations is undertaken along similar 
 lines as for the posterior dislocations. 
 The patient is anaesthetized ; the knee 
 is flexed, as also the thigh upon the 
 abdomen, but in a position of abduc 
 tion ; circumduction inwards follows 
 (Fig. 196), and on extension of the 
 limb the head again enters the ace- 
 tabulum. The tliyroid variety may 
 sometimes be reduced by upward and 
 outward traction when the limb has been flexed to a right angle 
 in the abducted position, the unbooted foot being placed against 
 the pelvis to steady it. 
 
 If extension by pulleys is required in the thyroid dislocation, 
 
 Fk;. 196. — Reduction ok An- 
 TKRioK Dislocations OK Tiiii 
 Hir. (Bryant.) 
 
INJURIES OF JOINTS—DISLOCATIONS 
 
 5*9 
 
 it is made transversely outwards across the upper part of the thigh, 
 counter-extension being obtained by means of a band passed round 
 the abdomen. The limb, at first in a position of abduction, is 
 subsequently adducted forcibly by drawing the ankle inwards, the 
 band by means of which extension is being made acting as a 
 fulcrum to lever the head of the bone into the acetabulum. In 
 the pubic variety traction is made downwards, outwards, and 
 backwards, and the head of the bone drawn into its socket by a 
 towel passed transversely across the limb. 
 
 After reduction of any form of dislocation of the hip, the patient 
 should be kept in bed with the legs tied together for about a 
 fortnight, and then passive movement may be commenced, but 
 with considerable caution ; voluntary movements should not be 
 undertaken for another week or two. 
 
 Should the dislocation recur, it may be due to fracture of the 
 posterior lip of the acetabulum, or to some involuntary move- 
 ments of the patient, or perhaps to the fact that the displacement 
 has not been fully reduced. Under such circumstances further 
 attempts at replacement should be undertaken, and subsequently 
 the limb must be kept immobilized for a longer period than usual. 
 
 Irregular disl ocations of the hi p occ ur when the_Y-s haped 
 ligament is comgleteiy-torri through, so tTiiTt the head of the bone 
 is not restricted, b ut can be moved round the acetabular cavity. 
 ReduHionTs~usijallyjeasy. 
 
 Disloca tion of the Patella may occur outwards, inwards, or edge ways,. 
 A dislocation upwards resulting from rupture of the ligamentum 
 patella' is sometimes described, but it is scarcely to be included 
 in the same category as the others. The displacement may be 
 complete or incomplete ; in the former the capsule is always 
 lacerated ; in the latter, not necessarily so. 
 
 The outward variety is much the common est on account of th e 
 obliquity of ttttJ J hub, and may result ffgrn^jrvMgri]|f]t- piptinn, 
 i gspecialiy m p eople ~sa:llfi§ring from genu valgum ; it als o arises 
 bni di rect violence^ tiTeither case ii occurs most frequently 
 wlien file limb is extended, since during flexion the bone is more 
 tirinly lodged in the intercondyloid notch. When completely 
 , displaced, it lies upon the outer surface of the condyle, with its 
 i inner margin projecting forwards. In this situation it is easily 
 felt, whilst the knee appears flattened and broader than usual, 
 the intercondyloid notch being plainly distinguishable in the posi- 
 tion usually occupied by the patella. It is not unfrequently, 
 however, incomplete, and then the inner half of the articular 
 surface of the pat'iUa Hes in contact with the cartilaginous surface 
 lof the outer condyle, with its outer border projecting forwards. 
 mductioH may take place spontaneously, but is usually effected by 
 jmaninulation. The thigh is flexed on the abdomen, and the knee 
 ^extended, so as to relax the quadriceps, and then, with a little 
 
 34 
 
53° 
 
 A MANUAL OF SURGERY 
 
 pressure on its outer margin, the bone slips back into place. In 
 the incomplete form where one of the borders of the bone is lod'^ed 
 in the intercondyloid notch, reduction is sometimes very difficult, 
 and to effect it an open operation may be required. 
 
 The inward disloca tion is_rare, being always due to direct 
 violence. In characters an3 treatment it is the exact converse of 
 those met with when the bone is displaced outwards. 
 
 A dislocation edgeways, or Vertical Rotation of the patella, is 
 an interesting condition in which the bone is said to be twisted 
 vertically upon its own axis, and even to have been turned com 
 pletely round. Incomplete rotation is practically identical with 
 that just described as an incomplete lateral dislocation, whilst the 
 complete rotation of the patella must indeed be a rare accident. 
 
 C Dislocations of the Kne e may oc cur laterally, a s als o fovi mrds or 
 bacMmrdr. When due to disease of the jomt, the backwa rd dis- 
 Tbcafion is commonest ; b ut when arising from traumat i ccliuses , 
 the lateral i s the mo st frequent . 
 
 The lateral displacements are rarely complete, and are usually 
 associated with a certain amount of rotation ; the leg is partially 
 flexed. Reduction is effected without difficulty. 
 
 Dislocation of the tibia forwards is more common than dis- 
 placement backwards. It is frequently complete, the lower end j 
 of the femur projecting into the popliteal space, and compressing 
 the vessels. The upper end of the tibia, carryiiig with it thei 
 patella, lies in front, forming a well-marked swelling with a 
 hollow above it. There is usually considerable shortening of the [ 
 limb if the articular surfaces overlap. 
 
 Dislocation of the tibia backwards is a much rarer accident, and I 
 is more often incomplete than the former. The signs are exceed! 
 ingly characteristic, the pressure effects upon the popliteal vessels] 
 and nerves being less pronounced. 
 
 Reduction of either of these conditions is easily accomplished j 
 by traction on the limb, whilst the thigh is flexed, combined with 
 manipulation in order to guide the head of the tibia into its 
 normal position. The limb must subsequently be kept at rest] 
 in splints for two or three weeks. 
 
 Displacement of a S flTpilnnflr Cartilag g (Syn. : Subluxationo Qliel 
 Knee, iTitftmfl.^ "nflraTigftiinftnt nf tha K;i7flft-jn|pt) is a condition frej 
 quently met with, resulting from sprains and strains of tlie joint.l 
 In any rotary movement of the knee, which, however, can onlybej 
 undertaken when the limb is flexed, the pressure of the condyles! 
 always tends to modify the position of the cartilages ; moreover,r 
 with the limb in a state of flexion, they are relaxed and morel 
 freely moveable on the upper surface of the tibia than in exteni 
 sion. Any sudden strain or wrench, e.g., turning quickly round inl 
 such games as tennis, or slipping off the kerbstone with the kneel 
 
INJURIES OF JOINTS— DISLOCATIONS 
 
 531 
 
 bent, may lead to this accident. The internal cartilage is much more 
 frequently affected than the external, and the character and extent 
 of the lesion varies much in different cases. Not unfrequently its 
 anterior tibial attachment is torn through, thereby permitting con- 
 siderable lateral mobility. Its peripheral connections with the 
 capsule and internal lateral ligament may also be ruptured, whilst 
 sometimes a portion is more or less detached from its free border, 
 and in other cases the cartilage has been broken across a little 
 behind its centre. It is obvious that when once its connections 
 have been loosened it can be displaced readily, and may pass into 
 the intercondyloid notch, or may slip out from between the tibia 
 and femur, or may even be doubled over. After displacement it 
 becomes inflamed and swollen, and unless properly treated this 
 will be likely to perpetuate the trouble, and predispose to a 
 renewal of the displacement. 
 
 The Symptoms produced by this accident are a sudden sicken- 
 ing pain of much severity, located in the knee, which becomes 
 partially locked in a position of flexion, with inability to extend. 
 The patient may be able to ' wriggle ' his joint free, or the limb 
 may remain stiff for some hours, or even a day or two, when 
 movement suddenly returns more or less spontaneously, a snap 
 being at the same time felt within the joint. An attack of sub- 
 acute synovitis usually follows. In other cases the cartilage 
 remains out of place, until reduced by the surgeon, with or with- 
 I out an anaesthetic. If the case is not carefully treated, the dis- 
 1 placement is liable to recur, the cartilage constantly slipping in 
 and out, and getting nipped between the bones; as time goes on, 
 this becomes more and more easy, owing to the ligaments of the 
 joint being relaxed from the recurrent attacks of synovitis. In 
 fact, the limb may pass into Euch a state of chronic weakness as 
 to seriously interfere with the patient's comfort. No physical 
 [changes can as a rule be detected between the attacks, but there 
 lis usually a spot of localized pain in the front of the joint, cor- 
 Iresponding to the upper surface of the tibia ; possibly there may 
 jbe some amount of lateral mobility of the leg, and movement of 
 [the cartilage may be detected on flexing and extending the knee. 
 
 The Treatment in the early stages consists in replacement of 
 [the cartilage by manipulation. The limb is fully flexed and then 
 |suddenly extended, pressure being applied at the same time in the 
 peighbourhood of the displaced cartilage, which often returns into 
 Iiosition with a distinct snap. The limb is subsequently kept at 
 [est on a back-splint, and cooling lotions are applied until the in- 
 pmmation has subsided ; it is then further immobilized for some 
 »eeks in plaster of Paris or water-glass, so as to allow the 
 lacerated ligaments to reunite and consolidate. At the expiration 
 six or eight weeks after the accident an elastic knee-cap is 
 [pplied, and the patient again allowed to move the joint. 
 \\hen the cartilage has become loose and is constantly slipping 
 
532 
 
 A MANUAL OF SURGERY 
 
 out of place, immobilization of the limb, with pressure over the 
 painful spot by an elastic knee-clip, as recommended by Mr. 
 Howard Marsh, may be useful. Should this not prove satis- 
 factory, operative proceedings must be undertaken. 
 
 The knee-joint is opened by an incision on the appropriate side 
 of the patella, more or less transverse in direction, and the con- 
 dition of the cartilage ascertained. If of normal shape and merely 
 loose and moveable, it may be readily stitched to the periosteum 
 over the head of the tibia, so as to keep it from again slippinir 
 between the bones ; this is perhaps best accomplished by splitting' 
 the cartilage diagonally into two portions, and securing each of 
 these by two or three catgut stitches. If, however, it is doubled 
 on itself, or deformed, or if fixation seems impracticable, it mav 
 be removed ; it is astonishing how well patients get on after such 
 an operation. The greatest care must be taken to maintain 
 asepsis, and no strong or irritating antiseptic should be allowed 
 access to the joint cavity, which is closed by a series of huried 
 sutures, dealing in order with the synovial membrane, the L..^sule, 
 the superjacent tendinous tissues, and, finally, the skin. It is 
 advisable to drain the joint for twenty-four hours, and, as an 
 additional precaution against infection, it may be well to immunize 
 the patient by preparatory injections of antistreptococcic serum, 
 
 Dislocations of the Ankle-joint may occur in the following; 
 directions : outwards, inwards, backwards, forimrds, and upwards, this i 
 being the order of their frequency. Owing to the fact that the , 
 astragalus is wedged like a block into the cavity formed by the 
 lower ends of the tibia and fibula, it can be readily appreciated I 
 that fractures of these bones are frequently met with as compli- 
 cations. 
 
 The lateral dislocations are in reality fracture-dislocations, and j 
 have been already described in the chapter on fractures (p. 457! 
 
 Although the upper articular surface of the astragalus is broader! 
 in front than behind, dislocation of the foot backwards is a morel 
 common accident than displacement forwards. It results from J 
 falls on the feet while running or jumping, or by sudden violence! 
 applied to the limb when the foot is fixed. Usually both malleolij 
 are fractured, and the articular surface of the astragalus is thrownl 
 behind the lower end of the tibia. The heel projects undulyj 
 backwards and the lower end of the tibia usually rests uponthej 
 neck of the astragalus, the scaphoid, or even the cuneiform bonesi 
 
 Dislocation forwards is very uncommon, and may occur with-f 
 out any associated fracture of the bones of the leg. The foot: 
 apparently lengthened, and the tibia rests upon the posterior part 
 of the upper surface of the os calcis, behind the astragalus. IM 
 prominence of the heel and of the tendo Achillis is lost, and I 
 normal depression in front of the latter structure is occupied bij 
 the lower ends of the bones of the leg. 
 
INJURIES OF JOINTS— DISLOCATIONS 
 
 533 
 
 The tveatment of antero-posterior dislocations consists in reduc- 
 tion by traction. The leg is flexed upon the thigh, so as to relax 
 the tendo Achillis, and, if necessary, this structure may be sub- 
 cutaneously divided. The ankle is commanded by a pair of 
 Cline's side-splints, care being taken to ascertain tjiat the foot is 
 at right angles to the leg, and that the articular surfaces ~of-the 
 astragalus and tibia are exactly in eipposition, thus preventing any 
 displacement of the heel b ackwards o r forward s. A Roughton's 
 splint — i.e., an external splmt with a sole-piece — may^also be used 
 witli ad\antage. 
 
 A dislocation upwards has been described in which the astra- 
 i;alus, together with the foot, is carried up between the tibia and 
 
 Fig. 197, — Dislocation of the Astragalus Forwards. 
 
 fibula. To allow of such, the inferior tibio-fibular ligament and 
 [the lower end of the interosseous ligaraent must have been ruptured, 
 llmpracticable as such an accident appears, competent observers 
 [maintain that they have met with it. The displacement is very 
 parked, and the character of the lesion very evident. 
 
 Dislocations of the Astragalus alone are by no means common, 
 although their distinguishing features are well recognised. They 
 consist in a partial or complete detachment of the bone from all 
 Its normal connections, both to the bones of the leg and of the 
 |oot, and its displacement from under the tibio-fibular arch. It 
 nay travel backwards or fovwavds with or without lateral rotation. 
 
 Dislocation forwards (Fig. 197) is much the more common 
 
534 
 
 A MANUAL OF SURGERY 
 
 variety, although it is usually associated with partial rotation, the 
 displacement occurring more frequently outwards than inwards. 
 When complete, the bone is entirely detached from its connections 
 with the OS calcis, scaphoid, and bones of the leg, and lies upon 
 the upper surface of the scaphoid and cuneiform bones, the skin of 
 the dorsum of the foot being tightly stretched over it, or even torn. 
 The limb becomes shortened, and the malleoli approximated to 
 the sole, the lower end of the tibia resting on the upper surface of 
 the OS calcis. 
 
 In the incomplete variety, the head of the astragalus inipinges 
 either upon the scaphoid on the inner side, or the cuboid on the 
 outer, whilst the lower end of the tibia rests on the posterior half 
 of the articular surface of the astragalus. 
 
 Dislocation backwards is almost always complete, and niajdr 
 may not be associated with rotation of the bone, which can easi v 
 be felt between the tendo Achillis and the malleoli. 
 
 Treatment. — Reduction is only possible in the incomplete forms 
 of dislocation. The patient is anaesthetized, the knee flexed to 
 relax the muscles or the tendo Achillis divided, and traction upon 
 the foot established, so as to enable the surgeon to apply direct 
 pressure upon the displaced bone in a suitable direction. In the 
 complete variety reduction is impracticable, owing to the fact that 
 the OS calcis is drawn up into contact with the malleolar arch, j 
 In such cases manipulation is useless, and excision of the bone is 
 the best method to adopt. Comparatively little impairment in tie] 
 function of the foot results from this operation. 
 
 Subastrayaloid Dislocation^ — By this term is meant a displace 
 ment of all the bones of the foot from below the astragalus, which 
 retains its normal position between the malleoli. The interosseous! 
 and other ligaments passing from the malleoli and astragalus toj 
 the other tarsal bones are necessarily ruptured. The cause of this,! 
 as of other dislocations in the neighbourhood, is some violent strainj 
 or wrench of the foot. 
 
 Displacement of the foot may occur either forwards or backi 
 wards, but in the great majority of cases it is either backwards mil 
 inwavds or backwards and outwards. The luxation is rarely completej 
 as regards the calcaneo-astragaloid joint, but the articular surfacesj 
 of the head of the astragalus and scaphoid are completely separatedT 
 the former structure lying on the dorsal surface of the latter bone,! 
 The foot is greatly deformed, the anterior portion being shortened] 
 the heel prpjecting, and the toes pointing downwards. The heal 
 of the astragalus is very evident, forming a rounded globulaij 
 swelling under the tense skin. 
 
 In the inward displacements, the foot is somewhat inverted, 
 so that the outer malleolus is unduly prominent, and the inneJ 
 malleolus is lost in a deep depression caused by the lateral m 
 placement of the os calcis ; the foot is thus in a position some^vha 
 
INJURIES OF JOINTS—DISLOCATIONS 
 
 535 
 
 simulating talipes equino-varus. In the outward dislocations, 
 the foot is slightly everted, the inner malleolus prominent, and 
 the outer buried, a position of talipes equino- valgus being thus 
 assumed. In both forms the tendo Achillis is curved, with its 
 concavity towards the displacement. The Treatment consists in 
 reduction by manipulation, which is sometimes readily accom- 
 plished, but may at others be a matter of the greatest difficulty, 
 probably from the tibial tendons becoming hitched around the 
 neck of the astragalus. Section of the tendo Achillis is occasion- 
 ally needed. 
 
CHAPTER XIX. 
 DISEASES OF JOINTS. 
 
 Acute Synovitis. 
 
 By Synovitis is meant an inflammation limited almost entirely to 
 the synovial membrane, the ligaments and other structures of the 
 joint being usually but little affected. 
 
 The Causes are local and general. Local conditions include 
 cold and injury ; general or constitutional comprise rheumatism, 
 gout, syphilis, pyaemia, and gonorrhoea. 
 
 Patholopical Anatomy . — Acu^e3movitis.re$ulJ;& ioJiy ^eraemiaof 
 the syno vial membrane, ari3^xudation^of_^^^^ and leucoc;};t_es, 
 
 hrstly into~l!ie suBstance of the membrane^ causing it to Fe 
 thickened and spongy, and subsequently into the joint ; the 
 endothelium also proliferates, and is shed. In the early stages 
 the effusion consists of synovia, diluted with blood plasma, and 
 often discoloured with blood in traumatic cases, and hence on 
 removal is spontaneously coagulable ; after a time the plasma 
 may coagulate, depositing lymph upon the articular surface whilst 
 serum remains. The lymph thus deposited may either be removed 
 by a natural process of absorption when the inflammation comes 
 to an end, or it may organize, so as to form adhesions. In the 
 later stages the synovial membrane becomes somewhat thickened, 
 and the ligaments possibly a little infiltrated and relaxed. 
 
 The Clinical Signs of acute synovitis consist in the joint be- 
 coming painful and distended, whilst if the articulation is super- 
 ficial, as in the knee, a sense of heat may be imparted to the hand, 
 and the surface may even be red and hyperaemic. The limb is 
 maintained by muscular spasm in that position which gives the 
 most ease, viz., that in which its capacity is the greatest, and this 
 is usually one of slight flexion, but if the condition is neglected, 
 the flexion may increase considerably, the muscles undergoing 
 tonic contraction, and the limb remaining more or less fixed in an 
 undesirable position. The muscles governing the movements of 
 the joint occasionally undergo rapid atrophy, probably resulting 
 from a reflex disturbance of their trophic centres in the cord. 
 
DISEASES OF JOINTS 
 
 537 
 
 Evidence of Effusion into Various Joints. — Shoulder : The curva- 
 ture of the shoulder is increased, and the deltoid expanded by a 
 tluid swelling beneath it, which is especially noticeable at its 
 anterior border along the bicipital groove, and sometimes pos- 
 teriorly ; in the axilla a painful intumescence may also be felt. 
 These symptoms may be somewhat simulated by inflammation 
 of the inultilocular subdeltoid bursa, but the latter condition is 
 recognised by the absence of any axillary swelling, by its not 
 encroaching on the anterior and posterior borders of the deltoid, 
 and by the fact that, although when the patient voluntarily moves 
 his arm pain is produced, yet when the surgeon gently manipu- 
 lates it, so as to press the head of the bone against the glenoid 
 cavity, there may be none. Elbow : The hollows on either side 
 of the olecranon and tendon of the triceps are replaced by soft 
 fluid swellings, the outer of which also extends down to, and 
 masks, the head of the radius ; there is usually a little general 
 pufiliness in front of the joint. It is readily distinguished from 
 inflammation of the olecranon bursa by the fact that in the latter 
 condition there is a central fluid prominence over the bone, whilst 
 in the former the swellings are placed on either side of and above 
 tlie bony projection. Wrist : There is a general fulness both on 
 the anterior and posterior aspects of the joint, whilst fluctuation 
 may be detected beneath the dorsal tendons, which are slightly 
 separated and displaced. It is distinguished from synovitis of the 
 superjacent tendon sheaths by the fact of its strict limitation to the 
 neighbourhood of the joint, and the absence of the superficial 
 crepitus, so characteristic of the latter condition. Effusion into 
 the Hip-joint cannot be easily detected by digital examination. 
 There may be a little fulness and tenderness in the gluteal region, 
 or in the upper and outer part of Scarpa's triangle. The most 
 characteristic feature, however, is the position of flexion, abduc- 
 tion, and eversion taken by the limb, whilst limitation of move- 
 ment is equally marked. The Knee, when distended with fluid, 
 presents a rounded outline, in which all the normal hollows, 
 especially those on either side of the patella and ligamentum 
 patellae, have disappeared. There is also a swelling correspond- 
 ing to the subcrureal pouch, more marked on the inner than the 
 outer side, and extending for 3 or 4 inches above the patella. 
 Fluctuation can b? ■rg^dliY.,., 46 >^^ Ctg^ iW,b^" one hand is placed 
 af)o\e the pa tella, and the fingers 01 the other hand compress 
 the tissues o^^.,^JLl3^,.§]3jiJQjrt]^.JIgam 
 
 by alternate pressure on either side of the rectus tendon. When 
 tlie effusion is large in r.mount, the patella is felt to float, and 
 on pressing it sharply br.ckwards can be made to tap against the 
 intercondyloid notch of the femur. Enlargement of the bursa 
 patellae is easily distinguished from it by the swelling in the 
 former case being central and in front of the patella, so that its 
 outline is obscured. Ankle : The hollows between the tendo 
 
538 
 
 A MANUAL OF SURGERY 
 
 Achillis and the malleoli are replaced by fluctuating swellings, 
 whilst the dorsal tendons are displaced forwards, and a tiuid 
 swelling appears in front of each malleolus. Enlargement of the 
 bursa beneath the tendo Achillis is so obviously confined to the 
 back of the joint that it should never be mistaken for true synovitis 
 of the ankle. 
 
 When the acute stage has pa.ssed, the joint is usually left in 
 a somewhat weak and relaxed condition, with a little p'assive] 
 eflfusion, or perTiaps some adhesions. 'The adhesions which follow 
 acute synovitis are usually slight in character, if the case has been 
 properly treated ; they result from the union of patches of lymph j 
 on opposing surfaces of synovial membrane or bone, which 
 become organized into loose fibro-cicatricial tissue, containing a i 
 few delicate bloodvessels, and covered by endothelium extending I 
 over them from the adjacent serous membrane. The charac- 
 teristic signs of such a condition are painful limitation of move- 
 ment in some particular direction, and possibly a little soft 
 crepitus. 
 
 TJie ^Treatment of acute synovitis coxisists iji.-so. innpqbiHzingj 
 jAe_ ioint as,t9. g;i,Y§' UiP-.p.«ltient, ih& greatest amount oT ease,] 
 whilstj should^ ankj^losi§.r§suit, the limb is left in as favouraHIf a 
 position as _j)pssiijle. iqjt; subsequent utility. Thus, the shoulhl 
 sRouTd'be bandaged to the side and the hand kept in a sling ; the 
 elbow is placed on an internal angular splint, and flexed to a little 
 more than a right angle, whilst the hand is midway between! 
 pronation and supination ; for the zorist all that is needed is to I 
 apply a palmar splint to the forearm ; the hip is immobilized by 
 the application either of a Thomas's splint or of a Listen's long I 
 splint, or by placing the limb between sandbags and adjusting an 
 extension apparatus to the foot ; the knee is put on a back-splint, | 
 perhaps slightly flexed; whilst the ankle is best kept at rest by; 
 applying what is known as a Roughton's splint, i.e., an external I 
 splint with a foot-piece. Necessarily, in all severe cases of acute 
 synovitis the patient should be confined to bed and the limb 
 elevated. If the case has been neglected and the limb has 
 assumed a vicious position, the patient should be anesthetized 
 and the malposition corrected ; or gradual extension made by 
 means of a weight and pulley, until the correct position is 
 attained. In the early stages cold should be applied to the joint 
 by means of evaporating lotion, an icebag or Leiter's tubes, but j 
 this is not ad\'isable in old people. In the later stages fomenta- 
 tions give greater relief, whilst the application of a few leeches! 
 may also be beneficial. When the distension is considerable, 
 removal of some of the fluid by a carefully purified aspirator, or | 
 trocar and cannula, may diminish pain and hasten recovery. 
 
 In the subacute stage, when the joint is weak and relaxed,] 
 massage or friction with stimulating liniments should be em- 
 ployed, whilst in the more chronic forms firm pressure, and pre- 
 
DISEASES OF JOINTS 
 
 539 
 
 ferably by means of a Martin's bandage, is most useful as nn 
 [additional measure. 
 
 If adhesions are present, they should be carefully broken down 
 [under chloroform; the limb is subsequently kept at rest for a 
 
 lew (lavs upon a splint, whilst passi\e movements and massage 
 1 are altei wards adopted. 
 
 Chronic Synoviti s. 
 
 This afTection follows an_acute atta ck, or may be lighte d_up by 
 
 some injury^or condition insufficient to deternune a more violent 
 
 (orm of ioflanunation. . The 
 I synovial memBrane Becomes 
 
 tliicFancl infiltrated, whilst the 
 I e ffusioii ia SOtttethnes relaf wely 
 
 [less than in the a cut e for m, 
 
 sOTietTin es excessive, tlie n con - 
 
 sn tufjng t he con dition ~ de- 
 
 \'^)ediischyontc serous synovitis, 
 
 a^'' plTen 6mehoir7Io ften~ "se en 
 
 I a'ffecting the knees after rising 
 
 ironi a^rolonged stay'^^Be'd 
 
 lI'igTigH). The pain is usually 
 
 I not severe, being replaced by a 
 
 [ sense of uselessness and weak- 
 
 I ness. It is interesting to note 
 
 [that, in cases where the effu- 
 sion is well marked, the bursa? 
 
 I communicating with the joint 
 
 : frequently become distended ; 
 
 [they are prevented from par- 
 ticipating in the acute forms 
 of inflammation by the fact 
 tliat the apertures of com- 
 munication with the interior 
 
 [oftlie joint are narrow and slit- 
 e, and thus readily become 
 
 [occluded by the swelling of 
 the membrane. Crepitus is 
 sometimes inet with in chronic 
 synovitis, possibly from a roughening of the articular surfaces on 
 
 hvHcTPlymph has been deposited, or between which fibrous 
 
 [adhesions have formed. 
 Treatment consists in fixing the joint in a suitable position, and 
 
 [applying counter-irritation and pressure; blisters are especially 
 useful in this affection. At a somewhat later stage elastic 
 pressure by a Martin's bandage may be employed, together with 
 
 {friction with stimulating liniments, or even hot-air baths. Re- 
 
 FiG. ig8.— Chronic Serous Synovitis 
 OF Knke, with Distension of the 
 
 SUBCRUREAL PoUCH. (FrOM COL- 
 LEGE OF Surgeons' Museum.) 
 
S40 
 
 A MANUAL OF SURGERY 
 
 rnoval of some of the fluid by aspiration and subsequent com 
 pression may also do {,'o()d ; but if the affection resists sucli treat 
 meat, the best procedure consists in opening the joint, washing ii 
 out witii normal saline solution or with a solution of corrosive 
 sublimate (i in 4,000), and draining it for a few days. 
 
 / special Forms of Synovitis. J 
 
 Rheumatic aynoviti a is met with in the course of acute rheu. 
 matism, or as a chronic affection from the commencement. The 
 former is recognised by the presence of fever, a cid su(-ni^ \w\■^. 
 coloured urine loaded with lithates, and a tendency to nictastMs, 
 one join I trftor another being involved ; complete rcsoluiion 
 usually follows, but there may be some thickening of ligaments 
 and consequent impairment of"^mobility. If the disease is limited 
 to One joint, absolute disorganization, though without suppura 
 tion, may ensue (acute rheumatic arthritis). 
 
 The chronic variety is characterized by swelling of tiic joints, 
 due partly to effusion, partly to thickening of the synovial mem 
 brane ancl of the capsular and other ligaments. If neglected, it 
 may produce fixity of the joint, due mainly to ligamentous 
 changes, but also resulting from the dev'elopment of intra-articular 
 adhesions ; but there js never any lippjng of the cartilages or nyv 
 l oriuatioiT orT )one, as in osteojarthritis. Not unfrequently other 
 evidences ot rheumatism~inay be presen t, such as chorea, ery- 
 ttiema, etc., whilst rlieuniatic nodules {i.e., new growths of fibrous | 
 tissue in the suT)cutaneous tissues, perhaps reaching the size of a i 
 walnut, but more often much smaller) may also develop. 
 
 The Treatment of the acute form is rather constitutional than | 
 local, and consists in the administratiort of large doses of saHcy- 
 l ate of soda ; at first, whenTfie temperature is considerably raised, 
 20 gRliH^doses are giveri every"three or four 'liours, but as the 
 pyr^xiaTlDheriomenainsap tliese ITre gradually_diminis!ied in 1 
 
 frequency aiid amouTTtTljntil ffiereTy" i o grain doses are given 
 tlrfice daily. Som'e^patlents^Tannot take salicylates, as theyj 
 inducelTianiacal attacks of alarming severity ; under these circum- 
 stances the practitioner must depend on ciCiinine and bicarlioiiatej 
 of potash. Locally, tlie joints should be wrapped in warm cotton- 
 wool, or, perhaps lieliei, soda fomentations may be applied, 
 Should the inflammatio'i resist such measures, it is quite justifiahlej 
 to open and wash out the joint, which is found to be occupied byj 
 a greenish, semi-puriforrn effusion. , In the more chronic forinsl 
 salicine and iodide of potash are perhaps more eHecfual, togetfierj 
 w1ttr~aliraline"~rniiTera1 waIers7~^iA^nsF]^t ji i mlatin g friction 
 massage -m ay also be Tidopted'. Counter-irritation in fhe form oil 
 ffgT^e ntly repea led blisLeis, ui even of the actual cautery, niavj 
 prove beneficial ; whilst localized hot-air baths may be used wit 
 advantage in the earlier stages. Failing such treatment, a visi 
 to some of the home or Continental spas may be recommended, 
 
bis/s 
 
 DISEASES OF JOINTS 
 
 S4I 
 
 flouty Sjnqvitis/s characterized by certain_well-marked features. 
 It often attacks tlie nietataiso-plialangcal articulation of the threat 
 tiic (poiiagra), or the metacarpo-phahuigeal joint of the thumb 
 ulTeiraj^ra). Its onset is usually sudden, and it fre(j^uently_coru- 
 nilMices in the middle of tlie niffht. The joint l)ecomes swollen, 
 rtd, shiny, and (edematous, whilst the simerfidal veins aria 
 piniiiincnt. Tlie attack is exceedingfy pamiiil, and tTie skin 
 cxqiiisitely tender. These symptoms pass off in the course of a 
 few clays, leaving the articulation swollen and sensitive. 
 
 Even a single attack results in a sligiit deposit of biurateof soda 
 in acicular crystals in the matrix of the arti cular cartila ge close to 
 the surface ; but when the joint has beeiLaeYiiarTrmes liiTlanTed 
 tlie wiiole thTckness of the cartilage may be invaded~T)y_this 
 chnlky" depostl7~wlTi1st_the lif^aments and encls_ of the bones are 
 also infiltr ated? Tn tlie smaller joints it may increase to such an 
 rtTSfTTTis to form well-marked swellings, or ' tophi,' similar in 
 character to those so conmionly seen in tlie external ear. The 
 skin sometimes gives way over these, and a chalky discharge 
 results. In some cases the cartilages are eroded, and eburnation 
 of the exposed bone may follow, as in osteo-arthritis. The tyeat- 
 milt of acute gout consists in well fomenting the parts or applying 
 Silycerine of belladonna, whilst colchicum, citrate of lithia, and 
 alkaline nurgatives are administered. In the more chronic forms 
 iodide of potassium, and possibly piperazine, may be given, whilst 
 the diet and cuink are carefully regulated. 
 
 Qonorrhoeal Synovitis rarely arises iiefore the third week of the 
 
 j complaint, when the discharge is becoming subacute. It usually 
 
 attacks several joints, the knee, wrist, and ankle being those most 
 
 commonly involved, and that not unfrequently on both sides of 
 
 the body. It is marked by considerable effusion around the joint, 
 
 whilst that within is often but slight. The affection is very painful 
 
 and extremely chronic. If it is limited to one joint, disorganization 
 
 jmay result, with or without suppuration (gonorrhoea! arthritis), 
 
 ami ankylosis is an occasional consequence even of the synovial 
 
 norm. The affection is due to the development in the synovial 
 
 jmemhrane of the gonococcus, carried from the urethra by the 
 
 jblood-stream ; but if suppuration ensues, probably pyogenic 
 
 |orf;anisms are also present. The treatment is most unsatisfactory. 
 
 IThe urethral discharge must be arrested as soon as possible, whilst 
 
 Icomplete rest to the affected joints, moderate pressure and counter- 
 
 fcrritation, e.g., by the use of Scott's dressing, should be employed. 
 
 IPerhaps iodide of potassium, mercury, and quinine are the best 
 
 Mrugs to administer. Should the local phenomena be at all severe, 
 
 |t is necessary to open, irrigate and drain the joint. 
 
 Pysemic Synovitis is due to embolic infection from some sup- 
 purating focus. The joint becomes rapidly distended with pus, 
 
543 
 
 A MANUAL OF SURGERY 
 
 and often without pain. If the joint is promptly evacuated 
 washed out and drained, its disorganization may be in many cases 
 prevented (vide Pyaemia, p. 92) ; otherwise destructive changes 
 will quickly follow. 
 
 Hydrarthrosis (Hydrops Articuli) is the term applied to anv 
 condition of a chronic nature in which the joint is much distended 
 with fluid. It may arise from at least five different afli'ctions; 
 (a) Chronic serous synovitis ; (b) in osteo-arthritis, perhaps the 
 most common cause ; (c) in Charcot's disease ; (d) in secondarv 
 syphilitic synovitis ; and {e) very rarely in tuberculous synovitis. 
 It must be remembered that it is but a symptom, and not a disease 
 sui generis, and treatment must be directed to the cause. 
 
 Baker's Cysts. 
 
 This condition, first described by the late Mr. Morrant Baker, 
 consists in a hernial protrusion of the synovial membrane 01 ;i 
 
 Fig. 199. — Baker's Cysts from Back ok Knee. (Howard M.\ksh| 
 
 joint through an aperture in its fibrous capsule (Fig. 199), Itisj 
 usually due to some chronic affection of the articulation, especiallvj 
 osteo-arthritis, or tuberculous disease, whereby the intra-articiilarj 
 pressure is increased, and not uncommonly several such sacsarel 
 met with in the same joint. They vary much in size, contaiDj 
 .synovial fluid, and, though at first communicating with the 
 cavity, have a tendency to travel away from it, burrowing aloDjj 
 muscular and fascial planes, and coming, perhaps, to the surfac^ 
 some distance from their origin, the aperture of communica 
 
DISEASES OF JOINTS 
 
 543 
 
 evacuated, 
 many cases 
 ve changes 
 
 ilied to any 
 ch distended 
 t aftVctions; 
 perhaps the 
 n secondary 
 us synovitis. 
 not a disease 
 se. 
 
 jrrant Baker, 
 emlirane oi ;i 
 
 [w\RV Marsh) 
 
 'ig. 199)' ^"^' 
 ition, especi 
 
 intra- articulail 
 vl such sacs aR 
 lin size, contatj 
 
 with the 
 lurrowinfi alon^J 
 I, to the surfaci 
 
 communici 
 
 with the joint having in some instances been shut off. If causing 
 no troul)lesome symptoms, there is no necessity to interfere ; hut 
 if they i)ecome inconvenient or painful, it is easy to dissect th' n 
 out, closing where necessary by ligature or suture the narrow neck 
 which leads into the joint. Of course, the strictest asepsis must 
 he maintained in all such proceedings, and the causative af/ection 
 must not be forgotten. 
 
 Acute Arthritis. 
 
 By the term Arthritis is meant any Inflammation of a joint 
 which involves all the structures of which it is composed, viz., 
 bones, ligaments, cartilages, and synovial membrane. 
 
 Causation. — Acute arthritis is practically always due to infection 
 oi the joint cavity with bacteria, which reach it either from within 
 or without the body, (i.) It may be due to the entrance of cocci 
 through a punctured or valvular wound of the joint, or during 
 operations. It is interesting to note how extiemely prone to in- 
 flammation is the synovial membrane when opened, even after the 
 most careful antiseptic precautions. The micro-organism most 
 commonly present is a modification of the Streptococcus pyogenes, 
 known as the Strep, articiilorum ; it is pathogenic to mice and 
 j rabbits, hut not to guinea-pigs, and when injected into a rabbit 
 seems to especially select the joints. Various non-pathogenic 
 orj,'anisms have also been found in special cases, (ii.) It may arise 
 in a manner exactly analogous to that in which acute infective 
 josteomselitis is produced; i.e., the patient is in a low state of 
 lliealth, hiis natural germicidal powers are diminished, pyogenic 
 jorf,'anisnis are present in the blood-stream, gaining access through 
 home hreach of surface, and, finally attacking any weak or 
 {damaged tissue, produce therein suppurative inflammation. A 
 ilij^'ht injury, e.g., a sprain or strain occurring in a weakly child, 
 [convalescent from measles or scarlet fever, may result in this 
 Section, (iii.) It may be produced by the lodgment of a pya:?mic 
 nholus, and in a similar wa" it "ot unfrecjuently follows as a 
 quela of fevers, such as ent^^uc . ;jneumonia, by direct trans- 
 ssion of some iniectivr; material, (iv.) It is sometimes met with 
 a result of gonorrhoea, anJ may then run its course with or 
 jfithout suppuration, (v.) It ma • be lighted up as a result of ^\\e 
 stension of inflammation fr^ m the end of a neighbouriu]^ .tone, 
 trom the bursting of a su L cutaneous or bursal abscess into the 
 pint. Acute arthritis of the hip-joint is commonly due to the 
 pnier of these conditions, br'ng consecutive to an acute infective 
 fconiyelitis of the upper end of the femur. 
 [ Finally, it is occasioi^ally observed as a result of yJieuniatism, the 
 
 lendin'. 
 
 lamniatum runnmg a very acute course, iwc ie 
 gimizatioii of the joint, though withoat suppuratior 
 ol)al)ility such attacks are bacterial in origivi. 
 
 vO dis- 
 In all 
 
 m 
 
S44 
 
 A MANUAL OF SURGERY 
 
 Course of the Case. — In the early stages acute arthritis manilests 
 itself as a hyperacute synovitis, combined with severe pain and 
 fever. The pain is often so intense that the patient cannot hear 
 the part to be touched or the bed shaken, and indeed the slightest 
 jar of the limb is so exquisitely painful that the patient niav 
 scream with agony. The joint itself is distended with a turhid 
 effusion, which rapidly becomes purulent, and the tissues around 
 are hyperaemic and oedematous. The patient naturally places 
 himself in that position in which the limb obtains the greatest 
 ease, and therefore usually semiflexes the joint and fixes it hv 
 muscular contraction. 
 
 As the disease progresses, pus is formed within the ( a'xuie^ I 
 bursting through it, and either travelling directly to the ..arface, I 
 or burrowing deeply into the substance of the limb ; thus, in I 
 the knee an enormous abscess may collect beneath the \asti 
 muscles, stripping them from the bone for a considerable distance. | 
 The pain increases whilst the abscesses are forming, and becomes 
 especially distressing at night, the patient being often wal-ed 'a a 
 painful start just as he has fallen asleep. This condirion i. '!Iv 
 indicates that the articular cartilages are becoming /ifTt i.^d „;iu 
 is explained by the fact that, just as the patient lo.ies iiscioii? 
 ness, the muscles which fix the joint are relaxed, and ;'"o\v i!v 
 inflamed surfaces to slightly shift their position, exciting severe! 
 pain and a sudden spasmodic contraction of the mus:l^s. r,radul 
 ally the deformity becomes more and more obvious, whilst ib_ 
 infiltration and relaxation of the ligaments sometini'is allow ot| 
 abnormal movements, ^.g^., of lateral mobility in the k-nee joint 
 the ends of the bones become carious, and absolute displacen"^\ 
 or dislocation may follow. Sinuses may open in all diicr'.ions,] 
 and the patient suffer from recurrent rigors, caused by toxamial 
 or the onset of pyaemia. The constitutional effects are alwavsl 
 severe, consisting of high fever, and rapid exhaustion from t!ie| 
 pain, sleeplessness, and absorption of toxins. 
 
 The terminations of this affection are as follow : {a) Recovery,] 
 rarely with a moveable joint, and then only after active inter! 
 ference ; in most cases ankylosis in a good or bad position, accord 
 ing to the treatment, is the best result that can be expected,! 
 {h) During the acute stage the patient may die of pyaemia, or aciitel 
 toxaemia and exhaustion, {c) If he survive the acute stage, cbroiiici 
 suppuration may ensie, and symptoms of hectic and amyloid del 
 generation in the viscera may supervene. In such cases sinusesl 
 leading down to carious bone exist, and, unless efficient meas.rei 
 are taken to obtain asepsis, or to remove the diseased structuresf 
 perhaps by amputation, the patient is likely to die from exhaustionj 
 or chronic sapraemia. 
 
 Pathological Anatomy. — The synovial membrane, at first merelil 
 infiltrated and hyperaemic, soon becomes converted into graniilaj 
 tion tissue from within outwards, exuding abundant (/js. 
 
DISEASES OF JOINTS 
 
 545 
 
 lets are always! 
 istion from tliel 
 
 ir active inter- 
 
 h cases sv.nm 
 icient meas.rea 
 
 lifravuitts in turn are sodden and relaxed by the presence of a 
 plastic exudation between the fibres, rendering them soft and 
 iidematous, so that the tonic contraction of the muscles easily 
 stretches them and brings about displacement. 
 
 The articulay cartilages are disintegrated and destroyed in 
 various ways, according to the acuteness of the inflammation and 
 the amount of pressure to which they are exposed. In acute 
 cases they early lose their normal bluish-white appearance, and 
 become opaque and slightly yellow. The central parts, which 
 are exposed to pressure between the ends of the bones, soon 
 disappear, whilst the peripheral portions are eroded by the growth 
 01 the granulation tissue developing from the synovial membrane. 
 When once the cartilage has lieen perforated 
 at any one spot, the suppurative inflamma- 
 tion spreads along its under surface, stripping 
 it from the bone, and thus inducing necrosis, 
 as a result of which isolated portions of dead 
 cartilage may be found lying in the joint. 
 hi the more chronic forms of the disease, 
 roliferation of the cartilage cells occurs, 
 nherehy the capsules become distended, and the 
 m.nrix encroached upon ; some of these cavities 
 iHir;t into the joint, and leave more or less 
 ask shaped openings into which pyogenic 
 ■•jjanisnis find their way, thus aggravating 
 the misch.ief ; others nearer the deep aspect of 
 tlie cartilage become transformed into granu- 
 lation tissue by vascularization from the vessels 
 in the bone. In these ways the cartilage is 
 [destroyed or replaced by granulation tissue, 
 |a proceeding analogous to ulceration of the 
 softer parts. The intevavtkulay cartilages are 
 affectt ' , a very similar manner, and quickly 
 [disaop " . 
 
 Ti ends j the hone pass into a condition of 
 Id' ic :.sti i«^is resulting in the transformation of fig, 200. -Ends of 
 
 THE Bones aftkr 
 AcuTF, Arthritis 
 OF Elbow, show- 
 ing THE Carious 
 Surfaces devoid 
 OF Car tilage, 
 AND THE De- 
 velopment OF 
 Stalactitiform 
 Osteophytes. 
 (Fergusson.) 
 
 t li'.. 'I '• into granulation tissue, absorption 
 lot the ■ ^1 y ca: celli with or without suppura- 
 |tion, and suiueiimes necrosis of small portions 
 the cancellous tissue {caries necrotica). The 
 l^eins within the cancelli become thrombosed, 
 and hence pyaemia may result. The periosteum 
 foveiing the ends of the bones is also inflamed 
 !ind hyperaemic, in consequence of which 
 |p:ailated or stalactitiform osteophytes are pro- 
 puoedil'ig. 2uo). The muscles \r\ the neighbour- 
 oil 0; ihp joint undergo rapid atrophy and fatty degeneration, pro- 
 ^'.v '■ a r^uJt of some reflex disturbance of the trophic centres 
 
 35 
 
546 
 
 A MANUAL OF SURGERY 
 
 Treatment. — In the early stages the Hmb must be elevated, abso- 
 lutely immobilized, and put into such a position that, if ankylosis 
 subsequently obtains, it may be of some use to the patient. 
 Fomentations or an icebag may be temporarily applied, l)ut ;b 
 soon as the symptoms point to suppuration, the joint should h 
 freely opened in one or two places, washed out witli some sterile 
 or antiseptic solution, and drainage-tubes inserted, whilst neces 
 sarily any peri-articular abscesses are dealt with in the same wav. 
 Openings should preferably be made on opposite sides of tlie 
 joint, so as to allow the cavity to be frequently flushed out. or, ii 
 considered desirable, for continuous irrigation of the joint with 
 some mild antiseptic {e.g., weak boracic lotion, or sublimate solu. 
 tion, I in 8,000), or some bland unirritating fluid, such as sterilized 
 normal saline solution. The fixation of the limb is maintained, 
 and the general health attended to. Irrigation chould be continued 
 until fill signs of inflammation, pain, heat, and startings of the limb 
 have , ssed away. Undci such a regime it is sometimes possi'ile 
 to ob.- useable joint, but more frequently ankylosis must 
 
 be exp;<.i''i. Excision may be required in order to preventer 
 remedy fa\:i:j ankylosis, or to place the limb in a good position: 
 it is also undertaken in some cases of chronic suppuration, with 
 caries of the ends of the bones and displacement, but, as a rule, 
 not until all acute symptoms have passed away. If the patient is 
 suffering from severe toxaemic or pyaemic symptoms threateniii;: 
 life, amputation may be required, as also for exhaustion from Ion;,'- 
 standing suppuration and hectic fever. 
 
 In rheumatic cases where suppuration is not expected or does 
 not tlireaten, the joint should be elevated and kept absolutely 
 at rest ; counter-irritation by means cf blisters, or even the actuiil 
 cautery, may be useful whilst suitable constitutional treatment is 1 
 adopted. In bad cases where such treatment has failed incision 
 and drainage are necessary. 
 
 Acute Art Jiritis of Special Joints. 
 
 In the Shoulder, infection sometimes occurs through the axilla 
 where the capsule is weak and easily invaded by organisms, 
 as after an axillary cellulitis ; more frequently it follows a pene- 
 trating injury. Severe pain is caused by any mo\ement of the I 
 arm affecting the joint, and the pus in the distended synovial 
 membrane comes to the surface in front of or behind the deltoid, | 
 or in the axilla. It may suffice to open the articulation anteriorly 
 and flush it out, but, if possible, a counter-opening should be made j 
 behind by cutting down on a pair of dressing forceps pushed back 
 wards through the capsule. In many instances the patient's! 
 condition will not improve until the head of the bone has been 
 excised. The subsequent results as regards movement and power j 
 of the arm are, on the whole, very satisfactory. 
 
DISEASES OF JOINTS 
 
 547 
 
 In the Elbow, there are no points requiring special mention as 
 to clinical history or results, although it must be remembered that 
 the superior radio-ulnar articulation is necessarily involved, and 
 hence the power of pronation and supination of the hand is 
 threatened. As to treatment, incisions should be made on either 
 side of the olecranon, the ulnar nerve being avoided. The limb 
 is then placed on a rectangular splint, and with the hand midway 
 between pronation and supination ; of course, the patient is kept in 
 bed, with the arm raised on a pillow. In an adult excision may 
 be undertaken as soon as the acate stage has passed, in order to 
 obtain a moveable elbow ; but in children, where the growth is 
 incomplete, it is better to allow ankylosis to occur, and excise, if 
 need he, at a later date. 
 
 The Wrist may be infected secondarily to septic conditions 
 following,' operations on ganglia in the neighbourhood, or through 
 direct injury. The essential treatment consists in free incisions 
 parallel witli the tendons, and avoiding the sheaths. Ankylosis 
 usually results, and excision is not resorted to except when the 
 disease has become very chronic, with extensive caries of the carpus. 
 
 Acute arthritis of the Hip-joint is usually a sequela of acute 
 
 infective osteomyelitis attacking the upper end of the shaft of 
 
 the femur, and involving the joint, owing to the epiphyseal car- 
 
 [\h'^e being intracapsular ; it also results from pyaemia, and 
 
 rarely from penetrating injuries. The symptoms are similar to 
 
 those of the first stage of ordinary tuberculous disease (p. 574), 
 
 but much more acute. There is high fever, together with intense 
 
 pain, marlved flexion and eversion of the limb, early suppuration, 
 
 and rapid disorganization if not properly treated ; indeed, where 
 
 nothinf( is done, and the patient lives long enough, the head of 
 
 the hone may be entirely absorbed, or is detached and remains 
 
 as a sequestrum in the disintegrated articular cavity. As soon 
 
 as the capsule gives way, the pus may come to the surface in 
 
 jany of the usual localities for hip-joint abscesses. In treating 
 
 ! these cases, the joint should be freely laid open in the situation 
 
 which appears most favourable. The anterior incision is more 
 
 suitahle for the early, and the posterior for the later stages, when 
 
 I the head of the bone is either dislocated, or remains in situ and 
 
 [separated from the shaft. A double opening may sometimes be 
 
 s utilized with advantage. 
 
 The Knee-joint is more frequently involved by this disease than 
 [any other, and is usually infected from without. The symptoms 
 
 are exceedingly typical: the pain is very acute and the joint hot 
 [and distended to its utmost capacity, the limb lying semiflexed 
 [and on its outer side. Left to itself, the capsule gives way, and 
 [suppuration rapidly extends upwards beneath the vasti or down- 
 [wards into the leg, the pus ultimately finding its way to the 
 'surface. The deformity gradually increases, until in the worst 
 j forms the tibia slips behind the condyles of the femur, the leg is 
 
 35—2 
 
548 
 
 A MANUAL OF SURGERY 
 
 flexed to a right angle and rotated outwards, and if the Hinh has 
 long rested on its outer side, considerable lateral displacenient 
 may also occur. Early and efficient treatment will usualh 
 prevent such a disaster. The joint should be freely incised oii 
 each side of the patella, so as to open up the crureal pouch, and 
 the whole articular cavity well washed out. In some cases a 
 counter-opening may be made with advantage and a drain-tuht 
 inserted, by passing a pair of sinus forceps through the outer 
 portion of the posterior ligament of Winslow, and cutting down 
 on it to the inner side of the biceps tendon and clear of the e,\ 
 ternal popliteal nerve. By this means more efficient drainaj^'e of 
 the articular cavity is obtained. 
 
 When the Ankle-joint is involved, amputation has often to be 
 resorted to, in consequence of the difficulty of securing <(oo(l 
 drainage, although excision of the astragalus will sometimes cut 
 short the disease and lead to a good result. 
 
 Tuberculous Disease of Joints. 
 
 T- . ,. ?rculous Artliritis(5)';/. ; Pulpy Degeneration of the Synovial 
 Membrane, White ""Bwemng, etc.7"iiTay "commence eithei Tn tic 
 sjnovial membrane or in the articular end of the adjacent hone 
 (tul.. cu''-LiS epiphysitis, p. 481) ; or it may spread fioni tlic 
 periosteum to the syno\-ial membrane, as a result of a tuber- 
 culous periostitis, or from a neighbouring bursa. Tlie synovial 
 origin is more common in children and adolescents, the osseotb 
 in adults. 
 
 The Causes may be summed up as follows : The indi\ idual i.- 
 predisposed to the development of tuberculous disease, usually as 
 the result of an inherited tendency, a family history of tuhercle 
 being often obtainable ; the general liealth of the patient may lie 
 at fault, owing to insufficient or inappropriate food, bad hygienic 
 surroundings, or exposure to cold. Some slight injury of which 1 
 but little notice is taken may lead to the actual deposit of tht 
 Bac. tuberculosis, which gains access to the body through some 
 breach of surface, or even perhaps through a healthy mucous 
 membrane. Severe articular lesions, such as dislocations, arej 
 much less likely to induce tuberculous disease, partly because theii 
 gravity demands efficient treatment, partly because the activityotj 
 the reparative process is capable of dealing with the organisms. 
 even if they are brought to the spot. 
 
 Pathological Anatomy. — The synovial memhrane becomes thick- 
 ened, pulpy, and edematous, and in the early stages, on naked-eyel 
 examination, may be found to be studded with small gelatinonsj 
 nodules, about the size of a pin's head, situated ininiediatelvl 
 beneath the serous lining ; later on, these may amalgamate intoj 
 caseous masses which burst and discharge into the joint, leavinsj 
 ulcerated surfaces. Finally, the synovial membrane is chan),^eill 
 
 Fig 2or.-TuBER( 
 
 -UEMBRANE OV£ 
 I'AKTS UETACHE 
 
 OF Surgeons' I 
 
 ^^iiculay catiilage, j 
 
 I 't; just as, accordi 
 
 j^'ongawali. On 
 
 cartdage is found 
 
 thickness is destro 
 
 Y''' of the bone be 
 
 f^^pread along unde 
 
 p"Pply, and thus 
 
 [assist ni its destru 
 
DISEASES OF JOINTS 
 
 549 
 
 into a so-called pyogenic membrane, consisting of granulation 
 tissue similar lo that lining the cavity of a chronic abscess, and 
 more or less closely attached to the surrounding structures, which 
 are transformed into cjedematous fibro-cicatricial tissue, whilst the 
 superficial parts undergo fatty or necrotic changes (^Fig. 201). 
 Microscopically, one finds all the ordinary appearances of tuber- 
 culous disease, the vessels being in a state of endarteritis for some 
 distance from the serous surface. Fringes of the synovial mem- 
 brane, swollen and succulent, spread over the margins of the 
 
 Fig. 201. — Tuberculous Disease of Knee, showing the Synovial 
 Membrane overlapping the Cartilage, which is eroded, and in 
 Parts detached from the Bons and Necrosed. (From College 
 OF Surgeons' Museum.) 
 
 inticulai' cartilage, and as they increase in size become adherent to 
 it. just as, according to Billroth's classical description, ivy creeps 
 alon<^ a wall. On lifting the edges of these fringes, the underlying 
 cartilage is found hollowed out and eroded. As soon as the whole 
 thickness is destroyed at any one spot, the cancellous tissue at the 
 cid of the bone becomes similarly affected, and the granulations 
 f spread along under the cartilage, cutting it off from its nutritive 
 [Supply, and thus necrosis, as well as superficial ulceration, may 
 I assist in its destruction. As a result of the hyperaemic condition 
 
55° 
 
 A MANUAL OF SURGERY 
 
 of the end of the bone, a new formation of subperiosteal osteo- 
 phytes, stalactitiform in character, sometimes takes place, luii nut 
 
 to such an extent as in acute 
 arthritis. Occasionally the 
 periosteum itself is invcjlved in 
 the tuberculous process, and 
 the disease may then extend 
 some distance from the joint. 
 When the iione becomes 
 involved, either primarily or 
 secondarily, any of the mani- 
 festations of tuberculous 
 disease described in Chapter 
 XVII. may be met with, and 
 thus it is not unconiinon Ui 
 find sequestra in connection 
 with tuberculous arthritis. 
 When it originates in the 
 bone, the tissue directly con- 
 tiguous to the articular carti- 
 lage is often that primarily 
 attacked ; but sometimes it 
 starts immediately beneath the 
 epiphyseal cartilage. The ex- 
 tent of the mischief in the hones 
 may be ascertained by the X 
 rays (see Plates XXIV. and 
 XXV.). 
 
 Clinical History. — The dis 
 ease usually commences in a 
 most insidious manner. It 
 may be dated back to some 
 injury, but as often as not 
 no such occurrence has heen 
 noted. Slight impairment of 
 movement, together with some 
 pain, especially when the limh 
 is jarred or twisted, is perhaps 
 the first sign, causing the 
 patient to limp if one of the 
 lower extremities is in\olved. 
 This becomes more and more 
 marked, and the joint is fi.xed, 
 usually in a semiflexed posi- 
 tion, whilst it looks slightly 
 swollen. On inspection it is 
 white, smooth, and rounded, the swelling being more marked on 
 account of the wasting of adjacent muscles. On palpation, the 
 
 Fig. 202. — Bones entering into For- 
 mation OF Knee-joint, which has 
 
 BEEN disorganized BY TUBERCULOUS 
 
 Disease. (From College of Sur- 
 geons' Museum.) 
 
 Tlie cartilage is almost entirely de- 
 stroyed, and the exposed bone is 
 carious and eroded. 
 
DISEASES OF JOINTS 
 
 551 
 
 part is found to be hotter than that on the opposite side of the 
 body, whilst fiuctuation is not readily detected, there being but 
 little fluid in the joint, though the affected tissues are elastic 
 and puffy. In a few rare cases, where the synovial membrane is 
 widely affected, there is a considerable serous exudation, giving 
 rise to a condition known as tuberculous hydrops ; after persist- 
 ing for a while, the usual manifestations of the disease show 
 themselves. 
 
 From time io time exacerbations of pain and increase of swelling 
 occur, which subside after a few days, but leave the joint more 
 and more crippled. Sooner or later abscesses are likely to 
 develop, with increased local disturbance, and often starting pains 
 at niglit, due to the erosion of cartilages, together with slight 
 general fev .rand malaise. If they burst, temporary relief follows; 
 but if the discharge continues, and fresh abscesses form, septic 
 phenomena are usually added to those already present. The 
 patient develops a hectic temperature ; amyloid degeneration of 
 the viscera may supervene, the joint becomes more and more 
 deformed, abnormal movements from relaxation of ligaments may 
 exist, and finally the patient, exhausted partly by the discharge, 
 partly by the pain, and partly by the want of sleep, becomes 
 iinaciated, and may even die, unless prompt measures are taken 
 for his relief. 
 
 Results. — {a) If seen in the early stages, and suitably treated, 
 the disease may be entirely cured, and a moveable joint result. 
 [h] More frequently the articular structures are so severely 
 damaged, that a cure can only be established by means of anky- 
 losis, c^nless measures ha\e been adopted to maintain the 
 limb in a satisfactory position, permanent deformity may ensue. 
 If) If sepsis has been admitted, the patient will probably develop 
 hectic or amyloid disease from chronic toxaemia, and from this 
 he may succumb. On the other hand, in a few instances he 
 may survive such dangers, the sinuses alternately drying up and 
 discharging, although he remains a permanent invalid, and the 
 joint is crippled, {d) Acute miliary tuberculosis is occasionally 
 met with as a complication of this affection, whilst similar 
 associated disease of the lungs, brain, kidneys, or other viscera, 
 may be lighted up. 
 
 The Prognosis is mainly influenced by the condition of the 
 individual and his surroundings. In children of the better classes, 
 where every hygienic and medical assistance can be given, re- 
 covery generally follows, unless there is a strong counterbalancing 
 hereditary tendency. Ainongst the poorer classes, and especially 
 in ' slum children,' the outlook is correspondingly serious. More- 
 over, the extremes of life are unfavourahle : babies res ist tuber - ^ 
 culous invasion badly, and patie nts over fi fty have comparative ly 
 ■Ijttjej-e cuperative power ; lience radical rather tha n co nservativ e 
 measures have often to be resorted to in these two classes^ ~ 
 
 ^-^ 
 
552 
 
 A MANUAL or SURGERY 
 
 Tlie Treatment of tuberculous joints varies not only with iln. 
 articulation affected, but also with the type of patient, imd tin 
 extent to which the disease has advanced. 
 
 1. Hygienic Treatment. — Local tuberculosis is a manifesti'tion of 
 a general condition of weakness which can often be eradicated 
 from the system by suitable constitutional treatment. COnsf. 
 ([uently, in the early staj^es, many cases of tuberculous synovitis 
 can be cured by keeping the limb absolutely at rest, by means of 
 splints, plaster of Paris, etc., and elevating it if there is much pain. 
 The general health should be improved by sending the child to 
 the seaside, giving it plenty of good food, and administering cod- 
 liver-oil and syrup of the iodide of iron. An endeavour ninst be 
 made at the same time to correct any faulty position of the liinli 
 by a process of gradual extension, made at first in the direction 
 of the displacement, and with only just sufficient energy to keep 
 the joint surfaces at rest and counteract the tonic muscular con- 
 traction which is tending to produce a fixed deformity ; it may he 
 necessary to employ tenotomy for this purpose. Any form of 
 apparatus which depends upon a screw mechanism to straighten 
 out a limb is certain to increase intra-articular tension, and there- 
 fore is not to be used. The sudden application of force under an 
 anaesthetic is also unadvisable, since tuberculous material may 
 thereby be disseminated through the system. Counter-irritation 
 by blistering or iodine paint, or combined with pressure in the 
 form of Scott's dressing, is often useful in promoting repair. 
 Possibly the severe pain experienced when the contiguous osseous 
 tissues are involved may be relieved by an application of the 
 actual cautery, but it is doubtful whether the progress of the 
 disease can be checked by such means. 
 
 2. Parenchymatous injections of iodoform suspended in glycerine 
 into the articular cavity, or into the substance of the synovial 
 membrane, ha\'e been much recommended of late, and have 
 apparently done good ; lo parts of iodoform are mixed with 20 of 
 sterilized water, and made up to 100 with pure glycerine, and 
 about an ounce of this fiuid is injected. The limb is at the same 
 time immobilized. The injection usually needs to be repeated 
 more than once, ^-naphthol and some other antiseptics havi 
 also been employed in a similar fashion. 
 
 3. A new plan of treatment was suggested by Bier of Kiel 
 a few years back ; it consists in inducing venous engorgement of the 
 diseased tissues by applying an elastic bandage above and below 
 the joint, but only loosely over it ; the pressure is kept on for 
 two or three hours daily, if the patient can bear it, and during 
 the intervals a splint is applied. The general health must also U 
 attended to during the treatment. The process is based on the 
 observation that phthisis rarely develops in association vith 
 mitral regurgitation, whereby pulmonary engorgement is induced ; 
 whilst if the cardiac lesion supervenes in a phthisical subject, the 
 
DISEASES OE JOINTS 
 
 553 
 
 lunj,' symptoms improve. It is too early yet to say what the final 
 verdict as to this method will be, Init the results hitherto "gained 
 are encourajfinf^.* It must never be employed when septic 
 sinuses are present, as it considerably af^f^ravates the trouble by 
 providing increased pabulum for the micro-organisms. 
 
 ^. Abscesses are, if possible, dealt with sufficiently early and in 
 juch a manner as to obviate the need for prolonged drainage. To 
 this end they must never he left long enough to allow the skin 
 and subcutaneous tissues to become involved, but as soon as a 
 collection can be detected it should be tapped by a large trocar 
 and cannula, the cavity well irrigated, and injected with iodoform 
 emulsion. It is wise to incise the skin with a knife, and not to 
 puncture it with the trocar ; the irregular wound made by the 
 latter niigiit not heal quickly ; a stitch closes the incision and 
 assists satisfactory healing. 
 
 Of course, when the skin is reddened, and the pus subcutaneous, 
 the abscess must be incised and drained in the usual manner, any 
 thin and undermined skin being snipped away. 
 
 j, In other cases where expectant treatment cannot satis- 
 factorily be carried out, or where the disease is progressing, 
 iiiilmctomy, or t' tal removal of the diseased tissues with the least 
 possible disturbance of the parts, should be undertaken. This 
 treatment is only feasible in certain joints, viz., the elbow, knee, 
 and ankle, which can be readily reached, and more or less effi- 
 ciently dealt with. It consists in freely opening the articular 
 cavity, and cutting or scraping away the diseased membrane, 
 whilst carious foci in the bone are scraped and purified. The 
 advantages claimed for it are, that it interferes neither with the 
 immediate length nor with the subsequent growth of the limb, 
 and that no bone is cut through, and hence risk of tuberculous 
 infection of this structure is avoided. As to its practical value — 
 I if the proceeding is limited to the synovial membrane, we have 
 ! little confidence in it, recurrences being frequently met with ; but 
 if it is modified in the knee and ankle by the additional removal of 
 t a thin slice of articular cartilage, so that it is converted into a 
 j limited excision, and osseous ankylosis between the two epiphyses 
 is obtained, good results may be anticipated. At the knee, how- 
 ever, there is some tendency to subsequent flexion and dis- 
 j placement. 
 
 6. Excision is at the present time being utilized much less 
 [frequently in the treatment of tuberculous joints than a shor^ >\-\e 
 back, owing to increased confidence in conservative measu ■ • it 
 is quite possible that this neglect of operation is being carried too 
 jlar. We advise its employment under the following circum- 
 jstances: [a) To cut short the course of the disease where con- 
 htitutional and expectant treatment cannot be efficiently carried 
 lout, or where owing to constitutional weakness or defective 
 * Arcliiv. f. klin. Chirurgie, vol. xlviii., bd. ii., p. 306. 
 
554 
 
 A MANUAL OF SUHGERY 
 
 hygiene it has failed; (h) where extensive superfK-iai aliscesses 
 have formed, reciuiring prolon^'ed drainaj^^e, and the (hscase lias 
 serioiislv involved tlie hones; {c) for total disorganization of the 
 joint ; {(I) to prevent ankylosis in certain joints, \ iz., thr elbow 
 and teinporo-maxillary ; and (e) to remedy ankylosis in a faulty 
 position. In tletei mining whether or not excision is advisaiilf 
 tlie following considerations must he passed under re\ iew : (i.) The 
 operation makes a considerable call upon the recuperative powers 
 of the indixidual, and hence is not to be recommended in inlants 
 or in patients of ad\'anced age. N'arious age-limits are ,L,M\t;n jiv 
 difTerent authorities, but, speaking generally, we would say tluit 
 the operation should only be undertaken upon those I n five 
 
 and forty-five years of age. In infants arthrotomy, w, at most 
 arthrectomy, is all that is practicable ; the ends of the bones are 
 so largely cartilaginous that extensive osseous trouble is not 
 likely to be present. In the hip-joint, however, removal ot the 
 head of the femur often gi\es excellent results even in the younj,'. 
 The latter limit depends more on the vitality than on the actii;il 
 age of the individual, whilst some joints are more anienahlf tu 
 excision in elderly patients than others ; thus, one would exiise 
 the knee or shoulder in cases where one would not think of 
 dealing with the wrist, ankle, or elbow in this manner, (ii.) M(,rc. 
 over, the general health of the individual must be sufticientiv 
 good, otherwise repair will not be satisfactorily accomplished. 
 Hectic and amyloid disease, unless very advanced, do not conini- 
 indicate this proceeding, but in weakly children living in the shims 
 it is often better practice to amputate, (iii.) The er of the 
 disease in the bones is also a matter of importance e, if a 
 
 large amount of bone ha? to be removed, a shortened oi nail-like, 
 useless limb is almost certain to follow. More bone can, however, 
 be removed without detriment in the upper than in the lower 
 extremity, (iv.) Again, the disease must not have inxaded the 
 soft parts too extensively ; if the skin is unhealthy and riddled 
 with sinuses, removal of the limb is often preferable, (v.) Finally, 
 no acute or subacute septic trouble should be present, iox fear of 
 lighting up similar disease in the bones. Under such circum- 
 stances the limb may sometimes be saved by making free incisions 
 to relieve tension, and deferring excision until the more active 
 symptoms have subsided. 
 
 7. If, after carefully weighing the preceding considerations, 
 excision is not thought desiralde, and the case is steadily pro- 1 
 gressing from bad to worse, amputation would p^pppiu- to hp the<f 
 
 only treatment availabl e. In addition, it is indicated in patients 
 \vliere excision has been undertaken and failed, either trom the 
 limb becoming subsequently flail-like or useless, or from recurrence j 
 owing to incomplete eradication, or from the advent of sepsis, 
 Lastly, if the disease is present in two joints at one time, or in a j 
 joint and some other organ, neither of which is improving, total [ 
 
DISEASES OF JOINTS 
 
 fM 
 
 rem()\al of one focus of mischief will often induce ;i rapidly favour- 
 ;il)le change in the other. »/ 
 
 Tubeniilms. Discqsc of Special Joints. 
 
 riic Shoulder -joint is but rarely affected in children, and not 
 urv commonly in adults. The disease usually starts in the head 
 ,it tlu' humerus, affectinf,' sul>se(iuently the synovial membrane, 
 iiiuj perhaps also the },denoiil cavity. If abscesses form, they are 
 likely to point either in front of or behind the deltoid, in the former 
 case extendinf^f alonj,' tlie syno\ial membrane lininj,' the bicipital 
 ;'roove. Kxcision of the head of the bone is almost always 
 required in order to effect a cure. 
 
 In tlic Elbow the disease starts in children most commonly i.) 
 the svnoxial membrane, and then usually in that portion placed 
 within the superior radio-ulnar articulation ; in adults it is often 
 primarily osseous, commencing in the olecranon or lower end of 
 the hi'.inerus. Sinuses form on either side of the olecranon, or an 
 absctss may burrow upwards along the ulnar nerve and open on 
 the inner side of the arm. Prolonged immobilization, followed, 
 it need be, by incision and partial removal of the synovial 
 Dienihrane, often suffices in children, leaving, however, a stiff 
 elbow ; in adults excision is the correct practice, and the results 
 are very satisfactory, provided that a sufficient amount of bone is 
 removed, and the muscular attachments interfered with as little 
 asi>(:sil)le. If expectant treatment is adopti >!, the arm should 
 k flexed to a right angle, and with the hand midway between 
 pronation and supination, so that, if ankylosis follows, the limb 
 may he in the most useful position. Arthrectomy is occasionally 
 adopted, and is best accomplished by means of an H -shaped 
 incision over the olecranon, which process of bone is divided at 
 its hase and turned upwards, so as to thoroughly expose the 
 interior of the articulation. After removing all diseased tissue, 
 the olecranon is replaced and wired to the shaft of the ulna. 
 
 In the Wrist diffuse disease of the synovial membrane and 
 hones is met with, starting most frec^uently from the former 
 structure ; it may also extend from a tuberculous affection of the 
 adjacent tendon sheaths. A characteristic doughy swelling forms 
 over the dorsum, displacing the extensor tendons, and sinuses 
 often develop on the dorsal aspect or by the side of the flexor 
 carpi radialis tendon. Prolonged rest may bring about a cure, 
 hut early excision in suitable cases gives satisfactory results, 
 though there is a great tendency to the production of a weak and 
 llail-like hand, so that the constant use of a leather support is 
 I essential after healing has occurred. In elderly people amputa- 
 I tion is the only resource. 
 
 D'';eases of the Hip-joint and of the Sacro-iliac Articulation are 
 [separately considered (pp. 572 and 580). 
 
 Tile Knee-joint is, perhaps, more often affected with tuberculous 
 
556 
 
 A MANUAL OF SURGERY 
 
 disease than any other articulation. Under ten years of a'^e n 
 synovuil origin is tlie niost conVn"ibir;"bet\veen ten and tweiuv tlu' 
 "osseous and syno^^al forms are about "equal ; \vliTrsr"aTteV hventv 
 years the osseous vane'fy'is iiiore usually met with, f^enerallv 
 starting on the inner aspect of either the femi;r or tibia. Se(]ue.st!a 
 are'foimd in nearly one half of the cases in which the hone i^ 
 affected. The disease runs a typical course, and needg no special 
 comnient. When the joint has become disorganized, the tibia i^ 
 displaced horizontally backwards, flexed and externally rotated, luid 
 ankylosis in this position is difficult to remedy, even by operation. 
 Prolonged immobilization on a back-splint, or, preferably, the 
 application of a Thomas's knee-splint (Fig. 203), together with 
 
 constitutional treatment, will be effectr.al ii. 
 many early cases. At a later date a inoditied 
 arthrectomy may be undertaken, and to earn 
 it out an incision should be made across the 
 front of the joint from condyle to condyle, as 
 for an excision, dividing either the ligamentum 
 patella?, and thus opening the joint, or perhaps 
 dividing the patella, which is subseijuently 
 wired together. The whole of the synovial 
 membrane is then dissected away, special 
 attention being directed to the su[)crureal 
 pouch and the back of the joint. A thin slice 
 should be removed from the surfaces of hoth 
 tibia and femur, and if the epiphyseal carti- 
 lages are not encroached upon, the growth of 
 the limb is not impaired to any great extent, 
 although it may become irregular and lead to 
 some deformity, e.g., well-marked flexion, or 
 genu recurvatum (p. 367). In suitable cases, 
 where the bones are not too extensively in- 
 volved, so that on section broad healthy sur- 
 faces can b^ apposed, excision is a most satis- 
 factory operation, provided that the bulk of tlie 
 synovial disease can be removed. Recurrence 
 usually results from a focal point of disease 
 being left in the synovial membrane or in 
 the bone. If amputation is necessary, the 
 supracondyloid operation can generally i'e 
 adopted ; when t!ie joint has lieen already 
 resected, or sinuses still persist in front, a 
 long posterior Hap is often the only healthy 
 tissue available for covering the bone. 
 
 The Ankle-joint. — Tuberculous disease of 
 this joint usually commences in the synovial 
 membrane rather than in the bone. If primarily osseous, the 
 astragalus is more frequently affected than the lower end ot the 
 
 Fig. 203. — Thomas's 
 Knee- si'LiNT ap- 
 plied. 
 
age ;i 
 nlv tlk' 
 Iwentv 
 iuerally 
 ;iiuestra 
 lione i^ 
 ) special 
 J tihiii is 
 lied, and 
 peration, 
 ibly, the 
 her with 
 ectual ii. 
 tuoditifd 
 I to cany 
 .cross the 
 jndyle, as 
 ;anientuni 
 jr perhaps 
 )se(iueiuly 
 J synovial 
 ,y, speciid 
 subcrureal 
 ^ thin slice 
 ;es of both 
 seal carti- 
 growth ot 
 eat extent, 
 nd lead to 
 flexion, or 
 able cases, 
 Insively in- 
 jealthy sur- 
 [most satis- 
 bulk of the 
 Recurrence 
 of disease 
 Irane or in 
 ;ssary, the 
 pierally W 
 len already 
 lin front, a 
 ily healthy 
 
 Inc. 
 
 disease nt 
 
 lie synovial 
 
 ,seous, the 
 
 end of tli*^ 
 
 PLATE XXIV. 
 
 TuiiERcuLous Disease ov Knee-joint, showing Invasion ok I'atki.la. 
 '"OT A 556.1 
 
libia. 
 
 which 
 
 front c 
 
 the te 
 
 immol! 
 
 Kxcisi( 
 
 unfret]! 
 
 when c 
 
 likely t 
 
 the oth 
 
 conditic 
 
 same ti 
 
 disease 
 
 will he 
 
 For c 
 
 Altho 
 
 pre\-a]er 
 
 and recc 
 
 iiimiic k 
 
 the joint 
 
 time. A 
 
 most CGI 
 
 trihution 
 
 considerr 
 
 consists 
 
 iroiii da) 
 
 treatmen 
 
 inflaninin 
 
 may not 
 
 period. 
 
 in nieasui 
 
 i'eyond a ! 
 
 , diffuse in 
 
 1 on to niiK 
 
 'ligaments 
 
 iiients fro 
 
 'nodules tr 
 
 I '■I'jiltmtioii 
 
 'Simulates 
 
 h'J distin^^n 
 
 [Other s}-p 
 
 "Hf^inalfy ; 
 
 jproliferatic 
 ftroded hy 
 
DISEASES OF JOINTS 
 
 557 
 
 ;ibia. The whole region becomes occupied by a pulpy swelling, 
 which first pushes forwards the extensor tendons and bulges in 
 front of the malleoli, and subsequently appears on either side of 
 the tendo Achillis. In the early stages prolonged rest and 
 immohili/iation in plaster of Paris are all that is required. 
 Kxcision of the joint gives fairly satisfactory results, but not 
 untrecjuently fails to eradicate the disease, owing to the fact that, 
 when once the astragalus is involved, the tuberculous process is 
 likely to spread to the articulations placed beneath it, and so to 
 the other bones of the foot. When there is any doubt as to the 
 condition of the astragalus, that bone should be removed at the 
 same time as the lower ends of the tibia and fibula. Where the 
 disease is more extensive, a supramalleolar amputation of the foot 
 will be necessary. 
 I'or diseases of the Bones and Joints of the Foot, see p. 480. 
 
 Syphilitic Diseases of Joints. 
 
 Although syphilitic disease of joints is rare in proportion to the 
 prevalence of syphilis, yet several varieties have been dffferentmted- 
 and recognised, (i) In the later stage of the secondary period a 
 Jmviic form oC synovitis occurs, evidenced by passive effusion into 
 the joint, with or without pain, and usually persisting for some 
 time. Any joint may be attacked in this way, perhaps the knee 
 most commonly, and the affection is often symmetrical in its dis- 
 tribution. The effusion may be only slight, but is frequently very 
 considerable (hydrarthrosis), and a marked feature in the condition 
 consists in the rapid variations in the amount of swelling, e\en 
 from day to day. In some few cases this affection resists all 
 treatment, and leads to ultimate disorganization. (2) Gummatous 
 inllaninuition of the perisynovial fibrous tissue, which may or 
 may not extend to the adjacent bone, is met with in the tertiary 
 period. It either appears as a localized hard nodule, resembling 
 in measuie a fibrous tumour, and then causing but little trouble 
 lieyond a sense of painful weakness in the articulation ; or it is more 
 uiffuse in its distribution, leading to a moderate effusion, and later 
 on to much thickening and infiltration of the capsular and other 
 liiiaments, and resulting in considerable impairment of its move- 
 iiiients from cicatricial contraction. Some of these gummatous 
 nodules may break down and ulcerate. (3) A diffuse gummatous 
 Unnltration of the synovial memhvanc itself is also seen. It closely 
 simulates a tuberculous synovitis, from which it is often impossible 
 jto distinguish it, except by the rapid onset and the presence of 
 [other syphilitic phenomena. (4) A chond ro-arthvitis, described 
 |(iri;,'inally by \'irchow, is the syphilitic analogue of osteo-arthritis. 
 |h conunences by fibriiration of' the hiatrix of the carHTage,'and 
 Iproliferation of the cells. The cartilage softens, and becomes 
 Itroded by friction of the articular surfaces. The bone thus 
 
558 
 
 A MANUAL OF SURGERY 
 
 exposed is worn away, and curiously ' pitted ' and exca\ated. h 
 is recof^nised from osteo-arthritis by the facts that there is usuallv 
 hut little or no pain ; that the eburnation of the exposed hone h 
 less extensive, and therefore crepitus is but little marked ; uiiils; 
 the typical osteophytic growths, causing ' lipping ' of the joint 
 margins, are absent. The eroded areas, moreover, do not corrc 
 spond with the sites of intra-articular pressure, and are more 
 rounded and punched out, and not arranged in linear groo\es, as 
 in the latter disease. It is not uncommonly associated with a 
 gummatous thickening of the synovial membrane, and, indeed, 
 the hollows or pits alcove mentioned may be filled with caseous 
 material, derived from degeneration of this tissue. 
 
 The Treatment in the early manifestation consists in the 
 administration of mercury, and the judicious application of pres- 
 sure with or without inunobilization, according to the reiiuire- 
 ments of the case and the joint affected. In the tertiary forms 
 iodide of potassium m gradually increasing doses has a rapidly 
 beneficial action, which confirms the diagnosis ; it may be 
 occasionally combined with a small amount of mercury, either 
 given internally, or applied locally if any ulcerative lesion exists. 
 In the most pronounced cases, where the pain is severe and 
 disorganization of the joint has occurred, excision may be neces- 
 sary, and the results are often very satisfactory. 
 
 Osteo-arthritis. 
 
 Although this disease is extremely common in this country and 
 has well-marked characteristics, its nature is still extremelv 
 obscure, as is evident from the large number of names that have 
 been applied to it, such as chronic rheumatoid arthritis, rhcnmalu 
 gout, arthritis deformans, arthritis senilis, arthritis sicca, etc. There i; 
 not the slightest doubt that several distinct types of disease have 
 fi§e22. confonunded_togetli^er_u and_.althougii at the 
 
 present time it is admitted that rheumatic and gouty conditions 
 are to be excluded, yet it is probable that we are still inrludinj,' 
 more than one type of chronic articular trouble. 
 
 .Etiology. — Exposure to damp and cold is doubtless an im- 
 portant factor in the production of osteo-arthritis, especially in 
 elderly people, or when some depressed condition of the nervous 
 system is superadded, whether such be due to worry, anxiety, or 
 to defective nutrition. In other cases where there is no (luestion 
 of exposure, the affection is by some attributed to nervous 
 influences (Senator, Ord), and particularly to affections of the 
 uterus and o\aries, which it is supposed are capable of induciiis; 
 reflex changes in the joints. Such an idea may explain some ol 
 the trophic and nervous phenomena associated with this trouble, 
 but it is a little difiicult to accept the theory in its entirety, 
 Others again attribute it to auto-intoxication due to indi<;estion 
 
DISEASES OF JOINTS 
 
 559 
 
 ess an mi- 
 
 (if duodenal origin. Recently a theory of bacterial causation 
 has been propounded, and although it cannot be considered as 
 proven, yet evidence in favour of its probability is steadily 
 accumulating. It is supposed that the organisms find their 
 way into the joints from some other focus of infection, and in 
 this connection it is interesting to note the statement that in a 
 larjje series of cases 55 per cent, were preceded by some other 
 infective fever or disease (Bannatyne). Tliey develop in the joints 
 and produce toxic bodies which act locally by inducing destructive 
 phenomena of a special type, whilst by their general absorption 
 various trophic and nervous symptoms are caused, whose existence 
 has lieen constantly noted, but for which hitherto there has been 
 no adeiiuate explanation. Such an origin will also explain the 
 presence of enlarged glands in the neighbourhood of some of the 
 attected joints. Several observers have found bacteria within the 
 ji lints, and Bannatyne and others have described a short bacillus, 
 the ends of which stain deeply whilst the intervening portion 
 remains unstained, causing it to look like a diplococcus. This 
 was found in several cases, but though injected into the joints of 
 animals, no results followed. 
 
 Traumatism plays an important part in the production of 
 certain types of osteo-arthritis," and Lane is emphatic in maintain- 
 ing that these cases should tJS'TeiegJited to a diflferent category, 
 and he known as chronic traumatic arthritis ; the changes, how- 
 ever, are so similar to those of osteo-arthritis that we prefer to 
 consider it a subdivision or variety. The injury may be slight in 
 nature, such as a sprain or strain, 
 or more severe, such as a frac- 
 ture or dislocation involving the 
 articular surface ; thus, it is not 
 uncommon to see it following 
 Colles's fracture or one of the 
 cervix femoris. Abnormal pres- 
 sure maintained for a long time 
 also causes changes of a similar 
 type, and thus many of the joints 
 of labouring men are deformed in 
 a peculiar fashion, according to 
 the special type of work and the 
 particular joints that are exposed 
 to strain. 
 
 Pathological Anatomy. — The 
 disease conunences in the articu- 
 lar cartilage, the matrix of which ^'^^\^°t 
 cracks and undergoes fibrillar 
 changes, and presents a villous 
 appearance, resembling the pile of 
 velvet (Fig. 204). The cartilage ceils proliferate, so that the 
 
 Patella from Eaulv 
 Case of Osteo-arthritis, show- 
 ing Fibrillation of Cartilage. 
 (Howard Marsh.) 
 
56o 
 
 A MANUAL OF SURGERY 
 
 capsules contain many instead of one, and these, givinj^^ \v;iv, dis- 
 cliarge their contents into tlie joint. , The cartilage thus softened 
 is readily worn away by the movements of the articulation, and 
 the exposed surface of hone becomes hard, sclerosed, and polished 
 like ivory (eburnated). This usually occurs in certain defniite 
 directions. In liinge joints the surfaces become grooved Ion") 
 tudinally, whereas in ball-and-socket joints, like the hir, the head 
 is eroded in a circular manner. This condensed tissv.j does not 
 extend very deeply, and inunediately beneath it the cancellous 
 
 bone is of a mote open 
 texture than usual, and 
 tilled with fatty me- 
 dulla. In spite of the 
 sclerosis, the articular 
 end of the bone is con- 
 tinually being worn 
 away, and this may 
 go on to such an ex- 
 tent as to lead to actual 
 shortening of the limh. 
 Concurrently with this 
 destruction, new hone 
 formation is takinj; 
 place at the margins 
 of the articular carti- 
 lage, producing irre- 
 gular osteophytes,; 
 which ha\e l)een 
 likened to the gutterings 
 of a candle. Tliey are 
 preceded by an over- 
 growth of cartilage, in j 
 which ossification 
 
 Fig. 205— Late Stage of Osteo-akthritis ok takes place secondarily, 
 Knee, showing Destruction of the Akticu- \\;l„„ ^,,^u „„f„ro„.tUi. I 
 LAK Caktilage, an» Emcrnation of the \V hen such outgrouth 
 KxposED Bone in Longitudinal Orooves. have Lieen producea| 
 (From College of Surgeons' Museum.) more or less evenly j 
 Tlie margins of the surfaces are distinctly lipped, around the joint mar- 
 gin, a characteristic] 
 ' lipping ' of the edge of the cartilage results (Fig. 205). Some- 
 times tiiese osteophytes attain to a large size, and by interloekingj 
 may lead to ankylosis of the joint. The synovial membrane is 
 usually thickened, and the villi occasionally proliferate, and mayj 
 reach such dimensions as to be felt through the skin, rolling; 
 under the finger. They are red, vascular, and succulent durin^j 
 life, but after removal and preservation in spirit, they lo ' 
 shrunken and insignificant. This overgrowth is often associatedl 
 with excessive effusion, though usually the affection is of a dry 
 
DISEASES OF JOINTS 
 
 561 
 
 tvpe. Occasionally cartilaginous nodules develop in the villi of 
 the synovial fringes, later on becoming ossified, and if detached 
 constitute one form of loose cartilage. 
 
 Clinical History. — Se\eral distinct types of this disease may be 
 observed, but practically they may be subdivided into three chief 
 ijroups : A chronic type involving one joint only ; a chronic form 
 affecting many joints ; and an acute variety which is also poly- 
 articular. 
 
 1. The chronic monarticular variety is that most frequently seen 
 hv surgeons, and is constantly brought about by injury. Pain 
 and creaking of the joint on movement are the early symptoms 
 of this affection. There may be very little swelling, unless 
 efliision is present, but pain, especially at night, is most trouble- 
 some, being usually increased on changes of weather, particularly 
 if rain is threatening. The pain and stiffness are most marked 
 after keeping the parts at rest, and diminish when the limb is used. 
 As the disease progresses, the movements become more and more 
 impaired, and the crepitus more of an osseous type ; the ends 
 of the i)ones are felt enlarged and lipped, and deformity soon 
 kcomes ob\'ious. Exacerl)ations in the symptoms occur from 
 lime to time, resulting in increased crippling of the articulation. 
 Finally, the limb may become absolutely useless, partly from the 
 pain and partly from the limitation of movement produced by 
 
 jthe osteophytes. Wasting of the adjacent muscles is also a 
 : marked feature. 
 It is usually seen in elderly people, and may supervene very 
 
 quickly after an accident, such as fracture or bruising of the 
 [cervix femoris, and then the destructive phenomena may progress 
 
 at a rapid rate. When it appears in younger people, the osseous 
 [lesions are much less evident. 
 
 2. The chronic polyarticular variety arises independently of trau- 
 jmatism, and is most commonly seen in females of middle life. 
 
 may commence in one joint and spread to others, or it may 
 [appear in many joints simultaneously. Most frequently one or 
 [more of the phalangeal articulations is the starting point, par- 
 [ticularly the terminal ones. The joints become stiff and swollen, 
 [are tender, and small nodular bony outgrowths develop at the 
 [bases of the phalanges, which are known as Heberden's nodosi- 
 ties, The trouble gradually spreads to other joints, and although 
 [ttiere are often remissions, yet the condition progresses steadily 
 [until the patient may be entirely crippled thereby. Well marked 
 jovergrowth of bone and eburnation of the articular ends are 
 mracteristic features of this type. Sometimes there is consider- 
 iWe effusion, accompanied by overgrowth of the synovial villi, 
 M this is unusual. 
 
 3. The acute polyarticular variety does not often come to the 
 Nffeon for treatment, at any rate in the early stages. It usually 
 packs young or comparatively young people, and females rather 
 
 36 
 
562 
 
 A MANUAL OF SURGERY 
 
 than males, freciuently follo\vin<f some infective tr()ul)le, sir h a^ 
 influenza, scarlatina, tonsillitis, etc. It is often ushered in by a 
 distinct febrile attack with persistent increase in the rate of ttu 
 heart-beat; trophic and vasomotor phenomena are oticii (o. 
 existent, such as patches of pij^'mentation, clammy cold iiands, 
 and rapid muscular atrophy. The smaller joints of the liunds 
 and feet are mainly affected, and that more or less synmictricallv, 
 althouj^h the terminal interphalanj^a*al articulations ofti'u escape, 
 The capsules are distended with a certain amount of i Ifusion, 
 and at lirst there is but little osseous mischief. In not a tnv 
 cases a \ery characteristic deformity in the shape of ulnar 
 adduction of all the iinf;jers occurs. (iradually the IroiiMe 
 spreads to other and larger joints, and osseous manilVstations 
 appear ; but the progress is slow, and may be to a large cxttnt 
 arrested by treatment. Neighbouring lymphatic glands may In 
 enlarged in the early stages. 
 
 It is important to note that gouty and rheumatic troubles iiiav 
 be associated with osteo-arthritis ; the rheumatic affections iiiav 
 precede, the gouty usually follow. 
 
 The Diagnosis of osteo-arthritis per se is not usually difficult in 
 a well-marked case, the crepitus, pain, and enlargement of the 
 ends of the bones, together with the slight amount of effusion, 
 constituting a tolerably characteristic picture. From simple 
 chronic syiwvith it may be known by the history and smaller 
 amount of effusion, and by the pain and rigidity being fre(|uentl\ 
 more marked after rest, and diminishing after the joint lias been 
 actively used. There is more difficulty in distinguishing the form j 
 associated with increased effusion and enlargement of the svnovial 
 \illi ; careful examination may, however, enable the surgeon to make j 
 out these villi moving to and fro in the joint under his hand, whilst 
 possibly the ends of the bone may be lipped. For diagnosis from | 
 chyonic rhenmatisvi and Charcot's disease, see pp. 540 and 565. 
 
 The diagnostic points between polyarticular osteo-arthritis andj 
 gout are suggested in the following table : 
 
 Osteo-arthritis. 
 
 Gout. 
 
 Se.\ : 
 
 Type of patient 
 
 Females : 
 
 Poor, ill - nourislied, de- 
 pressed, an.xious; often e.\- 
 posed to damp and cold. 
 Onset. I Insidious. 
 
 Locality of onset | Usually in hands, espe- 
 i cially in the thumb. 
 
 Type of attack. 
 
 No obvious swelling or 
 redness. 
 
 Tain. I Slight and aching. 
 
 Symmetry. Well marked. 
 
 Depositof urate of ' Absent, 
 soda. I 
 
 Males : 
 
 Well - to - do and well 
 nourished people. 
 
 Sudden and obvious. 
 Feet, especially metatarso-j 
 
 phalangeal joint of .k'rrttj 
 
 toe. 
 Red and painful at fi^^t,j 
 
 with skin shiny over liiq 
 
 joint. 
 Severe and acute. 
 Not usually present 
 Present. 
 
DISEASES OF jfOINTS 
 
 563 
 
 PrflgTinaiH j^ ^isu ally unfav ounib lt^ . The fact that many 
 jiiints are affected is an indication tliat there is a considerable 
 omstitiitional tendency to the dexelopnient of the (hsease, and 
 although it may be temporarily cond)ated with success, still, 
 sooner or later, the patient is almost certain to be crippled by it. 
 [he affection of only one joint often points to a traumatic ori^dn, 
 ,mcl the outlook is corresp()ndin<fly brij^diter; but where the 
 disease attacks several parts of the i)ody, there is but little hope 
 ot clieckinf,^ it, and indeed cases are known in which every joint 
 has successively become implicated, the patient draj^'^nng on a 
 wiarv existence, ne\er free from pain, and usually in a cramped 
 ,11 sittiu},' posture, until death from exhaustion supervenes. 
 
 Treatment.— r^or this troublesome complaint there is, unfor- 
 uinatL'ly, little that can be effected in the way of cure, althouj^di 
 much can be done to alleviate. Locally, the articulations should 
 he protected from cold and injury by bein^^ swathed in flannel, 
 whilst stinndatinjjf embrocations and sedati\e applications may be 
 licnelicially employed. It is not adxisable to maintain the joints 
 absolutely and always at rest, otherwise they tend to become 
 tixed, and their mobility is seriously limited at an unnecessarily 
 ciirlv date. Moreo\er, it is often found that the more a joint is 
 movt'd, the easier and less painful do those movements become, 
 and hence regular niassajj^e is desirable. As to general treat- 
 ment, tlie indixidual is warned against exposing himself to cold 
 anil dauip, and, since the disease is often considered to be due to 
 perverted or diminished nervous acti\ ity, all possible sources oi 
 irritation and worry should be removed. \t the same time the 
 nutrition must be improved, and plenty of good food, cod-liver 
 nil. etc., administered. A large nundier of different drugs have 
 been tried for this complaint, but none of them are very satis- 
 factory. Perhaps the best is iodide of potash combined with 
 suiiie alkaline purgative and hepatic stimulant, such as sulphate 
 I of soda. Natural mineral waters and baths are often beneficial, 
 those of P>ath and Buxton in this country being most frequently 
 recommended. Arsenic is sometimes useful in cases where the 
 disease is probably of nervous origin. 
 
 Occasionally operative treatment in the shape of excision may 
 lt>e useful in this complaint, but only when the disease is limited 
 j;o one joint, and when it has progressed to such a stage as to 
 jseriously cripple the patient's usefulness, as in the knee-joint, 
 Iclbow or the shoulder, or when the act of mastication is impaired, 
 |o\vin<f to an affection of the temporo-maxillary articulation. In 
 suitable cases excellent results are obtained. 
 
 The hip-joint is not uncommonly the seat of osteo-arthritis in 
 [old people, and it always causes a considerable amount of pain, 
 ppecially on flexion of the limb, rendering sitting difficult and 
 
 Iking uncomfortable, whilst the movements are steadily more 
 
 36—2 
 
564 
 
 A MANUAL OF SURGERY 
 
 and more curtailed. The liiid) appears at first to he slii^htK 
 increased in lenj^'th, hut later on becomes shortened from crosioii 
 of the head and atrophy of the neck of the bone ; the trochanter is 
 also much thickened and more prominent than usual, on account 
 of the associated atrophy of neijjjhbourinf; muscles. Well-marked 
 crepitus is obtained on movin},' the thi;;h. The acetabular cavitv 
 is increased in size ovvinf^ to the formation of a projectin;^ rim 01 
 lip. If a patient falls on the afTected hip, some difficulty may h- 
 experienced in makinj( a diaj^aiosis from fracture of the neck of tlu; 
 thij^di-bone. The previous history and the facts that the trocliantcr 
 rotates around its normal centre, and is unduly prominent rather 
 than approximated to the median line, and that the ilio-tihial l)aml 
 is not relaxed, as in fractures, should suffice to pre\ent mistakes. 
 
 When the temporo-maxillary joint is affected, the condyle of the 
 jaw becomes larji^er than usual and somewhat flattened, whilst 
 the eminentia articularis is partially absorbed and the }.,'len()iil 
 cavity increased in size, so that there is a tendency for the 
 condyle to slip forwards owing to the action of the external 
 pteryj^oid muscles. If only one joint is affected, the hone is 
 carried towards the sound side, but when both are invohwl the 
 chin becomes prominent owinjjf to a forward displacement of the 
 whole bone. Pain and crepitus are experienced on openinf; the 
 mouth, renderin,<r mastication difficult, and even impracticaMe. 
 If ordinary treatment fails to give relief, the affected coiulyle nt 
 the jaw should be excised. 
 
 P'or osteo-arthritis of the Spine, see Chapter XXI. 
 
 Charcot's Disease {Syn. : Tabetic Arthropathy). 
 
 This disease, bearing the name of the late Professor Ciuircot. is 
 a peculiar affection of joints met with in the course of locomotor 
 ataxy. It is slightly more conunon in women than men, and i;* 
 almost always an early manifestation, occurring usually between 
 the lightning-like pains and the onset of the ataxic symptoms. 
 The most typical form is lighted up by some slight injury — c^., a 
 strain or sprain— and is characterized by a rapid painless dis- 
 tension of the joint with a light-coloured serum, which may alsn 
 extend into the communicating bursae ; there is some amount of 
 effusion into the surrounding cellular tissue, although without 
 (edema. This distension may be so rapid that abnormal mobility 
 or even dislocation may occur at the end of a few hours. The 
 joints most frequently affected are the knee, hip, and shoulder: 
 occasionally more than one articulation is involved. The course j 
 of the case varies ; in some few instances the fluid is gradually 
 absorbed and the joint returns to its normal size and shape, j 
 although somewhat weakened. Sometimes the attacks of dis- 
 tension recur, and after each the joint becomes more and morel 
 crippled. In others, however, and perhaps most frequently, the 
 
DISEASES OF JOINTS 
 
 S«5 
 
 bones become eroded to a considerable extent, the ligaments 
 stretclu'd, and a weak, flail-like articulation remains, in which 
 the eiuls of the bones are atrophied and displaced (iMg. 206). 
 In otiicr instances new osseous formations occur here and there 
 under the syno\ ial membran e, especially in cases where there is 
 .;^cTi disj£iiaiaji, so that on compressing the swel ling betwee n 
 'h^Thands, a sensation is produce d similar to that imparted l) y 
 .^r.isping a bag of bones. Occasioniiiry, underTaese circumstances, 
 tlirnKSPOTTsTriasses become welded together, giving rise to large 
 overgrowths, wliich lead subsecjuently to fixation of tlie jc.int. 
 The disease sometimes runs a more chronic course, and then 
 rioselv resem bles osteo-arthritis , since there is but little el hision . 
 whilst the ends of the bones ' become ero ded, and osteo phytes, 
 perhaps of great size, form around the edges of the, cartilii4jes, 
 iL';uling to defective mobility and crei)itus. 
 
 Fir,. 206.— Charcot's Disease of Left Knee and Shoulder. 
 
 The great atrophy of the ends of the bones, and the resulting dislocations, are 
 
 clearly evident. 
 
 The Diagnosis of Charcot's disease froni^ osteo-aythritis \s, as a 
 rule, r eadily m ade if one rememb ers the following points : Charcot 's 
 disease jsjisiiaUy xharact eflzed b y a rapid onset, limitation to one 
 ioin i. considerab le effusion^ absence of pam, atrophy of the ends 
 oTtlie bmies, and a tendency to the £r6 miction of a weak^ flail -like 
 pint, whijst t^ie general signs of tal^es are^ilso obs erved . Osteo- 
 llfthrTflsVon the other hand, comes on slowly, offen affects many 
 j joints, has but little effusion, is very painful, and is attended with 
 overgrowth tending to produce ankylosis. In the more chronic 
 cases the distinguishing features are much less evident. 
 
 As to pathological anatomy, the changes obser\ed are prac- 
 tically identical with those seen in osteo-arthritis, except that the 
 I erosion is more rapid, the effusion greater, and the formation of 
 osteophytes less constant. 
 
 The Treatment of Charcot's disease consists in keeping the 
 [limb at rest on a splint and applying elastic pressure. The 
 
 ^ 
 
566 
 
 A MANVAL OF SURGERY 
 
 effusion, when consicU'nvble, may hv retnoveil by an aspixalur. hut 
 is \ery likely to re-collect. In the later sta-^es, where the joint 
 is entirely disor},o'ini/ed, some form of tixud apparatus imiy |„. 
 a[)plie(l to render the linil) mort; useful, since no operatixe treat 
 ment can he undertaken. 
 
 Tlie same type of articular lesion occurs in SyiiiiiiiOiiycUa, a (iisi'asu wliidi 
 consists in a j,'liomatous development in tiie spinal conl, and usually in 
 .the cervico-dorsal region. It is characterized by loss of the senses of pain, 
 and of heat or cold, wiiilst tactile and muscular sensibility persists Atmplu 
 of \arious inuscles of the hanil or forearm also occurs, whilst tr'ipjiic lesions, 
 r./,'., whitlow, perforatiiij,' ulcer, etc., .are common Joint trouhits arc (ii)stT\tii 
 in at least one-third of the cases, mairdy in the upper extreniiis, t;^i)(;^ 
 generally affecting; the lower. Either atrophic or hypertrophic plu'imniena 
 are developed, and the course is identical with that of Ciiarcot's disL-ast 
 except that suppuration is a little more likely to follow, owinj,' to tlic frciiiiem 
 presence of septic sores. 
 
 Somewhat similar in nature to Charcot's disease is the chronic arlhiitis met 
 with in many conditions where the nervous supply to a lind) is impaired as ;i 
 result of central or peripheral disease of the nervous system. Tiuis, it nia\ 
 follow spina bifida, hemi- or para-plegia of cerebral or spinal uri>,'in, or ma\ 
 be secondary to a peripheral neuritis, due to either injury, syphilis, roui, 
 diabetes, leprosy, etc. The terminal articulations of finders or toes are tluM' 
 most often affected (acro-arthritis), althouf^h lar>,'er joints may be involved 
 They become swollen and painful, ami after a time ankylosis ensues, 
 
 Hsemophilic Diseases of Joints. 
 
 In haemophilia (p. 213) any injury to a joint, such as a sprain 
 or wTencht . may lead to ~a~cc7pr6us efTifsion ofblood jiiTo the 
 articular c avity, whic h beconies sudden ^y_s^voI^en^ distended, and 
 evidently full of firiicE There is some pain on moxement, the pan 
 becommg hot and tender, whilst when coagulation h as ta ken place 
 it is hard a nd fir m. , TotaTrecoxery may ensue, or tTie joint he left 
 wealv and liable to recurrence of ha?morrhaf.^e and inrianiinaiion. 
 The effects on the articular surfaces are curious : the caitila!,a> 
 usually retain their normal C(jlour, but become thin, worn, aiiii 
 rough, especially at the points of greatest pressure ; librilhir 
 degeneration of the matrix may occur, and in some cases the 
 cartilage has been found totally absent, being replaced by tihroii^ 
 tissue. Ecchondroses subsequently de\eloping into hone are 
 formed at the margins of the joint surfaces, the changes thus 
 produced being somewhat akin to those of osteo-arthritis. The 
 ligaments and synovial membranes may remain of a normal 
 texture, or are slightly thickened, and usually of n "i 'roAn| 
 colour. Adhesions are often present, causing on^ .eralm 1/ jiair 
 ment of mobility. The trcatuicnt cons\^\.': ' \ ng the part a. ^ 
 
 rest, and appU'ing ice in " tBe ~ early sta whilst, lat on. 
 
 friction, massage, aruT pressure may be en ived. The siuj^eon 
 iruist ne\er attempt to aspirate the joint, e\eu viti 1 fine needle, 
 
DISK ASICS OF y 01 NTS 
 
 5^'7 
 
 Loose Bodies in Joints. 
 
 Sl'\x'i;i1 \;iiieties of louse bodies lire met with in joiiits^wliich may 
 Ik described as follows: (i) The so-called ' m elon-seed bodies ' con - 
 ',ist()f iIi'Mst! fibroid tissue derived from altered blood-clot, or more 
 'requentl)' from a tibritious exudation in cases of \c'ry clironic 
 ailit'iculous disease. At lirst irregular in shape and lamina ted in 
 texture, they are generally transformed into roiuid pellets Ly the 
 iii()\eiii(iits of the articulation. lUusa- and tendon sh eaths are 
 nuicli more fre(iuently affected than juilllii. The number of them 
 present is usually considerable, whilst there is also some glairy 
 ctTiisioii, causing distension and a certain amount of creaking. A 
 tew years ag(j we operated on a case in which the l<net!-joint was 
 occupied by a nund)er of rounded ycllowisli-white foreign bodies, 
 
 Fu.. 207 -Foreign Hodv in Joint, prohahlv dkkive» kkom a I'urtion ok 
 
 Articular Cartilace. 
 A, cartilage ; B, bone. (From College of Surgeons' Museum.) 
 
 >c'veral of which were nearly as large as walnuts ; they were prob- 
 iiBly of ha^morrhagic origin. C2»Portions of articular or inter- 
 articular cartilage mgAibFlTroke n off as a resutT ^ormecHahica l 
 ley usually consist of a~ snToofh* rounded mass of 
 
 violeacfi. 
 
 artjcular carfilage^^^osing aTcentrar bony iitTcleus (i^ig. 207). 
 13) They are sometimes derived from the deveTbpmeht"~oT~carti- 
 lai;inous nodules in the synovial fringes or villi, which may either 
 remain adherent and become pedunculated, then occasionally wear- 
 ing; a bed for themselves in the articular surface, or may be totally 
 detached. Such structures are usually lobulated and irregularj_n 
 shapej an d consis t of calcified cartilage or bone, whilst a certain 
 amount ot norma l cartilage is also present (Fig. 208). " Tt is not 
 at all uncommon for this condition to be met with in osteo-arthritis, 
 Imt sometimes the cartilaginous cells from which they are derived 
 have persisted as a ' fcetal residue ' owing to some modification in 
 development. (4) Finally, portions of bone may become separ- 
 atee :om their surroundings, and remain loose in the cavity. 
 
568 
 
 A MANUAL OF Sinx'GliKY 
 
 'Pliiis, rcchoiuhosrs iiiiiy hi' hrokcn oil in cases of osteo aitliiitis 
 <M- portions of tiu' articniiur siirfacc clctacluH! by incclianic ,il niiaiis, 
 or cvt'ii sclcroseil areas isolaUxl by a j)r(H('ss ol raiclvinj; oi.lcjiis 
 without suppuration, constitutiu}; wliat I'aj^ct orij^Mnally dcsc ribcd 
 as ' (piii't necrosis.' 
 
 Aithou};h cut oil" from all vasculai sujipiv, the ;^'ro\vtli of soinc 
 ol these loose bodies is said to coiitiiuie, owin}^ to the liii^hlv 
 luitritions Ihiiil wiiich batlu-s their surface. 
 
 The Symptoms caused by this condition are i)roduc((i i)y ilir 
 loose body beinj; occasionally c;ui}^ht between tlie arti( uliir sin 
 liu-es, li'adinf; to a temporary locking' of tlu> joint and sexcic pain, 
 
 I"ic;. joS. — I.iiosK C"aktu.A(;i: in |oint. I'KonAiii.v i>i:\ i:i.()ii:ii in a 1'kim,i 
 
 ov Synovial Mkmiikank. 
 
 A, cartilage ; H, bdiuv (["loni I ■ollego of Surgeons' Musi'iini.) 
 
 owin,t,' to tlu' stretchinj; oi the ligaments. 'JMie fixation is hnt 
 momentary, since the forei^Mi body is readily chsplaced, hut ;n)j 
 ■ ittack of subacute synoxitis follows. When this has iia[)pciR(l 
 se\eral times, the ligaments are likely to become relaxed, and 
 the joint somewhat loose and distended. I'ndi-r such circum- 
 stances it may be possible to feel the foreign body and to sliilt 
 its position, init frequentlv the surgeon, owing to its ready 
 mobility, is unable to detect the intruder as it slijis awa\' into the 
 interior of the joint, i'rom this point of \ iew, the Cjerniaii teiiii 
 ' Gelenkmaus ' (joint mouse), as ai)plied to this affection, is most 
 happy. The knee-joint is that m ost frec^iijuitly affectec'j luiUli! 
 same cond itijn occu rs in the elbow and tenipiJio^niaMl';^ 
 articulati(2n.. " 
 
 T'he Diagnosis between a loose body and a displaced $(niilnnm 
 
 jiiylUairf intlu n<nee-it)in t is not always c'asy. since in hotli coiij 
 ditions painful locking of the joint occurs. The fixation, howmerJ 
 
 J ,-. j^ „. — J „ _ — . ^ _ 
 
 is but momentary in the case of a loose body, but may per^stj 
 until reduced in the latter, whilst a localized spot of tcnilirnessl 
 may be detected corresponding to the site of the injiuy tu the! 
 
1)1 SEAS US or y 01 NTS 
 
 5^'9 
 
 ,,,ieiarlicular carlila;,'(!. Moretwer, tlu; history of llu: case is very 
 ililli'ifiil, since (lie dislocation of a semilunar cartilaj^e is always 
 
 ■iriiiiarily lelenccl to some twist or sprain of the joint, whereas 
 with a loose body no such traumatic inlluence lured he present. 
 The Treatment consists in the remosai of the fori'if^ni ixxly. In 
 iiriiuT (lays this was done by means of \aiious suhcutani'ous 
 i|U'ratiiins whicli it is unnccessaiy to lU'scrihe here, siirre at the 
 nrescnt linu; removal by the open method is always practised. . In 
 ilu'kiii'c-joint a \ertical incision should be made, about 2 inch es in 
 ](\\<l[]], e.Ntendiii ' ^ a lltt it' a1)o\c; a nd b c-low th e IFn e Of tlie iijticuiii- 
 RfliT.'Tt should Ih' plac^ecT about i incirT^onrthe patella, on which- 
 evTTside the loose cartilaf^e picsenls most licfpiently, but preler- 
 ,ililvoii the outer. If possible, the foreign body should be fixed by 
 ;l,c liii^'cr in one of the lateral pouches of the joint biifore makin}^' 
 ihe incision. The ca|)sule and synovial niembiane are opened, 
 •JieioDSc body removed, and the (a\ity washed out, if thouf^'ht 
 (iisirahlc, with sterilized salini; solution. The wounds in the 
 viiovial mend)ran(', capsule, and skin are then ( ar(;fully sutured. 
 tlif joint should be kept at rest subsetpiently for two (jr three 
 wks, and an ehe.tic knee-c;q) worn for some lime. 
 
 Neuralgic Joints. 
 
 Ill neurotic- individuals, es pecial l y ytjung women , a nemal^ic 
 iiulilioii of t he joints is couHnonly niet with, suiTuiarm^ disc^ase 
 '"■li On carelul exanmiaiion the p ain \^ ruillitl iTT+wr 
 
 ux 
 
 biilHrficial, not increased by jarrinj^_tlj-^ articular ;?urfac es to gether, 
 ffloTTeiT not strictly conhned to the joint. The movements 
 larc apparently innited, but if tin; attention of the individual is 
 li.verlecl, or ana'Sthesia induced, they are found to be perfectly 
 lire'.'. Tiiere are no sij^Mis of effusion into the cavity, and no starting 
 Jpains at night. Occasionally a similar condition is met with in 
 linen, where then; is no suspicion of hysteria. 
 The /mj/;//f;// is constitutional and local. Tlu; former is directed 
 owarcis improving the general health, and correcting any error 
 lathe uterine functions. The latter is best accomijlished by the 
 lujeolcokl douches and electricity, although counter-irritation in 
 liie shape of blisters, or even the actual cautery, has an excellent 
 Tiural ellect. 
 
 Ankylosis. 
 
 I'lV ankylosis is meant a condition of inunobility, partial or 
 |jiiiplet{', of a joint, resulting fnMu some preceding inllannnation 
 pthe articular structures. 
 
 The term false ankylosis is sometimes ai)plied to a condition 
 lesiiltinj; from extra-articular lesions. Such may be either 
 
 iious or osseous, and is due to cicatricial contraction of tiie skin, 
 taenin^f of muscles, or even to the development of bony tissue 
 nthin them {myositis ossificans). True ankylosis, however, always 
 
S70 
 
 A MANUAL OF SURGERY 
 
 involves the articular structures, and, again, is either fibrous o: 
 bony. 
 
 Fibrous or incomplete ankylosis results {a) from thickeninj,^ an; 
 contraction of the liffanients, such as often occurs after gonorrhn a! 
 or rheumatic afl'ections ; {h) from the formation of cord- or hand- 
 like adhesions within the joint, after acute synovitis; (c) from I 
 erosion of the cartilage and exposure of the bone; granulation? 
 sprout up on each side, and by their union lead to dense fihroici 
 adhesions between the articular surfaces. Some amount of move 
 ment is possible in most of these cases. 
 
 Complete or osseous ankylosis (synostosis) arises from the unior. I 
 of either the whole or part of the opposing surfaces left hv the 
 destruction of the cartilage, the bond of union, at first tilirol 
 cicatricial, being subsequently ossified (Fig. 209); it may also Iv I 
 due to the interlocking and fusion of osteophytes, formed at th- 
 margin of the bone in osteo-arthritis or Charcot's disease. 
 
 The Causes of ankylosis are very variable, but may be arraiv^edi 
 as follows : 
 
 I. Injury to the articular surfaces, as from fractures which rmj 
 into a joint. 
 
 2. Non - suppurative inHaniiii;ij 
 tions of joints, in\olving the fori 
 mation of fibrous adhesions or tliel 
 contraction of ligaments, as 
 synovitis, whether traumatic, rlieul 
 matic, gouty, gonorrha'al etc., andj 
 the early stages of acute or tulw| 
 culous arthritis. 
 
 3. Destruction of bones, asso-i 
 ciated or not with articular diseasesJ 
 as in Pott's disease of the spinel 
 and the later suppurating staires o| 
 acute or tuberculous arthritis. 
 
 4. Nervous affections are ocaj 
 sionally the primary cause ot ankyl 
 losis, by leatling to a chronic foni 
 of arthritis. The lesions may 
 central, as in spina bilida, tai 
 and syringomyelia ; or periphera 
 as in neuritis, Raynaud's discax 
 diabetes, leprosy, or division 
 nerves. 
 
 5. Long - continued abiiorm^ 
 pressure of contiguous hones ma 
 result in ankylosis, as in later^ 
 curvature or osteo-arthritis of til 
 
 spine. In the latter affection tlie immobility may be due eitlid 
 to ossification of ligaments or to the interlocking of osteophyte^- 
 
 Fig. 209. — Ankylosis ok Hii-- 
 
 JOINT IN' CiOOl) I'OSITION AKTKU 
 KaKLV Hll' DlSliASE. (HOWARU 
 
 Maksh ) 
 
DISEASES OF JOINTS 
 
 571 
 
 ures wliich rrl 
 
 The position in whicii ankylosis occurs and the effects thus pro- 
 Iduced differ according to the joint affected. 
 
 In the shoulder there is hut little displacement, and the existence 
 lot iniiiiobility is of comparatively little importance, owing to the 
 Ifree nio\einents of the scapula and clavicle. The elbow-Joint is 
 Iverv commonly ankylosed on account of its exposed position, and 
 Ithe frequency of fracture-dislocations in its neighbourhood. The 
 Iformation of callus, and the adhesions likely to form within the 
 Ijoint in these cases, readily explain its frequency. The most 
 Ifavourahle position for ankylosis is when the arm is flexed to a 
 jlittle more tlian a right angle, with the hand midway between 
 Ipionation and supination. By this means access to the mouth is 
 Ipossible, and the patient can use his hand for feeding purposes. 
 Ilhe 'u'rist is most conuuonly fixed as a result of gonorrhceal or 
 jrheumatic synovitis. In the hip-Joint (Fig. 209) much depends 
 lu.uii the treatment as to whether the ankylosis takes place in a 
 J, od or bad position. In neglected cases the thigh may be in a 
 Ipisition of adduction and internal rotation, crossing in front of the 
 other leg. Occasionally a scissor-like deformity has resulted from 
 liiuiiniation of both hip-joints, one leg lying in front of the 
 pther; progression is accomplished with difficulty, the body 
 twistinf,^ at each step, and crutches are often needed. In the knee- 
 Li/ ankylosis in an absolutely straight position of the limb should 
 pot be aimed at, since slight flexion renders tlie leg more useful 
 oth in walking, mounting stairs, and sitting down. In the ankle- 
 pit considerable trouble may arise from inunobility, unless the 
 lot is at right angles to the leg. 
 
 Treatment. — Fibrous ankylosis may be treated by forcible, 
 
 lliuiigh judicious, manipulation of the limb under arr-^*SS«cs- 
 
 hetic, thereby rupturing adhesions ; tlie limb is kept at rest 
 
 lor a few days, and then inassage and passixe movements are 
 
 piiployed. If massi\e adhesions are present, but little good 
 
 rei^ards mobility results from such treatment, since, even 
 
 ruptured by the manipulations, they are almost certain 
 
 reunite ; in tuberculous cases it is unwise to attempt this 
 
 [ir fear of diffusing or again lighting up the disease. It must 
 
 l)e forgotten that marked atrophy of bone is often associ- 
 
 jted with this condition, and therefore a fracture ci\x\ easily be 
 
 jroduced. 
 
 I For osseous ankylosis \arious operative measures may be 
 
 piployed, with a view either to correct the deformity, or in other 
 
 ps to restore movement to the part. At the shoulder, wrist and 
 
 p nothing need be undertaken unless obvious and troublesome 
 
 jt-irinity is present. At the elboh' excision may be beneficially 
 
 piployed, and with every prospect of gaining a moveable joint. 
 
 • !io\ve\er, ankylosis is present in a child, the operation should 
 
 tdeterred until growth has come to an end. Ankylosis of the 
 
 in a lalse position needs cuneiforni osteotomy, or the resection 
 
572 
 
 A MANUAL OF SURGERY 
 
 of a wedge-shaped portion of bone, in order to secure a straight, 
 rigid and useful linih. 
 
 Ankylosis of the hip-Joint in a had position is best treated li\ 
 dividing the neck or the upper part of the shaft of the femur. 
 Several operations have been devised for this purpose : i. Adams 
 subcutaneous osteotomy of the neck of the bone consists in passini; 
 a sharp-pointed bistoury down to the anterior surface of tlie cervix 
 fenioris, from a point midway between the trochanter and the 
 anterior superior spine of the ilium. A track is thus made, 
 allowing the introduction of an Adams' osteotomy saw. bv iiieaib 
 of which the neck of the femur is divided subcutaneously. Tl.f 
 limb is put up in a straight position, and the bone allowed to 
 reunite. 2. The same result may be obtained by an open method. 
 making the same incision as in the anterior operation for exciMii:,' 
 the joint (p. 585). 3. Sayre has attempted to form a moveable 
 joint by dividing the femur by a chain saw between the greater 
 and lesser trochanters, and removing a segment of bone. Iti>j 
 very unlikely to prove successful. 4. Gant suggested divisimi 
 below the lesser trochanter. This may be accomphshed by cuttirj 
 down on the bone from the outer side and chiselling it across. 
 
 As to the operation to select in any particular case, the surijeon >j 
 choice must be guided by the condition of aff^iirs present. \j 
 skiagram of the neck of the femur should always be taken >}| 
 as to ascertain its condition. Sometimes it is stunted, and liasj 
 practically disappeared ; in other cases it is much thickened, aniij 
 forms a large bony mass passing from the trochanter to the iliun;,! 
 and probably containing encapsuled foci of tuberculous material^ 
 In both these conditions subtrochanteric osteotomy must 
 employed, and it is not unusual to find that the adductor nuisry 
 are so contracted, that their attachments to the pubes requirJ 
 section before the limb can be satisfactorily straightened. Divisioif 
 of the cervix can only l,e recommended when that structure is ol 
 normal length and size, vj 
 
 Hip-joint Disease. 
 
 Although the term ' hip-joint disease' is usually applied to J 
 tuberculous a^'thritis, it is not the only affection involvin<. 
 articulation. Simple synovitis occurs in the course of rlieumatii 
 gonorrhu'al, or pyaemic affections. Acute arthritis is also mj 
 with secondary to an acute infective osteomyelitis of the upp 
 end of the femur, and is evidenced by all the ordinary si;,fnsj 
 that affection, .separation and necrosis of the upper epiphyj 
 being a freciuent result. Osteo-arthritis is not uncommon (p. 5"1 
 whilst Charcot's disease may also occur ; but none of these i 
 for special mention here. 
 
 Tuberculous Disease of the Hip {Syn. : Morbus Coxae, Tuberculd 
 Coxitis, Coxalgia) differs in no respect from the same disease ai 
 
DISEASES OF JOINTS 
 
 573 
 
 ! a straight, 
 
 t treated U 
 
 the femur. 
 ; I. Adams' 
 ,ts in passiiii; 
 of the cervix 
 iter and the 
 
 thus niatk', 
 L\v, by lueaib 
 eoiisly. Thtr 
 le allowed to 
 open metliod, 
 ,n for excisk 
 n a moveable 
 n the |4re:Ui'r 
 )f bone. U i> I 
 rested division 
 Wlbycutlivi^l 
 g it across 
 e, the sm-^'fon'> 
 rs present. A 
 ys be taker, :-o 
 unted, and liasj 
 I thickened, ;i"'' 
 ter to the illuiv.,! 
 
 ulcus matenal] 
 
 itomy mii^^ ^ 
 ductor niuscl 
 
 pvdies reii«ira 
 lened. DiviMOil 
 
 structure is o| 
 
 affects other joints, and hence no detailed notice of the pathological 
 anatomv is required. Suffice it to say that it may origin ate in the 
 synovial membrane^ or hone, and in the latter c ommences eithe r 
 "beneath the articular cartilage, or on the sTiaft sTHe o f the epiph yseal 
 ritrtilaf^e of the caput fehi 6ns (Fig. 210). Very rarely tfie disease 
 beroiiies circumscribed in the neck of the bone, forming a chronic 
 abscess, the diagnosis of which is exceedingly difficult. More 
 usually the disease spreads to the imder side of the neck, and 
 thus invokes the synovial membrane, which passes into a state 
 of pulpy degeneration. Th , substance of the epiphysis is invaded, 
 and caries of the head iS thereby produced, together with necrosis 
 
 to] 
 'f till 
 
 [ly applied 
 involvin 
 L of r\ieum.itii 
 litis is also mi 
 lis of the up 
 rdinary sij^ns 
 
 lupper ^-piP^'y 
 
 \ommon(p.5" 
 
 jne of these 
 
 axsB, Tuberculj 
 
 [me disease a^ 
 
 : :io TuBERCfLOUs Disease of the Head and Neck ok the I'emur, 
 
 SHOWINT, SEyUESTRA IN AN AbSCESS CaVITV, AND COMMUNICATION ON 
 THE rXDEU SuJE OF THE NeCK WITH THE JoiNT. (TiLLMANNS.) 
 
 Jte cartilage has been entirely removed t. .m the articular surface, and the 
 contiiuiDUs black line indicates the amount of l)one which it would be 
 necessary to remove. 
 
 ulceration of the cartilage. The acetabulum undergoes similar 
 ranges; from the contact and backward pressure of the diseased 
 m the posterior acetabular margin is absorbed and the cavity 
 pnded, whilst at the same time a new rim of bone forms 
 heath the adjacent periosteum at a slightly higher level, thus 
 m<^ rise to what is known as a ' travelling acetabulum.' In 
 pway the socket is increased both in size and depth, travelling 
 kckwards and upwards with the head of the bone towards the 
 krsinti ilii. Other factors assisting in the displacement of the 
 lot the bone are : the tonic action of the muscles, keeping the 
 in a position of flexion, adduction, and inversion, thereby 
 psing a considerable portion of the head to project out of the 
 pbuluni ; and the early softening and destruction of the pos- 
 (!orli;;ainents, which are much thinner than those in front of the 
 ft. Occasionally a mass of protuberant granulations sprouts up 
 «ii the centre of the cavity, and may also assist in this process. 
 
574 
 
 A MANUAL OF SURGERY 
 
 Should the acetabulum he perforated, a tuberculous abscess in] 
 likely to tbnii within the pelvis. The adjacent pehic bones mav 
 either become thickened by the deposit of osteophytes, or cariofc; 
 if sepsis is present, necrosis may also super\ene. 
 
 ClinicalJHistory. — The patient, usually a child, is observed toi 
 limp, and may complain of pain either in the hip or inner sideof 
 the knee, the latter beinf,' due to the fact that both joints are 
 supplied by the same nerxes, viz., the anteriorcrural, sciutir. aiid 
 obturator trunks. There may be some history of injury, but not 
 necessarily. On examininji,' the lind) in the xuj^j i/a^Y, it is ubualh f 
 found iohii apparently /fi!gtluiiC(i,wh'\\st the thigh is slightly wastid, 
 The nates are flattened, and the gluteal fold lost, conditions partivl 
 
 X, 
 
 Fk; 
 
 A H C D 
 
 ill. — DlACKAM TO ll.l.lSTKATE THK POSITIONS ASSl'MKl) in THE 
 
 IN Tin; Kaklv AM) I. ATI-: Sta(;es ok Hii' Disicask 
 
 A represents the position of abduction taken by therif,'ht limb in the early sta-i 
 of hip disease, and J^, Nature's method of masking,' this by tiltiiif,' the peK;^ 
 di)wn <in the aflected side, whilst the other lejj is adducted : tiie t-ikxi^ 
 this on the spine, in causin^'a lateral defiection, is also indicated C >h'\ 
 the same thing in tlic later stage, when adduction is present, and ihepel\> 
 tilted upwards on tiie aflected side, thus producing apparent sliorteninsil' 
 
 due to atrophy of the muscles, partly to the flexion of the liml 
 The joint is more or less rigid, and pain is produced on attempting 
 to move it, or on jarring the leg, as by striking the heel or iw 
 chanter. The position assumed in this early stage is one of sliijhl 
 and increasing flexion, abduction, and eversion (Fig. 2i\, A), t!i 
 reason for this being that thereby the ligaments, and t'speciallj 
 the ilio-femoral, are most relaxed, and the capacity ot the joint il 
 at its greatest. The latter fact has been demonstrated in tJij 
 healthy cadaxer by inserting the nozzle of a syringe into the join 
 through the acetabulum, and forcibly injecting iluid, when thii 
 position is at once tissumed. The flexion and abduction, Imwi 
 e\er, are not always exident, since the flexion is masked li 
 lordosis of the spiiie (b'igs. 212, 213), and the abduction hy till 
 pelvis i)eing tilted down on the affected side, prodiiciiii; therrbf 
 
DISEASES OF JOINTS 
 
 575 
 
 apparent len<j;tlieninj^ of the diseased limb and lateral curvature of 
 •he spint', with its lumbar convexity towards the affected side 
 Fiij. 21 1, !>)• The sound lej^^ being brought into a position of 
 
 i ackliiction, the parallelism of the limbs is maintained. The 
 •lexion can be demonstrated by any method which obliterates 
 ihf lumbar curve of the spine, as by fully bending up the sound 
 
 l]inilu)n the abdomen, the affected thigh rising at once from the 
 inl and forming an angle which indicates the amount of flexion 
 iFii:. 31 ])' The abduction is demonstrated by laying a rod across 
 
 MJ- Ilii' DisKASK, WITH \Vi:ll-Makki:i) Comcensatokv Lordosis, 
 
 CAUSED BY liXTENDINii THE LeGS FlaT (JN THE TaHLE. 
 
 % 
 
 I ilj — (JN KLATTENINf, THE Sl'INE AC.AINST THE CoUCH BY RAISINC; THE 
 
 Inakkixted Left Le(; and pkessinc; it rr aoainst the Abdomen, the 
 1)e(.kei; ok Flexion of the Right Thigh at once becomes obvious. 
 
 [he two anterior superior spines, and placing another at right 
 f.ri\l\es to its centre. This will not correspond with the line of 
 
 k body or of the limb, but makes an angle with it. The 
 Mrsion cannot be masked. The rigidity is easily demonstrable 
 
 itliat all movements of the hip-joint are greatly limited ; thus if 
 atlt-mpt is made to bend the affected thigh on the abdomen, 
 Ihe corresponding side of the pehis is raised with it from the bed. 
 I As the disease progresses, and the bones become more exten- 
 Vely affected, the pain increases, with nocturnal startings, w^hilst 
 iWesses form, and a certain amount of fe\er and constitutional 
 
 ptiirhance is caused therebv. The position of the limb also 
 
 bntjes ; for although the flexion is maintained and even in- 
 

 576 
 
 A MANUAL OF SURGERY 
 
 creased, adduction and inxersion are now associated with it 
 The pelvis is tilted up on the affected side (Fig. 211, C and D 
 causin<^ apparent shortening, lateral curvature with a luinhar con 
 vexity to the sound side, and abduction of the healtliv linili 
 No satisfactory cause of this position is given, but it is iisuallv 
 attributed to the yielding of the posterior and outer part of the 
 capsule, together' wlTlrin1iltration and weakening of the small 
 external rotator muscles,'~altowtng the~ adductors and internal 
 rotators unopposed play. 
 
 When an abscess has formed, the most usual situation for it t, 
 point is a little in front of and internal to the great trochanter, 
 
 A B 
 
 Fig. 214 —Position ok the Limb in the Later Stages of Hip Disease^ 
 
 A shows more especially the adduction and inversion ; B, the flexion and 
 
 compensatory lordosis. 
 
 close to the insertion of the tensor fasciae femoris. It may reach 
 that spot either from an opening in the anterior part of th«j 
 capsule, coming thus to the surface along the line of leas 
 resistance, or it may burrow from the posterior portion of the! 
 capsule along the rotator muscles and superior gluteal nerveJ 
 Less fre([uently abscesses pass directly backwards to open in M 
 gluteal region, or forwards along the pubo-femoral li<;amentj 
 pointing on the inner side of the femoral vessels below Pouparti 
 ligament. As a rare complication, the tuberculous process ma)] 
 extend to the bursa under the psoas tendon, which usually comj 
 municates with the joint, leading to the formation of an abscesi 
 
PLATE XX\' 
 
 )F Hip Disease j 
 Ithe flexion and 
 
 
 • 
 
 
 
 
 ' '^ ' ^-'t^Mi^^^^H^^^^^^^^^^^^BI^^B^^^^^^^B 
 
 
 
 ^^^1 
 
 ^^^H 
 
 . " lift^lfl^^^^^^^^^^^^^^^^^^^l 
 
 
 
 ^^H 
 
 ^^^1 
 
 yiunS^^^^^^^^^^^^^^^^^^^^^^^^^^H 
 
 
 
 1 
 
 ffiR^'!^ 
 
 
 
 
 HBb-i'' 
 
 
 
 ^^^*^^^H 
 
 
 
 
 ■■HD^i|iQj^^^HB^^^^B|^v^^^|j|. ; 
 
 
 
 
 
 
 
 f 
 
 
 
 ^^^^^^^^^^^^ . 
 
 
 
 
 
 
 ^ti' '■ '''M 
 
 # 
 
 
 
 
 
 r 
 
 
 
 ^■Bj^^^^^^^^^HbL^'-' - -''-''jiHI^^^^H 
 
 ^^^HBv! '', 
 
 
 
 
 ^^' ' '^^HnHHII^^B^lHi 
 
 
 
 
 
 
 
 " ' 'j— .- 
 
 ^ 
 
 
 
 Wi^yt* 
 
 ••"™ 
 
 SI 
 
 ^llpll 
 
 
 ■■»#: 
 
 
 
 ■■ '7\':r' 
 
 4> 
 
 H 
 
 s 
 
 a 
 o 
 
 3 
 
 d 
 nl 
 u 
 
 BO 
 
 T3 
 
 c 
 
 u 
 ■/. 
 f. 
 Ui 
 r. 
 
 C ■ 
 1) TJ 
 T3 4) 
 
 > y 
 
 ^^ 
 
 :j — .5 
 
 c 
 
 !3E 
 -"^ S 
 
 u 
 
 a 
 
 ■5 
 
 O, 
 
 3 
 
 -3 
 1> 
 u 
 
 "a. 
 
 7) 
 
 ^ -3 
 
 a: 
 
 in 
 
 a 
 
 D 
 
 ii 
 
 J3 
 
 0) 
 
 
m 
 
 in the lo' 
 ireatrnei] 
 iipwarcis 
 (itliis I 
 Ifcise () 
 to tlie SI 
 iijaiiient 
 rectal tbs 
 The 111 
 d'ye to er( 
 Kircis ii[: 
 iiiicreast'd 
 mses pt 
 iK likely 
 At any 
 :::i';il)ii()r 
 ■v:lni(rsl ( 
 
 juifwhle I 
 h coi 
 
 ■mit ai 
 
 •iioiild pre 
 
 |L< recof^nii; 
 
 lades, 'J"h 
 
 hihil iiiisc. 
 
 pus at a 
 
 pnectif)!! 
 
 1(1 the a I 
 
 'uld iva( 
 
 wit must 
 
 Iftheliiiil) 
 
 •tliat is, : 
 
 rersion — n 
 
 )resent. 
 
 An aicaps. 
 
 i^'er)' (li/ 
 
 'P lioriu','- 
 
 iver the lie 
 
 anipiilated 
 
 '"'tare not 
 
 The Progi 
 
 mlition is 
 
 elop acut 
 
 ahscesses <- 
 
 fue. A pa 
 ptcting life 
 
/ 
 
 577 
 
 DISEASES OF JOINTS 
 
 ^ ^ ^ 
 
 ;r,the lower part of Scarpa's triangle, and in a case recently under 
 liieatment a typical psoas abscess resulted from an extension 
 tpwards within the sheath of the nuiscle of a tuberculous infection 
 Irttliis bursa. An intra-peKic abscess followinj^' perforation or 
 liiseiise of the acetabulum may cither burrow upwards, and come 
 liothe surface on the inner side of the vessels above Poupart's 
 liiSiiMient ; or it may j,na\itate d(jvvn\varils, and burst in the iscliio- 
 Iwtal fossa, close to the tuber iscliii. 
 
 I'hc Imal stage of the disease is one of nal shoytenhin (FifJf. 214), 
 Idoe to erosion of the head of the bone and its dTttpLirHiyiTMif \v.\rV- 
 Irards upon tlie dorsum ilii. The position assumed is one of 
 licreascd fTexion, adduction, and inversioiiY'wTiilst it septic" 
 liTnuses persist, hectic fever and amyloid changes in the viscera 
 lire likely to follow. 
 
 At any stage cure by ankylosis may be obtained; but unless 
 lie ainiormal position has bei'n corrected by extension, def(M'mity 
 IsaliiKist certain to be present. 
 
 m\w Diagnosi s of hip disease appears to be a matter of con- 
 ii!Jdal)le difficulty to some, if w e may argue from the mistakes 
 lihich co mmonly occur . The pai n in lliu_Jmee present i n the 
 harr y stages^ '^^iins' ^'' ^'^ tV»'r|iiMntly I'^^in^r mj^fnW^n for d isease of 
 |t^^rtiriil"qtinii.- a Very slight amount of care in tTTe examination 
 niild [)re\ent such an en or. i-'rom disease of the opposite hip, it 
 Is rtcoj^Miised by the relati\e mobility of the thigh on the two 
 IsiifS. Tile diagnosis from sacvo-iliac disease is gi\en at p. 580. 
 Xipuil mischief mi\.y also be confounded with it ;f a psoas abscess 
 If lilts at any of the ordinary situations in which sinuses form in 
 I iniction with the hip-joint. The presence of spinal deformity 
 larul the ability to perform the test movement for hip disease 
 pdd readily enable the surgeon to make a correct diagnosis, 
 |k;t it must not be forgotten that the two conditions may co-exist. 
 itlielimb can be put into what is known as the tailor's position 
 -that is, flexion to a right angle with marked abduction and 
 [[version — one may be practically certain that hip disease is not 
 present. 
 
 An cncapsuled abscess in the mrk of the femiv is a condition which 
 
 Bi> very diflicult to distinguish from true hip disease. A constant 
 
 ieqi boring patiriscomplainedOfVwRiclf is increased by pressure 
 
 kver the neck, or by jarring the troclianter ; but if the limb is 
 
 panipulated gently, it can be pro\ed that the movements of the 
 
 are not really impaired. 
 The Prognosis of hip disease is by no means unfavourable if the 
 Nition is properly treated. Of course, the patient is liable to 
 plop acute tuberculosis or tuberculous disease elsewhere ; or, 
 [abscesses are allow ed to become septi c, serious complica tions — 
 as p yaem ia, sapraemia, hectic arid amyloid disease— -may 
 psne. Apartfrom l:liese7 however, no serious consequences 
 pt^cting life need be feared, although the usefulness of the limb 
 
 37 
 
578 
 
 A MANUAL OF SURGERY 
 
 may be seriously crippled from shortening' or ankylosis, espociallv 
 if the latter occurs in a faulty position. 
 
 The Tr eatment oL.hiiL.t)'^'-'' t:;^' nui st he conducted al< )!!(,' the 
 same lines as for fiilwrrnhmtn*'^"*"^ ^rrnar-Ttty: tii the cail\ sTU^^ 
 the limb is kept at r(; st by the a pplication of a. Li.s tpn's spliiifjjfTr | 
 may be placecl between sandbjiiis, and a wei^t an(l pulkiy atliidicd, 
 hy this means not only is rest assured, but def(>rnutyTs~pi' vciiftd. 
 If the amount of llexion is but slif^ht, the lin\l> may he ;illi)\\|.,| 
 to lie on the bed in the horizontal posture ; this will possililv 
 induce some compensatory lordosis, but as the musciilai spasiii 
 relaxes, the curvature of the spine disappears. When, ImuLvcr, 
 a considerable def^ree of flexion is present, extension must In 
 made alonj,' the axis of the flexed limb, which is supporttil on 
 pillows. It w il l be found that Jifter a few days tlic tltxioii 
 diminislies^and the limb will then gradually assTmuTThe tirirlzonral 
 position. Should tTiTs jirecaution no't l)e^TidoptedrtlTt' 'exTCTRion 
 merely produces lordosis, and the pain from intra-articulai tension 
 is increased thereby. The general health of the patient must al , 
 the same time be attended to, and cod-li\er oil and syru[) ot the 
 
 iodide of iron may be administird 
 with benefit. When the more ur),rent 
 symptoms have disappeared, a 
 Thomas's hip-splint is applied, soasj 
 to enable the patient to i;et ahoiitl 
 (Fig. 215). This consists of a tlai 
 rod of malleable iron, about an imli 
 and a half wide, extendinj,' fnjin the! 
 axilla to below the knee ; it is shaped! 
 so as to fit the varying curves of the 
 Ixxly, and cross-pieces embrace the 
 trunk at the level of the ni|)ples, as 
 also the thigh and the tall; it isj 
 firmly bandaged to the body and 
 limb. A patten is placed under the] 
 boot of the sound leg, and the patienj 
 allowed to get about on crutcheJ 
 This apparatus should be worn toi 
 six months after all signs of acti\i 
 disease have disappeared. It iiiai 
 also be employed in the earlier ani 
 more painful stages if it is at (irsf 
 bent so as to acconunodate itselt t| 
 the flexed position of the limb; 
 the effect of the rest becomes evidei^ 
 in a diminution of muscular spasiij 
 the splint can gradually be straightened out, so that at leiK'tf 
 the limb is fully extended. 
 When abscesses form, they may be opened antiseptically aa 
 
 Fig. 
 
 215. --Thomas's Hh'- 
 
 SPUNT AI'PLIEl). 
 
DISEASES OF JOINTS 
 
 S79 
 
 drained, or prefcrahly tapped and injected with iodoform, the 
 (ormiT precaulioiis as to rest and constitutional treatment heinjif 
 still maintained. More extensive operative measures-such as 
 (hvioii of the head by the nntcviov methfxl (p. 3S5)— ;ire sometimes 
 undertaken in the early stai^'es to cut sliort the chsease, especially 
 when prolonf^H'd treatment is impracticable, as anionj^st the poor, 
 urwhen the f^eneral health and constitutiojial powers are defective. 
 The retnoval of the whole head necessarily involves the upper 
 epiphysis, and lience defecti\e f;rowth of the femur results, as well 
 ;is imniediate shortening,'. For these reasons, as also becavise 
 repair is possible in most cases without operation (when there is a 
 certain amount of recuperative power and prolonj^ed treatment is 
 teasibk). this proceeding,', at one time so common, is being dis- 
 carded more and more in favour of conservative measures. 
 
 It is sometimes possible, however, to sa\e some portion of the 
 head, and if so, this should always be attempted. A very success- 
 (iil series of cases has recently been published, in which the joint 
 was opened from the front, the interior freely curetted (in one case 
 lifter a temporary dislocation of the head), the bone scraped, and 
 in more than one case a channel gouged along its anterior wall to 
 expose and remove a deep focus. Indeed, when one attempts to 
 ;ave the head of tiie femur in this way, it is always well io remove 
 the compact tissue from the front of the neck so as to expose and 
 explore the epiphyseal line. By this plan, shortening and defecti\e 
 aowth can to a large extent be a\oided. 
 
 In the later stages, and especially where sinuses have formed in 
 
 the ^'luteal region or behind the trochanter, excision by the posterior 
 
 method (p. 586) is preferable; this is usually an easy matter 
 
 I since the head is probably eroded and displaced. The sinuses 
 
 Uhould, if possible, be included in the incision, but under any cir- 
 
 I fimistances must be opened up and scraped. When the aceta- 
 
 Idiim is extensively implicated, the disease can only be satisfac- 
 
 Itorily dealt with by removing the head of the bone, and the posterior 
 
 method affords the best means of sidisequent drainage ; of course 
 
 [this presumes that the general condition of the patient has 
 
 been seriously undermined, and that there is a good pros- 
 
 Ipect of gaining a useful limb. Otherwise amputation through the 
 
 jbipjoint is required, especially when the mischief has extended 
 
 [into the pelvis, or when, after excision, a weak, flail-like limb 
 
 jresults or osteomyelitis supervenes. Ic is also needed when after 
 
 lexcision sinuses persist and lead down into the acetabular cavity, 
 
 jbm which there is a plentiful secretion of pus, and over the 
 
 jentrance to which the upper end of the femur is drawn, thereby 
 
 lobstructing the escape of the discharge, and rendering dressing 
 
 jk)th difficult and painful. The operation often gives most excellent 
 
 Insults, the patient's condition rapidly improving. Removal by 
 
 PC anterior raccjuet method is perhaps the most convenient. \y 
 
 37—2 
 
! 
 
 
 580 
 
 A MANUAL OF SURGERY 
 
 Disease of the Sacro-iliac Joint. 
 
 Ti!!)erculous disease of this joint is nujst commonly imi with ii 
 adults, but rarely in children. It may conuncnce in the synovi;i; 
 mcMnhrane, hut is tVe(|uently the result of mischief startini,^ in th, 
 peKic bones, especially the iliiun. The Pathological Anatomy 
 calls for no description, inasmuch as it follows the ordinarv 
 course of tuberculous disease. 
 
 riie Clinical Signs consist oi pain and a sense of \veaknet,s in 
 the lower part of the back, increased by standinj^^, waii<inj(, or 
 any mo\('mcnt — sucii as couj^hiiif^, s'leezinj;, and the likt; -which 
 calls the llat abdominal muscles into sudden action and drags un 
 the ilium. It is of a \ery unpleasant character, a sensation as it 
 the pel\ is were coming to pieces being experienced by the un 
 fortunau' individual. Owing to the fact that the lumlx)- sacral 
 cord passes in front of the articulation, pain is often refei red to tlii 
 gluteal region uv down the leg. Movements of the liinl) caun 
 pain if the pelvis is not supported, but can be freely pcrforiiid i; 
 tl)e pel\ is is steadied. C'ompression together of the iiinoiiiiiKiir 
 bones, or tiieir forcible separation, is the means oi nujst cffcctualh 
 demonstrating the existence and situation of the pain. Thi.- 
 patient is unable to stand or to put any weight (jn the affeitiii 
 limb, and iience limps vluring walking, allowing his body to kir, 
 toi wartis, and making use of a stick. There is apparent lcnj,'theii 
 ing on tlie ai"fet:teil side, but oi. measurement from the anleriir 
 sui)erior spine to the internal malleolus the leg is found to beiii, 
 the same length as its fellow. This appearance is due to the fait] 
 that the v.IkjIc innominate bone is tilted downwards and foiward>. 
 so that the anterior superior spine is at a lower level and moiv 
 prominent than that on the opposite side. The region of tl.t- 
 synchondrosis is often swollen, puffy, and tender; wliilst after aj 
 time abscesses forn .vhich may either point inuncdialdy over 
 the articulatit)n, or may burrow upwartls into the hnnbar rcj,'ion. ( 
 or forwards into the groin, or downwards into the |)el\is, opciiiiii;! 
 in the ischiorectal fossa. The last is a most serious complication,] 
 since it necessaril}' introduces the septic element. 
 
 riie Diagnosis needs to bi; made from sciatica, hip disease, anJ 
 spinal disease. Siiutiia is known by the character (-. the pain,] 
 wliicii shoots down thi; back of the t.iigii in llu' course oft'". ,L;reat 
 sciatic ner\e, whiih may be distinctly tender on pressure. Theri' 
 is no apparent elongation of the limb, and compression loj,'etlicr 
 of the pel\ ic crests is painless. I'Tom affections of the liip-jovn. 
 sacro-iliac disease is recognised by the fact tha'., if the ju'lvis !> 
 supporteil, the thigh may be moxed in all ilirections without givatj 
 discomfort ; whilst compression of the pelvis in hip disease cause>j 
 no pain. Moreover, in the adsanced stages of hip disi ase, therij 
 is apparent or real shortening, a c(jndition never iKjticed in thfl 
 
 ffit^sii 
 
DISEASES OF JOINTS 
 
 s$t 
 
 sacro-iliac aflfection. From spinal disease, the diaf^nosis should not 
 tie diftu lilt if a careful physical examination of the spine and pelvis 
 is made. 
 
 Tlu' Prognosis of sacro-iliac disease, thou{,'h usually stated to 
 1* untax onraMe, is not necessarily so if asepsis is maintained; it 
 > the admission of the septic element that constitutes the main 
 lianiftT. It must not he forgotten thrt when aflfectinf^ ^'ifls? it 
 ■!;;iv lead to subsecjuent deformity of the ]iel\is and trouble in 
 iMituiition. 
 
 Treatment in the early stages consists in absc^lute rest, with 
 iheappli(.ation of a pelvic support, and attention to the general 
 health, combined possibly with local counter-irritation. When 
 abscesses form, they should be freely opened, and if diseased bone 
 can be felt with a probe, it should be srraped or cut away, and 
 ihe parts swabbed o\er with pu. c- carb< ii. acid. Occasionally it 
 s necessary to remove the posterior part of the iliac crest in the 
 :icif;hlH)urliood of the posterior superior spine in order to gain 
 jiccess to the diseased area; this may be accomplished by the 
 
 isel cr trephine through a vertical incision, and we have had a 
 [auMiber of excellent results demonstrating the value of this pro- 
 ceeding. 
 
 1 the anleriii 
 
 reuion oi 
 
 Inn bar rc<^ion. 
 
 lisease causes 
 
 Excision of Joints. 
 
 The excision of joints is a proceeding which, though formerly 
 jindertalien in "a" few isolated instances for compound fractures 
 liiml dislocations, has (Mily during tlie past fifty years been estab- 
 ii?!ud on a scientific basis, (jr utilized to any great extent. The 
 [late Sir William Fergusson wa.s one of the chief pioneers in this 
 [branch of operative surgery, and to his skill and insight we owe 
 [iiuiflt of what has thus been gained. Since the introduction of 
 [antisepsis, however, the operations ha\ e been still further elabo- 
 rated, and excision is now undertaken for many conditions that 
 rmerly would not ii.is'e been so treated. The chief articular 
 [lesions for which excision, partial or complete, is now reco?'i- 
 [niended are as folluv, : i, I'or compound dislocations or fracture- 
 Idislocations ; 2, f . r various forms of simple or conuninuted 
 jfraituR' in the neighbourhood of joints where ankylosis is likely 
 Ito tnllow, and either interfere seuously with the utility of the 
 loim or fix it in a bad position ; the shoulder and elbow are the 
 oinls most frecjuently deah with in this way; 3 for some forms 
 congt'iiital or old-standing dislocation which cannot be other- 
 itee remedied ; 4, in the later stages of acute arthritis, where 
 pe ends of the bones are carious, the joint disorganized, and 
 punic suppuration is present; 5, in tuberculous arthritis, where 
 [liilliative treatment has failed to cu. shoit the disease, or where 
 piM)r<;imization of the joint has occiurcd w ith erosion of the ends 
 the hones ; (), for ankylosis of certain joints, consecutive to 
 
S82 
 
 A MANUAL OF SURGERY 
 
 arthritis, either acute, tuberculous, or syphihtic, especially if jn a 
 had position ; 7, for osteoarthritis in special ref^ions. 
 
 The results to be attained necessarily vary in liie diltertn; 
 joints, and accordinff to the particular causes. Soinetiiius ankv 
 losis in a good pcsition is all that can be expected, in otliersa 
 freely moveable p:>eudarthrosis ; in some cases the removal (.i 
 certain diseased tissues is the primary object of the operation. 
 whilst in others no disease is present. AH these varyinj,' cun 
 ditions must be taken into consideration in determininjj; the natun 
 and extent of any excision. 
 
 Professor Oilier of Lyons deserves special and honourabk- 
 mention in this connection, in that he has emphasized and estah- 
 lished the benehts to be deri\ed from subperiosteal resections in 
 certain cases. Necessarily, every excision must lead to considL-r- 
 able interference with the peri-articular structures ; muscles and 
 tendons have to be detached from their insertions, and portions 
 of the bones renujxed. If, ho\ve\er, the periosteum is raiM-d, 
 tofj^ether with tlio attached muscles and tendons, ptior to sawini; 
 or cuttinj^f the bones away, a tnore satisfactory reproduction ot the 
 articvdar structures follows, and the movements of the joint sulTer 
 less interference than if one cuts away the periosteal envelope 1 
 with the bone. Of course, where the periosteum is invaded with 
 tubercle, this should not be attempted, whilst in some joint— 
 such as the elbow — tliere is no advanta^^e to be deri\ed frci 
 since there is always a tendency to too great a formation of Ik 
 and this would possibly be exaggerated by a subperiosteal restcj 
 *ion. It is rather in the operations undertaken for trauma; 
 lesions that this plan is U> be recomtnended. 
 
 In a small text-bo(>k like this we nuist perforce limit oursehol 
 to a description of the methods most commonly ado|)ted, audi 
 refer students to special works on Operative Surgery for furthcrl 
 details. 
 
 Shoulder joint. — I'lxcision of tlie slioiilder-joint ma\ be needed for liil)ercul' ii5| 
 disease, for the later sta^^es of acute artliritis, oecasionally for ostcn-;irtlinti> f 
 the disease is limited to this articulation, for com pound (jr comminuted tracturc^, 
 and possiblv for simyile fractures o( the anatomical neck when associated withl 
 dislocation of the small tletached head of the hone In old unrediiccd liiv 
 locations where passiw; mo\ement is impracticable, md there is little liii|itr 
 inipro\ement, excision may K'ive excellent residts, 
 
 Opiiatinn The patient lies on the hack, the shoulder projecting soniewlu 
 over the ed^e of the table, antl with a sandbajj beneath the scapula to stead 
 it The arm bein>( slightly rotated inwards, an incision is made tniiii a pun^ 
 midway between the coracoid process anil the .acromion, extendinu diiwnwanh 
 and outwards for j or .\ inches thidugh the fdires of the deliuHl iiuixlt 
 (Fi-,'. .:i(>) It is belter to incise the deltoid than to pass between it and ili 
 pec toralis major the cephalic vein and accompanying; artery \Km\l thu 
 uninjured The wound is thoroii>^hly opened up by means of retrattiirs, anfl 
 the bicipital groove looked for; an incision is made alonj,' its outer imrdei 
 aiul the long tendon of the biceps, if still present, tin"ned out, and iieidtmM 
 inner siile by a blunt iiook A twig of the anterior circumflex artery will lief^ 
 l>e divided, and nied a ligature The arm is now thoroughly everttil, and ihJ 
 
DISEASES OF JOINTS 
 
 583 
 
 teniion nt' the sul)sc;ipiilaris and tlu' antt-rior part of the capsule, with wliich 
 ;t i> incurporated, freely (li\ ided where practicable, the attaclimeiits of the 
 niKle til tiie hone sliould be sei,arated siibperioste<T.lly, a proceedin;,' pre- 
 ^entinji! no difficiiltv where inflammation has previously existed Tlie arm is 
 now inverted and held downwards bv the side of the table, so as to brinj; the 
 ;re.il tuhi't'osity into view ; the muscles attached to this process are dealt with 
 ;na-imi!.ir wa\ . and the upper part <>f the cajisule fr(!ely opened. The head 
 .f the 1)1 'lie is then protruded intuthe wound, and rei.;.)ved by the saw It 
 ..111! often suffice to apply tin- saw > )bli(|u(;ly through the substance of the 
 lalierositv ; this is to be preferred to removal of the whole tuberosity by a 
 hiirizontal incision at a lower level. The synovial membrane antl >,'lenoid 
 cavity are dealt svith as circumstances may dictate, and it is often advisaolu 
 I" make' a counter-openiiif^ throunh the posterio'' a.xillary fold for the insertion 
 
 Fi<; iiC) -Incisk.n for ICxcision of Siiouloer. 
 
 I if a drainage-tube : the anterior woiiiid can then be i-ntirely closed In 
 applyini,' the dressiiif^, care must be taken to put a j.;ood pad in t!ie axilla, so 
 toMkuep tile arm from beinj,' drawn forcibly inwards by the muscles attachtil 
 iio the bicipital f,'roo\e There is no need to commence passive mo\emer.ts 
 IWire tlic end ol tlu,' first week I'ibrous union usually results, and tlu' move- 
 Inient.s of the shoulder are ^jeneralK very f,'ood 
 
 Excision of the Elbow nia\ be reipiired for simple or compound fracture-dis- 
 I "cation, (11 lor subseejuent ankylosis, especially if the limb is in a bad position, 
 llor IuIhtcuIous arthritis, and possibly in the later stages of acute arthritis. 
 I The best plan of operatiii),' is as follows; .\ single longitudinal incision, 
 Ij inches 111 length, is mad»' in tin,' middh; line of the postt;rior aspect of the 
 pint, extciuling for ecpial distances abo\e and below the tip of the olecranon, 
 Iwd a little to the inner side The limb is held across the patient's bo<ly, the 
 hiirceon standing on the affected side I'lie incision extends tl. ough the 
 
•^ir 
 
 584 
 
 A MANUAL OF SURGERY 
 
 substance of the triceps down to the bone. The origin of the flt-Nur carii 
 uhiaris and tiie inner lialf of tlie triceps tendon are detached, and the lidlli w 
 between the olecranon and the internal condyle cleared, the knife Ixiiij; ki.it 
 close to the btme, and the soft parts retracted by a vigorous use of tin- tliumi/ 
 nail liy this means the ulnar nerve escapes injury, and, indeed, is ciftiMi mi 
 seen at all. The internal lateral ligament should be divided, and part of the 
 common origin of the flexors. The outer half of the joints is then (icaJt with 
 in a similar way, the anconeus being divided close to its insertion U> the nlna 
 the continuity of the triceps with the deep fascia covering it being iiImi mail 
 tained. The origin of the extensor muscles is separated from the ln'iic, an: 
 the external lateral ligament severed. The joint can now be frcel\ opened 
 !)y di\iding any of the (ibres of the posterior ligament which remain intact 
 The denuded ends of the bones are protruded from the wound, and the 
 olecranon, together with the upper articular surfcace of the coronoiil process 
 and the head of the radius, are sawn off, care l)eing taken to ilraw .-isiileand 
 protect the soft parts by retractfirs, especially those covering the ulnar nerve 
 the lower end of the humerus is now thoroughly cleared, and tlic articuLir 
 surface removed, whilst the synovial membrane can be dealt witii as nia\ he 
 necessary. ICven if tiie heail f)f the radius is free from diseasi', nothing 
 is gained by leaving it intact, since ankylosis is very likely to follow iinle« 
 plenty of bone is removed. I'or a similar reason subperiosteal resection h 
 needless, and, indeed, is an undesirable refinement. The wound is tartliillv 
 sutured, and a ilrainage-tube inserted for a few hours. The limb is kept una 
 hinged angular splint for a week, by which time union of the external wound 
 should be complete, but the position is altereil each day. After a ueek. th.,' 
 splint may be dispensed with, and the limb kept at rest on a pillow, frecpassn^: 
 movement, both angular and rotatory, being daily practised. Consulerahk 
 attention is needed in order to obtain a gootl result, but in a successful lase 
 e\ery movement of tiie joint is perfectly restored. As a rule, the lower tnd 
 of the humerus develops twT) lateral bony processes, like malleoli, within the I 
 grasp of which the upper rounded ends of the radius anil ulna an able vi 
 move. 
 
 The Wrist-joint is only excised for extensive tuberculous diseas(; «henj 
 abscesses and sinuses are jiresent. Ankylosis of the articulation, though a] 
 troublesome conciition, is not sufliciently so to require sucii treatment ibcl 
 best method to employ is that known as Lister's operation, a ^miu'wIiiU coii> 
 plicated proceeding, but which in suitable cases gives excellent results IVial 
 to operating the fingers are well bent, so as to break down any adliesionswliicli 
 are present. Two incisions are made, one on the radial side of tiic dorsurs 
 and the other on the inner or ulnar aspect of the wrist. The dorsal incisidnisj 
 angular (I'ig -'17, L, [,), commencing at a point on the back of tlie radius 
 between the tendons of the extensor secundi internodii pollicis (H; and thee\j 
 tensor communis digitorum (D) ; it is a* first parallel tolhe former tendon, an i 
 on its ulnar side, till it reaches the base of the second nietacari)al Ixme. whtiij 
 its direction is changed, and it courses downwards along tliat hone for ai 
 inch or two It should extend to tiie bone, and in doing so i lie tendons i[| 
 the extensor carpi radialis longior anil brevior (M and 1) are divided asde 
 to their attachments as possible. The tendinous structures are then strippeJj 
 off the back of the ilorsum on eiilier side of the incision, and on the outerf 
 side a pair of cutting pliers is insinuated so as to detach the irapeziuir 
 from the rest of the carpus. The synovial sheaths of these tendons should. 
 possible, not be opened. The hand is then rolled over, and the ulnar incisi<ii 
 made well on the inner side of (he limb, extending for at least j inche! 
 Iietween the extensor and flexor carjii uluaris tendons. The sei)aration I'l ih^ 
 i'xtensor tendons from the back of tiie carpus is now complett.'d, and till 
 attaclirient of the extensor carpi ulnaris (K) divided. The tissues or ih^ 
 palmar aspect of the joint are detached, the pisiform being severed fmij 
 the res: of the carpus, and where possible left, and the hook of the inicifon 
 clipper off with cutting pliers. The carpus is now free front and back, anJ 
 
DISEASES OF JOINTS 
 
 585 
 
 -lie bones are either removed piecemeal or taken away fit bloc by inserting a 
 pair of cutting pliers above and below, and dividing their upper and lower 
 ci'p.nectii'ns ; more usually the carpal bones are picked out in fragments. 
 \iientioii is then directed to the lower ends of the radius and ulna, and to the 
 articular rnds of the metacarpal bones, all the cartilage and the intervening 
 <inovial tissue being cleared away, iinally, the remaining fragments of the 
 carptis art' dealt witli as tiie case may retpiire. The radial incision may often 
 'aeeritirt'K closed, whilst a drainage-tube is inserteil through the ulnar wound. 
 Iheliaiul is placed on a special splint, with a thick convex cork support for 
 the pahii, which keeps tlie wrist slightly extended, and with a short lateral 
 ;iriiiectiiiii upon which the thumb can rest. The fingers must be thoroughly 
 t!f\e(l and exteniled daily, beginning on the second or third day, but the wrist 
 .iumld he kept at rest until it is (juite firm. There is a much greater tendency 
 l;i atlaii-like joint than to undue fixity, owing to the amount of bone removed, 
 
 Fig. 
 
 ivadial 
 1', ex 
 niKiii 
 liin>;i< 
 radial 
 
 'O' ' 'Cl 
 217. ICxcisioN OF Till-: Wrist 
 
 artery; H, extensor secundi internodii jiollicis ; (.", e.\t. indicis ; 
 t communis digitoium ; K, ext. minimi digiti F, ext. primi inter- 
 
 pollicis ; (1, fxt ossis metacarpi pollicis ; II, ext. carpi radialis 
 ir I, ext. carjji radialis brevior ; K, exi carpi uinaris ; I,, L, line of 
 
 incision. 
 
 (Lister.) 
 Jiollicis ; (." 
 
 ^dtiie necessary divisions of all the extensors of the carpus ; if such occurs, a 
 tiluT Mijiport must be worn, either as ,1 temjiornry or permant-f appliance. 
 I Till Hip joint is rarely excised for coiuhtions otiier than tulwriulwus disease, 
 
 (inen lor this it is performed much less freiiuently tlian lurmerly. There 
 
 c.wociiu'f inetliods of operating, the anterior and the posterior. 
 [I llxcision by the unttrior method is carried out as follows: The incision 
 |ig "I D . p 263) extends from inimedi I'cly belovv the anterior superior spine 
 
 tli:ally downwards for j or 4 inches, it passes between the tensor fascia? 
 
 Bdris and sartorius muscles supertirially, and between the glutei and rectus 
 
 ^pl\, a small arterial twig from the external circumflex lieing divided at 
 
 ^tafje The neck t)f the bone and capsule of tiie j tint are expos-.'d, and 
 
 flatter is freely incised along its attachment ti> the anterior intertrochanteric 
 .sn as to allow of the admission of the hnger, wliereby the joint can be 
 
 |iy explored . The neck of tlie bone is cut through 111 situ by means nf an 
 
 Mis' osteotomy saw, the incision through the bone being placed ol)liijuely 
 
S86 
 
 A MANUAL OF SURGERY 
 
 downwards and inwards. The head of the bone is now either prist-d nm ,,| 
 tlu- acetabiiluin i)v an elevator, or f^raspcd by Hon forceps and twisted out ,i 
 matter easily accoinpiislu-d wlicre tin; articular structures are ilisi'.iML-d, Inn 
 a proceeding of some ddticulty in a normal joint or on the cadiuer .\^ 
 much of the infectetl synosial mend)rane as possible is clipped awav witji 
 scissors, and the acetabulum scraped, if necessary. The external wound i> 
 either closed, with the exception of an openinj; lor a drainage-tube, or stutlwl 
 with K-'iuze soaked in iodoform emulsion. There mav be comparatively iiitlv 
 shortening of the lind) as the result of this proceeding, but the mo\ctiU'iit.sare 
 considerably limiteil 
 
 2. I'lxcision by the postoiov iiicllunl, as we liav(! alre.ady said, is usualK 
 undertaken in the later staf,'es of the ilisease. Any sinuses whi«.': exist fx v 
 teriorly may be utilized, but if the skin is unbroken, an incision known as] 
 Lanfienbeck's may be employed (I'ig. 218). The patient lies on the sound 
 lind), whilst the affected thi),di is (lexed 'I'he incision is m.ade in \.W line of 
 the lemur, exteiuliuf,' 2 inches above the top of the ),'reat trochanter, iiinl alxju! 
 J inches below it It is carried at once down to the bone, and tlic imisch.^ ! 
 attached to the summit and posterior border of the great trocliamer fretlv 
 divitl<;il, as close to the bone as possible The capsule is opened to a siitticitni I 
 exteiU to allow of the exploration of the joint by the finger. If the (lisea>e 
 is very extensi\e, the fenuir is now chiselled across, immediately helo's thel 
 great trochanter, but abo\e the lesser. The upper einl of the bdne isl 
 grasped by lion forceps, anti twisted out of tiie acetabulum, after i!i\biiinl 
 of the remaining Ntruitiires, whiih are attached chiefly along its antennri 
 bord»T The ligainentum teres has almost always been previously destriiyed, 
 and hence this stage of the operation is not esjiecially ilitlicult. The synovial I 
 membrane and acetaf)ulum are easily reached, antl the diseased portKinsj 
 remo\ ed In fa\ourable cases a drainage-tube may be inserted, and the \v(>uinl| 
 
 closed, but not uncommonly it is wiser til 
 
 partially stuff it with gauze infiltrated wulil 
 
 iodoform, and allow it to heal by j^ranuiatKn.l 
 
 Slight extension of the limb shouici lie suli- 
 
 seipiently made, so as to prevent undue sliortun-l 
 
 ing from the traction of the long thigii niiiscltsj 
 
 The leg is placed between sandbags, or a I.istmii 
 
 long splint applieil Fibrous ank\ iosis, with ; 
 
 certain limited amount of movt.'inent, is the| 
 
 usual result. 
 
 It is not always necessary to iiuludf tliej 
 trochanter in this operation. If the disease 
 limited to the heail of the bone, it alone should| 
 i)e removed, with as little ilistiirliance 
 possible to the muscles passing to tlie tidchanierJ 
 If such can be effected, the subseijuint inolulu/ 
 and usefulness of the limb are considerablv la 
 creast.'d. 
 
 The advantages claimed for the anterwil 
 method are : that it is a less severe operation 
 that fewer muscles and tendons are interlerd 
 with, that no vessels of importance are diviiledl 
 and that only the head of the bone is exci.sedj 
 The objections to it are : that the ijr.iinage pro| 
 vided is very unsatisfactory, that the tr(Kliame( 
 cannot be readily dealt with, whilst it is also difficult to remove all th| 
 synovial membrane 
 
 The great advantages of the posterior operation are that, in spite of a M 
 division of tiie muscidar and tendinous attachments, excellent ilraina^e 1 
 provided, anil both trochanter and acetabulum are readily accessdjlu 0( 
 the whole, the anterior method should be employed in the early stages of ih 
 
 I'ui JiX I.anc.f.nheck's In- 
 cision KOK IvXClSION OKTIIK 
 llir FROM UliUlNIJ. (TlLL- 
 MANNS.) 
 
DISEASHS OF JOINTS 
 
 S«7 
 
 T prised out of 
 , twisted out, a 
 c diseased, lut 
 ! cadaser .\^ 
 ped away with 
 ernal wound :~ 
 •tul)e, (ir stuttd 
 iparatively link- 
 movements are 
 
 said, is usuail\ 
 wliii:- exist fn v 
 :isi()n l<n'>\Mi ai 
 s on tile sound | 
 le ill the line oi 
 anter, and alwui 
 md the inuscii> 
 rochaiuer fretly 
 led to asutticicm 1 
 if the ilisea>s 
 iatelv belo'v the 
 
 of tlie tnine is 
 n, after division] 
 long its anterior] 
 ioiislv destroyed, 
 t. 'ihe syniiviall 
 liseased portumil 
 d, and thewoundl 
 
 it is wiser til 
 
 infiltrated ttiih| 
 1 l)v ^;raiuilatiiin. 
 
 shoiilii he suli' 
 lit lllldlle^hont•n•| 
 ;ig thi^;li nuiscle- 
 y.iiis. ural.istoiii 
 ;inkyl('sis, with 
 oxeiiient. i-< M 
 
 to include tli«| 
 If the disease 
 le, it alone shouldj 
 
 disturbance 
 |to ihetnichanierJ 
 jsi-'qiunt niobiliiif 
 
 consiilerahly 
 
 Ifor the anienoll 
 
 |se\ ere operation 
 
 Ins are inlertere< 
 
 lance are ilividedj 
 
 hone is excised! 
 
 thediainaKepro 
 
 |at till' iidcliaiitel 
 
 reiiu've all thi 
 
 In spite of a M 
 lleiit drainage " 
 acce-'sible 01 
 krlv sta.nes of t.il 
 
 disease, the posterior in the later. The situation of abscesses or sinuses may, 
 hiiwever. determine the choice of the surgeon. 
 Tlie Knee-joint is exciseil for tuberculous disease, osteo-arthritis, or deformity 
 jue to osseous or fibrous ankylosis in a l)<id position. A horseslioe-shapeil 
 ir.cision is made, extending from the back of one condyle to the other, reaching 
 Jowiiwards nearly as far as the tubercle of the tibia. The limb is well Hexed, the 
 liuamentiiin patell.r divided, and the joint opened The skin and subcutaneous 
 tissues an' then s(!parated irom the anterior surface of tlie patella, wliich may 
 iieatonce removed by a curved incision above it, communicating on eitlter 
 side with that already made below. The flexion is now incre.ised, and the 
 lateral li;;aments divided : by this means the interior of the joint is freely 
 exposed, so that the attachments of the crucial ligaments to the tibia can also 
 Ic severed . The lower end of tlie femur is then cleareil of diseased synovial 
 membrane, so as to allow of the application of a broad excision saw. The 
 usual rule given as to the direction of the saw-cut in the bone is that the 
 f,vpesed bony surface left after removing its articular end should be absolutely 
 hurizontal, supposing the patient to be standing upright ; personally, we 
 prefer to make the sections so that the limb shall be left \ery slightly flexed 
 ,wd in-kn(t!d, a position wliich greatly adds to the sub.secpient comfort of the 
 patient To accomplish this, the saw must be applied parallel to tlie articular 
 lurface, it., at right angles to the axis of the body, not of the femur, and with 
 a slight upward slant from before backwards. The bone should be partially 
 sawn tliri High l)y a side-to-side movement, but the pf)sterior surface of the 
 condyles sliould be dividerl by raising or depressing the handle of the 
 instrument, so that the structures lying behind in the intercondyloid notch are 
 Lot encroached upon. Sufficient bone should be sawn off in the ailult to 
 mc'.O'le tile greater part of the articular caitilage, but as little as possible con- 
 sistent with removing all the disease, (jtherwise the limb is shortened to such 
 an extent as to interfere with its subseciuent usefulness. The he.id of the tibia 
 istlien luotruded, and cleared from the neighbouring soft parts; it is held 
 Jjbsdlutely \ertical, and a saw applied in a horizontal position, the bone being 
 Idivuled Irom before backw.ards. Any diseased svnox ial membrane is now 
 jdissected away, special attention being directed to the subcrureal pouc h .Ml 
 WeeilinK-points having been secured by ligature, the bones are fitted together, 
 and ifconsiilered advisable, secured in position by thick silxer wire, or silver- 
 jlated nails or screws The external incision is closetl, drainage-tubes being 
 linst-rteil at each angle of the wound. A (ioochs splint is applied to the limb, 
 land in this it remains until sound healing has occurred, after which an iin- 
 Iniinable i ase either of plaster of I'aris or water-gl.'iss is kept on until eight or 
 Itenwfeks have elapsed since the operation. 
 
 The Ankle-joint is excised for tuberculous disease Two incisions are made, 
 Ian inner and an outer. The outer incision runs along the anterior border of 
 Itlie fibula, anil curves round the outer malleolus, being about j inches in 
 lleni;tli Tlie lo wer end of the fibula is exposed, and by preference subperiosteally. 
 iThe external lateral ligament is split vertically, ;,nd separ-'.ed from itsattach- 
 linents to the fibula, its continuity with the periosteum being, howexer, main- 
 jtained The fibula is then divided about i inch aliove the tipof the malleolus, 
 land the latter process of bone remoxed The periosteum and ligaments are 
 |»parated ,as far as possible from the front and back of the bones The 
 lioner incision is T-shaped, and is made along the inner surface of the tibia, 
 |«ith a sliiirt transverse cut at its loxver eiul, xvhich reaches just beloxv the 
 liiiner malleolus. The periosteum anil internal lateral ligament are dealt with 
 lisun the (uiter side, and the front and back of the tibia are easily ilenuded, 
 |The inner malleolus is projected from the xvoiind, and the lower end of 
 ll-V tibia removed by a keyhole saw, the dorsal structures being held aside 
 Iky a retractor. The articular surface of the astragalus is sawn off from the 
 per wound, or, if advisable, the xvliole of the bone may be removed. 
 The alH)ve siibperiosteal method of excision is one of the best that have 
 *n suggested The greatest care should be taken not to open the sheaths of 
 
588 
 
 A MANUAL OF SURGERY 
 
 the teti'lnns, and in dressinj,' the wound tlic foot must be kept at rinlu alleles 
 to tlie Icfi, and no lateral deviation permitted. As soon as possiiile u js 
 encased in plaster of I'aris, windows being left for the dressing of the wounds 
 if necessary. 
 
 In non-tuberculous cases a transverse incision extending from f)ne malleolus 
 to the other may Ihj employed. Sutures are placed through the tcnddiis alunc 
 and lielow, and they are then divided ; tlu; anterior tibial nerve is siinilarl\ 
 secured above and below before division, and the vessels are divided hoiwetn 
 ligatures \\y opening the capsule a very free exposure of the joint siirfatc^ 
 is provided, permitting a very thorough excision. The tendt)ns and nervf are 
 carefully sutured together before closing the wound 
 
 Ivxcision of the Astragalus is sometimes retjuired in the treatment of mhn 
 culous disease of contiguous joints, as also in some cases of falipcs .md (,| 
 fractures or dislocations of the btme. Many methods of operating li.uc l)«.n 
 described, but we think it is best accomplished through a single vtrtical 
 incision over the front of the ankle, running parallel to the vessels and t^'nllon^, 
 which are carefully avoided and stripped back from the dorsum bv means nf 
 periosteal detiichers, so that the upper surf.ice f)f the astragalus can n.adiK !«• 
 reached The astragalo-scaphoid anil ankle-joint are then freely opined, and 
 the ligamentous and fascial connections on either side severed. Tiie neek nf 
 the bone may with advantage be divirled at this statre nn.1 w^- !,c;i,! r.iihned, 
 so as to give access to the under surface and allow of the division of tiiestroMK 
 interosseous ligament extending between the adjacent surfaces of the astragalus 
 and OS calcis. It may be possible to remove the rest of the bone in one fray- 
 ment, but it is certainly wiser to break it up with chisel or gouge, and take it 
 away piecemeal. 
 
chaft1':k XX. 
 
 INJURIES or THE SPI NE. 
 
 [hi; siMi Kil co rd is protected from injury in a most roii_i plet^; and 
 ticacmns manner, (a) Its posilitju between the bodies and t he 
 „>,„ina with the spinous processes "anslnf; therefrom is itself 
 niechaniially ad\ antageous, si nce, whether the spine is forcibly 
 Sexed or extended, the cord remain, muhvay between the points 
 li chief compression or extension, and hence in a position of rest. 
 '1 The buffer-like action of the intervertebral discs, aluT the 
 wuviri},' curves of the column, ser\e to distribute some part of 
 liDv toire that reaches it. (c) There is ample j>p ace in the 
 
 foi 
 
 r.rihiilarv canal, in which the cord with its memTuanes is slunj,' 
 [iv prolon.Ljations of dura mater around tlie issuing' nerves, whilst 
 ihccDid itself han<;s loosely within the dura mater, suspended by 
 ihelit^aiiunta denticulata, and surrounded by cerebro-sj)inal Huid. 
 j) Moi cover, t he cord terminates , in an adult, at the low er 
 xircler of the nrst lumbiU" vertebrara spot well above the junctio n 
 ofth'' ti\c(] base and tli e mo\able up per part, a p oint where the 
 etiiLt of jars and wrenches Is^ mainly feTtl (c) Nature lias, more- 
 over, introduced a whole series of bufTers and other means of 
 Ipaveiiliiif; shock from reachinj^^ the spine when a person falls on 
 Ifefeet, c.^'., the arches and elasticity of the foot, the chanj^es in 
 Idirection of the bones at each joint, the interarticular cartila^'es 
 jofthe knee, etc. 
 The parts of the spine most exposed to injury are th ose \vhere_ 
 id Alld liioijlbje^ J)orUoiiJji£iiI, <•.^^, the dorsi-lum bar and \h e. 
 |ctr\ico-(i()rsal regionsj^ The upper part of the dorsal curve, which 
 Itrt'lativcly weak and projects backwartls, is thereby exposed to 
 |iii]ury, so tiiat fractures are not at all uncommon about the fourth 
 jdorsal vertebra. The close proximity of the head explains the 
 piuency of lesions about the upper cer\ ical ref.,Mon. 
 
 ^/-^^ 
 
 Sprains. 
 
 Sprains and strains of the spine lire very conimgn a cciden ts, a 
 kt not to^Re" wonderecTlil, wTien we consider the complicated 
 
590 
 
 A MANUAL OF SURGERY 
 
 musc ul.'ir and li^anumj^qus_arriui|;iimcnts present. 'Iliey arc 
 pr()clucecIT)y any sudden or unexpected movements, sucli as falls, 
 especially from horseback, railway accidents, and the [[!<(■. '|hi' 
 injury is most likely to alVect mobile parts of the spine, , .^r., the 
 cervical and Imnbar regions, and may be liniited to tin- Ik,. 
 mentous or muscular structures^ or may involve both. The 
 resulting Signs arc simply those of a se\ere^l)uf lo'cairzeH Iraiwrn, 
 viz., pain, tenderness, bruising, and perhaps a little swelling ;jj2e 
 subjective phenomena are much increased by movement, so thut 
 the spine is always kept rigidly (juiet. if only the muscles ,r | 
 intersjiinous ligaments are invol\ed, no further consciiuends 
 are likely to arise; but when the ligamenta subflava arc lii( t-ratt I. j 
 and the spinal canal is thus opened, the gravest syiuptuius niav 
 ensue from blood linding its way into the canal outside tiu' (luriil 
 muter, leading possibly to paraplegia, which may be of a ttiii|:M. 
 rary or permanent nature. Inflammation of the damaged fiJiroiiJ 
 lissucs may alsn c.vlend to the meninges and cord, ami caibe 
 compression of the latter or even organic disease. MorcoM-r, in 
 patients of a tuberculous temperament, spinal caries mav he ^et 
 up as a result of such injuries, whilst syphilitic or mali),'iiaiitj 
 disease has also been known to follow. 
 
 In the cervical region, sprains are \ery liable to occur as a_r£sult| 
 of'*se\ere blows on the licadi causing rupture of the inter- triuiaversel 
 ligaments, and tiie disj)lacement may be so great as to isiiuuliitel 
 dislocation. The head and neck are htild immo\able ami rii;iil,| 
 and there is often considerable loss of power, the patient i)eini;| 
 sometimes unable to lift the head spontaneously from the pilhm, 
 Sprains in the liiiiilutr region are very conunon, both as a lusuitl 
 of railway injuries, when they are often associated with nervuii^ 
 symptoms (p. 601), and as a consc(|uence of oserlifting, when tht 
 quadratus hunborum is most likely to lie affected. Tlie ha(k;s| 
 kept fi.xed and rigitl, the patient being unable to turn or stdup 
 without pain. Sometimes hatMiiaturia results from injmies in tliej 
 lumbar region, arising from contusion of the kidneys. 
 
 Treatment. — The patient should be kept at rest, and tonnntaJ 
 tions ap|)licd to the injured part. When the painful 01 intlain'j 
 matory symptoms ha\e disappeared, massage with stiinulatiiia 
 liniments is needed. In the severer cases the indixidual sliDuld 
 kept in bed for six or eight w^-eks, an d in the cervical region sD i i ia 
 form of mechani c al su p port uiav be sidisecpiently necessaiy. Tti] 
 appearance of inflammatory sympfoms invoh'Tng tlie Tiu'nin','d 
 calls for greater care ; the patient should then be kept as niuii 
 possible in the prone position, and a spinal icebag applied. II 
 onset of paraplegia, due either to ha'tnorTliage or inllainniatur^ 
 exudation, would raise the (Question of laminectomy (p. ^>05). 
 
 "i ' 
 
l>iyURIES OF Till- SI'lNIi: 
 
 $91 
 
 Penetrating Wounds of the Spine. 
 
 These lesions are, fortunately, uncommon in civil practice, 
 
 Kinn ^'I'lierally due to stabs with pointed instruments, sucli as 
 
 lavont'ts, or to j^'unshot wounds. 'I'liey occasionally result from 
 
 falls, the unfortunate indixidual becomin",' impaled on area 
 
 railiiifjs, branches of trees, etc. The Symptoms produced are 
 
 ji tliDNc due to the wound in the soft parts, which may also 
 
 involve the peritoneal and pleural ca\ities, or damaf,'e some of 
 
 the viscera ; in the neck, the vertebral artery is expcjseil to injury 
 
 troiii this type of accident, leadinj^' to serious ha-morrhaf^'e ; 
 
 ,M various forms of fracture, the cord bein<f compressed by 
 
 fra;,Miients of bone which have been dri\i'n inwards, or by 
 
 t\travasated blood ; (r) those due to layinj^ open the spinal mem- 
 
 liranes, f.f^., loss of cerebrospinal fluid, which in itself miffht 
 
 j prove fatal by drainiu}^' the cerebral cavity, and so causing' pressure 
 
 on the base of the brain, or at a later date may determine the 
 
 patient's death by setting up difluse septic meninj^itis (|). 600) ; 
 
 and ((/) those due to wounds of the spinal cord. The ell'ects of a 
 
 total trans verse lesion a t ( lifferent l(;\els of the spine are gi\en at 
 
 p, 604; even if the patient escapes the danj^^ers ot difluse septic 
 
 nienin},Mtis, he will later on develop the sij^^ns of acute myelitis. 
 
 Of course, the division of the cord may be only partial, or it may 
 
 escape entirely, whilst nerve roots or trunks may be involved, 
 
 and in the lumbar or sacral re},Mons the cauda e(iuina may be 
 
 I divided. 
 
 Treatment consis ts in thorouuhlv explorint^ the wound under 
 Ian anaslhetic, reinovjn^ fc)reign bodies or displaced fnigments of 
 jlHiiie, and attempting to render it aseptic. Wounds of the vertebral 
 larlery or other structures are dealt witli secundum arteiu, and special 
 [atttntioii is naturally given to the cord and its membranes. Should 
 jtlit dura mater have been opened, and the cord have escaped 
 linjiiry. an attempt may be made to close the wound in the 
 InieiiinLjcs, and the patient should subsecjuently be kept in the 
 Iprone position and with the head low, so as to prevent, as far as 
 Ipc'ssihle. t he es c ape tff cerebro-spinal fluid . If the cord itself is 
 jdnided or lacerated, it is useless trying to unite it, since its function 
 In conducting impulses from the l)rain downwards is inevitably. 
 <lc>tmv((l. Wher e, however, the cauda ecuiina has heefT injuT 
 jiisijerT ectly jTisTifiable to lay open the spinal canal to a sufhcient 
 pent to expose the divided ner\e trunks, and theiTto suture them 
 
 f'lgether. " — -^ 
 
 Fractures of the Spine. 
 
 • — The spine may be broken as a result of (a) direct 
 
 le spi 
 
 _ _ a fall on the back over some projecting body , 
 
 '^ irs :i_ carpe nter's bench or a l^ailinL^ or a blow on the back 
 
 ith a heavy stone or with a swinging baulk of wood, or a gun- 
 
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 (716) 872-4503 
 
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 592 
 
 A MANUAL OF SURGERY 
 
 shot wound. This type of accident may involve any part of the 
 spine, and, exchiding those afistng from gunsTiof7 is less fVequem 
 than the class nexftO be^escrfbe^T^ Ut iTecessity, tEe spine breaks 
 at the point struck ; the posterior parts of the vertebrae are most 
 likely to be damaged in this form of injury, (b) Fractures are 
 also due to w^?>ff^ v iolence , then usually occurring in the lower 
 cervical or uppe r dor.al reg ions. They are caused by forcible 
 flexion of the spine, as by a fall do\vnstair_s_ wTtJi t he head_dfHiX)le(i 
 up, or by taking a 'laeader ' '."t!I'_^^^^^OW water, o*" whpn ^ man, 
 being driven under a bridge, omits to stoop, and so is caut;ht 
 between the arch and the cart, or sometimes by the fall of a heaw 
 weight on the back of the neck, the spine bending and hreakini; 
 at the weakest spot. 
 ' Fractures of the spine may be divided into two main classes, 
 according to whether or not they are complete — that is, accordiiis; 
 to whether the continuity of the column is destroyed or not, 
 
 (A) Incom plete FracturesnU tiy he~Trmt-wtth In xarious fornix. 
 and are most frenueii tlyi-^"^ ^q dirprt \inlpnrR. 
 
 (i.) Fva ctuves of the S pinoits Processes ra rely occur exc( .- ;pt iiij lv- 
 lower cervical or dorsal regions . In the upper cervical region :lit: 
 spmes are short and retracted to allow of extension of the head, 
 whilst in the lumbar they are also short, but very strong. The 
 fracture is almost always due to direct violence, and is charac- 
 terized by the signs of a local trauma, together with grea; 
 mobility, perhaps crepitus, and irregularity in the line of the 
 spines. The process is occasionally much depressed, and mav 
 even cause paraplegia by being driven into the spjnal canal. 
 
 (ii.) Fyactiiye of the Lamina is a not uncommon accident, always 
 resulting from direct violence. If only one lamina is broken, the 
 signs are not very distinct, and cord symptoms are rare. When 
 both laminae yield, the posterior part of the neural arch, carryini: 
 with it the spinous process, is very likely to be depressed to ;i 
 sufficient extent to compress the cord and gi\e rise to parapleidil' 
 Cre pitus is often obtainable, and a gap m i-hr hne nt the ^pmniKJ 
 
 processes can usually be felt 
 
 (iii.) Fyacture of the Tvansvcyse Processes is but rarely met wjli j 
 apart f rom other lesions of the spine. 
 
 (iv.) Partial Fracture through the bodies may occur in the fori'i 
 of fissures, which produce but little effect, except pain andj 
 rigidity, and cannot be diagnosed with c ertainty . 
 
 In any of tlTeSB" fiacluirs whci'e'Tttsplacement is not prcscD;. 
 paraplegic symptoms may arise, either immediately from con- 
 cussion of the spinal cord, or later on from the pressure of hsiiior-l 
 rhagic or inflammatory effusions. 
 
 The TreatmenTmere T y consists in keeping the Pciti ent.cUre.HJ 
 for a tTme. The qjjfisti Qii of lamin ectomy for pa raplegiiL-dutj 
 e.itlierTo di.splaf^niept "L^^^~*''^"^'"^~"'^il^-ljy"^"'"^^^ wiill'sl 
 
 discussed later (p. 605). 
 
INJURIES OF THE SPINE 
 
 593 
 
 (B) C omplete ^ Fractures are usuall y asso ciated with displace- 
 ivieirtj_ 'an(i loss~or~CDntinuity ot the~spinal cf^lumn, and hence 
 are ofte n termed Fracture-i>isiocations. 1 h ey result eith^r 'ffohi 
 direct or indirect violenc e^ 'I'here is always a tolerably extensive 
 lesion (Fig. 219) ; thus, the spinous processes and laminae may or 
 may not l-»e fractured, 
 the'ligamenta interspi- 
 nosa, supraspinosa, 
 and subflava torn, the 
 articular processes 
 fractured in the lum- 
 bar and dorsal regions, 
 or displaced without 
 fracture in the cervi- 
 cal, and either the in- 
 tervertebral substance 
 torn across, or the 
 Ixxlies bro ken, thus 
 severing tTie spme in to 
 t\\-oliaIves. i'he upper 
 or moveable portion is 
 usually driven for- 
 wards over the lower 
 or more fixedfirag- 
 ment,_and i mpactio n 
 or c niniinution is 
 The 
 
 FiG. 219. 
 
 CoMi'LETE Fracture - Dislocation 
 OF THE Spine in the Lower Dorsal Region 
 WITH Displacement, and Compression of 
 the Cord. (After Keen and White.) 
 
 ot"teir~present. 
 spinal cord is c6m~ 
 pressed between the 
 upper end of the lower fragment and the lamina; of the uppe r 
 fragment, and" "although the displacement may be naturally 
 remedied by the falling back of the bones into position (' recoil '), 
 yet the effects of the crush on the cord are usually irremediable. 
 In slighter cases the spinal membranes may be merely punctured 
 by a splinter of bone, or haemorrhage may occur either within the 
 membranes, or outside them in the fatty theca vertebralis. 
 Excessive indirect violence may lead to an associated fracture of 
 the sternum. 
 
 The Signs of a complete fracture are usually very evident, con- 
 sisting of loca l pai n, swelling, and bruising, and a certain amou nt 
 t angul;ir..d£iiprmi ty, more or less according to circ umstances. I t 
 lay be possible to elic it cFepi tusTlFThe parts are not impacted, 
 ut^all unnecessary mo ve iilfihl ijtrould Lj e ^ ?< , V0'^^^ ^^^ 
 ^"n|T~tcr the injui'V of the c ord. Paraplegia below the part 
 
 yured is present in most cases , and with it some amount ol 
 eneral shock. When the cord is disintegrated or divided, 
 lymptoms of sp inal myelitis rapidly follow, and a fatal issue 
 iften occurs at ~an ea rly date trom to x aemia following septj^ 
 
 — _ 3» 
 
 ^ 
 
594 
 
 A MANUAL OF SURGERY 
 
 cystitis or sloughing of the nates. . The special phenomena of| 
 paraplegia are dealt with at p. 603. 
 
 TheJPro gnosis of these cases turns largely on the sitii;itinn (^ 
 the injury and the amount of mischief sustained by the cord. 
 The higher the lesion, the greater the danger, although patients] 
 with paraplegia from cervical fracture may live for years, and 
 may even partially recover, if the cord has not been totally dis- 
 integrated. 
 
 The Treat ment naturally varies with the character of the r f^ iA 
 TEe^ patient is carefully placed on a prepared bed, the great 
 gentleness being used in handling and lifting him, for fear of| 
 increasing the damage to the cord. The bed must be firm, thoiich 
 not hard, and is perhaps best made of horsehair mattresses placedl 
 over fracture-boards ; nothing more soft or yielding is permissihle.i 
 A water-bed is required in the later stages, but should not be used! 
 at first, as it is scarcely firm enough. The shock resultinf( from] 
 the accident is treated in the usual way by warmth and, if need! 
 be, by stimulants ; but it must be remembered that anajstheticj 
 regions of the body can be easily blistered or burnt by hot-waterj 
 bottles, unless carefully guarded by flannels. When reaction has! 
 occurred, a more thorough examination of the patient can hel 
 made, and the subsequent course of action decided on. 
 
 (a) In a small minority of the cases operative treatment is justiti-j 
 able. We shall discuss later on (p. 605), the indications ton 
 laminectomy. 
 
 (b) When the displacement persists owing to impaction of 
 fragments, reduction under an anaesthetic may possibly be under] 
 taken, provided that the lesion is not in the cervical region, and 
 the paraplegia not complete. Of course, if other internal injuries 
 are present which render the case hopeless, nothing should hi 
 done. Great care must be used in attempting reduction, sincj 
 the object is to relieve pressure on the cord, and any undii^ 
 violence may readily increase the mischief ; in the lumbar region 
 however, considerable force may be employed without niucli 
 danger. Whether reduction is accomplished or not, the furthel 
 treatment must be directed in accordance with the indication 
 given in the next paragraph. Where the surgeon fails to rediicj 
 the deformity, it may sometimes be advisable to make gradu^ 
 extension from the feet or neck by the use of weight and pulley. 
 
 (c) In many cases, as soon as the patient ifi laid flat on a bed 
 the displacement remedies itself, especially if the spine has beel 
 c ojnminut(;(;l. and then the treatment must be symptomatic, as al^ 
 after reduction or operation, where the paraplegia persists on 
 only slowly recovered from. He is kept in bed, absolutely fla 
 and with the head low ; perhaps some form of mechanical suD 
 port, e.g., a plaster of Paris or leather jacket, may be considera 
 advisable ; but its application is always a matter of difficultj 
 and, at any rate, in the early stages it does but little good. Focj 
 
INJURIES OF THE SPINE 
 
 595 
 
 lenomena ot 
 
 is regularly administered, and at first must be light and readily 
 I assimilable. 
 
 The c hief care of the attendants must be directed to the skin, 
 j bladd er, an d bowels^ Bedsores are extremely liable to form on a ll 
 Ipomtsuf pres!^lll't!,"irTId hence the nates and heels must he care- 
 
 ItuHF gu^ f ded (p. 6^ In tur nmg the patient to attend to the 
 
 I nates^ t he body must be^roUed over as a whole, and not merel y' 
 
 the pelvis twisted. It will often be found advisable to have a 
 
 3iviaed mattress placed T)eneath ~the pelvis , so IImt_pne JateTal 
 
 hegment may Jbe_removed at a t ime, and thus rotation oFTE e 
 
 I body will not be neede d. A bedpa n can also be used in ^his wa y 
 
 ftTtTiout dis turbing the sp ine. WH^en the bladclev is paralyzed, t in 
 
 ipnp" must be >yithdra wn by a" catheter . One of the greatest 
 
 dangers that the patient runs is t rom the supervention of sep tic 
 
 cvstitis, and t he extension of the ^in fla mmation upwar T rioth e 
 
 Hneys. " This is ahvays due to intection trom without, and the 
 
 greatest care must be taken to prevent it. The penis should be 
 
 I' noroughly purified, and the urethra we ll "Hushed uiil befuin- 
 
 mssins an instrument in these c ases ; in t h6 intervals between 
 
 linstrumen tatTon the penis is wrapped in a dry an tiseptic or sterilized - 
 
 fesin^ Only soft rubber catheters are employed, and these 
 
 [must be kept absoluteTjT^sepIic 1)y~rmmefston~in 5 pet* ceW. 
 
 artralic lotioir,"Tjr^i-rooo sublimate, which is su bsequently re- , 
 Imoved b efore use _ by washing with a~solution of boric acid. 
 
 '*' '"'^Isepsis- occur, ThB^iTtadder is^Trrlgated twice~"dairy with 
 
 |Some mild_ anti septic, su ch as~ Dondy^ fluid, boric "acTd, boro- 
 lyceride_(i in 2 0). or sanftas (i lrTao), whilst salol or boric a cid 
 jirrio^rain doses may be ad ministered by the mouth thrice daily. 
 i ProBabiy, inTspite of all precaution5rtiTe~cnirdition will persist r 
 [ andprove fatal from extension to the kidneys. The bowels are 
 tlways obstinately constipated, and must be opened either by 
 pgatives or simple enemata. 
 Under such a regime the patient may gradually recover, but 
 tore often succumbs to septic poisoning or exhaustion. Occa- 
 iionally he may live for a long time, although paralyzed, possibly 
 leveloping^^s pme aq iountof reflex micturition , if the lumbar 
 ptres are not in\^olved. Varying degrees of restoration of 
 mtx in the lower limbs are also met with. 
 
 Dislocations of the Spine. 
 
 By dislocation of the spine is meant a displa cement forwards , 
 fe partial or complete. Of the upper pAtt 6f the spine, with 
 jeparation of t he articular processes, and tea ring ot the ill Le i - 
 
 [tfilff a r suB s Fanc e i - A pure dislocation can only occur in the 
 jtrvical region, and even then it is not uncommonly associated 
 jitli a fracture. The reason for this depends partly on the 
 pmobility of the dorsal and lumbar vertebrae in the latter regions, 
 
 38—2 
 
596 
 
 A MANUAL OF SURGERY 
 
 and partly on the direction of their articular process& s. In the 
 cervical re^^ion^ these look mainly upward s and dow nwards, witiT a" 
 slight slopelorwards^and backwar dSjjoJhat^ iti s not dif iicultjcjr 
 one to slip oveYTHe otller ; in the~dbrsai region they are placed 
 nearly vertical, looking forwards and backwards, whilst in the 
 lumbar they are also vertical, but look inwards and outwards, the 
 lower enclosing the upper as in a sheath, so that in the last two 
 regions of the spine dislocation is impossible without concurrent 
 fracture of the articular^ processes and j)robably of the lanrintT. 
 
 ' Any part of the cervical reg io n may be the s eat of a di sl ocatinn. 
 The occiput has been d isplaced frorn the atlas in a few cns f<; 
 re^uTtingliirsu dden death ; but if incomplete, life has been pro- 
 longed for a few hours or days. Disloca tion of the atlas from tk 
 axis h as followed blows on the neck, or has been the r:iii «;p r . t 
 death in hangmg, whils t the attempt, t*^ ^'f*" ^ '^^'""ggling rhiliHn 
 fheTi^d has sorneiimes led to tjiis cajamity. In almos t all cases 
 the odontoid process has "been frac tured or the transverseltfjlt^ 
 ment torn, causing mstant death trom coiTr pressio i r --oftlTe"'cord, 
 owing to th^ head and atlas slipping forwards. Lateral displace 
 ment from rotation has also been observed, the cord symptoms 
 then being of a milder type. 
 
 Dislocation may occur between any two of the lozvey five cavkd] 
 vertebra, but perhaps most frequently between the fifth and sixth. 
 It is almost invariably the result of forcible flexion of the head) 
 and neck, perhaps combined with rotation, and as a rule thej 
 intervertebral articulations are torn open, whilst the supraspinousl 
 and interspinous ligaments, the ligamenta subflava, and the! 
 anterior and posterior common ligaments, are lacerated, and tliej 
 intervertebral substance torn across, or a scale of the articularj 
 surface detached. The head and upper portion of the spine arej 
 displaced forwards, so that the cartilaginous surfaces of tlit 
 articular processes of the lower vertebra project behind the! 
 laminae and transverse processes of the upper, and the loweij 
 articular processes of the upper vertebra lie within the inter] 
 vertebral notch of the lower bone (Fig. 220, A and B, a). Tw(f 
 forms of dislocation are met with — the unilateral and bilateral. 
 
 {a) I j^a^eral Dislocati on of the cervical spine is due to ford 
 applied^ from the back and side of the neck. The head is turneJ 
 towards the opposite side, and more or less fixed, whilst there il 
 no evidence of compression of the cord, although a tingling ani 
 neuralgic pain along the course of the nerves may arise froif 
 pressure upon and stretching of the nerve trunks in the inteij 
 vertebral notch. The spinous processes may be irregular ani 
 displaced laterally, whilst the line of the transverse processes ip 
 similarly altered ; such signs are, however, very difficult to mala 
 out in thick necks. If left unreduced, the vertebra becomes fixd 
 in its new position, the head and neck displaced, and permanea 
 neuralgia may result. In such cases, if seen early, vcpkccm 
 
INJURIES OF THE SPINE 
 
 %9t 
 
 may be attempted. The patient is anaesthetized, the body fixed, 
 the head and neck flexed, and traction made in that position, so 
 as to unlock the edges of the articular processes. Reduction may 
 be accomplished with a definite snap or catch. In old-standing 
 cases an operation may sometimes be attempted to relieve pressure 
 on the nerves, but it is impossible to replace the bones. 
 
 [h) Bilateral Dislocation (Fig. 220, A and B), if complete, is 
 ahvays accompanied with pressure upon the cord and paraplegia ; 
 
 ^iG, 220— Dislocation of the Cervical Spine. (After Keen and White.) 
 
 As seen from in front ; B, side-view ; aa indicate the lower articular facets 
 of the upper or displaced vertebra, which are thus seen to lie in front of 
 the upper articular processes of the lower vertebra. 
 
 iccasionally, however, it is only partial, and then the cord may 
 [scape without immediate injury, owing to the large size of the 
 nal in this region ; haemorrhage and inflammation may subse- 
 uently cause grave symptoms. Treatment is of but little avail in 
 pt of the cases of complete double dislocation, since probab ly 
 prord is irretrievably damaged ; but where paraplegia is incom- 
 fcte it js possibl e, that benefit may arise from _ early interferenc e. 
 leplacement by traction on the head with tHe neck flexed may 
 I first carefully tried, and failing that laminectomy should be 
 pformed. After stripping the muscles from the bones, the 
 
mm 
 
 598 
 
 A MANUAL OF SURGERY 
 
 surgeon will see the two cartilage-covered surfaces of the upper 
 articular processes of the lower vertebra standing out clearly 
 behind the laminae of the displaced bone. Upward traction on the 
 head may now again be made, and reduction thus attempted; but 
 if this does not succeed, as small a portion as possible of the upper 
 margins of the exposed articular processes is excised in order to 
 allow of the unlocking of the bones ; if the whole processes are 
 removed, reduction is much easier, but Nature's barrier to prevent 
 a recurrence of the trouble has been taken away, and fixation 
 of the spinal column in its natural position becomes impossible, 
 The sudden relief of pressure not uncommonly causes such an 
 interference with the intravascular tension in the cer\ ical cord 
 as to lead to a temporary cessation of the breathing, for which 
 artificial respiration is required. It is usually advisable not onlv 
 to replace the bones, but also to open the spinal canal and mem 
 branes, so as to remove any pressure of blood or inflainmatorv 
 exudation which may exist. The results of such operations are j 
 not particularly satisfactory. 
 
 Secondary Effects following Spinal Injuries. 
 
 Thus far we have limited ourselves to describing the immediate effects oi| 
 injuries of the spinal column. Such, however, are frequently associated with, 
 or followed by, other conditions affecting the cord and its membranes which! 
 may lead to the gravest results, even when the local lesion to the spine hasj 
 been comparatively slight. These are frequently combined with one anotherl 
 in the most puz2;ling fashion, so that it is often difficult to state the exact nature! 
 of a certain group of symptoms; for simplicity's sake we shall discuss thenl 
 here without attempting to describe the various combinations which mav| 
 present themselves. 
 
 The following secondary effects may be met with after spinal injunes:j 
 (a) Direct spinal concussion ; (/;) spinal haemorrhage ; (c) spinal meningitis, 
 ((f) spinal myelitis ; and (e) a series of phenomena which we shall discuss imder| 
 the title of spinal neurasthenia (or railway spine). 
 
 Direct Concussion. — This condition may be due to severe blows in tlie back,! 
 which do but little damage to the spinal column, or may be caused by accidents! 
 which lead to the infliction of greater mischief, but without any serious dis-f 
 placement of parts. The term ' concussion ' should be limited to those .jsiij 
 i^'liei'c energetic traumatic influences {falls, bloics, collisiois, etc.) have i^'ivcii rniii 
 severe disturbance of the functions of the cord without any considerable risible niuitomiim 
 changes in the latter (Erb). In fact, the term is really only applicable to those 
 cases which recover more or less completely ; if recovery does not ensuel 
 minute extravasations or other lesions have been present, constituting a coni 
 dition of contusion rather than concussion. It is somewhat doubtful, howeverj 
 whether all these cases are not due to minute haemorrhages. 
 
 The Symptoms produced are those of a more or less complete and immediall 
 loss of function of that portion of the cord situated below the point structf 
 Thus, a varying degree of paraplegia is produced, the signs of which clifferuii} 
 the region affected (see p. 604). In addition, the patient is usually prostratl 
 from general shock to the system, and the reflexes are often totally lost-f 
 at any rate, for a time — as a result of the shock to the cord. Death mayl 
 caused at once by a blow in the upper cervical region, or varying degrees 
 loss of power and sensation may be produced in any or all of the limbs II 
 the lower cervical region the arms are mainly affected, and perhaps somepaf 
 ticular nerve may be picked out and paralyzed. In the lumbar and dors^ 
 
INJURIES OF THE SPINE 
 
 599 
 
 regions a more typical paraplegia is produced, with loss of power over the 
 sphincters, and loss of reflexes. Priapism never occurs in simple concussion. 
 The temperature of the body may he depressed, and tlie extremities pallid and 
 cold; tlie pulse is rapid and weak, and the respirations sliallow. 
 
 The I'lvgnosis is always uncertain, as in cases where there is no displace- 
 ment it is impossible to gauge the e.vtent of tlie mischief. If merely con- 
 cussion is present, the patient is likely to recover; if the cord is contused, or 
 hcTmorriiage has occurred into its substance, a perfect recovery can scarcely 
 beexpectecl. 
 
 In tlie Tnutment absolute rest to the spine is of the greatest importance, and 
 this should be maintained if possible in the prone position, so as not only to 
 iliniinish static congestion, but also to remove any pressure on the spine, and 
 1 1 allow topical applications to be made. A spinal icebag may be applied, or 
 the back may be dry-cupped, whilst the patient is kept absolutely still, and on 
 alow diet. The bladder and bowels need attention, but no special drugs are 
 necessary. Of course, local injuries require suitable treatment. 
 
 Spinal Haemorrhage. — We can here only discuss the subject of spinal 
 hitmnrrhage as resulting from injuries. It also occurs idiopathically, and it is 
 interesting to note that such happens more frequently in young persons between 
 thf aj;es of ten and twenty than in old people, as with cerebral haemorrhage. 
 The bleeding may take place either into the cord itself, or outside it, and hence 
 the two following varieties are described : 
 
 i,ii Intramedullary Hsemorrhage, or spinal apoplexy, is met with as a result 
 ofinjury, which need not necessarily involve the spinal column. Extravasation 
 into the cord is rarely extensive, and may occur in the form of one clot, usually 
 not larger than an almond, or more commonly in many spots, the grey matter 
 being more or less ploughed up. Should the patient survive the injury for any 
 length of time, secondary degenerations are established, and run the usual 
 course. The patient is suddenly struck down with a more or less complete 
 paraplegia, and with perhaps pain in the back, and to these are soon added 
 the signs of a quickly developed transverse myelitis. The Diafinosis of h.nemor- 
 rhage turns on the rapid onset of paraplegia without fever, and without spinal 
 irritation. The Prognosis depends on the size and situation of the clot, a large 
 clot producing more injury than a small one ; haemorrhage in the cervical 
 ; region may be immediately fatal by interference with the respiration, whilst 
 in the lumbar region it is unfavourable on account of the effect upon the 
 sphincter centres. The outlook is best when the dorsal region is affected. 
 [The In (//;«(•«/ is the same as was indicated for direct concussion, whilst the 
 administration of ergot may be beneficial. 
 
 ('jl Eztramedullary HsBmorrhage is a more frequent complication of spinal 
 j injuries, such as sprains or limited fractures, than the former. The blood is 
 I usually extravasated between the bones and the dura mater, especially in 
 [the cervical region, but may occasionally be found within the dura mater, 
 {having sometimes trickled down from the upper part of the column. The 
 [symptoms are, in brief, those of spinal irritation, e.g., pain, hyperajsthesia, 
 [spasms, cramps, etc., rapidly followed by loss of power in the muscles supplied 
 from the damaged area, or by 'gravitation paraplegia' (Thorburn), which 
 Igradually extends from below upwards, causing death by asphyxia, the whole 
 [series of phenomena being afebrile. In intramedullary haemorrhage the 
 [symptoms of paralysis are more evident, and those of spinal irritation less 
 Imarked. If a diagnosis can be made, ergotin may be injected, and ice applied 
 ito the spine, or even laminectomy performed to relieve pressure ; later on, 
 Iprolonged rest may cause the absorption of the clot, and even total restoration 
 |to health. 
 
 Spinal Meningitis.— Inflammatory conditions of the spinal membranes may 
 IspreacI downwards from the head, or commence as a local affection. Two 
 porms are met with resulting from injury : 
 
6oo 
 
 A MANUAL OF SURGERY 
 
 (a ) In Acute Spinal Menlngrttia the i n flammation ma inly affects the ai aclmoiil 
 and pia m.-ULT (leptonicnm^'itis). rTisusually gen eraTized in clistribn ilimTanil 
 not iinfre(|iiently extends to the cerebral memhranesi It occasional! v folTrTws 
 simple injuries, but~is always infective in" OTt]?tfl, being due to a i h|^il(ic(JccLis 
 (? pneumococcus) in subcutaneous injurie^Sj or to tlie ordinar y pyogc'iiTcTorcj 
 in open \v77umTs. Pathotof^uaUy , it is evidenced by hypera?mia and loss of 
 polish of all the membranes, with an abundant exudation; later pn, ivmphdr 
 even pus may collect, especially aboiTt The"posterior surface" f)T~tlte cgnl 
 ^hnuld t he'patient live, organization of the ef fiisedJviIlpll-iua.v len d to e.v - 
 tensive adhesions. Clinically, tlie disease is usually ushered in l)y a rijjdr 
 especially m the septic cases, and then runs a marked pyrexia! coiirse 
 The symptoms are: pai n in Vne back, deep-seated, boring , and se vere jp . 
 creasecTon JiTrmovements, and often extending down the limbs or anuind the 
 body ; rigidity of the spine and limbs, accompanied by painful cramps and 
 muscular spasms, almost simulating tetanic convulsions ; extreme inper- 
 asthesia, especially of the legs, and increased reflex excitability ; wliilst rapid 
 emaciation from pain and sleeplessness is soon produced. If tiie cdnditun 
 is limited to the spine, it is probably followed by signs of myelitis, \iz , para- 
 
 Elegia, together with bedsores and vesical troubles, and these may lead to a 
 ital issue ; cases, however, are met with which pass into a chronic state, and 
 may more or less recover. If the process also involves the cerebral mem- 
 branes, as in septic cases, the symptoms of difiuse cerebral meningitis are also 
 present, and the patient dies of coma. Treatment in the cases due tn a 
 penetrating injury is of no avail if prevention of the disease by asep.sjs fails 
 In simple cases an icebag should be applied to the spine, the patient remaining 
 in the prone position. Ergot and belladonna may be given internally, and 
 general measures to allay inflammation adopted. The bladder and rectum 
 must be attended to, and bromides and chloral may be administered to »ain 
 sleep. 
 
 (b) Chronic Meningitis is usually localized, and may occur either as an 
 inflammation of the arachnoid and pia mater (leptomeningitis), or be mainlv 
 limited to the dura mater (pachymeningitis). It either originates as a clironic 
 affection, or is the sequela of an acute attack, and is more likely to supervene | 
 in syphilitic individuals. The membranes become hyperaemic and tlncl<ened, 
 and adhesions between the cord and its membranes may occur. Tlie extensions I 
 of pia mater into the cord readily explain the fact that a chronic sclerosing! 
 myelitis is frequently associated with this affection. The Symptoms are tliose 
 of localized pain and rigidity in the back, increased on all movements, and 
 accompanied by shooting pains and hyperaesthesia, and perhaps muscular 
 pains and cramps. The reflexes are usually exaggerated, and vesical com- 
 plications may follow. Treatment consists in prolonged rest, witli counter- 
 irritation in the form of blisters or the button cautery applied to the back, 
 whilst mercury is administered internally. 
 
 Spinal Myelitis. — Inflammation of the spinal cord may follow injuries of tlie I 
 spine, either as a direct consequence of depressed or displaced bone, or from I 
 simple concussion or contusion with haemorrhage ; it may also be caused at a I 
 later date by extension of inflammation from the meninges, or result from com- 
 pression by lymph, pus, granulation or cicatricial tissue, or callus. It maybej 
 acute or chronic. In the former the cord becomes red and softened; thel 
 nerve elements are destroyed, and finally replaced by cicatricial tissue if thel 
 patient live long enough. In chronic cases the connective tissue becomesj 
 thickened, and the nerve structures compressed and disintegrated, wliilstthej 
 meninges are always adherent and thickened. j 
 
 Symptoms. — Acute Myelitis is evidenced by the presence of pain in tlie backj 
 and along the course of the nerves arising from the inflamed area, liyper-l 
 aesthesia, and muscular cramps in the earlier stages, soon followed by paralytici 
 symptoms, if these are not already present as the result of the injury. Thel 
 irritative symptoms are, however, much less marked than in acute meningitis 
 
INJURIES OF THE SPINE 
 
 Cot 
 
 i\v injuries of the j 
 2d bone, or from 
 ;o be caused at a I 
 result from com- 
 -illus. It may be j 
 id softened; the! 
 cial tissue if the! 
 ; tissue becomesi 
 [rated, whilst the! 
 
 pain in the back! 
 led area, byper-f 
 (wed by paralytic! 
 ;he injury. The! 
 icute meningitis I 
 
 The refli'xes vary accordinf,' to the amount of destruction of the cord substance, 
 
 whilst muscular atrophy is not especially rapid, except in tiiose muscles 
 
 (ortnerly supplied from the affected area. The sphincters of both blailder anil 
 1 rectum are paralyzed, causing retention of urine and incontinence of fu'ces ; 
 
 ihe former is almost invariably followed by septic cystitis, especially when the 
 I iriipliic centres in the lumbar enlargement are involved, liedsores are very 
 [liable to be produceil, and may become very extensi\eand serious. I'rinpism 
 1 awl hyperpyrexia are often present when the cervical region is affected. Tiie 
 
 iatal issue is usually due to septic poisoning from the urinary tract, or perhaps 
 [ffomthe bedsores. 
 
 Chronic Myelitis gives rise to a great variety of symptoms, but those most 
 [marked are a graiUially increasing motor weakness, going on to paralysis, 
 
 ;.;dlier with various sensory phenomena ending in anaesthesia, whilst there is 
 
 ir.iible with the bladder and rectum. 
 The treatment of each of these conditions is mainly symptomatic. 
 
 Spinal, or Traumatic, Neurasthenia (.S>;/. ; Railway Spine, Indirect Concus- 
 liionof the Spine). — Cases are not uncommonly met with in which, although 
 here has been no direct injury to the spinal column or cord, and no immediate 
 Isvinptoms of importance, the fact is manifestly demonstrated in various ways 
 lihat considerable commotion and disturbance have been producetl in the 
 InerviHis system. Railway accidents are the most common cause of this con- 
 dition, but it may arise from any jar to the spinal column. The reason why 
 jraiKvav accidents are so often responsible for this state is that the forces 
 lemplnyed are very great, and the collision unexpected, so that the muscles and 
 llnanients are taken at a disadvantage, being off their guard, whilst the shock, 
 lierror, and mental disturbance are also important factors. Ligamentous and 
 Imiiscular lesions — i.e., sprains and strains— are the usual local phenomena 
 iproduced by such accidents. 
 In tbe majority of cases the symptoms are mainly due to excessive irrit- 
 ibilitv and weakness of the spinal and cerebral centres, constituting a condi- 
 |iionofner\e prostration, or Neurasthenia, and the history will usually besome- 
 [nhatof this type : The individual at the time of the accident is thrown from 
 I to side, or severely shaken, but does not lose consciousness, and, although 
 seling somewhat dazed, is able to alight without help, and may even assist 
 lothers. He perhaps continues his journey, and goes to his business, but finds 
 Dthe course of a few hours that his back is painful, his head aching, and that 
 le cannot apply himself to his work. He returns home and goes to bed, 
 pding for his doctor, who will probably prescribe rest and bromides. His 
 Milition remains for a time unaltered ; he complains of pain and tenderness 
 Iver certain regions of the spine, especially the lumbar, and is unable to 
 Valk, or to undertake any serious mental or physical effort, whilst all exces- 
 jive sensory stimuli, such as a bright light or noise, are unusually disturbing. 
 pralgia is often present, whilst the pulse is weak ; the urine may be retained 
 irmay dribble away, and the temperature be for a time subnormal. Accom- 
 bodative asthenopia (or the inability to accommodate for near objects), result- 
 kin a temporary condition of presbyopia, is also a marked feature in many 
 (these cases. All the symptoms are aggravated by mental excitement and 
 isertion, such as are often produced by the necessary interviews with doctors 
 bd solicitors pending the financial compensation by the railway company. 
 '; immediate improvement which often follows the satisfactory settlement of 
 sclaim for damages is not necessarily due to imposture, but may result from 
 le removal of mental tension and anxiety. 
 
 [This condition of neurasthenia may develop immediately after the accident, 
 ian acute condition, the patient lying helpless and prostrate, or more 
 Iten chronically, as in the more common type of cases described above. To 
 I however, is frequently added a considerable element of Hysteria, in the form 
 per of acute attacks of hysterics, or of a chronic unconscious exaggeration 
 |the sensory symptoms. If the patient is examined in the supposed hyper- 
 
602 
 
 .1 MANUAL OF SURGERY 
 
 ^A 
 
 rpsthetic area whilst his attention is distracted, possibly no pain will he com 
 plained of. 
 
 The rin^iinsn is generally favourable, the patient recoverhiK pcrlii tU .ifttrl 
 a piTioil of rest and change, Imt in a few instances perniaiieiit etlcc i^ niav lj«i 
 produced. 
 
 In the Treatment, a good dejil of care is needed to judge rightly when the! 
 period lias arrived for encouraging movement rather than rest, and thus to 
 prevent the patient from developing a condition of chmnic invalidism (^^.jjj 
 in bed is to be recommended at first, bromides given in moderatiiiii,,-ind fomcnJ 
 tations applied locally. Later on, friction with liniments and mas^.i^u should 
 be employed, and when all chance of secondary inflammatory disturli.inceisatl 
 an end, movement should l)e encoif"ged, and change of air advised, whilst 
 course of strychnine and iron may be administered. 
 
 In a few cases, however, fortunately much rarer, the symptdnu nm on 
 into those of a chronic inflammatory condition of the spinal conl and it^ 
 membranes, and these, to which lirichsen formerly applied the tenn Indirecil 
 ConcuBBion, are of the gravest import. In others, nothing may he iioticej 
 by the patient for some weeks or months beyond the fact that he feels i 
 little shaken, and not so capable of doing his work as formerly : hut, at thd 
 same time, he loses flesh, and looks worn and fagged. (Iradually dthei 
 phenomena develop. His brain power is diminished, and any muntal efri 
 causes him to be muddled ; memory fails, the temper is irritahh', and hij 
 sleep disturbed ; the head is often hot. The vision is usually defective 
 and he complains of noises in the ears. The sense of toucli is impaired 
 so that all delicate movements are hindered. The spine is kept ri^idl 
 stiff, the head fixed, and the gait is somewhat unsteady and shamhlinf; ; th| 
 walking powers are much diminished, and going up and down stairs is esn 
 daily difiicult. Motor power in all regions of the body is partly lost; any 
 every modification of sensation may be met with, whilst the reflexes aii 
 increased. The bladder may lose its power of retaining urine for a time, In 
 this is not always a marked symptom ; there is great impairment of both se\uj 
 desire and power. On examining the back, distinct tenderness is felt overon 
 or more spots, especially in the lower cervical, mid-dorsal, and lumbar rej;i(in| 
 In such cases, where the symptoms develop slowly, and remain uiinltered 
 treatment, the Prognosis is most unfavourable, since they are prob. ,, duel 
 inflammatory changes in the cord and brain, and although the patient mi 
 live for j-ears, yet he is permanently crippled, and becomes a confirmed invaliJ 
 Treatment in the earlier stages consists of rest, preferably on a prone couci 
 with counter-irritation, such as blisters, or even the actual cautery, over tJ 
 spine, whilst mercury or iodide of potash, and bark, are administered. Carefj 
 nursing and massage of the limbs, or galvanism, are needed, and warm se| 
 water douches may be most useful. If, however, no improvement follows, t^ 
 patient must be encouraged to get about as best he can, and to jiooutini 
 invalid cliair, so as to maintain the general health, whilst careful attention] 
 directed to the personal hygiene. 
 
 Paraplegia. 
 
 Paraplegia arises in the course of spinal injuries from a variel 
 of causes, which may be classified as follows : 
 
 I. Paraplegia arising immediately after the accident, from : 
 
 (a) Direct concussion without evident lesion, if siichj 
 
 condition be possible ; 
 
 (b) Disintegration of the cord from intramedullary hsmij 
 
 rhage, or from contusion without displacement 
 bone ; 
 
INJURIES OF THE SPINE 
 
 6oj 
 
 from a \anel 
 
 ((•) Displacement of bones, with or without rec(jil, crushinj^ 
 
 the cord ; 
 (d) Penetratinf^ wounds divichnj,' the cord. 
 Ho\vt'\er produced, the same symptoms manifest thcmseKes if 
 •je lesion is complete; reco\ery is alone possible in the first and 
 erliaps in the second K^^^np. whilst in the other forms the para- 
 l^lejjia is maintained by a subsecpient acute transverse myelitis. 
 :, Paraplegia arising after an interval, ftom : 
 
 ((t) Extramedullary spinal luemorrha^^e, if the symptoms 
 show themselves without pyrexia in twenty- four or 
 forty-eight hours ; 
 {!)) The pressure of inHammatory exudations, as in spinal 
 meningitis, when the symptoms are preceded by 
 inflammatory phenomena, and do not appear before 
 se^■enty-two hours at the earliest ; 
 ((•) The pressure of callus or of cicatricial adhesions around 
 the cord and membranes (i.e., peri-pachymeningitis). 
 It is unnecessary to discuss further the special signs and 
 livmptoms accompanying each form ; they have been already 
 liientioned under the appropriate headings. We merely propose 
 lij indicate briefly the effects of a total ttai verse lesion, and then 
 jo describe the results of paraplegia as the > vary with the situa- 
 jiionof the injury. 
 A Total Transverse Lesion, destroy] bj absolutelv .me sugment 
 loithe cord, will result in the following symptom' ; 
 
 Paralysis of the muscular area supplied by the destroyed 
 !>., ,ient, followed by rapi I atrophy, reac'ion of degeneration, and 
 [bss of reflexes in this particu;ar group of muscles. 
 
 2, Paralysis of all the muscles supplied b) ihe segments below 
 laat which has been destroyed. The trophic conditi jn remains 
 |iormal, at any rate, for a time, but when secondary descendin.^ 
 
 ie^eneration in the antero-lateral columns has occurred, the 
 Euscles become contracted, tense, and rigid (late rigidity). The 
 Icondition of the reflexes after a total transverse lesion has been 
 Ifertile source of discussion, but it is now maintained that the deep 
 Rllexes are entirely and permanently lost, whilst the superficial 
 [ellexes, though absent for a time, may reappear. If, however^ a 
 lortion of the cord remains intact, both superficial and deep 
 [eliexes may persist or reappear, and even be exaggerated. 
 
 3. Complete anaesthesia of the sensitive area supplied by the 
 |lestroyed segment, and of all the sensitive areas below\ 
 
 |. A narrow zone of hyperaesthesia is found at the upper level 
 t the anaesthetic area, due to the irritation of the nerve roots at 
 lesite of injury. 
 
 , 5. Vasomotor paralysis combined with trophic disturbances in 
 ft parts which are paralyzed. 
 
 6. Visceral changes, especially in the bladder and rectum. 
 
6o4 
 
 A MANUAL OF SURGERY 
 
 Phenomena of Paraplegia at Different Levels. 
 
 I. At the Upper End of the Sacrum. — Total transverse lesions 
 at this spot are exceedingly rare ; they only involve the cauda 
 equina and cause paralysis of the sacral plexus. The effects 
 produced are : (i.) Paralyvsis of all the muscles of the legs, except 
 those suppHed by the anterior crural nerve, the obturator, and 
 the superior gluteal, whilst the perineal and penile muscles are 
 also affected, (ii.) Anaesthesia of the penis, scrotum, perineum, 
 lower half of the gluteal region, and the whole of the le<'s 
 except the front and outer part of the thigh, supplied by the 
 cutaneous branches of the anterior crural, and the region supplied 
 by the long saphena. (ill.) The bladder and rectum are both 
 shut off from their spinal centres, and hence there will be tem- 
 porary retention of urine, followed by distension with o\erflow, j 
 and incontinence of faeces. The bladder, however, gradual!' i 
 contracts, its walls become thickened, and its capacity steadily 
 diminishes, so that incontinence becomes more and more absolute. 
 f2.\ If the lesion is situated in the D orsi-lumb ar re,f(ion, or 
 pas^s. through the lumbar_jerilargem ent7~ which COTTfispondslo 
 the twelfth dorsal and first lumbar vertebrae, there is complete 
 paralysis of the muscles of both limbs, including those passing to 
 them from the trunk ; total anaesthesia of the legs, gluteal and | 
 perineal regions, and possibly the lower part of the aLdomen; 
 whilst, if the vesical centres are destroyed, there is total paralysis 
 of the bladder, with relaxation of the sphincter, dribbling ofj 
 urine, which early becomes ammoniacal, and cystitis, due to 
 trophic changes; inhajjsjoJjj^eSjescaBe, fjstept^^ 
 the usual result : the recturn and sphincter ani are paralyze!!, 
 causmgTricohlinence~or faeces, the passage oif which is unrecognised | 
 rrbm the anaesthetic condition of the anus. 
 
 3. Injhe Mid-(iorsa,l.jeg.ipn the same phenomena are met with, 
 but to them are added a more extensive region of anaesthesia, 
 limited above by a hyperaesthjetic-zone, which feels like at 
 painful girdle round the waist-; paralysis of the flat abdominal] 
 musclesj, retention of urine, followed by distension with over-j 
 flow, which, however, when asepsis is maintained, may occaj 
 sionally be followed by a state of reflex micturition in which the] 
 patient passes water unconsciously and involuntarily, whenever! 
 there is sufficient present to cause sensory stimuli to ascend toj 
 the undamaged centres.. The abdominal paralysis is a mostj 
 fmportant addition to the gravity of the case, for all straining! 
 movements are thereby prevented, and thus coughing is em-i 
 barrassed and defaecation hindered. The g ases develop ing froauhe 
 stagnant faeces accumulate and cause, distension of the bellyj 
 (mjptPiQriRi>i.)j„aiid ^^^^'^p|jjLI£SI2il^QI'_^'-^By ^^*^ sftrjn^isly inipakedf 
 Tlie diaphragm, moreover, is hindered in its action, since tlia^ 
 
INJURIES OF THE SPINE 
 
 605 
 
 lower ribs cannot be fixed or steadied, and hence its contractions 
 tend to pull thetn in\Yajds»,iristead of increasing the dimensions of 
 the thoracic cavity. 
 
 4- 
 
 In the Cervico-dorsal 
 
 region 
 
 all these phenomena are 
 
 present, but the anaesthesia extends over nearly the whole trunk, 
 and the hypera^sthesia may involve the arms, whilst the inter- 
 costal and spinal muscles are also paralyzed. Respiration has 
 therefore to be carried on by the hampered diaphragm, with the 
 assistance of a few of the accessory respiratory muscles in the 
 neck, and hence is much impeded ; if bronchitis is present, it will 
 prove fatal by asphyxia in a few days from the inability to 
 expectorate. Priapism is a marked feature of cervical paraplegia. 
 
 3. In the Lower Cervical region the arms also become invoK-ed 
 in both the paralysis and anaesthesia, and if the lesion is situated 
 at or above the fourth cervical vertebra, instant death results from 
 paralysis of the phrenics and consequent stoppage of the respira- 
 tion. 
 
 Death from Paraplegia, therefore, may arise from a variety of 
 
 causes and'~at vanous periods. It may be immediate, from 
 
 ['respiratory failure in lesions above the fourth cervical vertebra ; 
 
 or it may occur from accumulation of mucus or pus in the 
 
 I air-passages, Avhen the lesion is in the upper dorsal region ; or it 
 
 ; may be delayed for weeks, or even months, and then is due to 
 
 sloughing of the nates, or septic absorption from an inflamed or 
 
 ulcerated bladder, which is often associated with suppurative 
 
 [pyelonephritis. 
 
 The Prognosis and Treatment both depend on the position and 
 [character of the lesion causing the paraplegia, and on the previous 
 habits and condition of health of the individual. 
 
 Laminectomy. 
 
 By laminectomy, or, as it used to be badly termed, trephining. 
 
 Ithe spine, is meant an operation for th6 removal of the laminae 
 
 land spinous processes of one or more vertebrae, in order to relieve 
 
 Ipressure on the cord, jwhfithej: , due to depressed bone, abscess, 
 
 Igranulation tissue, excessive callus, cicatrices, or tumours. The 
 
 loperation consists in making a longitudinal incision in the middle 
 
 [line of the back, extending to the spinous processes ; the muscular 
 
 and tendinous structures are then cleared from the posterior aspect 
 
 bf the vertebrae as far as the transverse processes, a proceeding 
 
 usu.lly attended with considerable haemorrhage, which can be 
 
 jchfcked, perhaps, better by hot sponge pressure than by attempt- 
 
 fj!,' to secure the individual vessels. The neural arches are then 
 
 jamined for injury, etc., and those which seem to be most 
 feted removed by cutting pliers, Hey's saw, or laminectomy 
 iorceps. The posterior aspect of the membranes of the spinal 
 lord is thus exposed, and the various conditions which may be 
 
 C 
 
6o6 
 
 A MANUAL OF SURGERY 
 
 met with are dealt with according to circumstances. In this 
 place we have merely to consider the use of this operation after 
 injury to the spine. For its employment in other conditions, see 
 Chapter XXI. 
 
 Much controversy has arisen as to the_ value of this o))eratioii 
 .^iJidLthe circumstances unJer 'XyTTicTT'Tr may be justifiable. f| 
 must ^ie reriiehTBered as a fundamental guiding principle that 
 repair is impossible after the spinal cord has been di\ided, or 
 any one segment totally disintegrated, and hence, if it is certain 
 that a total transverse lesion of the cord has been caused by an 
 accident, it.is. absolutely useless to operate. Early and complete 
 disappearance of all the reflexes is a suggestive phenomenon, Imt 
 cannot be looked on as absolute evidence of a total transverse 
 lesion ; if, however, the deep reflexes remain absent for anv 
 length of time, even though some of the superficial ones have 
 reappeared, operation is useless. The presence of the deepil 
 reflexes is always an evidence that at any rate a portion of the I 
 cord remains uninjured, and would encourage one to operate. 
 This question cannot, however, be absolutely settled in the earlv 
 stages of the case, where an exploration is likely to be of most 
 service, and therefore there will always be a certait number of 
 cases in which it will be a matter of doubt as to whether ornoT 
 any benefit will accrue from operation. The final decision under 
 such circumstances will depend on the special predilections and 
 opinions of the surgeon who is in charge of the case, and the 
 general state of the patient. >ll 
 
 Apart from these doubtful cases, the following are generally' 
 admitted as being suitable for operation : (i) Penetrating wounds 
 or fractures with displacement which involve the spine l)elo\vthe1 
 "Hrst lumbar vertebra; thfij^auda eq^uina is present below that level, 
 and not the spinal cord, and it is reasonable totreat it in the samel 
 way as one would treat a single peripheral nerve : (2) When the! 
 injury is mainly limited to ihe JieuraLajxh, which has been driven] 
 in by direct violence : (3) In all cases of bilateral dislocation 
 the cervical spine \vhere the patient is not moribund : (4) 
 paraplegia arises with or without inflammatory symptoms, when] 
 an interval has elapsed since the accident ; the pressure in such] 
 cases may be produced by blood or inflammatory exudations, and! 
 benefit may possibly arise from the operation ; if, however, it isJ 
 due to a total transverse myelitis, no good can follow. (5) When! 
 symptoms of irritation or paralysis supervene at a later date,! 
 from contraction of cicatrices around the cord or its membranesj 
 (peri-pachymeningitis), or from excessive callus formation, lamin- 
 ectomy may be performed with good hopes of a successful result, 
 
CHAPTER XXI. 
 
 k 
 
 DISEASES OF THE SPINE. 
 
 Spina Bifida. 
 
 I By Spina Bifida is meant a condition of imperfect development of 
 some portion of the posterior aspect of the spine, with or without 
 I a similar affectioiT^TtKe^lglnaJ,^^ rriemEranes. 
 
 It must be remembered that the spinal corcT is developed as 
 [a linear involution of the epiblast, t"He edges of this medullary 
 [groove growing up and uniting, so as to include a passage lined 
 [with epithelium, and subsequently known as the central canal. 
 [The cord is gradually separated from the overlying skin by an 
 [i'ltrusion of mesoblastic elements, from which the vertebrae, 
 [together with the spinal muscles and ligaments, are developed. 
 [The ossification of each vertebra originates in three main centres 
 [-one for the body, and one for each half of the neunJ arch, 
 [whilst epiphyses are developed as plates above and below the 
 Ibodv, as also for the transverse and spinous processes. 
 
 The following are the chief forms of spina bifida : 
 
 1. A Myfilocele reRuTts " From non-closure of the primitive 
 bedullary groove. It is characterized by the appearance in the 
 lumbo-sacral region of a raw surface, which consists of the spread- 
 put structures of the spinal cord, at the upper part of which opens 
 {he central canal. The condition is evidently incompatible with 
 pfe, and the children, if they are not stillborn, as is usually the 
 
 do not live beyond a day or two. 
 
 2. A Syring o-myelocele arises from a distension of the central 
 anal of the cord, the posterior portion of which usually remains 
 kdherent to the skin, from which it has never been separated, 
 Iwing to defective development of the mesoblastic tissues. The 
 Ipinal nerves travel round the walls of the cyst in order to find 
 Itieir way to the intervertebral foramina. Trophic phenomena 
 
 ireprobai)ly always a prominent feature of these cases. 
 
 3. A Meningo-myelocele is due to a development of fluid within 
 Jie menibranes which remain adherent to the skin, the spinal cord 
 r nerves of the cauda equina passing down the posterior aspect 
 
\ cl 
 
 60S 
 
 A MANUAL OF SURGERY 
 
 J 
 
 of the cavity as a strap, and the nerves traversing and peiforatinif 
 the sac to reach the intervertebral foramina. 
 
 4. A Meningocele is characterized by a protrusion of the niem. 
 branes, containing cerebro- spinal fluid, through a defect in the 
 posterior walls of the vertebrae, the spinal cord and ner\ es heini; 
 in their normal position. This variety is uncommon. 
 
 Of these forms, the meningo-myelocele is that most frequently 
 seen in living children, although, according to Bland Sutton, from 
 
 whose book on Tumours the above l 
 description is mainly derived, the first | 
 is really the most common. 
 
 Clinical CliaTacters. — A spina bifida 1 
 is recognised by the appearance of a 
 tumour in the middle line of the back! 
 i¥ig. 221), most commonly involviii<r 
 the lower part of the spine ; it may be 
 covered by normal skin, but usually | 
 that over the apex is thin and trans- 
 lucent, and not unfrequently a certain! 
 amount of naevoid tissue is incorpor-J 
 ated in it. On compressing the tumour,] 
 its size can be diminished, and ini 
 infants distension of the anterior fon-j 
 tanelle can be felt, showing that thel 
 sac is filled with cerebro-spinal flui(],[ 
 and there is always a distinct inipulsej 
 on coughing or crying. The defect in 
 the posterior portion of the vertebra 
 is very evident, the edges of the boned 
 Lad aged Sixteen, pro'b'- being felt at the margins of the tumour) 
 ABLY OF THE Meningo- Various other deformlties may bc assoj 
 MYELOCELE Type. (From A ciated with spina bifida, especially 
 Photograph.) hydrocephalus and talipes, which ard 
 
 The swelling had not increased perhaps most common in cases oj 
 muchinsize sincehevvas a syringo-myelocele, whilst perforating 
 child, but distinct trophic < "^ 1 1 • r ^1 .l • 1 1 ' 
 phenomena were being de- "leer, ankylosis of the terminal pha 
 vetoped in the shape of langes of the toes, and other trophii 
 talipes of both feet. phenomena, are also seen. 
 
 The Prognosis of the case dependi 
 mainly on the thickness and character of the overlying skin, I| 
 it is thin, and the cord evidently adherent to it, as sometimes i 
 dicated by a cicatricial depression or dimple, the sac is \ery like! 
 to give way, causing either death from sudden escape of cerebri 
 spinal fluid, or a fatal issue in a few days from septic meningitii 
 If the spina bifida is small, and covered with healthy skin am 
 subcutaneous tissue, the patient may reach adult life, but evei 
 then trophic phenomena may supervene. Occasionally a menii 
 gocele, with only a small aperture of communication with tl 
 
 Fig. 221. — Spina Bifida 
 
DISEASES OF THE SPINE 
 
 609 
 
 spinal canal, may be cured spontaneously by the opening being 
 iiradually occluded. 
 
 " Treatment. — The majority of these cases are best left alone, the 
 tumour being merely guarded from injury by the application of 
 a suitable cap. If the sac is gradually increasing in size, and 
 threatening to give way, operative interference is absolutely 
 necessary if life is to be saved. Acupuncture through the 
 thinned integument, the cerebro-spinal fluid being allowed to 
 drain away subsequently into an antiseptic dressing, or tapping 
 through the healthier integument around the base, repeated 
 several times, and followed by compression, may lead to a cure 
 in favourable cases. Statistics, however, go to prove that the 
 best results are obtained by tapping, followed by the injectio 1 of 
 Morton's fluid (1^ : iodi, grs. x. ; pot. iod., grs. xxx. ; glycerinum, 
 ad ^i.). A small quantity of the cerebro-spinal fluid is withdrawn, 
 and then from half a drachm to a drachm of the iodine solution is 
 introduced. It diffuses itself slowly, and tends to act locally, so 
 that if the child is kept quiet, and only sefiii-recumbent, its effect 
 will be limited to the sac of the spina bifida and its neighbourhood. 
 In some cases persistent leakage may follow this treatment, and 
 such is dealt with by means of a firm antiseptic compress ; in 
 many the injection needs to be repeated more than once. 
 
 Of late years treatment by operation has been coming more 
 
 and more into vogue, thanks largely to the able advocacy of 
 
 Mr. Mayo Robson, of Leeds. Naturally, ii is chiefly applicable 
 
 in the meningocele type, and infants or those suffering from 
 
 trophic phenomena do not stand it well. An incision is made 
 
 I over the sac, either in the middle line if it is certain that the cord 
 
 j is not there, or to one side, if it is. The child shoidd be kept with 
 
 I the head low when the sac is opened, so as to limit, as far as 
 
 possible, the loss of cerebro-spinal fluid. In a meningocele, the 
 
 protruding membranes are cut away, the wound in them is very 
 
 {carefully sutured, and the spinal muscles drawn together by deep 
 
 stitches, so as to create an extra protective barrier, in addition to 
 
 [the skin and subcutaneous tissues. When the cord runs down 
 
 the back of the sac, it is freed by incisions on either side, and if 
 
 itcannot be separated from the skin, the whole strip is replaced in 
 
 Ithe vertebral canal, the membranes are closed over it, and finally 
 
 jthe muscles and skin are united by rows of sutures. The results 
 
 [obtained by this means have been encouraging, and in suitable 
 
 leases operation may be recommended with some prospect of 
 
 Isuccess. 
 
 Spina Bifida Occulta is the term applied to a condition in which 
 Ithe posterior portion of the vertebrae is absent, but without any 
 jprotrusion of the cord or its membranes. The overlying skin 
 y be cicatricial in character, or a large growth of hair may 
 rise from it ; occasionally a lipoma develops in this situation, 
 
 39 
 
6io 
 
 A MANUAL OF SURGERY 
 
 and by its downward growth compresses the spinal cord, causing; 
 paraplegia. Unless such a condition is present, spina bifida 
 occulta calls for no treatment, but an exploratory operation 
 should always be undertaken when nervous phenomena supervene, 
 
 Congenital Sacral Tumours. 
 
 Other congenital conditions of the lower end of the spine are 
 described as congenital sacral or coccygeal tumours. The majoritv 
 of these arise from what is known to embryologists as the ncurcntcru 
 canal. In early foetal life it is supposed that the neural and 
 alimentary canals are continuous, the passage of communication 
 being known by the above name. Ordinarily, it entirely dis- 
 appears after the union of the proctodeum with the intestine, but 
 evidences of its existence are occasionally met with, either in the 
 form of a cicatricial dimple adherent to the tip of the coccyx [post- 
 anal dimple), or as one of the following conditions : 
 
 (i.) A dermoid cyst, containing the usual mixture of sebaceous 
 material and epithelial cells, and often a tuft of hair ; it develops 
 in the space between the rectum and coccyx, and may either 
 project posteriorly, below the coccyx, or open into the rectum; 
 the tuft of hair may thus find its way out of the anus. In a case 
 recently under the care of Mr. W. Turner, at Westminster 
 Hospital, it was actually connected with the spinal meninges, 
 removal involving the loss of cerebro-spinal fluid. 
 
 (ii.) A tumour of a glandular or adenomatous nature is occa- 
 sionally found in the same region. It is characterized micro- j 
 scopically by the existence of alveoli, lined by cuboidal epithelium. 
 held together by connective tissue ; it may attain a large size, 
 but is quite innocent. Such growths are termed by Mr. B. Sutton 
 thyroid-devmoids, but a better name would be a congenital adenoma of 
 the post-anal gut. 
 
 Various other tumours are met with in infants in this region, 
 and the same title of congenital sacral or coccygeal tumour has 
 sometimes been applied to them : 
 
 {a) A spina bifida of the meningocele type, which may com- 
 municate with the subdural space, or may have been shut off In j 
 a natural process of cure. 
 
 [b) A lipoma may also form here, and in some cases has simu- 
 lated by its shape a caudal appendage. 
 
 {c) A partially developed foetus may be met with, enclosed! 
 within the subcutaneous tissues of the sacral region, and is knownj 
 as a teratoma. 
 
 (d) Sarcoma and cystic hygroma have also been observed. 
 
 The conditions are so exceedingly rare that it is unnecessary tol 
 enter into details of treatment, which is conducted in accordancej 
 with general -prifKiiiplag ,. «.,. 
 
DISEASES OF THE SPINE 
 
 6ii 
 
 rd, causing 
 pina Inftda 
 r operation 
 L supervene. 
 
 le spine au- 
 rhe iiuijority 
 he nciircntmi 
 neural and 
 nmunication 
 entirely dis- 
 .ntestine, but 
 either in the 
 coccyx {post- 
 
 of sebaceous 
 ; it develops 
 d may either 
 , the rectum; 
 xs. In a case 
 Westminster 
 nal meninges, 
 
 lature is occa- 
 erized micro- 
 al epithelium, 
 a large size, 
 Mr. B. Sutton 
 lital adenomn of 
 
 L this region, 
 lal tumour has 
 
 Jch may com- 
 sen shut off hy ] 
 
 Lses has simu- 
 
 I with, enclosed! 
 ^, and is kno\vn| 
 
 served. 
 
 unnecessary tol 
 
 in accordance! 
 
 Inflammatory Affections of the Spine. 
 
 Several distinct forms of inflammatory mischief are met in 
 the spine, and must be described here, viz., acute osteomyelitis 
 of the vertebrae, tuberculous disease (by far the most important 
 on account of its great frecjuency), syphilitic disease, rheumatic 
 spondylitis, and osteo-arthritis (or spondylitis deformans). 
 
 I. Acute Osteomyelitis of the Spine is an uncommon affection, 
 which has only recently been recognised. It is due to the same 
 causes as similar disease elsewhere, viz., infection with pyogenic 
 organisms in an individual of low germicidal power. It is charac- 
 terized by severe pain in a localized portion of the back, and fever ; 
 deformity is not a marked feature, since massive necrosis occurs 
 and not a gradually destructive caries. Abscesses form early, and 
 there is great danger of an extension of the inflammation to the 
 spinal meninges leading to a fatal issue. The prognosis is ex- 
 tremely bad, owing to this latter complication, and the only 
 possihle treatment consists in early incisions to give exit to the 
 pus. Sequestra can easily be removed from the back of vertebite, 
 
 t from the front only in the lumbar and cervical regions. 
 
 'S 
 
 II. Tuberculous Disease of the Spine or Spinal Caries {Syn. : Pott's 
 Disease, Angular Curvature). — The ab o ve names are applied to a 
 condition due to t uberculous disease ofthe vertebr ae, o riginaFin g; 
 ahnost in\ arjabl y in their bodies ; as aj;e sult these"structures are 
 lao ie or less destroyed, as also the neighbouring mtervertebrai 
 di scs^ leading/to the jojcallgd^ ^ngu lat cuiVi ature' Of the spiiie T 
 This latter title is most misleading and inaccurate, and should l)e 
 discontinued, since the deformity, though sometimes angular in 
 character, can scarcely partake of the nature of an angle and a 
 i curve at the same time. The tqrm * Pott's disease ' is deri\ed 
 [ from Percival Pott, who first accurately described it in I779 . 
 
 jEtiolo gy. — The causes of tuberculous disease of the spine are 
 [much the same as those of tuberculous affections elsewhere, viz. : 
 it affects an individual predisposed to the development of tuber- 
 iculous disease either by some inherited tendency, or by impair- 
 Iment of his general health as from some preceding illness, or 
 [exposure to defective sanitary conditions. The actual deposit of 
 [tuhercle is probably determined by some injury which, though 
 
 li!,'ht and perhaps not noticed at the time, is sufificient to cause 
 focal diminution of vitality, thereby constituting a favourable 
 nidus in which the Bac. tuberculosis can develop. It is most fre- 
 quently met with in children, but may arise at any age, and 
 mally hi either sex. Sprains and strains of the vertebral column, 
 prof the soft parts attached thereto, are the local lesions mainly 
 tesponsible for it. Any part of the spinal colun^n may he involved. 
 [ut^the lower dorsk l is by tar the commonest. The cervical 
 
 39—2 
 
6l2 
 
 A MANUAL OF SURGERY 
 
 m 
 
 •jif.ia' ■.■ fi? 
 
 region is rarely attacked, except in children, whilst in adults the 
 dorsi -lumbar vertebra are the favourite seat. 
 
 Patholoii;ical History. — The actual changes in the bones in Ptjtts 
 disease are exactly similar in nature to those we have alroadv 
 described as occurring generally in cancellous bone (p. 47^). anil 
 
 no special description need 
 be given here. The disease 
 starts in one of two jilaces, 
 either under the periosteum 
 cm^rrilTg tne anterior sur- 
 face of the vertebra' (this 
 most often in adults), or at 
 the line of junction of the 
 upper or lower plate-like 
 epiphyses with the body, the 
 usual situation in children. 
 In the former case the suh- 
 periosteal tuberculous de- 
 posit early extends to the 
 subjacent bone, and spreads 
 to neighbouring vertebra, 
 either along the under sur 
 face of the anterior common 
 ligament, or through the 
 intervertebral discs, which 
 are disintegrated by the 
 process. When it spreads 
 along the anterior common 
 ligament (Fig. 222), the 
 disease may be very exten 
 sive, body after body beinj^ 
 eroded, and the interverte- 
 bral discs suffering evenj 
 more than the bones. Inj 
 such a case the deformityj 
 produced is not stricthi 
 angular, but rather of 
 general kyphotic nature. Occasionally, however, the diseas e 
 s tarts simultane ously in many fo ci,^o th at the b odies o t seven 
 vertebrgp herr)rrie_-pitteH and r^rin^is, wit hoiit p roducing generj 
 destruction^ In other cases the process is limited to ' 
 and intervertebral discs of two adjacent vertebrae, the periosteur 
 being but little affected. This variety is, perhaps, most coniiiK 
 in the lumbar region, where the bodies of the vertebrae are lar« 
 and permit a limiting zone of sclerosed tissue to form; it 
 also not uncommon in this situation to find definite sequestj 
 <Fig. 223). 
 
 The terms already described as characteristic of the difiere 
 
 Fig. 222.— TuKEKCULOUs Disease OF Spine, 
 SHOWING Destruction of the Bodies 
 OF THE Vertebr.1-:, and Abscess For- 
 mation beneath the Anterior Common 
 Ligament. (Modified from Specimen 
 IN College of Surgeons' Museum.) 
 
 'e slighi 
 'ressiire 
 
DISEASES OF THE SPINE 
 
 613 
 
 adulls the 
 
 BS in Pott's 
 ,ve already 
 5. 47S), and 
 iption need 
 The disease 
 two places, 
 ; peri osteuiu 
 nterior sur- 
 irtebr-cc (this 
 .dults), or at 
 iction of the 
 er plate-like 
 the body, the 
 1 in children. 
 case the sub- 
 aerculous de- 
 xtends to tin- 
 le, and spread> 
 ring vertehra, 
 the under sur- 
 tterior common 
 through tile 
 
 forms of caries may be applied to the varying conditions met with 
 in this disease. Thus, when it runs its course without suppura- 
 tion, cayies sicca is said to be present ; if pus forms, as is so 
 trefiucntly the case, cayies siippuyativa ; and when sequestra occur, 
 iitrics necyotica. 
 
 Cure is effected by the bodies of the vertebrae falHng together 
 and becoming ankylosed, so that a deformed and immobile condi- 
 lion of the affected portion of the spine is often the best result that 
 can be anticipated. The new bone thus formed becomes in 
 time sclerosed and very dense, and the synostosis also involves 
 the spines and laminae. Occasionally, the tuberculous process 
 extends backwards through the body of the bone so as to im- 
 plicate the posterior common ligament, and paralytic or other 
 symptoms may then arise from pressure on the cord. 
 
 I the periosteul 
 |s, most coninij 
 Ttebree are lata 
 I to form; 'M 
 lefinite sequestl 
 
 of the differej 
 
 Fig. 223. — Tuberculous Disease of Two Lumbar Vertebr.'e, showing 
 seyuestrum on the anterior aspect, and lateral thickening 
 preventing angular deformity. (college of surgeons" museum.) 
 
 Rare cases have been described in which the disease mainly 
 [affected the sides of the vertebrae, as a result of which lateral 
 deformity occurred ; and still more uncommon are those in wdiich 
 [the posterior portion of the neural arches is primarily involved. 
 
 The Signs and Symptoms produced by tuberculous caries of the 
 [vertebrae vary considerably in different situations, but for practical 
 I purposes may be described under the following live headings : 
 
 I. Pain is a constant and invariable accompaniment of the 
 Idisease, although in the early stages it may not be specially 
 Iprominent, being only elicited by careful examination. It is of 
 Itwo main types, the local and the referred. Local pain is more or 
 jless similar in character to that always experienced in disease of 
 jbones, although, owing to the cancellous nature of the osseous 
 [tissue involved, there is often but little tension, and hence it may 
 |be slight. It can, however, be elicited in all cases, either by 
 pressure or percussion over the spines, or perhaps more effectually 
 
mm 
 
 614 
 
 A MANUAL OF SURGERY 
 
 by pressing upon the transverse processes, so as to induce njtation 
 of the vertebral bodies one on another. Movements of the spine, 
 bending or twisting, are similarly painful, whilst the same result 
 can be brought about by jarring the spine, as by a blow on the 
 head or nates. The old plan of testing for pain by means of a 
 hot sponge applied over the back is comparatively useless in this 
 disease. Referred pain is produced by pressure upon, or irritation 
 of, the roots of the nerves as they emerge from the intervertebral 
 foramina ; consequently it is always noticed in those parts of the 
 body which are supplied with sensation by the nerves issuin),; 
 from the spinal canal in the diseased area. If the lumbar region 
 is affected, the pain is referred down the legs ; in the dorsi- lumbar 
 region it may follow the last dorsal nerve, and be noticed in tht 
 lower part of the abdomen, or in the gluteal region ; in the lower 
 dorsal region pain is referred to the epigastrium, children who are 
 unable to differentiate its precise nature complaining of ' belly- 
 ache ' ; in the upper dorsal and lower cervical regions the pain 
 extends into the arms, whilst in the upper cervical region neuralgia 
 follows the course of the cutaneous branches of the cervical nerves. 
 Thus, if the third and fourth cervical nerves are involved, pain 
 is felt along the course of the descending sternal, clavicular and 
 acromial branches ; if the second and third are implicated, pain 
 may be confined to the great auricular and occipital nerves ; it 
 the atlas and axis are affected, the neuralgic pain, if any, follows 
 the occipital branches. 
 
 2. Rigidity of the spine is a constant accompaniment of I'ott's j 
 disease. In the early stages it results from muscular spasm, the 
 object being to fix and immobilize the painful part. If the lower 
 portion of the spine is involved, the back is held stiff and straight, 
 the patient abstaining from all movements which would bend or 
 stretch it. Thus, in order to pick up an object from the floor, the 
 knees and hips are flexed, and the patient gradually lets himself 
 down with an absolutely rigid back into a sitting or squatting 
 posture ; the body is raised in a similar manner by resting the 
 hands upon the thighs, the patient, as it were, climbing with 
 extended arms up his own legs. In a child rigidity in the dorsi- 
 lumbar region can be demonstrated by laying him on his face, 
 grasping the ankles, and ascertaining the amount of movement 
 of the spine at that region by lifting the legs from the table, 
 and also by moving them from side to side. In a healthy child 
 the legs can be elevated, and the spine bent back in the dorsi- 
 lumbar region, nearly to an angle of sixty degrees ; whilst lateral i 
 mobility to the extent of thirty or forty degrees on either side of 
 the median line is obtainable. When caries is present, neither 1 
 of these movements can be made without including the thorax [ 
 and dorsal spine. In cervical caries the patient steadies the head, 
 and at the same time raises the shoulders by the help of the! 
 trapezius and sterno-mastoid muscles, whilst the chin is often] 
 
ves issuin'; 
 
 DISEASES OF THE SPINE 
 
 615 
 
 supported by one hand, and the patient twists his whole body in 
 order to look sideways. 
 
 In the later stages of the disease, when repair is taking place, 
 „r has occurred, rigidity of the spine is due to osseous ankylosis. 
 After a cure has been established, compensatory movements of 
 other portions of the spine mask, to a certain degree, the localized 
 ri!,'idity. 
 
 3. Deformity, the result of Nature's method of repair by means 
 of osseous ankylosis, is necessarily present in almost all instances, 
 although in a few cases, taken in hand early, it is possible that 
 
 :<£)** 
 
 Bl 
 
 liG. 224— Diagrams to illustrate Deformities in Spinal Curvature. 
 
 (After Noble Smith.) 
 
 In .V tlie result of the bodies falling together to form a wedge-shaped mass is 
 seen in the anterior displacement of the upper half of the spine ; in B the 
 compensatory curves utilized by Nature to maintain the erect posture are 
 indicated ; in C the same process is seen in an exaggerated stage. 
 
 [recovery may occur without it. The amount and character of 
 I the deformity depend on a variety of circumstances, and perhaps 
 
 most of all upon the number of vertebrae affected. Where only 
 itwo l)ones are involved, a true angular deformity may result, 
 
 the body of the upper vertebra being welded to that of the 
 [lower, so as to produce a wedge-like mass (Fig. 224, A), the 
 
 surfaces of which are inclined to one another at an angle ; com- 
 Ipensatory curves of the spine elsewhere enable the patient to 
 lassuine the erect posture (Fig. 224, B). In the lumbar region, 
 I'vhere the affection is often limited to a part of two vertebrae, 
 Ithere is usually little or no displacement, the disease being limited 
 [to the centres of the bones, so that the sides may escape alto- 
 
6i6 
 
 A MANUAL OF SURGERY 
 
 Fig. 225. — Well-marked 
 Angular Curvature 
 AS A Kksult of Pott's 
 Disease. 
 
 ^ether, and preserve the integrity of the spinal column ; when a 
 distinct projection of the spine is present, the portion ot hone 
 which appears niost prominent is the spinous process of the lower 
 of the vertebrae. When a large number of vertebra* are altt( ted, 
 
 as is connnon in the dorsal rej^ion, tin 
 cUr\ ature is never angular, but the whole 
 region becomes bent forwards, and ky 
 photic in type, or even almost rectaiii,'ular. 
 Owing to the oblifjuity and length ot tlie 
 spinous processes of the dorsal vertebra, 
 the projection, even when only two hones 
 are involved, is very considerable ; in the 
 latter case the spinous process of the 
 upper vertebra, by becoming horizontal, 
 is the more prominent. In the < ervical 
 region there is rarely much detotniity, 
 owing to the small size of the vertebra', 
 and to the stunted shape and deep posi 
 tion of the spinous processes ; if, liowcn er, 
 several bones are involved, the bead may 
 be carried forwards, together with the 
 upper part of the spine. 
 Secondary changes in the shape of the thorax necessarily ac 
 company the more advanced cases of caries in the dorsal rejfion. 
 the sternum becoming convex anteriorly so as to compensate for 
 the diminished vertical measurement of the thorax, and the ribs 
 crowded together to such an extent as to almost obliterate tht 
 intercostal spaces. The lower floating ribs may, however, retain 
 their normal position, and thus a horizontal groove may be pro- 
 duced corresponding to the line of the tenth rib. In such cass 
 the patient becomes much stunted in growth, and dwarfed, con- 
 stituting the typical ' hunchback ' (Fig. 225). 
 
 4. Abscess is the most serious result of spinal disease, for, owin;; 
 to its deep origin, it often attains considerable dimensions before 
 it is recognised or treated, whilst it is usually impossible to deal 
 with the causative lesion in the bones, and if once the cavity is 
 allowed to become septic, an exceedingly grave complication is 
 introduced into the case, which may even determine a fatal issue. 
 The pus collects originally on the anterior aspect of the vertebra', 
 beneath the anterior common ligament (Fig, 222), which may be 
 stripped from the bones for a considerable distance, owing to 
 the tension wuthin the abscess cavity. It thence finds its way 
 to the sides of the bodies after perforating the ligament, and 
 burrows in various directions, according to the portion of the 
 spine involved. 
 
 In the cervical region a chronic retropharyngeal abscess is first 
 formed ; it pushes the posterior pharyngeal wall forwards, and 
 may be detected from the mouth as an elastic fluctuating swelling, 
 
DISEASES 01' THE SPINE 
 
 617 
 
 uhicli, by its size, often leads to some difliculty in swallowing,' and 
 brtatliinf;, whilst (i-denia of the glottis may be induced. Left to 
 itself, \;irioiis courses are open to it: i. The abscess may burst 
 mci disch arge jnto the pharynx, the cavity nece ssarily becoming 
 j'eplic, an d the o sseous Tesion t hus aggravated . 2. I t may travel 
 (low m\' ;i cdaltiidlliMjJie c esophagus mto the posterior tne diastinu ni, 
 and thence extend in the same direction as abscessesTn tlie dorsal 
 Kjiion. 3. More often the pus fuids its way to the side of the 
 neck, being guided to the posterior triangle by the prexcrtebral 
 fascia, behind which it is situated; less fretjuently it pierces thi'^ 
 fascia, and presents in the anterior triangle. 4. In the lower part 
 ufthe lU'ck, it may spread under the clavicle into the axilla, being 
 directed by the same fascia, which in this region passes down- 
 wards behind the subclavian trunks, and forms the posterior wall 
 of the sheath of the axillary vessels. 
 
 In the dorsal region, the abscess starts in the same way in front 
 (if the vertebrae, and may thence extend as follows: i. Most 
 frequently it passes backwards between the vertebral ends of the 
 ribs to form a dorsal abscess, burrowing along the course of the 
 posterior branches of the intercostal nerves and arteries, and 
 ring a fluctuating swelling, 3 or 4 inches from the spinous pro- 
 ^ ses, with an impulse on coughing. 2. It may extend between 
 the ribs and the parietal pleura along the anterior branches of the 
 intercostal vessels, coming to the surface at the spot where the 
 lateral cutaneous branches are given off. Tuberculous disease of 
 the ribs, leading to caries or necrosis, or even a localized em- 
 pyeijia, may be induced in such cases. 3. Very rarely the abscess 
 may tra\el up to the neck, pointing behind the sterno-mastoid 
 iiuiscle. 4. Not uncommonly, however, it works its way down- 
 wards, passing under the ligamentum arcuatum internum of the 
 diaphragm, thus entering the psoas sheath, and giving rise to a 
 psoas ai)scess. 
 
 In disease of the dorsi-lumbar or lumbar regions, either a 
 hnnhar or a psoas abscess may result. A himhay abscess is due to 
 the passage backwards of the pus along the posterior branches of 
 the lumbar vessels and nerves to the outer border of the erector 
 spins, and usually presents superficially in Petit's triangle — i.e., 
 hetween the adjacent borders of the latissimus dorsi and external 
 oblique muscles. It there forms a tense fluctuating swelling, 
 wi.h an impulse on coughing. A psoas abscess lies within the 
 sheath of the psoas muscle, the pus being usually superficial to 
 tlie muscular fibres, some of which are probably destroyed. It 
 piisses downwards, giving rise to a fusiform enlargement, deeply 
 placed in the back of the abdomen ; at the brim of the pelvis, it 
 usually burrows outwards under the fascia iliaca to form a tense 
 rounded swelling in the iliac fossa (Fig. 6 ; p. 36). It thence 
 travels under Poupart's ligament, behind and external to the 
 common femoral vessels, being constricted at this spot so as to 
 
6i8 
 
 A MANUAL OF SURGERY 
 
 form a narrow neck. The sac then expands behind the common 
 femoral sheath, the vessels being often displaced forwards, and 
 the vein flattened out and compressed. Thence passing aloni,' 
 the tendon of the ilio-psoas, to the neighbourhood of the lesser 
 trochanter, the abscess comes into relation with the internal 
 circumflex artery, and usually points at or near to the saphenou:. 
 opening to the inner side of the main vessels. It may, however, 
 follow the different branches of the internal circumflex amonfjst 
 the adductor muscles, forming a large swelling on the inner side 
 of the thigh, displacing these structures, or it may even travel 
 along its main trunk behind the neck of the femur to reach the 
 surface behind the great trochanter. In other rare cases the 
 abscess has been known to extend down the leg, and has even 
 been evacuated by the side of the tendo Achillis. Occasionally, 
 the pus finds its way down into the pelvis instead of passing under 
 Poupart's ligament, and then points in the ischio-rectal fossa, or 
 possibly burrows through the sacro-sciatic foramen. 
 
 The constitutional disturbance associated with the formation of 
 these abscesses is usually but slight ; perhaps there is a small rise 
 of temperature, but if, as occasionally happens, ordinary pyogenic 
 organisms find their way into the sac from within the body, this 
 may become more marked. As they come to the surface, con- 
 siderable pain may be experienced from the tension and irritation 
 of the soft parts, and fever of a hectic type is induced. 
 
 (5^ Parapleg ia is fortunately not a common result in tuberculous 
 cartes ot the^ spine, only occurring in the worst cases, or in those 
 where treatment has been neglected. It is scarcely ever due to 
 the acuteness of the curve, since the spinal cord is almost always 
 efficiently protected by Nature. It has been known to result from 
 a fracture of the spine, the integrity of which has been weakened 
 by the inflammatory process, but is usually caused by an extension 
 backwards of the disease, so that a nodule or button of tuberculous | 
 material forms beneath the posterior common ligament, or pusht 
 through it, compressing the cord against the laminae, and actuallyj 
 invading the dura mater. It occasionally originates in the pressiirej 
 induced by an abscess, which extends backwards into the spinalj 
 canal. 
 
 The effect produced on the cord varies with the rapidity and! 
 acuteness of the process. When the pressure is rapidly developed/ 
 a subacute myelitis ensues, but more frequently it is of a chronicj 
 or sclerosing type. The cord is then found to be constricted or in' 
 dented by the tuberculous mass, and perhaps considerably reduced^ 
 in size ; its texture is firmer than normal, and the colour greyish 
 The onset of symptoms may be suddenly induced by hannorrhad 
 or displacement of bone, but is more usually gradual. The dorsa 
 region (about the eighth vertebra) is that most often in\olvedj 
 since there is plenty of space in the cervical region, and in th^ 
 lumbar the cord has broken up into the cauda equina. Statistic 
 
DISEASES OF THE SPINE 
 
 619 
 
 seem to indicate that paraplegic phenomena occur in about one 
 out of every thirteen cases. 
 
 The symptoms arising from pressure on the cord must be dis- 
 tinguished from those due to irritation of, or pressure on, the 
 nerve roots. The latter causes neuralgic pain along the course of 
 some particular nerve, possibly in the later stages associated with 
 anasthesia {anesthesia dolorosa), or a limited motor weakness if the 
 anterior roots are involved. In compression of the cord, motor 
 ohenomena are more evident than sensory, since the sensory 
 track Ues towards the centre of the cord, and so is more protected 
 uoiii injury. At first there is some dragging of the toes on walk- 
 ing, and loss of power in the legs, combined usually with neuralgia, 
 weakness of the sphincters, and exaggeration of the reflexes. 
 Later on the paralysis becomes complete, and, as degeneration of 
 the cord follows, secondary contractions and rigidity occur, and 
 [the reflexes diminish. Absolute incontinence sometimes super- 
 venes, the bladder emptying itself periodically and involuntarily, 
 or the urine trickling away continually from either a full or empty 
 [viscus. 
 
 Special mention must be made here of a grave complication 
 j only occurring in the upper cervical region, and which may result 
 [in sudden death. Tuberculous disease of the upper two vertebra* 
 [usually involves, even if it does not originate in, the large articu- 
 iiations on either side of the atlas ; if these joints become dis- 
 organized, displacement may occur at any moment, and in this 
 [ivay the occiput slips forwards upon the atlas, and may lead to 
 gradual or sudden compression of the cord and consequent death. 
 [The disease sometimes spreads to the body of the axis, and by 
 Jthis means the odontoid process becomes detached, or the trans- 
 |erse ligament gives way ; in either case, rhe weight of the head 
 arries the arch of the atlas forwards, and death ensues from com- 
 pression of the medulla. 
 Course of the Case and Prognosis. — Left to itself, the disease 
 ilways progresses more or less steadily, the bone lesion becoming 
 pdually more marked, and abscesses tending to develop. If 
 [leated efilciently, and taken in hand early, repair by ankylosis 
 flay he confidently expected. Even when an abscess forms, 
 Irolonged rest may lead to its disappearance, the fluid part of 
 |e pus being absorbed, and the solid elements becoming in- 
 jpissated and dry, forming a putty-like mass lying on the front 
 the vertebral column ; this may subsequently break down, 
 pobably owing to infection with pyogenic cocci, constituting 
 li^.i is known as a residual abscess. Should, however, the 
 pscess burst or be opened, and become septic, symptoms of 
 pic fever and amyloid disease are almost certain to develop, 
 Y the patient is sooner or later exhausted by the discharge, 
 P dies from asthenia. If dealt with judiciously, and sepsis 
 joided, the abscesses ir ay be cured, and if at the same time 
 
620 
 
 A MANUAL OF SURGERY 
 
 the spine is kept at rest, the lesion in the bones is able to con- 
 solidate. The onset of paraplegia, again, must not be looked on 
 as rendering the case hopeless, since with prolonged rest the 
 paralytic phenomena can entirely disappear. Septic cystitis and j 
 bedsores often arise as complications, and, if allowed to proj^ress, 
 cause the death of the patient. Occasionally, as a result of the! 
 implication of the spinal canal, diffuse meningitis follows, ieadin"! 
 to a rapidly fatal termination. As in tuberculous disease else^l 
 where, the patient also runs the risk of acute miliary tuberl 
 culosis, whilst other organs, e.g., the lungs, brain, or kidney, niavl 
 become affected. In spite of these possibilities, however, tliel 
 prognosis is good as regards life in cases free from complications! 
 and where suitable treatment has been adopted. 
 
 The Diagnosis of spinal caries is never a matter of difficultyl 
 when the characteristic deformity exists, but in the early sta"esf 
 when the displacement is not evident, or if there is only a very 
 slight prominence of the spinous processes, it is likely to be misi 
 taken for a simple rachitic or statical curve ; whilst if neuraljiij 
 pain 'is a prominent symptom, it may possibly be looked on as; 
 case of spinal or intercostal neuralgia, or as rheumatism, or even hi 
 ascribed to renal affections. Tumours of the spine, such as cancetf 
 or hydatid cysts, syphilitic disease, and aneurismal erosion, ala 
 produce symptoms somewhat resembling those of spinal carieJ 
 and in adults it may be impossible to determine from the locJ 
 phenomena alone which of these conditions is present, althouJ 
 a careful consideration of the general history and of the onset 
 the symptoms may throw some light upon the case. Frequent^ 
 the course of the disease and the reaction to treatment must I 
 mainly relied on in forming a diagnosis. The spine should ahvaJ 
 be examined from before and from behind, and pain on pressu 
 over the transverse processes and rigidity of the back are til 
 symptoms on which most stress should be laid. 
 
 The diagnosis of the abscesses connected with spinal carij 
 is sometimes not devoid of difficulty, especially when they pol 
 in the groin or the lumbar region, since similar collections of 
 may arise from a variety of other causes, (a) i\. pennej)bi 
 abscess is recognised by the association or pre-existence of syiif 
 toms of renal disease, whilst a spinal lesion may be absent. 
 course, both conditions may be present in the same individij 
 and the diagnosis can then only be made by an exploration of I 
 abscess cavity, (b) An empyema occasionally points in the loin 
 even in the groin, but should be recognised by an exaniinatioii 
 the thorax, (c) A chronic abscess due to appendicitis may prea 
 very similar signs to those of a deep-seated abscess in the I 
 psoas region on the right side, if it has not extended bel 
 Poupart's ligament. Careful examination, however, will dein 
 strate the upward extension of the abscess towards the spind 
 the latter case, whilst the previous history will differ consij 
 
DISEASES OF THE SPINE 
 
 621 
 
 , ji,iy in the two conditions. The character of the pus is, more- 
 
 jover, a distinctive element, in that it has almost always an offen- 
 
 Uive smell when due to appendicitis, on account of the presence of 
 
 ihe5rt^- coli communis, (d) An iliac abscess may arise from a variety 
 
 0! conditions other than spinal disease, ^.g-., necrosis or caries of 
 
 the ilium, or cellulitis in the tissues under the fascia iliaca. It is 
 
 reco'^nised by being, as a rule, more distinctly limited in extent 
 
 than an ilio-psoas abscess, and by the absence of symptoms of 
 
 hpinal disease, (e) Abscesses arising in connection with hip disease 
 
 occasionally point in the groin, but are easily distinguished from 
 
 a psoas abscess by not extending upwards along the course of 
 
 the psoas muscle, and by the evident signs of hip disease which 
 
 [are always present. (/) Diffused or ruptuyed ane 11 y ism of the iliac 
 
 jartery may give rise to considerable difficulty in diagnosis, since 
 
 la non-pulsating tumour in the course of the muscle is sometimes 
 
 Inroduced. The preceding history, the absence of fluctuation, the 
 
 Idtma and congestion of the leg, the interference with the pulse, 
 
 land the rapid increase of the tumour, should indicate the nature 
 
 lof the case, (g) The diagnosis of abscess from Jcmoyal hernia is 
 
 Ijiven elsewhere. 
 
 I Treatment. — The great essential in the treatment of spinal 
 [caries is absolute immobilization, perhaps associated with the 
 Bpplication of some mechanical support, which takes the weight 
 lithe body from the seat of disease. This may be effected in any 
 jol'the following ways : 
 
 [a) By the Adoption of the Recumbent Postiiye. — The patient is kept 
 
 [nbed either in the prone or supine position, until the pain in the 
 
 lack has diminished to such an extent as to warrant the applica- 
 
 of a spinal support. In any but the youngest children the 
 
 krone position on a suitably constructed couch may be adopted 
 
 Vith advantage, since by this means the weight of the body is 
 
 pore completely taken off the spine, whilst local applications, 
 
 luch as blisters, or even the actual cautery, can be made. In 
 
 py cases it may be advisable to combine treatment in this 
 
 ishion with the application of a removable poroplastic or leather 
 
 binal jacket. If thought desirable, extension by weight and 
 
 |iilley attached to the legs, as described at p. 444, may also 
 
 employed in these patients ; pain and irritation due to the 
 
 bessure of the diseased bones one on the other is thereby 
 
 Wmized. 
 
 m By the Application of Sayre's Plaster Jacket. — If the disease 
 
 fists in the dorsal region, the trunk is encased in plaster of Paris, 
 
 ihich should extend from the axillae to just below the iliac crests. 
 
 |he patient is stripped to below the waist, and a closely-knitted 
 
 ollen vest fitted to the body, and fixed by straps passing over 
 
 shoulders. A pad or folded towel is placed beneath it over 
 
 alxlomen to allow for distension after meals, and in women 
 
 lilar smaller pads may be placed over the mammae to protect 
 
622 
 
 A MANUAL OF SURGERY 
 
 them. Coarse canvas bandages, into the meshes of whicli plaster 
 of Paris has been rubbed, are thoroughly soaked in water, to 
 which a Httle salt may be advantageously added, and then wound 
 evenly round the body until a layer of five or six thicknesses is 
 obtained. Over this a paste of plaster of Paris, prepared as 
 described at p. 399, is laid, until the jacket has 
 attained sufficient thickness and consistencv, 
 It is allowed to dry before the patient's posi- 
 tion is altered. In adults, where the disease is 
 chronic and not acute, the jacket should hel 
 applied whilst the spine is extended by sus- 
 pending the patient by the head and axilla 
 from a suitably arranged tripod. In children, 
 or when the disease is acute, it will suffice if 
 the parent or an assistant partially supports the I 
 patient from the armpits, or the apparatus can 1 
 even be applied with the child in l' e recumbent | 
 posture. The jacket rr '.t be worn until ail 
 pain and evidence of acnve disease have dis- 
 appeared, and after that the patient should Iwi 
 fitted with a poroplastic support for a time. ln| 
 disease of the cervical or upper dorsal vertebra:, 
 Fig 226 — Savrf's ^ special jury-mast is required, in order to steadyj 
 Plaster Jacket, the head and take the weight off the spinel 
 WITH Jury-Mast (Fig. 226). It consists of an iron rod, fixed toj 
 FOR Cervical a plaster or poroplastic jacket, acconitnodatingl 
 
 MANN^iT' ^^^^"^ ^*^^^^ *° ^^^® curves of the head and neck; 
 above, it extends forwards as far as the vertex,! 
 and has attached to its upper end straps, which pass downwards] 
 beneath the occiput and under the chin. 
 
 (c) ^ the Use of Phclb£ Fin v.. — This plan of treatment, which! 
 has been advocated by rhelps of New York, consists of a woodenf 
 box 6 inches deep, the lower end of which is divided into twoj 
 portions, one for each leg, a suitable aperture being left at thej 
 junction of the divided parts for the passage of the excreta.f 
 Careful padding is applied to the whole of the interior, and thej 
 child is strapped and bandaged into this apparatus, and kept! 
 there for a period varying from six to twelve month s. Thel 
 whole trunk is thus absolutely immobilized, and one great advan- 
 tage is that the patient can be easily carried about in his boxj 
 and taken into the open air. Extension can also be made, if] 
 necessary, by elastic accumulators attached to the head and neck,j 
 or legs. 
 
 {d) In very young children perhaps the simplest apparatus is 
 a double Thomas's splint, with a suitable crutch above to fix and 
 support the head. 
 
 During the whole course of treatment, the general condition ol 
 the individual must be carefully attended to, and suitable foo(f 
 
DISEASES OF THE SPINE 
 
 623 
 
 and tonics administered. Wherever possible, the child should be 
 taken regularly into the open air, and in the later stages a change 
 to the seaside is often most beneficial. When all symptoms of 
 pain and irritation have disappeared, the patient may be allowed 
 gradually to get about again with a mechanical support, and, 
 i indeed, this should not be dispensed with for six or eight months 
 after apparently complete recovery. 
 
 Counter -irritation is but seldom required. It may be useful, 
 
 however, when severe pain exists in the early stages, especially 
 
 i in adults. The best means to employ is the actual cautery, 
 
 I either applying a button cautery at several spots on each side of 
 
 j the spine, or searing the skin longitudinally. 
 
 Recently it has been proposed by Calot and others to overcome 
 
 I the deformity of Pott's disease by forcible straightening under an 
 
 anaesthetic. A considerable number of cases have now been 
 
 [treated in this way, and with a moderate degree of success; 
 
 unfortunately many deaths have been the direct result of this 
 
 procedure, whilst the subsequent immobilization needs to be very 
 
 prolonged, and the deformity may recur. Personally we consider 
 
 that although it may be safe and desirable to straighten the back 
 
 [in a few cases, yet the risks are so great and the process so 
 
 jopposed to Nature's method of cure that unless future statistics 
 
 [show much better results than hitherto, the proceeding is scarcely 
 
 [justifiable. The most interesting point observed in this connec- 
 
 jtionis the fact that cases of paraplegia seem to be immensely ini- 
 
 jproved by this process, and that within a few days. It is also 
 
 |do\v maintained that no very great degree of power is required to 
 
 ) all that is desirable ; the patient's head and feet are steadied by 
 
 [assistants making traction, and the surgeon merely uses as much 
 
 [force as can be applied by one hand placed over the curve. 
 
 The Treatment of the Chronic Abscesses so often met with in 
 [spinal disease is always a matter of anxiety, since, when once 
 lopened, they usually take a considerable time to heal, and if 
 lailowed to become septic, the prog losis of the case is seriously 
 affected. A general description of the methods employed has 
 already been given at p. 39. Formerly, owing to the fear of 
 «psis, surgeons used to teach that the longer a chronic abscess 
 kmained unopened, the better for the patient ; but at the present 
 py the majority of cases are treated as soon as pus is diagnosed 
 pith certainty. 
 
 \ Retro-pharyngeal Abscess should always be dealt with from the 
 jieck, as described in Chapter XXVI. 
 A Dorsal, Lumbar, or Psoas Abscess should be tapped with a 
 itge aseptic trocar and cannula ; after the escape of the pus, 
 k cavity is thoroughly washed out with a mild antiseptic 
 ption, or with sterilized water at a temperature of 105^^ to 1 10" F. 
 In the case of a psoas abscess, this irrigation may be combined 
 Vith gentle massage of the abscess cavity, in order to detach as 
 
m 
 
 m 
 
 
 624 
 
 A MANUAL OF SURGERY 
 
 far as possible the pyogenic membrane, and to assist in the re- 
 moval of curdy debris. When the lotion returns uncoloured 
 or but slightly tinged with blood, an ounce or two of a 10 per 
 cent, emulsion of iodoform in glycerine is injected, and diffused 
 if possible, through the abscess cavity by manipulation. The 
 cannula is then withdrawn, and the external wound closed, 
 Occasionally a cure can be obtained in this way by one tappini' 
 but only when no active disease is present, and when the 
 patient's general health is good ; more commonly the fluid will 
 re-collect, and the same process may need to be repeated two or 
 three times. Sometimes the fluid finds its way along the track 
 of the cannula, and a sinus results ; such must be dressed anti- 
 septically until cicatrization has occurred. The best position 
 in which to tap a psoa;. abscess is at a spot just internal to 
 the anterior superior spine ; a small incision is made in the 
 skin, sufficient to allow of the insertion of the trocar through the 
 abdominal muscles into the cavity of the abscess, but the surgeon 
 must make certain that the intestines have been previously dis- 
 placed to one side ; as a rule, no fear need be entertained on this I 
 score, since the parietal peritoneum is always pushed inwards. If 
 there is any doubt, the abdominal muscles must be cleanly divided f 
 through an incision about i^ inches long, so as to expose the 
 abscess sac ; a sinus is, however, more likely to form if this is done, 
 Should the abscess point below Poupart's ligament, close to the 
 saphenous opening, it may be necessary to open it there, perhaps! 
 in addition to tapping it in the usual place. It must be reniemberedj 
 that the femoral vessels are displaced somewhat and stretched overj 
 the sac, and precautions should be taken to prevent puncturinj 
 the vein, an accident which has occurred. 
 
 Some prefer to open the abscess freely, and scrape out itsl 
 interior with a Barker's flushing gouge. Certainly by this meansi 
 the tuberculous pyogenic membrane and debris can be morel 
 thoroughly removed, but the sharp edge of the instrument ia 
 capable of doing a considerable amount of harm in this situationj 
 and there is also more likelihood of a sinus remaining. Personalis 
 Ave are not in favour of its use for this purpose, and r.iaintain thai 
 the method which w^e have advocated above is better, since therd 
 is less probability of the wound becoming infected with the tul)er| 
 culous material, and hence of the formation of a sinus. 
 
 Occasionally it may seem advisable to freely open the sac of i 
 psoas abscess, and where the disease originates in the lumbal 
 vertebrae it has been recommended by Mr. Treves and others tl 
 cut down along the outer border of the erector spina.', and de/ 
 with it from behind. A vertical incision is made in this situatioq 
 down to the transverse processes, and the lumbar fascia 
 quadratus lumborum are divided by a transverse cut opposite tli 
 tip of one of these ; the abscess sac is then easily reached an 
 opened. The great advantage of this method is that the bodid 
 
DISEASES OF THE SPINE 
 
 625 
 
 of the vertebrae can be examined, and even scraped, or sequestra 
 removed. 
 
 When symptoms of paraplegia arise in the course of Pott's 
 iisease, it is usually unnecessary to do more than maintain the 
 immobilization of the spine, since, as already stated, the natural 
 tendency of these cases is towards recovery. At the same time, 
 extra precautions should be adopted in order to prevent bedsores 
 jover points of pressure. Should any difficulty in micturition 
 arise, regular catheterism must be adopted, and the greatest care 
 directed to the sterilization of the catheters, septic cystitis being 
 always due to external contamination. In such cases it would 
 be wise to purify the penis and urethra, and to keep the former 
 livrapped in a dry aseptic dressing in the intervals between catheter- 
 ism. A certain amount of forcible extension may be permitted in 
 jthese cases, and will probably do good. Laminectomy (p. 605) is 
 [required in order to relieve pressure upon the cord in the following 
 leases: (a) When septic cystitis or the existence of deep bedsores 
 (is threatening life ; (b) when, in spite of prolonged rest, the 
 jsvmptonis persist or increase ; (c) when paraplegic symptoms 
 Idevelop late in the case, and are possibly due to a development 
 jof fibro-cicatriciai tissue outside the membranes (peri - pachy- 
 Imeningitis). (d) Finally, whenever the tuberculous process mainly 
 latfects the neural arches, there is no reason for not treating it 
 
 jby early operation. 
 
 \@ 
 
 III J Syphilitic^ Disease of the spine develops in the shape of 
 ummata, commencing" beneath the periosteum which covers the 
 dies ; it is of unfrequent occurrence, and gives rise to symptoms 
 uctly similar to those of tuberculous caries, from which, indeed, 
 e condition cannot be diagnosed, except by the history and its 
 eaction to treatment. It usually occurs in adults, and is said to 
 lainly affect the cervical vertebrae (Tubby). Suppuration and 
 ibscess formation are not commonly observed. The co-existence 
 a syphilitic history and of specific lesions elsewhere may help 
 me in coming to a decision as to the nature of the affection. 
 Treatment consists in the administration of suitable anti- 
 iphilitic drugs, and in the use of a spinal support. 
 
 1\'. Bh euma tic Spondylitis is a condition occasionally met with 
 rising ^m the same~causes, and associated with much the same 
 penomena as r heumatism elsewhere . It may involve either the 
 |anientous or muscular tissues, or may attack the intervertebral 
 lints. Any part of the spine is involved, but perhaps the most 
 larked features are presented in the cervical region. Consider- 
 [le impairment in the movements of the head is then produced. 
 Id the neck may be laterally deflected, somewhat simulating 
 Fticollis. If untreated, adhesions form between the bones, and 
 
 40 
 
626 
 
 A MANUAL OF SURGERY 
 
 
 The treatment is of an 
 
 the loss of movem> nt may he permanent, 
 ordinary anti-rheumatic nature. 
 
 The so-called Gtonorrhoeal Rheumatism also affects the spinel 
 occasionally, and brings about much the same results. 
 
 (y) Osteo-arthritis somet i mes attacks the vertebral colui im 
 leading to destruction of the mter vertehral discs and ot tWe 
 articular cartilages, together with erosion ot the bones and tlie 
 fofnmt ioii of osteophytic masses a mamtr-r A laFge portion, irTiot 
 ihe whote", of the S|:rtne"is usually" involved by this disease, and 
 a prominer:t feature is the almost invariable supervention of 
 ankylosis, either from ossification of the anterior or posteriori 
 common Hgaments, or from interlocking or fusion of osteophytes. 
 A marked kyphosis results, and great pain is present. FinallvJ 
 the process spreads to the articulations between the ribs and tliej 
 vertebrae, and when these become fixed the respiratory movel 
 ments are considerably impaired, and hence death is likely toj 
 ensue from pulmonary mischief. Treatment is as for siniilarl 
 disease elsewhere. 
 
 Tumours of the Spine are usually malignant in character, and most com-l 
 monly secondary developments of cancer or sarcoma. Simple tumours, sudij 
 as osteoma and hydatid cysts, do occur, as also primary sarcoma. Tl'e chief) 
 symptoms are severe and localized pain, which is constant, and unrelieved bm 
 rest in the recumbent posture, together with early excurvation and parapief;la.j 
 These three phenomena manifesting themselves in an adult should alwavs 
 suggest the presence of a morbid growth. Treatment necessarily is but rardyl 
 feasible, although an exploratory operation is quite justifiable if the patient i 
 not profoundly cachectic from the generalization of the disease. 
 
 Tumours of the Spinal Cord and Membranes de\-elop in se\ eral situationsj 
 and the symptoms are thereby somewhat modified, {a} Outside the s/:d 
 dura. Lipoma and sarcoma are here most often seen, and the symptoms oh 
 cord pressure, such as loss of power and sensation, are preceded by tiioseol 
 spinal irritation, e.f^., neuralgic pain, increased on movement, and are oftea 
 limited for some time to one side, (b) They may grow from the iunev aspect ei&k 
 dura mater, and thus produce symptoms of cord pressure and meningeal irritaj 
 tion concurrently. Sarcoma, fibroma and gumma, are the commonest formsoj 
 neoplasm in this situation, (c) From the spinal cord itseU, myxoma, psammomaj 
 and sarcoma may originate. The symptoms are those of paraplegia combinei' 
 with some localized and referred pain or tenderness, and usually bilateral iroti 
 the start. Left to themselves, patients suffering from any of these growthi 
 are certain to die, and hence an exploratory laminectomy, with a view tf 
 removal of the growth, if practicable, is always indicated when a dia^'nosij 
 has been effected. The possibility of the disease being syphilitic in origij 
 must not be overlooked, an-:' hence a preliminary thorough course of iodide c 
 potassium should always be instituted before operating. The results liitherrf 
 obtained have been distinctly encouraging, although many of the cases aij 
 left till too late, and the mortality is certain to be high. 
 
 The only inflammatory disease of the cord which need be alluded to hej 
 is one, the results of which have already been mentioned constantly in tj 
 chapter dealing with the deformities of the body (Chapter XV.), viz.,Iiifanti 
 Paralysis. This condition is due to an inflammation of the anterior cornuaj 
 the grey substance of the cord (anterior poliomyelitis), as a result of which tlj 
 multipolar ganglion cells situated therein are destroyed. The symptoms cofl 
 
DISEASES OF THE SPINE 
 
 627 
 
 :menl is of an 
 
 cts the spine j 
 ts. 
 
 ;bral column, | 
 s antl o[ the 
 oones and_the 
 ■portion, ir not I 
 IS disease, and 
 ipervention of 
 r or posteriori 
 Df osteophytes. 
 sent. Finally,! 
 e ribs and the| 
 piratory move- 
 it h is likely tol 
 as for siniilarl 
 
 ;r, and most cnm-l 
 iple tumours, suclij 
 rcoma. Tbe chief 
 anci '.inrelievedbj 
 ion and paraplegiaJ 
 ult should ahvav! 
 5sarily is but rareh 
 lie if' the patient li 
 lease . , 
 
 several situationsj 
 Outside the spmi 
 Id the symptoms ol 
 ■eceded 'by those oj 
 lent, and are ofted 
 'he inner aspect (<i fi\ 
 id meningeal irntaj 
 ;ommonest formso| 
 1,-xoma, psammoma 
 araple^ia combine 
 ;uallv bilateral frot 
 l^• of these growth! 
 iv, with a view i 
 when a diagnosil 
 [syphilitic in ongu 
 course of iotliJet 
 •he results hitherti 
 iV of the cases afl 
 
 on abruptly, and are often introduced by a short febrile attack ; paralysis 
 
 sSJfvvsltself at^once, and quickly attains its maximal proportions, being possibly 
 
 [■^nwed by a certanTamoun t of reco very. The portions that remain pafal>v.ed 
 
 early lose their nutrition, owmg to tKe destruction of their tropTuc ganglionic 
 
 centres, and become cold and bluish in colour ; finally, deformities (lue to the 
 
 r.balanced action of opposing groups of healThy muscles may appear, whilst 
 
 iheilevelopment and growth of the affected limbs are impaired. The distribu- 
 
 ;,onof this affection is very variable, but, speaking generally, the legs are most 
 
 commonly affected, the lower halves, and not the upper, being mainly involved ; 
 
 various forms of talipes may result therefrom, as also weak and flail-like con- 
 
 l^ditions of the knee and ankle. When the thigh is included, the quadriceps 
 
 extensor and adductors are usually picked out. In the arm the deltoid is most 
 
 1 often paralyzed, and after this the muscles on the extensor side oT the forearm, 
 
 e\dudiriR'thB'supinator longus. The face and neck are rarely involved, but 
 
 I ihe abdominal and back muscles maybe attacked. The Treatment in the 
 
 earlv stages is di rected towards improving the general health, and maintaining 
 
 liie nutrition ot tTie affected muscles as far as possible by electrici ty and 
 
 i friction. In the later stages, when deformed or weak and tlail-like limbs have 
 
 giiltecl, various means may be adopted in order to improve the functions of 
 
 luepart. (<i) Mcchan ual suppovt is often negded, and this must be c arefully 
 
 reijulated, in order to assist, and not to hamper, the movements ol tlie indi- 
 
 vidual by its unnecessary weight. 'Tfipal-aTytic taJipes^ irons. fixecl to the boots, 
 
 land rising above the Icnee, or even soiiTetrmes running up to the pelvis, are 
 
 frequently required, {b) Ten otomy, or division of muscles or fasciae, may also 
 
 berequired in certain deformities, {c) Tenoplasty, or the grafting of a heal thy 
 
 [lendon into a paraly zed one, has been occlTslonally uftltzecl, as also the trans- 
 
 JplafiriiTi ori ot tne'bony attachments so as to put the relaxed and weak muscles 
 
 iMftliesTi ^tch . ((/) Artliyodesis, or the hxation ot joints, is a useful proceeding 
 
 IliKrer circumstances where the unnatural mobility is diflicult to control, or 
 
 I would necessitate considerable increase in the weight of the apparatus 
 
 Irequired, or where, from the poverty of the patient, the apparatus cannot 
 
 [kobtained. It is especially serviceable in cases where two joints in a limb 
 
 [are flail-like, one of which may then be ankylosed with advantage. The 
 
 loperation consists in a modified excision, the cartilage alone being sawn or 
 
 licraped from the ends of the bones, (c) Where the whole limb is hopelessly 
 
 Iparalyzed and a great inconvenience to the patient, amputation is often the best 
 
 Ipractice.i/ 
 
 ^^n 
 
 J be alluded to hej 
 Id constantly m 13 
 
 Ixv 
 
 . viz 
 
 ,, Infant! 
 
 : anterior cornua j 
 result of which ij 
 'he symptoms conf 
 
 40 — 2 
 
CHAPTER XXII. 
 
 HEAD INJURIES, 
 
 Injuries of the Scalp. 
 
 WouNus of the scalp are produced either by sharp or hhmtj 
 instruments, by falls on the head, or by gunshot injuries. Fronif 
 the tenseness of the scalp over the cranium, it often happens 
 that a blunt weapon, such as a policeman's truncheon, will causeaj 
 wound nearly as cleanly cut as if it had been made with a sharpj 
 instrument. The depth to which the injury extends is a most iml 
 portant element in these cases, and, so long as it is limited tol 
 those parts superficial to the occipito-frontalis aponeurosis, Initj 
 little harm is done ; if, however, the layer of loose cellular tissue 
 between the aponeurosis and the pericranium is opened up and 
 infected, septic cellulitis (p. 82) is likely to ensue, and fatal conse-j 
 quences may result. The superficial extent of the wound is 
 matter of little moment, since the vascular supply is so good thad 
 sloughing is uncommon ; a large portion of the scalp may he torn 
 up and bruised, and yet, if it is carefully washed and rendered 
 aseptic, there is every probability that it will retain its vitality. 
 
 The Treatment of scalp wounds is conducted on exactly tha 
 same lines as that of wounds elsewhere ; that is to say, atten 
 efficient purification they may be stitched up, provision beinoj 
 made for drainage, if necessary. The hair should, of course, I 
 cut away from the neighbourhood of the wound, and an antiseptiJ 
 dressing applied. Haemorrhage from the scalp may he severa" 
 owing to the division of some of the large arterial branchesj 
 it is dealt with according to the general rules of surgery. 
 
 Contusions of the scalp may occur without solution of continuitj 
 of the surface, and results in the formation of bruises or haema 
 tomata. A similar condition is found in new-born infants; 
 is due either to pressure or injury to the head during its passag 
 through the mother's pelvis, or to. the compression of obstetrij 
 instruments. Three varieties of the so-called cephalhaimtoiii^ 
 have been described, viz. : (a) the Superficial, which, confined 
 the dense subcutaneous tissue, is necessarily small and limited 
 
HEAD INJURIES 
 
 te9 
 
 the Subaponeurotic, occupying the loose tissue under the 
 I aponeurosis, and only limited by the attachments of this structure. 
 It tonus a large, soft, fluctuating swelling, upon which the scalp 
 appears to float, bagging down over the eyes or occiput, (c) The 
 iSiibf't'ru'ranial is limited by the pericranium dipping down into 
 the sutures around the bone with which it is connected. Most 
 commonly it forms over one of the parietal bones, presenting a 
 soft, fluctuating swelling, which soon gains an indurated margin 
 owing to a deposit of fibrin, and in this condition may simulate a 
 depressed fracture of the skull, inasmuch as the cup-like fluid centre 
 allows the finger to sink in and touch bone below. It is not diffi- 
 cult to recognise, however, since the indurated margin can be 
 readily indented by the finger, whilst the edge is definitely raised 
 above the surface of the cranium, and hence the sensation of 
 depression of bone felt through the fluid is only apparent. In 
 old-standing cases ossification of the walls of this cavity has even 
 jheen known to occur. Treatment. — All that is required is the 
 [application of evaporating lotions. There is hardly ever any 
 [need to lay open or drain these swellings. 
 
 Traumatic Ceplial-hydrocele is the name gi\en to a rare condition 
 jtollowing head injuries, especially in children. It is characterized 
 Itivthe formation of a fluid sweUing under the scalp, which pulsates 
 [synchronously with the heart-beat, and has a definite impulse on 
 lanv expiratory effort ; it varies in size from time to time, and is 
 Isometinies partially reducible. It contains cerebro-spinal fluid, 
 land is due to a simple fracture of the vault, laying open either 
 lone of the lateral ventricles or the subarachnoid cavity. In 
 [one case it was proved on operation to be connected with an 
 larachnoid cyst, due to a localized subarachnoid haemorrhage. 
 IProhahly it is wise to leave this condition studiously alone, 
 lalthough, if one could be tolerably certain that the ventricle was 
 pot affected, it might be laid open and drained. 
 
 Injuries to the Cranial Bones. 
 
 Contusions of the Cranial Bones apart from fracture may lead to 
 
 srious results, i. Many of the inflammatory conditions of bone 
 
 described elsewhere may be started ; e.g., if the patient is in a 
 
 londition of low germicidal power, acute osteomyelitis may 
 
 lollow, associated with pyaemia from thrombosis of the large 
 
 leins of the diploe ; or chronic sclerosis and overgrowth of the 
 
 pe, local or diffuse, may supervene. Syphilitic or tuberculous 
 
 panifestations may be similarly lighted up if the patient is the 
 
 iiibject of either of these diseases. In their treatment pus must 
 
 i let out, necrosed fragments removed, and, if pyaemia arise from 
 
 liploic infection, the outer table should be removed, and the 
 
 jloughing diploe scraped away and purified. 2. In addition to 
 
 [uch osseous conditions, pus may form within the cranium outside 
 
•Stf 
 
 A MANUAL OF SURGERY 
 
 the dura muter {suhcranial abscess, p. 651), and necessitate trephjn. 
 ing. 3. The dura mater may be detached by a simple contusion 
 leading to meningeal lin'morrhage (j). (i-\2). 4. Any of the 
 cerebral lesions detailed liereafter may be produci-d, so that 
 contusions of the cranium must never be treated lightly, even 
 when they are associated with unbroken skin ; much more are 1 
 they serious when compound, sepsis being thereby rcadilv 
 admitted. 
 
 Fractures of the Skull. These may be described for conveniena-j 
 under the following headings: Fissured Fyactures of the Viudt;\ 
 Fractures of the Base (usually fissured); and Depressed or VundimA 
 Fractures. 
 
 I. Fissured Fractures of the Vault are always due to externalj 
 violence, direct or indirect. In the former case the skull fust yieldsl 
 at the injured spot, but a fissure may extend from it for sdiiiel 
 distance; in the latter the fracture results from the yielding,' of j 
 the skull when compressed beyond its natural limits of elasticity. 
 
 A simple fissure gives rise to no symptoms indicating its pre-l 
 sence with certainty. There may be some amount of superticiall 
 ecchymosis together with concussion of the brain, but iiothin* 
 more definite. When compound the line of fracture may l)e seen 
 as a red streak, or even felt with the finger as an irregular .id^'e] 
 It consists of a mere longitudinal fissure, or may be staraJ 
 if uncomplicated with other injuries, it is of but little importance 
 and needs nothing beyond general treatment — of course, tliJ 
 greatest care being taken to ensure asepsis. Occasionally, howl 
 ever, an osseous growth forms from protuberant callus on t!i{ 
 internal aspect of the cranium at the site of fracture, and give 
 rise to traumatic epilepsy or insanity (p. 665). 
 
 II. Fractures of the Base of the Skull are almost ahvay 
 fissured, only occasionally punctured or depressed. 
 
 Causes. — {a) Violence may he directed to the vertex or to some pint 1 
 the cranial convexity, as from a blow or fall upon a hard substanc 
 There has been a good deal of discussion as to how a fall 
 the vertex; causes fracture of the base, The old idea of contr^ 
 coup, i-.e., t' at the force was transmitted from one side of tn 
 skull to the other, producing a fracture, may be decently burid 
 and fojgo.ten, whilst two main theories still hold the field, eaij 
 being probably responsible for a certain number of cases. 
 Aran's theory of irradiation maintains that a fracture of the basej 
 always due to direct extension of the fissure from the injured vert^ 
 a proposition probably quite true in many cases, but insufficiei 
 to explain all. (ii.) A more recent idea, known as the btirstmn 
 compression theory, is based on the fact that the cranium is m 
 solid and totally unimpressionable body, but is highly elastic, 
 
HEAD INJURIES 
 
 •31 
 
 has been proved by the observation tliat hairs and pieces of skin 
 have Uvn found nipped in a simple tissured t'ractiue of the vault, 
 which had evidently t,Mped open and closed aj^ain. Se\ere com- 
 pression necessarily diminishes the diameter of the skull along the 
 ixis of f^reatest pressure, making it bulge in other diameters; and 
 if this distension exceeds the limits of elasticity, the bone gi\es 
 ivav. The direction of fractures produced in this manner varies. 
 j[,Ist commonly the lines of fracture are parallel to the direction 
 of the compressing force, the bone thus bursting open along its 
 I convexity (fracture by bursting); less frefjuently it gives way at 
 right angles to the direction of the force where the bulging is 
 L'reatest (fracture by compression). Inasmuch, however, as the 
 force is transmitted e(iually in all directions, che weakest part is 
 Lost likely to give way, viz., the base. It has been pointed out 
 bv Felicet that the skull consists of alternate strong and weak 
 parts, the stronger Inittresses being formed by the occipital ridges, 
 the petrous bone, the greater and lesser wings of the sphenoid, 
 and the frontal crest, and that consetjuently fractures are more 
 iiliely to involve the intervening weaker parts. Whether these 
 [ideas are justified is a (juestion ; certainly the figures (juoted by 
 helps* indicate that irradiation is responsible for a very large 
 Ipropurtion of fractures of the base, {h) Direct injury to the base 
 Itf the skull is undoubtedly the cause of a certain number of 
 liractures, and some of these are depressed, and not fissured, in 
 Idiaracter. Thus, the point of an umbrella or stick may be thrust 
 j'Tough the upper wall of the orbit, or up the nose through the 
 jcnbrifonn plate of the ethmoid ; the condyle of the jaw may 
 Ite driven through the glenoid cavity into the middle fossa by a 
 IHow on the chin ; direct injury from a fall or a stab may pene- 
 lirate the occipital bone, whilst a gunshot wound in the mouth 
 L another illustration of this kind of injury, {c) The impact or re- 
 Mum of the vertebral column against the occipital condyles produces 
 pctures in the posterior fossa which radiate from the foramen 
 ignum, and may even occasion a ring-shaped fracture around 
 t(Fig. 227). They result from falling on the vertex into a aoft 
 mass, e.g., a bale of wool, or by alighting from a height on the 
 lieels or nates. 
 The fracture may run in any direction, longitudinal, oblique, 
 [ransverse, etc., according to the direction of the compressing or 
 acturing force, and it may affect any part of the base, either 
 leing limited to one of the fossae or involving all ; it may 
 f)llo\v the sutural lines in part, but it is no uncommon thing to 
 seven the dense petrous bone traversed by a fissure (Fig. 228). 
 jiaturally, transverse fractures tend to be limited to one of the 
 psae, whilst a longitudinal fissure may involve them all. 
 ] Soine fractures of the base of the skull are simple in nature, 
 t the majority are compotmd. In the anterior fossa the fissure 
 Traumatic Lacerations of the Brain.' London : Henry Kimpton ; 1898. 
 
6;,2 
 
 A MANUAL OF SURGERY 
 
 extends through the cribriform plate and nasal mucosa, and the:;] 
 lays open the nose ; or a communication may be established \\\: 
 the external air through a penetrating wound in the orbit, uri 
 through the ethmoidal or sphenoidal sinuses. In the middle fossa 
 a fracture through the base of the sphenoid opens the roof of the | 
 naso-pharynx, or the fracture may involve the tympanic cavitv, 
 In the posterior fossa the basi-occipital may be broken, and the] 
 naso-pharynx again opened, although the fracture here is niord 
 commonly simple. 
 
 Fractures of the base of the skull, though very seriuus, arelnj 
 no means necessarily fatal, and, indeed, during the last twtntv 
 
 Fig. 227. — Fracture of the Base of the 
 Skull from Force acting against the 
 Occipital Condyles, and producing 
 almost an Annular Fracture around 
 the Foramen Magnum. (Tillmanns.) 
 
 Fig. 22S. — Transverse Frac- 
 ture across the B.^SE "F| 
 
 THE Skull. 
 
 years or more the results have immensely improved, owing to 1 
 use of antiseptic precautions. The main dangers to be apprehended! 
 are : (i.) Damage to the base of the brain, including the pons ai 
 medulla, especially in cases where the foramen magnum is splinteredjj 
 from the impact of the spine against the condyles ; (ii.) haGmorrhageJ 
 arising either from the venous sinuses, or from the meningeal orl 
 cerebral arteries ; and (iii.) septic meningitis, due to the fact thatj 
 the injury not only fractures the bones, but also lays open theduraj 
 mater, a grave addition to a compound fracture. 
 
 The Signs of a fractured base are exceedingly equivocal, and itl 
 is often only by a consideration of the whole picture that a certain! 
 diagnosis can be attained. For convenience they may be anangedj 
 under four heads : 
 
 I. Signs of severe cevebral mischief, such as is indicated by conj 
 
HEAD INJURIES 
 
 633 
 
 [cussion of the brain and prolonged unconsciousness. This is, 
 [however, by no means always present ; thus, in a case ue had in 
 jlio'^pital a few years back, the patient was capable of going about 
 |his work for ten days after the accident. 
 
 2. HirmoyyJiage manifests itself in various directions, according 
 Itothe situation of the fracture. 
 
 In the anterior fossa there may be free bleeding from the nose, 
 lowing to the fracture extending through the cribriform plate of 
 jtlie ethmoid ; but a portion of the blocd may pass backwards 
 jinto the pharynx, and, being swallowed, is perhaps subsequently 
 Ivomited. More often, however, the line of fracture runs across 
 llhe roof of the orbit, causing escape of biood into the areolar 
 jtissue of this cavity. The ecchymosis shows itself as a gradually 
 [developing subcutaneous distension, involving the lower lid, bluish- 
 jpurple in colour at first, but passing later through the other stages 
 |o: a bruise ; there is probably no contusion of the skin, as in the 
 jordinary black eye, which is at first reddish-purple ; the ocular 
 Iconjunctiva is considerably involved, but the effusion rarely extends 
 jabove the cornea, and its posterior limits cannot be seen. The 
 jbleeding usually arises from laceration of the dura mater and 
 Ibone, hut, when abundant, may come from the cavernous sinus, 
 land the eye may even be pushed forwards (proptosis) ; in some 
 leases pulsation is to be felt within the orbit, and then a traumatic 
 loibital aneurism or aneurismal varix is present. 
 
 In the middle fossa the blood may enter the nose or mouth, a 
 [part being swallowed, but more commonly it escapes from the 
 jears. If abundant, it probably comes from one of the vascular 
 Ichannelc at the base of the brain ; but if only slight in amount 
 land of short duration, it may be induced by any of the following 
 lesions, as well as by a fractured base, viz. : {a) A simple rupture 
 jofthe rrembrana tympani : (i) separation of the cartilage of the 
 jpinna, with tearing of the lining of the external meatus ; (r) fracture 
 lot the anterior and lower part of the tympanic plate, as by a blow 
 Ion the jaw, which drives the condyle forcibly against it. 
 I In ihe posterior fo<:sa the bleeding is usually subcutaneous, show- 
 pn<; itself aroi.nu >,' mastoid process, and extending downwards 
 p.on'^st ll]e mujcles at the back of the neck. 
 
 3. Di^ka:^^^ of cerebrospinal fluid is an indication that a com- 
 fimnioaiion dxifts with the subdural space. The fluid may be 
 discharged re in one or both ears, but - •: also been met with 
 jcoming frcn' the nose or cranial vault; when from the ear, the 
 |iura matei lias probably been laid open through the prolongation 
 fthich acccrr.panies the auditory nerve in the internal meatus by 
 ifnicture traversing the petrous bone. It is watery and limpid in 
 paracter, Avith a specific gravity of ub;)ut 1005, slightly alkaline, 
 pd containing a fair quanLity of uMoriie of sodium, with, traces 
 pt albumen, and of a jubsta\.re kno^vn as pyrocatechin, which 
 pets in the ^ame way a:^ K^^pe sngai with Fehling's solution. 
 
634 
 
 A MANUAL OF SURGERY 
 
 At first it may be slightly blood-stained, but this soon ceases, the 
 fluid becoming quite clear. The amount discharged may be 
 small, but not unfrequently it comes away in large quantities 
 soaking the pillow and dressings, and, indeed, can sometimes hei 
 caught in a test-tube as it trickles from the meatus. As a rule 
 the flow commences soon after the injury, and quickly ceases: 
 but a few years back a curious case occurred, under the care of! 
 Lord Lister at King's College Hospital, of a man who had fallen f 
 backwards oft" a high bed upon his occiput ; he was temporarilv 
 stunned, but returned to bed, and, on awaking the next mornin<;, 
 found that both eyes were black. He continued work for some 
 days, complaining, however, of headache and at the end of that) 
 time of earache, which grew steadily worse, until relieved bv 
 something giving way in his left ear. This was followed by a! 
 copious discharge of cerebro-spinal fluid, which was maintained! 
 for some time, and from the after-history there can be no doubt| 
 that it was due to a fractured base. 
 
 Escape of brain substance from the cai lias also occurred inal 
 few instances, most of them fatal. 
 
 4. Lesions of the nevves issuing from 'le bass. of the skull arel 
 occasionally produced. For symp:oms, etc, set. Chapter XII.l 
 The nerve most commonly involved is the, facial, as it passes! 
 through the aqueductus Fallopii, and paralysis of t)iis nerve mayj 
 result either immediately, or more often about the second or thir(i| 
 week after the injury, disappearing in about .". .iionth, and then 
 evidently due to its impHcation in tht- callus. A certain amount) 
 of deafness is often associated with ii from njury to the portiq 
 moUis. 
 
 The Prognosis of fractured base has much improved durin* 
 recent years, as a result of the application of antiseptics to tha 
 auditory meatus, thereby preventing the occurrence of sepsii 
 within the meninges. If the patient escapes death from, cerebral 
 complications, the bones of the skull unite rapidly, 
 result may be expected, although troublesome seque se May 
 from the injury sustained by nerves or vessels, or leii cui»ipies| 
 sion in callus or new bone. 
 
 Treatment. — Seeing that the chief danger to the pa: :^ arise 
 from septic contamination of the meninges, th( greater- 1 wie nii 
 be di''ected towards preventing decomposition of the discharges! 
 Unfortunately, it is impossible to apply dressings to the nasa 
 pharynx, or even to thoroughly wash it out with antiseptics, anj 
 the only satisfaction about such cases is that the radty of thelosf 
 of cerebro-spinal fluid suggests that the membran(;s of the brail 
 are not very often damaged in that situation, whilst it has alsj 
 been shown that in the majority of cases the upper part of th 
 nasal cavity is aseptic (St. Clair Thomson). W-ih the ear, hovi^ 
 ever, things are very different ; the meatus shouh'. hs .■ . '• ^yringo ' 
 with carbolic lotion (i in 20), and plugged witii ne ^Sicti 
 
 a good 
 
 ■■lOWl 
 
HEAD INJURIES 
 
 63s 
 
 [dressing, a large pad of the same being bandaged over the affected 
 Lide of the head. This must be replaced as often as necessary. 
 iBevond this, the treatment of fractured base is directed to the 
 [cerebral condition, and does not differ from that usually applied to 
 jliead injuries, viz., cold to the shaved head (preferably by means 
 [cfLeiter's tubes), a smart calomel purge to start with, low diet, 
 land absolute quiet in a dark room. The patient should be kept 
 [from 
 
 (Toing about his work for at least six weeks. 
 
 so occurred in al 
 
 I. Depressed j^yi Puncture d Fractures usually involve the 
 Ivault ot tne cranium, and are due tooirect violence, either from 
 I fall or blow, causing a simple or compound fracture, or from a 
 .ting injury occasionirg a punctured fracture. In both 
 leases there is often a considerable amount of comminution. 
 
 It is quite possible for the outer table to be broken and depressed, 
 wiJiout any injury to the inner, where an air cavity exists in the 
 lone, or if the diploe is \'ery thick ; thus, the bone may be driven 
 [nover the frontal sinus without injury to its inner wall, or the 
 nastoid may be similarly affected. The inner table has also been 
 l^rokfiji* an d frag ment s even separated, as a result ot a simple 
 
 oression without fracture of the outer table ; this rarely occurs 
 In adults, but is not uncommon 'in children. Amongst the latter , 
 lis also possible for a congijdp^^^"'^f^ depresj^ion to exist without 
 bv tracture ev en o f the i nn er table . . 
 
 ■ I . ._-— — ^^-^»" " • ■ I'll' "^ 
 
 Hore usually both inner and outer tables are involved, and 
 then such is^ due to force l^eacliing it from without, the inner 
 table is always more damaged than the outer, especially in tlie 
 [iiinctured variety (Fig. 229, A and B). When, however, the for ce 
 
 applied from within, as by a bullet which has traversed the 
 
 irain,TTie" outer table suffers more than the inner . The causes of 
 
 jjs cond ition are simil ar, from whichever side the f pr'^fi ^^"^^^ ; 
 
 psliall, "however, only discuss the case of a wound coming from 
 
 Jithout. (a) The inner table is less supported than the outer, 
 
 i?ving merely the soft brain and dura mater within, and hence is 
 
 Is ensively splintered, just as a nail driven through an unsupported 
 
 iieceof wood causes ripping up of its under surface, (b) The loss 
 
 [(momentum of the fracturing body will assist this ; the greater 
 
 lie momentum of a bullet, the more cleanly it cuts, a smaller 
 
 pomentum breaking or splintering rather than cutting ; of course, 
 
 considerable amount of force is expended in penetrating the 
 
 ^iter table, (c) The de|) r is cau sed by th e injury to th e o jter table 
 
 add to the buTTT'of the p e netraTing^bdy, arid IfB Wad|^H-llRe 
 
 Won sti l l mrtne r increases tne injury to the inner tabl e, (ci) Xh 
 
 (Tce tenJs ro radiate and dtttufe^ itself trom the sput struck, and 
 
 pee, if the outer table is first injured, the force will be dis- 
 
 rninated over a much wider area of the inner. 
 
 I The Symptoms and Signs arising from a depressed fracture vary 
 
 [idely in their nature, and are partly due to the injury inflicted 
 
636 
 
 A MANUAL OF SURGERY 
 
 Fig. 229. — Depressed Fracture of Skull seen from Withoi't and frojJ 
 Within. (From Specimen in King's College Mlsel-.m.) 
 
 on the bone, partly to that sustained by the brain, whilst tli^ 
 septicity or not of the wound is of the gravest significance. 
 
 Locally, when an external wound is present, one sees blood oa 
 cerebro-spinal fluid escaping, or even brain-substar.ce protrudingj 
 
HEAD INJURIES 
 
 637 
 
 The damage t o the bon e m ay be seen or felt, and the extent o f 
 
 .CHpp ression or comminution ascertained, W hen there is no 
 
 exIeFnaT wound, a haematoma of variable size forms under the 
 
 <c.ilp, more or less obscuring the fracture. The character of the 
 
 lesion is a matter of considerable importance from a prognostic 
 
 point of view. When the bone shelves evenly in all directions, a 
 
 mi or sancev fracture is said to be present, and such is tolerably 
 
 [amenable to treatment ; when, however, the depression is sudden 
 
 and complete, the detached portion lying below the level of the 
 
 rest of the bone, it is termed a gutter fracture, and the prognosis is 
 
 increasingly grave. The two forms are, however, often assnrintpd . 
 
 Necessarily, cot isideraI)le variations are met with in this type of 
 
 IractureT accordmg to the nature oi the injury and the means by 
 
 [duclTit was inflicted. Thus, if it is due to a fall on the vertex, 
 
 tliere is often a ragged, irregular scalp-wound, through which the 
 
 depression can be seen or felt ; if caused by the puncture of a 
 
 [sharp tool, such as a pickaxe, there is only a small external 
 
 jopening corresponding to the hole in the skull, in which the point 
 
 [of the instrument may be found embedded. A slicing cut with a 
 
 [sabre or hatchet produces a clean incision through the scalp, 
 
 [together with a linear groove in the skull, perhaps somewhat 
 
 jlievelled, which may or may not penetrate its whole thickness. 
 
 [sometimes detached portions of the skull are raised above their 
 
 [ordinary level, constituting an elevated fracture ; it is usually 
 
 [associated with depression of surrounding parts. 
 
 Gunshot injitvies of the skull manifest any degree of severity, 
 
 laccording to the velocity and angle of incidence of the projectile. 
 
 [a non-penetrating wound produces either a severe localized con- 
 
 [tusionor a depression with or Avithout comminution. If a modern 
 
 jconical bullet, travelling at a high rate of speed, strikes the skull, 
 
 lit will probably penetrate, and possibly may traverse both sides 
 
 jand thus escape, doing comparatively little harm, except along its 
 
 (immediate track. If, however, the bullet is of an expanding type 
 
 ^r tired from close at hand, considerable additional mischief in the 
 
 Jshape of fissures extending widely through the skull is induced. 
 
 lit has been known for some time, and the point has been empha- 
 
 pized by Professor Horsley, that if a bullet traverses a dry and 
 
 ppty skull but little harm results, except the formation of the two 
 
 Ipenings where the bullet entered and left the cavity, and these 
 
 pith the modern weapon are small. If, however, the skull is first 
 
 lilied with damp sand or with water, or if the brain is left in situ, 
 
 pnd a bullet fired through it, the efifects are much more serious, 
 
 [arying directly with the viscosity of the contents ; such a result 
 
 'evidently due to the momentum of the penetrating substance 
 
 «ing transmitted to the molecules of water or brain substance, 
 
 nd thence spreading explosive-like in all directions. Not only 
 
 Roes this radiation of the force affect the skull, but the most grave 
 
 lonsequences to the brain itself ensue from the displacement of 
 
r,38 
 
 A MANUAL OF SURGERY 
 
 II 
 
 cerebro- spinal fluid, inducing increased pressure upon the centreJ 
 grouped around the fourth ventricle, and leading primarily to al 
 cessation of the respirations. Thus, Horsley fired a bullet throuiirl 
 the skull and brain of a living dog, and found that the breatliinj 
 stopped, although the heart still continued to beat ; by peJ 
 forming artificial respiration for a time, natural breathing wasl 
 re-established. 
 
 In a simple depressed fracture the patient is very likely to sufferl 
 from concussion, followed almost immediately by conipressionT 
 the latter due in part to the depressed bone, but mainly to exuda- 
 tion of blood and bruising of the brain, and if this remains] 
 unrelieved a fatal result almost inevitably follows. Where, iiowl 
 ever, the depression is but slight, the symptoms of compression) 
 may be absent or not marked, and the patient reco\ers, perhap{ 
 to become the subject of traumatic epilepsy or insanity at a latel 
 date, induced by the irritation of the dura mater and of the subT 
 jacent cortex. If the depressed fragments irritate the nioto| 
 area, convulsions, spasms, or paralysis may thereby be earl| 
 induced. 
 
 In a compound depressed or punctured fracture the immediate elTectJ 
 are not necessarily severe, the patient perhaps not even sufferini 
 from concussion, though brain substance presents in the wound] 
 the more limited the spot injured, the less the concussion. T\l 
 explanation of this fact is that the blow has expended its force ij 
 fracturing the cranium, and hence does little harm to the brain, 
 in the same way that a watch may receive but slight damage 
 a fall if the glass is broken, whilst if the latter remains intact tli| 
 works are liable to suffer. 
 
 Left to itself, such a fracture is sure to become septic, anJ 
 inflammation of the bone, brain, or membranes is very likely tj 
 follow. 
 
 Septic osteitis leads to necrosis of the fragments, which may 
 seen lying dead and yellow at the bottom of the wound, whilst tb 
 inflammation may either spread along the diploe to the surrouii(| 
 ing bone, causing extensive necrosis with pyaemia, or between thi 
 bone and the dura mater, leading to a subcranial abscess. 
 
 When once the dura mater has been penetrated, inflammatioi 
 is liable to spread to the meninges, and then a diffuse or localize! 
 suppurative meningitis, accompanied or not with a localiza 
 suppuration of the brain, will ensue. Even if the dura niat^ 
 has not been opened by the injury, the irritation of depress! 
 spicules of bone and the presence of a septic exudation often leal 
 to its ulceration at a later date. If there is a free external opeij 
 ing, allowing ^ ready exit to the discharge, and thus preventiif 
 tension, the process may be quite limited, and compression ofti 
 brain or diffuse septic meningitis is avoided ; but if the boni 
 are locked together as well as depressed, and the external woul 
 is small, retention of inflammatory products may lead to thJ 
 
HEAD INJURIES 
 
 639 
 
 ; diffusion, and the symptoms of compression will soon become 
 evident. A hernia cerebri may also form subsetjuently. 
 
 When the fragments of depressed bone are early removed, 
 even if perfect asepsis is not attained, the patient has a good 
 
 I chance of recovery ; whilst laceration of the dura need not result 
 in meningitis, since the opening in the subdural space can be shut 
 off by adhesions of the arachnoid in a very short time. 
 
 When an aseptic condition of the wound is obtained by early 
 interference, and depressed fragments of bone are successfully 
 elevated or removed, the prognosis becomes much better, and the 
 case may run an uncomplicated course towards recovery, unless 
 some deeper cerebral lesion co-exists. 
 
 I I 
 
 Ipir,. 230. — Instruments used in Trephining for or Elevating a De- 
 pressed Fracture, including Trephine, Elevator, and Hey's Saw. 
 (Down Brothers.) 
 
 The Treatment of these cases has been much changed by the 
 [introduction of antiseptics, the opinion now prevalent being that 
 |a patient runs greater risks from leaving a slight depression 
 unrelieved than by making even what may prove to be an un- 
 necessary exploration with the trephine. We may, therefore, 
 [epitomize the treatment thus : 
 
 (i.) In all punctured fractures, operate. 
 
 (ii.) In all compound depressed fractures, operate. 
 
 (iii.) In simple depressed fractures : In adults, always operate ; 
 in children, if gutter-shaped, operate ; if pond-shaped, wait for 
 fymptoms, unless the fracture is a bad one. 
 
 The most debatable of these propositions is that relating to the 
 Jiniple depressed fracture in an adult. It may be objected that 
 nany such cases have recovered without operation, and that 
 Iherefore in shallow depressions one should wait for symptoms ; 
 
 
 »i>9' 
 
640 
 
 A MANUAL OF SURGERY 
 
 but whilst admitting the fact, we recall cases where the neglect 
 of such treatment has led to serious trouble, and we have been 
 called on not unfrequently to trephine for traumatic epiiej^sv due 
 to this very type of injury. The operation is so slight, and the 
 risk so insignificant when asepsis is maintained, that the patient 
 
 should be given the bene- 
 fit of an explorati(;n, espe- 
 cially since one can never 
 be certain of the amount 
 of injury sustained by the 
 inner table. 
 
 When an operation has 
 once been decided on, the 
 sooner it is undertaken 
 the better. The scalp 
 should be sha\ed and 
 thoroughly purified. An 
 anaesthetic may or mav 
 not be given, accordinj; 
 to the condition of the 
 patient. In a simple de- 
 pressed fracture the 
 surgeon should never in- 
 cise the skin directly over 
 the wound, but should 
 turn down a flap to avoid 
 the presence of a cicatrix 
 over the lesion in the bore. 
 Having cleared a\va\ 
 blood-clot and exposed 1 
 the fracture, if there is no 1 
 projecting margin of bone 
 he will have to trephine,] 
 placing the centre-pin 
 upon some firm undepressed bone as near the edge of the wound as 
 possible (Fig. 231). An elevator can now be introduced, the frag- 
 ments prised up into position, and the condition of the inner table] 
 investigated. The opening in the skull may be enlarged by 
 cutting pliers or a Hey's saw, but all the bony tissue taken away I 
 during the operation should be kept in warm boracic lotion, or, 
 better still, in warm saline solution or blood serum, if obtainable. 
 When the loss of substance is small, there is no need to replace J 
 the fragments, but where it is of considerable size it is wise toj 
 attempt this, wedging them accurately together, so that none lief 
 loose in the wound. An opening for drainage may be left between] 
 them, if need be. In other cases they may be chipped up intaj 
 small pieces and powdered over the wound. 
 
 In a compound depressed fracture, the skin- wound may bej 
 
 Fig. 231.^ — Punctured Fracture of Skull, 
 SHOWING Spot for Application of Tre- 
 phine. 
 
HEAD INJURIES 
 
 641 
 
 re the neglect 
 we ha\e been 
 c epilepsy due 
 ilight, and the 
 lat the patient 
 fiven the bene- 
 ploration.espe- 
 one can never 
 of the amount 
 istained by the 
 
 n operation has 
 decided on, the 
 is undertaken 
 :. The scalp 
 i sha\ed and 
 ! puriiied. An 
 : may or may 
 iven, accordin;; 
 indition of the 
 In a simple de- 
 fracture the 
 hould never in- 
 iin directly over 
 id, but should 
 I a flap to avoid 
 ice of a cicatrix 
 isioninthehoie, 
 cleared away 
 and exposed j 
 e, if there is no 
 margin of bone 
 ve to trephine,! 
 the centre-pin 
 of the wound as I 
 tduced, the fraj,'- i 
 the inner table ] 
 3e enlarged by 
 ^ue taken away! 
 racic lotion, or,] 
 1, if obtainable. 
 leed to replace] 
 ze it is wise t^j 
 that none lie] 
 Ibe left between 
 |hipped up into 
 
 /ound may be] 
 
 enlarged, or a flap turned down, and the bone dealt with according 
 to circumstances. It may suffice to saw off a portion of a pro- 
 jecting fragment, so as to allow entrance to the elevator, or it 
 niay be necessary to trephine. In these cases, the fragments 
 of bone removed must be well purified in warm carbolic lotion 
 
 in 40) before being placed in the saline solution. The brain 
 and membranes will need careful purification if wounded, and 
 this may be accomplished without fear by washing with a 5 per cent. 
 carbolic solution. Protruding brain substance may be removed, 
 and the dura mater lightly stitched across the gap ; the bones 
 niav then be replaced, but room must be left for a drainage-tube to 
 pass within the dura to carry away any fresh effusion ; it may be 
 removed in forty-eight hours, if the case progresses satisfactorily. 
 
 In a punctured fracture, although the opening in the bone may 
 I be small, a large circle is removed, since the inner table is almost 
 always extensively damaged. The centre-pin should rest on 
 sound hone, as near the opening as possible (Fig. 231), and care 
 must be taken to include all depressed fissures in the field of 
 operation, 
 
 In all cases the patients should be confined to bed with the head 
 
 jlow, and the general rules suitable to head injuries followed. It 
 
 is by no means certain that elevation of the depressed bone will 
 
 relieve the symptoms, as they may be due to ha^morrhagic effusion 
 
 [into the brain which cannot be reached. 
 
 For treatment of gunshot injuries of the skull, see pp. 167 and 
 1 660. 
 
 Injuries to the Int racranial Bl ood vessels . 
 
 I. Wounds of the Ven ous Sinuses_are by no means uncommon, 
 
 [being' torn across m fracfures, or punctured either by some 
 
 [sharp instrument, or by spicules of bone. The superior longi- 
 
 [tudinal, petrosal, lateral, and cavernous sinuses are those most 
 
 Ifrequently involved, especially the first, because it is more inti- 
 
 linately connected with the bones than any of the others. When 
 
 Ithere is no external wound, and only the outer wall of the sinus 
 
 been opened, the haemorrhage, if at all severe, will strip 
 
 lup the dura mater and compress the brain, producing effects 
 
 Iresembling those due to meningeal haemorrhage, but slower in 
 
 Iheir onset, and less severe in their course ; if the wound is small, 
 
 pe bleeding is not so great, since comparatively little pressure 
 
 Buffices to arrest it by flattening the sinus against the bone, or 
 
 llie hole may be filled by the spicule of bone, and bleeding does 
 
 lot occur till it is displaced. If, however, the inner wall of the 
 
 linus is torn across, the blood finds its way between the meninges, 
 
 Ind gives rise to the symptoms of diffuse intra-meningeal haemor- 
 
 lliage. When an external wound exists, there is the usual 
 
 kvidence of venous bleeding, but it is readily checked and rarely 
 
 41 
 
642 
 
 A MANUAL OF SURGLlis 
 
 fatal. Septic thrombosis and pyaemia are the chief danfjers, 
 but entrance of air has also led to a fatal issue m a few cases,' 
 Treatment, wlien practicable, consists in plugging the sinus with 
 aseptic gauze, and applying an antiseptic compress, pcjssihiy n... 
 moving fragments of bone in order to expor-e it. Where the outer 
 wall alone lias been torn, it may be possible to suture it \vitli(.iit| 
 interfering with its continuity. For symptoms and trealineiit of 
 septic thrombosis, see p. 655. 
 
 (^ Wounds of the 
 
 enTets* the skull attli etoranjerTs 
 
 ilft Mftn^"*^*^"^ Artery. — T1 
 anien sninosum , and subs 
 
 .—This vessel, wiiidi 
 sef^uently dividesi 
 into two branches whirl 
 ramJfy_]')eTween tiie sT< iiJ| | 
 and 
 
 t he dura mater, i> 
 occa' sion'n1ty'"''^t'Tirp t u r ed, 
 witli orwitliout a tractiiiei 
 of the skull. Theaiitcriiirl 
 branch is most fre(iiieiit 
 injured as it crosses the| 
 antero-inferior angle 
 the parietal bone, as tliel 
 result of a fissured frac-j 
 ture ; but it is \ery liablel 
 to be torn by a puiictiiredj 
 wound, since the bone isl 
 very thin in that locaIity,[ 
 or by a depressed fractua',j 
 The artery is, howevcrj 
 sometimes ruptured by 
 blow on the side of tlid 
 head, sufficiently severe toj 
 detach the dura materJ 
 but without causing iinyj 
 injury to the bone; this 
 membrane always carriei 
 the vessel with it, and il 
 it emerges from a bony canal just at that spot, as so otteif 
 happens, the artery is torn across by the projecting inner lip oj 
 the canal. Whether or not the dura is primarily detached, tlif 
 blood soon collects between it and the bone, pressing the brain 
 inwards, and burrowing down towards the base of the skulj 
 (Fig. 232). Such is due mainly to the force-pump-like action ( 
 the arterial pressure, for when fluid is driven into a closed cavityj 
 the power of the jet is multiplied by the area occupied. Theclor 
 rarely measures more than 4 inches in diameter. The posterioj 
 division is only wounded in about 5 to 10 per cent, of the cases. 
 The Symptoms are, unfortunately, often obscuied by soniecd 
 existent cerebral lesion or complication : but in a typical casi 
 
 Fig. 232. — Meningeal Haemorrhage. 
 (From Specimen in College of Sur- 
 geons' Museum.) 
 
HEAD INJURIES 
 
 643 
 
 three stages should be present, viz. : (a) A primary con^^iissioD . 
 ;is the resulX_^f the blow ; (/;) a temporary return to coriscious- 
 
 ness; :incr(f) the "gradual supervention of coma within twenty- 
 four hours, and that usually without any considerable rise of 
 I temperature. The interval of consciousness varies widely, but is 
 I not often longer than an hour or two, whilst in many cases it is 
 Uciircely recognisable. As accessory signs, the following may be 
 I mentioned : (a) Since the blood-clot is situated close to the motor 
 area of the cortex, and especially over the centres for the head 
 |;inilarm, twitching of these parts, followed perhaps by paralysis, 
 niiiy be a well-marked feature, and usually supervenes before the 
 onset of coma ; (b) when the clot extends to the base of the skull, 
 it presses on the cavernous sinus, and may induce passive con- 
 hjcstion of the eyeball, paresis of some of the ocular muscles, and 
 proptosis, with possibly a dilated pupil and high temperature; 
 ml (f) when a fissure exists in the bone, blood may filter through 
 [into the temporal fossa, and cause a marked fulness in that region. 
 The Prognosis is extremely unfavourable, von Bergmann stating 
 Ithat, out of ninety-nine cases, only sixteen recovered. 
 
 The Diagnosis of subcranial haemorrhage is easy if tliere is an 
 [open \vt)und, or if the symptoms are at all typical ; but even then 
 lu.s difficult in all cases to be certain that the middle meningeal 
 [artery has given way, and that the symptoms are not due to 
 Ivenous bleeding. An examination of the injury and of the part 
 struck, and the rapidity of onset of the symptoms, may help in 
 liis matter, but it is often impossible to make a diagnosis with 
 Iccrtainty. 
 The Treatment_con sists in trephining in order to remo\ e the 
 S^tne artery r^if sTtll t^leedin^^. 1 he soot 
 
 nod-cl ot" ap i-r c|pr. nrp_ tue art ery, ~it s zni Dieecimg. 
 seTect ed fp , ii , de^di^ng vvitji tlTe ante rior~division oi th e artery is 
 iT inches behind the externafangular process^ the rrontal hone, 
 nd i^ inches above the zygoma (Fig. 276, F), and this point 
 [should be marked on the bone with a bradawl through the scalp 
 ffore commencing the operation. The scalp is shaved and 
 horoughly purified, and a flap turned down, including everything 
 sfat as the pericranium (Fig. 69, E). A crucial incision is then 
 
 ade over the selected spot, and the pericranium reflected suf- 
 iciently to allow a i-inch trephine to be applied. On removing 
 :lie disc of bone, a mass of blood-clot presents, which should be 
 roken up with the finger and washed away. If the artery is 
 
 en bleeding on the dura mater, it may be possi'^' ; ':o pick it up, 
 nd tie or twist it, or a fine curved needle thre i • ' with catgut 
 
 ay be passed under it, and thus a ligature applied. If, how- 
 iver, the blood comes from a canal in the bone, the outer table 
 
 ust be clipped away, sufficiently to enable the canal to be seen 
 plugged by a small piece of aseptic wax, sponge, or gauze, 
 
 liich may be left without danger. The flap is then replaced, and 
 
 itched down, a drain-tube being inserted for a time. 
 
 41 — 2 
 
644 
 
 A MAS UAL OF SURGERY 
 
 The posterior branch of tlie artery can l)e reached hy tri|)liinini» 
 inunediately below tlie parietal eminence at i\w same level as tor 
 the anterior branch — i.e., i\ inches above Keid's base liiu'ior. 
 a^ain, it can be exposed nearer its origin at a spot i;,' inclits 
 behind the external angular process of the frontal bone, and > Inch 
 above the upper margin of the zygoma (Fig. 276, G). 
 
 3. Wounds of the Internal Carotid Artery, in its intracranial! 
 portion, are rare, but if complete are necessarily fatal. Tliev 
 usually result from penetrating wounds of the orbit, or from iij 
 gimshot wound, or the vessel may be torn by a splinter of hone in 
 a fracture of the base of the skull. fissures throii<;h the 
 carotid canal do little harm, since thei^ .^ plenty of room within 
 it around the artery. Occasionally, however, the artery is slij,'htlv 
 torn, and an aneurismal varix results between it and the ciuernuiis 
 sinus. Of seventy-five cases of pulsating exophthalmos, Rivinfj.l 
 ton found that forty-one were caused by trauma, and wcieprohl 
 ably of this nature. 
 
 Treatment. — The injury is fatal in the majority of cases iieforei 
 help can be obtained; if not, c(impression or ligature of the! 
 carotid trunk in the neck is the only hope. See also on intra-I 
 orbital aneurism (p. 244). 
 
 4. Intrameningeal Hemorrhage arises from wounds of iliJ 
 cerebral cortex or membranes in cases of fractured skull, or I'roinl 
 concussion without fracture. The blood may be derived tromthd 
 veins and capillaries so abundantly prr it in the pia mater, orj 
 from lesions of the inner wall of venoi uses, or even from tliej 
 
 middle meningeal artery, if the dura 1 er is also opened, llj 
 
 may be widely diffused over the surface of the hemisplieres, or h( 
 more localized. It is often but slowly absorbed, and may hecomd 
 encapsuled, constituting what is known as an arachnoid cyst, ),(.J 
 a closed cavity containing serum, the walls of which are formed o| 
 fibrous tissue stained brown with hajmatin. 
 
 The Symptoms are those of cerebral compression, and usualljj 
 supervene directly on concussion without any conscious intervall 
 The coma is often of long duration, though, as a rule, not of {^rea 
 intensity. Perfect recovery may ensue, even though unconscious 
 ness is prolonged for weeks; but adhesions may form as thj 
 result of a chronic meningitis lighted up by the iiccident, and thif 
 may lead to subsequent troubles. No focal symptoms are pn^ 
 duced unless the haemorrhage arises from or presses upon thj 
 motor area, when convulsions, or later on paralysis, may ensue. 
 
 The Treatment is symptomatic, the patient being kept absoiuteii 
 quiet, and all excitement and noise which might induce cerebr^ 
 congestion excluded. Should there be any focal sympton 
 indicating the position of greatest pressure, or should there ll 
 some concurrent lesion of the skull, the trephine may be applie^ 
 
HEAD INyURIES 
 
 64s 
 
 );)ne, iiiul ' ind 
 
 at this spot. It tmist not be forj,'otten, however, that the chief 
 hatnorrhaj^'e often occurs (as will he presently |)ointetl oiilj, not 
 ,it the point to which the injury was directed, but at an exactly 
 opposite spot on the other side of the cranium, and hence con 
 
 [ -iderable uncertainty in;iy arise both as to the advisabilits' of an 
 
 I operation, and the site. Shtndd the rij^dit locality have been 
 exposed, the dura mater will probably bul^'e into the wound, 
 after the circle of hone has been removed ; it is blackish blue in 
 
 1 colour, owinj^' to the clot lyinj^ beneath it, and the cerebral pidsa- 
 tions will not be detected. It is carefully incised, and the l)lood- 
 
 [dot removed; any bleedinj^-points should l>e tied or compressed, 
 or it may he necessary to insert a small wick of ai-i-ptic gauze for 
 
 ladiiv or two, in order to drain off serum and blood. 
 
 3. Cerebral Haemorrhage occurs more frecjuently from idiopathic 
 
 |c?iises than from trauma, except in the case of severe lacerations. 
 
 I In till' more aggravated forms, death is almost certain to follow in 
 
 a short time from coma ; the symptoms of the less serious cases 
 
 arc discussed later on under the heading ' Laceration of the 
 
 Brain' (p. 656). 
 
 General Conditions of the Brain after Head Injuries. 
 
 Conc ussion of the Brain, o r stunning, is a clinical condition 
 Ichar acterized hy a more or'less ccTnulete susoension r^f its; tnn c- 
 llion s as a result ot some m iu rv to the he?^d w^if >] p]^»y r>r mnw 
 "have produced ah anato mi c;il l<;;§jon . It varies with the 
 ^verity ol tne cause IronTa slight momentary giddiness and con- 
 Ifusion of thought to the most complete insensibility, and is closely 
 lalliedto shock, from which, indeed, it is often distinguished with 
 IffiuTty^ '^ 
 
 In fatal cases, one fi nds on post-mortem Q.xarnination merel vL 
 I 'he same conditions as^obtain in shock, v iz., en gorgement ot trie 
 |l!ifl££, viscera, and the right side ot tlie heart, w hilst the l^r;iin 
 j presenti; som^ lesion ot varying, sev erity, £rorn mere punctiform 
 jtcciiynioses to actual disintegration and disorganization. The 
 yinptoms are supposed to be due to a paralysis of the vaso- 
 motor centres in the medulla and subsequent loss of vascular 
 jtone, allowing the blood to gravitate to the most distensile parts, 
 p., the portal system. Reflex inhibition of the heart through 
 ie vagus may also assist in their production. More recently 
 Diiret has suggested that the blow on the skull causes a tem- 
 lorary depression, and this leads to compression of a cone-shaped 
 Tea of the brain substance. As a result, the cerebro-spinal fluid 
 s displaced and forced downwards to the base of the skull, where 
 'tends to collect, particularly in the fourth ventricle, and thus 
 llie vital centres grouped around this space are compressed, and 
 temia of the brain (which all authorities admit to be present) is 
 
m 
 
 646 
 
 A MANUAL OF SURGERY 
 
 produced. The explanation of concussion thus afforded is verv 
 feasible. 
 
 The Symptoms vary considerably in degree, but in a well-markid 
 case the stage of concussion is evidenced by unconsciousness, 
 more or less complete, although the patient may sometimes he 
 roused by shouting at him ; he lies on his back, with the inusclts 
 relaxed and flaccid ; the eyelids are closed, and the conjunctiva 
 often insensitive ; the pupils vary, but are equal and often con- 
 tracted, usually reacting to light, but in bad cases they may 
 be dilated, and do not contract when light is admitted. The 
 surface of the body is pale, cold, and clammy, and in bad cases 
 insensitive even to strung electric shocks. The respirations are 
 slow, shallow, and sighing, whilst the pulse is weak, flutterini;, 
 and scarcely sensible to the fingers ; the temperature is sub- 
 normal ; the sphincters are relaxed, with perhaps unconscious 
 evacuations from both bladder and bowel. The reflexes are 
 present in the milder cases, though sluggish ; in the more severe 
 tiiey may be entirely absent. 
 
 This condition may last for a considerable time, and then pass 
 slowly into more profound unconsciousness and death, or be 
 followed by the phenomena of inflammation, compression, or 
 cerebral irritation. If, however, the case is going on to recovery, 
 reaction soon begins to manifest itself. The patient is presumably 
 put to bed, and warmth carefully applied to the extremities. 
 The first sign of reaction is probably a slightly increased rate of I 
 both breathing and pulse, whilst he may be able to tell his name [ 
 and address ; sometimes the earliest indication of recovery is that i 
 he turns on his side, and pulls the bedclothes up to his face, since | 
 he feels cold and chilly as a result of the cutaneous anaemia. 
 Gradually he becomes more and more rational, and the functions] 
 of both mind and body are restored, reaction being fully estab 
 lished by the occurrence of vomiting, due to a condition of cerebral I 
 hyperaemia following the anaemia. Probably he suffers from 
 headache for some days, and a slight amount of fever will follow: 
 but this passes off, and leaves the patient either cjuite well, orj 
 with a somewhat irritable brain requiring prolonged rest. Subse- 
 quent events may, however, prove that more mischief has been I 
 done than appears at first. One sequela of concussion may bej 
 that some special function of the brain is permanently lost orj 
 impaired such as memory, hearing, or vision ; thus, a paticntl 
 may ferget the names of places or persons, or may lose all menioryj 
 of time ; speech may become defective or stammering, or a certain! 
 amount of asthenopia (weakness of vision) may supervene. Suchl 
 individuals are very liable to recurrent attacks of inflammation,] 
 one of which may prove fatal. Others are left with an in 
 ordinately irritable brain, incapable of standing any excess oti 
 work or diet ; and in such, a sudden fatal issue is not uncomnion.l 
 Others, again, seem to suffer from a general loss of nerve tone! 
 
HEAD INyURIES 
 
 647 
 
 fforded is very 
 
 a a well-marked 
 nconsciousness, 
 r sometimes be 
 ith the musclfcs 
 :he conjunctiva 
 and often con- 
 ases they mav 
 admitted. The 
 nd in bad cases 
 respirations art 
 '^eak, flutterint;, 
 lerature is sub- 
 ips unconscious 
 he reflexes are 
 the more severe 
 
 , and then pass 
 id deatli, or be 
 compression, or 
 f on to recovery, 
 nt is presumaliiy 
 the extremities, 
 increased rate of 
 to tell his name j 
 recovery is that 
 [to his face, since 
 aneous anemia, 
 nd the functions 
 ing fully estab- 
 ition of cerebral 
 |he suffers from] 
 ver will follow: 
 r quite well, or | 
 ed rest. Subse- 
 lischief has been I 
 icussion may bej 
 [nanently lost orj 
 thus, a patient 
 lose all menioryl 
 ing, or a certain] 
 pervene. Such 
 f inflannnation,| 
 left with an In- 
 ^ any excess ofl 
 not uncoinmon.j 
 ,s of nerve tone! 
 
 (neurasthenia), rendering them incapable of fulfilling their ordinary 
 duties in life. 
 
 The Treatment of concussion very closely resembles that of 
 shock, viz., the patient is at once put to bed, with the head low, 
 and is covered with warm blankets ; hot-water bottles may be 
 applied to the extremities, and friction to the surface. Any need- 
 less stimulation must be avoided, since it may suffice to light up 
 bleeding ; a liiiie warm tea may be given if he can swallow, or, 
 if in extremis, brandy or ether by the rectum, or a hypodermic 
 injection of strychnine. On the establishment of reaction, but not 
 tefore, a good purge, such as 5 grains of calomel, should be 
 administered, and the patient is then kept for some days in bed 
 oa a restricted diet, with the bowels freely open and all sources of 
 excitement excluded. 
 
 When the unconsciousness is prolonged, and the absence of 
 signs of fracture in the cranium or of focal symptoms prevents the 
 localizing of the lesion, the head should be shaved, and an icebag 
 or Leiter's tubes applied ; the bowels are kept acting freely, and 
 the state of the bladder attended to ; the room must be kept 
 dark and quiet, the attendants making as little noise in walking 
 I and talking, etc., as possible ; sufficient nourishment must be given, 
 either by a spoon, if the patient can thus take it, or by nutrient 
 enemata. In the former case iced milk and chicken broth or beef- 
 tea must be depended upon. 
 
 Cerebral Irritation. — By cerebral irritation is meant a clinical 
 i Condition characterized by great irritability of both mind and 
 bady, into which a patient sometimes passes after concussion. It 
 Usually follows blows or falls on the temple, forehead, or occiput, 
 'and is prol)ably due to a superficial laceration of the brain, possibly 
 I in the frontal region, and the hyperaemia caused by its subsequent 
 I repair. 
 
 The Symptoms are very characteristic, and usually manifest 
 
 j themselves two or three days after the injury. They may be 
 
 [divided into two groups, (a) Bodily Symptoms: The patient lies 
 
 on his side in a condition of general fiexion, the back arched, the 
 
 leii;s drawn up to his abdomen with the knees bent, and the hands 
 
 and arms drawn in. He is restless, and may toss about, but 
 
 never fully extends himself, or lies supine. The eyes are closely 
 
 shut, and he resists all attempts to open them ; the pupils are 
 
 contracted ; the temperature is usually a little raised, but the 
 
 hurface of the body and head are both cool ; the pulse is fjuiet, 
 
 jhut ueak ; the sphincters are usually in a normal condition, and 
 
 jthe excreta are often passed in the bed, but the bladder may 
 
 joccasionally need to be emptied by catheter. In some mild 
 
 jinstances the patient may get up to empty his bladder and then 
 
 jreturn to bed. {b) Mental Condition : The patient is by no means 
 
 junronscious, but he takes no heed of what is passing around, and 
 
648 
 
 A MANUAL OF SURGERY 
 
 is intensely and morbidly irritable. "When disturbed, lie will 
 gnash his teeth, frown, swear, and resent the intrusion in the most 
 expressive manner. At the end of a few days, or perhaps after a 
 week or two, a marked alteration in the condition of the patient 
 usually shows itself. He is less irritable, begins to stretch hiiuself 
 out, and with this is conjoined an improvement in both pulse and 
 temperature. A change is sometimes noticed in his mental state, 
 since he may be quite childish and weak. ' Irritability gives way 
 to fatuity ' (Erichsen). In this stage he may need to be treated 
 as a child, and even taught the names of persons and things ; later 
 on he may glibly detail the history and cause of his accident, 
 giving a fresh story every day, but frequently there is an ahsolute 
 lapse of memory concerning the accident and the events which 
 led to it. After a time the brain recovers, but more or less serious 
 after-effects are likely to ensue. Sometimes the symptoms pass 
 over, however, into those c .bacute or chronic meningitis. 
 
 In the Treatment the su. ^eon must remember that there is a 
 considerable tendency to asthenia, and hence, while the patient is 
 kept quiet and free from all noise or excitement, he must be well 
 supported by a light and nourishing diet. The h^ad should be 
 placed low and shaved, and Leiter's tubes fitted on, if the patient 
 will permit it ; but it is better to omit this entirely than to apply 
 cold intermittently. The bowels must be kept well open, and 
 possibly small doses of bromides, or even opium, may he useful, 
 If any signs of meningeal inflammation follow, such as rise of I 
 temperature and pulse, heat of head, and great sleeplessness, 
 blisters or leeches may be applied locally, and mercury ad- 
 ministered internally. 
 
 " 1 ■ I 
 
 Compression of the Brain. — Compression is the term given to a | 
 clinical condition due to some abnormal and excessive intra 
 cranial pressure which disturbs the functions of the brain. Wheni 
 of traumatic origin, it may arise from the following causes: 
 
 (a) Depressed bone or the presence of a foreign body, in which I 
 case the symptoms of concussion merge directly into those of 
 compression, and usually without any interval of consciousness;! 
 
 (b) extravasation of blood within the cranium, either outside the 
 membranes, or on the surface of the brain, or within its substance. 
 If the bleeding is extradural, there will probably be a short 
 interval of consciousness between the concussion and the com- 
 pression ; if the bleeding is cerebral, the symptoms of compression 
 may manifest themselves at once without any interval being! 
 noticed, (c) It may be due to an acute spreading adenia, the! 
 explanation of which is subsequently given (p. 657). {d) It niayi 
 arise from a collection of inflammatory exudation or pus, in wh 
 case the symptoms are preceded by those of inflammation, and atj 
 the earliest will not manifest themselves before the third day.) 
 whilst they may be deferred for a week or two. 
 
HEAD INJURIES 
 
 649 
 
 Compression may also arise as a result of idiopathic haemorrhage, 
 tumours, gummata, or abscesses, e.g., as a complication of middle 
 ear disease. 
 
 The Symptoms of compression are essentially those of coma. 
 When the condition is well established, the patient lies on his 
 back absolutely unconscious, and cannot be roused either by 
 shoutinf,' or shaking. His breathing is slow, laboured, and ster- 
 torous, the lips and cheeks being puffed in and out. The stertor 
 arises from paralysis of the soft palate, and the puffing of the 
 cheeks from paralysis of the facial muscles. In the later stages 
 the respirations may be more rapid and irregular, somewhat 
 approaching the Cheyne-Stokes type. Death arises from cessa- 
 tion of the respiratory act. The pulse is full and slow at first, 
 but later on becomes rapid and irregular, owing to increased 
 pressure upon and exhaustion of the medullary centres. The 
 mjiue of the body may either be cool, hot, or perspiring ; the 
 body Umpetatnre similarly varies, in some cases being hyper- 
 pyrexia!, in others low, and where the compressing force is uni- 
 lateral, there may be some difference on the two sides of the 
 body. The pupils become dilated without responding to light, 
 but vary according to the degree of compression and the situation 
 [of the compressing agent. If the cerebral pressure is equally 
 I diffused, both pupils first contract, and then gradually dilate and 
 I become reactionless ; but if one hemisphere is affected more than 
 [the other, the pupil on that side passes rapidly through these 
 [changes, whilst on the opposite side they are not developed until 
 [later. Thus, it is a common thing to find the pupils unequal in 
 :size, and reacting differently to light. The whole body in the 
 i later stages is in a condition of motor paralysis, but at an earlier 
 [period of the case there may be some difference on the two sides, 
 the lesion is unilateral ; thus, if the left side of the brain is 
 [primarily affected, a right-sided hemiplegia is likely to be present 
 [at a time when the muscles on the left side can still respond to 
 Icerebral stimuli. A localized compression involving the motor 
 [area may lead to convulsions in the corresponding group of 
 Imuscles. The bladder is paralyzed, and hence retention ensues, 
 jwhilst the sphincter ani is relaxed, and faeces pass involuntarily, 
 lalthough marked constipation is usually present. 
 
 The symptoms in some cases are ushered in by severe pain or 
 jlieadache, which is partly due to pressure upon and tearing of 
 Ithe dura mater, and partly to the altered \ascular conditions of 
 phe brain ; the brain substance itself is not sensitive, and hence 
 m pain is not directly referable to any lesion of or pressure upon 
 It. Naturally the clinical picture is modified according to the 
 pise of the compression, and it is impossible to discuss here more 
 pan the general features. The course of the case, too, varies 
 V'idely according to whether or not the compressing agent can be 
 femoved by the surgeon, or absorbed by natural processes. 
 
650 
 
 A MANUAL OF SURGERY 
 
 Patients not uncommonly recover from small cerebral and intra 
 meningeal haemorrhages causing temporary compression, hut 
 rarely do so without opera,tion if the symptoms are due to 
 depressed bone, the presence of a foreign body, or large exuda- 
 tions of blood, serum, or pus. 
 
 The Diagnosis of coma from compression, when a complete 
 history of the case can be obtained, is often easy, and, indeed, the 
 whole clinical aspect may be so typical that no question as to the 
 cause of unconsciousness can be raised. But when a person is 
 found in the streets unconscious, where no history either of the 
 patient or of an accident is obtainable, and where no serious 
 lesion of the skull is present, the diagnosis is often extreiiielv 
 obscure, since coma may be due to many other causes, (.(>,': 
 (a) Cerebral lesions, such as apoplexy, whether the result of 
 haemorrhage, embolus, or thrombosis ; or it may be the con- 
 sequence of a preceding epileptic fit, or due to a rapidly spreiiding 
 oedema in cases of cerebral tumour or abscess, (b) Various toxic 
 agen*^s may induce coma ; they may be introduced into the svsteni 
 from without, as in the case of alcohol, opium, or other narcotics, 
 or may be developed within the body, as in uraemia or diahetic 
 coma, (c) Heatstroke or exposure to cold may also lead toj 
 unconsciousness. In the latter case there can be but little doubt 
 as to the cause, since the patient is cold, pale, and in a state of j 
 severe prostration ; in the former the diagnosis may for a time be I 
 ^doubtful, (d) Lastly, it must not be forgotten that two or more 
 of these conditions may co-exist. Thus, a drunken man may fall 
 and break his skull, and then the smell of liquor in his breath itiav ] 
 lead to an erroneous diagnosis. 
 
 It is therefore evident that a very careful examination of the j 
 patient is required before any conclusion can be arrived at as to 
 the cause of the coma, and even then it may be impossible to 
 make a diagnosis. In such cases the patient should be carefully 
 tended and watched, and not shut up for the night in a police-cell j 
 witliout attendance. 
 
 The following points should always be observed in the! 
 examination : (i) A rapid note should be made as to the sur-j 
 roundings of the patient — whether there is blood or ^omit nearj 
 him, how the body is lying, and the nature of the ground. 
 (2) The depth of the coma should be ascertained, and, if possible.j 
 the man should be roused, and asked to give an account of 1 
 self. (3) A most thorough and complete investigation should bej 
 niiule as to his condition. His skull must be first examined, toj 
 settle if possible whether there is a fracture present ; the surtacej 
 temperature of the body is noted, as also the character of tliepulsel 
 and respirations. The tongue should be looked at, as it is utten| 
 bitten in an epileptic fit, and the smell of the breath should M 
 be noted. The condition of the pupils may throw some light on 
 the case ; in opium-poisoning they are small and equal, a condij 
 
HEAD INJURIES 
 
 651 
 
 tion also seen in haemorrhage into the pons ; in alcohoHsm they 
 
 are often dilated and fixed, but vary considerably in different 
 
 cases. The amount of power and the state of the reflexes are 
 
 then observed, any inequality probably indicating a unilateral 
 
 lesion in the brain. The urine must be drawn off, and carefully 
 
 examined for albumen and sugar. (4) In dubious cases, and 
 
 : especially where there is any suspicion of drunkenness or poison, 
 
 jthe stomach should be emptied and washed out. (5) Finally, if 
 
 the cause is still uncertain, the patient should be put to bed and 
 
 I carefully watched. 
 
 The Treatment of compression must be, where possible, directed 
 
 I to removing the cause. When it is due to depressed bone or a 
 
 [ foreign i)ody, immediate operation is required ; collections of pus 
 
 i should he opened and blood-clots removed. Failing such measures, 
 
 the treatment of the condition resolves itself into keeping the 
 
 patient (juiet, with the head low and cool, the room dark and 
 
 [noiseless, the bowels open (using croton-oil on sugar, or enemata, 
 
 [for this purpose), and the bladder empty. The patient may have 
 
 to he fed by the rectum, and if the breathing or pulse is very 
 
 laboured, and cyanosis begins to show itself, venesection may be 
 
 [advisable. Considerable interference with the respiration arises 
 
 [from falling back of the tongue, as often occurs in profound anaes- 
 
 Ithesia during surgical operations, and if due to this cause the head 
 
 liiiav be rolled over to one side, or the tongue pulled forwards, j 
 
 [Orasionally patients remain in this condition for weeks or months, v 
 
 Intracranial Inflammation. — Inflammation of the cranial contents 
 lis often met with as a result of injury, and although we shall 
 [describe several distinct varieties, it must be vemembered that 
 he various forms run into one another, and that in practice mixed 
 |types are the more common, giving rise to a corresponding com- 
 )lexity of symptoms. For descriptive purposes the following 
 [groups may be distinguished : 
 
 (i.) Subcranial Inflammation. — This may occur in the form 
 [either of an effusion of pus between the dura mater and the 
 [bone [suhcvanial abscess), or as a thickening of the dura mater 
 ftichymeniugifs). 
 
 The former results from either a compound depressed or a 
 Ipanctured fracture, in which the dura mater is only separated 
 jtrom the bone and not lacerated, especially when the external 
 jwund is small and efficient drainage is not obtained. It some- 
 limes occurs, however, in consequence of a simple contusion or 
 picture of the skull, leading to a detachment of the membranes 
 pi a collection primarily of blood and later of inflammatory fluids 
 fn the ca\ity thus produced. Microbic invasion is here due to 
 »uto-infection, or to the passage of organisms through the bone. 
 t\part from injury, its most common cause is, without doubt, 
 ptension of inflammation either from the superjacent bone or 
 
6S2 
 
 A MANUAL OF SURGERY 
 
 from the middle ear. The Ssrmptoms produced are (i) those 
 generally characteristic of suppuration, viz., a high tempirature 
 with perhaps rigors. (2) The signs of intracranial pressure in 
 the form of fixed headache followed by coma are also present. 
 (3) If there is no open wound, an cedematous swelling of the scalp, 
 known as Pott's puffy tumour, may develop over the site of the 
 abscess (Fig. 233). When there is acoinound fracture of the skull, 
 the margins of the wound look unhealt.iy, and at its base may he 
 seen bare bone, yellow and dry, from which the pericranium has 
 separated, with perhaps pus oozing out between the fra<j;ments. 
 If the pus burrows towards the base of the skull, optic neuritis 
 may develop. (4) Focal symptoms of spasm or paralysis may 
 complicate the case if the dura over the motor area is involved, 
 The Treatment of such a condition consists in evacuating; the 
 
 Collection 
 of pus. 
 
 Inflamed (Edematous 
 bone. scalp tissue. 
 
 Subduial space, 
 
 Scalp. 
 Cranium. 
 
 Brain covered 
 by pia in.iter 
 and arachnoid. 
 
 jfW '\!^'^ 
 
 Fig. 233.— Subcranial Suppuration, involving Overlying Hone a.m)| 
 CAUSING an (Edematous Condition of the Scalp — Pott s Piffv 
 Swelling (Semi-diagrammatic). (From Treves' ' System of Sur- 
 gery.) 
 
 abscess ca-v'ity through a sufficient opening made by trephining, 
 or by removing loose portions of bone, and providing for draina),'e, 
 Sometimes more than one opening is required for this purpose. 
 
 Simple pachymeningitis, or thickening of the dura mater, niayj 
 result from a slight simple depressed fracture, or even from con- 
 tusion with or without a fissured fracture. No immediate syiiip-j 
 toms need arise, but those characteristic of chronic meningitisl 
 described below are usually met with at a later date ; in fact, itj 
 is impossible to distinguish clinically between the two affections, 
 
 (ii.) Acute Diffuse Meningitis is always infective in nature,! 
 although a simple form used to be described, supposed to resultj 
 from merely mechanical causes, but probably also due to bacterial 
 of lesser virulence, such as the pneumococcus. The symptonisj 
 vary considerably in their intensity, according to the method ( 
 
HEAD INJURIES 
 
 6S3 
 
 , SubiUual space. 
 
 inoculation and the activity of the organisms. The superficial 
 part of the brain is involved in the inflammation as well as the 
 meninges, and the term meningo-encephalitis would perhaps be 
 the better appellation. 
 
 The Ss/mptoms manifest themselves about forty-eight hours 
 after the injury, although sometimes infection may be delayed 
 heyond this period. In the early stages the patient complains 
 of severe, constant, and increasing headache, associated with 
 heat of head, a forcible pulsation of the carotids, a full pulse, 
 and general irritability of the brain, as indicated by vomiting, 
 intolerance of light and sound, delirium, and perhaps convul- 
 sive tvvitchings of the muscles, not only of the head and back, 
 but also of the extremities. High fever is usually present, and 
 possibly a rigor may occur at the onset. As the disease pro- 
 ijresses, the patient gradually passes into a state of coma, due to 
 cerebral compression, which usually persists until death ends the 
 chapter. 
 
 According to the site of infection, the inflammatory phenomena 
 may manifest themselves more acutely over one part than another, 
 and for descriptive purposes two chief varieties have been distin- 
 guished, viz., meningitis of the convexity, and meningitis of the 
 base. The general symptoms are alike in both forms, but slight 
 modifications occur in the details. Thus, when the convexity is 
 involved, convulsions are a more prominent feature in the case, 
 and may at first be limited to localized groups of muscles, whilst 
 in basal meningitis the temperature tends to run higher, the head 
 and neck are more retracted, optic neuritis is more frequent, and 
 joine form of squint is not uncommonly observed. 
 
 On post-mortem examination the skull-cap is separated from the 
 : meninges with some difficulty; the dura mater is thick and con- 
 [gested, and the subjacent veins are manifestly distended; the 
 cerebrospinal fluid is increased in amount, and turbid from ad- 
 mixture with lymph or pus; the arachnoid is thick and opaque; 
 the surface of the convolutions is flattened and cedematous, and 
 [lymph occupies all the sulci, matting them together ; the cortical 
 [grey matter is usually red and congested ; the underlying white 
 [substance of the centrum ovale is injected, numerous puncta 
 icruenta being evident ; the ventricles are distended with cerebro- 
 Ispinal fluid, and the choroid plexuses within are engorged with 
 Iblood. 
 
 The Treatment consists in shaving the head and applying cold 
 by means of an icebag or Leiter's tubes, care being taken that 
 pe application is continuous, and not intermittent. In the 
 pbust general venesection is useful, but in weaker individuals 
 pupping or leeching may replace it. The bowels are freely 
 Ppened and a bland diet ordered. The patient should be kept 
 polutely quiet in a darkened room, and every source of irritation 
 nd excitement removed. Even if recovery ensues, it is some- 
 
654 
 
 A MANUAL OF SURGERY 
 
 what delayed, and similar precautions as to quiet, etc., must be 
 maintained for some time. In the later stages, blistering of 
 the scalp or neck, and the administration of mercury, aif 
 advisable. 
 
 Attempts have been recently made to relieve the symptoms 
 and determine a cure by means of operative measures, directed 
 towards reducing the intracranial tension ; the subarachnoid 
 space has been opened below the tentorium, whilst others have 
 utilized Quincke's plan of puncturing the spinal membranes 
 between the third and fourth lumbar vertebra, i.e., below the 
 termination of the spinal cord. In no case of acute nieninffitis 
 has a successful result followed, and when one considers the 
 intricate character of the space to be drained, the fact that it is 
 sure to be subdivided into separate cavities by deposits of lymph, i 
 and especially when it is remembered that the important fourth 
 ventricle only communicates with the subarachnoid space throu"h 
 
 Collection of 
 
 pus beneath Inflamed 
 
 dura mater. bone. 
 
 Scalp. 
 Cranium, 
 Subdural space. 
 
 Brain with 
 pia mater 
 and arachnoid. 
 
 «.^4c>>^ 4^ •S'-^V" 
 
 -> * 
 
 Fig. 234. — SuTERFiciAL Abscess of Brain, spreading from Slbdip.,u| 
 Space (Semi-diagrammatic). (From Treves' ' System of Slkgeky ) 
 
 the small foramen of Majendie, which is certain to be early blockedl 
 — all these considerations go to prove that it is useless attemptingj 
 any such measures. 
 
 Acute Meningo- encephalitis is sometimes limited in characterl 
 when resulting from open penetrating wounds. Such can oniyj 
 occur when there is no tension from retained discharges, diffiisionj 
 along the meninges being prevented by the formation of adhesions.! 
 Localized suppuration is usually present, involving even the hniiif 
 substance ; but with care recovery may be possible, although 
 adherent cicatrix will be formed, giving rise possibly to suhsequenj 
 epileptic symptoms. A similar condition may result from bruisJ 
 ing of the bone and a localized suppurative inflammation connecteij 
 therewith (Fig, 234). 
 
 (iii.) A Subacute form of meningitis is occasionally met w'M 
 coming on at a somewhat later date. The patient may havf 
 
HEAD INJURIES 
 
 655 
 
 etc., must be 
 
 Iseless attempting 
 
 apparently recovered from his injury, with the exception of a 
 localized fixed pain. The onset of the symptoms is often due to 
 some indiscretion, and may be gradual or sudden. In all prob- 
 jliility this affection is also microbic in origin, and the delay in 
 its appearance depends either on the small number of bacteria 
 present, or on their being in a low state of virulence ; or pos- 
 sibly they have been lying latent for a time, and are aroused 
 into activity by later causes ; or, again, they may have gradu- 
 ally worked their way inwards along lymphatics or vessels from 
 the periphery to the meninges. The symptoms are similar in 
 character to those of acute meningitis, though somewhat less 
 [severe; but a fatal result is very apt to follow. In the tyeatmcnt 
 |o! this form, no active antiphlogistic measures should be adopted, 
 [since the patient's condition is somewhat asthenic. Absolute rest 
 and (juiet are essential ; counter-irritation should be applied to the 
 sciilp and neck, and possibly mercury administered. 
 
 (iv.) Chronic Meningitis may result from any injury of the 
 I meninges, and is very likely to occur in syphilitic patients. It 
 lis evidenced by infiltration and thickening of the membranes, 
 [which are usually adherent to one another and to the cerebral 
 [cortex. It gives rise to a localized headache, which is constant, 
 [and increased on excitement or the injudicious use of stimulants, 
 [whilst tenderness is often noted on deep pressure, and traumatic 
 [epilepsy may ensue. The tvcatwcnt consists in attention to the 
 [|;cneral health, abstinence from excitement or stimulants, the 
 [leal application of counter-irritants, and possibly the administra- 
 Ition of mercury ; the bowels must be kept regular, and if epilepsy 
 Ifollows, and the lesion can be localized, trephining may be 
 pecessary (see p. 665). 
 
 (v.) Cerebral Abscess may occur either in the early or late 
 |tai,'es of head injuries. In the early, it is usually superficial, and 
 pnected with some infective lesion of the scalp, cranium, or 
 nembranes, with or without a penetrating wound (Fig. 234). 
 In the later stages the pus forms deeply in the white substance. 
 It may be looked on as a more or less natural sequence of any 
 lenetrating wound, whether a foreign body is present or not, the 
 picrohes finding their way into the interior of the brain either 
 lirough the track of the missile, or along bloodvessels or lym- 
 Ihatics. When, however, it occurs apart from penetration, one 
 jan only suppose that it is due to auto-infection of a contused or 
 prated area. Chronic abscess of this type is most frequently 
 p on the same side of the brain as the lesion, and the parietal 
 Y frontal lobes are most often affected ; occasionally, however, 
 [may occur on the opposite side in the same way as a contusion, 
 [or treatment and symptoms, see pp. 680 and 778. 
 (vi.) In conclusion, one other form of intracranial inflammation 
 lust be mentioned, viz.. Infective Thrombosis of the Sinuses. 
 Tiis, though seen after injuries, is more commonly associated 
 
tifi 
 
 A MANUAL OF SURGERY 
 
 with suppurative diseases of the bone apart from trauma, and 
 one variety, viz., that affectinj^ the lateral sinus, is alniosi txelu- 
 sively caused by disease of the middle ear. It is also induced by 
 extension from scalp injuries as a complication of subaponcurutic 
 cellulitis, or may spread inwards from erysipelatous lesions of the 
 face or suppurative conditions of the nose. Puttin;,' aside the 
 results of chronic otorrhuea, che cavernous sinus is much more 
 frequently involved than any other. 
 
 Pathologically, the same manifestations are observed as in any 
 case of infective phlebitis. The sinus becomes impervious owin' 
 to the presence of a thrombus, and this in turn beconies dis- 
 integrated, and gives rise to multiple emboli, whilst various 
 inflammatory conditions of the surrounding tissues necessarily 
 result, e.g., necrosis or caries of bones, subcranial abscess, or 
 meningitis. 
 
 The symptoms are mainly of a pyannic nature. The tempera- 
 ture is high, but with remissions, and often with repeated rigors, 
 whilst fixed headache and early and continuous vomiting are also I 
 marked features of the case. With these may be associated 
 evidences of meningeal mischief, or of pulmonary trouble in the 
 shape of dyspnoea, whilst sometimes diarrhoea and septicemic J 
 manifestations may be the more prominent. 
 
 If the cavernous sinus is involved, marked exophthalmos, wittij 
 congestion of the orbit, eye, and even of the eyelids and face, inavl 
 result, and ptosis or squint may also be set up by implication otj 
 the nerves which lie in the w^alls of the sinus. 
 
 If the superior longitudinal sinus is affected, there may bej 
 turgescence of the veins of the scalp and foreheai together wii 
 tenderness along the line of the sinus and epistax.s, whilst con-j 
 vulsions may be induced by irritation of the neighbouring motorl 
 area. 
 
 For local results and treatment of thrombosis of the laterall 
 sinus, see p. 777. 
 
 Treatment, except for the lateral sinus, is but rarely possibleJ 
 and hence the importance of preventing this disease by a mos[ 
 careful attention to asepsis. For the lateral sinus much can ' 
 done, but for the other sinuses all that is feasible is attention 
 general measures. . 
 
 Laceration of the Brain. — Injuries to the brain and its niera 
 branes are \ery frequent complications of blows and falls on thi 
 head, and all the most serious results of these accidents arise troj 
 this source. They are produced in many different ways, anf 
 cause very varied symptoms ; but the most important distinctitj 
 to draw is between those wounds which communicate with 
 exterior and those which do not. 
 
 I. Non-pnnetrating Wounds of the Brain result from blows a 
 falls, which may or may not produce simple fissured or depress 
 
HEAD IN yu PIES 
 
 Iractiircs of the skull J., f ^^ ^' 
 
 ^^alsy.npto^KsfolJo^v'iWi;";^'"^T"^"^'>' ^'^^ most ZhZ ~ 
 
 "ocleprc.ss.on, ti,e ^.rentes n.ichr; r"' '" ^^^'^-^ vvl,.re the e is 
 ^ctly opposite to that ^/r i , ? ^'■^'^l"t;ntJy found -if . . 
 
 Ch sJk^hf..r TM.. '''f ■^^'^»^'<. whilst the I, J., I '"•' ''' '^ ("^'"t 
 
 l)served as in any 
 impervious owin" 
 
 Dsis of the lateral 
 
 . —,.,,^ Miearest uiisr^liw.f ; r -".^^r, vvncre there i< 
 
 ^.»fj..r portion ofll,' /, ^; ,'tn"ST';" »"™l"!i°n, ' ht ir" 
 
 produced. '^ '^' f'le subjacent hrain mav iJ 
 
 ^ Pathological Anatomy -TH • .• " '"'-^^ ^^^ «nlone 
 
 Ithoi.nf infl ?^ communcate with tu "^^^^.'" cases where 
 
 IK^^^ ''!!"' ^" ^^^ P''H inater thr "^"i ^^'^"^^ "pon the 
 
 I cired involved is small nr,^ • ^^ (i'^'//tf?.7 softeniim\ \( 
 ►over perferH,, fU r ^"" ""unnortanV fi. ^""J'^enttg). ii 
 
 I- ./st4'nVctr dtro''''"«?»'^<'rifc 
 
 P^«f. laceration of the brain th I P^^'^^^ysis must ensue In 
 
 42 
 
6s8 
 
 A MANUAL or SURGERY 
 
 m 
 
 talninfTf h.-rniatoidin crystals, whilst extravasated blood may W\ 
 orf^anized into a dirty brownish lamina, adherent to the pia matir, 
 or into an arachnoid cyst. 
 
 Clinical History. -The symptoms necessarily differ with the | 
 severity and locality of the lesion. 
 
 Whenever concussion occurs after a head injury, and the patitn'i 
 recovers slowly after it, the surj^eon will rij^htly suspect larerationi 
 or contusion of the brain. 
 
 If concussion is rapidly followed by the symptoms of ccrebrall 
 irritation, there can be no doubt as to the existence of a laccratiunj 
 which is probably situated in the frontal re^'ion. 
 
 If compression has supervened within twelve or twenty-fourl 
 liours, it is due to either depressed bone or ha^morrhaj^^e into tliel 
 cerebral hemispheres, if there is no interval of consciousness : liaij 
 if the patient has rallied for a time before its incidence, ha'inorrha,' 
 from the meningeal vessels or venous sinuses is to be diaj^'nosedj 
 or the existence of a rapidly s[)reading o'dema. 
 
 If localized or general convulsions occur within twenty-foul 
 hours of the accident, perhaps going on to compression, li;imor{ 
 rhage into the cortex of the motor area, or diffuse extravasatii 
 into the subarachnoitl space, is probably present. It is not eas] 
 to distinguish between these two, but haemorrhage into tlie corttj^ 
 usually produces a more regular extension of the convulsioiiij 
 which commence by twitching of some part of the body which 
 perhaps at the time paralyzed. Thus, if bleeding is occiirriDj 
 into the cortical centres for the face on the left side of the hoiiif 
 paralysis of the right side of the face may be presunt, and in 
 here that the convulsions will start, spreading regularly to tlij 
 right side of the neck, arm, and leg, and then involving thei 
 leg, arm, and side of the head in order, finally becoming general 
 as in an epileptic fit. After each convulsion the paralysis is foi!ii[ 
 to have spread. In haemorrhage outside the convolutions 
 paralysis is less marked and the convulsions less regular, tlioud 
 perhaps more generalized, but the symptoms of compressii 
 develop sooner. 
 
 If coma supervenes rapidly, and is accompanied by heinip^ 
 ha,'morrhage into the corpus striatum, internal capsule, or pwhaj 
 into the ventricles, is likely to be present. 
 
 In simple cases concussion is usuallv recovered from inal 
 hours ; the temperature subseque"t!) to about loo' F,, 
 
 remains so for a few days, ''ii ihe naiicnt complains of tisj 
 pain and headache, whit ..aitable •''eatment may entira 
 
 disappear. Some impairi of sense or iction may, liowevj 
 
 persist. 
 
 If subacute localized intlainma ion ensues, pain and lieadaj 
 will be complained of with some fever, and insensibility 
 supervene in four or five days, preceded by convu'^ions if| 
 motor area is affected. 
 
HEAD INJURIES 
 
 659 
 
 blood may be | 
 J the piii iniitti, 
 
 differ wilh tlv 
 
 ^, and the patitiv 
 Lispect hueral\Mr. 
 
 )toins of cerebrall 
 ce of a laceration,! 
 
 •e or twenly-fourl 
 norrhaf^e into tliel 
 insciousness ; but! 
 ence, ha'niorrhad 
 s to be diagnosed, 
 
 ,vithin t\venty-fuu| 
 mpression, lui'inorj 
 iffuse extravasatiuij 
 nt. It is 'lot eai 
 lage into the cortej 
 ){ the convulsions] 
 the body wbicb 
 ,edink' is occurrinl 
 t side of the bod 
 e present, and it 
 <r regularly to tb 
 ''involving the lei 
 becoming gened 
 e paralysis is toua 
 e convolutions ij 
 less regular, thou| 
 ims of compressi^ 
 
 inied by heniiple^ 
 capsule, ox peih- 
 
 l/ered from in a 
 about 100' I''.. 
 
 It complains of M 
 vtment nray entm 
 
 Suppuration in tlie wliite substance occasionally resiiUs at a 
 iiter date in this form of injury, giving rise to the symptoms of 
 Icerehial abscess. 
 
 The Treatment of these easels is always an exceedingly anxious 
 niitter for the surgecjn. In the majority of instances it is merely 
 hvmptomatic, following tlie usual course adopted in concussion, 
 cnnpression, cerebral irritation, etc., as indicated elsewhere. 
 
 :tion may. 
 
 howevi 
 
 pain and headai 
 Id insensibility " 
 convr' 
 
 qons 
 
 The patient is kept absolutely (juiet in bed, with an icebag to the 
 
 head, and a purge administered. Depressed bone, if present, 
 
 will, of course, be dealt with by operation. Early convulsions 
 
 and paralysis are carefully watched to see if any indication as to 
 
 the site of the bleeding can be obtained, since it is possible that 
 
 trephining over the injured spot and removing blood-clots might 
 
 k' advisable ; but the clinical records as to such treatment are 
 
 irv sranty. Late convulsions and paralysis due to inllammation 
 
 are best treated by shaving the head and applying an ice-cap. 
 
 ! the pulse is full and hard, and the patient otherwise young 
 
 pnd healthy, general venesection may be adopted; the bowels 
 
 Iriust be moved by a smart purgative, such as croton-oil, whilst 
 
 iromide in full doses may be administered. If the convulsions 
 
 :ontinue in spite of such treatment, and become more severe and 
 
 iNtensive, the patient will almost certainly die of coma ; trephining 
 
 ivtr the injured area is then di'^tinctly indicated, the surgeon 
 
 loping,' to find and remove some clot, or, at any rate, to relieve 
 
 tension within the dura. 
 
 II. Penetrating Wounds of the Brain result from blows or 
 
 lis, as in compound depressed fractures ; or from the entrance 
 
 if foreign bodies, such as bullets ; or from stabs or punctures, 
 
 hich most commonly occur in the weaker parts of the cranium, 
 
 [;,'., the temple or upper wall of the orbit ; or from sabre-cuts or 
 
 e-wounds, in which an oblique or almost valvular incision is 
 
 lade through the scalp and cranium, laying bare and wounding 
 
 le brain and its membranes. 
 
 [In these cases the general disturbance is often slight, compared 
 
 fitli the extent of the local injury, so that, although brain-sub- 
 
 ince may protrude from the wound, there is sometimes but 
 
 tie concussion. Any of the conditions due to haemorrhage 
 
 itailed above may follow, but they may be less severely felt, 
 
 icept in cases where the bleeding is into the substance of the 
 
 in, since the blood can escape from the wound. The inflam- 
 
 itory phenomena following such lesions are mainly septic in 
 
 iRin, and may be localized or diffuse. In the latter instance 
 
 leral meningo-encephalitis manifests itself in the course of two 
 
 three days, and is rapidly fatal ; in the former case adhesions 
 
 ivent the extension of the trouble beyond the neighbourhood 
 
 the wound. Hernia cerebri is very likely to follow, and not 
 
 frequently a deep cerebral abscess will complicate matters at a 
 
 r date. In cases that have been successfully rendered aseptic, 
 
 42 — 2 
 
66o 
 
 A MANUAL OF SURGERY 
 
 the course is similar to that run by a non-penetrating' \vouiul. 
 except that, if anything, the immediate pro^niosis is better, siiid 
 tlie opening in tiie skull and tiie possible removal of dam;i},'((l 
 brain substance diminishes the likelihood of compression fn)m 
 simple or spreading a'denui. Where the lesion has involved tht 
 motor area, pernianent monoplegia may persist. 
 
 Ihe Symptoms arising from a penetrating wound of the luain 
 liave been in measure indicated abo\e. In the worst ( ascs 
 inmiediate death may result, or severe concussion, merging (|iiicklv 
 into compression, from which the patient never recovers. In thi' 
 less serious cases there will be a \arying degree of concussioi,, 
 followed after a short interval by the phenomena of inflanini.itidi!. 
 localized or diffuse, which have already been sufficiently dcsi rilnd, 
 Focal symptoms may also arise from destruction of the corticai 
 <-entres. 
 
 Treatment. — In all cases of punctured or compound dcprcsMi! 
 fracture, we have stated that a thorough exploration of ilu 
 wound should be made, and all depressed or injured bone iv 
 moved. Foreign bodies should be also taken away, if found cl(Kr 
 to the wound ; but it is doubtful whether a bullet should I • 
 sought for, if it has penetrated deeply into tiie brain, or if it ha- 
 traversed the brain and fractured the bone on the other sid> 
 Probably an aseptic incision, with removal of the splintered (la- 
 ments and a limited search for the bullet, is tlie best treatnien; 
 to adopt, and, even if unsuccessful, will do but little harm, if 
 the patient's general state warrants an operation. When he i- 
 evidently moribund, it is better practice not to interfere. 1';; 
 truding brain tissue is gently remo\ed, and the whole woiiiul 
 thoroughly purified with carbolic lotion; e\en the i in 20 soliitinii 
 may be used without fear. The dura mater should, if possihk, I 
 be drawn together by one or two sutures, and a small druin-tiilie j 
 or a gauze wick inserted within it. Fragments of bone, if kept 
 warm and aseptic, may be replaced (p. ^>4o), and the scalp-wouiKil 
 closed, except at the drain opening ; the gau/.e or tube should I 
 removed, if all is going well, in about two days' time. It t!: 
 temperature rises as a result of septic infection, the wound 11111-; i 
 be reopened, and every effort made to relieve tension, and thii- 
 locali/.e the misciiief. Should diffusion occur, as indicated In an 
 increasing severity of the symptoms, the patient must be treats. j 
 in accordance with the general principles already laid down t.: 
 dealing with acute meningitis. 
 
 (In our description of lacerations of the brain we have piirposehi 
 omitted any mention of the fact that symptoms may arise tnffi 
 intlammatory conditions affecting the bones (p. 673). In ;utuai| 
 l)ractice the course of events is often considerably niodilid 
 such a complication.) 
 
HEAD INJURIES 
 
 661 
 
 Localized Injuries to the Brain. 
 
 Thus far we ha\e merely discussed the j,'enenil symptoms 
 arisiiif,^ from lacerations and wounds of the brain. We nuist now 
 rapidly pass in review the special symptoms resultinf^^ fn^m 
 injuries of particular re^nons. 
 
 Upper and Middle Frontal Convolutions.— Neither motor nor 
 sensory symptoms are noted, hut cerebral irritation and subse- 
 (Hient weak-mindedness are likely to follow, especially if the left 
 side is seriously involved ; lesions to the ri^dit frontal lobe do but 
 
 i"lG. 2J5.- HkAIN and Ct)NV()LLT10NS IN SlTU. 
 
 I The fissures of Kolando and Sylvius are indicated, and tlit- siuiatimi of tlic 
 diicf motor centres I'. C). F., Tarii'to-occipital fissuri; ; / /. level of 
 ttntnriiim with cerehcllum below it. The position of the lateral sinu^. is 
 also seen . 
 
 [little harm to a rif^ht-handed individual. Apparently the intel- 
 llectiial faculties are limited to one side of the brain, in the satne 
 pvay as the powi'r of speech. 
 Third Frontal Convolution. — INIotor aphasia, i.e., the inability to 
 
 prnduet! or articulate words, residts from lesions on the left side 
 fii ri-;ht-handed individuals, and on the rifjht side in left-handed 
 
 P("ple. Injury to the opposite convolution has no effect. If only 
 
^mmmmKmmm 
 
 662 
 
 A MANUAL OF SURGERY 
 
 one side is damaged, the other convolution can after a time he 
 educated so as to take on the function of the damaged region. 
 
 The Motor Area (Fig. 235) is comprised of the ascending frontal 
 and ascending parietal convolutions, respectively in from and 
 behind the fissure of Rolando, of the posterior half of the third 
 frontal convolution, and of the superior parietal lobule. The 
 centres for the leg occupy the upper part of the ascending parietal 
 convolution and the whole of the superior parietal lobule, those 
 for the hip being in front, and for the feet and toes behind. The 
 arm centres are located on either side of the middle of the lissure 
 of Rolando, the shoulder being in front and above, and the hand 
 and fingers below and behind ; whilst the centres for the head, 
 face, and lips are clustered together at the junction of the aseend- 
 ing and third frontal convolutions, the centre for movements oi 
 the angle of the mouth being higliest, whilst the lowest jiart of 
 the ascending frontal convolution governs the movements of tin 
 tongue and lips. Lesions involving any of these areas product 
 either spasm o paralysis of the appropriate region on the opposite 
 side of the body. 
 
 Wounds of one Occipital Lobe may cause a temporary hemiopia, 
 but no persistent loss of vision, unless the angular gyrus is also 
 destroyed. Lesions of the latter region are always associatd 
 with permanent disturbances of vision. 
 
 The Upper Temporo-sphenoidal Lobe contains the cortical 
 auditory centre, and lesions in this region cause deafness ; the 
 function of the middle and lower lobes is not yet ascertained with 
 certainty. 
 
 Injury to the Corona Radiata leads to paralysis of the regions 
 represented by the overlying cortex, but without convulsions: 
 whilst if the corpus striatum or internal capsule is lacerated, as 
 by haemorrhage, hemiplegia, with perhaps hemianjesthesui, will 
 result. 
 
 Wounds of the Cerebellum cause giddiness, vertigo, and ataxy, 
 the patient reeling about in a most characteristic manner, as if 
 drunk. 
 
 A wound of the Crus Cerebri occasions more or less complete 
 hemiplegia of the opposite side of the body, associated with total 
 paralysis of the 3rd (oculo-motor) nerve on the side of the iiijuiv, 
 
 Laceration or contusion of the Pons Varolii, if not immediately 
 fatal, may lead to paralysis of the opposite side of the body to the 
 injury, together with paralysis of the 5th, 6th, 7th, or ()tli nerves, 
 on the same side as the lesion, constituting the so-called ' crossed ^ 
 paralysis.' Marked contraction of the pupils (myosis) may alsoj 
 be present. 
 
 Wounds of the Medulla are usually fatal. If, however, the 
 patient should escape, he is liable to suffer from disturbed tunc 
 tions of the circulatory and respiratory centres, with perhaps 
 Cheyne-Stokes respiration and saccharine diabetes. 
 
HEAD INJURIES 
 
 663 
 
 Cranio-Cerebral Topography. 
 
 We cannot do more in this work than give a diagram repre- 
 senting the relations of the convolutions to the sutures (Fig. 235), 
 and, in addition, indicate the usual position of the two most 
 important fissures, viz., those of Rolando and Sylvius, and how 
 to mark out their situation on the cranium, although it must he 
 premised that their position is by no means constant. 
 
 The Fissure of Rolando may be found topographically by the 
 lollowing methods : (a) The upper extremity of the fissure 
 corresponds to a point half an inch behind the centre of 
 
 236- Diagram of Head to in'dicate Methoo of fin-ding the 
 FissLREs OF Rolando and Sylvius by Keid's Method. (After Keid.) 
 
 .1 /iss, Anterior branch of Sylvian fissure; 1*. (). I'iss., Parieto-occipital 
 fissure ; trans. Jiss., transverse fissure alouf,' line of tentorium ; A, external 
 anfjular process of frontal bone ; H., occipital protuberance ; C I), anterior 
 ptrpendiciilar in front of tragus ; IC F, posterior perpendicular through 
 liack of mastoid process. 
 
 Ithe line extending from the root of the nose to the occipital 
 
 tprotuberance. The direction of the sulcus is downwards and 
 
 Iforwards at an angle of about 67*^ to the middle line. This may 
 
 [lie indicated by laying a half-sheet of letter-paper over the skull, 
 
 |the long side corresponding to the middle line, and with its centre 
 
 over the upper limit of the fissure; the anterior half is now folded 
 
 over ohliijuely from this point, leaving an angle of 45" between 
 
 tie tront of the paper and the middle line of the skull ; and then 
 
 Itlie same process is again repeated, bisecting the angle and 
 
M«tM<UMlMMM«iiiMli 
 
 
 664 
 
 A MANUAL OF SURGERY 
 
 leaxing one of about 67", so that the anterior limit of the folded 
 paper corresponds to the line of the fissure, which is ;ihout 
 3^ inches in lenf^th. (b) A more exact method is that define! 
 by Dr. Reid, the measurements for which are all worked from 
 the so-called Reid's base-line, which is one drawn on the skull 
 from the lower margin of the orbit backwards through the centre 
 of the external auditory meatus, reaching the middle line behind 
 just below the occipital protuberance (Fig. 236). From it ar^ 
 drawn upwards two perpendiculars, one (C D) correspondin!; 
 to the small depression in front of the external auditory meatus, 
 the other (E l-') to the posterior border of the mastoid process 
 The fissure of Rolando extends from the upper limit of the 
 posterior vertical line to the point where the anterior line intir- 
 sects the fissure of Sylvius. 
 
 The Fissure of Sylvius is indicated by a line drawn from a point 
 1 1 inches directly behind the external angular process of tin 
 frontal bone, and about the same distance above the /.\ Lionia 
 (Fig. 236, A), to a spot three-fifths of an inch below the must 
 prominent part of the parietal eminence. The undivided portion 
 of the fissure is represented by the first three-quarters of an inch. 
 and from here the anterior limb (5,1'. a. Jiss.) rises vertically 
 upwards for about an inch, whilst the posterior limb extend> 
 backwards for the rest of the line. If prolonged to the middle 
 line behind, it indicates with tolerable accuracy the situation 0: 
 the parieto-occipital fissure (P. O. Fiss.). 
 
 Many complicated craniometers have been devised from time 
 to time, but need no description. For practical purposes tlie 
 above measurements suffice as a foundation to work out a 
 complete topography of the brain ; and, after all, when it is a 
 matter of operation, the surgeon does not usually limit his lield 
 to a single small trephine aperture. 
 
 Hernia Cerebri. 
 
 By hernia cerebri is meant a protrusion of the brain siil)staiice j 
 through an acquired opening in the skull. It thus differs from 
 an encephalocele, which consists in the protrusion ot hraiiii 
 substance through some cougenital defect. 
 
 It is always an evidence of increased intracranial pressure, ami 
 may be looked upon as Nature's safety-valve for the lelief of| 
 compression. It is met with in two distinct forms : 
 
 I. When an opening has been made by the surgeon for tliej 
 treatment of a cerebral tumour, which is subsequently foi.nd to 
 be irremovable. The disc of bone is not replaced, and the liram 
 substance protrudes through the opening under the scalp; l\v 
 this means a temporary relief of intracranial tension is hrought 
 about, the patient's life prolonged, and possibly consciousnesH 
 
HEAD INJURIES 
 
 665 
 
 (or a time restored. The tumour, however, continues growing, 
 and sooner or later the patient dies comatose. 
 
 2. The other variety, due to a compound depressed or punctured 
 fracture, is the result of sepsis in the underlying brain substance, 
 and the increased pressure within the skull thereby induced leads 
 to a protrusion of inilamed and (edematous brain matter through 
 the wound in the dura, which is usually of small size. The tumour 
 is soft and dusky in colour, and pulsates synchronously with the 
 heart, the pulsations being often evident to the naked eye, and it 
 usually increases in size somewhat rapidly. At first the mental 
 condition o'' the patient is unimpaired, but sooner or later coma 
 follows, if the hernia progresses, ending in the patient's death. 
 To bej,Mn with, the mass consists mainly of oedematous granula- 
 tion tissue covered by blood-clot, without much brani substance, 
 but later on brain tissue itself may protrude. The condition is 
 usually fatal, though recovery is occasionally seen. Treatment. — 
 Prevention of this affection must always be aimed at by en- 
 deavouring to render any wound in\olving the meninges aseptic 
 iand providing for drainage. Punctured wounds and depressed 
 fractures of the skull, even when giving rise to no urgent symp- 
 toms, slioi 'd always be operated upcm, since free relief of tension 
 may prevent the formation of a hernia cerebri, even should absolute 
 i asepsis not be attained. If, however, protrusion occurs, it may 
 he possible in a few cases to apply a dry dressing and elastic 
 pressure, and thus prevent it increasing in size; this, however, 
 must not be attempted when the inflannnatory symptoms are at 
 [all marked. In such cases it is of little use to slice off the tumour 
 [and apply pressure, and possibly the best treatment that has been 
 ^ug),festell is to paint the projecting mass with absolute alcohol 
 loiice or twice a day ; it is an efficient antiseptic, and also tends by 
 its dehydrating pov\ . r to diminish the size of the hernia. If such 
 Itreatinent is successful, the tumour slowly granulates over and 
 [cicatrizes. Traumatic epilepsy may, however, ensue. 
 
 Traumatic Epilepsy is the term applied to an epileptic condition 
 [rcsultin-; from injuries. It may arise from any of the following 
 conditions: (i) A neuralgic and irritable cicatrix in the scalp; 
 [^ a sliglit unrelieved depression of the skull ; (3) excessive 
 fi)rniation of callus after a fissured fracture, or chronic thickening 
 i the bone from osteitis after a contusion, whereby the dura 
 l^iater is pressed upon and irritated ; (4) chronic meningitis. 
 Usually associated with an adherent cicatrix in the brain, and 
 Particularly liable to occur in syphilitics; (5) a single depressed 
 Ipicule of bone projecting into the cerebral substance. A similar 
 loiulition is seen apart from injury in consetjuence of irritati\e 
 
 sions (if the dura mater or cerebral cortex, as, for example, 
 Ni an osteoma on the inner wall of the craniiun, or enlarged 
 Rcchionian bodies. The Ssrmptoms produced are epileptic 
 
wm 
 
 666 
 
 A MANUAL OF SURGERY 
 
 seizures of the Jacksonian type, with or without a definite aura, 
 according to the function of the portion of cerebral cortex which 
 is involved. LocaHzation of the lesion depends partly on iW 
 character of the aura, partly on the associated symptoms, such 
 as a fixed headache, or the presence of a cicatrix. The Treat- 
 ment is not particularly satisfactory. If there is any means of 
 determining the site of the irritation, an exploratory operation i- 
 always justifiable, since some removable fragment or spii ulu ci 
 bone may be the cause of the symptoms. If, however, nothing,' i^ 
 found except an adherent cicatrix between the membranes and 
 the underlying brain, it is very questionable whether the siirf,a(in 
 should proceed further. In a considerable number of cases the 
 cicatrix and surrounding brain substance have been removed; 
 the fits have ceased for a time, but in almost every instano 
 recurrence has sooner or later followed, owing to the formatii n 
 of a fresh cicatrix at the site of operation. Moreover, perinaneii; 
 paralysis of the portion of the trunk governed by the removed 
 cortical area has resulted, and hence the general opinion at the 
 present time is that such an operation is unadvisable, ex( ept asaj 
 life-saving measure when the fits are extremely numerous and| 
 severe. Such a decision emphasizes the importance of the stale- 1 
 ment made before as to the necessity of dealing with all cases oil 
 simple depressed fracture in adults by operation. If it is decided 
 that an exploration is desirable, the sooner it is undertaken thej 
 better, since the longer the epileptic habit lasts, the less favour- 
 able is the prognosis. 
 
 As an alternative to excision of the cicatrix, various plastic j 
 measures have been suggested in order to prevent the scar in the 
 brain and dura being dragged on by the scalp, or irritated thn)ii;,'hj 
 it, when the bone over it is defective. See autoplasty and hetero- 
 plasty (p. 672). 
 
 Traumatic Insanity is sometimes produced by slight depressions 
 or lesions, similar in nature to those causing epilepsy, and can! 
 occasionally be relieved by operation. Certainly, when a distinct j 
 history of injury precedes the mental aberration, and when therej 
 is any localizing lesion or symptom, an exploratory operation k 
 justifiable, and in a number of cases excellent results havej 
 followed. The type of insanity is not constant, but varies \vith| 
 the condition and environment of the individual. 
 
 f 
 
CHAPTER XXIII. 
 
 DISEASES OF THE SCALP, CRANIUM, AND CBANIAL 
 
 CONTENTS. 
 
 Diseases of the Scalp. 
 
 Jr would in\olve a needless amount of repetition to mention and 
 
 |lcscribe in detail all the many conditions which may he met with 
 
 ithe hairy scalp, and therefore it is only necessary to deal with 
 
 which are of the f^reatest importance. 
 
 Suppuration is of common occurrence, arising mainly from septic 
 
 Infection from without, but beinf( occasionally due to disease of 
 
 jlie subjacent hones. The extent of the abscesses is limited by 
 
 I same anatomical features as obtain in connection with hajmor- 
 
 |hage. Thus, a subcutaneous abscess is necessarily small in size, 
 
 ff:m<f to the density of the tissues in which it is located ; it arises 
 
 liost ire(iuently as a result of eczema or impetigo, and is often 
 
 |iie to the presence of pediculi, or to the action of irritants used 
 
 Ithe cure of ringworm. A subaponeurotic abscess usually results 
 
 j^om a soptic penetrating wound, and is associated with cellulitis. 
 
 [iiibpcricranial abscess is rarely seen except in connection with 
 
 |ijury or disease of the bony calvarium ; the pus is limited to the 
 
 lected portion of bone. 
 
 Erysipelas and Cellulitis have been described elsewhere (pp. 85 
 nd 82). 
 
 Tumours occurring in and under the scalp may be considered 
 (ccording to whether they pulsate or not. 
 
 I Pulsating Tumours of the Scalp arise from three distinct sources : 
 1 1. They may be of Extracranial origin, and then are mainly asso- 
 atedwith the superficial bloodvessels, (a) Ordinary aneurisms of 
 kaumatic origin are not uncommonly seen ; they rarely attain any 
 Vnsiderahle size, and are readily dealt with by excision, (b) A rterio- 
 imsi.mnds give rise either to an aneurismal varix or to a varicose 
 Heurism. They usually involve the temporal trunk, and their 
 |niptoms and treatment require no special notice, (c) A curious 
 Pated and tortuous condition of one of the scalp arteries, most 
 
mm 
 
 668 
 
 A MANUAL OF SURGERY 
 
 often the temporal, is occasionally seen, and is known as an iirUrk 
 varix ; it may be treated by complete excision, (rf) A navits situated 
 o\er the anterior tontanelle may derive a communicated impulyt 
 from the subjacent dura. It has no special features apart from 
 this, and is to be treated in the same way as other n;i\ i of the 
 scalp, viz., by excision or electrolysis, [c) A much more serious 
 and interesting phenomenon than any of the others is tliat know;. 
 as a cirsoid mieuyism. 
 
 Cirsoid Aneurism is more freijuently met with in the scalp than 
 elsewhere, and mainly involves the temporal rej^ion,but iiiayaiMi 
 spread in all directions, even downwards into the neck. A tuiiiour i 
 of {greater or less size is seen under the skin, consistini,' of dis 
 tended, tortuous, pulsatinj^, l<luish-lookin^ vessels, the arteries I 
 opening directly into cavernous spaces without t)ie inttrventinn [ 
 of capillaries ; it is easily emptied by pressure, but quickly ref 
 owing to the abundant arterial supply. The rate of growth i>j 
 varial)le, and the patient often complains of headache and <^M\\ 
 ness ; the skin becomes more and more thinned and atrophia thi 
 hair falls out, and finally ulceration may occur, the patient I 
 probably dying from hemorrhage. The Treatment is eininenthl 
 unsatisfactory, complete excision being the ideal cure, but tlii>iii 
 the worst cases is impracticable. If it be attempted, the incisionsj 
 should be made wide of the disease, and the supplying \esselj| 
 secured, if possible, between double ligatures before (li\idin,'j 
 them ; if this precaution is not adopted, frightful lianiorrha^'e 
 may result. It is necessary in some cases to deal with the tunioiirl 
 in separate segments, allowing time between the operations tori 
 the patient to recov<n' from the loss of blood. Probably ddirohul 
 combined with ligature of the main nutrient vessels, holds out thel 
 best chance of success. (For methods of electrolvsis, see p. JM.j 
 
 2. The chief pulsating tumours of Cranial orig.. are as follows: 
 (rt) Sarcomata arising from beneath the pericranium or from tliei 
 diploe (p. 674). {b) Secondary nodules of cancer may develop inj 
 the diploic tissue ; those due to the form known as thyroid cancerj 
 are specially noted for their pulsation, [c) Aneurism by aiiasto 
 mosis occasionally develops in the cancellous tissue of the clipli 
 and gives rise to pulsation, which can be felt when the hones arej 
 sufficiently expanded and atrophied (p. 500). 
 
 3. Pulsating swellings of lutracranial origin include the following 
 conditions : Encephalocele (vide infra) ; traumatic cephal-liyilrocela 
 (p. 629) ; hernia cerebri (p. 664) ; and sarcoma of the dura mm 
 (P- 675)- 
 
 Non-pulsating Tumours of the Scalp.— Almost any of the ordiiia 
 connectix e tissue or epithelial growths may occur, but the followj 
 ing are the more important : 
 
 Papillomata are not unconunon in the form of small liardwarii 
 outgrowths, giving rise to but little inconvenience, unless sitiiate< 
 
 iHli 
 
DISEASES OF TH^ SCALP 
 
 ssels, the arlLrits 
 
 of the dura niaw 
 
 l^jiisoine spot where the hat rests. They are easily removed, and 
 it is advisable to touch tlie base with nitrate of silver. 
 
 Epithelioma also occurs, arising,' either from an irritated papil- 
 iloiiKi, Of possibly in connection with a sebaceous cyst. As soon 
 as a diaj^nosis is made, the ^'rowth should, if possible, be ex- 
 tirpated, and the resultinj,' raw surface may either be left to 
 |;'riinuhite, or dealt with by Thiersch's method of skin graftinj^. 
 
 Fibroma is either seen in the shape of a localized develop- 
 iiiRiit of liard fdirous tissue, and often growing on the forehead 
 [where the hat crosses it ; or it may attain much larger dimensions, 
 linvdlviii},' perhaps half the scalp, and f^'ivinj^ rise to an irrej,'ular 
 [nodiilatfd outf^rowth of fd)ro-cellular tissue, which has sometimes 
 Ibttii termed ix. pachydcymatocclc (p. 133). blither form may be dealt 
 |\vith by excision. 
 
 Sarcomata of various types invoK e the scalp, presenting as large 
 
 k>\\) tumours which may pulsate (jr fungate. They usually 
 
 jdevelop rapidly, but are limited for some time by the aponeurosis 
 
 lit the occipito-frontalis ; glandular infection is uncommon. In 
 
 Itheir removal it is useless to attempt to save the aponeurosis ; 
 
 [the whole thickness of the scalp must be sacrificed, and the in- 
 
 Icbions should be wide of the growth. The wound is allowed to 
 
 Iframilate. or covered in with Thiersch grafts. 
 
 Dermoid Cysts are by no means uncommon in this regicm, their 
 
 a\i)urite situation being near the outer canthus, the temple, or 
 
 lie root of the nose. For a general description, see p. 146. 
 
 hey do not attain any great size, and ma\ not become evident 
 
 1 after puberty. The underlying bone is often hollowed out 
 
 Ironi a defective development of the mesoblastic tissues annmd 
 
 Ihem: and a congenital opening may even exist through wliicii a 
 
 liirrow neck passes, bringing the cyst into direct connection with 
 
 he dura mater. The tyeatmcut consists in removal ; but it is 
 
 kdvisaMf to delay this till after puberty if the tumour seems at all 
 
 pd to the skull, or if the bone is felt to be defective beneath 
 
 .as in sucli cases the C(jmmunication with the interior of the 
 
 pallium is often shut off by that time. 
 
 Sebaceous Cysts (p. 332) find their most usual situation in the 
 
 pip, where they not only are fretjuently nniltiple, but also may 
 
 pch a considerable size. Their removal is best accomplished 
 
 |y traiisiixion, sciueezing out the contents, and picking out the 
 
 >t wall by a pair of forceps without dissection. The wound 
 
 I closed by one or two stitches. 
 
 Affections of the Skull. 
 
 ' Congenital Affections. 
 
 1 Meningocele, Encephalocele, and Hydrencephalocele consist of 
 
 protrusion of the dura mater, with or without part of the brain, 
 
 V'w^\\ an opening in the cranial wall, due either to defective 
 
670 
 
 A MANUAL OF SURGERY 
 
 clevelopiiient oi llie bones or to the non-closure of one ot ih, 
 sutures. They occur most fre(iuently at the root of the nose, ami 
 in the occipital rej^ion (l-'if,'. 237), occasionally at the anterior nri 
 one of tile lateral fontanelles, or at the base of the si\uil. .\I 
 Mcniiifrocele is simply a protrusion of the brain niemhraiit's con 
 taininj; cerebro-spinal thiid. It forms a soft, rounded, ihic tiiatiii,'! 
 swellinf,', attached to the skull by a base of {,'realer or less si/,, 
 and covered by skin, wliich may be thick and healthy, 01 tiiinntd, I 
 bluish, and translucent when the tumour is large. The vesseisl 
 present in the skin are often dilated and nu'void. It iiit teases in f 
 size .and tension on any expiratory effort, such as coiii^hinj,' or 
 cryinf^, and it may be partially reducible, thus allowitif,' the! 
 marj^^'ins of the openinj; in the cranium to be dehned. S\mptonis 
 of cerebral compression, convulsions, etc., are likely to be producd 
 by such manipulation. An Encephalocck is a similar ivpe ifl 
 
 Fir; 2J7 
 
 -Congenital ENCEPnALOCELii of the Occiimtai. Kegua 
 
 (TiLLMANNS.) 
 
 tumour, but contains brain substance, and pulsates nearly 
 synchronously with the heart ; it is most commonly situatd at] 
 the back of the skull. A Hydyenccphalocelc, or Meninf(o-ciK tpha!o| 
 cele, is a condition in which the tumour contains i)()th braiq 
 substance and fluid. Two varieties have been described, one ia 
 which there is a small protrusion of the brain associated with an 
 ordinary menin<^ocele, and the other in which the fluid is contained 
 in a cavity conununicating with one of the ventricles, and cover? 
 by a thin layer of brain substance. They are usually of considerable 
 size, and situated in the occipital region, either above the tentoriunij 
 and then possibly associated with distension of the posterior cornij 
 of one of the lateral ventricles, or below that structure, the osseou 
 defect extending in some cases as far as the foramen magnum. an(j 
 a portion of the cerebellum being within the sac. 
 
 The Prognosis of these conditions is exceedingly gra\ e. Fori 
 tunately, many of the subjects are born dead, or die soon aftei 
 
AFFECTIONS OF THE SKULL 
 
 «7i 
 
 cciriTAi. Kkli'^n 
 
 birth. In the more sesere cases, idiocy and tnicroceplmly are not 
 •jnconiinonly associated. Tlu; protrusion may increase steadily in 
 si/eiuul finally burst, causinj^' death by pundent nieninj,Mtis, or in 
 aioie t'avoural)le cases it may temain stationary. In a menin- 
 ;;ocele, the subsecpient {^aowth of the cranial bones may suffice 
 to close the communication between the interior and the tumoiu', 
 which thus becomes shut off, and remains as a cyst-like swelling, 
 vith ttif base fixed, and without pulsation or respiratory impulse. 
 Treatment. — When possible, the patients should be left alone; 
 Initii llie tumour is steadily increasing in size, antiseptic puncture 
 and subsequent compression may hinder tlie process; a pure 
 menin},'(n ele may possibly be cured in this way. Where the 
 comimmication with the skull is small, it may be feasible to totally 
 [excise the tumour, taking special care to securely suture the base, 
 [andiitteinpting when practicable to make good the cranial defi- 
 litiicy by osteoplasty. 
 
 2. In infants the ossification of the bones may be incomplete, 
 [constituting what is known as aplasia cranii congenita. This may 
 
 iDcalized, occurring in patches scattered here and there, or may 
 |e\tincl over the whole cranium. A thin layer of bony material 
 nav suhsecpiently be laid down in an irregidar manner, so that if 
 I complete ossification follows an unusual nund)er of sutures are 
 present. The cause of this affection is said to be fo'tal rickets, 
 arisiiijf from a cachectic condition of the mother. Great care will 
 be needed in dieting such children and protecting them from 
 injury. Occasionally a similar atrophic condition of the bones 
 may persist through life, expos ig the patient to increased risk 
 I from injuries which otherwise would do but little harm. 
 
 3. Localized congenital atrophy of the bones is also sometimesi 
 [net with in connection with dermoid cysts, as mentioned above. \/ 
 
 11. Acquired Affections of the skull are atrophic, hypertrophic, 
 I inflammatory, or neoplastic in nature. 
 
 Acquired Atrophy of the skull occurs in many forms : 
 
 ((I) Craniotahes is a condition met with during the first year of 
 
 life, as a result both of rickets and of inherited syphilis, though 
 
 Imore frequently tlie former. Portions of the occipital and parietal 
 
 [iiones hecome soft, and on digital pressure yield with a sensation 
 
 |!ikethat derived from stiff parchment. There is in most cases a 
 
 )tal absence of bony tissue at the spot. 
 
 [h] Senile atrophy may affect the whole cranium, which becomes 
 Ithinned and rarefied, the change commencing from without, a 
 jsimilar condition also occurring in the jaws from the loss of teeth, 
 land subsequent absorption of the alveoli ; or it may be localized, 
 h pointed out by the late Sir G. M. Humphry,- to the parietal 
 pnes, constituting hollow depressions which extend antero- 
 
 * Med.-Chir. Trans., 1890, p. 327. 
 
672 
 
 A MANUAL OF SUHGEIiY 
 
 posteriorly. No symptoms are caused tluTchy, hut tlm paiitn; 
 runs a certain increased risk froiu injuries to the h(;a{h 
 
 (( ) Locahzed loss of suhstance may resvdt from the pressuffot 
 tumours, surh as Pacchionian hodies and aneurisms, or from 
 necrosis, or traiunatic and opi-ratise lesions. If these are at all 
 extensive, thecerehral pulsations can be felt distinctly throui,'!! the 
 skin, it is then advisable to provide tiie patient witii sonic Ltuard 
 to protect him from injury. This may be accomplished by iiicaib 
 of a metal plate worn over the scalp ; but where the lesion is duf 
 t(i injury or operation, surj^'eons Ikim- of late years been endeavour 
 inf,' to remedy the defect in a more satisfactory manner bv opira- 
 tion. Antoplasty is the term applied to a proceeding whereby the 
 defect is closed by a plate of bone removed from the patient's own 
 skull. A suitable scalp Hap is turned down, and then a portion 
 of the outer table is chiselled up suflicient in size t(j close tlie 
 aperture. The pericranium is utilized on one side as a i)alick'. 
 and by means of this it is stitched down into the j^^ap, the tnar;,'in> 
 of which have been previously freshened. Hy heterophnty is meant 
 a similar [noceedin},^ when the hole is closed by a plate ot ;,'ijld, 
 platinum, or \ulcanite let in imder the pericranium or iiistrtd 
 between the dura mater and the cranium. The results ot these 
 procedures ha\e been on the whole satisfactory. 
 
 {d) //)'</wtY/'//<j//^s is always associated with atrophy and thiiinin;; 
 of the cranium. It may be conj^'enital, or may commence early in 
 life, but is always a chronic condition. (The so-called acute 
 hydrocephalus is in reality tuberculous meninj^itis.) It is pri)duad 
 in almost all cases by a distension of the lateral ventricle^ with 1 
 fluid, the result of congenital malfonuation, or of inflainmatd'v 
 alfections, causinjf exudation from the choroid plexuses, pressure! 
 upon the veins of Galen or inferior longitudinal sinus, and possibly 
 closure of the foramen of Majendie. The head becomes more 
 and more distended, the bones expanded and thinned, and the 
 sutural areas increased, whilst the brain is subjected to suthj 
 pressure as may be incompatible with life. Fluctuation is dis- 
 tinctly felt, and the bones may crackle under the hni^ers; thel 
 face looks abnormally small, and the eyes protrude, owinj,' \A 
 the depression of the orbital plates. Treatment. — The \entriiles 
 may be tapped at a spot some little distance from tiie median 
 line, and a considerable amount of the fluid withdrawn, whilst 
 elastic pressure is subserpiently maintained ; but as the caiisej 
 cannot be removed, recurrence is almost inevitable. It hasl 
 recently been demonstrated that there is a direct absorption ofl 
 fluid into the veins from the subdural space at any tension alwvej 
 the venous pressure, and hence it is suj^gested that, by establishi 
 ingaconuuunication between the ventricular and subdural spaces,! 
 the excess of flu'd in hydrocephalus might be absorbed. This liajj 
 been attempted in two or three cases, and the results have beeiil 
 encouraging. 
 
^^'^^CnONS OF TflB SKULL 
 
 - ^3 
 
 {(} By micyocephalv is nif^n — ^ — -———__ 
 
 Ije cranial caxity iue tc, paVntun!^''"''''". ^'^^'i'^'nishecl sixe of 
 li IS usually associated u-if . ; "^^ ">^sihcati(,n of tli,. ^,, 
 
 "'■ '-'^t^' ye.'irs attc. p ts M '"'>' ''"^'' P"«si''ly w t In ' ''• 
 oFation of linea'^n^ .;^^;^'"-'« to re^!^^^, -^r '-;; 
 '^^■^n.um so as to allow of teev.n "'''*"' ''^ P^'-^'ons of the 
 >mp of l,onc. is excised on eithe m'"","'/''^' '>'-'-^'"- A I nnJ 
 
 antero.posteriorly j,,- .. rlr. ,1 ''^^'" ^'le openin.^'is nnJ 
 
 iisuallv (lea t with Tt ««,. '"'^^"r i|,e two s des of tulJu^ 
 i,>c cJi J ."''" "I ■''Cparate tin^^B t """^-^ <>' tne skull are 
 
 , Hypertrophic ChanireH nf *i, «, 
 
 Uo \Xml \)f^^' /" '^ontiasis osse-i7n ? f ^P' ^'^"^ ' '^"^ 
 li-^enm c el 1'""'^'^"^^ ''^"^1 enlar-^ed L r*.^'"'^ '^'" ^''■'■^"'""■n 
 
 ■ '- tuLKA.cnecl on rnnc«-if.,(.' ■ '■>'''■'> ')llt t/le r-nti .. I 
 
 fs^'^-'S'^sr-'-" ™. 
 
 J ■ Acute Periostitis, or PeriPraJ.-r* ^>^ "^c""" '» H)ne 
 
 psses opening in m-mv^^-f 5 'PP"^''^tion beneath \t .l\ 
 |r bnin , '""animation to the m^t^i ^^ pyaemia or 
 
 43 
 
674 
 
 A MANUAL OF SURGERY 
 
 3. Chronic Periostitis of the cninium is occasinn;iIly imi with 
 in tlic lonn of ;i node;. It is usually the result of some Iomk. 
 continued irritation, such as carryinj; baskets or weij^lits on th,. 
 iiead. I natmcut consists in the removal of the irritation, and 
 tliere is no objection to chisellinj; away tin; node, if necessary. 
 
 4. Tuberculous Disease of the cranial bones is not common; it 
 occurs as a primary phenomenon, or is secondary either tu a ; 
 cutaneous lesion, such as lupus, or perhaps more connnonly to 
 a meniuf^^eal 'ocus. It may start in tlie periosteum or diplot-, 
 leadiu}; to the formation of a node or perhaps to expansion of the 
 bone, and followed by suppuration and caries. When of imnii: 
 f^eal orif^Mn, there is a considerable amount of erosion of tlic inner 
 table, and possibly some necrosis; sooner or later the outer (aMi- 
 is p''rforated and a subpericranial abscess forms. The aniount 
 of mischief in the outer table is no criterion of the extent 
 of the disease within, and hence \(;ry thorough exploration h\ 
 necessary. 
 
 5. Syphilitic Disease of the cranium, on the other hand, :> 
 exceedingly commt)n, occurrinj^ usually in the tertiary staj^'e, aiil 
 aflectiu},^ most frecjuently the frontal and parietal bones. It h;b| 
 been already described (p. 4S5). 
 
 Tumours of the Cranial Bones. The chief Tumours alTci tini,' tin 
 
 calvanum are osteomata and sarcomata. 
 
 Osteoma of the cranium occurs as a localized overffrowth either! 
 of cancellous or of compact bone, more commonly the latter, hi 
 {^■rows from the cniter surface t)f the caKarium, from the inner, lirj 
 from both. If arisint; externally, a smooth, rounded, ^'lohiilarj 
 swelliu},^ is produced, hard to the touch, (piite painless, and attachd 
 to the subjacent bone by a broad base; more than onemayhel 
 present. If the main {^nowth is internal, the early syinptonisj 
 wi" 'epend on its situation, as to whether evident t'unclinnal 
 dis.urbance of the cortex will be produced; when very lari,'e, itj 
 ,t,n\es rise to compression of the brain, and possibly optic neuriti<,| 
 Osteomata are to be distini^uished from intlamuMtory liypeiostoMsj 
 (usually of syphilitic orijijin) by their siiarp limitations, ahseno 
 pain, and slower proj^rcss : whilst osteo-sarcomata are cdninii)ni.| 
 rapiil in j,M'owth, painhil, and of unequal consistency in clillird;! 
 parts. Trcaiiiiciit is rarely possible in tin se developing' inside iliej 
 skull except when situated o\ er the motor area, since the diseas< 
 has usuallv jiioj^nessed too far before cominj^ under observationJ 
 The external tuuiours may be freely chiselled away, but it iiiii*l[ 
 not be for>j[otten that cerebral concussion may follow the pioj 
 lonj^ed use of tiu' chisel and m diet a}.(ain:it the skull. 
 
 Sarcoma of the cranium orif.(!naies eitiier from the pcricianiuml 
 the diploe, or from tin; dura maier. 
 
 The extra- or pcyi-cranial variety consists of a round or spimilel 
 celled tumour f^rowing from the pericraniuiu, and possihiy attain! 
 
AFFECTIONS OF THE SKULL 
 
 675 
 
 ijvlly iiH'l with 
 of sonic loiv^'- 
 veit:;hls uii tlu- 
 irritiitinii, and 
 necessary. 
 ot common; it 
 .ry eitluT to ;i 
 i coninuinly li 
 euiu or diplof. 
 <]);uision of tlu' 
 ^'hen of nuMiin- 
 ion of the innri 
 
 the ouUT laMf 
 The anumiil 
 
 of tlic extern 
 1 exploralinn i>l 
 
 other liaml. 
 
 rtiiuv ^'ii^^'' '"'^■' i 
 I hones. U bib 
 
 ours 
 
 alTeclinji thel 
 
 jverf^rowth citlier 
 ly the lalUT. It 
 loni the inner, or 
 .)inulecl, ;4l"l'i'l''' 
 ess, iind attached 
 than one may be 
 early syniptom> 
 \ ident fvuictiiin'ilj 
 u'n very hv^xA 
 ,ly optic neuritis. 
 tory hypeiiist'w 
 Uions,' iiliseno 
 lilii are coninioiii. 
 Aency ill tlill'-'H 
 lelopinu inside thj 
 since the di^'^;'^ 
 In'ler ohservationj 
 vvav, l>ut it H 
 y follow the pi"' 
 
 UuU. 
 
 \\ the pericranuiinl 
 
 I round or spiiHile| 
 Id possihly attiuni 
 
 in^j a considerable size. It may contain a certain amount of ossific 
 deposit, or the tunK)ur remains of a soft consistency, and then often 
 pulsates. 'I'lie subjacent bone is sometimes absorbed, and the 
 dura mater affected secondarily. General infection of the system 
 follows. 
 
 Central sarcoma of the cranium starts from the diploe as a 
 invtioid tumour. It does not fjjrow so rapidly as the other forms ; 
 It is single, and generally covered with a layer of expanded bone, 
 which f,^i\es a sensation of e{,'f^shell cracklinj^f to the finder. 
 Later on it invokes the dura mater and skin, and may funj^'ate 
 externally. 
 
 Sarcoma of the dnya maler may be attributed to some injury to 
 the head, and is characterized by the occurrence of severe cerel)ral 
 svipptoms, c.<i., intolerable localized lu.'adache, ei)ileptic fits, 
 doiihle vision, o;'iic neu:itis, etc., prior to any evident appt'arance 
 of a tumour, (iraduaiiy the bones become expanded and per- 
 forated, and a soft and exceedinf^^ly vascular pulsating' ^'rowth is 
 kit beneath the scalp. This sooner or later funj^ates, and 
 possibly the meninf^eal cavity is laid open by ulceration, death 
 from septic menin{,Mtis, cerebral compression, or exhaustion endin^f 
 the chapter. 
 
 Troitiiiciit of these cases is almost impossible, since the f^rowth is 
 |well-nij;h certain to have gone too far before being recognised. If 
 j an early diagnosis can be arrived at, free remoxal may be under- 
 taken by trephining and the use of the chisel, sharp spoon or 
 [ gouge. 
 
 Affections of the Frontal Sinuses. 
 
 These sinuses are cavities in the frontal bones lined with a 
 Imucous membrane continuous with that of the nose. Tliey can 
 jhardly be said to exist in children, not developing much before 
 jthe age of twenty. In adults they \ary nmch in size and shape, 
 
 and are often \ery asymmetrical ; the prominence of the super- 
 [cilui, ridges is no guide to tlu>ir extent. 
 
 P'aciure of the anterior wall is not uncomm'^M as the result of a 
 [''r-et blow, depression of the fragments Iteing produced, but 
 Jwifhout cerebral complications. If the nmcous membrane is 
 [torn, surgical emphysema of the scalp and face may follow, and is 
 Inatinally increas'U on blowing the nose. In compound frai tures, 
 
 puppuration usu.illy occurs, leading to septic osteitis and necn^sis 
 j)fthe ftoptal bone, and, if the pr^sterior wall is invoKcd, to a sub- 
 cranial or e\cn a cerebral abscess, in rare cases, when the anterior 
 l*all has been destroyed, a localized collection of air may form 
 
 pnder the skin, and remain as a permanent tumour, constituting 
 hat is known as a pncumatocdc capitis: it rises and falls with 
 
 I'Tced respirations. .\ similar condition may also result from a 
 
 pcture into the mastoid cells ; in either situation it should be 
 
 iieated by compression, or, failing this, incision. 
 
 43-2 
 
676 
 
 A MANUAL OF SURGERY 
 
 Inflammation of the frontal sinus is caused by extension ot 
 catarrh from the nose, by penetrating wounds or frarturcs, liv 
 foreign bodies, or it may be secondary to disease of neigh hourin'' 
 bones. But httle effect is produced, unless the infundihuluni 
 becomes blocked, and then distension of the sinus is produc ed. If 
 occupied by mucus (hydrops), a slowly-forming tumour is noticed 
 Without much pain or discomfort, but the l)ony wails gradn- 
 aliy become thinned, and may give a sensation of ('g;::;shell 
 crackling. If distended with pus {empyema), , milar symptoms 
 result, perhaps with concurrent inflammatory disturbance iiiul pain 
 in the neighbourhood. Occasionally extension of mischief to the 
 ca\ernous or other xenons sinuses may follow. The case must 
 be treated by laying the cavity open and draining it. I'or this 
 purpose a curved incision is made along or innnediately below 
 the eyebrow, and the soft parts stripped from tlie bone, which !> 
 trephined or punctured with a gouge, according to its thickness, 
 close to the middle line ; the pus or mucus is removed, and the 
 passage into the nose explored and dilated so as to allow of free 
 drainage. The cavity is syringed out for some days, and the 
 wound usually closes readily, although a fistula occasionallv 
 remains. A median vertical incision is useful if the^'e is anydoiiht 
 as to which sinus is involved, or if both are affected. It has also 
 been proposed to deal with this condition from within the nose, 
 and in the hands of skilled rhinologists this is practicable, especiallv 
 if the anterior half of the middle turbinal is w-. ': removed. 
 
 The chief Tumours growing from the fron ,• guises arc mucous 
 cysts or polypi, and ivory osteomata; they may also be in\olve(J 
 in diffuse sarcoma or carcinoma, but the disease is then not 
 limited to the sinus. The main symptoms and signs resnit from 
 diste.ision of the walls of tlie cavity, which may yield anteriorly, 
 causing a large frontal swelling, or the posterior wall is ahsorhed, 
 leading to cerebral compression, or the upper wall of the orbit 
 may be depressed, causing dislocation of tlie eyeball, and possibly 
 blindness (Fig. 31, p. 131). Tumours which liaAe attained con 
 siderable dimensions can rarely be removed, death then resiiltini; 
 from cerebral compression; but occasionally bony masses niavj 
 necrose, and beccjine loosened by suppuration around them, and 
 in a few cases they have been taken away successfully. 
 
 Cerebral Tumours. 
 
 The chief Varieties of new growth met with in the brain areas] 
 follows : (i.) Glioma, or gliu-sarcoma, which consists of a small 
 round-celled neoplasm with a very delicate intercellular si'bstance.i 
 similar in character to the neuroglia; it may occur in any partofj 
 the brain. It is always continuous with the surrounding rerebralj 
 tissue, and is scarcely ever encapsuled, so that to the naked eyeitj 
 may i)e indistinguishable from brain substance, althou,L;ti ratherj 
 
CERKDRA L TUMO URS 
 
 677 
 
 harder, and hence its limits can seldom be accurately defined. 
 lii.) Tnie sarcomata also occur, and occasionally secondary carcino- 
 matous depo'^its. (iii.) Tnherciilous foci are met with apart from any 
 iiienin^,'eal infiltration, varyinf:^ in size considerably, and may be 
 either firm and caseous, or with a diffluent centre, (iv.) Gnmmata 
 ot the brain usually sprinf,^ from the meninges, and are more 
 irregular in shape than tuberculous masses, (v.) Occasionally 
 akiid rysts are found, as also other less common conditions. 
 
 Cerebral tumours are more often observed in males than in 
 ftinales. and the different forms occur at varyinff periods of \'\[\ 
 Thus. t,dioma and sarcoma are most common at puberty or in 
 middle life; tuberculous foci, in children ; fi;ummata, in the fourth 
 or fifth decade; carcinomata, in middle or late life; and parasitic 
 uiniours in the second and third decades. 
 
 TKi- local effects of a cerebral tumour may be to cause some 
 amount of sclerosis of the surrounding^ brain substance, whilst, if 
 superficial, the membranes may become adherent and the over- 
 Ivin;,' bone thickened. 
 
 The Symptoms ot a cerebral tumour can be classified as 
 follows: (i) Thost due to increased intracranial pressure, such as 
 tixed headache, fjf'ddiness, epilepsy, loss of memory, and stupor, 
 tmallv endinf,' in roma. The headache varies inuch in character, 
 hut is usually localized, occurs in severe paroxysmal attacks, and 
 is often associated with tenderness on deep pressure oxer the scalp. 
 it is increased by rinythinj^f that causes passive congestion of the 
 lirain, such as coughing, ar d it is most import'uit to note that the 
 sites of the ma.ximum pain and of the tumour often correspond. 
 I Occasional Iv coma and a fatal issue su^jervcne suddenly as a 
 rt-suit of acute spreading u-dema (p. <557). (^) N'omiting and 
 
 mstipation are also very marked phenomena, associated with 
 
 [loss of appetite and great emaciation. The vomiting bears no 
 
 relation to the ingestion of food, and is not preceded by nausea. 
 
 It often develops concurrently with the pain, or uiay relieve it, 
 
 land is most common in subtentorial tumours. The temperature 
 
 |isusii;dly subnormal, but if O.iereisany b.'isal meningitis it may be 
 
 tievated. (3) Optic neuiitis is generally present, and is supposed 
 
 Itii he due either to the increased intracranial pressure causing 
 
 uhstruction to the return of blood from the eye to the cavernous 
 
 piniis, or to a descending neuritis, or possibly to both. In the 
 
 Icirly stages, the clear definition of the disc margin becomes 
 
 loliscured, and the retinal veins congested and tortuous ; the retina 
 
 jisddeniatous, so that the vessels are only seen at intervals, and 
 
 jlinear ecchymoses may also occur. If the patient lives long 
 
 |enou>fh. atrophy (jf the disc follows. In the early stages vision 
 
 I may be but little affected, but, as a rule, it is considerably im- 
 
 Ipaired towards the end. In some cases this condition may 
 
 jlie more marked on the side of the lesion, but is generally bi- 
 
 llaieral. (^] Focal symptoms (p. 661) are only produced when 
 
m 
 
 A MANUAL OF SURGERY 
 
 some area of the brain with definite functions is in\oKed. 
 Irritative phenomena manifest themselves first ; paralytic sviiip. 
 toms develop later on. General convulsions sometimes occur, 
 hut are without nuich significance. We must refer students to 
 text-books of medicine for a further consideration of these lesions. 
 The surgeon is seldom called upon to make a diagnosis in these 
 cases, and therefore the full details of this intricate subject will 
 not be considered here. 
 
 Treatment. — In every case, the possibility of the syniptoir.s 
 iieing due to gummatous disease must not be forgotten, and laive 
 and increasing doses of iodide of potassium (even up to 40 nr 
 60 grains three or four times a day) should be administered before 
 undertaking (operative proceedings. Symptoms of gastri( irrita- 
 tion must be pre\ented by giving some alkaline carbonate 
 (especially the anunonium or soda salts), whilst the dose should k 
 freely diluted with water. 
 
 Operation. — It is most desirable that this should be undertaken 
 as early as possible, since, even if no tumour exists, tiie patient 
 runs but little serious risk, whilst delay until all the classical 
 symptoms are well marked may prevent the total remo\ al of the 
 growth. Occasionally it is divided into two stages, one consisting; 
 in the removal of the bone, and the other, six or eight days later, 
 involving the intracranial portion ; but such a modification is not 
 essential, and is sometimes undesirable. 
 
 The scalp should be entirely shaved a day or two previously, I 
 and very thoroughly purified. A (juarter of a grain of morphia is 
 injected about half an hour before the operation, with die idea 
 both of reducing the \ascularily of the brain and of dullin},' the 
 patient's sensations, so that a smaller amount of ana-stlietic is 
 subsefjuently needed. Chloroform sh(,uld be employed rather 
 than ether, as it produces less congestion of the head. The 
 surgeon marks the spot selected for the application of the trephine 
 by drilling the bone with a l)radawl through the scalp. A lar(;e 
 semicircular flap is then turned down, exposing a considcrablej 
 area of the caKnrium, so that if a larger amount of i)one than isl 
 expected needs to be removed, no fresh scalp incisions arej 
 recpiired ; moreover, the cicatrix will in this way be prevented] 
 from forming over the trephine opening. A crucial incision is^ 
 made through the pericranium, which is retracted to a suflicientj 
 extent to allow a 2-inch trephine to be applied, the centre pinl 
 being placed in the hole previously made by the bradawl. Al 
 Gait's trepiiine (i.e., an instrument with shelving borders) i^toliej 
 preferred to one of the ordinary type. The disc of bone is (are! 
 fully removed, and placed in warm and sterilized noniial saline 
 solution, so that it may be subsetjuently replaced if mnessaryJ 
 either methods of removing the calvarium have been introduiedJ 
 so as to enable a considerable area of the brain to he exposed^ 
 Thus, the bone may be partially sawn through in sucli ;i way 
 
CEREBRAL TUMOURS 
 
 679 
 
 ydivicle the portion to be removed into rectan<,ail;ir areas ; then 
 1 i! the \s hole thickness of the hone is retncnecl at one s[K)t by a 
 I trephiiit^', it is easy to cut away the remainder with bone pHers. 
 Mlther siirj^'eons prefer Wa;,'ner's osteophistic metiiod, which con- 
 Lsistsin turning down a Hap of skull with the soft parts. After the 
 Uuix'rfiiial incision has been made, the bone is di\ided alonj^ the 
 Uame line, either by a circular saw drixen by electricity, or by 
 one of the ingenious surgical engines — more or less resembling a 
 ilcntal drill — which have been recently introduced, or by a digli 
 L.W [i.c-i a piano wire with a screw thread turned on it). In 
 using the last-mentioned contri\ance, two or three trephine open- 
 ings must be luade along the line of incision, and the wire carried 
 hhrou(,'h on a probe from one to the other. Handles are attached 
 au-acii end, and the sawing is soon accomplished ; it is advisable 
 111 bevel the cut so as to give a shelf for the flap to rest on when 
 renlaced. The base of the flap is partially or wholly sawn through, 
 and then the upper portion prised outwards. It is for such severe 
 liiieasures as these that the operation in two stages is recommended. 
 
 The dura mater when exposed under normal conditions is tniu, 
 kit yit'kls slightly to the hnger, and allows the pvdsalion of the 
 
 ibjaccnt brain to be felt, if the latter is healthy and no imilue 
 
 [pressure is present within ; but if the intracranial tensicm is 
 
 nurkedly increased, the dura mater bulges into the wound, feels 
 
 liirm aiul unresisting, and the cerebral pulsations are diminished 
 
 |crai)St'nt. 
 
 The dura mater is next incised crucially, or a flap turned down, 
 Icare being taken to a\oid, if possible, the meningeal vessels ; the 
 Ibrain substance protrudes if the intracranial pressure is excessive. 
 iTlie region is gently explored by the finger, and .any areas of 
 lalnornial hardness or softening noticid; failing this, a grooved 
 Incedle is inserted in different directions, or a line trocar and 
 cannula. In introducing such instruments, care must be taken 
 [to make direct stabs, and never any lateral movements, which 
 iMcessarily lead to laceration f the brain. The opening of tiie 
 Iskull may be enlarged, if need be, either by the use of the bone 
 |i :i);tur or by additional small trephine holes. It is but rarely 
 
 lliat a cerebral tumour is so placed that enucleation is possible. 
 
 :. however, a cortical tieop.j,-;tv. is found, it is isolateil from the 
 Isurrouiuling brain substance by blunt mstruments.r./;., the handle 
 a scalpel, or a flexible knife, made (j1 platinum, as suggested by 
 
 lorsley, and the mass freely removed. Ha'morrhage is controlled 
 by the application of a fine ligature, or by the use of serrefines, 
 jor by sponge pressure. The dur.i mater is then loosely stitched 
 fOiiether, and a drainage-tube inserted, reaching to the bottom of 
 
 tie wound, and l)rought out at one angle of the incision in the skin, 
 
 *iiirh may be closed by a ct-ntinuous suture. If the tuniour has 
 I'ten satisfactorily enucleated, the disc of bone may be placed 
 f" 5i/», room, however, being left for the passage of the 
 
mm 
 
 OSo 
 
 // M INI'AL OF SUlidliKY 
 
 tui.' ; but if tluMc is any (li)ul>( as to its rompN^tr K'mnx.il. ti„.] 
 i)|it'ninf; in llic lioiic is lelt. Altci the npcration, tin- patient nmst I 
 In- l<i'pl ai)S()iiitrly <iuicl, witli tlu* head sli},'litly raised. I'ln, 
 drainai^c IuIh' may !)«• rcmov cii in lucnty lour or h)i ty-i!i[,dii \unns I 
 anil till' stalp wound is usually licaU'tl in six or scmmi days. 
 
 IC\(Miir tin- luinoui is ina( (('ssihlc or ii rcnuivable, tiiii[)ui;irv 
 hiMudit often results fioni an exploratory operation, since ,i suli 
 cutaneous henna cerehii is theiehy allowed to lorni, and inti;, 
 eianial tension relieved, as e\ideiui'il |)y an inipioxcil incni,,! 
 eomlition ami loss of pain; as the tumour j^rows, ho\ve\er, iIilI 
 patient relapses into liis lormei slate, and death soonei m |;n,,f| 
 iollows. 
 
 ^ I W'> « 
 
 Abscess of the Brain. 
 
 Causes. Ilie most IVe(|iient sounc of cerebral ahsn-ss isl 
 chronii- disease ol tlie middle ear, and Harker states that fiillyf 
 50 [HM icnl. ol all cases ;irise iVom tliis t ause. They usually nmj 
 a somewhat chronic couisi', l)Ut may suddenly f,'i\e ris' lol 
 sym|)toms of aiaite coma, either l)y hurstinj; into onc^ of the latcrall 
 vt:ntricles or by the supiMvention of a spreadinj,' (edema. \[ 
 certain pcicentaf^e of cases is also due to tiaumatisni, cithcrl 
 innnediatcly or remotely ; in the former the symptoms aic amtc 
 and probably result from a |)enelralin}f wound, whilst in the latturl 
 instance they are more ( hionic, ami may not supei vene lor months 
 luberi Ic and pyaniia are also responsible for a lew cases ufl 
 cerebial abscess. 
 
 The Symptoms \ary somewhat with the method ol onset andl 
 the th.uaclci s ol the abscess, if trauniatic and due to iiilVdiiinl 
 trom without, the case runs an acute course, associated wiilij 
 intense pain in the liead, recurrent rij^ors, and rapid cle\(>lc)pimiit| 
 of coma. Pilluse menin,i;itis is often present, and the twt) oiii-j 
 ditions c an scarcely be distin^uisheil. 
 
 \\ hen tin- lase is sid)acute or ihronic, the symptoms are more 
 characteristic, and may be f^rouped toj^ether under the tollowinJ 
 thre(> heads : (1) Those resulting; from the presence of pus withinl 
 the boily. These are, howe\er, not typical, since, altli(iu;;li tluiel 
 may be an initial ri}j;or, the ti'uiperature is usually normal or sul 
 normal, unless basal menin^dtis co-exists. (2) 'I'iiose due to 
 intracranial pressure ami irritation. Pain in the head is iisuiill 
 the earliisi and most marked of these ; at first it is often f^'eiieialJ 
 but later on becomes ti.\ed, and localized to the seat of tlieabscesJ 
 it \aries jjjreatly in amount, sometnncs being of the most a},'on!/| 
 inj; type, sometimes very slif,dit ; it is usually continuous, hut m;iv[ 
 be intermittent, and entirely disappear for a time. .\noreMaJ 
 malaise, vomitiu};, and constipation are often present ; the pul* 
 is usually slow and intermittent, and Cheyne-Stokes respiratinij 
 may occur in the later stages. lipileptic seizures may also 
 
CF.IiF.UUAI. ABSCESS 
 
 CKi 
 
 indiK ((1, iiiul \.\\v p.'iticnt passes into a stale ol iiiental torpor, and 
 i.\cn(()ma. ( )|)ti( neuritis, more niarUed on the anectecl side, is 
 aiiollici symptom, and the pupil on that side is (hlated and do(!s 
 lint rcai I to M^ht. (3) l-'ocal plienomena arise; as in ( ascrs of 
 ccicbral tumoui, Tlie chiel facts in eoiuK^e tion with ('erehral 
 liiciiliziitio" hav(; been (Uscussed at j). ')hi,und th(;spe( iai features 
 ,it ;il>s( ess in the tcsmporo sphenoidal lobe or in the eerebellum 
 arc iU'st ribed at p. /'/(S, it umclieved, the patient dies in a state 
 ntcoma, from interierentx; with the vital centres in tlu; medulla. 
 
 Diagnosis. Imouj iiiniiiif^itis, a ((irebral abscess is usually 
 ttcoK'"''^''^' ^'y ^'"-' ''I' I *'''''^ '" ^''^^ former condition irritative 
 phenomena, such as acute and active delirium, contraction of the 
 pupil, |)liotophobia, rif^'idity and spasm of nuiscles, esp(!cially in 
 [he b;i( k of th(! nee l<, and severe pain, aie more evid(;nl and are 
 piodii'dl earlier. The temperature is usually hij^di, and mental 
 iliiliiess comes on within thret; or four days of an injury, whereas 
 ana!)S(('ss rarely forms before the end of tlu; first week, i'.xtm- 
 kul iil>Mfss (subcranial) is associated with a hif^h tcimpiirature, 
 earlier onset after an injury in traumatic cases, and more rapid 
 compression symptoms ; optic neuritis is only occasionally mt!t 
 with, and the vomitin/^f is less troublesome. There is also likely 
 111 |)i' some localized (edema or tt;nd(!iness on deep pn-ssure. 
 Fur tlif (liaj^nosis from lateral sinus pyumia see p. 77H. It is often 
 impossiiile to diaj^iiose between a chroni( abscess and a hiiiwur of 
 k lirniii : the symptoms in the latter may, howe\er, come on 
 I more slowly than in tlu; former, but the pro>^'ri;ss is steatly and 
 imnliniiinfj; ; the temperature remains near the normal, and there 
 bliss f,'astric disturbance. The history of tlu^ case may throw 
 Millie li^lit upon its nature, since in cases of cerebral abscess 
 tluri' is usually some causative septic focus, but an (ixploratory 
 opciiitiDii is often necessary to clear it up. Tiunour is more 
 
 mimoii in the iVontal and parietal re},'ions, abscess in the 
 Ikiiiporo-splienoidal lobe. Optic neuritis is more marked and 
 iiiiorf loininon in tumour than in abscess. 
 
 Treatment. — The suspected area of the brain must he. exposed 
 land e\[)loied as for a cerebral tumour, and when the presen(c of 
 pus lias i)een demonstrated, a delicate pair of sinus forceps may be 
 p;issL'(l uionj.^ a t,'roo\('d .leedle, :.nd on opening; them the pus Mows 
 jiHit. The ca\ity, which is rarely larj^'e, is <^'ently irri^^'ated, and a 
 jdraina^,'e-tul)e inserted; this should be kept in for a few days, but 
 jntt lou'^cv than is absolutely necessary, for fear of a hernia 
 Icert'liri lieiuf,' induced thereby. 
 
CHAPTKR XX !V. 
 
 wmm 
 
 ^m. 
 
 ifiii 
 
 AFFECTIONS OF THE LIPS AND JAWS. 
 
 Affections of the Lips. 
 
 Hare-lip. — By hare-lip is meant a congenital fissure i)i the upper 
 lip, which may extend for a variable distance thnuij^h the soft 
 tissues alone, or may also implicate, the bony al\ l;;1u.-. ami thf 
 
 Fig. 238.— Sinolk Incomi'leti-: Hakk- 
 
 Lir, INVOLVINi; .MKKEI.V THE TISSUES 
 OK THE LH', and not E.\TENl)lN<i 
 
 INTO THE Nose. 
 
 I-'h;. 2J(J. Doflll.E M.VKl.-LII' CiiV- 
 PI.BTE ON THE I.EKT SlIU:, I.SCi'M.| 
 I'LETE ON THE Km.111 
 
 A B 
 
 Fic. 240, -Double Comi'LETe Hakk-i.M', with Disim.achment Iokwakq 
 OK THE Central Portion ok the Intekmaxilla (Os Incisivlmi 
 
 A, Front view ; H, seen in profile. 
 
 floor of the nose, and extend backwards through the palate. 
 name is not a good one, since a hare's lip is cleft in a ^ •sIkii'< 
 manner, the fissure being central below, and bifurcatinj; a 
 into each nostril. 
 
AFFFXTIONS OF THE LIPS AND J.I II 5 
 
 683 
 
 VS. 
 
 •e of 111'' ^W"' 
 irovij;li ilif st.u 
 vcolur. imd the! 
 
 Varieties. — A hare-lip is complete ox iiuoiiiplttt', accordinf; to 
 |»mther or not it extends into the nostril. It is termed siniplc if 
 
 niited to the soft parts; alveolar, if the bony aheohis is also in- 
 ivolved : complicated, if associated with a cleft palate. The defect 
 Ijiav exist on one or both sides of the middle line; if unilateral or 
 IsinKle, it is most conmion on the left side, in the proportion of 
 koto one; if double or bilateral, it is usually, but n(Jt invariably, 
 jalveolar, and accompanied by a complete cleft of the palate. The 
 Ictntral portions of the lip and alveolus (os incisi\um) may either 
 Iitiain their normal position, or, as is more frecjuently the case. 
 
 ,1- Hakk-lip; com-! 
 
 l.l'.KT SlPi:, INCiiM-j 
 
 Kii.iu 
 
 J4I HliAl) OF F<1;TL'S, of AHOl'T 
 
 |F:vK Wkkks, FROM Ventral A.si'KCT 
 (UKR His), showing the I'rimi- 
 
 Vt Slii.Mon.KUM HOUNDED AHOVK 
 
 IHK I'NDlVniED FroNTO-NASAI, 
 
 IhiKESS, LATERALLY HV THE MaX- 
 
 LURY, AND BELOW HY THE STILL 
 
 btrARATic Mandihular Frocesses. 
 
 JSVTTON.) 
 
 iiuiiu)ue-ratliate apjiearance is 
 well represented. 
 
 Fic. 242. — Head of F(i;tl's of a 
 Little Later Date Six to Seven 
 Weeks), from the Ventral 
 Aspect. (Sutton ) 
 
 The mandibular processes have now 
 united ; the ocular vesicle is seen 
 on either side towards the upper 
 end of the orbito-nasal fissure, 
 and the fronto- nasal process has 
 tUneloped internal and external 
 nasal processes on eitiier side of 
 the still unclosed anterior nares. 
 
 
 .\K« 
 
 llhe palate 
 
 3tt m a 
 furcatinj^ 
 
 \-M^ 
 
 [oject forwards at the end of the nose, forminfj a proboscis- 
 appendage (Fig. 240, A and B). Even in simple cases the 
 is deformed, being broad and flattened, a condition which 
 omes much more marked when the alveolus and floor of the 
 iare widely fissured. Hare-lip is not uncommonly associated 
 otiu'r deformities — <r./o'., spina bifida and talipes and it is 
 |]uently transmitted from one generation to another. Occa- 
 ally a thin red line, as of a cicatrix, is seen occupying the 
 ition of a hare-lip cleft, and is probably due to a persistence of 
 
TT 
 
 684 
 
 A MANUAL OF SUKGEKY 
 
 i m\ 
 
 the raphe of union of the labial segments ; a slight gro(i\i; in ihg 
 alveolus may also be observed at a corresponding point. 
 
 Development. -(For fuller details (if the development of h.ire-!i|) and clfit! 
 jialatf, we must refer readers to ' Harelip and Cleft Palate,' hv \\ |<(,>ej 
 Lewis and Co , iHcji. Sp.icx- onlj- permits a very brief summary iHrc ) Tli« 
 l)ony and tlesln parts of the f.ice originate from tlie out^rowtii ol pmcttv 
 around the cavity formed by tiie b(,'n(lin>{ forward of the primitisc cereliral 
 
 \esicle over the end of tile notoclmrd At alxiut five weeks after i 
 
 iMlCcptldl 
 
 the primitive buccal ca\ ity or stomodaiini has a (|uin(iue-r.idiatf apiHaninceJ 
 due to the manner in wiiich these processes are formed (I'iK ^JM Abroad 
 median lappet (frontonasal process) descends from above; tiiis is separated, 
 by a fissure on each side from the symmetrically-placeil maxillary pmcesses] 
 and these af,'ain below from the more prominent mandibular processes, which 
 early unite across the mitldle line, to form the lower jaw The fmntunasal 
 process soon, howe\er, clian>,'es, developiii),' four rounded buds, the rt'latmnj 
 of wiiich are indicated in l-'i^ 242. On either side (-f <i slifjiit depression ;ii 
 the meilian line is placed the internal nasal process, from whicli are pnuluiei 
 
 Fig 24J.— DiAi.KAM to kei-kesknt the Alhreciit Tiikokv oh IUkklipI 
 SHOWING THE Situation of the Cleft in the Ai.vkolus hktmeeI 
 THE Inner and Outer Segments of the Intermaxilla 
 
 RCi, FndoK'nathion ; M(l, mesoKnathion ; 
 incisor; /.,, lateral incisor; c, canine; w, 
 
 XCi, exognatliion ; 
 
 reiilral 
 
 ;».,, first and second molars 
 
 superficially the central portion of the upper lip, and from its deeper asjit 
 the inner segment of the intermaxilla (endognathion, l"ig 243, IC(;), carryml 
 the central incisor Separated from this by a hollow, which siil)stM|uiT.il 
 forms the anterior nares, is the rounded external nasal process, from whicl 
 develop the siile of the cheek, the ala nasi, and from its deep side tlu'iuiief 
 segment of the intermaxilla (mesognathion, MG) and probably tiie latera 
 incisor. Fxternal to this a fissure runs up to, and even beyond, the primitil 
 eye (naso-orbital fissure), and this is later on closed by amalgamation ol ihi 
 internal and external nasal processes on the inner side with tin- adjaceDJ 
 maxillary process on the outer, except in the deepest part, which constituiel 
 the nasal duct The integrity of the upper lip is obtained by tiie union 
 the lower parts of the internal nasal and maxillary processes, wiiich liiij 
 exclude the external nasal from participation in its free border It 
 doubtless owing to this arrangement that the sulcus or depression around ih| 
 ala nasi constitutes such a distinct and characteristic feature of the tace 
 the same time the deeper parts of these nasal processes are unitiiiK withoa 
 another and with the palatal plates, which grow horizontally inwanis fromiB 
 under side of the maxillary processes, uniting in a Y-shaped suture, the poi( 
 of junction of the limbs being situated at the anterior palatine canal TB 
 
AFFl'XTIONS or THE LIPS AND jfAWS 
 
 m 
 
 H- II of all these elements is taking pl.nce from the sixth tn the tenth week, 
 L-'i'V tliat (Icite even tiu; uvula, tlu- last part to unitt', slioulil he miiipU'te. 
 
 iiriiinary hare-lip is chu- to a failun; of union of the intfiual nasal process 
 
 |v;ii the structurt's in otfrnal rt-lation with it; if liinit«'il to tlic soft parts 
 
 Lmple liare-lip), tin; cleft runs Ix-twi-cn the internal nasal and maxillary 
 
 Iprxessesi if coinplt-te or alveolar, hetwt-'cn the sanu! two In-low anil super- 
 
 llciillv, but in addition between the internal and external nasal processes 
 
 ■jSne and on the deep side. The cleft in the alveolus passes between the 
 
 lancr anil outer segments of the interniaxilla (I'iK .'4J), and is thus bounded 
 
 mhe inner side by the central incisor, on the outer side b\- the lateral incisor 
 
 loccasionally two teeth are foinul Krowin^ from tlu; endo'^'nathion, the outer of 
 
 Ithetwd heiuK an accessory tooth, whilst the lateral incisor, and presumably 
 
 Deniitcr sej,'nient of the interniaxilla, are often undeveloped, or exist in a very 
 
 [iimentary conilition attached to the maxilla 
 
 The (IS iiicisi\um, or projecting portion of the intermaxilla, consists of two 
 jKinents of bone, the two endoj,'nathia, united in the median line, and in a 
 Ichiklcimtains two milk central incisors, and the rudiments of tlie two perma- 
 itni lines ; occasionally, as \se have just stated, there may be an accessory 
 x'th (lev eloped on one or both sides of the process. 
 
 .\ simple hare-lip does not interfere seriously with the infant's 
 
 kiatrition, but when associated with a cleft palate, and especially 
 iliiuhle, < onsiderable troid)le may arise, thus necessitatin}^ 
 
 iin:ical treatment as a life-sa\in^' measure at a \ery early date. 
 
 I; must also he remembered that all movements of the face — 
 
 L, in cryinf,' or lau},,'hin}.j — exaf,'f,'erate the deformity from the 
 
 Vluhmccd action of the divided orbicularis oris and other 
 
 muscles. 
 As to the period at which to operate, it is better to allow the 
 
 niant to ^'et over the shock of entrance into the world and 
 iKime acclimatized to an independent existence, whilst at the 
 
 H:ik' time the operation should be performed before the troubles 
 : dentition begin. I'Vom six weeks to three months is perhaps 
 
 ^xbest a,'.,'e for operation — in well-nourished and healthy childien 
 
 ! the earlier date, in poorly-fed and weakly children at the later, 
 
 rss the inanition is due to the difficulty of f^Mvint; nutrition 
 
 l«in;; to the deformity. Under such circumstances the operatii^n 
 
 |iay have to be undertaken within the first three weeks. 
 
 Operation for Single Hare-lip. — The child should be laid on an 
 
 ^ratinj;- table with its arms bound to the body. The surgeon 
 
 Amis hcliind it, the anaesthetist and assistant one on each side. 
 
 [he operation may be described in three stages : 
 
 I. Tile lip is thoroughly dissected up from the maxHUr and aheoli 
 
 I}' cutting through the reflections of mucous membrane and the 
 
 ptachnieiit of the muscles and other soft parts. This is mainly 
 
 «de(l on the cuter side, and where there is much flattening of 
 
 Y nose the ala nasi will also require to be separated. This 
 
 iy cause some amount of bleeding, but sponge pressure easily 
 
 (introls it. 
 
 12. The edges of the deft are then pared. Many difTerent methods 
 
 kve been employed to accomplish this, but it is only necessary 
 
 mention two. The object to be attained is the union of the 
 
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 23 WEST MAIN STREET 
 
 WEBSTER, N.Y. 14580 
 
 (716) 872-4503 
 
y MP< 
 
 L<>/ 
 
 \ 
 
686 
 
 A MANUAL OF SURGERY 
 
 cleft lip by means of a cicatrix, which shall be as unobtrrsive a^ 
 possible, whilst the red margin must be continuous, and the 
 section such that the raw surfaces are larger than are absolutelvi 
 necessary, so as to allow for subsequent cicatricial contraction 
 without the development of a notch. The methods recommended 
 are as follows : 
 
 (a) The incision extends from the apex of the cleft, or fromj 
 within the nostril, in a crescentic manner (Fig. 244), so that J 
 slight angular projection is formed to constitute a prolabiuniJ 
 
 Fig. 244. — Rose's Operation for Single Hare-lip. 
 
 On the left side the semilunar incisions are seen extending as far as the fred 
 borders of the lip. The right-hand figure shows the parts drawn intq 
 position ; the wide cross lines represent the wire sutures, the narrow one 
 the catgut or horsehair stitches. 
 
 This is done on each side, and where the nose is much flattenedJ 
 more tissue is removed on the outer than on the inner side, soj 
 that when the parts are sutured together the nostrils become si 
 nearly as possible symmetrical. By this means the depth of tha 
 lip is increased to allow of subsequent contraction, whilst the leij 
 margin can be made continuous. 
 
 (b) Miraulfs Operation (Fig. 245). — The inner margin and apeji 
 
 Fig. 245. — Mirault's Operation for Hare-lip. 
 
 In the right-hand figure the prolabial flap is shown ready to be implanted | 
 
 on the prepared inner side. 
 
 of the cleft are pared, so as to leave a raw surface ; a flap of rej 
 marginal tissue, as thick as possible, is then cut from the outrf 
 side, and implanted on the bevelled raw surface of the red margin oj 
 the inner side, the upper portions of the cleft being also apposedj 
 3. Sntuycs are now inserted to maintain the lip in the posm 
 into which it can be drawn by the fingers without tension, m 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 687 
 
 j deep silver- wire sutures should be introduced, one just above the 
 red margin, and one close to the nose, to draw into position and 
 I steady the nostril, which should be left smaller than that on the 
 other side, so as to allow for subsequent dilatation, which is certain 
 ! to occur. Horsehair or catgut stitches are used to bring the exact 
 j margins together, the continuity of the muco-cutaneous line being 
 accurately preserved, and the cut edges of the mucous membrane 
 Upon the deeper aspect being sutured, each stitch, after it is tight- 
 ened, i)eing used to elevate and evert the lip and thus assist the 
 insertion of the next. The wound is dressed with a small piece 
 of gauze, and secured by another dry piece cut in the shape of a 
 kitterHy, so that the narrow body shall fit over the lip, and the 
 wings spread over the cheeks ; this is fixed by collodion, and 
 maintained for some days after the stitches are removed, the deep 
 ones on the fourth day, and the superficial ones about the eighth 
 I or tenth. Careful feeding by the spoon is necessary, the mother's 
 milk being drawn off and given in this way, if possible. In simple 
 leases the child may be returned to the breast about the fifth day. 
 jln order to prevent the child from picking at the lip or disturbing 
 dressing, it is well to put a splint on the fiexor side of each 
 [arm to control the elbow-joint. 
 
 The Treatment of Double Hare-lip may be discussed under two 
 llieadings, viz., the treatment of the os^ i_ncisj_v um, and that cf the 
 [ soft parts. 
 
 The OS incisivum ne ed not be touched if it retains its normal 
 tositiona_jancl the laBial clefts are t hen alone d ealt With ; but if_ il 
 |jro[ects forwards, as is often th e case, i t must be either removed _ 
 [orjeplaced. {a) In the former case the Antral portion ot the 
 |iipperirpls freed from it by dissection, and the base of the process 
 Idivided with cutting-pliers ; a small artery in the bone will spurt 
 Ivigorously, and may need an application of the cautery to stop it. 
 [Tlie operation on the lip is deferred till ten days later, ( b) Re- 
 Iposition may be effected by forcible backward pressure, which 
 Iprohably fractures the pedicle of support, and may be dangerous 
 [from the fissure extending up to the base of the skull, or from 
 Ibleeding. Prolonged elastic traction on the process may suffice 
 [in the slighter cases, but not in bad ones. The best method of 
 joperation is Bardeleben's, who incises the lower border of the 
 jseptum, strips off" the muco-periosteum from either side, and then 
 pnds or breaks the bone back into position, fixing it by silver 
 rvires, and uniting the lip at once to form a splint to maintain it 
 situ. The advantages claimed for reposition are that the 
 atient retains his own central incisor teeth, and that the normal 
 Ntourof the jaw and face is not interfered with. Against this 
 plan, however, must be placed the facts that the bone rarely be- 
 pnes firmly united, that the teeth are stunted and erupt obliquely 
 Packwards from rotation of the process, and that its presence 
 prevents the maxillae from falling together and increases the 
 
688 
 
 A MANUAL OF SURGERY 
 
 difificulties of subsequently closing the palatal cleft. Personally 
 
 ■.,ro rcmmmfinH pxfirnatinn in harl rnt;p<;. t;inrp thp flicfimiiv.nir.^'f 
 
 aimcuillcti ui sui^acquciiiiy ciusmy luc pclicllcll uic 
 
 we recommend extirpation in bad cases, since the disfigurement 
 can to a large measure be removed by adding a projecting cheek- 
 plate to that which carries the artificial incisors, thus pusliin<,' tl e 
 upper lip forwards, {c) Where, however, the projection is iKt 
 
 f 
 
 IPP^Ti 
 
 
 1, 
 
 i 
 
 
 
 m 
 
 
 Fig. 246. — Rose's Operation for Double Hare-lu'. 
 
 The central tubercle is pared in a V-shaped manner, and the lateral segments 
 by curved incisions, extending to the red margin, and then inwards. Only 
 the apex of the central portion is included in the completed lip. The loni; 
 cross lines represent the position of the wire stitches, the shorter ones dt | 
 the catgut sutures. 
 
 great, it is possible to diminish the size of the os incisivum by 
 gouging away the teeth contained within it, so that the lip can be] 
 closed over it. 
 
 The soft parts of the lip are dealt with in much the same way 
 
 Fig, 247. — Median Hare-lip. 
 (Pitts' Case.) 
 
 Fig. 248. — Oblique Facial Clkkt, or,! 
 RATHER, Cicatricial Deformity ■vLoxiJ 
 THE Line usually traversed by sfCH| 
 a Cleft. (Kraske's Case.) 
 
 as in single hare-lip. They are freely detached from the inaxillaj 
 and the edges pared, as shown in Fig. 246, the central portion! 
 being cut into a V, and no attempt made to incorporate it into the 
 free margin for fear of depressing the tip of the nose, whilst the 
 lateral segments are pared as in the single operation. These| 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 689 
 
 h the same way 
 
 latter are now drawn together and united in the middle line below 
 the central portion, so that a Y-shaped cicatrix results. One of the 
 deep silver stitches should lix the apex of the V ; the other should 
 be inserted just above the red margin. The dressing and after- 
 ireatnient are as in the single operation. For a time the child 
 may have difficulty in breathing owing to the diminution in the 
 size of the oral aperture, l)ut this is obviated by the nurse drawing 
 down the lower lip with the fingers, or by painting it in a vertical 
 I direction with collodion. 
 
 Other congenital abnormalities of the lip are met with, which, however, can 
 Idvbe itriefly mentioned here. 
 
 Median Hare-lip may occur in one of two forms : either a simple cleft exists 
 i;n the middle line (Fig. 247), or tiiere may be an absence of ihe intermaxilla 
 lir.ilnasat septum, causing tiattening of the bridge of the no.se, and abroad 
 I »!ian defect, tlantced by the ma.xillary portions of the lip. 
 
 Oblique Facial Cleft is an uncommon deformity, characterized by a cleft or 
 
 1 Sulcus in the face, starting from the usual situation of a hare-lip below, but 
 
 ranning up outside the nostril to the inner side of the lower lid (Fig. 248). 
 
 iyol)oma of the iris or choroid is sometimes associated with this rare defect. 
 
 1 The deformity is due to non-closure of tlie naso-orbital fissure, and runs along 
 
 ■he line of the nasal duct. It may be 
 
 Ihinited to the soft parts, or may involve 
 
 .i'.e hones, even laying open the antrum. 
 
 Macrostoma (Fig. 249) is characterized 
 
 ■van abnormal width of the moutii, and 
 
 niue to non-union of the maxillary and 
 
 Mandibular processes. It may be uni- 
 
 r hi-lateral, and is usually associated 
 
 iithanomalies of development of the ear, 
 
 laccessorv auricles being often present. 
 
 ].\5arule, a small papilla on the upper 
 
 adlower margins will indicate the true 
 
 'mits of the mouth, being constituted 
 
 :ythe points of attachment of the orbicu- 
 
 llaris The existence of these is of grt.t 
 
 Importance as indicating the extent to 
 
 l^hich tile cleft must be pared in order to 
 
 |restnre the mouth to its normal size. 
 
 Mandibular Clefts are exceedingly rare. 
 [They are due to non-union of the man- 
 jjibular processes in the middle line, and 
 J.r.volve either the soft tissues of the lower 
 j;? alone, or may extend to the bone, and 
 jfvcn the tongue. Treatment is as for 
 |iKinary hare-lip. 
 Microstoma is the term applied to 
 1 condition in which the fusion of the 
 
 farts entering into the formation of the lips progresses to a greater extent 
 
 pn usual, so that the oral orifice is contracted. It may be associated with 
 
 itiective development of the lower jaw. In the more severe cases, where the 
 
 'Uth is extremely narrowed, a transverse cut should be made outwards on 
 
 tschside, and the mucous membrane stitched to the skin. 
 
 Macrocheilia, or hypertrophy of the lip, occurs in three forms : 
 
 The congenital variety, a condition analogous to macroglossia, 
 
 ^nd due to a congenital distension of the lymphatic spaces, or 
 
 44 
 
 Fig. 249. — Macrostoma 
 Auricular Appendages. 
 
 GUSSON.) 
 
 WITH 
 
 (Per- 
 
690 
 
 A MANUAL OF SURGERY 
 
 chronic lymphangiectasis, accompanied by overgrowth of the 
 connective tissue. The lower lip is most often involved, and is 
 hrin, thickened, and everted, causing considerable defonnitv, 
 The treatment consists in the removal of a V-shaped portion from 
 the centre. 2. An acquired form occurs in children and youiif; 
 people with a tuberculous inheritance, constituting the so-called 
 ' strumous lip.' Either lip may be affected, but perhaps mon 
 frequently the upper ; the thickening is probably of a chronic 
 u'dematous nature, maintained by the persistent irritation of cracks j 
 and fissures. If these can be healed, and the general health 
 improved, diminution in the size of the lip soon follows. 3, In 
 adults, macrocheilia is in almost all cases due to tertiary syphilis 
 The lower lip is most often -.enlarged, and becomes thick and hard. 
 It is due to the diffuse sclerosis characteristic of tertiary mischief, j 
 General treatment, and not local, is needed. 
 
 SypMlitic Affections of the lip are not uncommon. A priuutn 
 chancre may be caused by kissing, or by smoking an infected pipe, j 
 
 or drinking from a glass] 
 with an infected rim. It 
 usually presents a smooth 
 ulcerated surface, dis- 
 charging a small amount 
 of sero-pus, resting on a 
 mass of infiltrated tissue j 
 which may extend over I 
 the whole lip (Fig. 2501.1 
 The induration is not sol 
 great as in chancres uponj 
 the genital organs, biitj 
 the infiltration is miich| 
 more extensive. An in- 
 dolent enlargement of one j 
 or more of the sub-l 
 maxillary lymphaticj 
 glands occurs very early,! 
 and the disease us-ialiyj 
 runs an acute course. 
 Ordinary specific treat- 
 ment is all that is needed, 
 A labial chancre mavl 
 
 Fig. 250. — Chancre of Upper L^^ 
 
 closely resemble epithelioma, but is distinguished from it by it^ 
 rapid development up to a certain point, by the early implication^ 
 of the glands, which soon become very large, by the absence ol 
 typical cachexia, by the age of the patient, and the course takeij 
 by the case, as well as by the local appearances. The surface \i 
 usually flattened, and less warty and irregular than in epitheliomaj 
 whilst the skin is more involved than the mucous membrane 
 
 TfSiff" ?ffliH5f^' 
 
AFFECTIONS OF THE LIPS AND JAIVS 
 
 691 
 
 Should the chancre have existed for any time, the presence of 
 a rash or sore throat may materially assist in forming a 
 Jiafiiiosis. Moreover, it is said to be more common on the 
 upper lip, whilst epithelioma is usually seen on the lower 
 compare Figs. 250 and 251). In the secondayy stage mucous 
 tubercles are frequently met with, involving the inner side of the 
 lip and the angle of the mouth. In the tcvtiavy period serpiginous 
 ulceration and gununata may occur, or the diffuse induration 
 Jtscribed above. In inherited syphilis, cracks and mucous tubercles 
 I are constantly present, and may be so extensive as to leave cica- 
 trices radiating from the mouth, which are very characteristic. 
 
 Cracked Lips (or, as they are often called, chapped lips) are 
 usually the result of cold weather, a central crack or fissure 
 torming which is extremely painful, and liable to bleed very 
 readily on everting or stretching the part. The lower lip is that 
 ijenerally affected. In tuberculous children more than one may 
 occur, and by their persistence give rise to a considerable degree 
 of induration and infiltration, and perhaps lead to glandular 
 trouble. All that is needed in the shape of tveatment is the appli- 
 cation of a little lanoline or cold cream, but if they persist, it may 
 be advisable to touch them with nitrate of silver. 
 
 Herpes Labialis is a condition usually associated with catarrh, 
 and not unfrequently with pneumonia or other fevers. Either 
 lip may be affected, and the herpetic eruption is quite limited in 
 extent. It consists of a number of little vesicles situated on a 
 hyperaemic and painful base ; after a few days the vesicles become 
 transformed into pustules, and these in turn burst and dry up, 
 
 [the whole affection lasting perhaps a week or ten days. No 
 special treatment is required. If the inner aspect of the lip is 
 
 I affected, the epithelium early becomes sodden and is shed, so that 
 
 I the vesicular stage is much shorter. 
 
 Mucous Cysts occur on the inner side of the lip in the form 
 I of small rounded swellings, which are translucent and contain a 
 [glairy fluid. They are often due to trauma, Avhereby the opening 
 [of a mucous gland is blocked. The whole cyst svall should be 
 [dissected out, and the wound closed by stitches. 
 
 Navi are frequently met with in the lip. If confined to the 
 Imner aspect they may be dissected out, but when large and 
 jinvolving the whole thickness, they should be dealt with by 
 
 lelectrolysis. 
 
 Warty Growths are often seen on the lower lip, especially near 
 
 |the angle, and may then simulate epithelioma. They are dis- 
 
 nguished, however, by the fact that ulceration is not often pre- 
 
 44—2 
 
692 
 
 A MANUAL OF SURGERY 
 
 sent, that tlie lymphatic f^lands are not involved, and that there 
 is but little infiltration of the base. They, should, hovvevt-r, he 
 remo\ ed as early as possible, since malignant disease often starts 
 from them. 
 
 Epithelioma of the lip usually occurs in men of the working' 
 classes, and is conmionly stated to be due to the irritation pro- 
 duced by sniokin<,f a 
 short clay pipe, whicli 
 is allowed to rest on 
 one or the other side 
 near the an.t^lc. A 
 semicircular notch will 
 fretjuently be noticed 
 in the teeth of the 
 upper and lower jaw, 
 corresponding to the 
 situation of the growth . 
 on the lip, and caused 
 by the constant fric- 
 tion of the pipe-stem. 
 It may also start 
 opposite the site ot 
 some projecting rou^li 
 or carious tooth. It is 
 but rarely met with 
 in women, occurrini: 
 in England in not more 
 than 5 to 6 per cent, of 
 the cases, and of these, 
 according to Hutchin- 
 son, half are clay-[iipi' 
 smokers, whilst in 
 Warren's female cases, 
 amongst the Irish in 
 Glasgow, three-quarters were smokers. It is also more common 
 amongst country folk who use the short clay pipe than anionf^st 
 the cigarette and cigar smokers in towns. 
 
 The disease may start as an induration around a crack or 
 fissure, which gradually extends, forming a typical rnali.i^nant 
 ulcer ; or as a wart-like growth, which fungates and ulcerates ; or 
 as a chronic infiltration leading to an irregukir nodular thirkenini,' 
 of the lip (Fig. 251). 
 
 If allowed to run its course unchecked by treatment, the disease 
 steadily progresses, forming an ulcerated mass of greater or less 
 size, and even involving the jaw. The submental and suh- 
 maxillary glands are early implicated, and secondary deposits are 
 also found in the glandular concatenatae. Beyond this, however. 
 
 Fig. 251. 
 
 -Chronic Epithelioma of Lower 
 Lip. 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 693 
 
 the disease rarely extends, visceral complications being uncommon. 
 When a fatal issue results, it is generally caused by the secondary 
 j^rowths in the neck, which attain considerable dimensions and 
 then ulcerate, this stage being possibly preceded by one of cystic 
 ilt'^jeneration. I'rom these ulcerated surfaces a xariable amount 
 ,if discharge occurs, varying with the septicity or not of the 
 wounds. Ha;morrhage is also likely to follow from erosion of 
 some of tlie vessels in the neck. 
 
 The Diagnosis of epitheli(jma is rarely doubtful, but occasionally 
 warty growths, or even a primary chancre (p. 690), may be mis- 
 taken for it. The clinical history generally suffices to determine 
 the nature of the mass, as also the character of the base and the 
 appearance of the parts ; but in uncertain cases the removal of a 
 Miiall portion under cocaine, and its microscopic examination, are 
 required to set doubts at rest. 
 
 Treatment. — The primary growth can almost always be excised 
 completely without much difficulty ; if glands are also enlarged, 
 these should be removed 
 where such is feasible, 
 Imi when once the con- 
 catenate group has been 
 attacked, they often con- 
 tract such adhesions as 
 to render their extirpa- 
 tion impracticable. If 
 the growth is limited to 
 one part of the lip, a 
 \ -shaped wedge ex tend- 
 inis half an inch beyond 
 it in all directions may 
 he taken away (Fig. 252), 
 and the wound closed, as 
 ma case of hare-lip, with- 
 out much deformity re- 
 sulting. When it is more 
 extensive considerable in- 
 
 ;;enuity must be exercised in order to make good the defect. 
 One plan that often gives good results is to excise the growth by 
 a somewhat larger V-shaped incision, and then to extend the 
 lalnal fissure transversely to one or the other side, or to both, 
 dissecting up these segments from the bone ; the flaps can then 
 usually be brought together, whilst the mucous membrane is 
 united to the skin along the margin of the new lip. 
 
 When the whole lower lip requires removal, Symes' operation 
 may he performed with advantage. It consists first of all in the 
 complete excision of the diseased lip. Two curved incisions are 
 then made, starting from the middle line of the wound, and ex- 
 pending downwards under the chin, to terminate below the angles 
 
 Fig. 252. — V-sHAi'ED Incision for Removal 
 OK Epithelioma ok Lip. 
 
694 
 
 A MANUAL OF SURGERY 
 
 of the jaw, an in\ertecl V-shaped portion of skin between them 
 remaining fixed to the symphysis nienti to form a l)ase of support 
 for the new lip. The lateral Haps are now dissected up, niiswl, 
 and united one to the other in the middle line, so as to constitutr 
 the new lip, an inverted Y-shaped cicatrix resulting. The elasticitv 
 of the skin in this region allows this to l)e accomplished, aiul the 
 whole wound closed, without leaving any part to granulate. The 
 mucous membrane shoidd be finally stitched to the skin over the 
 upper free margin. Healing by first intention usually follows. 
 
 if the whole of the upper lip needs to be removed, it may he 
 restored in a variety of ways. Perhaps one of the best consists 
 in making incisions which skirt the alas nasi on each side, and 
 then extend outwards into the cheeks sufficiently to allow the 
 tissues, when they have been freed from the maxilla,' by under- 
 cutting, to be drawn together in the middle line. In such cases 
 care must be taken not to encroach on Stenson's duct. 
 
 Affections of the Qums and Alveolar Processes. 
 
 Spongy Gums are not unfrequently met with as a result of the 
 administration of mercury, or from scurvy. They are characterized 
 by being soft and congested, bleeding readily on pressure, and 
 perhaps showing signs of ulceration. All that is necessary is the 
 correction of the determining cause and the use of an alum 
 mouth -w^ash. 
 
 Alveolar Abscess is almost always associated with suppuration 
 around the fang of a carious tooth. The alveolar walls become 
 expanded, and the pus finds its way over the edge of the hone, or 
 even through the osseous tissue, under the external periosteum. It 
 limited in extent, it perforates the gum directly, and is then known 
 as a gum-boil ; but it occasionally burrows beneath the periosteum, 
 which is stripped from the bone, and may thus lead to an abscess 
 of larger size, possibly resulting in necrosis of the jaw. The 
 formation of an alveolar abscess is almost always associated with 
 a considerable amount of pain of a very irritating nature, and 
 when extensive may give rise to serious constitutional dis- 
 turbance. Occasionally graver complications ensue ; thus, in 
 the upper jaw the antrum may be opened, and suppuration 
 in this cavity follow, whilst in the lower the abscess may travel 
 downwards and burst externally, either close to the lower 
 margin of the bone or in the neck. A troublesome sinus results, 
 which can only be cured by the removal of the tooth, and 
 even then a depressed and adherent cicatrix ensues, which is 
 very unsightly. The most essential point in the treatment neces- 
 sarily consists in the removal of the offending tooth. Often 
 this is quite sufficient, and possibly the tooth may come away 
 with an abscess cavity attached to one of the fangs. \\he" 
 suppuration occurs beneath the periosteum, the pain can at first 
 be relieved in measure by fomentations, but as soon as Huctua- 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 695 
 
 lion is detected an incision should he made through the mucous 
 nienihr.ine, and the cavity emptied. Possibly it may be wise to 
 keep a small piece of stuffing in for a few hours, but if a large 
 enouf^h opening has been made, all that is subserjuently re(|uired 
 is repeated and frequent irrigation, preferably with peroxide of 
 iivdrogen. If a small sinus persists after remoxal of the tooth, it 
 must be opened up, and any carious or necrosed bone removed. 
 
 Pyorrhoea Alveolaris (or Riggs's Disease) consists in an inflam- 
 matory condition of the margins of the gums, accompanied by 
 ,1 muco-purulent discharge, which arises from pockets or pouches 
 which may extend a greater or less distance along the roots of 
 the teeth. In consecjuence of this the tissues of the gums shrink, 
 ml, together with the alveolar border, become atrophic ; the 
 laiigs are thereby uncovered, and the teeth loosened, so that after 
 nvliile the patient is likely to become edentulous. The process 
 IS limited to a few teeth, or may involve many. It is always pre- 
 ceded by an excessive deposit of tartar, beneath which bacterial 
 infection occurs. Treatment consists in the removal of the tartar 
 and the application of astringents and antiseptics, preferably 
 peroxide of hydrogen, not only to the exposed mucous membrane, 
 hut also into the pouches and pockets where pus collects. Treat- 
 ment is often prolonged and tedious, but must be persisted in, not 
 only to save the teeth, if possible, but also to pre\ent or remedy 
 the toxamiic and dyspeptic symptoms which are due to the absorp- 
 tion of the pus. In many cases, howe\ er, the teeth ha\e to be 
 sacrificed. 
 
 Hypertrophy of the Gums is met with in the form of a sessile 
 overgrowth, sometimes almost cauliflower-like, around and between 
 the teeth ; it occurs most frequently in children, but occasionally 
 in older subjects. It is sometimes associated with carious teeth, 
 and should be cut away with a scalpel. 
 
 Dental Cysts are by no means uncommon, resulting from the 
 irritati\'e eft'ects of dental caries ; hence they follow the distribution 
 of that affection, and are most frequently seen in connection with 
 the upper first molars and bicuspids. They develop at the roots 
 of the teeth, causing a painless regular expansion of the bone, 
 free from inflammatory phenomena, unless infected secondarily 
 with bacteria. After a time the centre of the swelling softens, 
 and, as tlie bony wall is absorbed, parchment-like crackling can 
 he felt ; finally, the condition presents as a rounded tense elastic 
 I swelling, around the margins of which the remains of the expanded 
 hone can be detected. The tooth which is the cause of the trouble 
 is always dead, and frequently merely a septic root is present. 
 
 f he cause of these cysts is probably the proliferation of certain 
 
 I embryonic remains of the enamel organ, brought about by the 
 
 irritation of septic matter which has escaped from the pulp cavity. 
 
 These foetal residues are lighted up into activity, develop into 
 
 i masses or cylinders of epithelial tissue, and then undergo cystic 
 
696 
 
 A MANUAL OF SURCEKY 
 
 (lef,'ent'rution. Their patli();;,'t'nesis is practically identical with 
 that of the epithelial odoiitome, l)Ut merely one cyst (lex ('lops 
 here, instead of niany. The lluid contained therein is thitk and 
 mucoid in character, and broken-down epithelial cells and (holes- 
 terine are seen in it on microscopical examination. 
 
 Treatment. — • The cvst 
 must be laid freely opm 
 into the mouth, the scptii 
 tooth or stump rcmnvLd, 
 and the anterior wall of its 
 alveolus cut away. Tlif 
 alveolus and cyst thus laid 
 into one ca\ity are scraped 
 so as to remove all the 
 epithelial lining, and 
 packed with j^rauze so as {u 
 ensure healinj; by .ijraiuilu- 
 tion. 
 
 Epulis. — 15y this term 
 is meant a tumour growin;,' 
 from the aKeolar perios- 
 teum. Two vari' ;i> art' 
 described, viz., the simple 
 and the nuui; aant. 
 
 A Simple Epulis is 
 usually of a iibromatous 
 nature, and may arise from 
 the alveolus of either jaw, 
 althouf,^h it is more com- 
 mon in the lower. It is 
 possibly due to the irrita- 
 tion of diseased teeth, and although most marked on the outer 
 aspect, it burrows between the teeth, and is also found on the 
 inner side. It appears as a red fleshy mass, smooth, or perhaps 
 lobulated (Fig. 253), of an elastic consistency, and possil)lv 
 associated with a little superficial ulceration. It is covered with 
 mucous membrane, and may contain a few spicules of bone. The 
 treatment consists in removing the growth together with the teeth 
 or stumps with which it is connected. If small, it will suffice to 
 cut it away and scrape the bone from which it arises ; hut it 
 large, or if it recurs after such treatment, the portion of the 
 alveolus from which it springs must also be excised. This is 
 best accomplished by extracting a tooth on either side of the 
 tumour, and cutting vertically through each socket with a saw. 
 the two incisions being united below with a chisel, so as to remove 
 a quadrangular portion of bone without interfering with the con- 
 tinuity of the jaw. 
 
 Fiti. 253. — Simple Epulis. 
 
A I' FECI IONS OF THE LIPS AND y.llVS 
 
 697 
 
 1 lining;, and 
 h f^aui/e so as to 
 linj; by j,'ianulii- 
 
 Malignant Epulis. - This title is applied to ;i sarcomatous 
 ;,iiiiour j,M()win^' tVoin the alveolar luart^iu. It is usually of a 
 nyelnid ciiaracter, and forms a soft rapidly increasiTi;^^ mass of a 
 Jiiskv purple colour, wiiich runs on to ulceration or fun>,Mtion. 
 lilt: tl(.'r|)er portions of tlic j^nowth may contain an ossilic deposit. 
 \s with all forms of myeloid {^M'owth, it is only locally mali^;nant. 
 Iniitiiiait consists in free remo\al of the mass and of the portion 
 , if alveolus from which it arises. In the upper jaw this usually 
 necessitates excision of the complete palatal sef^nnent of the 
 iiaxilla, but in the lower jaw it is generally possible to maiiUain 
 the continuity of the mandible by merely removing a (juadri- 
 liiteral portion in the same way as for a simple epulis. 
 
 Epithelioma and Sarcoma (round or spindle-celled), arising from 
 ;!k' ;,'uin, are both occasionally met with. JCpithelioma in this 
 Mtuation rarely fungates, but rather tends to in\ade the bony 
 n-sucs, and in the upper jaw '^teiids upwards to the antrum; 
 itiice, it is sometimes termed a leeping or burrowing epithc- 
 iiiiiiia.' The ordinary signs of iliis ilisease become evideiu, 
 lymphatic glands are enlarged and typical 'dceration of the gum 
 fuljows. The only possible : atmcnt con.ists in free excision (jf 
 till' },aowth, together with the portion ol bone affected. 
 
 Necrosis of the JaT?'. — Causes : ^ 1 ) Subperiosteal alveolar abscess, 
 
 omiiected with dental caries. (2) Traumatism, such as blows 
 
 111 the jaw, with or without fracture, m the latter instance being 
 
 liiiL' to septic periostitis or osteomyelitis, owing lo tlie lesion 
 
 litcoming compound. It has also followed the extraction of a 
 
 1 touth with dirty forceps, setting up infective osteoni\'(;litis. 
 
 13) In tertiary syphilis necrosis also occurs, affecting most 
 
 tiequently the palate or alveolar border;;. (4) it occasionally 
 
 results from mercurial poisoning, but such is rarely seen at the 
 
 [present day. (5) Phosphorus necrosis is met with amonj^st those 
 
 who work in lucifer-match factories, but only when ordinary 
 
 phosphorus is used; the amorphous form is harmless. The 
 
 tiimes are supposed to gain access to the jaws through carious 
 
 teeth, giving rise to a somewhat acute inflammation, which 
 
 terminates in necrosis. A considerable amount of new bone 
 
 {forms beneath the periosteum, and the sequestrum, which 
 
 lis curiously grey and porous, like dirty pumice-stone, is always 
 
 hlow in separating. Either jaw may be affected, but perhaps 
 
 jtlie lower a little more commonly than the upper. (6) Necrosis 
 
 I'liay follow one of the exanthemata, arising as an infective 
 
 lidiopathic or embolic osteomyelitis, and then probably affecting 
 
 [1 considerable extent of bony tissue, possibly the whole mandible. 
 
 (7) Tubercle is occasionally responsible for this condition. 
 
 The Clinical Phenomena associated with necrosis of the jaw are 
 jnecessarily much the same whatever the cause. In the acute 
 
mmmmm 
 
 698 
 
 A MANUAL OF SURGERY 
 
 form, inflammatory symptoms are well marked, the face becominijj 
 swollen, red and shiny, and severe pain being experienced. Soonerl 
 or later an abscess forms, which may point either in the mouth orl 
 on the face, or the pus may burrow downwards for some distance! 
 into the neck. Sinuses persist, discharging the most oftensivel 
 pus ; a new case of bone forms, enclosing the sequestrum in the! 
 lower jaw, but in the upper this is but rarely noticed. 
 
 Treatment. — In the early stage the mouth should be fomented,) 
 and as soon as there is any suspicion of pus a free incision isl 
 made down to and along the bone. When necrosis is present,! 
 it must be treated in the ordinary way, the sinuses being flushedl 
 out with an antiseptic solution two or three times a day until the) 
 sequestrum is loose ; *it is then removed, if possible, from withinj 
 the mouth. 
 
 Affections of the Antrum. 
 
 Suppuration within the Antrum frequently arises from disease! 
 connected with the fangs of the first or second molar or bicuspid) 
 teeth ; it not uncommonly extends from the nasal cavities in) 
 connection with disease of the middle turbinated bone, or mav[ 
 be infected secondarily from suppuration within the frontal sinus:) 
 it is occasionally lighted up by injury. 
 
 The Symptoms produced are often extremely equi\ocal, and tliej 
 condition may be present for some time without being recognisedl 
 In the chronic forms there is usually a little local tenderness overj 
 the antrum, and perhaps some swelling of the mucous membranel 
 or of the cheek, whilst there is an intermittent discharge of pusj 
 into and from the nose. This varies considerably in amount and! 
 character, being sometimes extremely offensive. It is stated by[ 
 Heath that, although the patient notices the foetor himself, it isl 
 not, as a rule, discerned by other people, thus differing fronJ 
 oza'na. On holding the patient's head forwards, it can be demon- 
 strated that there is an overflow of pus into the nostril, and some- 
 times when the patient reclines it flows back into the pharynx, 
 Should the opening into the nose become blocked, all the symp- 
 toms are aggravated, the pain becoming more marked and the| 
 swelling increasing. Signs of distension of the cavity may also 
 produced in this way ; such are manifested in four directions:] 
 (a) Inwards, causing obstruction to nasal respiration, and possiM}| 
 epiphora, from compression of the nasal duct ; (b) upwards, leau-f 
 ing to protrusion of the eyeball or exophthalmos ; (c) downwards, 
 resulting in depression of the side of the palate, and possibi 
 irregularity in the line of the teeth ; and (d) outwards, giving risa 
 to a somewhat characteristic projection of the cheek beneath m 
 malar eminence. Under these circumstances, a finger inserted 
 into the mouth, between the cheek and the bone, will detect a losa 
 of resistance in the anterior wall of the antrum, and if the disttcj 
 
AFFECTIONS OF THE LIPS AND J A \VS 
 
 699 
 
 3 face becominj;! 
 ienced. Sooner 
 in the mouth orj 
 ir some distance! 
 i most oftensivcl 
 juestrvim in the! 
 :ed. 
 
 ild be fomented,! 
 free incision is! 
 rosis is present, 
 js being flushed! 
 3 a day until thej 
 Ible, from within] 
 
 :juivocal, and the! 
 
 being recognised.! 
 
 I tenderness overj 
 
 ucous membraiiej 
 
 discharge of pusl 
 
 y in amount andj 
 
 It is stated byl 
 
 jtor himself, it isl 
 
 IS differing froral 
 
 it can be denion-j 
 
 lostril, and some-l 
 
 nto the pharynx! 
 
 sd, all the sympj 
 
 marked and the 
 
 vity may also 
 
 four directions j 
 
 -ion, and possiM)] 
 
 \b) upwards, leaui 
 
 ; {c) downwards, 
 
 ite, and possibly 
 
 ^ards, giving risj 
 
 .icek beneath tlij 
 
 a finger inserted 
 
 will detect a M 
 
 land if the disten] 
 
 hion has lasted long, eggshell crackling may be noticed, or the 
 hhole anterior wall may be absorbed and an elastic swelling take 
 jits place. Infraorbital neuralgia is often a marked feature in 
 jihese cases. 
 
 hi acute ca.'.es all the above phenomena may be present in an 
 laccentuated degree, accompanied by severe tensive pain and some 
 lamount of febrile disturbance. Necrosis of the lining bony walls 
 jmay also be induced, owing to the fact that the mucous mem- 
 jkane is closely adherent to the periosteum. 
 
 The Diagnosis of suppuration within the antrum is by no means 
 Ireadily made, since there are many conditions which simulate 
 lit somewhat closely. Perhaps the most important sign is the 
 Ipfriodic discharge of pus from the nose, and if this can be induced 
 Ibv change of position of the head, it is pathogncmonic of disten- 
 tion with pus of one of the accessory sinuses connected with the 
 Use, probably of the antrum. The association of such a pheno- 
 [nenon with a dead or painful first molar or bicuspid is also a 
 most suggestive occurrence. Another method which has been 
 Recommended is that known as transillumination of the antrum . A 
 electric lamp is placed within the mouth, and if the patient 
 Is in a dark room, and his antra are normal, the cheeks, lips, and 
 lower margins of the orbits become of a rosy-red colour. If, 
 pvever, the cavities are occupied by pus, blood, or a growth, the 
 |)arts remain dark. Transillumination does not answer in every 
 ndividual, and hence the value of the test is much diminished. 
 fhe presence of illumination excludes intra-antral growtiis or 
 Ibscess, but its absence, unless unilateral, is not of much 
 Igniticance. 
 The Treatment of this affection consists in freely opening the 
 ntrum from the mouth, so that the cavity may be washed out 
 nd drained. Various methods have been adopted to attain this 
 Ind, and perhaps the most satisfactory consists in making an 
 Vision through the anterior wall above the first molar after 
 )ividing the mucous membrane. This tooth, the fangs of whicli 
 Dcroach upon the cavity, may also be drawn, and the anterior 
 Nl of its socket cut or gouged away. The cavity is sul)- 
 pquently washed out freely every day until it has healed. To 
 vent the opening from closing too quickly, a wire tube made 
 |f ilver, and fitted to a small tooth-plate, should be inserted. It 
 f-aken out and cleansed night and morning, and plugged during 
 pals. In those cases secondary to intranasal disease, the first 
 pntial is to deal with the origin of the mischief by scraping 
 »ay all granulation tissue and diseased bone. The antrum may 
 I this way usually be opened from the nose, and in the majority 
 '■ cases this will suffice to enable the cavity to be irrigated and 
 pined. In old-standing cases where chronic suppuration per- 
 ft?, the cavity should be freely opened up from the mouth, 
 ^amined by the finger, scraped, flushed, and stuffed with gauze. 
 
700 
 
 A MANUAL OF SURGERY 
 
 Hydrops Antri is the term applied to a chronic distension ofl 
 the antrum with a glairy mucoid fluid, somewhat similar 'm\ 
 character to that contained in a ranula. The condition is pain- 
 less, and free from inflammatory phenomena, and as the exl 
 pansion increases, eggshell crackling of the anterior wall, or even! 
 distinct fluctuation, may be observed. It was formerly supposodl 
 to arise from obstruction to the aperture into the nose and re-l 
 tention of secretion, but it is in reality due to a cystic tumouri 
 forming from the mucous membrane and the glandular elementsl 
 contained therein. The treatment required is to thoroughly open! 
 the cavity through the mouth after dividing the mucous nieinbrane,f 
 and removing a sufficient portion of the anterior wall to enable it| 
 to be washed out and drained. 
 
 Various Tumours may originate in the antrum, e.g., mucous 
 polypi, fibromata, odontomata, osteomata, sarcomata, and cancers! 
 If limited to the cavity, they produce no definite symptoins,r 
 except when large enough to give rise to expansion of its walls.) 
 Malignant growths, however, usually pass beyond the limits of 
 the antrum, and lead to the usual signs of malignant disease oil 
 the upper jaw. Tveatwent consists in removing simple growths,! 
 if possible, without interfering with the integrity of the maxilla.1 
 This may be accomplished by reflecting the overlying cheek, ag 
 in excision of the upper jaw. For malignant tumours, removal 
 of the whole bone is the only possible remedy. 
 
 Tumours of the Upper Jaw. 
 
 Many of the Simple Tumours springing from the upper ja\\j 
 have been already described amongst those involving the alveoku 
 border and antrum. Only a few remain to be dealt with. 
 
 Osteoma occurs either in the form of a tumour composed ol 
 compact tissue, then usually growing within the antrum, or it i( 
 occasionally met with as a diff"use symmetrical overgrowth, con! 
 stituting the condition known as leontiasis ossea. A tew cases o| 
 Chondroma have also been reported. 
 
 By Leontiasis Ossea is meant a disease, fortunately extremely 
 rare, characterized by the formation of diffuse hyperostoses Iron 
 either the cranial and facial bones, or from both. It usually cuinj 
 mences in young adult life, and both rickets and syphilis have been 
 suggested as playing some part in its causation, although rea" 
 nothing definite as to its origin is known. Nodular outgrowtlii 
 of soft spongy bone are gradually developed, increasing slowlj 
 in size, and giving rise to irregular bony protuberances projecting 
 beneath the skin, and when affecting the maxilla; and mandible 
 leading to an extremely repulsive appearance of the individua 
 Sometimes merely the cranial bones are affected, at other times onlj 
 the jaws, whilst occasionally the whole skull participates in tlif 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 701 
 
 change, which is almost always symmetrical. As growth pro- 
 gresses, the new bone tends to encroach on the cavities contained 
 ivithin the skull, so that the antrum may be obliterated, the eyes 
 iiiav protrude owing to the contraction of the intra-orbital space, 
 I and even coma and death may supervene from cerebral compres- 
 jion. Prior to this, however, a \ ariety of symptoms, especially 
 i neuralgia, may be induced by pressure on the cranial nerves. 
 JmUncnt is only occasionally possible, and consists in the removal 
 of the projecting masses of bone by the chisel. A few fairly satis- 
 [tactory results of such a procedure have been recorded. 
 
 Malignant Disease of the Upper Jaw occurs in the form of 
 varcoma or cancer. 
 
 Sarcoma is perhaps the more common, and originates either 
 lirom the anterior wall, from the ca\ity of the antrum, or from 
 the spheno-maxillary fossa behind the bone. Sarcomatous naso- 
 pharyngeal polypi also spread from the nose, and involve the 
 maxilla secondarily. Not unfrequently these growths have a con- 
 siderable ossific deposit within them, and this is occasionally so 
 extensive as to obliterate the antral cavity, and convert the bone 
 I into a solid mass. 
 
 Cancer develops in the form of squamous epithelioma, springing 
 [either from the gums or from the antral mucous membrane ; or 
 as a columnar or acinous cancer starting in the glandular tissue, 
 I found both in the nasal and antral ca\'ities. 
 
 The Clinical Features of all forms of malignant disease are 
 [practically identical. 
 
 If arising from the anteyiov aspect of the bone, a tumour is 
 [produced which projects under the cheek, the tissues of which 
 [are iiavaded by it ; it tends to travel down towards the mouth, 
 land is readily detected through the mucous membrane. It may, 
 
 uever, spread deeply, and in time involve the cavity of the 
 lantrum. It causes no obstruction to nasal respiration, and no 
 [epiphora except in the later stages. 
 
 If it originates within the antrum, the usual signs of distension 
 lot tliat cavity are produced, associated with a foul, and often 
 jlilood-stained, discharge from the nose, within which the ulcerated 
 jsurface of the growth may be seen. Epiphora is caused by 
 jpressure on the nasal duct, whilst the growth has been known to 
 |i)i;rrow upwards along this passage and project near the inner 
 |canthus. The passage of air through the nose on that side is also 
 
 npeded. 
 
 If the growth commences behind the maxilla, it usually springs 
 Ifrom one of the walls of the spheno-maxillary fossa, or from the 
 jhase of the skull, and is then characterized by a great tendency 
 P spread or burrow in all directions. Thus, it may perhaps push 
 pe whole bone bodily forwards without encroaching upon the 
 Ptrum ; sometimes it finds its way outwards to the pterygoid 
 
702 
 
 A MANUAL OF SURGERY 
 
 fossa through the pterygo-maxillary fissure, or inwards to the 
 nose through the spheno-palatine foramen, or even up into the 
 orbit ; whilst more rarely it spreads downwards along the posterior 
 palatine canal, so as to appear at the postero-external corner ot 
 the palate ; in the later stages it is not uncommon to tmd the 
 antral cavity also involved, and even the base of the skull is not 
 exempt from the ravages of the disease. 
 
 The General Signs of a malignant growth of the superior 
 maxilla consist in the appearance of a tumour which, accordin" 
 to its origin, produces various effects, but finally tends to destroy 
 the bones and occupy the whole of the maxillary region. 
 is usually accompanied by nasal obstruction, epiphora, and; 
 frequently by a discharge of blood or pus from the nares. Severe! 
 pain sometimes accompanies the process, especially alfectins; 
 the second division of the trigeminal. Neighbouring lympliaticj 
 glands become enlarged, more especially in the carcinomata 
 those in the submaxillary region are first involved, and afterwards] 
 those in the anterior triangle ; secondary deposits in the viscer; 
 may also occur somewhat later. The tumour follows a typicalj 
 malignant course, and, owing to the great vascularity of the parts, 
 its onward progress is very rapid. 
 
 The Diagnosis of malignant disease of the jaw from a simpli 
 tumour should be readily made ; the later age at which it appears, 
 the rapidity of its growth, the greater pain and more abundani 
 discharge from the nose, the associated enlargement of thi 
 lymphatic glands, and the tendenc}^ to spread and to encroacl 
 upon surrounding structures, all point to malignant disease 
 some cases, however, an exploratory incision must be made inti 
 the antrum, in order to make certain of the diagnosis. Mori 
 frequently the existence of a tumour at all is for some timi 
 entirely overlooked, some one prominent symptom, such 
 neuralgia or epiphora, being treated without ascertaining thi 
 cause. 
 
 Treatment consists in free removal of the growth, if such 
 practicable, together with total or partial ablation of the superiol 
 maxilla. Where, however, the tissues of the cheek have beei 
 invaded, or where the growth has spread beyond the limits of thi 
 antrum, the surgeon may well hesitate before recommending 
 operation, since complete eradication is always a matter of uncei 
 tainty and difficulty, and often secured only at the expense 
 terrible mutilation and considerable risk to the patient's life, 
 course, in those cases which spring from behind the niaxil 
 operative treatment should never be lightly undertaken. 
 
 Excision of the Superior Maxilla. 
 
 The operation is performed for the purpose of removing ni 
 growths, simple or mahgnant, either originating in the upper ja 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 703 
 
 inwards to the! 
 ven up into the] 
 )ng the posteriori 
 xternal corner oij 
 mon to find the! 
 f the skull is not! 
 
 of the superiorl 
 which, accordin^j 
 ' tends to destroy! 
 Uary region. Itl 
 [1, epiphora, and! 
 le nares. Severel 
 pecially al'fectinj 
 )Ouring lymphaticl 
 :he carcinomata;! 
 ;d, and afterwardsl 
 its in the visceraf 
 : follows a typical] 
 larity of the parts, 
 
 aw from a simple 
 t which it appears] 
 id more abundan^ 
 llargement of the 
 and to encroacH 
 nant disease, li 
 tust be made into 
 diagnosis. Mor^ 
 is for some time 
 mptom, such 
 ascertaining th^ 
 
 rowth, if such 
 Ion of the superiol 
 
 cheek have beeJ 
 -d the limits oi tb] 
 Irecommending 
 
 matter of uncer| 
 it the expense 
 [patient's life. ' 
 kind the maxiH^ 
 lertaken. 
 
 la. 
 
 of removing nej 
 in the upper m 
 
 lor extending into it, whilst it is also sometimes employed as a 
 preliminary in dealing with tumours of the base of the skull. 
 Naturally the exact steps vary considerably in different cases 
 I according to the character and extent of the disease. 
 
 Operation. — The patient's head and shoulders are well raised, 
 j and anaesthesia is maintained by means of chloroform given by 
 junker's apparatus. Some surgeons undertake a preliminary 
 tracheotomy, and plug the pharynx, in order to prevent the 
 entrance of blood into the air passages, but such is scarcely 
 necessary or desirable if good assist- 
 ance is to hand, since it increases to 
 a certain extent the risks of the 
 [operation. The proceeding may be 
 I described in stages as follows : 
 
 Stage I. : Incision and Reflection of 
 
 \ik Soft Striictuves of the Check, — The 
 
 Icentral incisor tooth ■ f the aflfected 
 
 [side having been extracted, the 
 
 [upper lip is divided in the middle 
 
 line as high as the columna nasi ; 
 
 incision is now carried round 
 
 [the ala and along the side of the 
 
 [nose, to a point half an inch below 
 
 [tlie inner canthus ; it thence extends 
 
 the same level along the lower 
 
 lorbital margin to a point below its 
 
 [outer border, or even to the zygoma 
 
 (Fig. 254, A) . The flap thus marked 
 
 out is raised from the bone, and 
 
 pected outwards so as to clear thf; 
 
 zygomatic eminence, the knife being 
 
 fcarried as near to it as is considered 
 
 ftise, and the more important arteries secured, as they are 
 jdivided, by Spencer Wells' forceps. 
 
 Stage II.: Division of the Bony Attachments. — A keyhole-saw is 
 bowpassed into the nose, and the alveolus and hard palate divided 
 [rom before backwards through the empty socket of the central 
 ncisor tooth. There is no need to incise the muco-periosteum 
 breviously, as is sometimes recommended ; division by the saw 
 lauses less bleeding than the use of the knife. The side of the 
 pose is then freed from its bony attachments, and the periosteum 
 [tripped from the floor of the orbit, the eyeball being protected 
 ly a spatula. It is most desirable that the orbital periosteum 
 phould be preserved intact, so as to prevent septic invasion 
 ¥' the urbit. The nasal process of the superior maxilla is now 
 [tit through with a saw, and also the malar bone divided so as 
 |o open into the spheno-maxillary fissure. The surgeon then 
 akes a pair of long-handled cutting pliers, and completes the 
 
 Fig. 254.— a, Incision for Re- 
 moval OF Superior Maxilla ; 
 B, FOR Removal of Lower 
 Maxilla ; C, for Kocher's 
 Operation for Removal of 
 Tongue. 
 
704 
 
 A MANUAL OF SURGERY 
 
 division of each of these bony attachments, but reversinjf the 
 order, dealing with the malar bone first, next with the nasal 
 attachments, and finally with the palate. The cuttiiii,^ pliti> 
 must always be applied with the smooth surface towards the 
 tissues which are to be left, and the bexelled surface towards 
 the part which is to be removed (Fig. 255). When the section 
 of the palate is completed, the cutting pliers are used as a lever 
 to prise the bone out of its bed, the sound bone acting as a 
 fulcrum, the posterior attachments being thus fractured. The 
 pterygoid processes are broken through close to their origin from 
 
 Fig. 255. — Excision of the Superior Maxilla. 
 
 the sphenoid, and the lateral mass of the ethmoid yields along tliej 
 inner orbital margin. 
 
 Stage III. : Removal of the Bone and Tumonv. — The bone is no\v| 
 seized by lion forceps, one blade holding the alveolus, and tli^ 
 other the infra-orbital border, and twisted out ; the mouth is| 
 gagged open, and the soft palate, if free from disease, is divided 
 from its attachment to the hard by a transverse incision, and al^ 
 other muscular connections severed. Some care is needed in 
 removal of the projecting hamular process. Considerable hamor-j 
 rhage may occur at this stage from some of the branches 
 the internal maxillary artery, especially the infra-orhital ana 
 posterior palatine ; it is checked temporarily by plugging tha 
 wound firmly with a sponge, and subsequently the chief vesselj 
 are secured by ligature, whilst smaller bleeding points may 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 70s 
 
 reversin<f the 
 ^'ith the nasal 
 cuttiiiii pliers 
 e towards the 
 .rrface towards 
 len the section 
 used us a levt'r 
 le actin;^^ as a 
 ractured. The 
 leir ori";in from 
 
 touched with the cautery. Any outlying portions of the tumour 
 ,tre now dealt with, and the cavity, after being dabbed o\er with 
 a solution of chloride of zinc (40 grains to the ounce), is plugged 
 vith strips of cyanide gauze soaked in the iodoform glycerine 
 dinilsion. The wound in the cheek is closed, the greatest care 
 being taken to obtain accurate apposition of the Hap, especially at 
 the lip margin, and dressed with gauze secured with collodion. 
 
 In the majority of cases there is comparatively little shock, and 
 the patients do remarkably well — at any rate, for a time — although, 
 unfortunately, recurrence is only too likely to follow. The plug 
 in the nose is left in situ for twenty-four hours, and then removed 
 throu<^h the mouth, and the wound irrigated with some antiseptic 
 solution. The plug maybe replaced, but can usually be dispensed 
 with if the patient washes out the cavity several times a day. 
 Healing is effected by granulation, and of course a large gap 
 communicating with the mouth remains. This can be subse- 
 uiently remedied by an obturator, to which is attached a cheek- 
 plate to pre\ent falling in of the cheek. The patient is fed for 
 the first few days by the rectum, or by a tube passed intc the 
 pharynx, but soon ac(|uires the knack of swallowing fluids, 
 I especially when the soft palate has been left intact. 
 
 Partial Operations. — Many modifications of the above may be 
 [undertaken in order to minimize, as far as possible, the amount 
 of tissue removed, and to prevent any unnecessary scarring. 
 When the alveolus alone needs removal, the external incision 
 maybe limited to division of the lip, the soft tissues of the cheek 
 heins; stripped up as far as necessary from the bones. If part of 
 lihe body of the bone recjuires removal as well as the alveolus, only 
 the nasal half of the incision need be made, and indeed, wherever 
 !t is possible, the orbital plate should be left in order to prevent 
 displacement downwards of the eye and subseqvient diplopia. In 
 such cases a saw is carried from the anterior nares across the front 
 ixiLLA. ^ofthe antrum to the malar bone. The alveolus and palate are 
 
 now divided, and the growth with this portion of l)one detached 
 i yields along tlieMfrom its posterior connections. The upper part can also be re- 
 iinoved separately, the palate and alveolus being left intact ; the 
 operation should, in fact never be looked upon as a fixed and 
 efinite proceeding, but may be modified to suit the particular 
 xigencies of the case. 
 
 Various forms of osteoplastic resection of the superior maxilla 
 required for the treatment of tumours of the naso-pharynx are 
 lescribed later (p. 724). 
 
 —■The bone is nowl 
 ilveolus, and tliel 
 t ; the mouth isj 
 .isease, is divided 
 incision, and all 
 , is needed in tlid 
 [siderable hamorj 
 the branches ofl 
 .infra-orbital aiij 
 
 by plugging M 
 the chief vesselj 
 ig points may ' 
 
 Tumours of the Lower Jaw. 
 
 These are similar in character to those met with in the upper 
 ^w. Thus, Chondroma, Osteoma, Fibroma, and the simple and 
 palignant forms of Epulis, have been already described. 
 
 45 
 
7o6 
 
 A MANUAL OF SURGERY 
 
 Dentigerous Cysts form around teeth which are so misplaced 
 that they cannot erupt ; though occasionally seen in the upper! 
 jaw, they are much more common in the lower. Their characters! 
 and nature have been already described under the title oi folluuhn] 
 odontomcs at p. 135. They are met with in young people, and! 
 give rise to expansion of the jaw (Fig. 256) ; the tumour thiisj 
 formed is at first hard and solid to the touch, but later on ej;;,' 
 shell crackling and even true fluctuation are observed when thel 
 
 encasing wall has become tliinl 
 or absorbed. Irregularity in! 
 the line of the permanent teeth! 
 may sometimes be noted, butl 
 not necessarily, since the milkl 
 tooth corresponding to thatl 
 which is misplaced is notj 
 always shed, owing to thel 
 absence of pressure from below.j 
 Occasionally suppuration withinj 
 the cavity may be caused by aiij 
 extension of inflammation from! 
 the fang of a neigh bouriii<,i 
 tooth, or by the cyst beini;. 
 opened during its extraction.! 
 A sinus discharging offensive 
 pus will then form, and the 
 surrounding tissues become re 
 and congested. Treatment con-j 
 sists in freely opening the cysd 
 through the mucous membranej 
 and removing a sufficient porj 
 tion of the bony wall to allovj 
 of the removal of the niisplacetj 
 tooth. The cavity is left oped 
 and allowed to heal by granuj 
 Fk;, 256.-- DENTinERous Cyst, show- lation, during which procesi 
 iNG Expanded Condition of the ^^.^.-^^^ attention to cleanlines| 
 Lower Jaw, and Unerupted Tooth , , , 
 
 LYING horizontally WITHIN IT. ^^lust oe oDserveQ. 
 (College of Surgeons' Museum.) Fibrocystic Disease of till 
 
 Jaw (epithelial odontoiiie, p. 133] 
 has been already mentioned as characterized by the formation 
 a tumour, often of great size, which consists of spaces lined wit 
 cuboidal epithelium, and supposed to originate from the enam 
 organ (Fig. 257). They occur most frequently in young peoplfl 
 and, as a rule, run a perfectly benign course, although from thei 
 size they may lead to serious results. The only Treatment consis' 
 in complete removal of the affected portion of the jaw. 
 
 Myeloid Sarcoma is met with in the lower jaw, not only in t 
 form of a malignant epulis, but also occasionally as a centri 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 707 
 
 jrowth, usually attackinj,' the median portion of the bone, which 
 ii'comes expanded in the same way as when a similar disease 
 invades the end of a long bone. It presents but slight e\ idences 
 ,! malignancy, and may be treated in the first place liy opening 
 ;he outer shell of bone and scraping away the soft contents, the 
 avity thus formed being swabbed out with pure carbolic acid, 
 [and plugged with gauze. .Should it recur, the affected portion of 
 he bone must be removed. Whenever possible, a bridge of 
 lojseous tissue is left so as to connect the two segments of the 
 Jiaw; if this is not attended to, they are likely to fall together, and 
 I 'rad to considerable trouble. If the whole thickness of the bone 
 i;> excised, a wire frame or splint should at once be introduced 
 l.ttween the fragments with the same object. It is replaced later 
 
 nby a suitable plate carrying artificial teeth. 
 
 Round- or Spindle-Celled Sarcoma also occurs, usually springing 
 
 Fig. 257. — Fibro-Cystic Disease of the Lower Jaw. 
 iBy kind permission of the Council of the Itoyal College of Surgeons.) 
 
 |from the periosteum, the deeper parts undergoing ossification. 
 iThe course is typically malignant, and free removal of the affected 
 ption of the bone must be undertaken. 
 
 Epithelioma invades the lower jaw as an extension of a similar 
 fetion arising either from the gum, lips, or tongue. Excision 
 [t a portion of the bone together with the primary disease is 
 lluays required, unless it has extended so far as to render extir- 
 ation impracticable. 
 
 J Excision of the Lower Jaw is employed in the treatment of 
 [arious tumours arising from that bone, as also sometimes for 
 Intensive necrosis. In the latter case it may be possible to deal 
 lith it from the mouth, but w'hen required for the treatment of 
 plignant disease an external incision is absolutely essential. 
 
 If the whole of one side is to be removed, an incision is made, 
 [eaching from just below the red margin of the lip downwards to 
 
 45—2 
 
7o8 
 
 A MANUAL OF SURGERY 
 
 a point immediately below tlie symphysis, and thence alon^' the 
 under surface of the body of the jaw as far as the anj^li'; it i^i 
 then prolonged upwards as far as the posterior liordL-r of the 
 vertical ramus, not extending further than the attachment of the j 
 lobule of the ear, so as to avoid the facial nerve (Fig. 254, B), 1 
 When a large tumour is being dealt with, the whole thickness of 
 the lip should be divided, and the Hap tluis marked out dissecld 
 off the bone, and turned outwards. Where, however, the upper I 
 portion of the lip is left, the incisions are carried down to the 
 bone, the facial vessels being secured above and below before 
 division. The soft parts are then freed from the outer aspect of 
 the bone, and the cavity of the mouth opened. The central incisorl 
 tooth is drawn, and the jaw divided through the empty socket I 
 with a saw and cutting pliers. By this means the genial luhercles| 
 and their attached muscles are not encroached on, and the move- 
 ments of the tongue are left unimpaired. The bone is sei/ed and 
 drawn outwards, so that its internal connections as far as thel 
 angle may be divided. It must then be firmly depressed, and thel 
 muscular attachments of the masseter on the outer side, andof the| 
 internal pterygoid on the inner, cut through. The inferior dental 
 nerve and artery will also be met with at this stage. By still 
 further depressing the bone, the temporal tendon is exposed audi 
 should be divided by successive touches of the knife, which is kept! 
 close to the bone. Finally, the condyle is freed after division olf 
 the external pterygoid muscle and of the ligaments of the teniporoJ 
 maxillary articulation. The proximity of the internal maxillar/ 
 artery to the inner aspect of the neck of the bone must be reniemj 
 bered, and hence it is important to keep the blade of the knifrf 
 directed towards the bone. After haemorrhage has been arrested] 
 the wound is stitched together and dressed with collodion an(f 
 gauze ; possibly a drainage-tube may be inserted with advantad 
 for a few days through the floor of the mouth. Considerablf 
 deformity usually results from this operation, owing to tlie remain! 
 ing half of the bone being drawn across the middle line. 
 
 Diseases of the Temporo-Maxillary Articulation. 
 
 Acute Synovitis may supervene in the course of an attack 
 rheumatic fever, and is evidenced by pain on movement of th 
 jaw, with swelling due to a serous effusion into and around th 
 jomt. Resolution usually follows, but fibroid thickenin^^ of tli| 
 ligaments and impairment of movement may result. 
 
 Acute Arthritis arises from pyaemic infection after the eJ 
 anthemata, or from gonorrhoea, but may be caused by direct ej 
 tension of inflammation from the middle ear, as in scarlatina. 
 occurs in children, and is due ' to the persistence of a hiatus 
 that part of the tympanic plate which forms the floor of the meatj 
 and the roof of the articulation ' (Barker). It is characterized I 
 
AFFECTIONS OF THE LIPS AND JAWS 
 
 709 
 
 ;nce aloni; the 
 
 le ;in<;l(.' ; it i> 
 
 liordur of t!if 
 
 Lchment of the 
 
 (FiK; 254, li) 
 )le thickness of 
 d out disseclL'd 
 ever, tfio upper 
 d down to tile 
 1 below before j 
 
 outer aspect of I 
 e central incisor 
 B empty socket I 
 genial tubercles 
 , and the move-| 
 me is sei/.ed and 
 
 15 as far as the I 
 pressed, and thel 
 r side, and of thel 
 
 16 inferior dentall 
 stage. By ?tilll 
 
 in is exposed and! 
 ife, which is kept! 
 1 after division olj 
 s of the temporoj 
 iternal niaxillarjl 
 must be renieiuj 
 .ade of the knit'd 
 ,as been arrested! 
 |th collodion and 
 
 with advantad 
 |h. Considerable 
 
 g to the remainj 
 
 le line. 
 
 Iculation. 
 
 of an attack 
 iiovenient of tl 
 
 and around tl 
 thickening of tl 
 
 Lit. ■ 
 
 \n after the ei 
 Led by direct ej 
 fin scarlatina. 
 Ice of a hiatus 
 [oor of the meatj 
 characterized 
 
 the usual signs of a severe localized inllaniniation, with the foriiia- 
 lion of abscesses, and results conuiionly in ankylosis. ["Jest and 
 ihe antiseptic opening of abscesses constitute the only t-arly treat- 
 ment, although excision of the condyle is sometimes rec^uired at 
 ,1 later date. 
 
 Osteo-arthritis is by no means a rare afTection of this joint. 
 It is often synunetrical, and characterized by an fnlargcmont 
 „t the C(mdyle, which can be felt distinctly in front of the tragus, 
 r>pecially on opening the mouth, when crepitus is also noticed. 
 [lie pain is worse at night and in wet weather, and the jaw 
 becomes deflected to the sound side if the disease is unilateral ; 
 
 ihen both sides are affected, the jaw is pushed fowards, and 
 
 hhe chin projects. The articular cartilage undergoes the usual 
 
 chanf^es, the inter-articular cartilage disappears, and the glenoid 
 
 avity becomes enlarged and flattened, so that the eminentia 
 
 rticularis is relatively less marked, thus permitting the external 
 Ipieryf^oid muscle to draw the condyle forwards. After a time, 
 
 iiisiderable difficulty is experienced in opening the mouth, exen 
 liinounting to ankylosis. Ordinary medical ti'eaimcnt may be used 
 Inthe early stages, but in the later the condyle of the jaw should 
 |!t excised, a proceeding followed by excellent results. 
 
 Tuberculous Disease may arise either in the bone or synovial 
 liiitrmhrane, perhaps spreading to it from neighbouring lymphatic 
 Llands. It runs the usual course of the disease, terminating in 
 [caries of the condyle, and ankylosis after protracted suppuration ; 
 lij prevent this, excision of the condyle is indicated. 
 
 Immobility or Closure of the Jaw may be caused by a variety 
 
 i conditions : 
 
 1, True ankylosis of the temporo-maxillary joint, fibrous or 
 caseous, as the result of any of the diseases mentioned abo\'e. 
 
 2. Cicatricial contraction of the soft structures either within or 
 iMthout the mouth, as from burns, lupus, or extensive operations 
 |!ithe pterygoid regions upon the roots of the fifth nerve, from 
 
 (.mcrum oris, or very rarely from myositis ossificans. 
 j. Spasm of the muscles of the jaw (or trismus), due to reflex 
 
 |::itation, as from carious teeth, or an unerupted wisdom-tooth, 
 
 V some other local lesion. It is occasionally hysterical, and is 
 
 pe of the early symptoms of tetanus. 
 
 4. Local inflammatory conditions often render opening of the 
 
 puth impossible, both from the pain and swelling — e.g., in mumps, 
 
 arotid al)scess, acute alveolar periostitis — whilst in epithelioma 
 
 various forms of tumour the size of the growth may seriously 
 
 [iipair the mobility of the jaw. 
 
 The term ankylosis can only be applied to the conditions men- 
 toned in the first two groups. In the others appropriate treat- 
 ment must be instituted according to the character of the affection. 
 Ihere the closure of the jaw is permanent, it may be due to 
 peous ankylosis, the bony masses extending not only between 
 
r» 
 
 A MANUAL or SURGERY 
 
 the articular surfaces, hut also bclwccti the aKcoli, or lo Cilirmu 
 adlu'sioiis within the joint, or to extra articular (untraction ot the 
 soft parts, the skin and mucous membrane beinjif not only involved, 
 but also fre(|uently the muscles and de(!per structures. 
 
 |)i\ision of tiie neck of the bone or irxcision of the head ni;i\ 
 thus be impracticable, or, even if possible, is useless, since thi 
 muscles of the jaw hold the surfaci'S in sucii f^ood ajiposition ;h 
 to briu},' about a recurrence of bony imion, unless obviated Iv 
 implantiuf^f a ilap of the tem|)oral uuisclo or a vulcanite plat. 
 between the bony surfaces. Division of the intra- or extrahiiaal 
 cicatrices is unsatisfactory, owinj,' to their rapid re-formatio!!. Tli 
 best (rriiliiiciit in most cases is either removal of the vertical raimi-l 
 of the jaw down to the level of the alveolus, or the plan su-^j^t'stid j 
 by ICsmarch, viz., excision of a wedj^e of bone, with its api 
 towards the alveolar border, from the nei;,,dd)ourliood of the an!,'li. 
 and the establishment of an artilicial joint at that spot. The 
 incision should be made below and Ixihind the anj^de down to tlic 
 bone, from which the periosteum is stripped up, and ilivision i>j 
 accomplished by means of the saw. 
 
 Excision of the Condyle of the Jaw is not always a si-nniti 
 operation, since the space at the surgeon's disposal is very Hi, ' u, 
 owing to the presence of the zygoma above, of the facial nenci 
 below, of the parotid gland in front, and the external ear l)eliini 
 The best incision is a curvilinear one, commencing over the niidd 
 of the zygoma, and passing downwards in front of the trai^Ms. 
 should merely divide the skin and subcutaneous tissue, ;ii ' ♦!ie| 
 flap thus marked out is turned forwards. A transverse ii on 
 is now made through the deep fascia immediately below tliej 
 posterior extremity of the zygoma, extending down to the neck off 
 the bono, which is cleared by a raspatory and divided by cuttinjj 
 pliers ; the condyle is then grasped by necrosis forcep;., anJJ 
 twisted out. But little bleeding occurs, and the wound heals byf 
 first intention except along the track of the drainage-tube, whicli 
 should always be employed. 
 
CIIAI'TICU XW. 
 AFFECTIONS OP THE NOSE AND NASOPHARYNX. 
 
 Affections of the Outer Nose. Several forms of Injury, iiu hulin^ 
 fiacturc of the nasal hones and separation of the cartila;<es, have 
 brt'ii ulrrady noticed (p. .j-oH). 
 
 Depression or Flattening of the Bridge of the Nose is eithei a 
 
 ttsult ot" traumatism, sticli as a fracture of the nasal hones, or 
 
 I may arise from defectixe {j^nnvth of the ethmo-vomerine s(!ptmn, 
 
 line to disease either of syphilitic or tuberculous orif.(in early in 
 
 lite, whilst it may also result from similar conditions occurring,' in 
 
 [the course of tertiary syphilis. If caused hy injury, and dealt 
 
 with promptly, it may he remedied ; hut when once actpiired, and 
 
 especially if the consetpience of disease, treatment is well-nij^h 
 
 impracticable. Several cases have been lately recorded, however, 
 
 in which hone-{i;rafting has been successful. An incision is made 
 
 [down the middle line of the nose, the soft parts are reflected on 
 
 [either side, and, after making,' a comfortable bed for it, the bone- 
 
 [Kraft is introduced, and kept in position partly by sutures, but 
 
 [mainly hy closinj^f up the wound in the soft tissues. In one case 
 
 the patient's own fourth metatarsal bone was utilized with success, 
 
 [whilst platinum, ^old, or celluloid frames have also been employed 
 
 jin the same way. 
 
 Expansion of the Bridge of the Nose is always the outcome 
 lof some long-continued intranasal pressure, especially from the 
 jgrowth of polypi. It rarely follows the development of mucous 
 Ipolypi, except when they are very large and chronic, but it is not 
 Ian uncommon accompaniment of the fibrous or fibro-sarcomatous 
 jvariety. The bridge is flattened and bulged out on either side, 
 k'iving the face an appearance justifying the name ' frog-nose ' 
 |"»vliich has been applied to it. 
 
 It is impossible to discuss all the different affections of the skin 
 «f the nose. Many of them are associated with the sebaceous 
 glands, which in this region are very large and abundant. 
 Hius, acne is commonly met with, arising from an inflammation 
 U the glands after obstruction to their ducts. It is especially 
 jtequent in drinkers and dyspeptics, women addicted to tea- 
 
712 
 
 A MANUAL OF SURGERY 
 
 drinking often suffering severely. When the superficial capillaries 
 become markedly dilated and the face readily flushes on the 
 imbibition of hot or stimulating fluids, the term rosacea is attaclied 
 to it, whilst if acne pustules are also present, it is known as aciu 
 rosacea. Sometimes the spots become much enlarged, and tliere 
 is a considerable amount of infiltration of the base, a condition 
 described as acne hypertvophicnm. In the most exaggerated stage 
 the sebaceous glands become overgrown and form large protu- 
 berant nodular masses projecting from the end of the nose, and 
 covered with red greasy skin, in which the dilated orifices of the 
 glands are very evident, and with dilated capillaries coursin" 
 
 freely over it. This condition is 
 generally known as lipoma nasi, rhim- 
 phyma, or hammev-nose (Fig. 2^% 
 The treatment of simple acne con- 
 sists in correcting the dyspepsia, and 
 limiting the amount of, or interdicting' 
 entirely, alcohol or tea. Capsules of 
 ichthyol (3 to 10 minims), may also 
 be administered thrice daily, and 
 soothing applications should be used 
 locally, such as a lotion consistini; 
 of calamine, oxide of zinc and pre- 
 cipitated sulphur, held in suspensioi; 
 with glycerine and lime - water, 
 Dilated and unsightly capillaries 
 may be dealt with by puncturini: 
 them with the galvano-caute') or an 
 electrolytic needle. Rhinophyma requires operative proceedinifs; 
 the protuberant mass should be freely dissected away from the 
 cartilages, and the raw surface either left to cicatrize, or dealt 
 with by Thiersch's method of skin-grafting. 
 
 Partial or Total Destruction of the Nose may residt from t au 
 matism, but usually from some chronic inflammatory or malignant 
 growth, such as lupus, tertiary syphilis, or rodent ulcer. Epi- 
 thelioma sometimes attacks it, and requires total removal of the 
 nose for its cure. In any of these conditions the resulting de- 
 formity is so repulsive that the surgeon is certain to be asked to j 
 undertake some proceeding to remedy it. Various plastic opera- 
 tions have been devised, which, however, we can only indicate 
 briefly here, referring students to larger works of operative surgery j 
 for fuller details. 
 
 Fk;. 258. — Rhinophyma, or 
 Hammer-nose. (Tillmanns.) 
 
 The chief methods of Rhinoplasty are as follows : 
 
 I . The so-called Indian method consists in the formation of a nose from a j 
 flap of si<in obtained from the forehead. The flap (Fig. 259) is more or less 
 pyriform, with the pedicle so placed as to contain one of the frontal arteries 
 and the supratrochlear nerve. The frontal periosteum may or may not be 
 included in the thickness of the flap, which is twisted r?und and applied totlie 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 
 
 713 
 
 relreslicd margins of what remains of tlie nose (Fig 260). Heneatii tlie free 
 nil r)f tlie flap two portions of rubber or celluloid tube are inserted, so as to 
 irm the anterior nares, and the columna is constituted, either at the time or 
 -ubseqiiently, by turning up the centre of the upper lip, and uniting it to tlie 
 ■nder surface of the flap. When the union of the lower portion is sufficiently 
 tirm, tiie nose is made more shapely by partiallv di\iding the twisted pedicle, 
 hut if possible the integrity of the frontal artery should still be retained. 'I"he 
 Aiuinil in the forehead is drawn together as far as possible by sutures, and 
 healing promoted later by skin-grafting. 
 
 :. In the TagUacor.ruan or Italian operation (so called from Tagliacozzi, the 
 -argenn who first proposed it) a flap of skin is taken from the arm. The 
 iwticle must always be broad, and is left attached to tlie upper part of the 
 inner aspect of the arm ; it must be so placed tliat it can be brought into 
 apposition with the nasal defect without tension, tlie forearm and hand being 
 I nxed by a suitable apparatus above the head, and retained there until good 
 mion has been accomplislied, when the pedicle is gradually divided. Absolute 
 
 Y'r, 25Q. — Indian Method of Riuno- 
 
 !L\srV, SHOWING THE SHAI'E AND 
 
 Position of the Forehead Flap. 
 
 TiLLMANNS.) 
 
 Fig. 260. — Flap stitched in Posi- 
 tion. (TlLLMANNS.) 
 
 I.wiirn of the arm is an essential, and as this may need to be maintained for 
 lira or three weeks, the patient needs a considerable amount of pluck and per- 
 rvLTance. When the pedicle has been detached, subsequent plastic measures 
 lare required to mould the new tissue to the shape of the nose. 
 
 J The cheeks have also been made use of in what is known as the French 
 |f ;i:/ to supply material for the nose, flaps being dissected up from either 
 |s;ie, and united in the middle line. 
 4. Th(! above operations have the great objection that the new nose only 
 nsistsof soft tissues, and hence is very likely to shrivel up and contract, so 
 llatall that is finally obtained is a covering for the defect, which is often 
 jjiiiie flu;;li with the surface. To obviate this, and to secure a bony basis for 
 |M nose, attempts have been made to utilize a finger for tlie purpose, and 
 Tir .\stley IMoxam has iiad one or more successful cases. The terminal 
 palanx is removed , the soft parts split down the middle line on the palmar 
 rpect, and the divided segments united by suture to the margins of the nasal 
 rfect. When union is secured, the amputation of the finger is completed. 
 ^Naturally, where only a portion of the nose is destroyed, partial operations 
 »n be devised to meet the requirements of the case. 
 
ip 
 
 714 
 
 A MANUALOF SURGERY 
 
 Examination of the Nose and Naso-Fharynx. — In order to under 
 stand fully the diseases of the nose, it is essential that the interior 
 of the organ be efficiently examined, and to do this three chief 
 methods are resorted to : 
 
 1 . A nteviov rhinoscopy consists in the illumination of the front of 
 the nasal cavity through the anterior nares. A good light is 
 required, such as that derived from an electric head-lamp, and 
 some form of nasal speculum. Perhaps Thudichum's speculum 
 is one of the best ; it consists of two unfenestrated blades, con- 
 nected by a U-shaped spring, which is held in the hand, whilst 
 the blades are inserted into the nostril, the nasal vibrissa: heinj 
 thus held aside ; the ring and index fingers are placed one on 
 each limb, so as to regulate the amount of tension, and prevent 
 painful overstretching. By this or similar means one is enabled 
 to see the anterior part of the nasal fossae, including the inferior 
 turbinated bone, and the erectile tissue at its anterior extremity. 
 The amount of distension of the latter limits the view of othei 
 structures ; if greatly swollen, it feels soft and even fluctuating, but 
 collapses entirely on the application of a 5 per cent, solution of I 
 cocaine, allowing the free convex border of the middle turbinated 
 bone to come into view, as also the cleft or olfactory fissure j 
 between it and the septum. The septum can also be examined, 
 frequently showing deviations from the middle line, and thickenin<,'s| 
 or spurs of bone or cartilage, which run in an antero-posterior or 
 \ ertical direction. A certain amount of erectile tissue is also present [ 
 on the septum. 
 
 The introduction of a probe under the guidance of the eye is of I 
 the greatest value in examining the nose. It not only serves to 
 distinguish the diflt'erent qualities of growth that can be seen, 
 but will also give information concerning regions beyond tkj 
 surgeon's eye. 
 
 2. By posterior rhinoscopy is meant an examination of the posj 
 terior nares by a mirror placed behind the uvula and soft palate. 
 It is by no means easy to accomplish, and requires some dexieriiyj 
 and practice. The tongue should be depressed, and a small I 
 mirror, previously warmed to prevent condensation of moisture, 
 is then passed behind the uvula, without touching it or the! 
 posterior wall of the pharynx, and by shifting its angle andf 
 position a view should be obtained of the structures exposedl 
 posteriorly. If not successful, and it is absolutely necessary tol 
 obtain a view, the fauces should be cocainized and the velum helJj 
 up by some form of palate retractor, such as White's, riiej 
 posterior nares (or choanae) are seen, separated by the \ertical| 
 posterior free margin of the septum, and within each cavity the 
 rounded ends of the turbinated bones with the meatuses inter-| 
 vening. The inferior meatus often looks very small owing to 
 the prominence of the velum palati, whilst the middle meatuS 
 may be encroached on by the tumefaction of the erectile tissim 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 
 
 715 
 
 n of the front of 
 A. good light is 
 
 head-lamp, and 
 ;hum's speculum 
 ited blades, con- 
 the hand, whilst 
 l1 vibrissa} beinj; 
 e placed one on 
 ;ion, and prevent 
 ns one is enabled 
 iding the inferior 
 iterior extremity, 
 ;he view of othe: 
 ;n fivictuating, but 
 • cent, solution of I 
 middle turbinated | 
 
 olfactory fissure 
 ilso be examined, 
 e, and thickenintjs 
 .ntero-posterior or 
 sue is also present 
 
 at the back of the inferior spongy bone. Outside the choanae 
 are seen the yellowish openings of the Eustachian tubes, whilst 
 above and betw^een them Luschka's tonsil, a raised collection 
 of lymphoid tissue in the roof of the pharynx, is occasionally 
 observed. 
 
 3. Palpation of the Posterior Naves, with the index finger, pre- 
 viously disinfected, will, however, give better results in the 
 majority of cases to those who are not specially practised in the 
 above method. The index finger is passed behind the uvula and 
 velum, and the nares can then be well explored, and the existence 
 of adenoids or other growths determined. 
 
 Foreign Bodies are rarely impacted in the nasal passages except 
 in children, in whom the condition is not uncommon. Any uni- 
 lateral purulent discharge from a child's nose should suggest the 
 likelihood of such an occurrence, peas, beads, or buttons, being 
 the substances usually introduced. A certain amount of unilateral 
 obstruction to nasal respiration is caused thereby, followed by a 
 catarrhal or even suppurative rhinitis, and in old standing cases 
 a rhinolith or nasal calculus may be caused by the deposit of 
 inspissated mucus upon the outer surface of a foreign body. 
 Removal is often eflected by syringing out through the unaffected 
 nostril, the lotion rushing back through the other side, and 
 carrying the intruding body before it. Failing this, the child 
 should be anaesthetized and a forceps or scoop employed, the 
 5tirgeon's manipulations being guided by a rhinoscope and frontal 
 I illumination. Necessarily, all instruments used for this purpose 
 should be thoroughly sterilized. After the removal, the nostrils 
 are carefully washed out for a few days with a weak alkaline 
 i antiseptic lotion, such as salt and water to which a little sanitas 
 i has been added. 
 
 Acute Rhinitis. — Several distinct varieties of this affection are 
 i described. 
 
 1. The Catarrhal form is extremely common, constituting what 
 I is popularly known as a 'cold in the head.' Not only is the 
 
 nasal mucosa involved, but the inflammation often extends to the 
 bntal or maxillary sinuses, causing brow-ache and face-ache, 
 
 I whilst if it spreads to the mucous lining of the Eustachian tube, 
 temporary deafness may ensue. In infants great dyspnoea often 
 
 [results owing to the extreme narrowness of the nasal passages, 
 and this may be so marked as to interfere for a time with breast 
 feeding. Apart from the usual domestic remedies directed to in- 
 creasing the action of the bowels, kidneys, and skin, considerable 
 
 Jrelief can often be obtained by washing out the nasal cavities three 
 
 jor four times a day with a weak warm alkaline lotion containing 
 
 |lx)rax and possibly a little menthol. 
 
 2. A Suppurative form arises not unfrequently as a result cf acute 
 
■■ 
 
 7i6 
 
 A MANUAL OF SURGERY 
 
 suppuration in one of the accessory sinuses (acute empyema), and 
 then treatment must be mainly directed to the sinus. Occa- 
 sionally it is due to gonorrha;al infection either in adults or 
 infants, but perhaps more commonly in the latter. The discharge 
 is abundant, and causes much obstruction to nasal respiration, 
 whilst ulceration is likely to occur. The passages must be well 
 cleansed with a solution of boric acid several times daily, and the 
 interior sprayed or painted with a weak solution of nitrate of silver 
 (gr. 5 to the ounce) once every day as long as the suppuration 
 continues. 
 
 3. True diphtheria also occurs in the nasal fossae, usually as a 
 complication of the same disease elsewhere, and requiring a similar 
 form of treatment. 
 
 Chronic Rhinitis. — So many distinct types of chronic inllamnia 
 tion of the interior of the nose have been differentiated of late 
 years that it is impossible for us to give more ':han the harest 
 outline of them. For fuller details v would refer readers to , 
 Dr. Greville Macdonald's excellent work on diseases of the 
 nose.--' 
 
 One of the forms most commonly met with is characterized by 
 engorgement of the erectile tissue covering the inferior turhinated j 
 bone, causing considerable obstruction to nasal respiration and an 
 abundant discharge of muco-pus. It usually occurs in patients! 
 with long, prominent noses of the Jewish type, where the nasal 
 passages are narrow, and in consequence the air pressure isj 
 diminished ; it may be lighted up by some slight local irritant, 
 such as a sudden change of temperature. The anterior end of I 
 the inferior turbinated bone is swollen, red, and rounded, the] 
 mucous covering being oedematous, and the mass feeling, on I 
 touching it with a probe, like a sac full of fluid. The local appli- 
 cation of a 5 per cent, solution of cocaine causes its complete, 
 though temporary, collapse in a few moments. If it is allowed tol 
 persist, hypertrophy of the mucous membrane follows, and in thai 
 most marked types a projecting papillomatous-like mass, almost j 
 resembling a polypus, results. It is, however, merely an inflam- 
 matory hyperplasia, and not a new growth ; true papillomata of j 
 the nose are extremely rare. The posterior end of the bone niayf 
 be similarly affected, and the mucous covering of tlie middlej 
 turbinated may participate in the same process. A certain! 
 amount of pharyngitis or laryngo-tracheitis may also be present, 
 
 Treatment. — In the early stages all that is required is to wash 
 out the nasal cavity night and morning with some simple nosej 
 lotion, such as borax or bicarbonate of soda (5 grains to i ounce). 
 This may be accomplished either by sniffing the solution froinj 
 the palm of the hand, or by using some form of nasal doucheJ 
 Basdon's douche is perhaps the best for this purpose. If such 1^ 
 
 • ' Diseases of the Nose.' Alex. P. Watt and Son. Second edition, i8y2. 
 
AFFECTIONS OF THE NOSE AND NASOPHARYNX 
 
 717 
 
 insufficient to give relief, or if collapse is not produced by cocaine, 
 ;lie surface may lie swabbed over with some diluted caustic, or, 
 better still, a point of galvano-cautery at a red heat may be run 
 along the lenj^^th of the bone. In the later staj^es removal of the 
 hvpertrophied excrescences by the cold wire snare, or by the 
 calvano-ecraseur, is required. 
 
 Another group of cases of chronic rhinitis is associated with 
 
 collapse of the erectile tissue, and then there is but little discharge, 
 
 since the exudation dries within the nasal cavities and forms 
 
 inspissated crusts or scabs which are often difficult to remove 
 
 irliinitis sicca). The nasal fossae are in this case more patulous 
 
 than usual, and a dry pharyngitis and chronic laryngitis are often 
 
 present. Both nostrils may be involved, but occasionally the 
 
 affection results from deviations of, or cartilaginous excrescences 
 
 spurs) from, the septum, and then is unilateral, the discharge 
 
 coming from that side which is most patulous, whilst the narrowed 
 
 -ide remains healthy. When symmetrical, the disease is rather 
 
 Jue to constitutional than to local causes, occurring in weakly, 
 
 I anaemic women, and is to be treated by general rather than local 
 
 measures. In the unilateral form, deviations of the septum from 
 
 I the middle line must be rectified, or the spur removed by the 
 
 !sa\v. In this way the inspired air is made to pass more freely 
 
 along the narrowed healthy side, and the other nostril is dealt 
 
 with hy the use of weak alkaline lotions. It may be also advisable 
 
 to plug the dilated side with cotton- wool for some time daily, so 
 
 as to enforce respiration through the other nostril. Treatment is 
 
 always likely to be prolonged, and it is possible that a daily alkaline 
 
 nose lotion may be needed permanently. Stimulating applica- 
 
 I lions are never borne well, and hence should rarely be ordered. 
 
 Ozaena. — This term was formerly applied to any offensive muco- 
 [purulent discbarge from the nostrils, whatever the cause, and thus 
 [was made to include such conditions as tuberculous or syphilitic 
 [disease of the turbinated bone"^ or of the septum, suppuration in 
 [the accessory sinuses, the impaction of foreign bodies, or the 
 ilceration of malignant growths. Improvements in differential 
 jdiagnosis have reduced the cases of ozaena to a very small number, 
 and the term is new limited to one particular affection, and that a 
 [special form of rhinitis sicca. 
 
 The disease is usually met with in young females, and may 
 |5ometimes originate fiom traumatism, or after one of the exanthe- 
 jmata, or is associated with inherited tuberculosis or syphilis. The 
 Inose is almost always wide and roomy, and may be of the special 
 Itrumous type ; the lips are often thick and everted, and the 
 Imouth is usually held open owing to the impediment to nasal 
 pspiration caused by inspissated mucus. The foetor of the 
 I'reath is the special feature that calls attention to the complaint ; 
 *' is peculiarly searching and objectionable, but the patient 
 
^iMM 
 
 718 
 
 A MANUAL OF SURGERY 
 
 fortunately is not cognizant of it. It is due to the decomposition 
 of the niuco-pus collecting in the nasal cavity, and althouj,'h 
 Lowenberg's diplococcus is constantly present, tlie causative 
 organism has not been determined with certainty. There is nut 
 much discharge, l:)ut at varying periods large crusts come away, 
 giving relief both to the nasal respiration and to the fcjetor. Both 
 nostrils are usually involved. 
 
 On examination, the shape and size of the nares are the first 
 things tliat claim attention ; vibrissa; are scanty, and on insertinj,' 
 a speculum the unusual patency becomes evident ; in fact, after 
 clearing away all the dried mucus and scabs, it is often possible 
 to see the posterior pharyngeal wall, and even the orifices of the 
 Eustachian tubes. The mucous membrane over the turbinated 
 bones is dry, collapsed, and pale, and crusts may be found cover- 
 ing any or every part of them. The pharyngeal wall is also dry, 
 and may be coated with a film of inspissated mucus. No ulcera- 
 tion is present, although the removal of the crusts may be) 
 associated with a slight amount of bleeding ovv'ing to their close I 
 attachment to the mucous membrane. The examination of a I 
 case of suspected ozrena should also include the accessory cavities] 
 of the nose, since many cases in which crust-formation is aj 
 prominent symptom are really due to an empyema of one or niorej 
 of the sinuses. 
 
 As to .etiology, it is important to note that ozaena is never seeaj 
 in patients with stenosed and narrow nostrils, and is almost ahvaysj 
 associated with wide, roomy noses. In consequence, it is difficultl 
 to obtain sufficient air pressure within them to expel the exudationj 
 arising from any ordinary rhinitis, and hence the discharge tends! 
 to collect and necessarily to putrefy. The irritation thus indiicedl 
 is likely in weakly children to lead to suppuration. For the samel 
 cause the mucous membrane becomes dry and the erectile tissue! 
 collapses, so that an atrophic form of rhinitis sicca results, follo\ved| 
 in time by sclerosis and shrinking of the turbinated bones. Iti/ 
 always a prolonged process, although in the course of years ig 
 improves and gradually disappears. 
 
 Treatment. — The first essential is to keep the nose clean andj 
 free from putrefying masses of dried secretion. This must 
 accomplished by irrigating the cavity once or twice daily, and 
 preferably with warm water, to which a little alkali, such a^ 
 common salt, and an unirritating antiseptic, such as sanitas, ha 
 been added. At first it is well for the surgeon to see to this hiiiij 
 self, but after a while the patient or her friends can be entrustel 
 with the task. Every portion of scab ought to be removed dailvj 
 and the surface lubricated with some such application as a sprai 
 of menthol and paroleine (10 grains to i ounce). The nose shoulJ 
 then be partially plugged with a tampon of cotton-wool, especiallj 
 along the lower meatus, and if thought desirable the wool may 
 medicated with some antiseptic. By this means a flow of imicui 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 
 
 719 
 
 decomposition 
 and althoujib 
 the causative 
 There is nut 
 :s come away, 
 e faetor. Both 
 
 res are the first 
 ind on inserting,' 
 it ; in fact, after 
 s often possible 
 le orifices of the 
 : the tvirhinated 
 
 be found cover- 
 wall is also dry, 
 cus. No ulcera- 
 
 crusts may be 
 ng to their close 
 jxamination of a 
 accessory cavities 
 ;t- formation is a 
 ua of one or more 
 
 I from the membrane is determined, and the discharge is tluis 
 rendered more fluid, and inspissation prevented. A similar end 
 
 Imay also be obtained by partially plugging the nostril with an 
 indiarubber tube, so as to diminish its size. The general health 
 
 [must he attended to, and patience and perseverance will generally 
 he crowned with success. Operative measures are scarcely ever 
 
 [required in this disease, although they have frequently been 
 
 I resorted to most unnecessarily. 
 
 )n 
 
 Disease of the Middle Turbinated Bone and Ethmoid is sometunes 
 
 the cause of an offensive purulent discharge from the nose, which 
 
 i? often wrongly called ozai^na. It occurs in individuals of all 
 
 a^'es and classes, arising from syphilitic or tuberculous disease, but 
 
 ;■. perhaps most commonly due to septic infection from without, 
 
 the result of meddlesome and careless surgery. It must be 
 
 remembered that the upper part of the nose is normally sterile, 
 
 nd the introduction of dirty instruments is often responsible for 
 
 Ithis affection. It commences as a submucous infiltration, usually 
 
 the middle turbinal, and thence spreads, with or without 
 
 Iceration, to the periosteum covering the bone, which becomes 
 
 arious or necrosed. Various parts of the ethmoid, including the 
 
 ribriform plate, may also be involved, and adjacent bony cavities 
 
 lantrum, frontal and ethmoidal sinuses, etc.) are filled witli pus. 
 
 n bad cases the venous channels in the base of the skull — c.^., 
 
 le cavernous sinus — may be thrombosed and infected, and e\en 
 
 iscess of the brain has followed. The disease affects one or 
 
 ith sides of the nose, perhaps most frequently but one. On 
 
 samining the interior of the nostril, there is no patency of the 
 
 vity, as in ozaena, but a large polypoid mass of granulation 
 
 ssue may be seen blocking the middle meatus and covered with 
 
 ■-dried scab, whilst pus can be seen to exude from it when 
 
 jressed upon ; this usually comes from the antrum or frontal 
 
 mis, the mass of granulation tissue lying both above and below 
 
 e entrance. A probe passed into the mass always impinges on 
 
 seased or bare bone. 
 
 When due to syphilis, distinct sequestra are usually present, 
 metinies involving the septum and hard palate, but the accessory 
 vities are not generally invaded. 
 
 The Diagnosis from ozaena is made by remembering that in the 
 
 ter the characteristic features are the abnormal width of the 
 
 o see to this bimBisal fosss, the bilateral symmetry, the collapse of the erectile 
 
 can be entruste«siie, the more complete inspissation of the secretion, and the 
 
 ibe removed daibBtho^rnomonic stench, which are all absent in these cases. A 
 
 ication as a spnB^tain amount of odour is present, but it is mainly noticed by the 
 
 The nose shoul ^ie nt, not so much by outsiders. 
 
 n-wool, especiallj!reatm,ent consists in the removal of all dead and carious bone 
 the wool may bAt can be safely dealt with, together with the destruction of all 
 s a flow of mucu^trating granulation tissue, and the drainage of such accessory 
 
 :?Ena is never seen 
 i is almost always 
 ence, it is difbcult 
 cpel the exudation 
 discharfj;e tendsi 
 tion thus induced] 
 For the samej 
 the erectile tissue! 
 a results, follo^ 
 ted bones, h 
 ourse of years 1' 
 
 le nose clean ani 
 This must 1)( 
 
 twice daily, am 
 e alkali, such a! 
 
 :h as sanitas.n; 
 
720 
 
 A MANUAL OF SURGERY 
 
 cavities as can be reached, whilst attention is pfiven to maiiitain 
 cleanliness jnd asepsis as far as possible. Thus, the iniddlH 
 turbinated bone and its accompanying mass of granulation tissut 
 may be removed by the sharp spoon, snare, or polypus torce|i-, 
 The antrum must, if necessary, be opened and drained, and the i 
 walls of the ethmoidal cells may be laroken down, and exit thiiv 
 given to pus. The greatest gentleness and care must be exercised | 
 when any attempt is made to deal with the roof of the nose. 
 
 Nasal Polypi. — -Two forms of nasal polypus are described, \v... 
 the simple or mucous polyp and the fibrous or fibro-sarconi;itmi>. 
 Other malignant tumours occur in the nasal fossa, to whirh. 
 however, the term polypus can scarcely be extended ; they niainlv 
 originate from the superior maxilla. 
 
 The Mucous Polypus consists of a soft gelatinous mass, whit' 
 on microscopic examination much resembles myxomatous tissue. 
 covered by ciliated columnar epithelium, and supplied frt'cly withj 
 bloodvessels. There has been a good deal of discussion as tul 
 whether or not these polypi are really of a myxomatous naturej 
 but the general opinion of rhinologists is in favour of the vieuj 
 that they are inflammatory in origin, consisting merely of (idef 
 
 matous hypertrophic tissue! 
 The growths are usiialiyi 
 situated on the middle anil 
 superior turbinated hones 
 they rarely start from thd 
 roof of the nasal fossa, ocj 
 casionally in the sinuses, oj 
 at the orifices leading; inij 
 them ; they hardly e\er inj 
 volve the septum or inferiol 
 turbinated bone. The polyj 
 poid masses are general 
 multiple, a large one pr()jttt| 
 ing downwards and forward 
 towards the anterior nare^ 
 and covering or hiding 
 whole series of smaller one^ 
 which readily sprinj:^ intj 
 prominence when that il 
 front is removed. Theyatj 
 sometimes dependent oij 
 and kept up by, suppuratia 
 in one of the adjacent sinuses. They are usually attached b} I 
 small pedicle, and when developing in the nasal fossa are pyritori 
 and laterally compressed. When of large size, they may protrud 
 through the nostrils, and then the epithelium covering the antend 
 portion becomes squamous, and the whole mass firmer in textiifl 
 
 ■■ 
 
 w 
 
 m 
 
 
 
 1 , J ■'•>--«■».■■■' 
 
 
 
 
 
 ■■1 
 
 
 Fig. 261. — Mucous Polypi of Nose, 
 
 SPRINGING FROM THE i3ACK AND FrONT 
 
 OF THE Middle Turbinated Bone. 
 
AFFECTIONS OF THE NOSE AND NASOPHARYNX 
 
 721 
 
 and pupillomatous in appearance. Sometimes they project 
 l.acKwards into tlie pharynx, and are then more distinctly 
 i,'l()l)uhir and usually single. Occasionally they are the startinj^- 
 [loint of a myxo-sarcomatous growth, which develops rapidly, 
 iiul early tends to invade the surrounding bones. 
 
 The main Symptom arising from nasal polypi is obstruction to 
 
 hf passage of air along one or both sides of the nose, according to 
 
 he location of the growths. This is always of gradual onset, and 
 
 .iinariably worse in wet weather, on accoimt of the hygroscopic 
 
 property of mucoid tissue. There is often a thin, watery discharge 
 
 from the nose, which may perhaps be blood-stained. The patient 
 
 I is unable to blow the nose, and his articulation becomes nasal in 
 
 (|iialitv. On rhinoscopic examination one finds a greyish senii- 
 
 I translucent glistening mass occupying the nostril, and attempts to 
 
 Mow the nose render this more obvious. Its pedunculated nature 
 
 lean he easily demonstrated by passing a probe around it. When 
 
 oflarge size, some flattening or expansion of the bridge of the 
 
 nose may be caused thereby, and possibly epiphora from pressure 
 
 [on the opening of the nasal duct. 
 
 The Diagnosis should present no difficulty to one who knows 
 
 [how to employ the nasal speculum. Abscess, a spur, or deviation 
 
 of the septum, though causing unilateral obstruction, is recognised 
 
 by the exercise of a \ery small amount of intelligence, (lulema- 
 
 toiis masses of granulation tissue, associated with tid'jerculous or 
 
 syphilitic disease of the bones, are recognised by usually in\ol\ing 
 
 jtiie septum as well as the turbinals, by the purulent discharge, 
 
 l)v the absence of superficial epithelium, and by not being dis- 
 
 [tiiictly pedunculated ; carious bone can usually be felt by a 
 
 prohe through the granulation tissue. From hypertrophy of the 
 
 Imucous membrane over the inferior turbinated bone, a polypus is 
 
 Iknown by the fact that it scarcely ever springs from this region, 
 
 Iwhilst tlie former condition is sessile, red, and diminished con- 
 
 jsiderably in size by the application of cocaine. 
 
 The Treatment of mucous polypi consists in their removal either 
 iliy forceps or the snare. The former plan is usually condemned 
 [by rhinologists as unscientific and barbarous, and as utilized by 
 Iniany of the old class of surgeons, such it certainly was: but if 
 lemployed in the w^ay described below, it is just as efficient as the 
 hnare, and gives the patient very little, if any, more pain. Person- 
 jally, we must plead guilty to a very distinct preference for the 
 |orceps. 
 
 In undertaking avulsion by forceps, the patient is seated in a 
 Icbair, ?nd the surgeon sits or stands in front of him. The nasal 
 jcavitics are fully cocainized, and the situation of the pedicle ascer- 
 lained, as clearly as possible, by illuminating the interior and by 
 jtlie use of a probe. The forceps employed should be long, with 
 jilelicate, though strong, blades, which are deeply serrated on 
 leither side of a median groo\e. They are introduced open, with 
 
 46 
 
722 
 
 A MANUAL OF SURGERY 
 
 a blade placed horizontally on either side of the f^aowth, aiul aa 
 gently pressed upwards until the pedicle is grasped as close to the 
 turbinated bone as possible. The blades are then closed firiiilv, 
 and the polypi twisted off and renio\ed, a certain amount oi 
 lueniorrhage resulting. The same process is repeated to the 
 smaller tumours until the nostril is clear. It may be plugfjnl 
 with a strip of boric lint if the bleeding continues, but such shoiiki 
 never be left unchanged longer than twenty-four hours. The phi,' 
 is then removed, and the base of the growth carefully examind 
 and cauterized with the gahano-cautery by the aid of a nasai 
 speculum. This cannot be so accurately accomplished imniediatelv 
 after removal, as the bleeding interferes with clear vision. The 
 cauterization of the base is a most important item in the treat 
 ment, as without it the growths are sure to recur. Tlie patient 
 should be again examined after a short interval, so tliat am 
 smaller polypi which have commenced to develop may be suitablv 
 dealt with. 
 
 To remove polypi with the galvanic ecraseur or snare, a 
 speculum is inserted, and the wire loop passed round the growtli 
 so as to encircle its base, and gradually tightened until it has cut 
 through. This plan is specially adapted to large masses which 
 project downwards behind the palate. 
 
 Whichever method is adopted, recurrences are not uncommon. 
 and the treatment may in consequence be very prolonged ; but it 
 the surgeon will persevere in the way described above, the disease 
 can in time be eradicated without having recourse to such a iiiiiti- 
 lating procedure as removal of the turbinated bones ; indeed, after | 
 such an operation, considerable trouble may arise from the nasal 
 cavity being too patulous. 
 
 A Fibrous Polypus is the term applied to a fibroma, which tends 
 sooner or later to become sarcomatous, springing from the base j 
 of the skull, especially from the basi-sphenoid or basi-occipital 
 It is at first distinctly pedunculated, and is usually firm, smooth, 
 and fleshy in character ; when of large size, it may be lohuhated, 
 The early symptoms are almost limited to those of obstruction j 
 to nasal respiration, but to this is not unfrecjuently added severe | 
 epistaxis, owing to the vascularity of the capsule and of the over- 
 lying mucous membrane. As it increases in size, ulceration] 
 occurs, leading to a fcetid sanious discharge, and the growth rarely 
 remains limited to the nasal fossae. If pushing forwards, it may 
 lead to expansion of the bridge of the nose and separation of the| 
 eyes, which may even be made to diverge; but if backwards, it 
 may depress the velum, and hang downwards as a naso-phnryngeal 
 tumour. In other cases it may force its way into the orbit orj 
 any of the other surrounding cavities, or may even erode the base 
 of the skull, and encroach upon the cranium. It is rare for any i 
 of these latter manifestations to occur until after the tumour has | 
 taken on a distinct sarcomatous type. 
 
AFFECTIONS OF THE NOSE AND NASO I'lIAJiYNX 
 
 723 
 
 ^Towtli, and art- 
 ;cl as close to till' 
 en closed f'rnily. 
 iitain amount 01 
 repeated to the 
 may be phi{,'Kiil 
 , but such should 
 lours. The phi,' 
 refuUy exainimd 
 le aid of a nasal 
 shed ininiediately 
 lear vision. The 
 :eni in the treat- 
 :-.ur. The patient 
 ■val, so that any 
 p may be suitably 
 
 oma, which tends 
 g from the base 
 or basi-occipital. 
 illy firm, smooth. 
 nay be lobulated, 
 se of obstruction 
 .tly added severe 
 ; and of the over- 
 size, ulceration 
 the growth rarely 
 forwards, it may 
 icparation of the 
 if backwards, it 
 , naso-pharyngeal 
 
 ,nto the orbit or 
 :n erode the base I 
 t is rare for any 1 
 the tumour has 
 
 The disease usually attacks young pecjple, and mainly those 
 in the second decade of life. It progresses with considerable 
 rapidity, and the fatal issue may ba due to hu'morrhage, aspliyxia, 
 or cerebral complications. 
 
 Treatment. — Unfortunately this condition is but rarely recog- 
 nised in tile early stages, owing to the fact that the majority of 
 practitioners are (luite unable to use the rhinoscope. We woidd 
 impress upon students the immense imptjrtance of thoroughly 
 exploring both by the mirror and the finger passed behind the 
 velum every case of nasal obstruction or of chronic discharge 
 from the nose. When the growth is small and polypoid, it can 
 often be dealt with from the anterior nares by means of a galvano- 
 ccraseur. The wire loop is inserted from the front, and hitched 
 over the tumour, so as to encircle its base, by the assistance o^ 
 the right index finger passed behind the \elum. The pedi Je 
 must be divided as near the skull as possible, as otherwise recur- 
 rence is almost certain to follow. Nelaton's operation, described 
 below (p. 724), will in some instances assist the surgeon to 
 reach tlie base of the skull and deal with the tumour. 
 
 In the more severe cases, where the growth has become diffuse, 
 it is \ ery doubtful whether much good can be done by operation, 
 since the base of the skull is sure to be gravely affected. If treat- 
 ment is attempted, one or other of the many plans for exploring 
 the nose or naso-pharynx must be resorted to, and the operative 
 measures must be modified according to the peculiar requirements 
 of the case. Probably total ablation of the superior maxilla will 
 ;,'ive the best approach to the mass. 
 
 Other forms of Malignant Disease of the Nose are met with, 
 and may originate in any part of the nasal fossjo. Squamous 
 epithelioma is that which occurs most frequently ; the symptoms 
 consist in the presence of a blood-stained discharge, and a certain 
 amount of respiratory obstruction, together with pain and cachexia. 
 The lymphatic glands at the angle of the jaw are early enlarged, 
 and the course of the disease is usually rapid owing to the great 
 vascularity of the part. Up to within quite a recent period such 
 ;'rowths have been almost always looked on as inoperable, but 
 .within the last ten years attempts have been made to remove 
 I them, and although necessarily the mortality is great, and the 
 ibility to recurrence considerable, yet the results have been such 
 [as to encourage the practice of attacking the disease, even in such 
 [a difficult region to explore as the interior of the nose. 
 
 Sarcoma may also commence in the nose itself, quite apart from 
 
 that which originates in the superior maxilla, it gives rise to 
 
 the usual signs of an intra-nasal growth, and may be dealt with 
 
 in a satisfactory manner by local means, such as curetting and the 
 
 jappHcation of caustics. Not a few cases are on record in which 
 
 |such treatment has proved efficacious in curing the disease. 
 
 46 — 2 
 
7*4 
 
 A MANUAL OF SURGERY 
 
 't?lfi 
 
 Tlio operations wliich liavc In-cn dcvise'd for (l,\i!iii<: irttli i/isiuisc (,f tli, «, , 
 iiihl luisi'-phaiyiix arc so luiim.'roiis and ((jmplicatt'd tliat it is imposisiliic Inru, 
 U> inciuidn inori; than a few of tht; most uselul and important. 
 
 ((/) In many cases of intranasal discaso considi;ral)U' assistance can In- 
 derived Ijy nf'tiiiuf; up tlif auttiini luins. especially when one is opcratinK' lor 
 caries or nt'crosis of the turbinated hones It may sullice merely to div idf m;, 
 ala nasi and the attachments of the cartilaties to tin; maxilla; hut where hoii 
 sides are invoh fd, /i'ii//i,'('s opiiiilioii is advisable This consists in the (ieiacli 
 ment of the mask of the face from the maxilh'e by everting the upjier lipaiii. 
 incisinf,' the mucous membrane and subjacent tissues until the nasal cavitiu. 
 are opened. The sejitum nasi is divided by cutting pliers, and the ilxmi 
 cartilages completely separated The soft tissues of the face can then ht 
 retracteil upwards, and the nasal fossie fidly exposed. The bleedint^ i^aKv,i\- 
 considerable, and the s|iace j;ained in children is but slif,'ht. W'Iumi the (ipcia 
 tion is completed, the mask of tiie face is allowed to fall b.ack a^ain into pi . 
 tion, union occurring; without difliculty, although no sutures are emiijuyeil 
 
 When the upper and anterior portion of the nasal cavity is to be dealt witli 
 Lanf,'enl)eck's |ilan can sometimes be utilized with advantage. An incisi'i; 
 down to the bones is made alon^; tiie outer border of the nose from ilie rmi 
 downwards and outwards towards the ala The soft parts are retracted i : 
 eitlier side so as to expose the nasal lione and tiu; nasal process of tlicsuperii; 
 maxilla, a wedf,'e-shaped portion of which can be ilivicled by cutting pliersan! 
 prised upv.ards, but left with their superior connections untouched, sn tli;ii 
 after the operation they can be replaced. 
 
 When the septum alone is iinnKed in malignant disease, it is possible I'l 
 deal with it by an operation, which consists in splitting the ujiper lip in tiie I 
 middle line, ami carrying the incision round the ala nasi on each side so ilia; | 
 the lower portion of the nose can be turned upwards after dividing tiie septum 
 A wedge-shaped portion is then removetl from the front of t!ie palate alter 
 detaching the muco-periosteum from its buccal aspect. Anexcell-nt approaciij 
 is thus ol)taine(l into the nasal cavity, and the entire septum can i,; tliis\va\ 
 be removed without difficulty. The parts can be afterwards brought toKethi;r| 
 quite naturally, and the deformity is very slight. 
 
 {li) When the disease is located further back, originating rather in the I 
 naso-pharynx than in the nose itself, the palatine route maybe tisedwiilil 
 advantage. I'erhajw the best of the several suggested operations is thatolj 
 Ntiiitoii. This consists in a median section of the velum and of the miicoib 
 membrane covering the posterior half of tfie hard palate. A transversf| 
 incision is then matle on either side of tiie anterior extremity of this, and t"" 
 muco-periosteal flaps reflected, exposing a ([uadrilateral area of hone whic.'i 
 is removed by chisel and mallet. If need be, part of the vomer is also taken! 
 away, and thus the naso-pharynx is opened sufficiently to allow of theremovalj 
 of the polypus or growth. The reflected segments of the palate are sub* j 
 quently sutured together. 
 
 ((■) Various methods of osti'oplttstic section of the superior maxilla have beenj 
 practised, and Langenbeck's name has been associated with one or t"^ 
 dif^eri-iU plans, which are, however, only suited to particular cases of disease,! 
 and at lest give but poor access to the parts behind or above tiie siiperioif 
 m-ivil'.i, whilst they usually leave extremely obvious cicatrices. Perhaps tli^ 
 besi plan to adopt in any such case is to temporarily detach the superi'i 
 inaxilla from its bed, turning it outwards together with the cutaneous ani 
 subcutaneous tissues overlying it, and then, after completing the operatioiiJ 
 replacing the bone and suturing the soft parts into position. The resultso| 
 such practice have been encouraging. 
 
 Adenoids. — Although it is only twenty years ago since MeveJ 
 first drew attention to this condition, it is not too much to sal 
 that at the present time a large proportion of our children iinl 
 
Al'i-ECTIONS OF THE NOSE AND NASO-i'lLlhYNX 
 
 735 
 
 >h Huatt of the nou 
 
 is imposHililc for is 
 ant 
 
 assistance can lie 
 lue is oin'ratinn Inr 
 merely In ilividt.' om 
 Ua ; but wluTf txjili 
 nsisls in the (ietacli 
 [^ tlie upper lipniK 
 il the nasal lavitif. 
 tiers, and the iumI 
 - face can thi-ii Ix 
 le bleeding isalw;iv> 
 t. When tlic diHTV 
 back again into pr> 
 res are eniplnviil 
 y is to be ilealt wii':; 
 uitaj^e. An inci^i-r 
 ; nose Ircni \\w mil 
 .rts are rftr;icteil 1:' 
 rocess of tlic siiperii r 
 
 by cutting pliers ami 
 is untoucbfil, S(i tluii 
 
 2ase, it is possible t^ 
 ; the upper lip in tiie ] 
 i on each side so tha; 
 r dividing the septum 
 at of t!^e palate nitf: ] 
 AnexceU>MU approach 
 ptum can i.- thiswai^ 
 rds brought tof^etherj 
 
 nating rather in itid 
 [/(■ may be used wiih 
 operations is tliai'i 
 [n and of the mncuih 
 jalate. A transvtw| 
 hnity of this, and i«' 
 ll area of bone \vhic:i 
 ,e vomer is also taker. I 
 , allow of theremovall 
 the palate are M\m 
 
 Lr maxilLi have U'enj 
 
 fed with one or i«>| 
 :ular cases of disea>ej 
 Dr above the snperi'l 
 
 latrices. Perhaps tlie| 
 detach the superi' 
 
 [h the cutaneous anl 
 pleting the operati-nJ 
 hition. T!ie results 
 
 ago Since 
 
 Mevel 
 
 too much to Sill 
 our children jin^ 
 
 voting,' people are subject to it in a more or less a|,,'|,,'ra\at(il t'i)rm. 
 AdeiKtids are \cry common in chililrcn with an inlu-ritcd tiibcr- 
 ailuiis history, and are of considerable impoitaiue from the 
 results to which they give rise. 
 
 It has been already mentioned that the naso-pliaryii\ is the 
 seat of a large amoimt of lymphoid tissue, similar tn that met 
 with in the tonsil, which may either be distributed widely over 
 ilie whole mticoiis membrane, or may be gathered into a special 
 mass on the roof, known as the pharyngeal or Liischka's tonsil. 
 Aclennids consist in a hyperplasia of this tisstie, i-x.ictly analo 
 i;ous to the chronic hypertrophic- form of tonsillitis, witli which, 
 indeed, it is often associated. They may occiu' in the foini of 
 liroati, cushion -like masses springing mainly from tlu' roof or 
 posterior walls, or occasionally as peilimculated riimoins hanging 
 down into the posterior nares. I'ig. 262 represents such a condi- 
 tion as seen by posterior 
 rhinoscopy. The timioiirs 
 are extremely soft and 
 vascidar, bleeding \ery 
 readily. Not unconmionly 
 isolated masses similar in 
 structiue to the above are 
 also to be seen on the 
 posterioi wall of the 
 pharynx, and a certain 
 amount of chronic rhinitis 
 and laryngitis may be 
 associated. 
 
 The Symptoms induced 
 hy adenoids are mainly 
 due to obstruction to nasal respiration. The mouth is generally 
 held half open, so as to allow the child to breathe through it, 
 tlierehy exposing the upper central incisors (Fig. 263) ; for a 
 similar cause he snores during sleep, and tisually wakes with the 
 mouth and tongue dry. The nostrils are drawn in, and tlie nose 
 thin and pinched, the whole aspect being very characteristic ; the 
 ihildren often look sleepy and half silly, and indeed may be very 
 backward in their studies. Not uncommonly there is a certain 
 amount of semi-purulent discharge from the nose, or it may be 
 hawked up from the pharynx, perhaps mixed with blood. Deaf- 
 ness also results from extension of the catarrlial condition to the 
 mucous lining of the Eustachian tubes, and chronic otitis media 
 may be thereby induced ; both taste and smell may be interfered 
 with. The palate also becomes high and arched, owing to the 
 defective intranasal air pressure, and as the patient grows up, the 
 incisor teeth may project forwards, giving a curious rabbit-like 
 t'xpression to the face. The cervical glands are sympathetically 
 enlarged, and often the seat of tuberculous disease. In bad cases 
 
 ImG. 262. — AOENOU)S AS SKKN i.V lOsTICKlOK 
 KlIINOSCOPV. (TiLLMANNS.) 
 
726 
 
 A MANUAL OF SURGERY 
 
 which have been allowed to persist throughout adolescence con- 
 siderable deformity of the thoracic parietes is induced, owin<,f to 
 the inability of the child to take a really Jeep inspiration, the 
 ribs in consequence being drawn in, and the spine kyphotic 
 (Fig. 264). 
 
 Physical Examination consists in posterior rhinoscopy, by means 
 of which the growths can be seen, or in palpation of the posterior 
 nares, a process more suitable to children, who rarely have suffi- 
 cient control to permit of the former. On passing the fin<fei 
 behind the velum, the naso-pharynx is found to be occupied by a 
 
 Fig. 2G3. — Adenoid Faciks. (From a Photograph kindly liiNT isv 
 Dr. St. Clair Thomson.) 
 
 This illustration shows well the sleepy look, the pinched nostrils, tlie open 
 mouth and projecting upper central incisors so characteristic of thi> 
 condition. 
 
 soft mass of tissue which readily bleeds, and more or less obstructs 
 the openings of the posterior nares. 
 
 Treatment consists in the great majorit)' of cases in removal of 
 the adenoids by operation. If left alone, there is a tendency for 
 these growths to gradually disappear, but during this interval 
 development may be considerably hindered, and hence a cure by 
 natural processes in children should never be relied on. In yuuni; 
 adults, however, attention t'; the general health, combined will' 
 irrigation of the nose witli salt and water, and perhaps ^lie local 
 application of a weak solution of nitrate of siher (5 grains to 1 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 
 
 727 
 
 lolescence con- 
 Liced, owini; to 
 nspiration, tlu- 
 spine kyphotic 
 
 copy, by means 
 oi the posterior 
 irely have suffi- 
 sing the finder 
 s occupied by ;i 
 
 CINDLY LHNT 15Y 
 
 nostrils, the open 
 faracteristic of thi^ 
 
 lor less obstructs 
 
 kes in removal of 
 Is a tendency for 
 Inir this interval 
 1 hence a cure by 
 on. In youiii; 
 combined witli 
 jrhaps ^lie local 
 ir (5 grains to i 
 
 ounce) to the naso-pharynx, may suffice to bring about an 
 
 amelioration of the condition. 
 Operation. — Much diversity of opinion exists as to the character 
 
 and extent of the operation ; some authc : ities consider that all 
 
 that is required is to scrape the 
 
 (trowths away with the finger-nail, 
 
 and undertake this proceeding either 
 
 under nitrous oxide gas, or even with- 
 out an anaesthetic. Such a measur". 
 
 is, to our minds, unsatisfactory, in 
 
 that the adenoids cannot possibly be 
 
 entirely removed, and recurrence may 
 
 ensue. As a general rule, the child 
 
 should be anaesthetized with chloro- 
 form, and if enlarged tonsils co-exist, 
 
 these should be dealt with in the first 
 
 place. Lowenberg's forceps, curved 
 
 so as to allow of them being passed 
 
 behind the soft palate, are then intro- 
 duced with the right hand, whilst the 
 velum is protected by the left index- 
 tinger passed behind i:. The protu- 
 berant masses are grasped and lOrn 
 ft", special attention being directed to 
 
 [Clearing the posterior nares. The 
 
 oriiices of the Eilstachian tubes are 
 
 readily detected, and must not be Fig. 264.— Lateral View ok 
 
 injured. Care must also be taken not ^ Child with Negiectei, 
 
 ■',,,] r ,, 1 u • i- 1 Adenoids. (From a Photo- 
 
 |to lay hold 01 the uvula by mistake. graph lent hv Dr. St. 
 The surgeon's finger - nail may be Clair Thomson.) 
 used to complete the removal of any x^is i^ the same child whose 
 tags of tissue that remain. Of course, face appears in Fig. 263. It 
 there is considerable bleeding, but 
 this quickly stops of itself, and as 
 sion as the operation is over, the head 
 should be i irn'.i to one side, or the 
 child hek' lac downwards, so as ^o 
 allow the blood to run out of the mouth and nose. 
 
 
 
 !!•(%#»»*. 1 
 
 
 will be seen that tlie chest is 
 shallow and retracted, and the 
 spine kyphotic. The arms are 
 small, but the legs are well 
 developed. 
 
 The after- 
 Itnatii.cut consists in washing out the nose and throat with either 
 [salt and ^ atcr, or a weak solution of 31' 3 ; the patient is kept 
 lindoors lor a few days, and only fluid food allowed. Gottstein's 
 Iciirette is preferred by many rhinologists, and we have often used 
 |ii with ; d 'antage. 
 
 Epista.tis, or bleeding from the nose, may arise from a \ ariety 
 of causes, including traumatisir, directed either to the mucous 
 Dieinhrane.i or the bones, o ■ trcnn t.ie presence of ulceration or 
 puinours. Some of these irr,ai causes are veiy evident, if only 
 
728 
 
 A MANUAL OF SURGERY 
 
 they are carefully looked for with a rhinoscope and frontal mirror. 
 One of the commonest lesions is a small abrasion or ulcer of the 
 septum, due to detaching by the finger a scab or dried crust of 
 mucus which causes irritation within the nostril ; each time the 
 nose is ' picked ' in this way bleeding recurs. Another fre(juent 
 source of epistaxis is the rupture of a varicose vein in the mucous 
 membrane of the septum ; varix occurs not unusually in plethoric 
 individuals, and sneezing or blowing the nose violently may lead 
 to an attack. Foreign bodies may also cause haemorrhage, as also 
 ulceration of an angioma on the septum. It frequently occurs in 
 young people about .puberty in consequence of local disturbance 
 in the vascular arrangement of the part: , again, cerebral conges- 
 tion may induce it, owing to the communication by means of I 
 emissary veins between the interior of the skull and the venous ■, 
 plexuses in the nose ; excessive changes in the atmospheric j 
 pressure, as in mountaineering, may lead to epistaxis, whilst in 
 abnormal states of the blood it may be as'^ociated with hanior-j 
 
 WBT;*''' 
 
 /•/■' 
 
 5 ^jcsmaraEiMtTM J 
 
 LJ 
 
 majon;^ 
 :an 14 
 -I-.' 
 
 ine out ol 
 
 Fig. 265. — BELLocy'h Sp^nd. 
 
 rhage elsewhere, as in haemophilia, purpura, and scurvy. On 
 or both nostrils may be the seat of the bleeding, and it may bes 
 excessive as even to threaten life. 
 
 Treatment. — It must not be forgotten that, "n 
 of cases, there is some local cause of epistaxis 
 found and treated directly — a fact which once *" ore e:.:.;hasizei 
 the necessity for gaining a mastery over thf a.3u r.- ^.he rhino; 
 scope. The bleeding is generally unilateral, and l. 
 ten cases the source is within easy reach ■ f the a: 
 ard hence in many instances all that is required is to ^la^y tin 
 nostrils firmly, and thus allow the blood to collect within, am 
 give it an opportunity of clotting. At the same time, the patieii 
 should sit up, and cold be applied to the root cf the nose, or tj 
 the nape of the neck. If on examination ttie bleeding point 
 detected, whether it be a varicose vein or an ulcerated surfao 
 the haemorrhage can almost at once be stayed by appl) in- 
 pointed galvano-cautery, or by sealing the spot with a sw 
 soaked in a solution of chromic p^id. FailiiiK these me.vuri 
 the nostrils may need to be plugged, but such ■^ ■ . -iceclirif; cngl 
 
AFFECTIONS OF THE NOSE AND NASO-PHARYNX 
 
 729 
 
 to be seldom resorted to ; it is practically a confession of want of 
 skill in the use of the rhinoscope. It may suffice merely to stiff 
 the anterior nares with long strips of boric lint, but, as a rule, 
 the posterior nares also require plugging. For this purpose 
 Bellocq's sound (Fig. 265) is usually employed in order to pass a 
 tiiread round the l)ase of the palate, and out of both nose and 
 mouth ; but where it is not obtainable, a suitably curved pair of 
 laryngeal forceps or a catheter may be used instead. To the 
 lower end of tl.is thread a pledget of lint about i^ inches by 
 I inch in size U, attached, and this, guided by the finger round 
 the soft palate, is drawn tightly forwards into the posterior nares, 
 whilst the two ends of the thread are tied together round the 
 upper lip to prevent it from slipping. The plug is retained for 
 twelve hours, and then removed, and the nasal fossae irrigated 
 with a weak warm alkaline antiseptic lotion in order to prevent 
 sepsis. 
 
 Another method of arresting epistaxis is by Cooper Rose's 
 
 j inflating plug ; it consists of a piece of gum catheter, surrounded 
 
 in' a thin indiarubber bag, which can be inflated through the 
 
 hollow stem. It is oiled and passed well into the nose from the 
 
 jiront; the indiarubber bag is then inflated to the required extent, 
 
 the air being retained by a stop-cock. This generally acts most 
 
 efficiently, and can be introduced and removed with scarcely any 
 
 [pain to the patient. 
 
CHAPTER XXVI. 
 
 AFFECTIONS OF THE MOUTH, THROAT, AND 
 (ESOPHAGUS. 
 
 Stomatitis, or inflammation of the mucous membrane of the 
 mouth, is by no means vmcommon, especially in children. 
 
 1. Simple Catarrhal Stomatitis results from mechanical irritants, 
 such as roughened teeth, from irritating chemicals, or from that 
 septic form of inflammation which is so liable to follow operations 
 involving the mouth. It may also arise in the course of fevers, 
 and in conditions of debility such as follow measles and other 
 exanthemata in children ; or be associated with disturbances in 
 the alimentary canal, as by improper feeding, dyspepsia, etc. 
 The mucous membrane becomes hyperaDmic and swollen, usually 
 in small localized patches, which may gradually spread anil 
 become confluent, involving nearly the whole of the oral cavitv. 
 The exudation of mucus is increased, and becomes viscid and 
 turbid, whilst the epithelium, at first white and sodden, is after 
 a while rubbed off, leaving superficial erosions or distinct ulcers, 
 which are very painful. The treatment consists in the removal i 
 of all sources of irritation, and the administration of drugs to | 
 correct intestinal derangements. Chlorate of potash, possibly com- 
 bined with dilute hydrochloric acid, is very useful, both locally 
 and internally. In the more severe cases antiseptic mouth- 
 washes should be employed, such as the liquor soda^ chlorinataj 
 (i ounce to i pint of water), sanitas (i in lo), boro-glyceride 
 (i in 20), etc. 
 
 2. Aphthous Stomatitis occurs in badly-fed children, in the I 
 form of small whitish spots on a hyperaemic base, which rim 
 together, and produce ulceration. Attention must be directed tol 
 the general condition, and a little borax and honey or a solutionj 
 of boro-glyceride (i in 20) applied locally. 
 
 3. Thrush is a very similar condition, but due to the presence! 
 of a parasitic fungus, the Oidiiim albicans. It occurs in patches! 
 somewhat resembling curdled milk in appearance, and reciiireslhej 
 same treatment. In both these types there is often considerabl 
 
AFFECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS 731 
 
 T, AND 
 
 smbrane of the 
 hildren. 
 hanical irritants. 
 lis, or from that 
 bllow operations 
 :ourse of fevers, 
 iasles and other 
 disturbances in 
 dyspepsia, etc, 
 swollen, usually 
 dly spread and 
 the oral cavity, 
 imes \-iscid and 
 sodden, is after 
 distinct ulcers, 
 in the removal 
 ;ion of drugs to 
 j,h, possibly com- 
 [ful, both locally 
 itiseptic mouth- 
 ;odaB chlorinate 
 , boro-glyceride 
 
 [children, in the! 
 
 base, which run 
 
 fst be directed to! 
 
 ley or a solution j 
 
 to the presencel 
 
 xiirs in patches! 
 
 andreciiiresthe! 
 
 [ten consideraMel 
 
 lenlargenient of the lymphatic glands, which, however, frequently 
 |;ubside without suppuration on removal of the cause. 
 
 4. Gangrenous Stomatitis (or Cancrum Oris) is much the same in 
 
 Iprigin as the preceding, but more acute in its course, both from 
 
 [the virulence of the organisms causing it, and from the asthenic 
 
 :ondition of the patient. For description and treatment see 
 
 j.bg. 
 
 3. Mercurial Stomatitis may arise during the administration of 
 |a course of mercury, or occasionally from a single dose, in persons 
 Ivho are extremely sensitive to the action of the drug. It is 
 liacreased in its severity if the mouth and teeth are kept in a dirty 
 litate, or if the patient smokes to excess. The gums are swolleri 
 land tender, bleed on pressure, and are very painful, especially 
 luiien biting, or drinking hot fluids. If the drug is continued, the 
 leeth become loose and may fall out, whilst the alveolar borders 
 Iciav be laid bare and necrose. The tongue is sometimes swollen 
 land inflamed ; salivation is also :i marked symptom, and the breath 
 «comes very offensive. Treaiment. — Either leave off" the mercury, 
 Iratany rate reduce the dose considerably, and administer saline 
 Wfjatives. Chlorate of potash, combined with alum, dilute 
 Ivdrochloric acid, or tincture of myrrh, may be useful locally. 
 6, For Syphilitic Stomatitis, see Chapter XXXIX. 
 The buccal mucous membrane is also involved in the course of 
 Ither diseases, e.g., diphtheria, scarlet fever, and erysipelas, but 
 [pecial descriptions are not needed here. 
 
 Affections of the Tongue. 
 
 Congenital Abnormalities of the tongue are met with in the 
 
 lowing forms : {a) The tongue has been entirely absent. 
 
 One half of the tongue has been congenitally defective in size 
 
 hmtrophy). [c) Tongue-tie is said to be present when the frsnum 
 
 Ssliorter than usual, causing the tip to be depressed and fixed in 
 
 ptiocr of the mouth so that it cannot be protruded. Sucking 
 
 comes difficult in such a condition, and when it is allowed to 
 
 bist, there is often a lisp in the speech. Treatment is only 
 
 keded in the severer forms, and consists in raising the tongue 
 
 Ith the index and middle fingers placed one on either side, and 
 
 Jipping the frctnum, thus put on the stretch, across its centre with 
 
 [pair of blunt-pointed scissors, {d) The tongue may be adherent 
 
 jthe floor of the mouth, being hound down by folds of mucous 
 
 rmlirane {Anhyloglossia). This may also exist as an acquired 
 
 Indition due to cicatricial contraction after ulceration. In con- 
 
 ptal cases the adhesions are but slight, and the organ can be 
 
 |dily freed ; in the acquired condition this cannot always be 
 
 pjniplished. {c) The fraenum and tongue are occasionally too 
 
 k allowing of increased mobility, and even fatal results have 
 
 prred from the organ rolling backwards and impeding respira- 
 
732 
 
 A MANUAL OF SURGERY 
 
 tion. (/) The tongue may be cleft, presenting a bifid appearance; 
 this may be complete or partial, and is usually associated with a 
 congenital fissure through the lower lip and mandible, (fr) Maot'- 
 ^lossia (or large tongue), although sometimes acquired, is usuallv 
 a congenital deformity. The organ is enlarged in all directions, ami 
 protrudes from the mouth, so that the teeth indent it, and cause 
 ulceration and considerable interference with the venous return. 
 It thus becomes purplish and dry from exposure, the mucous 
 membrane looking almost like skin, although saliva dribble, 
 freely from beneath it. In old-standing cases the jaws are 
 often deformed, so that, even if the tongue is reduced to its j 
 normal size by treatment, it may be impossible to close the I 
 mouth. Pathologically, it is due to diffuse overgrowth of thej 
 connective tissue, secondary to lymphatic obstruction and dilata- 
 tion. The treatment consists in excision of a V-shaped portion,] 
 suturing the raw surfaces subsequently with catgut. 
 
 Wounds of the tongue are usually caused by theteeth,especialhl 
 during an epileptic seizure, or in children as a result of falls withf 
 the tongue out. There is often brisk haemorrhage for a few] 
 moments, which soon ceases, though blood may be extravasated 
 into its substance, and cause considerable swelling. In siniplej 
 cases the wound should be examined and purified, and the moutlJ 
 constantly cleansed with mild antiseptic lotions ; a few points ol 
 suture may also be inserted if necessary, but the wound nnist not 
 be entirely closed, or tension from sepsis will result. W'heil 
 smart arterial bleeding is present, the mouth must be opened, 
 tongue pulled forwards, and the wounded vessel sought for anj 
 tied. Failing this, the lingual artery may be tied in the neck.i 
 even the external carotid. 
 
 Poisoned wounds of the tongue from the sting of a wasp or 1 
 cause rapid swelling, which may extend backwards, leadin;,' 
 crdema glottidis, and possibly fatal suffocation unless relieved 
 opening the windpipe. 
 
 Acute Superficial Glossitis occurs as part of a general stonij 
 titis, and needs no special notice. 
 
 Acute Parenchymatous Glossitis, or acute inflammation of 
 tongue, may arise from penetrating, and of necessity sepl 
 wounds, or from the bites or stings of insects, or may be asf 
 ciated with acute stomatitis in the course of fevers, but is raj 
 commonly due to the injudicious administration of mercury, 
 condition may be limited to one half of the organ, but w ben arisj 
 from general causes is bilateral. The tongue becomes paiiif 
 swells up rapidly so as to fill the mouth, and even protriM 
 beyond the teeth, the pressure of which leads to superti| 
 ulceration. The salivary glands are enlarged and painful, 
 salivation is a marked feature in the case. Speech, swallowj 
 and even respiration are nmch interfered with, and there ma]] 
 considerable febrile disturbance. The case, if treated with ' 
 
 In 
 n 
 
 i\ 
 
AFFECTIONS OF THE MOUTH, THROAT AND CRSOPHACUS 733 
 
 appearance; 
 ciatetl with ;i 
 
 ed, is visually 
 lirections, anJ 
 it, and cause 
 enovis return, 
 the mucous 
 aliva dribble^ 
 the jaws art 
 ■educed to its 
 2 to close the 
 rgrowth of the 
 :ion and dilata- 
 ihaped portion, 
 
 '^' ■ 11 ' 
 
 teeth, especialh 
 
 ult of tails ^vi^ll 
 •hage for a tew 
 be extravasaiei' 
 ling. In simp' 
 i, and the moui' 
 a few points ol 
 wound must no| 
 
 ,, result. ^Vlle^ 
 st V)e opened, tkl 
 jl sought for anj 
 d in the neck, 1 
 
 of a wasp or b^ 
 Ivards, leaduij; 
 mless reheved 
 
 I a general stoiij 
 
 ^animation of 
 necessity sepi 
 or may be asi 
 .vers, but is nj 
 |of mercury. ' 
 but when ansl 
 becomes pi^'i 
 Id even pwU'" 
 ids to supertil 
 and painJl^l' ' 
 leech, sNVcilloNV 
 1 and there ma: 
 , treated with 
 
 usuallv ends in resolution ; but diffuse or localized suppuration 
 may ensue, as well as the most urgent dyspncca, arising either 
 from (jdema glottidis or from the pressure of the enlarged organ. 
 Ircdnuiit consists in stopping the mercury, or removing any 
 evident cause, and in the administration of saline purgatives with 
 chlorate of potash. Leeches may be applied beneath the angles 
 of the jaw, but in bad cases a free inc'sion into the dorsum should 
 be made on either side of the median line to give exit to the effused 
 fluids and blood. The most rapid relief to the symptoms is 
 therein- obtained, although the organ may remain enlarged for 
 some time. If asphyxia is threatening, high tracheotomy or 
 iarvn<,M)tomy is required. 
 
 Abscess of the tongue may result from the acute process 
 described above, but is more usually of a chronic nature, and 
 situated at the anterior part of the organ, it is usually due to 
 the admission of micro-organisms through some superficial lesion 
 which has quickly healed. It presents as a tense swelling, 
 tluctuation in which may be masked by the amount of inflam- 
 matory thickening which surrounds it. A free incision both 
 settles the diagnosis and cures the case. 
 
 Chronic Superficial Glossitis is an interesting and important 
 disease, which may be associated with a similar condition oi the 
 mucous membrane lining the interior of the* cheeks and lips. It 
 inmost commonly due to syphilis, occurring as a tertiary pheno- 
 menon, but may arise from excessive smoking, ragged and rough 
 teeth, or spirit-drinking, chronic dyspepsia, perhaps of a gouty 
 nature, being also present in many cases. It is very liable to l)e 
 iollowed by epithelioma. Barker stating that out of 1 10 cases he 
 [carefully investigated cancer occurred in 43. 
 
 For purposes of description it is useful to divide the disease 
 [into the following five stages, although it must be clearly under- 
 stood that they are artificial, and se\eral of them may be present 
 [in different parts of the same tongue, (i.) The papilkr become 
 enlarfjed and swollen, leading to the appearance of red hypera?mic 
 [patches, which cannot be recognised for certain unless the tongue 
 is thoroughly dried with a handkerchief, towel, or piece of clean 
 otting-paper, which must not be carelessly dabbed over the 
 )rsan, but should be firmly pressed down upon it so as to absorb 
 the moisture, (ii.) Overgrowth of epithelium follows, and as 
 increases in thickness, it becomes opaque and horny, so that 
 |lie red patches are replaced by white ones, leading to the appear- 
 ice which has been designated Leucophkia. Sometimes the 
 fapilla? become much enlarged, and stand out definitely and 
 eparately from the organ ; or the whole surface may be covered 
 pth dense white patches. To this condition the term Ichthyosis 
 psheen applied, (iii.) Later on, the excess of epithelium is shed, 
 saving red smooth patches in which the papillae are atrophied, or 
 ive entirely disappeared. If this occurs over the greater part of 
 
734 
 
 A MANUAL OF SURGERY 
 
 the organ, the f^lazcd red tongue so characteristic of tertiary syphiliJ 
 is produced. If, however, this process only occiu's in snialiirf 
 areas intermixed with portions covered with white epithelium, a 
 patchy appearance of the tongue results, wrongly termed /\';())';'((jij 
 lingua', (iv.) At varying periods of the disease, sometimes earlier,! 
 sometimes later, the organ becomes ulcerated, cvacked, or fismd 
 in a somewhat characteristic manner. A median fissure isusuallv 
 seen running down the middle, and from this cracks exteiii!! 
 transversely, di\iding the surface into rectangular comparuiienti', 
 Superficial ulceration often occurs, apart from these fissures, hein;- 
 probably due to some local irritation, or to smoking ; the atrophic i 
 condition of the mucous membrane explains the great lia!)ilit\ tiJ 
 this occurrence, (v.) Still later, epithelioma may devr'op, and! 
 usually in connection with one of the fissures, or of the cicatricesl 
 arising therefrom. It is often somewhat slow in its pro<,'res\| 
 owing to the amount of sclerosis induced by the precedinij in 
 flammation. 
 
 All these stages of the disease are accompanied with imicJil 
 discomfort, the tongue being so tender that the patient cannotj 
 drink hot fluids, or take condiments or stimulants without paiii.j 
 The speech, too, is interfered with, becoming thick and indistinct.f 
 The course of the case varies considerably, and if cancer does notl 
 follow, the affection usually settles down after a time, and caiisesj 
 but little discomfort, so long as the patient conforms to tliej 
 restrictions as to diet, etc., ^vhich are essential. 
 
 The treatment of the case is usually a matter of some difticiiitv.l 
 All sources of irritation are excluded from the moutl as a tirstr 
 precaution. Thus, smoking or chewing tobacco must he rii,'idly| 
 prohibited. Spirit-drinking and all acid wines wdiich cause painj 
 should be forbidden, dilute whisky and water being perhaps thej 
 best stimulant. The teeth must be well brushed night and niornj 
 ing, and all stumps and rough excrescences removed. Gondii 
 ments, such as mustard, spices, curry, and cheese, are excludedj 
 from the dietary, and only simple unirritating ingesta allu\ved.j 
 The mouth is washed out frequently with an alkaline lotion, - 
 bicarbonate of soda (20 grains to i ounce), or borax (10 j^rainstq 
 I ounce), especially after meals, so as to exclude all risk of aciti 
 fermentation in the debris of food. A solution of perch loride oq 
 mercury (2 grains to i ounce) may be painted on twice daily wlieij 
 the organ is cracked or ulcerated, and in the latter case powdereJ 
 calomel dusted on once a day may be beneficial, or the sores ma\| 
 be touched with solid nitrate of silver. 
 
 General antisyphilitic remedies are employed where necessaryj 
 the digestion is attended to, and if the new formation of epitheliiin 
 is excessive, arsenic may be administered. 
 
 On the appearance of definite epithelioma suitable operativ^ 
 measures must be instituted. 
 
 Ulceration of the tongue arises from a variety of causes, anil 
 
AFIECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS 735 
 
 tertiary syphilij] 
 curs in snialk-r 
 ite epithelium, ;; 
 
 termed /'scniiiiil 
 3metinies earlier, 
 racked, or fmtui] 
 1 fissure is usually 
 is cracks exteiul] 
 ar coniparuiifins.l 
 sse fissures, liein^ I 
 ing ; the atrophic I 
 
 ''reat hahilitytol 
 nay devr'op, and! 
 f of the cicatricts 
 V in its pro<,'rts5,[ 
 the preccdini: in 
 
 anied with iiiucli| 
 :he patient cannot! 
 mts witliout pai;i,| 
 lick and indistinct.f 
 . if cancer does not! 
 a time, and causes! 
 t conforms lo tliej 
 
 of some difticuky, 
 moutl as a tiist 
 o must be rij;idly 
 which cause paini 
 leing perhaps the 
 d night and morn- 
 removed. Condi-I 
 ese, are excliKled| 
 ingesta allowed; 
 ilkaline lotion, 
 or ax (10 grains t( 
 de all risk of acic 
 of perchlonde 01 
 twice daily wher 
 ter case powderec 
 , or the sores nwyi 
 
 where necessary; 
 ition of epitheluic 
 
 uitable operative 
 
 jty of causes, m 
 
 occurs in many different forms. Thus, iyritahlc ulcers are due to 
 rough and carious teeth. Dyspeptic ulcers are associated with 
 ,'astric disturbances ; they are usually located on tlie middle of 
 the dorsum, and are often very painful. It is sufficient to touch 
 iheni with lunar caustic after dealing with the cause. Titbo'culoiis 
 ulcers are not common, and are always secondary to pulmonary 
 phthisis, the organ being infected by the sputum. They com- 
 mence in the form of a subnmcous abscess, which bursts and 
 leaves a small painful sore, rarely situated on the dorsum, but 
 chiefly at the sides or near the tip. Secondary abscesses form 
 around and coalesce with the original ulcer. Treatment is chiefly 
 needed on account of the pain and discomfort caused by them ; it 
 consists in cocainizing and scraping the sores, touching the base 
 with pure carbolic acid, and dressing with iodoform. Applications 
 of cocaine may also be made 1 )efore meals, as a palliative measure 
 where radical treatment is not undertaken. Lupus also attacks 
 the tongue, but is very uncommon, and almost invariably 
 secondary to a similar affection of the skin of the face. In a case 
 1 under our care it appeared in the form of an irregular granulating 
 surface surrounded by nodulated cicatricial tissue of an exceed- 
 ingly dense character. The progress was very slow, owing to the 
 amount of sclerosis present. Treatment consists in scraping and 
 [cauterization. Syphilitic and cancerous ulcerations are described 
 I below. 
 
 Syphilitic Disease of the tongue occurs in a variety of different 
 [forms. A primary sore presents a characteristic indolent and 
 [in,active surface with subjacent infiltration, and much chronic 
 [enlargement of the submental lymphatic glands, which, how- 
 lever, do not tend to suppurate. In the secondary stage mucous 
 Itabercles, fissures, and ulcers form, and usually on the sides or 
 [near the tip. Occasionally one meets with a broad wart-like 
 jcondyloma on the dorsum, which may be associated with longi- 
 jtudinal fissures ; it is sometimes termed ' Hutchinson's wart.' 
 |In the tertiary period chronic superficial glossitis may de\ elop, as 
 plso diffuse infiltration of the organ, or gummata. 
 
 Gumma of the tongue is not uncommon, occurring usually in 
 
 btients under forty years of age, as a late tertiary phenomenon. 
 
 starts as a locaHzed submucous or intramuscular infiltration 
 
 bear the median line, and generally towards the middle or pos- 
 
 lerior part. The swelling is at first hard and firm, but later on 
 
 |ecomes soft and fluctuating, and in time the overlying mucous 
 
 nembrane, which was unaffected, yields, and gives exit to the 
 
 Characteristic contents. The ulcer thus procuiced is oval or 
 
 Ound in shape, and deeply excavated, the base b.^ing constituted 
 
 |y a slough, looking like 'wet washleather.' There is but little 
 
 pduration either of the base or edges, and one of the most 
 
 haracteristic features is the fact that neither the floor of the 
 
 Nth nor the base of the tongue is involved, so that the organ can 
 
736 
 
 A MANUAL or Sr Ix'C.I-h'Y 
 
 l)(' freely prolriuled, whilst (Icf^'lulit'on .'iiul arliciil.itioii aic S( .incl-, 
 intcrfi'ivd willi. The patient ccmplaiiis of little |)aiii, aiul ||., 
 subinaxillary ^^lands are only aHec led either as pait of a ^^ciiciil 
 eidatf^'eiiieiit throuj^dioiit the body, or from the local iiiitation. 
 The proj^Mess is slow, and the ellect of aiUisyphilitic iKMlmciit 
 very derided, tin- ^uiiiina ahsorhiiii,', oi the ult cr, if |)rc'si'nt, 
 healiii}^' readily, hut lea\ iiii^ a loiali/.ed area of seletosis or a dcci, 
 cicatrix, from w Inch malif^iiaiit disease may subseiiueiitly ori^^inati, 
 '{'he lirnliiiciit consists in the administration of iodide of polassiinn 
 with or withont mercury, whilst the month is kept clean with a] 
 simple mouth wash. 
 
 Innocent Tumours ;ii'e not frecpieiit in the touf^'ue, papijlom,!, 
 cysts, lipoma, and na'vi being the chief \arieties, and i('(|iiiiiii^ no 
 special treatment. 
 
 Dermoid Cysts also form within or under the tongue, orii^'inatiiii.' 
 usually in comiection with the thyro-glossal duct (p. y>''\). 
 
 Cancer of the Tongue occms in the fcjrin of siinamous cpitln 
 lionia, and is both a fre(]uent and a \'ery fatal \ariety of tliisi 
 disi'ase. It is usually met with in men, and may arise as a nsiiltj 
 of the irritation caused by e\cessi\e smoking, especially ()f(ii(;u\,j 
 cigarettes, or foul pipes. 
 
 Its mode of onset varies somewhat according to the sitii' ion: 
 (n) It aiiscs most connnonly as an ulcer at the margin of tliij 
 organ, towards the junction of the middle and posterior tiiiidsj 
 and is then probably due to the irritation caused by ra^'j^'al aml[ 
 irregular bicuspid or molar teeth ; (h) it may start in a cnuk| 
 fissure, or cicatrix on the dorsum, as a result of chronic siipetiuial 
 glossitis, or of a preceding gumma ; (r) it may connnerice ;i> a] 
 wart-like growth, the base of which becomes iidiltialed, tiief 
 tumour in\ading the muscular substance, and spreadiuL,^ to 
 root of the tongue; ((/) it may originate as a subnuicous inliltra^ 
 tion, starting as an ingrowth from the mucous mendiraiic, \vi 
 out much external manifestation of its presence ; (c) it may firsj 
 be noticed as an irregular ulcer in the floor of the mouth; ori/j 
 it may spread into the tongue from surrounding parts, such as tliJ 
 tonsil or larynx. 
 
 In ^vhatever way it starts, the same features are soon nianij 
 tested, viz., a new growth is noticed, hard in consistence, inj 
 definite in its extent, which may or may not be painhd from 
 first, and which ulcerates superficially, exposing a more or led 
 crateriform cavity, with a grey, sloughy, foul surface, readilj 
 bleeding when touched, and discharging a foul secretion, whicj 
 causes extreme foetor of the breath. The ulcer is surrounded li 
 an indurated mass, which gradually shelves off into the neislj 
 bouring healthy structures, or may be abruptly limited. Protusj 
 salivation is produced by the irritation of the branches of t|ij 
 third division of the trigeminal, and all ^.he movements of t^ 
 
 ^-"^^-eji. 
 
jii-i-i-:cii()Ns ()/•• •/•///■; Moi III, iiih'o.ir, and <i soriiAcus 7^7 
 
 lion arc si ;ui(l\ 
 (! piiiti, :uul llif 
 III of ii ^;i'iict;il 
 loc.'il iniliUiDii. 
 liilitif licaUufm 
 U(T, it' I'lcsi'iu,] 
 Iciosis 01 :i (Ircii 
 |ui'tUly orii^imtr. 
 rule of iintassiutii 
 cpl cleiiii with ;ii 
 
 m^^ue, p:ii)illnni,i. 
 ;uul rciiuiiiiv^ mil 
 
 Mif^vu', oii^iiKUiii;; 
 t(p. 7'^'). 
 
 s(iuiuuous I'pilhi 
 al vivricty of ihi!' 
 ly ivrise ;is :i ii'sultj 
 specially of (■i!,'ai>,| 
 
 r to tlu' silu:' '.(iir.j 
 the niati^in of tlitl 
 .1 posterior ihinlsl 
 sed by nij^},H.Hl ami 
 start in a track] 
 chronic supertuial 
 Ly coninicrice a> ;ij 
 es inliUiiUed, 
 I spri-adin-; t() tbt 
 Ul'iiiii^^'"^ infiltraj 
 Is inenibranc, wiiM 
 ;e ; {c) it niny tif>f 
 the niouih ; or \f\ 
 parts, such as thj 
 
 [es are soon nianil 
 lin consistence, ml 
 k painful from thj 
 In^' a more or lesj 
 k surface, readil 
 111 secretion, wluc] 
 ir is surrounded M 
 loff into the neigl 
 limited. Protus 
 branches of tt 
 ruoveinents of t" 
 
 jt(iM;,'Ui ;iie paiiiliil aiid limited on ;i( coiiiit of the iiililti ;it ion of 
 
 I [he jiase, so tiwit both swallowinj; and s| 
 
 )ec( h ail' 
 
 dilliciilt, thi; 
 
 mticiit aiiowinf; llie saliva lo dribbU- out of his nioiilli. The pain 
 
 li.iiften veiy excessive, and usually extends alonj^ many of llu; 
 
 |,r;iiu lies of llu! Idtli nersc, i'S|)e« iaily to the ear, so thai shiep 
 
 liftiiines ini|)ossil)le, and the patient's (oiidilion steadily and 
 
 ta 
 
 (lly 
 
 delei lotates. 
 
 'I'll 
 
 and 
 
 undei' the ( hin and at tlu; 
 
 if oi the jaw early heeonie nu( 
 
 lived 
 
 in tlu! disease, which 
 
 limalely attacks the ^dandula' concatenata'. 'ilies*! secondary 
 ij-iowllis are \v\y frecpiently cystic in ( liaracler, from the dej^'enera- 
 ljnnof the masses of epithelium formed within them ; aft(!r a time 
 
 iluv ai)|)roa( 
 
 h th 
 
 e suila<'e and burst, leavm/^^ raj^'jLjed mali^Miant 
 
 iliri 
 
 IS ui the ne( 
 
 k. The I 
 
 owci' law, moreo\(;r, is often uivai 
 
 lied 
 
 m 
 
 later sialics of the disease 
 
 The occurrence of tlu; typical cach(!xia is d(!t(!rmimHl not only 
 liv the pain and conseipienl sleeplessntjss, but also by tin; inability 
 [ill take suffunont nourishnuiut, th(; absorption of pioducls of 
 Ipulrcfaction swallowed with the saliva, tlw; excessi\'(' salivation, 
 Ithe occasional ha'morrhat,'es, and the extctnt of tin; secondary 
 Ipiiwlhs. The patient larely lasts, apart hom treatmiMil, for more 
 ihiiii t\vi'lv(! months att(M" the dis(;as(! has been (irst noticed. 
 
 Diagnosis. -When a case; is met with where the, ulcer is situated 
 
 [lit the side or base of tlu; louf^au! in a patient over forty-live years 
 
 |(ila;,c, with the typical etdarj^ement of the j^dands, profuse saliva- 
 
 Itioii, and impaired movements, there can be little doid)t as to the 
 
 iiai,'n()sis. J^ut when it is seen in tin; t;arly staj^e, as an infiltration 
 
 lof a syphilitic fissure or cicatrix, or as a siriall wart, it may be 
 
 |t\a'ediii^,dy difficult to determine whether or not niali^oiant disease 
 
 |i- present. The early enlarj^ement of the f,dands, the amount of 
 
 3,iin, the fixity of the orJ^^ln, and the infiltration of the base of the 
 
 ila'r,iuc important j^oiidin.L,^ mar'<s; but in doubtful cases a small 
 
 Mtion of the ^aowth should be excised under cocaine, and sub- 
 
 inud to careful microscopic examination, and thus its nature 
 
 Isartained. Moreover, the administration of steadily increasing 
 
 pes of iodide of potassium will generally brinj^ about rapid 
 
 mprovement in a syphilitic case, but will do nojijood to an epitlie- 
 
 ima, except perhaps temporarily when the two diseases co-exist. 
 
 Treatment. — The only hope of curinj,^ the patient lies in thorough 
 
 Ind early removal of the growth, which, it must be remembered, 
 
 las probably extended much further than one expects. Mence, 
 
 iialf-nieasures should be adcjpted, but complete operations, 
 
 |icluding also the lymphatic area, are desir- \,]-^, 
 
 Lif,'ature of the lingual artery and di.> > .1 of the gustatory 
 
 me have been performed in cases where the disease had pro- 
 
 [ressed too far to attempt radical treatment, with the double object 
 
 [starving the growth and relieving the pain ; such, however, are 
 
 Ilittle value. Dusting the surface of the tumour with pyoktanin 
 
 perhaps give the most relief to the unfortunate patient. 
 
 47 
 
738 
 
 A MANUAL OF SUUGEK\ 
 
 Many oper.'itions for removal of the tonj^ue luive been sn{,'(,'esteil 
 ;iiul [Mactisccl iVoin time to time, the majority of wliich have, Iidu 
 ever, lalleii into disuse, and will not even be notieed here. \\, 
 shall merely iridi( ati; the chiet plans of treatment adopted at tl;, 
 present day. i''or praetical purposes, tiie cases may be (lividuli 
 into two t^roups- -those in which the disease is limited to mi-; 
 poition of the tonj^ue, and the nuiscular tissu(> is not exteiisivik 
 iiuaded; and those in which glands or other structures arcals, 
 obviously in\olved, or the tonjjjue itself is widely inliltratcd. Irj 
 the lirst class of cases an intrabuccal operation will often suffice I 
 combined with separate removal of the f^lands; in tlu; scamd, 
 more extensive extrabuccal pror<'dures are recpiired. 
 
 Till! Intrabuccal Method now .ted for partial removal o[ 
 
 otf^an is that known as Whitehiua s Opcvalion. The liiif^ual artirvl 
 should always be prexiously secutcd in the neck (p. ^56), ilmJ 
 f^iviu},' the surf^eon an opportunity of removing; the subinaxillarvf 
 gland, with its associated lymphatics, which are so often alTecteu.f 
 The mouth is then well opened with an effu icnt gag, and [\.\ 
 chloroform administered by means of Junker's apparatus. \l 
 good assistant is necessary in order to prevent blood ciitciin'l 
 the larynx, small pieces of sponge held in smooth-nosed, lopi'i 
 handled forceps being used to clear the pharynx. A coarse sill 
 thread is passed through each half of the tongue to draw i 
 forwards and steady it, and if portions of both siiks are to 
 removed, a silver wire or silk thread should in addition he passeJ 
 through the base not far from the epiglottis so as to cuMiiiianJ 
 the stump. The essential featu''« of the operation is to caretiilljj 
 snip through the organ little b tie by means of long-handleii, 
 straight, blunt-pointed scissors ing up all the vessels as tliej 
 
 are divided, and by this means me loss of blood is reduced to{ 
 minimum. The modus operandi for partial removal of one half 1 
 as follows : The tongue, being drawn out of the mouth by t!ij 
 two anterior loops of silk, is carefully divided down the middle linl 
 into two segments, which are readily separated from one anothcT 
 by the finger, the scissors merely dividing the mucous nieinlmina 
 The base of the organ is freed by cutting through the linei 
 attachment of the mucous membrane to the alveolus, and tl 
 along the middle line of the floor of the mouth to the tip of 
 tongue, so that the sublingual salivary gland can be also takej 
 away — a most necessary step. The mucous lining of the dorsii 
 is now divided transversely behind the growth, and the nuisciilij 
 structure of the organ slowly snipped through with scissors,; 
 during the process, by the aid of the finger or a director, tij 
 vessels and nerves can be seen and recognised before divisioi 
 Removal of the diseased half with the sublingual gland is thj 
 easily accomplished by making the incisions meet, and dividingtj 
 intervening tissues. 
 
 If the tip is alone involved, it can be removed by a \'-shap 
 
tiriXTlONS OF THE MOUTH, [IIROAT, AND (ESOPHAQVS 730 
 
 v'hkli liiivi', liiiw 
 tict'd luTf. \Vi 
 il adoptril ill ll,-' 
 , nmy bt- (Uvicltii 
 IS limited to one! 
 is not cxtcnsivtly 
 Lnirtures wxv. iilsui 
 ly inliltriUcd. In I 
 will often suffice, 
 s ; in tlu' si'i'dihI 
 ired. 
 
 'tial reniornl of ihc 
 The linf;vi;il :irtm| 
 icck (p. 2.V)),lluis 
 r the subni;ixilliuy 
 e so often aflecteuJ 
 L'ient fj;iiu, iiiiil t'ej 
 ir's iippaiiiliis. \l 
 ent blood cnti'iini;! 
 ni 00th -nosed, loii'-f 
 yn\. A coarse si! 
 tongne to draw iJ 
 pth sides are to ' 
 1 addition be passed 
 s(i as to cunim;iii(| 
 ation is to caret ". 
 ^ns of long-liandleJ 
 the vessels as t!;e)j 
 jod is reduced to( 
 iioval of one halt if 
 the mouth by thi 
 ,o\vn the middle linj 
 ;d from one anothf 
 mucous meinbran^ 
 ;hrough the linei 
 , alveolus, and tliej 
 |th to the tip of tli 
 . can be also tak^ 
 ining of the dorsuj 
 ., and the musculj 
 h with scissors, " 
 or a director, tM 
 led before divisitf 
 ligual gland is m 
 eet, and dividin?t| 
 
 Led by a V-sh 
 
 im ision, maile after steatlying the tongue witli a deep sut\H« . The 
 ^iii:ill ranine artery will spurt on eaili side, but is easily secured, 
 ;iM(i llie gap closed by catgut sutures. 
 
 It the w/wlf loiif^iif is to be excised, or cviti when (jne side alone 
 lueds removal as far back as the epiglottis or hyoid bone, special 
 precautions have to be taken in order to diminish the risk of 
 ,is|)hy\ia from failing back of the stump of the organ after the 
 ,,[)(ration. 'IMuis, a thick silver win; can be parsed deeply through 
 the epiglottis, by means of which it is drawn forwards, and the wire 
 IS then lixed to the upper lip by a stri|> r)f gau/e and collodion. 
 The objection to this plan is tht; patent condition of the glottis, 
 mti) which septic exudations from the mouth are likely to run, 
 proluhly inducing septic pneumonia. A much better method is 
 ihat wiiich has been introduced and largely adopted of late, vi/., 
 the [u'rformance of a pnliminavy itachcotutny in order to allow the 
 pharynx to be plugged. A Hahn's trachea-tube (i.e., a large one 
 surrounded with compressed sponge; infiltrated with iodoform, 
 which will expand and absolutely shut off the lower respiratory 
 trad from the mouth) is inserted, or a Trendelenburg's air- 
 tampon; or an ordinary tube may be employed if the pharynx is 
 well packed with a sponge so as to prevent blood trickling down- 
 wards ; the ana'sthetic can then be administered through the tube. 
 The advantages of this method of treatment are threefold : {a) The 
 patient can be kept in a condition of complete ana'sthesia without 
 limdrance to the surgeon, o that the operation is more (juickly 
 tinislied, the shock is less, and the removal of the disease can be 
 more thoroughly accomplished ; {h) the patient runs no danger of 
 asphyxia during the operation by blood trickling into the lungs, 
 or by fragments of tissue or sponge getting loose in the mouth 
 and being inhaled, whilst later on falling back of the root of the 
 tongue does no harm ; and (t ) the chances of septic pneumonia 
 are reduced to a minimum. Of course, opening the trachea is 
 not entirely devoid of danger, and therefore this plan should not 
 be adopted except where extensive dissections are called for, and 
 then may be undertaken with advantage a few days previously. 
 At the time of operation the pharynx is firmly packed with a 
 jsponge. 
 
 Where the jaw, floor of the mouth, or glands in the neck are 
 pch implicated, or the tongue substance itself extensively 
 tiltrated, an Extrabuccal Operation is necessary ; and of the 
 any plans that have been recommended, we consider Kocher's 
 P^mtiou, or some modification of it, by far the best. The 
 "ncision (Fig. 254, C), commencing close to the lobule of the ear, 
 ns down along the anterior border of the sterno- mastoid to the 
 reat cornu of the hyoid bone, and thence forwards nearly to the 
 iddle line, and upwards to the symphysis. This flap of skin 
 nd subcutaneous tissue is dissected up, and stitched to the cheek 
 ut of harm's way. If part of the jaw also needs removal, the 
 
 47-2 
 
740 
 
 A MANUAL OF SURGERY 
 
 incision may have to extend throuj^h the lower Hp, and the flap i- 
 then turned outwards and backwards so as to expose the hom. 
 All the lyni])hatic glands in the region — the submental, suli 
 maxillary, and those lying over the carotid — are now removed, 
 as well as the submaxillary salivary gland, the lingual and facia; 
 arteries being tied close to the carotid. Any diseased portion i,; 
 the jaw is isolated by saw-cuts in front and behind, and mav 
 be removed at once if desirable, or left in situ and taken awav 
 with the disease; but, as already mentioned, it is always well, ii 
 possible, to leave a bridge of bone to maintain the continuity oi 
 the mandible. Where only half the tongue is to be removed, it 
 is now split down the middle line with scissors, and the nuicous 
 membrane in the floor and side of the mouth divided so as to | 
 leave that side of the tongue attached merely by the muscular 
 structures, which are snipped through with scissors, any bleeding' 
 points being secured as divided. If the whole organ is to kj 
 removed, it is unnecessary to divide it in the middle line. If tl;c 
 jaw is healthy, the reflection of mucous membrane is incised cliw 
 to the alveolus, so that, by detaching the mylo-hyoid from the 
 bone, a connnunication is made between the outside wound and 
 the mouth, and the tongue is then drawn through this lateral 
 opening, and removed close to the epiglottis behind, and close toj 
 the hyoid bone below, the whole floor of the mouth being effectu- 
 ally dealt with in this way. 
 
 The raw surface is painted with Whitehead's varnish (whiciii 
 consists of Friar's balsam, but with the rectified spirit replactJ 
 by a saturated solution of iodoform in ether), and, where iiachr- 
 otomy has been performed, the mouth is plugged with aseptic 
 gauze. 
 
 The external incision is closed by a continuous suture, a lar^fj 
 drain-tube being inserted at the lowest point for a few days, No 
 attempt is made to keep the base of the tongue forwards, and, 
 fact, it is better that it should fall back so as to close the openinJ 
 of the glottis, and so prevent septic saliva from entering the air] 
 passages; it will be subsec]uently drawn forwards again hvthe 
 process of cicatrization of the wound in the floor of tlie nioiithJ 
 The plug of gauze may be removed in twenty-four hours, anJ 
 replaced or not at the discretion of the surgeon. The nioiitlj 
 must be freely and frequently washed out with some uninitaiina 
 antiseptic lotion, f.f:,., sanitas (i in lo), boroglyceritle (i in 20] 
 boric acid (10 f'rains to i ounce), or a weak solution of Condvi 
 fluid. If all goes well, a smaller size of Hahn's tracheotoniytiib 
 is inserted on the second day, an ordinary tube on the fifth oj 
 sixth, and even this is removed in seven to ten days. The patieni 
 is fed per rectum for twenty-four hours, but afterwards a tiih 
 attached to the spout of a feeder is introduced into the pliaryni 
 or u'sophagus. In the simpler cases he is able to swallow treelj 
 and without difficulty in the course of a day or two, and even I 
 
yt-^_^-'^ :»Ajf 
 
 ip, and tbf Hap i^ 
 expose the bone. 
 
 submental, sub 
 re now removed, 
 lingual and facial 
 iseased portion of 
 behind, and may 
 [ and taken away 
 
 is always well, ii 
 1 the continuity of 
 
 to be renio\ed, it 
 s, and the nnicoib 
 1 divided so as to 
 ^ by the muscular 
 ;sors, any bleediii- 
 le organ is to k 
 iddle line. lftl;c| 
 ane is incised clw 
 ylo-hyoid from tiitj 
 outside wound and I 
 1 rough this lateral 
 shincl, and close to I 
 louth being effectii] 
 
 id's varnish (whic 
 
 fied spirit replaced I 
 
 and, where irache-f 
 
 liTired with aseptic] 
 
 ous suture, a hm 
 |or a few days, Nol 
 ie forwards, and. iaj 
 ^o close the openiii: 
 ',m entering the airl 
 wards again by M 
 [floor of the nioiitrJ 
 ,ty-four hours, arJ 
 in. The nioiq 
 h some unirritatin^ 
 lyceride (i i" M 
 solution of Condyj 
 [s tracheotoniy-tub 
 abe on the fiflb i 
 days. Thepatiei] 
 afterwards a tiilf 
 :l into the pharynl 
 le to swallow firtlj 
 >r two, andeveirl 
 
 AFFECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS 74! 
 
 •he worst cases he can feed himself with a long tube passed into 
 tht' pharynx in five or six days. Where no tracheotomy has 
 been jierformed, the greatest care and watchfulness will be re- 
 -uiired to prevent the stump of the tongue falling back and produc- 
 ini; asphyxia ; the mouth and pharynx must be constantly cleansed, 
 to diminish as far as possible the risk of septic pneumonia. 
 
 This operation is certainly the most successful of any for exten- 
 sive diser. ,c, and the immediate results are satisfactory; but 
 necessarily where the disease is so widely diffused as to need 
 such a severe procedure, a considerable percentage of the cases 
 will suffer from recurrence. 
 
 The great danger of the operation — septic pneumonia— is best 
 
 combated by carefully cleansing the mouth and teeth previously 
 
 with antiseptics, by a preliminary tracheotomy, and efficient 
 
 plugging of the pharynx. Secondary haemorrhage is occasionally 
 
 met with, but probably only when the patient is very exhausted 
 
 at the time of the operation, and wheri the mouth is not well 
 
 irrigated subsetjuently ; the bleeding vessel should be again tied 
 
 on the face of the stump, or in the neck if such has not already 
 
 I been undertaken ; failing this, one must depend on the application 
 
 |ot perchloride of iron or the actual cautery. Antistreptococcic 
 
 serum may also be utilized as a preliminary measure in order to 
 
 [prevent the occurrence of septic troubles ; three or four injections 
 
 of ID c.c. each are made on the day preceding the operation, and 
 
 [perhaps one or two afterwards. The results obtained in this way 
 
 lia\e been very satisfactory. 
 
 Kocher's lines of incision may be modified according to circum- 
 stances, provided that the essential principles are kept in view, 
 [viz., the complete removal of the primary disease and of the 
 [infected glands, and the provision of effective drainage. 
 
 The removal of a part, or even the whole, of the tongue is not 
 Isiich a mutilation physiologically as one might expect at first. 
 jDeglutition is interfered with for a time, but the power is soon 
 regained, and even articulation may be in great measure restored. 
 
 Affections of the Floor of the Mouth. 
 
 Sublingual Abscess, when acute, is due to infection of the sub- 
 jniucous tissue, as by puncture with a fishbone, or starts in a fol- 
 jlicleuf the sublingual or in a submucous gland. The inflammation 
 Ivhicli follows results in the formation of a puffy swelling beneath 
 |he tongue, which, if not opened early, may lead to an extension 
 linvnwtudsof the mischief into the submental region. The tongue 
 wunics swollen and turgid from pressure upon the \eins, whilst 
 itdematous laryngitis may also be induced. Considerable con- 
 stitutional disturbance generally accompanies this process. A 
 piedian incision through the nuicous membrane, and the insertion 
 and opening of a pair of dressing forceps, is the safest and best 
 iiethod of treatment, the cavity being subsequently washed out 
 
742 
 
 A MANUAL OF SURGERY 
 
 and drained. The more diffuse form of sublingual abscess ;-| 
 usually associated with submaxillary cellulitis (p. 82). 
 
 The sublingual region is also a favourite site for Actinomycosis! 
 (p. 113), which manifests itself as a diffuse brawny induration c; 
 the tissues, progressing slowly, and not very tender. As it cornel 
 to the surface, the skin becomes red and dusky, and sooner 0: 
 later a series of little pustules appear one after another with s 
 typical yellowish apex. These burst and discharge a glutinoti 
 fluid containing the fungus, and if kept aseptic and allowed t 
 heal, are followed by depressed a'xl puckered cicatrices. Thtl 
 administration of gradually increasing doses of iodide of potassiuirl 
 usually suffices to bring about a cure. 
 
 Salivary Calculus generally arises in connection witli the suji 
 maxillary or sublingual glands. For symptoms, etc., see p. 744, 
 
 Cystic Swellings are not unconunon about the floor of tlk 
 mouth, and amongst them the following may be described : 
 
 (a) Mucous Cysts r t from the distension of mucous ghmd?: 
 they form small tra, slucent swellings, elastic and fluctiuitiiic. 
 y\ll that is needed is to open them, and remove the anterior wall, 
 
 (b) Ranula is a very similar condition, but larger and unihiterai, 
 containing a glairy mucoid fluid, and due to obstruction and dis 
 tension of one of the sublingual ducts (or ducts of Rivini). .\| 
 similar condition has been caused in rare cases by a blocking; 0! 
 Wharton's duct, but this has generally been found to run ;do:i,'l 
 the outer surface of the cyst. The tumour may be as large as a 
 walnut or pigeon's egg. The treaiment consists in removing a 
 good-sized piece of the wall so that the cavity may be obliteiatec 
 by a process of granulation, or if that should fail, the whole cavitv[ 
 must be dissected out. 
 
 {c) Dermoid Cysts are frequently met with in the floor ofj/t 
 numth, occupying the middle line, and also projecting intfi CliH 
 neck beneath the chin. They are due to non-obliteration ci 
 the upper end of the thyro-glossal canal (p. 781). The contents 
 are of the usual sebaceous type. Such tumours should ne\erbt| 
 dealt with from the mouth, as they extend deeply, and need tobt 
 carefully dissected out. A free opening must be made jn the] 
 middle line under the chin, and, if feasible, the whole\Cj 
 removed unopened. If it gives way, the entire wall must 
 dealt with, or recurrence will certainly ensue. ___ — • 
 
 Affections of the Salivary Olands. 
 
 Inflammation of the Parotid Oland is met with in se\ eral different | 
 forms. 
 
 I. Epidemic Parotitis (Mumps) is an acute specific disease. I 
 usually seen in ch.iidren, highly infectious in character, and 
 generally epidemic. The period of incubation is about tluw 
 weeks, and the attack itself consists in a slight febrile dis 
 turbance, associated with swelling of one or both parotid glands: 
 
AFFECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS 743 
 
 lone {,'land is attacked first, being enlarged and tender, the swelling 
 
 jbefjinning to diminish about the fourth day, when the other side 
 
 [is similarly affected. Mastication becomes difficult, owing to the 
 
 [tension of the parts. The swelling extends below and in front of 
 
 the ear, and the socia parotidis can be distinctly felt lying over 
 
 the inasseter ; the submaxillary, sublingual, and neighbouring 
 
 llvnipliatic glands are also enlarged. Suppuration is rare, but in 
 
 adults metastatic inflammation of the testes, mamma;, or ovaries 
 
 is not uncommon. This complication is generally unilateral, and 
 
 thus, although atrophy of the testis commonly follows orchitis, 
 
 sterility is not produced. Treatment. — Keep the patient warm and 
 
 (luiet, and administer salines. In the later stages friction with 
 
 stimulating liniments will hasten resolution. After the acute-- 
 
 [attack, the gland may remain enlarged for some time. 
 
 2. A Simple Parotitis occasionally results from exposure to cold 
 I or from injury, whilst the presence of a calculus in the duct leads 
 
 to a chronic sclerosing inflammation. The symptoms consist of 
 
 pain and swelling, together with a certain amount of constitutional 
 
 I disturbance. An extremely interesting phenomenon is the paro- 
 
 [titis which follows injuries or diseases of the abdominal or pelvic 
 
 viscera. This condition is not very unusual, as is evident by the 
 
 fact that Stephen Paget has been able to collect 101 such cases. 
 
 It was formerly attributed to pyaemia, but is now considered 
 
 Jtohe due to infection of a mild type from the mouth, owing to 
 
 I a septic state of the teeth induced by prolonged rectal feeding. 
 
 in confirmation of this view is the fact that it has been seen 
 
 in not a few cases of gastric ulcer, where the patient had to 
 
 he fed per rectum for some time. Treatment in these simple cases 
 
 [consists in the application of fomentations, perhaps medicated 
 
 with belladonna. 
 
 3. Suppurative Parotitis is a much more serious condition. It 
 may extend from the mouth along Stenson's duct, or supervene in 
 the course of pyaemia, or as a sequela of some of the exanthemata, 
 eg'., scarlet or typhoid fevers. If the inflammation spreads up 
 from the mouth, suppuration occurs primarily within the tubules ; 
 under other circumstances, pus forms in the interstitial tissues. 
 The gland becomes much enlarged, with congestion and tL'dema 
 of the overlying skin, and, owing to the tension of the fascia, 
 exceedingly painful. For the same reason, pus cannot readily 
 find its way to the surface, and hence is likely to burrow in 
 various directions, e.g., amongst the muscles of the neck, or even 
 upwards and inwards towards the base of the skull, or to the 
 cavity of the mouth, finding its way over the border of the 
 superior constrictor (the so-called 'sinus of Morgagni '). The 
 constitutional symptoms from toxic absorption are usually very 
 severe. Owing to the fact that large veins and arteries pass 
 through the parotid gland, pyacmic symptoms are not unlikely to 
 supervene, and the prognosis is therefore somewhat serious. 
 
744 
 
 A MANUAL OF SURGERY 
 
 Diagnosis. — Inflammation of the lymphatic glands lying on tin 
 outer surface of the parotid closely sin^ulates the above affections, 
 but is distinguished from them by the fact that they are more 
 superficial, and that the socia parotidis is not enlarged. 
 
 Treatment. — In the early stages fomentations are employed, 
 but as soon as there is any indication that suppuration has occurred, 
 a free incision must be made, and the pus let out. Every precau- 
 tion should be taken to prevent mischief to the facial nerve, and 
 Hilton's method of operating may be advantageously employed : 
 but in the more severe cases where the patient's life is threatened 
 and the pus is burrowing in all directions, the knife must be freelv 
 used regardless of anatomical considerations. 
 
 Inflammation of the submaxillary and sublingual glands mav 
 arise in an exactly similar way, but no special description is called 
 for. Occasionally, however, the process extends beyond the sub- 
 maxillary gland to the neighbouring tissues, giving rise to what 
 has already been described as submaxillary cellulitis, or Ludwigs 
 angina (p. 82). 
 
 Obstruction to the Flow of Saliva results from various causes, 
 such as cicatricial contraction in the neighbourhood of the entrance 
 of the ducts into the mouth, or from the presence of a salivm 
 calculus, consisting of phosphate and carbonate of lime, and usuallv 
 fusiform in shape. 
 
 The chief Symptom of such obstruction is a painful enlargement 
 of the gland during and after meals, which slowly passes away as 
 the saliva finds its way past the block ; if it persists for long, the 
 gland becomes chronically enlarged, and its interstitial tissue 
 increased in bulk, whilst a certain amount of peri-adenitis also 
 follows. When a calculus is present, there is usually a consider- 
 able discharge of offensive muco-pus into the mouth. Where the 
 obstruction is complete, a cyst may form, and if this is opened, 
 or finds its way to the exterior and bursts, a salivary tistuki 
 results. The formation of salivary calculi is not very conmion 
 in connection with the parotid gland, owing to the fact that the 
 saliva excreted is limpid in character, whereas that arising from 
 the submaxillary and sublingual glands is thick and mucoid. 
 
 Treatment. — In cases of simple obstruction, an attempt must 
 be made to restore the natural exit, or to make an artificial one. 
 If a calculus is present, it can usually be seen or felt at intervals 
 projecting from the entrance of the duct ; in such a case the duct 
 must be incised, and the stone removed. Where, however, it is 
 located in the substance of the submaxillary, total removal of the 
 gland tnay be necessary. 
 
 Tumours of the Parotid Gland are of considerable interest, and 
 may be simple or malignant. 
 
ands lying on tlit 
 I above affections, 
 it they are more 
 larged. 
 
 ns are employed, 
 ition has occurred, 
 t. Every precau- 
 i facial ner\-e, and 
 eovisly employed ; 
 life is threatened 
 life must be freelv 
 
 igual glands may 
 sscription is called 
 is beyond the suli- 
 iving rise to what 
 ulitis, or Ludwig's 
 
 •m various cause\ 
 Dod of the entrance 
 sence of a salivan 
 if lime, and usuallv 
 
 linful enlargement 
 
 y passes away as 
 
 rsists for long, the 
 
 interstitial tissue 
 
 3eri-adenitis also 
 
 isually a consider- 
 
 3uth. Where the 
 
 if this is opened, 
 
 salivary fistula 
 
 lot \'ery common 
 
 the fact that the 
 
 that arising from 
 
 nd mucoid. 
 
 an attempt ^nl^t 
 
 an artificial one, 
 
 r felt at intervals 
 
 h a case the duct 
 
 :re, however, it is 
 
 1 removal of the 
 
 ible interest, and 
 
 AFFECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS 745 
 
 (a) The Simple parotid tumour consists of a growth starting 
 in the capsule or interstitial tissue of the superficial part of the 
 Ldand; it contains nodules of cartilage mixed with fibrous and 
 mucous tissue, whilst sometimes glandular elements similar to 
 those met with in the parotid are scattered through the mass. 
 It has been already mentioned that the cartilaginous elements are 
 probably due to the persistence of remnants of the embryonic 
 Meckel's cartilage. The tumour feels hard, firm, and nodular, 
 Init where there is much myxomatous tissue, areas of softening 
 may he interspersed amongst the harder portions. The mass is 
 situated between the jaw and the sterno-mastoid, accessory pro- 
 cesses also extending over the masseter in the region of the socia, 
 and later on burrowing deeply between the mastoid bone and the 
 styloid process, and beneath the ramus of the jaw (Fig. 266). 
 In the early stages the tumour is freely moveable on the 
 deeper parts, as is also the skin over it, but subsequently the 
 mass becomes fixed and adherent. The growth is usually slow, 
 and often quite painless, and there is no tendency to invade 
 Ivmphatic glands or produce cachexia. Mastication is much im- 
 paired, but otherwise the subjective symptoms are of but slight 
 importance, owing to the 
 tact that the growth is 
 superficial to the gland, and 
 to the more important 
 vessels and nerves. 
 
 (h) Malignant tumours of 
 the parotid occur in the form 
 either of sarcoma or carci- 
 noma. In the former case 
 the malignant disease is not 
 unfrequently grafted on to a 
 simple tumour, the change 
 of type being marked by 
 increased rapidity of growth 
 and greater pain. The mass 
 becomes more fixed, and 
 signs Ci pressure upon the 
 Vessels and nerves develop ; 
 
 - facial nerve is very likely 
 I to be implicated, leading to 
 paralysis of the face. More- 
 over, the skin becomes 
 hypera-mic and often 
 [adherent to the tumour, 
 and finally ulceration and 
 [tven fungation may obtain. Secondary deposits occur in the 
 neighbouring lymphatic glands or in the \iscera, and the patient 
 hoon passes into a state of malignant cachexia. Carcinomatous 
 
 FiG. 2G6, — Parotid Tlmckk. 
 (Fkrgusson.) 
 
!H 
 
 746 
 
 A MANUAL OF SURGERY 
 
 tumours are less common, but run a similar course, and, in 
 fact, the diagnosis from sarcoma is often only made by the ust 
 of a microscope. The growth is an adenoid cancer, not un 
 frequently of the soft or encephaloid type, and neighbourinf; 
 lymphatic glands are early invaded. 
 
 The Diagnosis of simple parotid tumours from maligniint 
 growths is a matter of the greatest importance from a prognostic 
 point of view, since simple tumours are distinctly encaf)suled, 
 and their removal, except in e.:treme cases, is not a matter of 
 special difficulty ; whilst malignant disease is much more diffuse, 
 rendering complete extirpation of the mass almost impracticable, 
 The distinction between the two forms is made by a consideration 
 of the signs and symptoms considered above, attention beini; 
 directed to the rate of growth, the condition of the skin and 
 surrounding parts, the mobility or not of the neoplasm, and the 
 general aspect of the patient, whilst associated paralysis of the 
 facial nerve is almost always characteristic of malignancy. The 
 lymphatic glands lying on the surface of the parotid, when invaded 
 by tubercle or by epithelioma secondary to some intrabuccal 
 growth, may closely simulate a true parotid tumour, but are recot; 
 nised by their more superficial position. 
 
 The Treatment is often a matter of some difficulty, owing to 
 the important character of the surrounding tissues. Removrd 
 should only be attempted if the skin is not extensively involved, 
 if the growth is moveable on the deeper parts, and if there is no 
 evidence of secondary deposits. Even simple tumburs become 
 irremovable after a time on account of their deep connections and 
 change of type, whilst it is seldom justifiable to touch maliffnam 
 growths on account of their early and wide dissemination. Simfu 
 parotid tumours are dealt with either by making a vertical 
 incision over the most prominent part of the mass, or by turnini; 
 forwards a flap, exposing thereby the capsule, which is incised 
 transversely ; for although the facial nerve is generally beneath 
 the growth, it occasionally runs superficial to it, or in its substance. 
 After this has been accomplished, the tumour is often enucleated 
 without much difficulty, but the surgeon must make certain that 
 no deeper processes are left, or recurrence will certainly ensue. 
 The haemorrhage from the transverse facial and other arteries is 
 free, but easily restrained. There is no need to remove redundant 
 skin in these c?ses, as it quickly contracts. 
 
 In dealing with early malignant disease, excision of the uMi 
 parotid gland may be occasionally undertaken. It is accomplished 
 through a vertical incision, or, if the skin is involved, by two 
 crescentic ones. The gland is then gradually freed from its 
 connections, care being taken, if possible, to keep outside its 
 capsule. It is best to deal with the lower part first, securinfi 
 with double ligatures the external carotid artery and tt inporo- 
 facial vein. The mass is then drawn upwards and forwards, and 
 
AFFECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS 747 
 
 r course, and, in 
 
 made by the ust 
 
 i cancer, not un 
 
 and neighbouring 
 
 > from malignant 
 from a prognostic 
 inctly encapsuled, 
 s not a matter of 
 nuch more difluse, 
 lost impracticable, 
 by a consideration 
 e, attention bpint; 
 ; of the skin and 
 neoplasm, and tlie 
 ;d paralysis of the 
 malignancy. The 
 "otid, when invaded 
 some intrabuccal 
 I our, but are recog- 
 
 difficulty, owing to 
 
 tissues. Removrd 
 
 :tensively involved, 
 
 ^, and if there is no 
 
 tum'ours become 
 
 ep connections and 
 
 touch malignant 
 
 mination. Siinfi 
 
 aking a vertical 
 
 lass, or by turning 
 
 which is incised 
 
 generally beneath 
 
 in its substance. 
 
 often enucleated 
 
 make certain that 
 
 1 certainly ensue. 
 
 1 other arteries is 
 
 remove redundant 
 
 m 
 
 )r 
 
 its deep connections severed. The facial nerve is, of course, 
 divided, and the patient must be warned before the operation of 
 the necessarily resulting facial palsy. Recurrence is almost certain 
 to follow. Removal of the angle of the jaw as a preliminary step 
 has been recommended, since considerable space is gained thereby, 
 and a better access to the field of operation. 
 
 Tumours of the Submaxillary Gland are very similar in nature 
 to those of the parotid. Simple tumours are represented by 
 (hondromata, which in this position are almost always pure and 
 without admixture of myxoma (Fig. 267). Sarcoma and car- 
 cinoma are also met witla ; if seen in the early stages they are 
 easily removed. 
 
 Salivary Fistula occurs almost solely in connection with the 
 parotid gland. It arises from penetrating wounds of the cheek 
 dividing Stenson's duct, or more 
 frequently it follows operations 
 in its neighbourhood. It is a 
 very troublesome condition, both 
 for the surgeon who is called 
 upon to treat it, and for the 
 patient who suffers from the 
 inconvenience of saliva flowing 
 down the cheek, the amount 
 heing, of course, increased at 
 meal-times. Stenson's duct ex- 
 tends forwards from the socia 
 parotidis across the masseter 
 muscle for a distance of about 
 2 inches, and then turns abruptly 
 inwards to pierce the buccinator, 
 and enter the mouth opposite the 
 second upper molar tooth. The 
 buccal and masseteric portions 
 are almost at right angles, the 
 
 latter being represented by a line drawn from the lobule of the 
 ear to a point midway between the ala nasi and the angle of the 
 mouth. The diameter of the duct is about one-eighth of an inch, 
 its narrowest portion being at the orifice. 
 
 Treatment. ^ — If the buccal portion is involved, a cure is often 
 attained by slitting up the duct within the mouth ; but when the 
 masseteric portion is wounded, and especially if near the socia 
 parotidis, treatment becomes more difficult. We ha\e several 
 times found the following plan successful : A fine probe is passed 
 along the duct from the mouth as far as the lesion ; it is then 
 grasped by forceps inserted through the external aperture, and 
 drawn out "on to the cheek, a proceeding sometimes facilitated by 
 i^lightly enlarging the wound. A double thread of silk is now- 
 tied to the end of the probe, and drawn through the thickness of 
 
 Fig. 267. 
 
 -SUUMA.XILLAKV 
 (TiLLMANNS.) 
 
 Tc.MOUK. 
 
748 
 
 A MANUAL OF SURGERY 
 
 the clieek, along the buccal portion of the duct, and out of the 
 external wound. A fine drainage-tube is then carried along ihc 
 same track, and left so as to project both externally and intern.-ilK, 
 A silk thread is attached to each end of the tube, and these are 
 knotted together round the angle of the mouth. By this means 
 a passage is re-established into the mouth, and as soon as i: 
 becomes easier for the saliva to travel along this than along the 
 external wound, the fistula will close. At the end of a few days 
 the outer half of the tube is removed, and only a silk thread 
 allowed to occupy the outer portion of the fistula, which gradually 
 contracts so that more and more of the saliva finds its way into 
 the mouth. The silk thread and tube are then finally removed, 
 and if the opening in the mouth is kept patent, the external wound 
 soon heals. In those cases where the buccal portion of the duct 
 is completely obliterated or obstructed so that a probe cannot lie 
 passed, a trocar and cannula are inserted through the external 
 wound and cheek into the mouth ; a silk thread is insiniiatid 
 through the cannula, and a tube drawn into position, as in the 
 former case. The subsequent treatment is the same as that 
 indicated above. 
 
 \AflFection8 of the Palate/ 
 
 Cleft Palate.— By cleft palate is meant a congenital defect of 
 the roof of the mouth, whereby the structures entering into its 
 
 A B C 
 
 Fig. 268. — Various Forms of Cleft Palate ; A, involving mekhlv the 
 
 VeLL'M ; B, TRAVERSING THE HaRD PaLATE AS FAR FORWARDS AS THE 
 
 Anterior Palatine Canal; and C.heing Complicated with a Poiiue 
 Hare-lip. 
 
 formation do not unite in the middle line, thus allowing; an 
 abnormal communication to exist between the nose and mcuth. 
 The term does not include losses of substance, resulting from 
 
AFFFXTIONS OF THE MOUTH, THROAT, AND CE SOPH AG US 749 
 
 injury, syphilis, or lupus. The cleft usually starts [losteriorly, 
 and extends forwards for a \ariable distance, althouj^di it has 
 been known to be limited to the anterior portion of the jialate 
 and bony alveolus, but only in exceedinj^dy rare instances. The 
 mildest cases consist merely of a bifid u\ula, perhaps not involvinf^^ 
 tlie palate at all ; the next dejjfree of severity affects the \elum 
 alone ; more or less of the hard palate may also be implicated, 
 the cleft reaching as far forwards as the site of the anterior palatine 
 canal (Fig. 268, B) ; whilst the severest type of the deformity 
 extends in addition through the alveolus and upper lip on one or 
 lioth sides, the os incisivum being in the latter case displaced 
 forwards, perhaps on the tip of the nose (Fig. 268, C). 
 
 On looking carefully at a cleft palate the defect usually appears 
 to be mesial, but occasionally it seems as if a unilateral or 
 jiilateral fissure existed. To understand such an occurrence it 
 
 A B C 
 
 Fig. 269. — Diagram to Show the MoniFicATiONS of Clkft Palate. 
 
 (r, Etlimo-vomerine septum : b, palatal segments ; c, tongue ; d, cavity 
 of the nose ; c, buccal cavity. 
 
 must he remembered that three bony processes unite in the 
 middle line of the roof of the mouth, viz., the two palatal pro- 
 cesses growing in horizontally from the maxilla', one on each side, 
 and the ethmo-vomerine septum projecting vertically downwards 
 from the under surface of the fronto-nasal process and base of the 
 skull. All these should amicably join together about the ninth 
 or tenth week of intra-uterine life. If, however, the palatal pro- 
 cesses fail to reach the middle line, a median defect appears 
 iFi<(. 26cj, A), unless the ethmo-vomerine septum be so hyper- 
 trophied as to project between them, when the appearance of a 
 double cleft is produced (Fig. 269, B). When one division of 
 the palate unites with the mesial septum, the other failing to 
 reach it, an apparently unilateral cleft results ; most commonly 
 the defect is on the left side, the vomer being attached to the 
 n,!,dn free edge, a left-sided aheolar harelip also complicating 
 the case (Fig. 269, C). The reason why the anterior portion of 
 tile palate is so rarely affected without the posterior part being 
 
750 
 
 A MANUAL OF SURGERY 
 
 also involved is that the union of the various segments progresses 
 from before backwards. 
 
 The Ji'idth of the cleft and the slope of the segments \;irie^ 
 greatly in different cases. The wider the cleft, the more im 
 favourable it is for treatment by operative means ; and this is imc 
 of the arguments used in favour of the removal of the internuixilla 
 in cases of double harelip, so as to allow of the approximation o; 
 the two maxilla,'. Re»no\e it, they fall naturally together ; leave 
 it, and they are wedged permanently apart. As to the slope o\ 
 the segments, the more vertical they are, the more favourable tor 
 operation, since the flaps of muco-periosteum easily meet iti the 
 middle line. When the palate is more horizontal, and like a 
 Norman rather than a Gothic arch, the Haps are shorter, and 
 greater lateral displacement is necessary to bring their edges iiitu 
 apposition ; this involves much more traction on the stitches, and 
 hence less satisfactory results. 
 
 The effect of such a deformity upon the infant, from a physio 
 logical point of view, is very serious. The process of mttvitm is 
 considerably impaired, owing to the fact that the power of suctiun 
 is lost, and fluids taken into the mouth are apt to escape throuj;!] 
 the nostrils instead of being swallowed. Consequently these 
 children must be carefully spoon-fed with the head thrown well 
 back, otherwise they become emaciated and succumb to inanition | 
 or intercurrent maladies. If they grow up, articulation becomes so 
 indistinct that it is often impossible to understand what tiiey sav, 
 the voice having a peculiar and characteristic intonation. All the i 
 letters know'n as explosives, whether dentals, labials, or gutturals, 
 requiring a certain amount of air-pressure within the mouth for 
 their due pronunciation, are difficult to proc ace, particularly i, i, 
 /*) if gi /» etc. Moreover, the exposure of the nasal mucous mem 
 brane to the air is so much greater than usual that it is liable to i 
 catarrhal inflammation, resulting in the formation of scabs which 
 undergo putrefactive changes and lead to a sort of ozaena. Both 
 taste and smell are much diminished, partly from the unhealthy 
 state of the mucous membrane, and also from the absence of an 
 opposing surface against which the food can be triturated by the 
 tongue. The moral effect of this deformity, particularly when 
 associated with hare-lip, is such as to cause such patients to shun j 
 publicity from a nervous feeling of self-consciousness. 
 
 As to the best period at which to interfere by operation, con- 
 siderable divergence of opinion exists. Some surgeons advocate! 
 its performance at as early a date as possible, and, in fact, it has I 
 been undertaken when the child was but a few days old. The! 
 success attending such practice has not been gratifying, since! 
 infants have no moral control, and are much more likely to suckj 
 at the stitches and interfere with them by the tongue, whilst thej 
 buccal cavity is small, and the tissues so delicate and friable.! 
 that the difficulty of the operation is much increased. On the] 
 
AFFECTIONS OF THF MOUTH, THROAT, AND G-SOPIIAGUS 751 
 
 nients prof^resses 
 
 other liand, it should not he tleferred too \ou\i, ; biid habits of 
 articulation will be contracted, and subsecjuent physiological 
 success, as gauged by the quality of the speech, is nuich less 
 likely to follow. After an extended experience, it may be stated 
 that the operation is best undertaken between the second and the 
 third years, when a child can be easily kept under control. It is 
 most important that the general health be good, and the niou 1 
 and throat free from Iccal disease or intlamuiation. To guard 
 a^'ainst accidents it is well to make a routine practice of keeping 
 a child under observation indoors for a f^w days before operating, 
 whilst for choice the spring or summer should be selected. If 
 the tonsils are enlarged, as is not uncommonly the case, it is by 
 no means necessary to remove them if no active inflammation is 
 present ; pharyngeal adenoids, moreover, may sometimes be left 
 with advantage, as they subsequently assist in shutting off the 
 nasal cavity during speech. 
 
 Operation. — The child should be placed on a suitable table 
 witli a moveable headpiece, if possible, as it is often necessary to 
 alter tlie position of the head during the proceedings. The arms 
 are fixed to the sides by attaching them to a strap or bandage 
 passed round the thighs below the trochanters, but the patient 
 should not be tied down to the table, so that, although he cannot 
 raise the hands to the mouth during the partial anaesthesia which 
 is often present, yet he can be turned easily to either side so as to 
 allow blood to run from the mouth. Anaesthesia is induced in 
 the ordinary way by chloroform dropped upon the corner of a 
 towel. The greatest care must be taken not to drop chloroform 
 into the mouth, and for the same reason Junker's apparatus is 
 undesirable, on account of the chloroform vapour irritating the 
 edges of the cleft. The mouth is efficiently gagged open, and 
 preferably by means of a unilateral instrument, which can easily 
 he slipped in or out of position. 
 
 In a case involving both the soft and hard palate there is no 
 reason why the whole cleft should not be dealt with at one sitting. 
 When the inter-maxillary bone has been previously removed, and 
 a considerable gap left anteriorly, it is often only possible to 
 close the posterior two-thirds of the cleft, either dealing with the 
 anterior portion at a later date, or trusting to the application 
 of a suitable obturator, to which artificial incisors can also be 
 attached. The proceeding now employed is practically identical 
 with that introduced by Langenbeck, and known as uranoplasty. 
 For convenience it may be described in four stages : 
 
 Stage 1. : Incision and Detachment of Muco-periosteal Flaps. — The 
 knife should be inserted close to the last molar tooth and about 
 half an inch from the alveolar margin, and carried forwards 
 parallel to the teeth to a spot just anterior to the apex of the 
 cleft; or if the alveolus is involved, the incision should stop 
 hehind the lateral incisor to preserve the vascular supply of the 
 
752 
 
 A MANUAL OF SURGERY 
 
 front of the llap (IM}^^ ^7t')- TIh' imico-periostt'iim is divided 
 down lo the bone, and by tlic usv of n suitable raspatory tlu 
 soft structures of the palate are strippi'd up towards the niiddli 
 line, until the point of the instrument is seen protruilin;,^ into 
 tlie cleft, (ireat care; is ni'cded in dealinj? with the hinder pan 
 to ensure its total detaehiuent from the hamular process and 
 back of the bony palate, and yet not to dania^a- it at this, its 
 weakest spot, 'i'his must be thoroughly carried out on ciihei 
 side, the extent of the incisions being shown by the contiiuums 
 black lini'S in I'ig. 270. Copious bleeding always acconipaniiv 
 this stage of the operation, and the head should be turned 011 oik 
 
 Fig. 270. — DiACKAM to Inticatk Extent ok Incisions in Uranoplasty 
 
 The thick black lines show the prim.iry incision ; the thick clotted lines the 
 extension backwards of the same to relieve any lateral tension: the thin 
 dotted linos indicate approximately the piosition of the free border of tlu 
 bony palate. The rii,'ht-hand lignre shows tht: position of the sutures, an I 
 the condition of the parts at the close of the operation. 
 
 side and lowered, and the pharynx constantly sponged so as to 
 prevent the blood entering the air-passages. 
 
 Stage II. : Paring the Edges of the Cleft. — This is accoinplislieil 
 by grasping the base of the uvula with a suitable pair of anf,'ular 
 catch-forceps. Thus steadied and held, a thin paring can be 
 removed, in one piece, if possible, on the side seized, and the same 
 process repeated on the oth( I arir g of the edges is pur- 
 
 posely deferred until a' ' _• niucu- periosteal flaps have ken 
 
 oned edge- do not thus get bruised 
 
 sponge ; n. cover, the bevel at which 
 
 can 1 • more accurately estimated when 
 
 rd. 
 
 detached, because th 
 by the frequent use o 
 the edges sliould be pa 1 
 the flaps have been loosci 
 
 Stage III. 
 
 Passage and Tighicniiig of Sutures. — The simplest plan 
 
riostcuin is divide 
 Uihic r;isp;it()i V tin 
 
 towards the middle 
 yii protriidiiiw i„tn 
 itii the hiiulcr pan 
 imilar process and 
 i.'iK^' it at this, its 
 tried out on citli,., 
 
 I'y the eoiitiiUKiiiN 
 Iways accoin[)uni(> 
 Id be turned nii ,,n, 
 
 ■Js IN Uranoplastv 
 
 hick (lotted lines tkt- 
 ral tension ; the lliin 
 lie free border of the 
 yn of the sutures, aiil 
 n. 
 
 sponged so as to 
 
 :s is acconiplislietl 
 le pair of an^'ular 
 1 paring can be 
 ied, and the same 
 the edges is pur- 
 flaps ha\e beer. 
 thus get i)riiisetl 
 le bevel at which 
 y estimated when 
 
 ^he simplest plan 
 
 Un 
 
 AFFECTION, OF TUH mUTI! TlIRn rr \ 
 
 t"''i«l"Pt IS that known -is fh« . i ~ " 
 
 ""I it is carried o rV. r m ^''''^' '"^'"'"^l ' of Sir \\ v 
 
 -•" '^ suitable cu ve .md I "'^^ {^ ^''^^-^-^^^^^A^^:^^^Tu' 
 
 ^vf'itesilk, is passed t.'?;^''^'^' ^^''^'' ''^''out r.S id,' '-■;';''« 
 
 'l>e cleft at an ex- K ''"'P«-'^ 'nserted thn^^'h t ' L ' •"'''^''•' ''^ 
 
 l'""R inserted ^,„\MX*°f ' « ""„., ,, ,^"^'^^-^3' ' <l ^i'm-l 
 
 '«. Hit. ends hei,,,, |,e|,l 1,^ Tl "''°''- P'''""^^- Tliev i?,^ If? 
 
 i'k ciieelfs unlil -,11 l,., ^ "'" ana'stlietist iir -i^^k, -^ .ire left 
 
 "*■"-■"«". 'i? w^: H" '"-^"'"i- -^ '>-inc w; ■;t;";i' 
 
 ,»»■> ">t" posieio,, by the siik H "J"''^ ''"^ed <,ver each I, n 
 "encin-,!,u '"^ Pf^^^ through both fWf> '' ''''"•" »" the 
 
 4« 
 
754 
 
 A MANUAL OF SURGERY 
 
 four. Milk and water, ^iven by a spoon oi from a feeder, will totm 
 the staple article of diet. By about the fifth day soft food, siuli 
 as soaked bread and custard pudding, may be safely given. 'W 
 patients are generally allowed up on the sixth day. The silvd 
 stitches may be left in for ten days or a fortnight witlujut doin- 
 any harm. 
 
 In dealing with clefts of the soft palate alone, a modification of 
 the abo\e operation may be performed, called staphyloiri\pk\. 
 The edges are fust pared, lateral incisions are then nuide to dividt 
 the levatores palati, and the stitches finally passed and tied. 
 
 Results. — In every case it is possible that articulation will m, 
 if anything, impaired as the immediate result of the opcratinn. 
 since the mechanism which the patient ordinarily employs i>j 
 thrown out of gear ; subsefjuent education at the hands of a voice 
 trainer is absolutely essential in order to correct this. I'^xcii tbfflj 
 the unpleasant articulation occasionally persists, owing to tlnj 
 patient being unable to draw up the velum so as to closv the 
 posterior nares ; this is due to a reduction of the depth of the sof;| 
 palate owing to the traction required to close the cleft. In spiti 
 of this, however, the operation is most beneficial in that it shut< 
 off the nose from the mouth, pre\ents the dropping of i;.uciis. 
 improxes the sense of taste, and adds greatly to the ^^enml 
 comfort of the patient. 
 
 Mechanical Treatment of clefts in the pulatr l)y means of oljturatcrscj 
 artificial vela is still advocated by some surgeons aiul dentists in prikance i 
 any operative interference. An (i/'/wcd/nr consists of an adjustable plate nrpl,;?| 
 fitted to and closing an aperture in the h.aril palate. It may be used wiiij 
 advantage in perforations due to traumatism or syphilis, and in ajvi lures lelif 
 after operations in whicli portions of tiie palate are removed, such • . ('\ci-; 
 of tile superior maxilla. In cases of double hare-lip and cleft pal ite, wiitfel 
 the OS incisi\ um has been extirpated, an aperture is often left anteriorly \vli:cl 
 cannot be satisfactorily closed except by an obturator, which also serves loj 
 carry the necessary artificial incisors, anil may ha\e clieei< plates attadied lol 
 push forwards the upper lip. For wliatever purpose an obturator is lueiltiil 
 it should never take the form of a closely-fitting jilug, which, by its cdiMartl 
 pressure and irritation, causes the aperture to become enlarged, but al\v;i\-iliai| 
 of a plate, either of thin \ulcanite or gold, whicli can be fixed to the tc'etii.arij 
 maintained in position by suction. It is sometimes found, however, that iiq 
 addition of an intrautasal projection to the upper surface of the plate impnie 
 the articulation by diminishing the size of the nasal cavity An tiitijicuiiui'M 
 consists of a plate obturator, to wliich is attached posteriorly a mnveabia 
 segment to take the place of the normal velum. Such consists (itlierfi 
 hinged metal plate, resting on the nasal siile of the segments nf tlie *« 
 palate, and moved by them, or of a thin indi.arubber bag filled witii an, -e«J| 
 to the back of the obturator. They are very complicateil and diHicuit tokefi 
 in order, and, to our minds, the results of operative interference are inliniifl]j 
 superior. 
 
 Ulceration of the Palate occurs in a variety of foiiiis, ^ 
 
 (a) simple, as an accompaniment of general stomatitis : (/') s)flnhtiit 
 which may involve either the hard or soft palate ; if supcrticialij 
 is usually a late secondary phenomenon; if deep it involves tr 
 
AFIECTIONS OF THE MOUTH, THROAT, AND OLSOPHAGUS 755 
 
 feeder, will form 
 ,y soft food, sudi 
 ifely ^'iven. 'I'll.- 
 day. 'I'liL- silver 
 ht without (Idiiv^ 
 
 a niodiiication of 
 Lid stnphyUnriipli). 
 en tiijule to diviiV 
 ed and tit-d. 
 ticuhition will In. 
 
 of tlic op(;talioii. 
 narily employs i^ 
 i hands of :i voict- 
 t this. V.wn tbffl 
 sts, owin^ to llicl 
 so as to close the 
 le depth of thf soft | 
 the cleft. Inspitf 
 ial in thai il slui!<| 
 roppinjj; of i-ucus 
 tly to the L^eiU'ral 
 
 lieans of ()litui;U(i> ^r 
 u.nists in picl'TciKi; L 
 adjustable plati' or pkil 
 I It may be used withl 
 s, and in ap-i lures kitj 
 Lived, such :v; excbiftl 
 Liul cleft pal.ile, wlwel 
 •nleft anterinily v\li;il 
 I- which alsc serves wl 
 Leek plates attached lol 
 tn (>bturat(u- is neeiW.I 
 which, by its cciwastl 
 ilarged,bui;ihv;i\>ilil 
 L- fixed to the teeth, aril 
 lund, however, tliattlif 
 e of the plate impri'va^ 
 '■itv An.iif//irw/;"« 
 posteriorly a moveabij 
 :h consists cither 'if 
 segments of the *^ 
 ,u_ filled with M\.^n 
 icilanddilfKultt"k«l 
 lerference are intimifl 
 
 [iety of foniis, i-i\ 
 latitis : (/') sj//"'f 
 Ite ; if superticial. 
 [eep: it involves tw 
 
 bones, and often leads to necrosis, and is then due to tertiary 
 iniscliief : {c) lupoid, a somewhat uncommon condition, which may 
 result in j^reat destruction of tissue ; it is usually seen in children, 
 and often associated with a similar disease of the nose, from 
 which, indeed, it may have spread : {d) tubennlous, due to the 
 lireakin},^ down of a tuberculous abscess imder the periosteum, and 
 thtii complicated with caries of the bony palate : {c) iiialii^iittnt, 
 usuallv resultinf.; from the j^rowth of epithelioma, either startinf; 
 iriniarily in the palatal mucous membrane, or extending to it 
 from the tongue, tonsil, or upper jaw. 
 
 Acquired Perforations of the Palate, though occasiijnally caused 
 bv traumatism or lupus, are in almost all cases due to tertiary 
 svphilis. The ethmo- vomerine septum is often involved in the 
 dtstriKtive process, giving rise to a most ofTensive discharge from 
 the nose. If the soft palate is alone afTected, the velum may 
 lieconio fixed by cicatricial adhesions to the back of the pharynx, 
 unci pharyngeal stenosis or considerable loss of substance of the 
 vcliiiii results, A nasal intonation of the voice is always caused 
 hv any condition wliich interferes with the closure of the naso- 
 pharynx by the velimi during articulation. 'J'he treatiuent of these 
 condiiions should follow the usual antisyphilitic course. Perfora- 
 tions ate best remedied by the use of plate obturators. We have 
 ~et'n out-patients make efficient obturators out of a piece of sheet 
 indiariihber maintained in situ by suction, or of two pieces stitched 
 t();,'etlu'r in the middle, one piece passing above and the other 
 below the opening. Occasionally when the aperture is small, 
 the local disease soundly ciued, aiul the general health good, an 
 attempt may be made to close it by stripping up muco-periosteal 
 ll:ips, paring the edges and suturing them together. The results 
 are, however, seldom satisfactory. 
 
 .\ny of the ordinary forms of inflannnation of bone may be 
 
 met with in the hard palate. Necrosis is usually due to tertiary 
 
 ."•philis, or may accompany acute subperiosteal suppuration, 
 
 extending from an alveolar abscess. In either case the surgeon 
 
 must wait till the se(iuestrum is loose, and then it may be 
 
 removed. Caries is generally due to syphilis or tubercle. 
 
 The following tumours occur on the hard palate. Simple epulis 
 
 p. 6()6) may extend from the alveolus, or an identical condition 
 
 [may start in the middle line. An adenoma of the palatal glands 
 
 s occasionally met with. It presents as a smooth or papillated 
 
 iniuiur, somewhat resembling epithelioma, but distinguished from 
 
 it by its slower rate of growth, and the absence of ulceration, 
 
 in, or of glandular enlargement. An operation limited tt; the 
 
 •It parts is probably all that is necessary. Sarcoma may be 
 
 'finiary. .uul is then often myxo-sarcomatous in type, or secondary. 
 
 n the former case it simulates rather closely a diflfuse alveolar 
 
 ibscess, but is recognised by its slower growth, less pain, absence 
 
 intlaimnation, and, if need be, by the results of an exploratory 
 
 48—2 
 
756 
 
 A MANUAL OF SURGERY 
 
 puncture. Epithelioma also occurs, but is uncommon. Treatment 
 for the two latter conditions, if limited to the palate, would (onsisi 
 in partial removal of the affected superior maxilla. 
 
 Elongation of the Uvula is frecjuently the result of a chronic 
 relaxed throat. At iirst it merely lasts for a time, and hy the 
 use of astringents disappears ; but later on the elongation becomes 
 chronic, and causes great irritation of the back of the tonLfue and 
 fauces, resulting in a troublesome throat-cough and even vomit- 
 ing. Under such circumstances it should be removed. y\liLi\veli 
 cocainizing the part, it is grasped by a pair of hook-forceps, which 
 seize not only the nuicous membrane, but also the inuscular 
 structures beneath, and a sufficient amount is then renuned !iy 
 snipping it across near the base with a pair of blunt-pointed 
 scissors, leaving about a third of an inch of the organ behind. 
 
 Affections of the Tonsils. 
 
 Acute Tonsillitis results either from cold, or from the inhahition 
 of impure air, especially when contaminated with sewer j^^as. \\ 
 is often seen amongst the residents in liospitals (hospital tliroiit, 
 and may precede an attack of acute rheumatism. Three varietib 
 are described : 
 
 [a) Acute superficial tonsillitis, which consists of a slight super , 
 licial inflammation, the result of cold, etc., in which tlie tonsil j 
 participates with the pharynx and velum. There is hut little 
 swelling of tlie part, which, however, becomes red and painful,] 
 rendering swallowing difficult. Ordinary anti-catarrhal remedies 
 are necessary, and a chlorate of potash gargle. 
 
 {b) Acute folliculay tonsillitis is characterized by a general en| 
 largement of the organ, which is dusky red in colour and painful, i 
 causing obstruction to both breathing and swallowing, the timsik 
 perhaps, almost meeting in the middle line. There is a good deal I 
 of yellow patchy exudation from the follicles, which may coa;,Hilatcj 
 on the surface and form a false membrane, distinguished froirJ 
 that of diphtheria by its want of adhesion to the suhjaceKJ 
 tissue, being readily detached by a camel's-hair pencil. 
 temperature is high, the glands below the angle of the jaii| 
 enlarged and tender, the tongue covered with a thick whitisli 
 and the bowels confmed. Such a condition may herald in arj 
 attack of so-called blood-poisoning, or septicamiia. 
 
 ((•) Acute parenchymatous tonsillitis, or quinsy, is a mcMC ditl 
 inllanniiation, which is not limited to the organ, but also invuhesj 
 the soft palate and fauces. The swelling is more ('\tensiK;,| 
 the pain is greater, and suppuration frecjuently results. OtlieJ 
 symptoms are much the same as in the above. 
 
 The Diagnosis must be made from scarlet fever by the ahsfncfj 
 of the characteristic rash and red tongue of the latter condilioil 
 and by the redness being more dusky and less diffuse in tonsil! 
 
AFl'ECTIONS OF THE MOUTH, THROAT, AND CESOPHAGUS 757 
 
 From erysipelas of the fames, it is known by the redness beinj; 
 more ccjncentrated, the a:demH less marked and more Hmited, by 
 the glands at the anj^de of the jaw being less enlarj^ed, and by the 
 absence of any external manifestation of the disease. 
 
 Treatment must always be commenced by a good calomel purge, 
 whicli may be followed by the administration either of salicylate 
 of soda (20 grains, thrice daily), or of chlorate of potash and 
 sulphate of magnesia, to which a few drops of tincture of aconite 
 may be added if the constitutional symptoms are severe. The 
 patient will experience much relief by inhaling the steam from hot 
 water (150° F.), in which a little creasote or carbolic acid is dis- 
 solved, or the tonsils may be scariiied. Suppuration is dealt with 
 1)\ a free incision, the knife entering the most prominent part of the 
 swelling, and cutting backwards towards the middle line ; the; close 
 proximity of the carotid should not, however, be forgotten. Hot 
 ilanneis or fomentations may be applied to the neck and throat, 
 and plenty of fluid nourishment administered. This is followed 
 as soon as possible by iron, bark, and other tonics. 
 Chronic Tonsillitis appears in two distinct forms : 
 ((() Chronic inflammatory tonsillitis occurs in children whose 
 tonsils, after one acute attack, remain enlarged, painful, con- 
 i;ested, and very liable to recurrence, which often runs on to 
 suppuration and ulceration. After a time the tonsils shrink back 
 and atropliy, ])ecoming hard and fibroid. 
 
 (/i) Chronic hypertrophic tonsillitis is met with in tuberculous 
 I children, resuUing from an overgrowth of the lymphoid tissue, 
 land is usually associated with the presence of adenoids in the 
 naso-pharynx. The tonsils are enlarged, pale in colour, and firm 
 inconsistence; the orifices of the crypts are very patent, and in 
 them are often seen plugs of mucous secretion, which may 
 [litcome infiltrated with lime salts, forming concretions, which 
 Ihowever, are never of any great size. The patients are very 
 Ihble to recurrent attacks of inflanuiiation, with or without 
 Isuppuration, and even cysts may form from the l)locking of the 
 Ifollicular ducts. When much enlarged, the tonsils may meet in 
 lit' middle line beneath the uvula, causing obstruction both to 
 iswallowing and respiration. The patient usually breathes with 
 Itht. iiioutli open, owing to the concurrent naso-pharyngeal obstruc- 
 tion, ami from the same cause speaks thickly, as if he had some 
 House body in the mouth, and necessarily snores during sleep. 
 itaring is often interfered with from the mucous lining of the 
 -ustac hian tube becoming thickened and inflamed. 
 
 Ilic Treatment of these cases consists in first attending to con- 
 itiuitional weakness by removal of the peitient to fresh or seaside 
 lii. and by the administration of iron and cod-liver oil; at the 
 anif time the throat should be painted twice a day with glycerine 
 p tannic acid, or with equal parts of glycerine and tinct. ferri per- 
 [hloridi, or touched with the galvano-cautery. Failing this, ton- 
 
75S 
 
 A MANUAL OF SURGERY 
 
 sillotomy should be performed ; in children the organ may he cut 
 away as far back as possible, but in patients over the age of Iw entv 
 only a thin slice should be removed, and never the whole oigaii, 
 since there is much more risk of grave haMiiorrhage ; the gahaiio 
 cautery is much better treatment in adults. It has also Ihth 
 suggested that the voice is weakened by tonsillotomy, but thisi^ 
 somewhat doubtful. 
 
 Tousillotomy may be undertaken in two ways : 
 
 {a) By the (guillotine. The fauces having been carefully anJ 
 repeatedly brushed with a 5 per cent, solution of cocaiiu', the 
 mouth is opened and one of the many forms of tonsil guillotine 
 introduced ; Mackenzie's spade guillotine is as good as anv, 
 The ring of the instrument is passed over the projecting orjjan, 
 external pressure behind the angle of the jaw assisting in thi^ 
 mand'uvre. By the pressure of the thumb the projecting mass is 
 cut off by the sharp blade. In dealing with the right side, unless 
 the surgeon is ambidextrous, he had better stand behind the 
 patient's head, looking over into the mouth. 
 
 (b) By the bistouyy. The tonsil is seized at its lowest point and 
 drawn well inwards by means of hooked forceps, and the pr 1 
 jecting mass removed by a straight blunt-pointed bistoury, tht 
 base of the blade being guarded, if preferred, by a piece of plastt: 
 wrapped round it. The incision should be made from hekwl 
 upwards, and the edge of the knife kept rather in than oui, so as 
 to a\oid all risk of wounding the internal carotid, which is inchw 
 contiguity to the outer surface of the gland. The surgeon iiiii:| 
 stand beliind the patient's head in dealing with the right side, aniil 
 in front when operating upon the left. Care nuist be taken : 
 include the lowest portion of the tonsil, which often han,L;s do«r. 
 into the piiarynx, and is liable to be left behind. 
 
 The ha'morrhage, though brisk for the moment, soon (eases it 
 care is taken not to cut too deeply, or encroach upon the sur- 
 rounding nuicous membrane. Should tiie bleeding coiilimiu, :| 
 can generally be arrested by the use of ice or the applieatioii 
 wool pledgets soaked in tinct. ferri perchloridi ; possibly a garsiei 
 containing hazeline may be efificacious in bad cases, or the t^^alvaii' 
 cautery may be applied. This is more likely to occur in aciiilisj 
 than in children. 
 
 Syphilitic Disease of the Tonsil is met with in various sia;;6J 
 The prituary chancye is seen occasionally, arising in one case we| 
 know of through infection from a stick of caustic which h 
 l>een previously used to cauterize a syphilitic ulcer and iibuij 
 ficiently cleaned before being applied to the tonsil, the surlact 
 which was abraded. The glandular enlargement in the neclii 
 very marked in such cases, and the course of the disease usikiI. 
 severe. Secondary ulcers of the 'snail-track' type {plaques iiniijuo'^ 
 are common in this region, being usually symmetrical. 1" ^ 
 
AFIECTIONS OF THE MOUTH, THROAT, AND UiSOPHAGVS 759 
 
 •rgan may W cut 
 the age of Iwcnly 
 the whole or^an, 
 ige ; the galvanic 
 It has also bmi 
 )tomy, but this is 
 
 ;en carefully and 
 
 n of cocaine, the 
 
 )f tonsil guillotine 
 
 as good as any. 
 
 projecting i^r^an, 
 
 V assisting in tbb 
 
 projecting niai-s is 
 
 e right side, unless 
 
 stand behind the 
 
 s lowest point and 
 ceps, and tlir pr i 
 inted bistoury, the 
 ,y a piece of plaster 
 made from bekw 
 r in than out, soasj 
 id, which is in cl 
 The surgeon nui-;| 
 the right side, and j 
 ; nuist be taken ii 
 often han:4s clo\\r.| 
 
 Inent, soon ceases i 
 xich upon the sv,:| 
 leeding ctnuinue. 
 the application 
 ; possibly a gamlel 
 Ues, or the iiaUan-J 
 to occur in iulults| 
 
 ii in various staijt^l 
 ling in one casewe| 
 1 caustic which ha 
 Jc ulcer and ui>ul] 
 lonsil, the surface o| 
 lent in the necki 
 1 the disease usiw 
 Le {pUiq»(^ mnqnmA 
 Immetrical. 1" '1 
 
 tertiary period a diffuse giuuDiatoia, infiltyatioii occurs, in\olving also 
 the palate and fauces (p. 761), and leading to pharyngeal stenosis. 
 
 Tumours of the Tonsil are almost always malignant in type, but 
 are not very common. Epithelioma occurs as a firm indurated 
 infiltration rapidly spreading to adjacent parts, and invohing the 
 lymphatic glands. It generally starts either in the root of the 
 t()ni,nie or in the pillars of the fauces, and presents a ragged 
 ulcerated surface with a hard margin and sloughing base. It runs 
 a rapidly fatal course if left to itself. Lyitipho-sarcoma of the tonsil 
 irises in the organ itself, usually after middle life; it presents a 
 >m' oth, dusky red appearance, the mucous membrane being 
 >tretched over it, and feels soft and almost fluctuating. In the 
 early stages it may be freely moxeable, but ere long it infiltrates 
 surrounding structures, and affects the neighbouring lymphatic 
 inlands. Round-celled savcoma also attacks the tonsil as a primary 
 i^rowth, and is less limited and defined than the former. In all 
 these varieties the growth extends into the pharynx, impeding 
 de},dutition and respiration, and ulceration with or without serious 
 hainorrhage may ensue ; indeed, the latter complication is a 
 tiv(]uent cause of the fatal result. 
 
 ;.'xtirpation of Malignant Tumours of the tonsil is often imprac- 
 ticable from the extent of the disease, and the early implication 
 if the surrounding structures, although it has now been shown 
 that they are more amenable to treatment than was formerly 
 thought to be the case. The disease may be dealt with in two 
 ways: [a) From the mouth in the case of the loosely encapsuled 
 i;uul freely mo\eable lympho-sarcomata. The capsule is dixidcd 
 preferably by a gahano-cautery, and the growth shelled out some- 
 I times with the utmost ease, and with very little lurmorrhage. 
 1 Recurrence in the lymphatic glands is, however, almost certain 
 ti) follow, (iy From the neck. The best plan is to make an incision 
 alonj,' the anterior border of the sterno-mastoid, and carefully 
 Idisbect down to the pharyngeal wall, removing all lymphatic 
 dands which are enlarged or suspicious, and securing the external 
 jcaroiid or its anterior branches. The mass is then isolated from 
 jthe surrounding structures and remo\ed. A good many cases 
 lliave now been reported which were treated in this manner with 
 jconiplete success, even when the tongue, palate, or pharynx were 
 jinvaded. It is occasionally necessary to make an incision from 
 jthe angle of the mouth backwards through the cheek ; the tonsil 
 lis thus well exposed, and can be dealt with satisfactorily. The 
 jpatient should always be inununized to streptococcal infection 
 iMore the operation. 
 
76o 
 
 A MANUAL OF SURGERY 
 
 Affections of the Pharynx. 
 
 Acute Pharyngitis is usually associated with a similar intlaiii 
 matory condition of the velum palati, nasal mucous menihiane, 
 and tonsils, and results from exposure to cold, from absorption ui 
 sewer <fas, and from general diseases of the exantheniatous type, 
 e.g., scarlet fever. It is characterized by redness, pain, ami 
 swellinff of the mucous membrane, which becomes covered with 
 nuicus or muco-pus. An irritable cough, with perhaps sneezinj;. 
 interference with nasal respiration, and great pain on swallowin:^ 
 are produced by this condition, and if it spreads to tlie Eustachian 
 tube temporary deafness is induced. Ulceration of the velun. 
 and fauces occasionally follows. 
 
 The Treatment consists in attending to the general condition, 
 especially if of exanthematous origin, and when due to catarrh, in 
 administering antiphlogistic remedies (e.g., purgatives, sud()i"ilic\ 
 and diuretics) and soothing local applications (e.g., ice to suck, 
 chlorate of potash gargle, etc.). Great relief is often gi\en by 
 inhaling steam from water at 150° F. to which a little I'riarV 
 balsam has been added. 
 
 Erysipelas of the Fauces and Palate has been already alluded t 
 (p. 86). 
 
 Chronic Pharyngitis is commonly met with in clergymen anJ 
 public speakers who are called upon to exert their voices for any 
 length of time, in costers and street-hawkers who shout their 
 wares, and in drinkers and smokers. It may commence as a j 
 chronic inilammation, or may follow an acute attack. The iniimb 
 membrane is more or less red and infiltrated, with vessels ct)Ui>in; 
 over it, and there is often a good deal of muco-purulent dischai);e. I 
 If the buccal side of the \elum palati is affected, there is usually 
 much less secretion than from the pharyngeal aspect, where ;■. 
 considerable amount of dark green viscid material may collect 
 and cling to the pharyngeal wall, constituting scabs, which may 
 decompose and cause the breath to be somewliat oflensix f. Twn 
 main varieties are described : 
 
 1. Chronic Folliculai' Pharyngitis, in which the lymphoid tollicle> 
 scattered throughout the mucous membrane become enl;n,i,'rt!. I 
 This is specially evident upon the soft palate, but is often j^Mcater 
 in amount upon the upper wall and sides of the pharynx, where 
 there is a mass of lymphoid tissue, sometimes known as thd 
 pharyngeal or Luschkn's tonsil {vide Adenoids, p. 724). Tlic uviil 
 may be also elongated and hypertrophic in this condition. 
 
 2. Chronic Atrophic Pharyngitis is usually associated with thcl 
 atrophic form of rhinitis sicca (p. 717), and possibly witli chionk 
 laryngitis. The mucous membrane is smooth, dry, and f^lazec. 
 and the exudation forms adherent scabs. The throat leels ilry| 
 and irritable, and the \oice is often husky. 
 
I similar in Ham 
 cous memlnane, 
 om absorption ui 
 tithematous type, 
 dness, pain, and 
 nies covered with 
 perliaps snee/.inj;. 
 in on swallowing,', 
 to the Eustachian 
 ion of the veluii. 
 
 general condition, 
 due to catarrh, in 
 
 natives, sudo^ilic^, 
 {e.g., ice to suck, 
 
 is often gi\en by 
 
 :h a little Vrm^ 
 
 already alluded i 
 
 in clergymen and 
 Iheir voices for any 
 who shout their 
 conunence as a 
 ick. The nuicoib 
 1 vessels coursin;; 
 nnulent dischai<.'e. 
 xl, there is usually 
 aspect, where ;•■ 
 erial may ct»llec;] 
 scabs, which may 
 It ofl'ensivt'. Iw^^ 
 
 lymphoid tolhcb 
 beconte ei\l;n-^'ei!. 
 )ut is often ^'te;Uer| 
 le pharynx, where 
 es known as tlie 
 
 724). Tlu' uvul;i| 
 Icondition. 
 Isociated with the I 
 Isibly witli .hiunic 
 [, dry, and ^^hizea 
 le throat feels dry| 
 
 AFFECTIONS OF THE MOUTH, THROAT, AND CE SOPH AG US 761 
 
 riic Treatment of chronic pharynj^ntis varies with the condition 
 and character of the affection. If of a simple type ('relaxed 
 throat'), all sources of irritation — such as smokinj,,', spirits, and 
 cdiidiincnts — nuist be avoided, the bowels and dij^^'stion attended 
 to. and astrin},'ent sprays, gargles or applications made use of, care 
 btin^' taken when necessary to apply these to the nasopharynx 
 by passing the brush up behind the soft palate. The most useful 
 rea^^ents to employ are the glycerine of tannic acid, e(]ual parts 
 ■if <,dycerine and tinct. ferri perchloridi, whilst chloride of am- 
 nioniuni inhalations are sometimes valuable, as also sprays of 
 nitiUhol dissohed in pan)leine. When the inflammation is of tlu 
 tillicular type, it may be further necessary to destroy the follicles 
 with the gahano-cautery after cocainizing the surface; eidarged 
 iind varicose \essels may be divided in the same way. In the 
 drv form of pharyngitis, inhalations of chloride of ammonium are 
 recommended, or chloride of annnonium lo/enges ; the nasal con- 
 dition, howexer, is that which most needs treatment. 
 
 Syphilitic Affections of the Pharynx may be met with in the 
 
 isntindary or tertiary stages. In the former they are of a super- 
 
 iticial character, such as mucous tubercles, snail-track ulcers, etc.; 
 
 in the latter they appear in the shape of a diffuse gummatous 
 
 I'miltnitioii, which is often of considerable conse(iuence, both at 
 
 [the time and subsecjuently. It manifests itself as a widespread 
 
 nodular thickening of the mucous membrane, especially in the 
 
 neii;hl)ourhood of the fauces and soft palate, which rapidlv runs 
 
 on to ulceration, and may impede both respiration and deglutition. 
 
 [The administration of mercury and iodide of potassium usually 
 
 Icaiises a rapid impro\ement, but the subsecjuent cicatrization may 
 
 jliind tlown the velum, and lead to pharyngeal stenosis of such 
 
 a (haracter as to constitute a fibro-cicatricial septum, with an 
 
 lopetiing through it perhaps only large enough to allow a small 
 
 |bim,i,ne 1.0 pass. For such a condition nuich may be done ; the 
 
 loptninL' may be more or less dilated by careful division of some 
 
 Id the hands and the passage of bougies ; and the soft palate can 
 
 jlvset free from the dorsum of the tongue. Of course there is t' 
 
 Igveat tendency for the opening to contract again, and treatment 
 
 |bv bougies must be persisted in. 
 
 A lociilizdi gumma may form in the subnmcous tissue, not 
 itieijuently in\olving the posterior pharyngeal wall, and running 
 JtMircliiiary course with or without ulceration. 
 
 Tumours of the pharynx are rarely primary. They may extend 
 nto it, however, from siurounding parts, e.g., naso-pharyngeal 
 K'lypi arising from the base of the skull, or retro-pharyngeal 
 (riiwths from the spine. 
 
 Epithelioma either involves the pharynx primarily, or spreads to 
 It troin adjacent parts, such as the tongue or tonsil. Tlie usual 
 
762 
 
 A MANUAL OF SURGERY 
 
 type of tumour develops with some amount of ulceration ; lym- 
 phatic glands become secondarily affected, and the tumour '^iiu\\\. 
 ally invades surroundinff tissues, although it is interesting to note 
 that for some time it is limited to the mucous membrane, exteiulini; 
 superficially over it, but not in\olving the underlying pharyngeal 
 muscles. Death results from haemorrhage due to ulceration into 
 large vessels, from interference with swallowing or breathing, fniin 
 pressure on important nerves, or from general dissemination. 
 
 Treatment.— It is only within the last decade that any attempt 
 has been made to deal with these cases ; e\en now the mortality 
 is very higli, and statistics go to prove tliat if the opiratidii 
 involves removal of portions of the upper or lower jaw, ;i fatal 
 issue is likely to follow. The same precautions as to cleansiiii; 
 the teeth, immunization to streptococcal infection, etc., must W 
 taken, as in dealing with naso-pliaryngeal or buccal growths. A^ 
 a general rule, an incision along the anterior border of tlie steriin- 
 mastoid is the best to employ, although occasionally a second m,iv 
 be required, splitting the cheek towards the angle of tlic jaw. 
 The external carotid is tied, all glands are removed, and then tht: 
 growth is extirpated, partly from without, partly from within, 
 It is always advisable to perform a preliminary tracheotomy, ami 
 feeding must be undertaken for some days by means of a sloniac' 
 tube. 
 
 Retro-pharyngeal Abscess is acute or chronic in its course. Tlic 
 acute form results from infection through the mucous memhiaiit, 
 as by fishbones, etc. ; or arises from an inflammation of the 
 lymphatic glands which are foimd in this situation in chiklrti!, 
 but atrophy in adults, and derive their lymph from the inteiidi i! 
 the nose and naso-pharynx. The chronic variety generally follows j 
 tuberc'iloi's caries of tlie spine, or disease of the bones at the b;M 
 of the skull. Whether acute or chronic, uie abscess forms a tens;| 
 elastic swelling, situated behind the posterior pharyngeal wall; mi 
 the former case it is associated with high fever, and locally miicfcj 
 redness and inflammatory cedema, which may even extend to tic 
 glottis, and cause dyspna^i ; in the latter, where the affection!: 
 chronic, there is less local inflanmiatory reaction, but signs oil 
 cervical spinal disease are present. The abscess may burst intoj 
 the pharynx, or may burrow outwards on either side, being guiiW 
 by the pre-\ertebral fascia, and point either in front of or heliimij 
 the sterno-mastoid. 
 
 Treatment should nexer be delayed, from fear of the superveii ; 
 tion of ct;dema of the glottis. The abscess should be opened trcsij 
 the neck in all cases, as then an aseptic course can be niaintaiiifd 
 and there is no fear that the pus will enter the air-passage.s, H 
 pointing in front of the sterno-mastoid, the abscess is openaluj 
 that situation ; but otherwise an incision should be made ali 
 the posterior border of the muscle, which nmst be drawn forwards,! 
 
AFI-ECTIONS OF THE MOV^H, THROAT, AND (ESOPHAC.rs 763 
 
 ilceration ; lym- 
 B tumour ^MiuUi- 
 terestin^' to miU- 
 brane, extcndini; 
 ying pharyngLiil 
 o ulceration into 
 ir breathing;, from 
 semination, 
 that any atttiupi 
 low the nioitalitv 
 if the opivalioii 
 jwer jaw, u tat.il 
 s as to cleansiii:; 
 on, etc., nuist be 
 :cal growths. .\^ 
 rder of the slerim- 
 lally iv second may 
 an^'le of tlu' jaw, 
 3ved, and then the 
 wtly from within. 
 ' tracheotomy, ami 
 cans of a stonuic!. 
 
 in its course. Inc 
 nucous memhrane, 
 flammation of the 
 luation in cluKirni. 
 ■rom the inteTior -! 
 y generally follows 
 e bones at'tlu' ba-r 
 jscess forms a teiK 
 haryngeal wall ; ir. 
 , and locally miKS 
 even extend to the 
 ■re the affection M 
 .tion, but sijinsol 
 ■ess may burst into 
 side, bein^ j^uhI^ 
 front of or belmii 
 
 tvr of the supeiveii- 
 Uld be opened In-^l 
 can be maintained.] 
 le air-passai;es, 
 hscess is openeaiai 
 luld be made alonsl 
 Ihe drawn iox\v.vb\ 
 
 ;ind the transverse processes of the cervical vertebra' defined. 
 Possibly the abscess will be opened by the necessary manipulation 
 ,4 thr wound ; if not, the index-finger of the left hand should be 
 placed against the abscess wall in the mouth to guard it from 
 injiirv. and a pair of sinus forceps thrust into it in front of the 
 vertebra' by the right hand. A drain-tube is tht-n inserted, and 
 the case runs an ordinary aseptic course. 
 
 Affections of the (Esophagus. 
 
 Malformations of the cesophagus are congenital or acfpiireil. 
 
 A Congenital conununication may exist between the u-sophagus 
 iind trachea, either in the form of a stuall fistula, or the upper 
 end of the oesophagus ends blindly, whilst the lower end opens 
 into the trachea near its bifurcation. Life is impossible under 
 such conditions, and the children die shortly after birth. Con- 
 ),'enital stricture may also be met with near the cardiac orifice, 
 rcsuhing in general distension and dilatation of the (I'sophagus 
 {iaoplui^'ocarle). The Acquired malformations consist in the 
 development of the so-called Diverticula. Two forms ha\e been 
 described by Zenker : (a) Pressure Diverticula, which are the more 
 (Dininon, and seem to be associated with some congenital weak- 
 iKSs of the wall, probably connected with the branchial clefts. 
 They vary nmch in size, perhaps becoming as large as a child's 
 head, and rarely come under obserxation before the age of thirty. 
 They usually spring from the posterior wall, close to the junction 
 of tht' pharynx and cjesophagus, constituting sometimes what is 
 known as a ' pharyngocoele ' ; the cavity extends downwards 
 between the cfsophagus and \ertebral column. The symptoms are 
 due to distension of the ca\ity with food which stagnates and 
 putrilifs, forming a swelling in the neck which can be emptied by 
 pressure; the difficulty of obtaining sufficient food gradually leads 
 to emaciation. When a bougie is used, it generally passes into 
 the diverticulum, and hence its onward course is arrested ; by 
 larefid manipulation it may be kept on the sound wall, and so 
 ^Hpped past the orifice into the stomach. Treatment, where 
 pissihlf, consists in exposing the diverticulum in the neck, 
 1 removing it, and stitching up the opening in the pharyngeal or 
 
 esophageal wall, {h) Traction Diverticula are nuich rarer ; they 
 [usually occur on the anterior wall, near the bifurcation of the 
 trachea, and are due to cicatricial traction from without, as by an 
 inllamed bronchial gland. They are always of small size, often 
 jniultipk', and cause no symptoius, unless a foreign body lodges in 
 jthem, when ulceration and perforation may lead to suppurative 
 jinediastinitis and death. They cannot be recognised ante mortem. 
 
 Foreign Bodies not unfrecpiently lodge in the (X'sophagus, 
 ^specially in children and lunatics. Portions of food, coins, fish- 
 jbones, pins, plates of false teeth, etc., are the substances usually 
 
764 
 
 A MANUAL OF SURGERY 
 
 met with. The patitMit conii)l<'iins tluit somethiiif^ li;is lod;;. d in 
 the f,aillet, c.iusinf,' ;i feehn^ of pain and distension, whilst 
 s\vaIIo\vin}jf is painful or impossible, and respiration may iu' inort- 
 or less hampered. Larj^e bodies are often impacted at the eiitiancf 
 to tlie },fvdlet, and then lause sudden di-ath from dys|)n(i'a; if tlu; 
 obstruction is not so ^aeat and remains unrelie\ed, u;dema of tlu 
 glottis may superxene. Impaction lower down is likely to In- 
 followed by ulceration, perforation, and deatli, either from linnioi. 
 rha^^e owing to one of the large \essels being opened, oi fmn 
 suppuralisc cellulitis, in some cases, however (Konig states al'.nii 
 50 per cent.), the foreign body spontaneously passes eitiur int( 
 the mouth or stomach. 
 
 The Treatment varies much according to the nature, size, aiiu 
 situation of the obstructing body. If small and incapable of heiii;: 
 detected by a sound — <'.(t,'., a fishbone — it is best renuned hy a: 
 expanding |>robang (Fig. ^71), being caugiit in the loops of thii.k 
 horsehair forming part of the apparatus. If a coin or small lian! 
 
 B 
 
 Fk;. 271. I'-XrANDINi; ruoltANC; IOK THK KkMOVAL ok FoKKKIN I'>nPI! 
 
 KKoM Tin: (I'^soriiAdCs. 
 
 substance is impacted, it may be remoxed by o'sophagenl foiapN 
 or i)y a coin-catcher. If it is impossible to draw it up, it may 
 sometimes be pushed down into the stomach. A largi- bolus it 
 food may be removed by forceps from the upper part of tk 
 a-sophagus, and large foreign bodies— r.^tf., plates of teeth— iiiav 
 be similarly extracted, though great care must l^e taken not to 
 tear the mucous membrane. Skiagraphy is now employed to 
 assist in the localization of metallic substances such as coins, as 
 also to determine whether or not they have been dislodged, whilst 
 removal may be much expedited by the use of the cryptoscope. 
 
 If impacted in the upper part, (Tsopha<:;otomy may be peifonnd. 
 An incision. 4 inches long, is made along the anterior holder I 
 of the sterno-mastoid, preferably on the left side, because the 
 a-sophagus naturally curves that way. The platysma and dtep 
 fascia are divided, and the muscle drawn outwards; the onio-hyoii!' 
 needs division, and the surgeon then carefully works his wa} 
 between the carotid sheath on the outer side, and the laryn.\anii| 
 trachea on the inner, avoiding the thyroid vessels and nerves. 
 The projection of the foreign body will indicate the situation 0! 
 the tube, and this is carefully incised, and the obstruction dtiJ' 
 with. The (Xisophageal wound may theii_be closed by siHin^ 
 
irFECTlONS OF THE MOUTH. THROAT, AND a-SOPIlAGUS 765 
 
 ,)l. I'oKlilGN llnlU! 
 
 wliicli do not include the imicous inembr.'ine, winlst the external 
 wound is either stuffed with <,'.'ui/e plug's or drained. When 
 located in the upper part of the tlioraeir portion of the o'sophaf^nis, 
 the tube is opened as low as possible; l^y euttinj; down on liu! point 
 iifa bdUj^'ie passed from the mouth, and then it is often possible to 
 ixtriiate it. 
 
 When the forei^Mi body is impaeti-d near the cardiac oritice. and 
 amnot be moved either up or down, the stomach may be opened 
 \Gastroiomy, \). ^^3), the finf^ers or even the hand inserted into it, 
 ilu' cardiac orifice dilated, and the obstruction removed. 
 
 When once the foreif^n body has passed into the stomach, 
 |nirL,Mti\»s and emetics should be avoided, and if not of larj^e si/e 
 iind iire^Hilar shape, the case is left to Nature, the treatment 
 bcin^' merely expectant. 'I'he patient is kept (|uiet, and fed on 
 pultiiccous food- such as brown bread, porridge, etc. and the 
 motidiis are carefully examined. Should, however, the foreif^n 
 body be larj^'e, and the gastric syujptcjms persist, it should be re- 
 moved by ;;astrotomy. 
 
 Inflammation of the (esophagus, with or without ulceration, 
 i> cuused by swallowing corrosives or irritants, and, in a more 
 i'lcilized form, by the impaction of foreign bodies. 'J'he symptoms 
 iiu pain and ilifficulty in deglutition, and the treatment consists 
 m tlie restriction of the diet to licpiids, whilst in bad cases rectal 
 keding may be necessary. Chronic catarrh results from the 
 (.ontinual drinking of raw spirits, and stenosis from cicatricial 
 rniitraction may gradually follow. 
 
 Varix of the veins in the lower ptjrtion of the (esophagus is 
 uicasionally met wit 1 as the result of pressure on the portal vein, 
 111 from cirrhosis of the liver. 'I'his is due to the fact that these 
 branches open into the gastric division of the portal system, 
 passing through the (I'sophageal opening in the diaphragm. 
 
 hi'niatemesis may result, and this has even ]ir()\ed fatal. 
 
 Spasm of the (Esopliagus, or hysterical stricture, arises in 
 
 j neurotic young women, usually under twenty-five years of age, 
 
 and, although sometimes independent of organic lesion, is often 
 
 hissuciated with some slight abrasion or ulceration of the mucous 
 
 {membrane, perhaps originated by the impaction at an earlier date 
 
 )f a fishbone. The symptoms complained of arc; difficulty in 
 [swallowing, and a sensation as of a ball arising in the throat 
 U'loks liystei'ictts), due to a spasmodic action of the pharyngeal 
 jcimstrictor muscles. At times, when the patient's attention is 
 Idiverted, deglutition Qccurs quite normally. The best course of 
 [traUmciit is anti-neurotic in character (e.g., cold douches to the 
 
 S'pine, massage, the administration of purgatives, valerian, etc.), 
 [^vhilst the passage of a full-sized oesophageal bougie is useful. 
 
 Organic Stricture of the (Esophagus occurs in two fornis- 
 ifibious and the malignant : 
 
 -the 
 
766 
 
 A MANUAL OF SURGERY 
 
 1. Fihi-otis Stricture of the (Esophaffits is usually located iic.ir its 
 coiiiMicnctMnent, just heliincl ihv cricoid cartilage, and is nwist 
 frefiucntly caused by the swallovviuf^f of corrosives, and tin 
 cicatrization of tlu' wounds caused thereby ; it also results Innii 
 syphilitic disease. At the cardiac orifice it may arise fiom the 
 healing and contraction of a gastric ulcer. The main syiitptim 
 produced is a gradually increasing difficulty in the swallowiiii;, 
 firstly of solids, but finally even of fluids. If the obstru( tioii is 
 placed at the upper end of the tube, food is returned inuuediutLlv; 
 but if lower down, the (esophagus may become dilated, and in 
 this pouch or (rsophag(Ko le the food collects for a time, and 
 then returns unchanged. There is but little pain in this form ot 
 stricture, although the patient is usually able to indicate the le\(l 
 of the obstruction. As the case progresses, he becomes stcadih 
 emaciated from sheer starvation, and may even die from tlii^ 
 cause. 
 
 2. Malignant Stricture of the (Jisophaffus is usually epitheliomatoib 
 
 in type, occurring in suhjcrt- 
 
 over forty years of age, ami 
 
 situated either at the jimctiun 
 
 of the pharynx and (esophaf,'us, 
 
 I.e., behind the cricoid cartilact 
 
 (Fig. 272), or in the niiddli' ui 
 
 the tube, where it is crossed bv 
 
 the left bronchus, or at the 
 
 cardiac orifice of the stomixi! 
 
 in the latter site, cohiiina; 
 
 carcinoma is the form usuallv 
 
 found. The growth involves 
 
 the whole circumference 0! 
 
 the tube, and sooner or later 
 
 ulcerates, perhaps perfoiatiii!.' 
 
 the trachea, pleural ca\itv, u:| 
 
 one of the large vessels. 
 
 Secondary deposits occur ip| 
 
 the lymphatic glands, either ni 
 
 the neck or posterior niedia.- 
 
 tinum, visceral complications 
 
 being uncommon. The >jw.'/ 
 
 /o;«s are similar in character to| 
 
 those of fibrous stenosis dt 
 
 tailed above, but in addition] 
 
 the vomited materials may con j 
 
 tain blood, and there is a '^w 
 
 deal of cough and pain, referred j 
 
 usually to the site of the diseiu*] 
 
 Shoukl the growth be at the upper end of the tube, a tumour inavj 
 
 be distinctly felt, placed deeply in the neck and more marked ob| 
 
 Fici. 272— Cancerocs Growth of 
 Till-: (Ksoi'HAGcs. (Treves' Sur- 
 gery. ) 
 
AFI FXTIONS OF THE MOUTH, THROAT, AND IKSOI'IIAGUS 767 
 
 Uic left side ; in the earlier stajjes rmthinj,' ran he felt externally, 
 ;ilthi)ii^;li the side-to-side moseinents of the larynx may he ini- 
 ptclt'cl. l'erf()rati(jn of the trachea leads to the entrance of food 
 into tlie air-passaf^a-s, and rapidly results in septic pneumonia and 
 ilciitli. When the upper part of tlie j^adiet is affected, the ^^rowth 
 iiiiiv spread to the hack of the larynx, and cause hoarseiuiss and 
 even aphonia. Occasionally the pneumoj^astric nerves may he 
 iiuoKcd in the mass, leading' to interference with tin- action of the 
 hfiirl. whilst implication of the recurrent larynj^eal ner\e causes 
 iiiiistant couf,'h and uni- cjr hi-lateral paralysis of the larynx. 
 
 Thr Diagnosis of (esopha},'eal stricture must he made on {general 
 principles, and by a pro cess of exc lusion of the nuuiy other form s 
 (ildysphajjjia detailed helow! It is confirmed by exanuniuff the con- 
 dition of the tube with an («;sopha};eal bougie. A conical-ended 
 instriinient of medium size should be ernptcjyed for diaj^Miostic 
 luuposes, and by this means the situation of the obstruction can 
 !)L' ascertained. To pass an asophai^cal hoiifj^ii' : The surgeon stands 
 111 front and slightly to the right of the patient, who is seated with 
 the lu-ad held forwards— if thrown backwards, the larynx is 
 (irt'ssed against the spine, and the dififuulty of introducing the 
 instrument increased. The bougie is well warmed and smeared 
 with glycerine, and, ha\ ing been suitably cur\ed, is guided by the 
 >uri,'t'()n's left index-finger o\er the epiglottis into the (j'so[)hagus. 
 This stage usually causes a certain amount of discomfort and 
 rttcliing on the part of the patient. Once past the entrance to 
 the larynx, the bougie is pushed steadily onwards ; if there is no 
 stricture, the instrument will enter the stomach at a point about 
 16 inclics frorwthe teeth. If any obstruction is present, the large 
 instrument is withdrawn, and the passage .uf _ a. sjuailet aue 
 attempted. The greatest care must be taken, especially in sus- 
 l)ectecl malignant disease, as it is by no means diflTicult to perforate 
 the walls and open up the mediastinal tissues, e\en causing fatal 
 cellulitis. A cancerous stricture sometimes feels rough and is 
 painful; a simple stricture is smooth, regular, and almo.t pain- 
 less. It is by no means easy to distinguish the two for.ns, and 
 the history of the case and general condition of the patient will 
 need to be thoroughly investigated ; a hacking c(nigh with no 
 >pecial pulmonary symptoms is always a bad and suggestive 
 si<:ii. 
 
 Treatment of Fibrous Stricture of the (Esophagus. — (a) Dilatation 
 [III the stricture ^^y means of gradually increasing bougies; for 
 this purpose it is better to use conical-ended instruments rather 
 than the usual type, which are of the same calibre throughout. 
 An int(r\al of some days should elapse between the attempts 
 Ht dilatation, and during this period the patient should be given 
 his nuicli food as he can take in the shape of strong broths, 
 jiiiinced meat, raw eggs, etc., or, if need be, rectal alimentation 
 iiiust he resorted to. {b) If it is impossible to dilate, or if the 
 
768 
 
 A MANUAL OF SURGERY 
 
 stricture recurs, a Syinoiids' Tube may be inserted. It consists of 
 a gum-elastic, funnel-shaped tube, passed tlnou}j;h the stricture 
 by a whalebone introducer, the funnel restinj^ a},'ainst the fact 
 of the stricture. A thread attached to the upper end is bioiif^flit 
 out of the mouth in order to remove and clean it, a proccediiif,' 
 needed about once a fortnij^ht. (t) Internal (csophn>j;otoiiiy by means 
 of a concealed knife has also been att(!nipted, the stricture JHiiii; 
 divided posteriorly ; it is a somewhat risky proceedinj^s and is only 
 feasible when the lesion is situated hij^di up in the tube, (d) \\h,\\ 
 the contr'";tion is at the pharynj^eal extremity, it may be possible 
 to open the (i^sophaj^us below, and either di\ide and dilate the 
 stenosed portion, or cesophagostomy may be performed by sewini; 
 tlie mucous meiubrane to the skin, thus forminj^ an eiiiniiio- 
 to the alimentary canal in the neck. Under these (iKum 
 stances, it is better practice to completely divide the o'sophauih 
 closing the upper end by sutures, and fixing the lower end to t'l 
 margin of the wound, {e) If the cardiac orihce of the stonuu: 
 is contracted, the stomach may be opened as in gaslrotoim , 
 (p. H63), and the fingers used to dilate the stricture (yctro'^roM 
 dilatatiou), a proceeding similar to Loreta's operation for strirtiiiv 
 of the pylorus. (/) Where none of these proceedings arc possiblt-. 
 or if tried have failed, the stomach may be opened, and (livisiii 
 of the stricture by Abbe's $trin<:^ saw attempted. The patient :< 
 made to swallow one end of a piece of string, or a small shot I 
 may be clamped on a piece of fine silk, and allowed to liiul its I 
 way into the stomach. W^hen this viscus is opened, the free eiiJ I 
 is secured, and by its means a coarse silk thread is cuirnii I 
 through the obstruction ; by up-and-down sawing movements ihc I 
 stricture can be thereby divided, enabling the surgeon to intiodua- I 
 bougie.;. Excellent results have been reported from such j)racti(f. I 
 (ji^') G astrostom y is the final resource (p. <S^>4) ; occasionally, ulun I 
 the (esophagus has by this means been kept at rest for some tiiiic. I 
 the stricture will yieltl, and dilatation by bougies becomes pru I 
 t .iible. In such a case the opening in the stomach may 1 
 allowed to clo.se. 
 
 Treatment of Malignant Disease of the (Esophagus. Oihitai 
 by bougies should not be employed as a routine practice. >' •" !■ 
 of increasing the ulceration, causing severe ha'morrhage. or |n 
 lorating the walls of the tube, it may, however, be used ;i> .1 
 temi)orary measure in the earlier stage to enable the patient to 
 take an increased amount of food, anci thus for a time improve lib 
 gcni'ral condition and render hirn more fitted to imdergo lurilur 
 treatment. Symonds' nu;thod of inhale may be utilized in main; 
 nant disease, the patients often lu-aring the inserted tube weli.ivtn 
 when the 'ardiac orifice is involved, the lower end then piojeclin,' 
 into the ca\ ity of the stomach. Unfortunately these tulxs occa- 
 sionally slip through into the stomach, or the guiding strin;,' '? 
 swallowed ; moreover, under the best circumstances the tube nt'cils 
 
APrECTIONS OF THE MOUTH, THROAT, AJD (ESOPHAGUS 769 
 
 It consists of 
 ^h the stricture j 
 ri^ainst tin.' fine 
 :r end is bmutdii 
 I it, ;i prcKt'cdin^: 
 ifTotomyhy nu'aib 
 J stricture iHin.; 
 ;clin}^, iuul is unly 
 inbe. ((/) Whtn 
 : may he iMissihle 
 le and dilalo the 
 Drnied hy sewim; 
 iiin^ an iMilraiuc 
 iV thes(^ circuin 
 ,e the (rsoplnii^ib. 
 i lower end to t'u 
 e of tlie stomaci. 
 is in ^astrotoiin 
 .ricture {yciropd. 
 ration for slrictuii- 
 dinj^s ari' possiWc 
 ened, and divismi. 
 . The patieiU b 
 jr, or a small shut 
 jlowed to riiiil it> 
 )ened, the free iiu! 
 thread is lain-j 
 n^ movenu'uMlif 
 [r|.n,'on to iiurodua' 
 om such pracliif. 
 )Ccasionally, wlun 
 est for some limi:. 
 cs becomes pra 
 stomach may 1" 
 
 (hanging every fortnight, and the ulceration may he increased 
 thereby. Hence gastrostomy, perforined as soon as possible hy one 
 of the moder n m et]iods7is a mu ch more satisfcictory plan of treat- 
 ment. Excision of the growth m tlie neck lias been successfully 
 accomplished in a few cases when the disease was recognised early, 
 ;ind very limited in extent. Tracheotomy is occasionally required 
 in the later stages, from implication of the glottis or tracliea. 
 
 Hv tlie term Dysphagia is meant a Cv)nclit ion i n which swallowing is painful 
 or (lifFiciih. The Causes are very numerous, and may be arranged as 
 1 illows ; 
 
 i r/iti;j/i^C(j/-<'^., acute or chronic inflammation, whether simple, scarlatinal, 
 liiphtiifiitic, etc. ; ulceration of syphilitic or malignant origin ; stenosis, as a 
 result of ulceration ; paralysis (e.g., labio-glosso-laryngeal or bulbar) or spasm ; 
 nipaction of foreign bodies ; naso-pharyngeal polypi projecting behind tiie 
 velum ; retro-pharyngeal abscess or tumour, etc. 
 
 ii Laiyngcul—e.t;., acute or chronic laryngitis; tuberculous, syphilitic, or 
 malignant di "^ase. 
 
 iii. iEsophiij^eal — e.^., acute or clironic inflammation, impaction of foreign 
 hvjies, the presence of di%erticula, (rsophagospasm, and simple or malignant 
 vtricture 
 
 iv Extrinsic. In tlie iur/< : goitre, enlarged glands, aneurisms, etc ; in tlie 
 ■.'..•rjx: mediastinal growths or glands, aneurisms of the aorta and large vessels, 
 lunidurs growing fro.m the vertebral bodies, pericardial effusion, and displace- 
 ment backwards of the sternal end of the clavicle. 
 
 To ini'fstifiittc tt case 0/ ii'yspliiif^ia, note: (i.) tlie method of onset, whether acute 
 
 .rchronic -if the former, it isprobably due to a foreign body ; (ii.) the condition 
 
 "f the pharynx as seen from the mouth and on digital exploration ; (iii ) the 
 
 icmditiiin of the neck as seen and felt from witiiout, whether or not a tumour 
 
 is to be felt behind the cricoid, or whetlier a goitre or aneurism exists; (iv ) the 
 
 I character of the voice, as indicative or not of laryngeal mischief — if the voice 
 
 s husky, a laryngoscopic examination must be m.ade ; (v.) the chest must be 
 
 [carefully examined for aneurisms, etc. ; (vi ) the resophagus may be auscultated 
 
 'alin),' the vertebral groove whilst the patien: drinks water to ascertain the 
 
 jsituationof tiie mischief; (vii ) it must be examined finally by bougies. If 
 
 the obstruction is in the oesophagus, the patient's age and general condition 
 
 W\\\ i(\\c f'lima fiuie evidence as to whether or not it is due to malignant 
 
 (liiease ; i ui it must not be forgotten that the stenosis /"f*- sc causes some of 
 
 [the loss of flesh and of weight. The presence of blood and offensive mucus on 
 
 jthebouijie or in the material vomited, and the existence of enlarged glands in 
 
 Itheneck, will also assist in establishing a diagnosis. 
 
 lagus. !)il;'^'' 
 practice. •' '' I' ' 
 Imorrhage. or pi 
 
 ,cr, be used ;b > 
 )le the painnr 
 time improve hi- 
 ) undergo furilut 
 utilized in iiwl'^ 
 Id tube \vell.e\< 
 lul then projecii:i 
 Ithese tulu'S oa;' 
 jguiding stiiii'r; '■ 
 :t-s the tube luW: 
 
 49 
 
CIIAFTICK XWII. 
 AFFECTIONS OF THE EAR. 
 
 Ii" is impossible to do more tlum deal villi some of tlu- mmv 
 iaiportunt surj^Mcal aspects of diseases of the ear in this place, and 
 for a more detailed consideration of the subject we must refer ciir 
 readers to special text-books. 
 
 The External Eax is the site of various affections wiiic h iii;i\ 
 come under the observation of tiie {general sur^^eon. Tims, tin 
 pinna may be congenitally absent, and e\ en the external nieatii> 
 closed, a malformalion often associated with mai rnsttniia. 
 Notiiinj^f can be done for this want of developmi-nt, and the 
 surj^eon must nexer be tempti'd to try and dij^ out the cdiucaU 
 mendirana tympani. More frecjuently ?"?e88ory auricles arc pa 
 sent, consisting merely of libro-cartilagc coMired with fat aiul skin. 
 Large and prominent ears constitute a \iiy unsigtuly dcloniiity. 
 for which operative interference is occasionally reciuircd. The 
 size may be diminished by removing a \'-.shaped portion from the 
 upper part ; the prominence, by excising a portion of skin ar.i! 
 cartilage through an incision on the posterior aspect. Tiic \viiuni;>j 
 thus produced are accurately sutured together, and cuiisulcial'Iel 
 improxement in the appearance results. Hsematoma of tlu' t;ir 
 is usually due to injiny, but is occasionally idiopathic in ori;'iii, 
 especially amongst tlie insane. The auricle becomes swollen 
 and enlarged, and of a bluish-red colour in traumatic cases! 
 (Fig. 273); unless inflamed it should not be interfered with, asaj 
 general rule, although, if the appearance of the patient is iniiioriar:.j 
 it may be ad\ isable to remoxe the blood, since its orgaitiA'tM; 
 and svdiseciuent contraction may lead to considerable dcforniitv. 
 Eczema, boils, and other inti-untuatory affections, are nut with ^ 
 tlie exti'rnal ear and pinna, but these call for no special nientioii. 
 
 Plugs of wax (cerumen), which become dark and induiated, ii'tj 
 unfrequently block the meatus, leading to more or less compit 
 deafness; this may come on suddeidy after bathing, owiiij; tot!''! 
 plug rapidly ssvelling up. If they encroach on the iiRMiibiarJ 
 tympani, subjective symptoms of giddiness, vomiting, and nishina 
 noises in the ear may also be caused. On examination with ■"! 
 
^^fPECTIONS OF THE EAR 
 
 tar speciiliidi, their . 
 
 -ist> ill uashin.r fi, '''"^''^^"^■^ 's readily deterfpH r ~ ' 
 
 ^tre.ui. of warn) u-.f • ■' ''"^'' ^ 
 
 --iHuJarlVrJno d';r "''•.'r^^^'^' 
 -nn.n,.:Vtira;'V;:;r*''^^''>^ 
 
 I'Ut it must he V "^ ^'''^ Pi'fpose, 
 Lehincl .Ik! oXnT'7'';''";^ ^''^^^ 
 
 Patienc or fo^ ^ ^ ;' ■<- -^ m.- 
 
 .e...a,d;;^;''--"^^''epassa,,ar,dn-a,,....„ov^ 
 ' ^!^^^!^^^^f:^'^^^ ^' Ohronic Oto.h.a are T , 
 
 per:::::"":""' •"-■■•■- " 
 
 ' "f t'"- tissues involved. 
 49—2 
 
77a 
 
 A MANUAL OF SURGERY 
 
 They shouUl be fomented with hot water, and opened when pu^ 
 has formed. 
 
 (c) Inflammation may occasionally spread from the meatus tn 
 the tympanic plate of the temporal bone, leading to subperios- 
 teal abscess and necrosis ; or it may extend into the teinporo 
 maxillary articulation, giving rise to suppurative arthritis and 
 disorganization of that joint (p. 708). 
 
 The cranial complications of otitis media are often of a <^'ra\e 
 nature, and may end in permanent deafness, or even end;inj,'tr 
 the life of the individual. 
 
 (a) The ossicles frequently necrose, and are cast ofl in tlic 
 discharge, and thus hearing may be impaired, althouf^'li mi 
 necessarily destroyed ; ankylosis of the ossicles one to another 
 may also be determined, leading to considerable, if not total, loss 
 of function. 
 
 (/;) The inflammation may extend from the lining membrane d 
 the tympanum to the bony walls surrounding it, giving rise i, 
 a limited caries or necrosis of the temporal bone. This may be 
 associated with suppuration within the skull, and any (jf tlie 
 intracranial complications mentioned below. The root oi the 
 tympanic cavity, which is very thin, is especially liable to be , 
 affected in this way. If diseased bone can be felt thnmi^h the, 
 external auditory meatus with a probe, an attempt should bej 
 made to remove it; if this is impossible, the part must he l;epi| 
 clean by the injection of mild antiseptics, retention of discharj,'t< 
 being prevented by the regular use of Politzer's bag. 
 
 {c) Poljrpi may also develop, consisting essentially of granulation | 
 tissue protruding through the opening in the membrane; theyi 
 lead to considerable obstruction, and may do harm by keeping 
 back the discharge. They should be removed by the curette, 
 and the bare bone, usually felt at their base, scraped ; the pan 
 is subsecjuently syringed with a weak carbolic solution ;ind| 
 dressed antiseptically. 
 
 (d) Facial paralysis not unconunonly arises from sclerosisj 
 and thickening of the bony tissue surrounding the a(]uedii(tU5| 
 I'^allopii, causing pressure on the nerve in that region. It niustj 
 be remembered that the bony canal lies immediately behind the! 
 tympanic cavity, and to the inner side of the passage iiom liiel 
 attic to the mastoid antrum (iter ad antrum). All the niu.sclesuni 
 that side of the face are involved, and possibly also the palate andj 
 uvula. No radical treatment is practicable, althougli the line 
 should be regularly farad ized, so as to maintain as far as possible] 
 the tone of the muscles. 
 
 (e) Inflammation may also extend into the mastoid cells, givinsa 
 rise to the condition known as mastoiditis. The mastoid proccsi 
 is a triangular mass of bone, which is practically undevelop 
 until the age of puberty. P>efore that period a single cell reiaj 
 
AFFECTIONS OF THE EAR 
 
 171 
 
 pened when pu- 
 
 w the meatus tu 
 ing to subpcriiis- 
 ito the teniporo- 
 ive arthritis and 
 
 often of a },'rave 
 )r even enclanf,'er 
 
 ; cast ofl" in the 
 ed, althou^'h \\u\ 
 ; one to ;inotlur 
 , if not total, lo^s 
 
 ning membrane it 
 it, giving rise tu 
 ►ne. Tliis may be 
 , and any of tht 
 The roof of the 
 :ially HabU- to be 
 e felt thri)Uf;h the 
 Utempt should be 
 -)art must be l;cp;| 
 ition of discliari^'ts 
 
 illy of granulatiur. I 
 membrane ; they j 
 harm by keepin;; 
 id by the curette, 
 icraped ; the parti 
 ilic solution and 
 
 from sclerosis I 
 
 |g the a<iuedu(tU5| 
 
 region. It mu>tl 
 
 hately behind thel 
 
 passage i'lom tiiel 
 
 \11 the muscles onl 
 
 [iso the palate andj 
 
 lilthough the taceT 
 
 as far as possible 
 
 Istoid cells, giving 
 mastoid proce 
 pally undovelop 
 [x single cell rei-i 
 
 lively of large size commimicates with the posterior portion of 
 the tympanic cavity and represents the antrum ; but after 
 puberty the whole bone becomes hollowed out into a series 
 of spt)ngy cells, lined with mucous membrane, which open into 
 the floor of the antrum. When the inflammatory process in 
 otitis media, which is almost always septic, extends into this 
 bony process, severe local and general symptoms are likely to 
 result. The patient complains of intense pain in the ear, with 
 tenderness on pressure, and perhaps redness and tL'dema over 
 the mastoid process. The discharge from the ear often ceases for 
 a time at the commencement of these symptoms, but reappears 
 later on. As the case progresses, febrile symptoms of an inter- 
 irittent type, and even rigors, may supervene, whilst the patient 
 becomes drowsy, or may be irritable and restless. An abscess 
 may fortn under the periosteum covering the mastoid process, 
 with or without caries or necrosis of the outer table of the bone ; 
 m children, where this bony lamella is thin, it is not unfre- 
 iliiently absorbed, and on incising the abscess protuberant masses 
 of j;rauulations, springir g from the interior of the bone, may be 
 seen. Any of the intracranial complications mentioned below may 
 occur as secjuelne. Occasionally the mastoid trouble is of a more 
 chronic type, and e\en tuberculous in nature, the cells being choked 
 up with lymph and inflammatory material of a cheesy nature, 
 whilst the bone itself becomes thickened and condensed. The 
 process feels distinctly enlarged, and a good deal of deep-seated 
 [pain of an aching character is e.xperienced, and worse at night. 
 
 When the discharge is inspissated and mixed with epithelial 
 kells and cholesterine, so as to form flaky masses like the layers 
 lot an onion, the condition is known as cholesteatoma. It is often 
 the cause of great distension uf the antrum, which in a case 
 operated on by one of us measured tjuite i^ inches across. The 
 Uyniptoms, at first of a chronic type, are likely to be followed 
 [sooner or later by an acute attack of septic inflammation. 
 
 Treatment. — In the eaiiy acute stage belladonna fomentations 
 [may be employed, and the patient kept quietly in bed, whilst the 
 diet is regulated and a sun able purgative administenxl ; accu- 
 jmulated discharge is removed from the tympamnn by the use of 
 jPolitzer's bag. Two ur three leeches may also be applied 
 [over the mastoid process, and relief to the pain thus obtained, 
 lthouf,'h it is often only of a temporary character. It is most 
 [important not to rely upon such palliative measures for too long, 
 jbut when the symptoms are well marked, even in the early stages, 
 land before suppuration has occurred, it is good practice to make 
 jan incision {Wildes incision) down to the bone, reaching from the 
 pse to the apex of the process ; much relief is always obtained 
 jby this procedure, and the inflammatory phenomena are some- 
 |tinies completely checked. Should this not succeed, the mastoid 
 f^iimn must be laid open and its contents evacuated {Sclnmrtze's 
 
774 
 
 A MANUAL OF SURGERY 
 
 operation). Many instruments have been supfpfested in okUt t> 
 accomplish this; thus, it lias been reconnnended to use the hr;u! 
 awl, trephine, gou{,'e, or j^'inilet ; the {^ouf^e is, ho\ve\er, proliahK 
 the best. A cur\ ed incision is made immediately behind tiie ear, 
 which is drawn well ft^rwards {V'v^. 274), and the ^'ou^^c ;ipplit,i 
 on a level with the roof of the external auditory meatus, atul ahou; 
 ^, inch behind its centre (Fif^. 275). A small dimple in the hon, 
 can often be felt at the refjuired spot, which can also he foimij 
 by takin{,( the point of junction of two lines drawn as tanj,'eiii- 
 to the roof and posterior wall of the bony meatus respcctivelv 
 {V'\U,. 27ft, C). The direction iaken by the j,^oujjfe should \l 
 sli;,,ditly downwards, forwards, and inwards, and a useful miiii- 
 \\ill be found in a probe j^assed down the external auditiiy 
 meatus, the borinf^ bein;,; made exactly parallel to this. In av 
 
 Fig. 274. 
 
 Incision for Mastoid 
 Operations. 
 
 I'm. 275. — SlTK FOR DrII l.!N(, IViNl 
 
 in orim:r to oi-kn riii: M.kst : 
 Antrlm. 
 
 It is often well to .ipply the chisel as indicated here so as to inchule ,1 trian,;!( 
 tiie centre of whicli corresponds to the apex of the so-called supra-meaa 
 triangle. As soon as tiie outer layers of the bone ha.e been rt-niovedb 
 the chisel, the KOURe is used to reach the deeper parts. 
 
 adult the mastoid antrum is reached about three-hfths ot ai 
 inch from the surface of the bone. The surj^eon recogni/e^ 
 that he has opened the cavity by the loss of resistanct- , and j 
 the escape of exceedinpfly ofTensi\e pus. The opening; is iht;" 
 freely enlarj^ed by the use of the gou^e and cuttin}.,' pliers, and tht I 
 cavity syrinj^^ed out throuf^h the external meatus. Diseased benej 
 in the mastoid process or around the tympanic cavityniaytti 
 scraped away, and the wound plugged with antiseptic ^^auze ;:[ 
 should be syringed through from the external meatus daily. 
 the more chronic cases it may be advisable to split off thewhifj 
 of the outer coating of bone from the mastoid process, so as tolajf 
 open all the cells, which will often be found filled with iiispissateiij 
 pus. In the more severe forms it is recommended to dctixh im 
 auricle posteriorly from the bony margins of the meatus, and the:! 
 to gouge away the whole of the osseous tissue inters eniiiL; bet\v«!l 
 the meatus and the opening into the mastoid antriim. 1"(| 
 
AFFECTIONS OF THE EAR 
 
 775 
 
 istecl in oiclcr ti; 
 I to use thf brad 
 lowever, probably 
 iV behind tbt- ear, 
 Lhe \l,o\v^v iipplici! 
 mealus, and about 
 iniple in tbe boiit 
 :an also be foiiiui 
 lawn as tan^ent^ 
 eatus resiK'ctivcly 
 
 •^oil^e sbiiuld lit- 
 nd a useful \^\vaV 
 
 external auditdiy 
 i\ to this. In x\ 
 
 E KOK DKILI-IN'j BOSI 
 
 o oi-i:n TiiK MAsT-r 
 
 IS to incUule a tria!ii;lir 
 so-called snpra-meM'. | 
 ha.e been removed b; 
 
 irts. 
 
 It three-fifths of an I 
 Isur^^'on ^t■c()^'niz'^^ 
 1 of resistance, and 
 Ihe t)peninK' is thw 
 Ittin^^ pliers, and the 
 lus. Diseased bene I 
 anic cavity niayl;?! 
 Imtiseplic -jauzfit 
 meatus daily, n 
 I, split oil the whole 
 Iprocess. so as to lav I 
 lied with inspissaidl 
 Inded to detach m 
 he meatus. andtl'.«| 
 nterveninu l^'^twD 
 Itoid antrum. '"<' 
 
 remains of the membrane and the ossicles are then reincncd, and 
 the whole cavity well curetted. The deep portion of the posterior 
 meatal wall is incised transversely, and the marj^dns of the aperture 
 stitched to the posterior edj,'e of the wcnnid, the meatus thus lead- 
 in^i to the whole of the openinf,' in the bone, which can in this 
 way be syrin^'ed out and cleaned more efficiently (Stackc's opera- 
 tioii). The results of this proceedinj^ have been \ery satisfactory, 
 hut the proximity of the facial nerve nuist not be forj^otten, and 
 the anasthetist should be instructed to watch the face continu- 
 (iiisly for any twitchinj,', which indicates that the nerve is beinj^ 
 touched, inasmuch as the surgeon is working at the side ancl 
 cannot see. 
 
 )rrh( 
 
 xh 
 
 llu intracranial complications of 
 abscess, localized or diffuse meningitis, thrombosis of the lateral 
 sinus, and abscess in the cerebrum or cerebellum. 
 
 ((I) Subcranial Abscess. — When the roof of the tympanum or 
 any part of the lining of that ca\ity which encroaches on the 
 cranium becomes inflamed or carious, suppuration between the 
 skull and dura mater may ensue. The membranes are gradually 
 stripped from the bone by the increasing pressure of the exuda- 
 tion, anl symptoms of cerebral compression and irritation are 
 thereby induced. Accumulations of pus occur most couunonly 
 alon;,' the summit of the petrous portion of the temporal bone, 
 and in the sulcus in which the lateral sinus is lodged. 'I'he 
 patient complains of pain and he.'idache, which increase for a 
 time, and are then followed by drowsiness, which may pass into 
 coma. The temperature is usually raised, but rigors, even if 
 present at first, are by no means a constant feature of the 
 case. The pulse is of the usual febrile type, viz., full and bound- 
 in;,', There is no pain in the neck along tlie course of the jugular 
 vein, but retraction of the head occurs if basal meningitis is 
 present, and vomiting is a marked symptom. Optic neuritis 
 may be ()bser\ed in consequence of the infu'unmation extending 
 to the mend")ranes at the base of tfie brain. There may be 
 Miine tenderness on pressure over tlie temporal region, and even 
 possibly (jedeina. In some cases the pus finds its way outwards 
 alon^f tlie mastoid emis.^ary \ein, or through the suture between 
 the ()C( i()ital and temporal bones. (See also p. f^^i.) 
 
 rbe Diagnosis from ccrcbyal abscess is sometimes a matter of 
 considerable difficulty. The symptoms, however, set in some- 
 what more acutely, whilst tlu; temperature is raised, and the signs 
 iif irritation of the membranes, such as retraction of the neck, all 
 ^'I'k'f^'est that the lesion is extradural, and not cerebral in origin. 
 'he pulse is fast, and not slow, and focal symptoms are less likely 
 t') develop. 
 
 llie Treatment consists in trephining above and behind the 
 "icatus, so as to escape the lateral sinus, and in iiuieh the same 
 
3 a s '. 
 
 c/) 
 
 3 3 « i 
 
 : 5if^ 
 
 rt'l^ S ,' -■- 
 
 t/i 1) 
 
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AFFECTIONS OF THE EAh' 
 
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 1) 
 
 situation as for a temporo-sphenoidal abscess (({.v.). The pus is 
 washt (1 out, and a drainage-tube inserted for a few days. 
 
 (h) Meningitis may be localized or difTuse. Tiie former often 
 accompanies some other condition, and is in itself of little moment. 
 h iiiuy produce fixed headache, but, if non-suppiuative, usually 
 disappears when the originating disease has been cured. The 
 ilitViisc variety is generally septic in nature, and secondary to some 
 suppurative aflfection in the neighbourhood, or to thrombosis of 
 the lateral sinus. For symptoms, see p. 653. Occasionally a 
 simplf serous effusion occurs within the meninges, leading to 
 increased pressure and consequent drowsiness, but disappearing 
 eiititely when the cause has been removed. 
 
 (1 } thrombosis of the Lateral Sinus arises froiu direct extension 
 of tlu- inflammatory process from the middle ear through the 
 mastoiil bone, or it may be set up by a septic thrombosis of the 
 mastoid emissary vein spreading to the sinus. A clot forms 
 within it, which, gradually increasing in size, leads finally to 
 (icclusion of its lumen. Infection with pyogenic organisms deter- 
 mines ilisintegratioii of the clot, septic emboli are detached, and 
 thus pyivmic symptoms originated. In well-marked cases the 
 throiuhus extends as far back as the Torcidar Herophili, and 
 downwards along the jugular vein into the neck. 
 
 The most marked Ssrmptom of the case is the sudden appear- 
 ance of a high temperature, which is usually remittent, and 
 associated witli rigors, vomiting, and localized pain in the head, 
 perliaps most marked over the point of emergence of the emissary 
 vein at the posterior border of the mastoid process. The pulse is 
 slow and easily compressible, and in the later stages the patient 
 is drowsy and dull, probably from serous exudation within the 
 meninges. The discharge from the ear, which may have been 
 previously offensive, usually ceases. Optic neuritis may or may 
 not exist, being often preceded by photophobia. If the thrombosis 
 extends into the neck, a firm, tender, elongated swelling is felt in 
 the region of the jugular vein, and, owing to the interference with 
 the venous circulation, the face often becomes dusky. Stiffness of 
 the muscles at the back of the neck is an evidence of a certain 
 I amount of associated basal meningitis, as is also the optic neuritis. 
 [Suppuration may occur outside the sinus, or around the vein in 
 I the neck, which becomes swollen, red, and uidematous. 
 
 In well-marked cases the Diagnosis is easily made, but in the 
 
 I early stages, and especially in children, it is often a matter of 
 
 some difficulty. The abrupt onset, the oscillating temperature, 
 
 i the recurrent rigors, the pain in the neck, and the deep tenderness 
 
 on pressure over the course of the lateral sinus or jugular vein, 
 
 [are the most trustworthy signs of this affection. 
 
 Treatment, to be successful, should be undertaken early. The 
 'i'l^ull is trephined at a spot about | inch abo\e Reid's base line, 
 aiul about i inch behind the centre of the external auditory meatus 
 
 i 
 
778 
 
 A MANUAL 01- SURGERY 
 
 \\ 
 
 (Fij;. 276, A or 1>). 'IMic outer w.ill of the sinus is tli(r(l)\ 
 (•xpos(>(l, and a puncture witli a line needli- readily deteiniinf- 
 wliellier it contauis lluid l)loi)(l or tluonihus. It it is throniljostd, 
 tliere is often some e\ idence of inllaniination or |)us around ii, 
 between the dura mater and tlie bone. Ila\inj; tluis \( lilicd th, 
 diaj^nosis, an incision is maile alon^; tlie anterior border of tin 
 sterno-mastoid, tbrouf^'li wliieh the juf^'ular \ein is tietl at ,1 spi.i 
 below the lowest point of the throndius, so as to prexcnl t'u 
 escape of anv more emboli into the j^eneral circulation. jh, 
 lateral sinus is now freely opened, anil the septic thionilnis partK 
 scraped, partly waslu-d away, ailditional bone beinj; renioNcd \\ 
 necessary, it is desirable, but not essential, to completely rcmu\( 
 the lower part of the thrombus; if such is attempted, the jii^'iilai 
 must be opened above the lif,'atiue, and tlu' clot syrin<,fi'd away. 
 Hleediufj; occurs from the posterior part of the u|iper opening,' ;i^ 
 soon as all the coaj^'ulum is removed, but it is easily ( onliollid hv 
 plu|.,'f;in^' the sinus with a small piece of aseptic sponj,^' or i,'aii/t'. 
 The wound in the neck should be lif.;htly stuffed and not ( losed, 
 since septic infection is almost certain to follow. The upper woiiii: 
 is also packed in the same way, and allowed to f^ranulatf. 
 
 {(i) Abscess in the cerebrum or cerebellum is a <'oiuplicatiii!: 
 not unfrecpiently met with, and, indeed, 50 per cent, of a! 
 abscesses of the brain are due to this cause. The inllanimatin! 
 spreads from the middle ear throufjjh the bone to the ni(niii},'(>, 
 and thence either directly to the cerebral substamc tlirouyh 
 adhesions which have previously formed, or alon^i \»iiis n: 
 lymphatics. In the majority of cases (Harker states nine-lfmli> 
 the abscess is situated in the posterior part of the teniporo 
 sphenoidal lobe. Cerebellar abscess is more common in adult- 
 than in children, and occurs in the anterior pt)rtion of one of tin 
 lateral lobes. 
 
 The General Symptoms of cerebral abscess are consiik-rcd ik 
 where (p. 6.S0). In middle-ear mischief they are usually iiisi(lioi;> 
 in onset and chronic in type, though they may terminate suddmh 
 in a train of phenomena similar to apoplexy, due to rupture m 
 the lateral ventricle, or to the occurrence of an acute spivadiii;; 
 (edema (p. 657). The focal effects \ary with the situation. 1" 
 most cases of temporo-sphenoidal abscess they are not markiil: 
 but if the anterior part is involved, irritative or paralytic syniptois 
 may be noted on the opposite side of the face, or aphasia it tic I 
 lesion affects the left hemisphere, whilst if situated in the posttricrj 
 part symptoms of incoordination and giddiness may arise fwf 
 pressure on the cerebellum through the tentorium, almost exacthi 
 simulating those due to an abscess or tumour in the cerehellui"' 
 
 The Diagnosis from thrombosis of the lateral sinus is, as a niie.j 
 not difficult, owing to the fact that in abscess symptoms of com j 
 pression are associated with a low temperature and marked ofU 
 neuritis ; whereas in thrombosis the temperature is higli ii'"j 
 
 »viiN^ 
 
Aii'iicnoss 01- THE i:ar 
 
 779 
 
 sinus is llnrcln' 
 caililv (It'tti minis 
 t ii is tluniuhusfil. 
 
 or pus ivrouml ii, 
 i.r tluis \crilit'(l the 
 lior linrdfi ti{ till 
 ^ is tied ;il :i iii.i 
 
 jis to pi»'\ctU I'll' 
 
 circulation. The 
 til- ihrouilnis iwlly 
 . bi'inu ifiHovfd il 
 , lomplftcly iciiKnc 
 rinpti-tl. ll>f lu^ul.u 
 :lot syrin-iiil ;i\v;iv. 
 e upptT optninf,' a- 
 
 easily i-ouirolkil In 
 ,tif sp'oti^^i- or '^'iiu/e. 
 affeil ivnil not dosed, 
 ,v. Thi- nppt-f wniim: 
 
 granulate. 
 ,n is a i:on>plicatioi! 
 50 per tent, "f all 
 ., The iiitlaniuKiUni! 
 Ine to the nu'nin;;e>, 
 
 1 substanie ihiou':! 
 or alon^^ veins or 
 r states uine-tenilb 
 
 art of the temv^'f"- 
 t. i-onnnon in lulult- 
 ,ortion of one ot lb 
 
 s are consiilereil tin 
 "are usually insiauu;> 
 _y terminate suiUunl! 
 y, due to rupture mw 
 • an acvUe >iv,r:uliK 
 h the situaiixii. I" 
 hey are not niarU; 
 ,r paralytic sy nipt"';-' 
 ace, or aphasia it i^ 
 luated in th.' posterior 
 ness mav arise tro:t 
 briuni. almost exactAl 
 [r in the cerebellum. 
 Ill sinus is, as a rule. 
 U symptoms ot con.I 
 ure and marked opu 
 
 >erature is high ar:il 
 
 oscillatinf,', optic neuritis may be absent, and there may be tiie 
 (haiai teristic tenderness in tiw neck. It must not be torgotteii 
 that the two conditions mav (o-e.Nist. 'I'lie diagnosis from siih- 
 jtinuil (thsit'ss has been already noted. 
 
 The Treatment consists in ^,'i\ inj,^ exit to the pu-^ as (hNcribed 
 at p. 'I'^^i. I'or an abscess in tlie teinpoio-sphenoidal lobe, the 
 ontre pin of the trejihine slioulil be placed i } inches above Keid's 
 base liii", and about the same distance behind the centre of the 
 txtenial auditoiy meatus, altiiough some authors rei ommend a 
 >p()t ',' inch abo\e Keiil's base line, and corresponding; to the 
 posterior border of the osseous meatus (I'ig. 2y(y. D). I'or an 
 aliscess in the cerebellum the point selected is i.^ inches behind 
 the centre of the e.xternal auditory meatus, anil } iiu li below the 
 hasc line (I'lg- 27b, E). In the latter case the scjft parts, including 
 the muscles anil periosteum, should be stripped oil" the occipii.d 
 lume. and turned ilown wards, and it is often uniiei essary to apply 
 a trephine, as the bone is \ery thin, and may be bioken through 
 with a gouge. 
 
 When the diagnosis is doid)tful, the mastoid antrum is first 
 upeiunl and explored ; by carefully reiiiov ing the bone behind and 
 above this opening, the lateral sinus is ne.xt exposed ; and, finally, 
 bv wotking above or below it, the cerebrum or cerebellutn can be 
 (\aiiiineil, and, if need be, incised. 
 
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CHAPTER XXVIII. 
 SURGERY OF THE NECK. 
 
 Affections of the Neck. 
 
 Affections connected with the Branchial Clefts. — In the second or third week 
 of intra-uterine life a series of branchial arclies form in the human embryo, 
 as in other mammalia, constituting the foundation from which the future 
 structures of the neck are developed. In the majority of mammals five such 
 post-oral arches occur, separated from one another by the so-called branchial 
 clefts ; but in man the fourth and fifth are amalgamated. They project from 
 the side of the primitive spinal column, and consist of mesoblast lined on 
 either side by epithelium. They unite across the median line at an early date, 
 and also one with another, thereby leading to a large extent to the obliteration 
 of the clefts. Occasionally, however, this union is imperfect, and sundry 
 malformations result. 
 
 It must be remembered that the mandible and the processus gracilis of j 
 the malleus arise from the first arch ; the Eustachian tube, tympanic cavity, 
 external auditory meatus, and Glaserian fissure from a normally unobliterated , 
 portion of the first cleft ; the styloid process, stylo-hyoid ligament and lesser 
 cornu of the hyoid bone from the second arch ; the body and great cornu oi | 
 the hyoid bone fiom the third arch ; and the rest of the cervical tissues from 
 the remaining arch ; whilst the second, third, and fourth clefts are, under 
 ordinary circumstances, totally obliterated. 
 
 Branchial Fistuise are due to imperfect closure of the branchial clefts. Tliey 
 consist of narrow sinuous tracts extending inwards from the skin, and perhaps I 
 communicating, but not necessarily so, with the pharynx. The external I 
 opening is usually situated along the anterior border of the sterno-mastoid, 
 and most commonly near its lower end, close to the episternal notch, the | 
 fistula then arising from the lowest cleft. They are lined with epithelium, 
 and secrete a glairy or mucoid fluid. They are not uncommonly associated! 
 with other abnormalities, such as macrostoma, absence of the pinna, or 
 accessory auricles situated either near the orifice of the fistula or close to the 
 ear. In the majority of cases they may be disregarded, but if troublesome 
 should be laid open and the lining membrane either dissected away or | 
 destroyed with the galvano-cautery. 
 
 Branchial Cysts arise from incomplete closure of a branchial cleft, the! 
 unobliterated portion being distended with secretion. They usually appear in 
 adolescents, often between the ages of ten and twenty, and are frequently 
 attributed to a blow, which, it may be presumed, brings into activity struc- 
 tures which would otherwise have remained passive. They grow slowly and 
 painlessly, forming rounded swellings with more or less distinct fluctuation, f 
 according to the depth at which they are situated ; their contents, if neartliel 
 cutaneous end of the cleft, are sebaceous in character, similar to that found I 
 in dermoid cysts, but if placed nearer to the pharynx they are occupied byaj 
 
SURGERY OF THE NECK 
 
 781 
 
 I. 
 
 he second or third week 
 in the human embryo, 
 from which the future 
 y of mammals five such ^ 
 y the so-called branchial 
 ted. They project from 
 ;t of mesoblast lined on 
 iian line at an early date, 
 extent to the obliteration 
 5 imperfect, and sundrj- 
 
 he processus gracilis of 
 n tube, tympanic cavity, 
 a normally unobliterated 
 yoid ligament and lesser 
 body and great cornu oi 
 the cervical tissues from 
 fourth clefts are, under 
 
 e branchial clefts. They 
 am the skin, and perhaps 
 pharynx. The external 
 - of the sterno-mastoid, 
 lie episternal notch, the 
 [e lined with epithelium, 
 uncommonly associated 
 jsence of the pinna, or 
 [the fistula or close to the 
 rded, but if troublesome 
 ither dissected away or 
 
 fjlairy mucoid fluid. They are usually lined with squamous ep'thelium, but a 
 lew cases have been recorded in which the cells were columnar, and even 
 cihated, in character. The most common situation is in the third cleft, the 
 cyst then lying between the thyroid cartilage and the anterior border of the 
 sterno-mastoid, in relation with the great wing of the hyoid bone ; when of 
 large size they may extend beneath that muscle, displacing it outwarcls. More 
 rarely a cyst arises from the second cleft, being then located in the upper third 
 of the neck, and tending to spread up towards the styloid process; it may 
 even reach from the mastoid process to the hyoid bone, running parallel to 
 the posterior border of the jaw, and fluctuation may be detected through the 
 mouth. Treatment consists in extirpation when the condition has attained 
 sufficient size to be troublesome. 
 
 Branchial Carcinoma. — Considerable doubt has been expressed as to whether 
 it is possible for carcinoma to originate in the unobliterated remains of the 
 branchial clefts, cases which might have been considered of this nature being 
 ascribed to developments of epithelioma in the deep lymphatic glands which 
 have undergone cystic degeneration, and secondary to some undiscovered or 
 aborted lesion in the pharynx or larynx. The balance of evidence is, how- 
 ever, in favour of the fact that carcinoma can start in this way, giving rise 
 to what has been described as a inalif^nant cyst of the neck. It is characterized 
 by the formation of a tumour placed deeply beneath the sterno-mastoid, 
 iiidefinite in outline, and of firm consistence. Considerable pain is experi- 
 enced, and lymphatic glands become secondarily enlarged. The disease runs 
 its ordinary course, but may destroy life through haemorrhage from the main 
 vessels, which are invaded by the tumour. The cyst sometimes gives way 
 into the pharynx, and a malignant ulcer of the pharyngeal wall is thus 
 induced. Pathologically, the condition is an interesting one, since the tumour 
 does not always possess the characters of an epithelioma. Its embryonic origin 
 is sometimes indicated by the fact that myxomatous and cartilaginous tissue is 
 included in its substance.* Treatment is usually impracticable owing to the 
 deep connections of the growth. 
 
 Various other congenital conditions may be met with in the neck. Con- 
 genital induration of the sterno-mastoid in all probability arises from injury 
 during parturition, and usually occurs in head presentations, probably from 
 bruising of the side of the neck against the under surface of the symphysis ; 
 
 lit is said to be more common on the left side than on the right. In cases 
 that have been examined microscopically, the indurated mass has been found 
 to consist of fibrous tissue. It disappears spontaneously after a time, but 
 may lead to torticollis at a later date. The congenital form of torticollis 
 (P 349). cysts in connection with the thyro-glossal duct, and cystic hygroma, 
 
 I may also be mentioned. 
 
 Cysts of the Neck. 
 
 Many different varieties of cyst are found in the neck, and may 
 |be described as congenital or acquired in origin. 
 
 I. Cysts of Congenital Origin. — (a) Dermoids occur here as in 
 [any other region where congenital remains are found. As already 
 [mentioned, they may develop from the branchial clefts, but may 
 [also be found in the middle line, or in connection with the thyro- 
 [glossal duct, (b) The thyro-glossal duct (Fig. 277) consists of a 
 [tubular outgrowth from the embryonic pharynx passing down- 
 vards behind the body of the hyoid bone in front of the larynx 
 and trachea as far as the isthmus of the thyroid gland, which 
 
 I' For pathological report of a case see Veau, Revue de Chirurgie, March, 1900. 
 
782 
 
 A MANUAL OF SURGERY 
 
 is subsequently developed from it, and unites with the lateral 
 lobes, which in turn spring from the deeper parts of the branchial 
 arches. The upper end of this duct is situated at the foramen 
 caecum of the tongue, and thence traverses the substance of that 
 organ between the genio-hyo-glossi muscles to reach the liyoid 
 bone ; the lower end is represented by the pyramid of the thyroid 
 isthmus. The whole of this tube disappears under ordinary 
 circumstances ; if, however, the upper part remains unobliterated 
 a dermoid cyst may originate from it, placed either in the suh- 
 
 ill 
 
 
 FiCi. 277. — Median Section of Tongue, Larynx, and Trachea, showint, 
 Thyro-glossal Duct extending from the Foramen C^cum of the 
 Tongue downwards behind the Hyoid Bone, and in Front of the 
 Trachea to the Isthmus of the Thyroid Body. (Semi-diagram- 
 matic, FROM College of Surgeons' Museum.) 
 
 A small dermoid cyst in the centre of the tongue is also represented. 
 
 stance of the tongue or immediately below it (see p. 742). If the 
 lower portion remains patent, a cyst develops containing mucoid 
 or glairy fluid, which, however, is not present at birth. It 
 it bursts spontaneously, or is opened, a so-called median cervical 
 fistula results, which requires the same treatment as a branchial 
 fistula, viz., incision, and complete removal or destruction of the 
 epithelial lining. Accessory thyroid growths of an adenomatous 
 nature may develop from any part of the duct, but especially from 
 the lower end ; they are quite innocent in nature, and unless 
 troublesome may be left alone, [c) Cystic hygroma is sometimes 
 congenital, but may also be acquired. It consists of a multi- 
 
SURGERY OF THE NECK 
 
 783 
 
 ilso represented. 
 
 locuhir swelling, the spaces composing it being due to dilatation 
 of lymphatic spaces, and filled with serum. The tumour is often 
 of considerable size, with a sinuous, irregular outline, and may 
 rroduce great deformity and marked pressure effects. The skin 
 0- er it may be occupied by dilated lymphatics. Unless extending 
 to inaccessible parts, such as the superior mediastinum, it should 
 be dealt with by excision. 
 
 2. Acquired Cysts of the Neck are of the following types : 
 u!) Sebaceous cysts develop in the skin as elsewhere, but need no 
 separate notice, (b) Biiysal cysts are stated to occur in connection 
 with the larynx and hyoid bone. There is usually a bursa over a 
 prominent pomum Adami, and this may become enlarged and 
 distended with fluid. A bursa also exists between the back of 
 the hyoid bone and the thyroid cartilage, which might easily be 
 mistaken for one of thyro-glossal origin. In doubtful cases a 
 microscopical examination of the lining wall will quickly settle 
 the diagnosis, since if it is bursr.1 in origin it is lined with endo- 
 thelium, whilst if it is thyro-glossal it is lined with epithelium. In 
 the former case incision and drainage usually suffice to bring 
 about a cure, although excision is preferable ; in the latter case 
 the lining wall must be entirely removed, [c) Unilocular serous 
 (ysts are sometimes met with in the lower part of the posterior 
 triangle, constituting the condition known as ' hydrocele of the 
 neck.' They contain serous fluid, with perhaps an admixture of 
 blood. Their origin has not been defined with any certainty, but 
 they are probably due to a dilatation of the lymph spaces, and 
 are best treated by excision, (d) True hydatid cysts also occur in 
 this region (see p. 151). (e) Blood cysts have been found in close 
 connection .v'ith the large vessels of the neck. They are possibly 
 due to the dilatation of a vein, and may communicate or not 
 with some vascular channel, such as the jugular, being then 
 partly emptied on pressure. Where no communication with a 
 venous trunk exists, the lining membrane is intensely vascular. 
 In the former case they may be treat >d by excision, securing 
 the vessels with which they communicate above and below ; in 
 the latter tapping and injection of perchloride of iron may suffice, 
 or they may be opened and stuffed. (/) Cysts are also occa- 
 sionally met with in connection with the salivary glands and the 
 tkj'roid body, (g) Malignant cysts arise, as already mentioned, 
 from the remains of the branchial clefts, or from a degeneration 
 of epitheliomatous lymphatic glands. They are often of large 
 size, and their removal is impracticable owing to the adhesions 
 which they contract to the deeper structures. 
 
 Cut Throat. 
 
 Injuries of the neck are commonly met with in cases of attempted 
 homicide or suicide, and vary much in severity according to the 
 
784 
 
 A MANUAL OF SURGERY 
 
 extent and position of the wound. A right-handed suicide usuallv 
 cuts his Ihroat from left to right, and therefore the incision is bold 
 and clean on the left side, tailing off towards the right ; in a left 
 handed suicide the incision runs in the opposite direction. A 
 homicidal cut-throat varies in its direction according to whether 
 it is done from behind or in front, and also with the hand eni{)loyed. 
 If the front of the neck is mainly involved, the air-passa^^es are 
 laid open and the patient's life, though much endangered, is not 
 necessarily destroyed. If, however, the wound chiefly affects the 
 side, the great vessels and nerves may be divided, and death from 
 haemorrhage is very liable to ensue. The course and treatment 
 of the latter class of case require no particular notice, since the 
 general principles relating to all wounds must be adhered to, 
 Where, however, the air-passages have been opened, special 
 conditions and complications arise, requiring suitably modified 
 treatment. 
 
 Wounds involving the Air-passages, the result of cut throat, may 
 be situated at four different levels : (a) above the hyoid bone, 
 encroaching on the base of the tongue ; (b) through the thyro- 
 hyoid space, the most common situation ; {c) in the larynx ; and 
 (d) opening or dividing the trachea. 
 
 The immediate effects of such lesions are due to shock, liaemor- 
 rhage, asphyxia, or the entrance of air into veins. When above tk 
 hyoid bone, the root of the tongue and submaxillary region are 
 involved, and haemorrhage from the lingual or facial arteries or 
 their branches follows ; if the wound extends far enough, the 
 main vessels are divided, and death results. In the less severe 
 cases the patient runs considerable risk of being suffocated by the 
 epiglottis and base of the tongue falling back over the larynx. 
 Much difficulty will be subsequently experienced in feeding the 
 patient, owing to impairment of the movements of the tongue. 
 When the thyro-hyoid space is opened, the origins of the facial and 
 lingual arteries are again in danger, as also the upper part of the 
 superior thyroid. The base of the epiglottis is divided, and portions 
 of mucous membrane around the entrance of the larynx may be 
 detached, and cause obstruction to respiration. Blood may also 
 trickle down the larynx into the trachea, and lead to asphyxia, 
 Wounds of the larynx are usually transverse, and not very exten 
 sive, owing to the resistance offered to the knife by the cartilage. 
 The thyroid body may be wounded and bleed freely, otherwise 
 there is but little haemorrhage. Blood may find its way into the j 
 trachea or lungs, and asphyxiate the patient. When the tvachu 
 is involved, the common carotid and inferior thyroid vessels are j 
 very liable to be wounded, giving rise to severe, if not fatal, 
 haemorrhage. Asphyxia may be brought about by displacement \ 
 of the severed portions of the tube, or from the entrance of blood 
 into the air-passages, whilst air may also be sucked into opened j 
 
SURGERY OF THE NECK 
 
 785 
 
 \eins. The recurrent laryngeal nerve may be di\ided, causing 
 paialvsis of the larynx. 
 
 ThV secondary eflfects following cut throat are mainly inflain- 
 nuitorv in origin, {a) Any form of septic inflammation may occur 
 in tlie wound, possibly giving rise to cellulitis, whicii may spread 
 downwards to the mediastinum. Where it involves the tissues 
 above the entrance to the larynx, cedema of the glottis may be 
 produced. Secondary haMnorrhage also arises from this cause, 
 and e\en general pyaemia. {h) Inflammation of the aii'-passa<j;es, 
 tracheitis, bronchitis, or broncho-pneumonia, frequently follows, 
 partly as a result of the entrance of cold air, partly from the 
 admission of septic material, such as food, decomposing blood- 
 clot or discharges. The patient may become cyanosed from these 
 causes, and in consequence of this partial asphyxia, the sensibility 
 of the mucous membrane of the glottis is diminished, allowing of 
 the passage into it of food which appears at the mouth of the 
 wound ; in some cases this may have arisen from division of the 
 superior laryngeal nerve, but the depth at which this structure is 
 situated in the neck makes it difficult to conceive how it could be 
 divided without injury to the main vessels, (c) Suvgical emphysema, 
 or the entrance of atmospheric air into the cellular tissue, may 
 also follow a wound involving the air-passages. It is not limited 
 to the neck, but extends to the trunk, being recognised by the 
 puffy distension of the part, and by a soft crackling crepitus 
 elicited on pressure. It is of no great consequence, and usually 
 disappears in the course of a few days, {d) Septic traumatic fever 
 is almost always present in these cases, the temperature varying 
 with the extent of the inflammation in the cellular tissue or in the 
 luns,^s. 
 
 The Treatment consists in securing all bleeding-points, if pos- 
 sible, but occasionally they are placed so deeply that it is neces- 
 -<\\\ to tie the external carotid. General oozing from the surface 
 must be attended to, for fear of blood being sucked into the air- 
 passages ; if it persists after thoroughly opening the wound and 
 : exposing it to the cold air, it must be checked by sponge pressure. 
 Every attempt should be made to render the wound aseptic, and 
 there is a reasonable prospect that this has been attained, it 
 [may be closed by sutures in the ordinary way. Where, however, 
 asepsis is doubtful, only the ends of the incision should be drawn 
 to::(ether, the central portion being left open. 
 
 The treatment of the air-passages varies with the site of the 
 I lesion. If the trachea has been roughly divided, the portions should 
 be steadied by a stitch on either side, and a tracheotomy-tube 
 Imserted — at any rate, for a few days ; in some cases where cleanly 
 cut, total closure without the use of a tube can be safely effected. 
 [When the wound involves the larynx, it is desirable to close 
 [the opening at once, since the larynx does not readily tolerate 
 [the presence of a tube ; if it is necessary to introduce one, it is 
 
 50 
 
786 
 
 A MANUAL OF SURGERY 
 
 better to perform a high tracheotomy. When the wound iiuoKts 
 the thyro-liyoid space, or is situated above the hyoid bone, it iv 
 c|uite safe in many cases to totally close the wound layer by lavtr 
 after carefully disinfecting^ it. The mucous membrane is first 
 dealt with by stitches wiiich do not penetrate its whole thickness, 
 and then a more thorough purification of the wound can be under 
 taken ; if the epiglottis is divided, it must be accurately sutured, 
 If there is any doubt as to the advisability of this proceedini;. a 
 high tracheotomy is first performed, and then the wound closed 
 as far as possible. 
 
 In every instance the head should be flexed on the chest, and in 
 suicidal cases a careful watch maintained to prevent the patient 
 tearing the wound open. Extreme shock from loss of blood is 
 dealt with by the infusion of saline solutions, and the patientV 
 general health attended to. Feeding should always be under- 
 taken through a tube passed into the oesophagus, whether that 
 structure is wounded or not, and such should be continued until 
 the patient's natural powers of swallowi g are restored. 
 
 The following Sequelae occasionally result from a cut throat; 
 (a) An ai'yial fistula is the term applied to a persistent communi- 
 cation between the air-passages and the external air, and occur.^ 
 most often in the thyro-hyoid space, the skin and mucous mem- 
 brane uniting one to the other around the margins of the openinf;, 
 In some cases it may be closed ; but if laryngeal stenosis or ad- 
 hesions are present, it must be left alone for a time until these 
 conditions have been treated. The operation consists in separat- 
 ing the skin from the mucous membrane, and in order to accom- 1 
 plish this, the external wound must be enlarged vertically. The 
 edges of the mucous membrane are then pared, and stitched j 
 together horizontally. The external wound is either left open to 
 allow of the escape of air and discharge, or may be partially closed, j 
 and a drainage-tube or gauze stuffing inserted. \h) Layyiigail c. 
 tracheal stenosis, due to the cicatrization of wovmds in these regions, 
 may be remedied by wearing an O'Dwyer's tube (p. 8i]) for a 
 time, or may necessitate the constant use of a tracheotomy-tube, j 
 (c) Aphonia may arise from division of the recurrent laryn,i(eai 
 nerve, and is then usually persistent, (d) Gtsophagcal or phavyuiiii 
 fistula may also in rare instances complicate the healing of an 
 extensive wound in the throat, but tend to close of themselves. 
 and require no special treatment. 
 
 Diseases of the Thyroid Body. 
 
 Goitre.— Enlargement of the thyroid body, or, as it is termedj 
 bronchocele or goitre, is a condition frequently seen in thi,; 
 country, and to which much attention has been directed of recenij 
 years, owing to the discovery that the thyroid body exerciser 
 considerable influence over the metabolism and nutrition of tliel 
 
SURGERY OF THE NECK 
 
 787 
 
 le wound involves 
 hyoid bone, it is 
 md layer by layer 
 lembrane is first 
 s whole thi( knesv, 
 and can be undei- 
 ccurately sutured. 
 this proceeding', a 
 the wovuid closed 
 
 in the chest, and in 
 )revent the yatient 
 m loss of blood !> 
 •„ and the patient's 
 
 always be under- 
 :igus, whether that 
 
 be continued until 
 restored. 
 
 from a cut throat; 
 lersistent comnumi- 
 rnal air, and occutj 
 
 and mucous mem 
 gins of the openini;, 
 geal stenosis or ad- 
 ■ a time until these 
 
 consists in separat- 
 . in order to acconi- 
 •ed vertically. The 
 ' lared, and stitched 1 
 either left open tj 
 be partially closed. 
 
 •d. (b) Laryngeal (A 
 
 ds in these rc<iioiis. 
 tube (p. 811) for a 
 
 a tracheotomy-tube. 
 
 recurrent laryngeal 
 
 \phageal oi' pharyimal\ 
 . the healing of an| 
 lose of themselves. 
 
 , or, as it is termed, 
 Lently seen in this 
 in directed of recent 
 Iroid body exerci* 
 \nd nutrition ot the| 
 
 body. Total absence or removal of the gland or its complete de- 
 . feneration leads to accumulation of mucin in the body, producing 
 niyxddema or tetany; whilst recently it has been suggested that 
 the symptoms of Graves' disease are due to the excessive absorp- 
 tion of normal or vitiated thyroid secretion. 
 
 The Causes of bronchocele are still enshrouded in a good 
 deal of uncertainty. It occurs endemically in this and some 
 other countries, being especially fre(]uent in the hilly parts of 
 Derbyshire and Gloucestershire (and known, in fact, as Derby- 
 shire neck), whilst it is also exceedingly common in Switzerland. 
 The old idea that it occurs more frecjuently in places located on 
 chalk or magnesian limestone is not true, it being more common, 
 perhaps, in regions where the green sandstone and carboniferous 
 limestone crop up. Possibly the disease is due to the presence 
 or absence of some mineral constituent of the drinking water, 
 and the discovery made by Baumann, of Friburg, suggests that 
 an absence of iodine is the cause of the trouble. At any rate, 
 iodine is to be found in the normal thyroid secretion in close 
 combination with albumen, whilst it is absent in cases of goitre, 
 the enlargement of the gland being looked on in the light of 
 a compensatory hyperplasia. Other causes which have been 
 sufjgested are want of sunshine and air, as in the case of individuals 
 who live in viilleys into which the air does not readily penetrate, 
 or in the underground kitchens and cellars of large towns, defective 
 sanitary conditions and the habit of carrying weights upon the 
 head also possibly assisting. In the form ordinarily met with, it 
 is not hereditary to any great extent, and is not influenced by 
 intermarriage ; but it may be congenital, and if associated with 
 skeletal changes, defective growth, and intellectual weakness, 
 constituting the condition known as cretinism and in reality a 
 manifestation of myx(jedema, it certainly runs in families. Cre- 
 tinism is, however, more frequently due to total absence of the 
 1,'land than to degeneration of a goitrous tumour. The ordinary 
 type of goitre seen in this country is much more common in women 
 than in men. 
 
 Varieties and Clinical Features. — Four chief forms of goitre are 
 
 described, viz. : The parenchymatous or simple, the fibro-adeno- 
 
 matous, the cystic, and the exophthalmic ; but the thyroid body 
 
 may become enlarged in other ways, giving rise to the conditions 
 
 ; known as malignant goitre and acute goitre, whilst acute inflam- 
 
 imation is sometimes seen. 
 
 General Features. — In all these cases the thyroid body is the 
 [site of a swelling involving its whole substance, or one or other 
 jot its lobes, or possibly the isthmus alone. Its consistence varies 
 [with the nature of the growth, but it always moves with the 
 [larynx on deglutition. In every form there is probably a certain 
 [amount of anaemia, whilst some of the symptoms characteristic 
 [of the exophthalmic variety are often produced even in simple 
 
 50—2 
 
788 
 
 A MANUAL OF SURGERY 
 
 cases, possibly from tlie excessive absorption of thyroid secretion. 
 Pressure on surrounding; structures leads todyspnoa or dyspha^na 
 and cerebral symptoms may arise from interference with llic mail, 
 vessels, which are displaced outwards. The tracliea is espct iall\ 
 liable to clianj^es of situation and shape from its compression; it 
 is usually flattened from side to side, and is sometimes pushed an 
 inch or more from the middle line (FM^^ 281); atropiiy .if tin 
 cartilaginous rings may also be induced. Pressure on the re- 
 current laryngeal nerve leads to harshness in speaking or ajihonia, 
 and to spasmodic attacks of dyspncea, wiiich may even prove fatal. 
 Simple or Parenchymatous Goitre (I'^ig. 278) consists of a dilTus,' 
 overgrowth of the whole thyroid body, the parts retaining to a 
 
 Fig. 278,— Large Simple or Pakenciivmatous Goitre involvim, 
 
 THE WHOLE GLANI). 
 
 great extent their usual proportions. The acini are not niarktdivi 
 enlarged, but contain colloid material, and there is a nornialj 
 amount of fibrous stroma present. The whole gland is generalivj 
 involved, but possibly one lobe is larger than the other. It iJ 
 soft and elastic to the touch, quite painless, and unless largej 
 gives rise to but little inconvenience. It consists of a diffel 
 hypertrophy, with perhaps some cystic development or iiewi 
 formation of an adenomatous type. When the interstitial tissue! 
 is abnormally abundant, as often occurs in the later stages,! 
 tumour feels harder than us.ual, and is perhaps lobulated. Itij 
 then termed a fibrous goitre, and if the sclerosis is very niarkedj 
 myxoedema may supervene. 
 The Fibro-adenomatous Goitre (Fig. 279) consists in the developj 
 
SURGERY OF THE NECK 
 
 789 
 
 thyroid secretion. 
 iid'Hor clysplKi-,na 
 nee with the miiin 
 iicht'ii is es|Mriall\ 
 ts coinprcssiiiii ; it 
 lu'limes pushed an 
 ) ; atropliy "f ibf 
 rcssure on the ru- 
 jeakin^ or aj'hunia, 
 [\y even prove fatal, 
 -onsists of a dilfusc 
 arts retainin;4 to ;i 
 
 nient of one or more encapsuled adenomatous nodules in the sub- 
 stance of the tliyroid i^ody, which is itself sometimes concurrently 
 enhirf^'ed. These nodules are perhaps most common in the isthmus, 
 luit may occupy one or other lobe, or, when multiple, he scattered 
 throu;,^h the substance of the orj^an. If situated near the surface, 
 their limitation and free mobility in the <,,dand can be easily 
 detected, but when placed deeply their special features cannot be 
 rt'CO},niised. Their structure is identical with that of the },dand, 
 hut may be of a more end)ryonic type. It is impossible to draw 
 [III exact line of separation between this condition and the simple 
 hvpertrophy, which is often of a diffuse adenomatous nature, 
 whilst cystic chan<fes are not unconunon. 
 Cystic Goitre (Cysto- adenoma) arises from the dilatation into 
 
 Goitre invoi.vin<. 
 
 :)1 
 
 ini are not niarke(ilv| 
 there is a norii 
 e gland is ^^enera 
 an the other. It is| 
 jss, and unless largel 
 consists of a ditW 
 evelopment or mi 
 the interstitial tissuj 
 the later stages, ttid 
 .aps lobulated. Itil 
 rosis is very maikt(i| 
 
 )nsists in the develop] 
 
 279. — Fnmo-AOENOMA OF Isthmus of Thyrou) Body in a Woman, 
 AGEU Twenty-three Years. 
 
 lasts of alveolar spaces in the normal gland tissue or in a 
 Ilocalized adenoma. They may be single or multiple, and contain 
 jeither a thin fluid or a thick grumous colloid material, somewhat 
 Bike furniture polish. Intracystic growths of a papillary nature 
 are not unfrec]uent. The lining membrane of these cysts is 
 epithelial in nature, the individual cells being cuboidal when the 
 cyst is small, and flattened out or squamous when large. It is 
 pometiivies intensely vascular, and haemorrhage into the cysts is 
 py no means uncommon, causing the contents to be brown or 
 |)lood-stained. 
 
 Secondary changes occur in any of these varieties, chiefly 
 klfecting the interstitial tissue, which may develop into cartilage 
 brbone, or may calcify, but only in very chronic cases. Haemor- 
 
790 
 
 A MANUAL OF SUUGLHY 
 
 rhaj^'c into tho alveolar spaces or cysts is not uncommon ; iiciit. 
 infective inflanunation may also invoke tin- mass, and mali^qiant 
 disease, visually of a cancerous nature, sometimes su[)erven(s. 
 
 The Treatment of the three preceding forms of j^oitrc niav 
 be considered tof^^ether, as they are Ncry didercnt in nature ii, 
 those which follow. In the early staj^'es palliatixe measures i an 
 be employed, consistin},' in the improvement of the {general licahh 
 and the correction of errors in the personal and sanitary liVLticni. 
 Chanj^e of air to the seaside is often athisable, whilst iron and 
 iodide of potassium may be administered internally, and iodiiK 
 paint or iodide of potassium ointment applied locally. In India 
 cures are often produced by inunction of iodide of niciciny 
 
 Fig. 280. — Diffuse FuiKO-AUKNo- 
 
 MATA OF TuVKOm BOHY WITH A 
 TENDENCY TO BECOME CySTIC. 
 
 Fig. 281. — Large U n ilatkkai. 
 
 (iolTUE DISPLACING THE TkaCHEA 
 
 TO TiiK Right, and Comi'rks.sini, 
 IT Laterally to a Serious Ex 
 
 TENT. (TiLLMANNS.) 
 
 ointment, the part being subsequently exposed to the rays of the 
 mid-day sun ; such treatment is generally impracticable in this 
 country. The deficient amount of iodine present in the gland in 
 these cases explains why this drug is so pre-eminently useful, ami 
 it has been found that the active principle of the gland isolated by 
 Baumann and called ' thyro-iodine ' is the best form in which it 
 can be administered. The exhibition of thyroid extract is some- 
 times followed by a diminution of a simple goitre, and the same 
 explanation of its value probably holds good. 
 , In cases where, in spite of such treatment, the growth persists j 
 or increases in size, other measures must necessarily be employed, 
 and there is no doubt that removal of the tumour or of a part j 
 of the gland is the best practice to adopt. Total extirpation, 
 
SURGERY OF THE NECK 
 
 791 
 
 incoiunion ; ;kuI' 
 iS, Jvtul iii;ili;4nam 
 s supt'txcncs. 
 IS <it' j^oitrc may 
 rent in niiture Id 
 ive measuR's liin 
 the f^cncral hcalili 
 ?aiiit:u"y h\,L;it'ni', 
 e, whilst iron and 
 rnally, and iodini 
 locally. In India 
 udicle of nicrcuiv 
 
 
 RC-.E Un'ilatkk.u 
 li.ACiNc. THE Trachea 
 
 IT, AND COMI'KKSSIN'. 
 
 V TO A Sekious Kx 
 
 , MANNS.) 
 
 I to the rays of the 
 practicable in this 
 pent in the ^dand in 
 linently useful, and 
 le gland isolated by 
 it form in which it 
 [id extract is some- 
 litre, and the same 
 
 Ithe growth persist? 
 Isarily be employed, | 
 Wour or of a part j 
 Total extirpation. 
 
 as already mentioned, results in myxtedeina; but as long as a 
 sufticient portion of the secreting substance is left, whether it is 
 deriM'd from the isthmus or from one of the lobes, no such 
 aaiilcnt need be feared. The opi'ration necessitates a somewhat 
 Jeep dissection, and will encroach on important structures; but 
 witli due care and the maintenance of efficient asepsis, the most 
 satisfactory results are obtained, except when the growth is of 
 very great dimensions. We would particularly emphasi/e the 
 fact that goitres should be treated in the same way as other new 
 i^rriiwths, viz., by removal when small. There is still unfor- 
 tiiiuiti'ly a considerable tendency amongst practitioners and 
 patients to leave them untouched imtil they are of large size, thus 
 ^'really increasing the risk of the operation. Other plans of treat- 
 ment have been utilized in the past, i.t;., ligature of the thyroid 
 vessels, division of the isthmus, curetting the mass with a large 
 \oll<inann's spoon, passage of a seton, or intraglandular injection 
 of irritants, such as tincture of iodine ; but they should be entirely 
 discarded in fa\our of more radical measures. 
 
 Piiyiial thyyoidcctomy (or Kocher's operation) is conducted as 
 follows : An incision is made over the most prominent part of the 
 luinour, preferably along the lower third of the anterior border 
 nf the sterno-mastoid. Kocher recoii:.' '^nds a transxerse or 
 ,ini,ailar incision in order that the scar my be less visible, and 
 iliis may be employed in suitable cases. The platysma and deep 
 fascia are di\ided, the sterno-mastoii.' drawn out^'.nds, and the 
 >terno-hyoid, sterno-tbyroid, and oiwo-hyoid fl'^placed inwards, 
 o! if need be, divided. The lobe to be removed is thus exposed 
 „;,iiin its capsule, which should not b : ripened. The limits of 
 the mass are defined by the finger oi a liiunt dissector, and the 
 vessels entering or leaving it are secured. The superior thyroid 
 vessels are doubly ligatured and divided at the upper end of 
 the growth, the middle thyroid vein is secured at the middle 
 of its outer border, whilst the inferior thyroid vessels are 
 dealt with below, special care being taken of the inferior or 
 recurrent laryngeal nerve by tying the vessels as near to the 
 Inland as possible. The lobe is now freed from the underlying 
 structures, as also the isthmus from the trachea. In detaching 
 the latter, the surgeon must not forget that the cartilaginous rings 
 may have been absorbed, and that the walls of the trachea, being 
 then merely fibrous in nature, are easily wounded. The isthmus 
 should be transfixed cind tied in two halves with a silk ligature, so 
 as to prevent ha-morrhage. The growth can now be removed, 
 the bleeding points secured, and the wound closed, the muscles 
 and fascia being drawn together by buried catgut stitches. A 
 drainage-tube is best inserted for 24 or 48 hours, as it is difficult 
 to employ much pressure on the neck, but this precaution may 
 sometimes be omitted. Healing by first intention should be the 
 invariable result. 
 
792 
 
 A MANUAL OF SURGERY 
 
 *;.ii 
 
 Fihro-adcmmata, when multiple or deeply placed, are treated hv 
 extirpation of the affected lobe ; but if the new growth is single 
 and superficial, its enucleation should be undertaken by the pro 
 ceeding known as Sociti's operation, which has been mainly popu- 
 larized in this country by Mr. C. J. Symonds, of Guy's Hospital. 
 The skin and muscles are divided as before, and the gland substance 
 .tnd capsule incised down to the growth, which is readily shelled out. 
 
 Cystic goitre is treated in the same way as fibro-adenomata, by 
 enucleation, although if several cysts are present removal of the 
 affected lobe may be necessary. The old line of practice, which 
 is still occasionally utilized, consisted in tapping with a full 
 sized trocar and cannula, and injecting with tr. ferri perchlor. or 
 iodine. Good results sometimes followed these measures, hut 
 occasionally the sudden relief of tension within the cyst gave rise 
 to severe haemorrhage from its walls, which threatened the patient's 
 life. In such cases the cyst was laid freely open, and the cavity 
 plugged with sponges or gauze soaked in some strong haemostatic; 
 or it was sometimes feasible to rapidly enucleate the wliole cyst, 
 and then command the haemorrhage by ligaturing the supplyini; 
 vessels. 
 
 Myxmicina (or cachexia strumipriva) is a curious condition, which, as 
 already mentioned, supervenes when tlie thyroid body is totally removed, (r 
 so absolutely disorganized or infiltrated by a new growth as to be functionles> 
 Although it is possible that we still have much to learn of the duties of thi^ 
 organ, yet we do know that the elimination, if not the development, of mucin in 
 the body is controlled by it, and that its absence leads to an accumulation ci 
 this substance in the blood and tissues. The condition and appearance ci 
 the individual are very characteristic. The face is puffy, waxy white and 
 expressionless, with perhaps a hectic flush over the malar eminences ; the 
 tongue is enlarged ; the limbs become thickened and clumsy by an increase i:; 
 bulk of the soft tissues ; there is often a puffy mass occupying the supra 
 clavicular fossa, which, however, does not pit on pressure. The mental 
 faculties are dulled, and all intellectual processes are slow ; the temperature 
 is subnormal, and the heart's action weakened. Left to itself, death will 
 supervene from asthenia sooner or later ; should the case be treated by tliyroiii 
 gland or extract (half a gland, raw or lightly cooked, twice a week, or?. 
 5-grain tabloid once or twice a day), the symptoms soon disappear, and the 
 ciiange from the dull, heavy condition of myxcedema to one of normal health 
 of mind and body is almost miraculous. 
 
 Similar treatment should be employed for niyxcEdematous cretins, wlio often 
 start growing rapidly as soon as treatment commences. 
 
 Tetany is another condition which obtains after complete removal or dis- 
 organization of the thyroid body. It consists in a peculiar irritability of the 
 gray matter of the spinal cord, resulting in the development of tonic contrac- 
 tion of groups of muscles which may last for minutes, hours, or even a da\ cr 
 two ; the irritability of the facial nerve is especially noticeable. The condition \ 
 may prove fatal from spasm of the respiratory muscles, but is more usually 
 chronic, lasting perhaps for years, and running its course concurrently with i 
 myxcedema. It is supposed to be due to actual poisoning with mucin, ami 
 the treatment require'd is the same as for myxcedema. 
 
 Exophthalmic Ooitre, or, as it is often termed, Graves' or 
 Basedow's disease, is a condition characterized by a diffuse 
 
SURGERY OF THE NECK 
 
 793 
 
 ;d, are treated l)y 
 growth is single 
 aken by the pro- 
 sen mainly popu- 
 [ Guy's Hospital. 
 le gland substance 
 eadily shelled out. 
 »ro-adenomata, by 
 nt removal of the 
 of practice, which 
 iping with a full- 
 ■. ferri perchlor. or 
 3se measures, hut 
 the cyst gave rise 
 itened the patient's 
 len, and the cavity 
 strong haemostatic; 
 ate the whole cyst, 
 iring the supplyins.; 
 
 condition, which, a- 
 ■ is totally removed, cr 
 th as to be functionles. 
 rn of the duties of thi, 
 velopment.of mucinin 
 5 to an accumulation ut 
 on and appearance of 
 puffy, waxy white anJ 
 malar eminences; the 
 umsy by an increase ir, 
 
 occupying the supia- , 
 
 pressure. The menial 
 
 I slow ; the temperature 
 
 :ft to itself, death will 
 
 ie be treated by thyroid 
 
 Id, twice a week, or ?. 
 
 ion disappear, and the 
 
 one of normal health 
 
 latous cretins, who often 
 
 Implete removal or d^- 
 ^uliar irritability of the 
 jment of tonic contrac- 
 .lours, or even a day cr 
 Iceable. The condition i 
 les, but is more usuallv | 
 lurse concurrendy wU'i 
 toning with mucin, and 
 
 termed, Graves' or! 
 rized by a diftuse| 
 
 en 
 
 argement of the thyroid body, which often pulsates forcibly 
 
 owing to the dilatation of the vessels (particularly those in the 
 capsule), associated with marked anaemia, severe palpitation and 
 cardiac irritability (tachycardia), and protrusion of the eyeball 
 (exophthalmos or proptosis). The nature of the disease has long 
 been a topic of discussion, one of the earliest ideas being that 
 it results from some derangement of the sympathetic nervotis 
 system, or possibly of the medulla. Lately, however, owing to 
 the fact that in cases where thyroid extract has been given to 
 excess symptoms somewhat akin to those seen in this condition 
 have arisen, it has been suggested that the disease is due to the 
 excessive absorption of thyroid secretion, although why it occurs 
 in some cases of enlargement, and not in others, has not been 
 explained. In all probability the truth lies half-way between 
 the two theories, the enlarged thyroid and some of the symptonts 
 being alike due to some central disturbance in the upper part 
 of the medulla, whilst others are due to excessive absorption of 
 thvroid secretion. 
 
 The patients usually affected are females, about the middle 
 period of life, whose menstrual functions are often impaired. 
 Overwork, worry, and severe mental strain, are apparently re- 
 sponsible for the onset of the symptoms in many instances, and 
 a sudden shock or fright accounts for others. The protrusion of 
 the eyeball is a marked feature of the case, and has been supposed 
 to he due to an increase of the orbital fat, but this is very doubtful. 
 Contraction of the so-called muscle of M tiller (unstriped muscular 
 fibres stretched across the spheno-maxillary fissure) has been 
 suggested as a more plausible theory. When the patient looks 
 down, the upper eyelid does not immediately follow the eyeball, 
 allowing the white sclerotic to be seen between the lid and the 
 cornea (von Graefe's sign). A fine fibrillary tremor of the limbs 
 is also conunonly observed in these cases. The patient is always 
 extremely nervous, and the pulse-rate high ; any exertion or 
 excitement increases the irritability of the heart's action, and 
 I may induce considerable respiratory distress. Left to itself, the 
 disease in some cases tends to improve, but in others it may 
 progress to a fatal issue from asthenia or cardiac complications. 
 
 Treatment consists in freeing the patient, if possible, from all 
 sources of worry, whilst bromides, iron, and perhaps iodide of 
 potassium, are administered internally, attention being also directed 
 to correcting menstrual derangements, or any other abnormalities 
 of function or structure ; thus, the cure of a nasal catarrh by 
 the nasal mucosa has several times led to a rapid 
 aiiielioratioa of the symptoms. Phosphate of soda has lately 
 Ibeen much connnended in this disease, and Kocher speaks favour- 
 iahly of it when conjoined with suitable hygienic measures. 
 
 liymus extract has also proved beneficial. 
 
 Since the introduction of the theory that the derangement is 
 
794 
 
 A MANUAL OF SURGERY 
 
 mainly tliyn)i(lal in orij^'in, surf^ical treatment by removal of a 
 portion of the t^laiul has been suffj^^ested, and the residts f^aiiud 
 so far have been enconraffinj;, altliou},^! the proceedinf^^ is noi 
 devoid of serious risk, and should not be lightly undertaken. 
 Half of the f^land has usually been removed, but some suis^cons 
 have been satisfied with tyin^if three of the thyroid arteries in 
 order to starve the fijrowth. The patients never take an anas 
 thetic well, and several fatal results have ensued from this ( ause. 
 They are also very liable to syncope after the operation, and occa 
 sionally a curious train of symptoms supervenes within a few 
 hours. The temperature rises suddenly to 104° or 105", the pulse- 
 rate is f^reatly accelerated, and the patient becomes delirious, 
 and finally comatose, dying in that state in about forty-eight hours. 
 It is supposed that excessive thyroid toxicmia is responsilile for 
 these phenomena. In the cases that recover, a gradual itn[)r()ve- 
 ment usually shows itself, but the full benefit ■ "" the operation is 
 rarely gained under six or twelve months, and even then the 
 exophthalmos often persists. It is a little doubtful whether the 
 improvement is really to be ascribed to the operation, or to the 
 altered environment necessitated by it. The symptoms sometimes 
 recur at a later date, and such cases have been treated by re- 
 moving another jiortion of the gland. 
 
 b2xcision or di\ision of the cervical chain of sympai''etic 
 ganglia has also been employed in this condition, and apparently 
 with good effects ; but no final statement as to its value can yet 
 be hazarded. 
 
 Malignant Disease of the Thyroid Body is more fretjuently 
 cancerous in nature than sarcomatous, usually taking the form 
 of an adenoid cancer, and alv/ays preceded by simple enlari,'e 
 ment. The tumour grows rapidly, infiltrating the surrounding' 
 parts, and causing enlargement of the lymphatic glands, ami 
 secondary deposits in the viscera and elsewhere. The trachea is 
 severely compressed, and in some cases perforated by the growth. 
 The secondary deposits frequently affect osseous tissues, con- 
 stituting pulsating tumours exactly simulating thyroid tissue in 
 nature. Myxerdema may ensue as a complication, owing to tht 
 total destruction of the glandular substance. Treatment hy 
 extirpation can only be undertaken in the early stages. 
 
 Acute Goitre is but rarely met with, consisting of a rapid 
 enlargement of the thyroid body, which attains a considerahle 
 size in the course of a few days or weeks. It affects yoiiiii; 
 subjects, and is generally fatal from asphyxia due to pressure on 
 the trachea or spasm of the glottis. Comparatively little can l)e 
 done for such cases ; incisions into the fascia, division of the 
 isthmus, and tracheotomy, have been suggested. In the latter 
 
SURGERY OF THE NECK 
 
 795 
 
 case it will be necessary to have a specially lon^; tube, which can 
 he passed for some distance down the trachea. 
 
 Inflammation of the Thyroid Body, or acute thyroiditis, occa- 
 sionally supervenes as a complication of an ordinary f^foitre. It 
 is almost always infecti\e in nature, the c(jcci reaching it from 
 without, as in a punctured wound, or from within the liody on a 
 pvii'iiiic embolus, suppuration bein}^ usually induced ; it some- 
 times follows a blow, and may then be simple. The f^land 
 hecoiiies enlarj^ed, hot and tender, fever and rigors follow, and 
 the presence of pus is indicated by superficial (edema and fiuctua- 
 tion. The early treatment consists in the application of fomenta- 
 tions and perhaps leeches, or in the use of an ice compress. The 
 patient is kept in bed, purged, and carefully dieted. Under such 
 aiej,'iiiie, resolution may occur ; but if, as happens more frecjuontly, 
 pus forms, free incisions should be made. 
 
 Accessory Thyroids sometimes develop above or below the 
 isthmus, or closely attached to one of the lateral lobes. They 
 are recognised by their connection with the thyroid body, moving 
 up and down with it on deglutition, and if troublesome should be 
 removed. They may also occur in any part of the thyro-glossal 
 duct, and even in the base of the tongue, in that situation 
 
 resembling a dermoid cyst. 
 
CHAPTER XXIX. 
 
 SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST. 
 
 Foreign Bodies in the Air-passages. 
 
 A\Y part of the respiratory tract may be partially or completely 
 obstructed by the presence of some foreign body, the effect ot 
 which may be of greater or less gravity according to the situation, 
 character, and size of the intruding substance. 
 
 1. In the Nasal Passages, see p. 715. 
 
 2. Obstruction occurring at the Rima Glottidis, or pharyngeal 
 entrance to the larynx, is usually due to attempts to bolt largt 
 masses of food, which, becoming impacted, may cause immediate 
 death. A person, eating a meal voraciously, turns black in the 
 face and falls off his chair, dead. A similar result has followed 
 such a foolish iict as attempting to swallow a billiard ball. If 
 the obstruction is not complete, as vi'hen a plate of false teeth 
 becomes impacted, great dyspnoea is caused, and absolute inability 
 to swallow, the symptoms rapidly increasing owing to a>dema of 
 the submucous tissue of the glottis. Accidents of a similar nature 
 may occur during chloroform narcosis, an epileptic fit, or drunken 
 ness, some such substance as a plate of teeth being dislodged from 
 the mouth, or a mass of food being vomited, and blockinj, the 
 entrance to the larynx. The Treatment must be very prompt, 
 since there is no time to lose. The mouth should be forced open 
 by the handle of a fork or anything suitable that happens to be 
 near, and the finger rapidly swept round the pharynx so as to 
 dislodge the foreign body. Failing this, laryngotomy must be 
 performed at once, and artihcial respiration, if necessary, instituted. 
 In less urgent cases there is time to remove the substance from 
 the mouth with the assistance of a frontal mirror. 
 
 3. In the Larynx. — A foreign body enters the larynx by inliala 
 tion during a deep inspiratory effort, when the glottis is widely j 
 open. Anything large is likely to be stopped above the larynx, 
 and hence the type of foreign bodies we find in this region consists j 
 of small coins, buttons, nutshells, or a small tooth-plate. It may 
 cause total obstruction and immediate death, or may enter one of I 
 
3, AND CHEST. 
 
 ally or completely 
 3ody, the effect of 
 ng to the situation, 
 
 idis, or pharyngeal 
 mpts to bolt lars^f 
 ay cause immediate 
 turns black in the 
 result has followed 
 a billiard ball. It 
 plate of false teeth 
 id absolute inability 
 owing to trdeniaof 
 s of a similar nature 
 ;ptic fit, or drunken- 
 ,eing dislodged from 
 |d, and blocking the 
 ist be very prompt. 
 lould be forced open 
 that happens to be 
 . pharynx so as to 
 .ryngotomy must be 
 lecessary, instituted. 
 the substance from 
 
 Irror. . 
 
 ihe larynx by mhaln- 
 he glottis is widely 
 id above the larynx. 
 in this region consists 
 tooth-plate. It may 
 , or may enter one 
 
 SUKGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 797 
 
 the ventricles, and only produce partial obstruction, as evidenced 
 by a sudden sense of suflfocation, urgent dyspna-a, and a violent 
 attack of coughing, attended perhaps by vomiting, such as occurs 
 when anything is said to have ' gone down the wrong way.' The 
 voice becomes croupy and hoarse, respirations stridulous, and any 
 movement of the patient may for some time bring on a spasmodic 
 fit of dyspnoea. After a while the obstruction, which is at first 
 partial, may become complete from oedema of the glottis, whilst 
 perichondritis and ulceration or necrosis of the cartilages may be 
 induced. Laryngoscopic examination should reveal the situation 
 of the intruding body. The Treatment consists in attempting to 
 remove it through the mouth with suitably curved forceps guided 
 hv a laryngoscope (endo-laryngeal method) ; or, failing that, a 
 laryngotomy is performed, and the body dislodged if possible from 
 below. Should this not be successful, thyrotomy (p. 802) must 
 he undertaken. 
 
 4. In the Trachea. — To lodge in this situation a foreign body 
 must be small enough to pass through the glottis, and not too 
 heavy, otherwise it drops into one of the bronchi ; it may become 
 impacted, if it has jagged edges, but is not uncommonly free. It 
 may remain in one spot, only moving when the patient alters his 
 position or coughs, and then the longer it stays, the less moveable 
 it is, owing to its becoming embedded in mucus. 
 
 The Symptoms may be described as those of obstruction, irrita- 
 tion, and inflammation. During the passage of the body through 
 the larynx, the patient suffers from a severe attack of spasmodic 
 dyspncca and coughing, which may last for some time. Later on 
 similar attacks may be induced by the foreign body being coughed 
 up against the lower aspect of the vocal cords, and death has 
 even resulted from its impaction in the larynx brought about in 
 this way. The irritation of the unusual occupant of the trachea 
 produces tracheitis, with frothy expectoration and spasmodic 
 cough ; the lower it lies, the less the irritation, the mucous 
 membrane being apparently less sensitive as it descends from the 
 larynx. Treatment consists in performing a low tracheotomy with 
 a good-sized opening, and if possible removing the intruding body 
 at once ; or the patient may be inverted and the back well 
 concussed in order to dislodge it. Failing this, the wound in the 
 trachea must be left widely open, by inserting a wire stitch 
 through each side of the incision and tying the ends behind the 
 neck ; very probably the body will be expelled through it during 
 an attack of coughing. 
 
 5. To become iinpacted in a Bronchus, the foreign body nmst 
 
 he sufficiently small to pass through the rima glottidis, and heavy 
 
 and smooth enough to allow of its dropping down the trachea : 
 
 ;the nujst common articles met with are buttons, pebbles, slate 
 
 [pencils, an O'Dwyer's tube, or the inner cannula of a tracheotomy- 
 
 Ituhe. The right bronchus usually becomes obstructed, the 
 
^1! m 
 
 798 
 
 A MANUAL OF SURGERY 
 
 reason for this being that although the left bronchus is niorc in ^ 
 direct line with the trachea, yet tlie right is the larger, the S( ptum 
 between them lying to the left of the middle line. A sciies oi 
 symptoms similar to those described above manifests itsell, viz., 
 obstruction, irritation, and inHannnation. The obstruction is 
 twofold : inuiiediate, as a result of the passage of the hotly 
 through the glottis, a condition due more to spasm tlian li) 
 mechanical causes ; and late, as a sequence of its lodgiiicni in 
 the bronchus. Even if at first the obstruction is partial, it soon 
 tends to become complete from swelling of the mucous menihrane ; 
 for a time it is more or less valvular in cliar^^cter, allowing exit 
 to air during expiration, but absolutely preventing its entrance'. 
 Collapse of that portion of the lung supplied by the affected 
 bronchus is thus induced, as indicated by dulneas and the absencu 
 of breath-sounds. Irritation and inflammation soon follow, re- 
 sulting in bronchitis, the formation of a bronchiectasis, and peri 
 bronchial pneumonia ; suppuration ensues, and the foreign hodv 
 may be expelled sooner or later with a sudden gush of pus durin|j 
 a fit of coughing. Thus, in a case treated by the late Mr. \\'ii;iani 
 Rose (grandfather to one of the authors'''), a beech-mast was 
 inhaled in November, 1812, and was not extruded till May, 1822, 
 the patient having in the meantime developed all the symptoms 
 of a bronchiectasis. Sometimes the at)scess may extend tlnou.i,'li 
 the lung substance to the pleura, setting up a localized empyema. 
 through which, when opened, the article is expelled. In other 
 cases the lung becomes riddled with abscesses, and the patient 
 dies of exhaustion. 
 
 Treatment. -The position of the foreign body must be, if 
 possible, ascertained by careful examination of the lungs. 
 which may reveal a certain amount of collapse, whilst skia- 
 graphy may also be useful. A low and extensive trache- 
 otomy is then performed, and the bronchi examined by a lorn; 
 bullet probe, suitably curved. The foreign body may thus In 
 felt, and its removal accomplished by a delicate pair of forceps, a 
 loop of wire, or a coin-catcher. Abscess of the lung, and localized 
 einpyema, are dealt with by incision, and it is possible that thr 
 foreign body may be removed by this means through the thoracic 
 parietes. 
 
 Injuries of the Larynx. 
 
 Several conditions arising from traumatism of the upper air- 
 passages have been already described, e.g., fracture of the hyoiii 
 bone (p. 413), and incised wounds, as in cut throat (p. 784). 
 
 Occasionally the thyroid or other cartilages may be injured or 
 fractured by direct violence, as in garrotting, causing local pain 
 and haemorrhage, and possibly some obstruction to the respira- 
 
 * Lancet, August, 1843. 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, .IND CFIEST 799 
 
 tion. As a rule, no treatment is re(]uirecl beyonil keepin<f the 
 piitit'iit ([uiet, but should symptoms of dyspna^a arise, intubation 
 
 of the upper air- 
 Lcture of the hyoid 
 
 roat (p. 7^4)- 
 may be injured or 
 causing local pam 
 
 ion to tbe respira 
 
 or tracheotomy must be undertaken. 
 
 Diseases of the Larynx. 
 
 !. 
 
 Till! study of laryngeal diseases can only be briefly referred to liere, since it 
 is now s<j extensive as to reciuire special text-books. 
 
 Hefure the student can understand the subject, it is alisolutely essential for 
 liim to master the use of the larynguscopc . This consists of a circular mirror 
 ,et at an angle on the end of a 
 int'tal stem, which is inserted 
 into the patient's widely-opened 
 inoutli in ;iuch a way that it 
 rests af,'ainst, and slightly ele- 
 vates, tile soft palate. A beam 
 of lif^ht is thrown into the 
 moiitli, either from an electric 
 head -lamp on the surgeon's 
 loifhoad, or reflected by a 
 irontal mirror from a suitable 
 xmrce of illumination. The 
 patient's tongue, held with a 
 towel, is drawn well forwards so 
 as to enable the light to reach 
 the larynx, the image of which 
 is seeii in the mirror. Con- 
 siderable practice is needed in 
 order to attain any facility in 
 
 the use of this instrument, as 
 
 also to be able to recognise 
 
 normal from abnormal struc- 
 tures. The use of cocaine to 
 
 aiia'sthetize the fauces is in 
 
 many cases indispensal)le. It 
 
 must be remembered that the 
 
 image is always inverted, so 
 
 that the anterior portion of the 
 
 larvnx appears behind, but there 
 
 is no reversal of the sides. 
 Acute and Chronic Laryngitis 
 
 are conditions of but slight 
 
 surgical interest. The acute 
 
 atlection arises from cold or 
 
 over-exertion of the vocal ap- 
 paratus, and is characterized 
 
 \'\ apiionia (loss of voice) and 
 
 I 'Ugli. Locally, the vocal cords 
 
 are seen to be hyperajmic and 
 
 swollen. The Treatment is rather 
 
 medical tlian surgical, although 
 
 HI children intubation or trache- 
 
 utomy may be sometimes re- 
 quired. 
 Diphtheritic Inflammation of the Larynx is usually met with as an extension 
 
 "I a similar affection of the fauces. It gives rise to severe dyspna;a from 
 
 i)hstruction in the rima glottidis, and, if the condition does not yield to the 
 
 injection of the diphtheritic antitoxin, will probably require intui)ation or 
 
 traclieolomy. 
 
 Fig. 282. — (lCi:)KMA ok Glottis and Tonguk 
 
 FROM lililllND. (CoLLKdE OI" SUKGEONS' 
 
 Museum.) 
 
 The tongue is seen to be enlarged and swollen, 
 and the aryteno-epiglottidean folds are 
 cedematous, so that the entrance to the 
 larynx is represented by a mere ciiink. 
 
'fiM m 
 
 800 
 
 A MANUAL OF SURGERY 
 
 Acute (Edematous Laryngitis, "r (i;demanf the glottis, is acondition nf cun 
 sidorahle burgicai importance. Causes. — (u) It is eitlier secondary tu sfinir 
 otlier laryngeal affection, siicli as acute catarrhal laryngitis, or acute pirj. 
 chondritis; or (/j) may extend from inflammatory conditions of noigiihourini; 
 tissues, such as the root of the tongue, or the sid)maxillary region, ,.;■., ;,^ 
 cellulitis or Ludwig's angina; or it maybe secondary to a retropharvn.i,'(;il 
 abscess. (c) It is also not unfreeiuently seen in cliildren from tlrinkin;. 
 scalding water, as from the spi)ut of a kettle, or sometimes in adults Iri ni 
 swallowing corrosives, (d) It may result from the presence of a foreign lioiK 
 Cluiniitiis. — The folds of mucous membrane extending on eitlier side of tin- 
 epiglottis both to the root of the tongue and b.ackwards to the arytenoid car- 
 tilages become swollen and crdematous from a serous infusion into the suli 
 mucous tissue (Fig. 282). The same condition also involves tlie inter-arvteiv 1 ' 
 fold and the false vocal cords (superior thyro-arytenoid folds), extending,' dnnn 
 as far as the true cords. The process is checked at this level owin^' to tlu.- 
 absence of submucous tissue, the vocal cords consisting of elastic filirts, 
 merely covered with a layer or two of squamous epithelium. The epij,'lotti^ 
 becomes folded laterally upon itself as a leaf, merely leaving a valve-like ciiink 
 which permits of expiration, althougli considerably checking inspiration Tl.^ 
 Syiiiptoiiis produced by this condition are those of mechanical dvs|)iiiia 
 to which, not unfrequently, spasm of the glottis is superadded, and tliis ;, 
 sometimes of sufficient intensity to destroy the patient's life. There ni,->y iie 
 also some amount of febrile disturbance. Tlie diagnosis is made, either liv 
 passing the finger into the pharynx, when tlie rigid swollen epiglottis ciii 
 be felt, or by laryngoscopic examination, when the slit-like opening of tht 
 glottis, bounded below and behind by thickened (edematous folds nt imic( n- 
 membrane, can be seen. Treatment consists in scarification of tlie swdllii. 
 tissues below and behind the epiglottis, which can be effected, after spraviiu' 
 the parts with cocaine, either by the finger-nail or with a suitable knife f,'ui(lil 
 by a laryngoscope. The usual result is a rapid diminution of the (edema, 
 and additional relief may be gained by inhaling steam arising from liot water, 
 to which some tinct. benzoini co. has been added. Fomentations or ice com- 
 presses applied externally are also useful, especially the latter. In nioresevir 
 cases, and especially in children, intubation may be necessary, or tlie a:r 
 passages may be opened below the obstruction, laryngotomy sufficing in adiil:^ 
 but a liigh tracheotomy being needed in children. 
 
 Sjrphilitic Disease of the Larynx. — In the sceondayy stage, mucous tuherclc^ 
 or superficial ulcers occasionally form in the neighbourhood of the vocal ciiri!\ 
 concurrently with the rash on the skin, and the formation of condylomata am! 
 mucous tubercles elsewhere. It is very likely to occur in costermonKers ir 
 those who have to speak loudly, and may then lead to a good deal of thicker.ini' 
 of the cords. Apart from such cases, it rarely causes much trouble lieyniil 
 a little hoarseness. No special treatment is required, although po.ssii)ly tiK 
 parts, if ulcerated, may be brushed over with a solution of perchioriile "t 
 mercury. In the tertiary period, diffuse gummatous, infiltration or locali/ei! 
 gummata may develop, giving rise to destructive ulceration, which especially 
 aftects the epiglottis and aryteno-epiglottidean folds, and may spread back- 
 wards and involve the whole glottis (Fig. 283). Inflammation of tlie peri- 
 chondrium is likely to follow, leading to necrosis of the cartilages. Hoarseness I 
 and dyspnoea are the chief symptoms of this affection, whilst considerable] 
 obstruction may be subsequently caused by cicatrization and laryngeal steiio.s!.< 
 Treatment consists in the administration of iodide of potassium and lueiciiry, 
 whilst ulcers may be sprayed with perchloride of mercury solution, ordiistedl 
 over with calomel or iodoform. Should urgent dyspnoea arise, tracheotomy | 
 must be undertaken. 
 
 Tuberculous Laryngitis (Fig- 284) is occasionally a primary manifestation,! 
 but is much more frequently secondary to phthisis, arising from infectionj 
 of the mucous membrane owing to the constant passage over it of tliel 
 sputum. It usually commences at the posterior part of the laryn.x in ihel 
 
IS a condition of cdii- 
 ■ secondary tn some 
 igitis, or acute pi-ri- 
 ons of ncii^liliouriiii; 
 illary region, c.k.. in 
 to a retropliarvntjtal 
 Idren from diiiikin;' 
 times in adults In ni 
 nee of a foreifjn liody 
 on eitlier side of ilie 
 to the aryteniiid car- 
 infusion into ihf siih- 
 /estlie inter-arytem :! 
 olds), extending down 
 lis level owinj,' to tl\e 
 :ing of elastic fibris, 
 2lium. The epiKloltis 
 ,'inK a valve-like chink 
 kin" inspiration Tlie 
 mechanical dvsiimi;!. 
 peradded, and this ;. 
 s life. There mny he 
 isis is made, either l-y 
 swollen epiglottis ran 
 .it-like opening of ih- 
 aatous folds ot nnici .b 
 ication of the swolkn 
 effected, after spra\ in;; 
 a suitable knife f^uidfl 
 inution of the (edema, 
 arising from hot water, 
 )mentations or ice com- 
 latter. In more severe 
 necessary, or the air- 
 tomy sufticing in adiilo 
 
 itage, mucous tuherclcs 
 [hood of the vocal cerds, 
 fion of condylomata and 
 ur in costermoiiKers or 
 1 good deal of thickening! 
 Is much trouble heyimd 
 1 although possibly me 
 lition of perchUn-ide "I ■ 
 [infiltration or locahzed ] 
 Iration, which especialv 
 1 and may spread bac»- 
 ammation of the per;-, 
 cartilages. Hoarseness 
 [on whilst considerahlef 
 [n and laryngeal stenosis : 
 jotassium and mercury, 
 [cury solution, or dusted 
 ',noea arise, tracheotomy 
 
 , primary mani{estati<;n,j 
 
 I arising from infecu-"! 
 
 Ipassage over it ol w\ 
 
 frt of the laryn.x in ttel 
 
 SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 8oi 
 
 neighbourhood of the arytenoid cartilages, as a submucous infiltration, which 
 breaks down, and leads to typical tuberculous ulcers, similar to those occurring 
 in otber viscera (p. 330). Considerable destruction of tissue ensues, involving 
 the whole circumlerence of tiie larynx, and even leading to necrosis and 
 destruction of th> cartilages. Hoarseness, cough, and perhaps a certain 
 amount of dyspnoea, in a patient suffering from phthisis, are the chief symptoms 
 arising from this affection, the prognosis of whicli is always of a grave nature 
 Tnatiiioit. — In phthisical patients local treatment is of but little avail, but 
 where the disease is primary an attempt should be made to deal with it ; such, 
 however, can (mly be undertaken by the skilled laryngologist, as it consists in 
 the topical application of caustics and antiseptics. Thyrotomy or subhyoid 
 pharyiigotomy has sometimes been practised, in order to attain this ol)ject 
 more thoroughly. 
 
 Paralysia of the Larynx is observed in a variety of conditions, but is only of 
 surgical interest when arising from injury or division of, or pressure upon, the 
 recurrent laryngeal nerve. It may follow the removal of a goitrous tumour 
 or of tuberculous glands, but is most commonly seen in connection witii 
 aneurisms of the innominate or aorta, or tumours in the same neighbourhood, 
 1 1,', cancer of the oesophagus. Paralysis from the above causes is generally 
 
 Fig. 2S3. — Gummatous Disease of 
 THE Larynx. (Tillmanns.) 
 
 Small gummata are seen invading 
 the mucous membrane of the 
 epiglottis and front of the larynx. 
 
 Fig. 284. — Tuherculous Disease 
 OF the Larynx, with Extensive 
 Ueceration in Front and Behind. 
 (Tillmanns.) 
 
 a, I), c, Remains of the epiglottis. 
 
 unilateral, but if due to cancer both sides may be involved. The effect of 
 complete paralysis of one recurrent laryngeal is to produce total immobility 
 nn the affectecl side of the vocal cord, which lies in what is known as the 
 cadaveric position,' i.e., midway between that in which it is placed during 
 phonation and during inspiration. Not uncommonly the paralysis is incom- 
 plete, and then merely affects the abductor muscle (the crico-arytenoideus 
 posticus). The Symptoms arising from unilateral recurrent paralysis are often 
 slight, tiie voice being usually but little modified, owing to the healthy cord 
 being capable of passing across the middle line. If, however, l^oth sides are 
 
 I completely paralysed, absolute aphonia, without dyspnoea, results ; but if only 
 the abductors are involved, the voice may be unimpaired, although severe 
 
 i dyspncea is often present, and this may prove fatal unless tracheotomy is 
 promptly performed. 
 Papilloma of the Larynx (Fig. 285) occurs in the form of wart-like masses, 
 
 [usually growing from the true vocal cords, and giving rise to considerable 
 lioarseness and perhaps some dyspnoea. They are recognised on laryngoscopic 
 examination, and may be removed successfully by laryngeal forceps, after the 
 
 [parts have been efficiently cocainized. It is recommended by some authorities 
 
 jto destroy the growth with a galvano-cautery. 
 Epithelioma Laryngia occurs in patients over forty, originating as a papillary 
 
 lovergrowth, usually near the base of the epiglottis, or from the true or false 
 
 [cords (Fig. 286), The tumour gradually spreads, both superficially and deeply, 
 
 51 
 
802 
 
 A MANUAL OF SURGERY 
 
 m 
 
 ;■ r-' 
 
 and may invade the cartilages, giving rise to necrosis. At a later sta;;t; u 
 extends beyond the limits of the larynx, attacking the base of tlie t(in;;uf, 
 u'sophagus, and even the lateral walls of the pharynx. As long as the discax 
 is strictly limited to the larynx (intrinsic), tl e growth is often niiil.ittrn!. 
 causing hoarseness and aphonia, together witli an irritai)le cough and tlif 
 expectoration of blood-stained muco-pus, which may be horribly offensive; it 
 is associated with but little tendency to affection of lymphatic glands. Wlien. 
 however, the growth has extended to surroimding structures (exlrinsici, 
 lymphatic enlargement follows, and the disease runs its usual course, dcstniv- 
 ing life by dyspncraand exhaustion. Pain is often a most distressing symiitMii, 
 being referred either to the larynx or pharynx, or, according to ZiomsMii, imt 
 unfrequently to the ear. Ticittiiunt. — In the early stages it is possible that 
 thyrotomy and efficient curetting and cauterization may suffice to bring alrmi 
 a cure. Later on, removal of one or botli halves of the larynx will he 
 required, and the operation may even include parts of the tongue aiul 
 
 Fig. 285. — Papillomata of the 
 Larynx, springing from the 
 KiGHT Vocal Coro. (Till- 
 
 MANNS.) 
 
 Fig. 286. — Epithelioma OF THE I..\kvn\ 
 iNVOLViNfi the Right Vocal Corp 
 AND Base of the Epiglottis. (Till- 
 
 MANNS.) 
 
 pharyngeal wall. Where, however, the disease has spread extensively, its 
 total extirpation is rarely practicable, and all that can be done is to trcai 
 symptoms as they arise, and perform tracheotomy when necessary. 
 
 Operations upon the Air-passages. 
 
 1. Subhyoid Pharyngotomy was devised by Malgaigne, in order 
 to provide access to the upper parts of the larynx in the treat- 
 ment of foreign bodies or tuberculous disease. A transverse! 
 incision is made through the thyro-hyoid space, the pharynx is 
 opened, and the epiglottis detached from the base of the ton|,aic 
 (Fig. 287, I.). It is a proceeding that is seldom undertaken, ami 
 scarcely necessary. 
 
 2. Thyrotomy (Fig. 287, II.) consists in a partial or completej 
 vertical section of the thyroid cartilage, and may be required! 
 for the removal of foreign bodies or tumours, or for the radical! 
 treatment of laryngeal tuberculosis or cancer. Tracheotomy isj 
 performed as a preliminary measure, and the trachea plugf,'e(lj 
 around the tube. An incision is then made in the middle lineol 
 the neck, extending from the hyoid bone to the cricoid cartilage,! 
 The crico-thyroid ligament is clearly defined and severed trans-J 
 versely, and the thyroid cartilage accurately divided by a knifeJ 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 803 
 
 i^t a later slai;e il 
 ISC (it tli« li'n;;ut', 
 lon^; as the iliM,a>e 
 is often unilateral, 
 lie ciHinh and llie 
 ,rril)lv I'iTensive; it 
 tic glands. Wliun, 
 nctin-es (extrinsic), 
 iual course, (listrcA • 
 istressin},; symptom, 
 n^^ to Ziemssen, imt 
 s it is possible thai 
 uffice to brint; alniu 
 the larynx \vill i'f 
 of the tonfiiu- ami 
 
 UOMAOFTHEl.ARVNX, 
 
 ■ RIGHT Vocal Corp 
 HE Epiglottis. (Tul- 
 
 spread extensively, it> 
 tn be done is to treat 
 m necessary. 
 
 ges. 
 
 Malgaigne, in order 
 larynx in the tre;U- 
 ase A transverse 
 \ce* the pharynx IS 
 base of the tongue 
 ,m undertaken, mid 
 
 I partial or conrplete; 
 
 'i may be require : 
 
 s or for the radical 
 
 br Tracheotomy is 
 
 L trachea plugged 
 
 tn the middle hne of 
 
 the cricoid cartilage,' 
 
 and severed tran^ 
 
 divided by a b*, 
 
 cuttinf]f pliers, or fine saw. The lateral halves are separated, 
 and the intra-laryngeal portion of the operation proceeded with. 
 
 When closing the woimd, the greatest care must be taken to 
 
 bring the sides together in such a way that the \ocal cords may 
 
 be exactly opposite each otiier, or phonatiun will lie considerably 
 
 impaired. This is best ensured by 
 
 making a horizontal cut across the 
 
 front ofthe cartilage before dividing it. 
 3. Extirpation of the Larynx 
 
 (Laryngectomy) is always a serious 
 
 ijpcration, which is never imder- 
 
 taken except for malignant disease. 
 
 According to the site of the tumour, 
 
 the removal may be partial or com- 
 plete ; for a growth strictly limited 
 
 to one side, extirpation of that half 
 
 will suffice, and admirable results 
 
 have follow^ed such treatment, dis- 
 tinct speech remaining ; but if the 
 
 whole larynx is removed, although 
 
 the patient is subsecjuently able to 
 
 whisper, plionation is impossible 
 
 withtnit mechanical assistance, whilst 
 
 if the disease has extended beyond 
 
 the limits of the larynx, operative 
 
 interference is very unsatisfactory. 
 
 Operation for Complete tlxtivpation. — 
 A low tracheotomy should be per- 
 formed, as a preliminary measure, 
 and preferably a few days before ; 
 the trachea is plugged with a 
 Hahn's tube or a Trendelenburg's 
 air tampon at the commencement of 
 the operation. An incision is made 
 in tire middle line of the neck from 
 the hyoid bone to below the cricoid 
 cartilage, at the upper end of wdiich 
 
 a transverse cut is made, extending as far as the sterno-mastoid 
 muscle on either side. The soft parts are then stripped from the 
 lateral borders of the thyroid cartilage with raspatories, the sterno- 
 hyoid, sterno-thyroid, and thyro-hyoid muscles being divided at 
 their insertions. Both the superior and inferior laryngeal vessels 
 are tied and divided. Having thus freed the larynx anteriorly, 
 the subsequent steps of the operation may be undertaken either 
 jlrom below upwards or from above downwards ; the former pro- 
 ceeding is, to our minds, the better. The crico-tracheal mem- 
 brane is divided, and the larynx drawn forwards, so as to enable 
 [the posterior attachments, i.e., the connections of the constrictor 
 
 51—2 
 
 Fig. 287. — Oi'KRATioNs on the 
 
 AlR-TASSAGES. (TiLI. MANNS.) 
 
 I., Subhyoid pharyngotomy ; II., 
 thyrotomy : III., lary ngotomy ; 
 IV.,cricotomy ; V.,high trache- 
 otomy ; VI., low tracheotomy; 
 Z, hyoid bone; Sch, thyroid 
 cartilage ; R, cricoid ; Th, 
 thyroid body. 
 
ffl if 
 
 804 
 
 A MANUAL or SURGERY 
 
 muscles to the cricoid and thyroid cjirtilages, to be severed by 
 scissors, tile hirynx beiii},' thus separated from tlie antiTinV 
 pharynj^^ea! wall, which must be left intact, if possible. The 
 thyro-hyoid membrane and the base of the epif,dottis ate (in 
 throu^'h, and the fmal steps of the operation consist in cleanini^ 
 the superior cornua of the thyroid, and dividing' the lateral thvm 
 hyoid li}^aments. The operation is not particularly diffKult or 
 danj^erous, provided that the sur^'eon keeps close to the larynx. 
 and that the disease does not spread beyond its limits. W hen 
 other structures, such as the base of the tonj^ue, have ht-fii 
 invaded by the {,frowth, these steps must be modified so as to 
 secure, if possible, complete removal of the disease. I'"in-illv, tlir 
 transverse incision is sutured, but no stitches are inserted in tlu' 
 median wound, which is piuf,%'ed, and allowed to heal by ^Manilla 
 tion. The upper end of the trachea should be secured to tiu' skin 
 at the lower angle of the wound, so as to prevent its retraction. 
 The patient is fed per rectiiiii for a few days, or by the passaijc of 
 an cesophageal tube. At the end of a week the tracheotomy tube 
 is removed from its original situation, and inserted into the upper 
 end of the trachea, the lower opening being allowed to close. 
 When the wound has healed sufficiently, an artificial larynx can 
 be inserted, by means of which the patient is able to speak in a 
 somewhat reedy monotone, but it is seldom satisfactory. 
 
 Dr. H. Lambert Lack advocates the total closure of all com 
 munication between the pharynx and the air passages after 
 laryngectomy. The upper end of the trachea is securely stitched 
 all round in the lower angle of the incision and flush with the 
 surface. The rent in the mucous membrane of the pharynx is 
 then carefully closed ; the wound is thoroughly disinfected, and 
 the various layers of muscles are sutured together, as also the 
 skin. Union by first intention can thus be attained, and the 
 results have been most gratifying. Phonation is of ctnirse lost 
 absolutely, but the patient can whisper, the necessary air-pressure 
 being obtained in the dilated pharynx or upper end of the 
 (esophagus. 
 
 If the disease is limited to one-half of the larynx, the thyroid 
 cartilage is cleft in the middle line, and the operation confined to 
 the affected side. 
 
 4. Laryngotomy is always undertaken for the relief of dysp 
 noea arising from some sudden obstruction to the respiration, 
 and is thus to be looked on as an operation of urgency. It is 
 required in cases where the entrance to the larynx is obstructed 
 by a foreign body, for spasm of the glottis, or for accumulations 
 of blood in the neighbourhood of the larynx during an operation, 
 It is readily performed by making a vertical incision over the 
 situation of the crico-thyroid membrane, which is then divided, 
 transversely along the upper border of the cricoid cartilage, the 
 sterno-hyoid muscles being, if necessary, drawn aside, and a tuhej 
 
SUliGERY OF Till: AIR. PASSAGES, LUNGS, AND CHEST 805 
 
 1)6 seVL-rt'il by 
 1 the anterior 
 possible. 'I'lu' 
 irlottis :uf lui 
 iisl in cU'iinin- 
 e lateral thym 
 irly (liftuuU or 
 to tlu! hiryiiN. 
 limits. When 
 jue, liavf been 
 ulifiecl so as to 
 ,e. iMnally, the 
 I inserted in the 
 ileal by ^m;uui1;i- 
 ;urecl to the skin 
 nt its retraction. 
 y the passa^'eof 
 rac.heotomy tube 
 ;d into the upper 
 illowed to close. 
 ficial larynx can 
 lie to speak in a 
 factory. 
 
 osure of all com- 
 |ir passajjjes after 
 securely stitched 
 id flush with the 
 )f the pharynx is 
 ^ disinfected, and 
 ither, as also the 
 attained, and tlu- 
 is of course lost 
 ;ssary air-pressure 
 .pper end of the 
 
 irynx, the thyroid 
 ration conhned u^ 
 
 iiistrted. Possibly the small crico-thyroid artery arisinj^' from the 
 superior thynjid may re(iuire a lij^uture. In cases of f,'reat 
 iu>;ency, a simple transvcrsi" incision may be made with a pen- 
 kiiifi', and the larynx opened, the marf,nns of the wound lH'inj4 
 held aside by a hairpin, or by the handle of a scalpel turned edf^e- 
 ways, or a toothpick will serve temporarily as a cantuila. When- 
 (■\ir there is time to operate deliberately, a hi^,'h tracheotomy is 
 the lietter practice, since a tube inserted throuf^h the crico-thyroid 
 space j,Mves rise to considerable irritation, and tlu' voice may be 
 suhse(|uently impaired by the contraction of tiie cicatrix. A 
 special laryngotomy tube is recpiired, the Imnen of which is oval 
 aiul flattened from above downwards, not circular. 
 
 In ciiildren, where there is but little space, the proceedinj^' may 
 l)c modified by division of the cricoid cartila^'e, and even of the 
 first ring of the trachea, constituting what is known as ciicotomy, 
 {)X Lvyugo-tyacheotowy (Fig. 287, IV.). 
 
 5. Tracheotomy. — The trachea usually consists of from sixteen 
 to twenty rings, of which six or seven are situated above tlu? 
 sternum. The isthmus of the thyroid body usually covers the 
 third and fourth rings, and the trachea tiiay be opened either 
 ;i' \e or below it, or even sometimes behind, the isthmus being, 
 i. ecessary, divided. Tracheotomy ir required in any condition 
 in which there is serious obstruction to the respiration, e.u;., 
 various forms of laryngitis, and especially that due to diphtheria ; 
 for stenosis, tumours, and some forms of paralysis of the larynx ; 
 for the removal of foreign bodies, either in the larynx, trachea, 
 or one of the bronchi ; or for compression of the larynx or trachea, 
 hy external tumours, such as an enlarged thyroid body. It is 
 also undertaken as a preliminary measure in operations on the 
 mouth, tongue, pharynx, or larynx, in which there is any likeli- 
 hood of asphyxia or secondary septic pneumonia, owing to the 
 entrance of blood or septic discharges into the air-passages. As 
 a general rule, the high operation (that is, above the isthmus of 
 the thyroid body) is to be preferred, but under special circum- 
 stances it may be advisable to open the trachea lower down. 
 The risk attaching to the high operation is considerably less than 
 to the low, but the opening is made nearer to any disease which 
 may exist in the larynx. For the removal of foreign bodies from 
 the bronchi or trachea, the low operation should always be 
 employed. 
 
 The high operation (Fig. 287, V.) is performed as follows : The 
 patient is placed on the back, with a sandbag or pillow beneath 
 the neck, so as to throw the head backwards and put the struc- 
 tures on the stretch, and with the shoulders somewhat raised. 
 Anesthesia may be induced by chloroform, but it is unnecessary, 
 and indeed unwise, to push the anaesthetic, since it is only needed 
 for the division of the skin ; where the dyspnoea is considerable, it 
 is better to employ cocaine. The head is held exactly in the 
 
8o6 
 
 A MANUAL OF SURGERY 
 
 middle line, and the surgeon feels for, and identifies, the cricoid 
 cartilage. The incision extends from this structure downwards 
 for about i^ inches. The superficial fascia is divided, and the 
 interval between the sterno-hyoid muscles made out, so as to 
 enable them to be separated one from the other. The edj^es of 
 the wound are drawn aside by blunt hooks, which should both 
 be held by one assistant, so as to ensure equable traction. 
 
 The isthmus of the thyroid body may now be seen, and, if pro- 
 jecting unduly upwards, should be pushed down after the fascia 
 along its upper border has been transversely incised. The trachea 
 is next clearly exposed by using the handle of a scalpel and dis- 
 secting forceps, and should be fixed and steadied by insertin<T a 
 sharp hook into the lower border of the cricoid cartilage. The 
 wound is freed froni blood as far as possible, and the trachea 
 opened by inserting the point of the scalpel and dividing two of 
 the rings from below upwards. A deep inspiration is usuallv 
 
 Fig. 288. — Durham's Tracheotomv-tube. (Down Brothers.) 
 A, Outer-tube with introducer ; B, lobster-tailed inner-tube. 
 
 taken at once, followed by a severe fit of coughing, and if the 
 operation is undertaken for diphtheria the surgeon must be careful 
 not to let any membrane which may then be expelled enter his 
 eyes, nose, or mouth. The insertion of the tube is in many cases 
 easy, in others a matter of some difficulty ; a good deal depends 
 upon the age of the patient, the urgency of the symptoms, and 
 the depth from the surface at which the trachea lies. Anything 
 which suffices to separate the lips of the tracheal incision, eg,, 
 the handle of a scalpel introduced and turned, a couple of hooks, 
 or dressing forceps, will form an efficient guide for this purpose, 
 The breathing soon becomes quiet and regular, and the tube is 
 fixed in position by tapes passed through lateral openings in the 
 face-plate, and tied round the neck. No dressing is required for 
 the wound except a few layers of gauze about the tube beneath 
 the plate. 
 
 Loto tracheotomy (Fig. 287, VI.) is performed in almost pre- 
 
in almost pre- 
 
 SURGERY OF THE AIR.PASSAGES, LUNGS, AND CHEST 807 
 
 cisely tlie same way, except that the incision extends farther 
 downwards, even reaching,' to the episternal notch, although the 
 deeper part of the wound should never pass beyond a finger's 
 breadth above the sternum, for fear of opening that portion of the 
 cervical fascia which is prolonged downwards to the pericardium, 
 or of wounding the left innominate vein. The superficial layers of 
 fascia are divided, and the sterno-hyoid and sterno-thyroid muscles 
 drawn to either side by retractors. The inferior thyroid veins 
 then come into view, and may cause trouble if they are distended 
 with blood, as is so frequently the case in patients suffering from 
 dyspncKa. They must be held aside by hooks, or divided between 
 ligatures, and the deep layer of fascia behind theni incised so as 
 to expose the trachea, which is cleared, fixed, and opened in the 
 same way as described above. 
 
 Many different forms of tvachcotomy-tuhc have been used from 
 time to time, but that most generally employed consists of a 
 doable cannula, the inner portion of which can be readily remo\ed 
 and cleansed ; it should always be longer than the outer, in order 
 to prevent any plug of mucus being left within the outer tube on 
 removal of the inner. A face-plate, or some similar contrivance, 
 is attached to the outer cannula, 
 in order to fix and steady it. 
 One of the best is that known as 
 Durham'' slohstcv-taikd tracheotomy - 
 Inhc (Fig. 288, A and B) ; the 
 rigid outer tube of this instru- 
 ment is introduced by means of 
 a flexible guide set on a handle, 
 and passed within it. The guide 
 is then withdrawn, and replaced 
 bytheinner flexible cannula (B). 
 Ptu'kci''s tube (Fig. 289) also has 
 a handy introducer, and is per- 
 haps of a better shape than most 
 of the others, following more 
 dosely the direction of the 
 Uachea. The bivalve tube is 
 anothf. useful instrument; the 
 outc sheath consists of two 
 lateral portions, attached to a 
 single face-plate, and these can 
 be pressed together, and hence 
 with care easily ir.sei ced through 
 tlie incision in the trachea. The 
 surgeoii must see that both limbs 
 enter tne trachea, as trouble has 
 arisen from one limb passing outside, and the other inside, and 
 tlms the introduction of the inner tube is prevented. In cases of 
 
 Fig. 289. — Parker's Tracheotomv- 
 TUBK AND Introducer. (Down 
 Brothers.) 
 
8o8 
 
 A MANUAL OF SURGERY 
 
 preliminary tracheotomy (p. 739), undertaken to prevent the en- 
 trance of blood during operations, a Hahi's tube may be used with 
 advantage ; in this the outer cannula is covered with a layer of com- 
 pressed sponge which swells up from the absorption of moisture, 
 and thus occludes the lumen of the trachea. Trendelenburg's tampon 
 is recommended by some surgeons for the same object ; tlie outer 
 tube is here ensheathed with a thin indiarubber casing, whicli can 
 be distended with air at will. 
 
 Difficulties and Dangers of the Operation. — Although the above 
 description might lead the student to suppose that tracheotomy 
 is ixn easy operation, this is by no means always the case, partly 
 owing to the fact that it frequently has to be undertaken in a 
 hurry, with perhaps inefficient assistance, and in a bad light, and 
 partly owing to the intense vascular engorgement of the structures 
 met with. A cool head and a steady hand are in such cases 
 of infinitely more value to the operator than the most perfect 
 anatomical knowledge. The following are the chief conditions 
 which may lead to mistakes and accidents : 
 
 (i) The administration of any general anaesthetic is often 
 inadvisable in semi-asphyx-ated patients, since complete cessa- 
 tion of respiration may be caused thereby, possibly from spasm 
 of the glottis. In such the cutaneous incision may be made 
 under the influence of some local anaesthetic, whilst for the 
 deeper parts of the operation nothing is required. 
 
 (2) It is not always easy to find the trachef^, especially in the necks 
 of fat children, or where it is hidden by an unduly large thyroid I 
 isthmus, or possibly by the projection of the thymus gland into I 
 the neck. It is here most essential to remember the old adage, 
 In medio tutissimus ibis, although occasionally the trachea may be 
 displaced from the middle line by some external growth, andean] 
 then only be found by careful exploration with the finger. 
 
 (3) Hemorrhage is generally troublesome. It is usually venous! 
 in character, arising either from the anterior jugular vein or from 
 the inferior thyroid plexus. If possible, it should be controlled j 
 by forcipressure before opening the trachea ; but this is not ahso- 
 lutely necessary in urgent cases, since it usually ceases as soonj 
 as easy respiration through the tube has been established. Tliej 
 presence of the left innominate vein in front of the tracheal 
 must not be forgotten, although it but rarely reaches above thej 
 sternum. In about 8 per cent, of all subjects an arterial twigj 
 (the thyroidea ima) courses upwards from the innominate arter\j 
 along the trachea, to reach the isthmus of the thyroid body; i| 
 divided, it can be easily secured and tied. Should much blood 
 inspired, it may determine the occurrence of septic pneumonia atl 
 a later date. 
 
 (4) The possibility of the entrance of air into veins must not bd 
 overlooked, although it is an uncommon accident, since the intra-j 
 venous pressure is so great. 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 809 
 
 prevent the en- 
 lay be used with 
 ;h a layer of corn- 
 ion of moisture, 
 delenburgs tampon 
 )bject ; the outer 
 asing, which can 
 
 hough the ahove 
 :hat trachecjtoniy 
 5 the case, partly 
 
 undertaken in ;i 
 1 a bad light, and 
 t of the structures 
 ire in such cases 
 
 the most perfect 
 i chief conditions 
 
 aesthetic is often 
 :e complete ccssa- 
 ,sibly from spasm 
 on may be made 
 ic, whilst for the 
 d. 
 
 icially in the necks 
 iduly large thyroid 
 thymus gland into 
 |ber the old ada^e, 
 e trachea may 1* 
 l1 growth, and can 
 the finger, 
 is usually venons 
 ligular vein or from 
 [ould be controlled 
 lut this is not abso- 
 Uy ceases as soon 
 established. The 
 [nt of the trachea 
 reaches above the 
 s an arterial twii; 
 innominate arter\j 
 ,e thyroid hody; if] 
 ,uld much blood h* 
 ;ptic pneumonia iitj 
 
 veins must not hel 
 gnt, since the intraj 
 
 (5) Not unfrequently considerable mischief has been done by 
 ^n incautious use of the knife, especially if the operator forgets to fix 
 the trachea with a sharp hook before opening it. In a child the 
 tracliea is small ; and if it is moving rapidly up and down, as 
 happens in urgent dyspnoea, or if the child is restless, and not 
 completely under the influence of an anaesthetic, the difficulty is 
 manifestly increased. Many accidents ha\'e happened from this 
 cause, e.g., wounds of the large veins or arteries of tlie neck, or 
 even of the tt;sophagus or bodies of the vertebra; ! 
 
 (6) As soon as the trachea is opened, a severe fit of coughing is 
 induced, which is sometimes so prolonged as to interfere with the 
 introduction of the tube. Under such circumstances the incision 
 in the trachea may be opened up wdth a tracheal dilator, or by a 
 pair of sinus forceps, ancl a few drops of cocaine swabbed over the 
 mucous membrane. 
 
 (7) The introduction of the tube is a matter of no difficulty if the 
 surgeon takes the precaution of not removing the hook until this 
 is satisfactorily accomplished. Many mistakes have followed the 
 non-oi)servance of this rule ; thus, the tube has missed ihe trachea 
 altogether and passed into the fascial interspace in front, as also 
 to one or other side ; as before mentioned, the outer portion of 
 a bivalve tube has often been passed with one limb within the 
 trachea and the other outside. A very dense diphtheritic mem- 
 brane has also been a cause of difficulty, in that, although the 
 tube has been really passed into the trachea, it has not penetrated 
 the membrane, and thus has hindered rather than helped the 
 hreathing. In all cases of diphtheria the trachea should be 
 freely opened, and the interior carefully examined by separating 
 the lips of the incision before attempting to insert the tube. 
 In order to prevent the downward passage of the membrane, 
 
 j some surgeons have recommended that the lower portion of the 
 larynx should be carefully stuffed with antiseptic gauze above 
 I the tube. 
 
 After-Treatment. — The patient is placed in bed, in a room kept 
 I a; a uniformly warm temperature (75° F.), the air being moistened 
 by the steam issuing from one or more bronchitis kettles, so as to 
 make up for the absence of nasal and oral respiration. All 
 draughts are excluded by curtains, and nothing should be placed 
 over the entrance to the tube, so that respiration may not be 
 hindered, nor the expectoration of mucus, false membrane, etc., 
 prevented. One of the most frequent sources of extension of diph- 
 theria to the lungs, or of septic pneumonia, is the re-inspiration of 
 material which has been coughed out upon a portion of musHn or 
 I gauze, placed with excellent intentions over the mouth of the tube. 
 I A nurse should be in constant attendance on the patient, in order 
 to wipe away all such material as it is expelled. 
 
 The inner portion of the tube is removed by the nurse, and 
 [cleaned two or three times a day, any inspissated mucus upon it 
 
8 10 
 
 A MANUAL OF SURGERY 
 
 being readily removed by the use of a solution of bicarbonate of 
 soda (20 grains to i ounce). The outer tube is also renio\ed once 
 a day for cleansing purposes, but only by the medical attendant. 
 Should the respiration become impeded by a collection of mucus 
 in the trachea, a fine feather may be passed down the tube in 
 order to clear it. but never in diphtheritic cases; for such a con- 
 tingency special suction-tubes have been devised. Attempts have 
 been made to clear the passages by applying the lips to the tube. 
 and removing the block by suction ; such is, however, (luite un- 
 justifiable, and several promising house-surgeons have in tbiswav 
 lost their lives. 
 
 The period for which the tracheotomy-tube is kept in position 
 varies in different cases, but its removal should always be under- 
 taken at as early a date as possible, for fear of leading to impair- 
 ment of the voice. In order to prevent this, the inner cannula is 
 made with a hole in the upper end, so that part of the air uiav 
 pass through the larynx. If the patient can then breathe co;n- 
 fortably when the finger is placed over the entrance to i e tube, 
 its presence is no longer necessary. 
 
 After-complications of Tracheotomy. — (a) 1 he tube may gi\e 
 rise to ulceration of the trachea if it is not correctly shaped. 
 Thus, if too much curved, it tends to irritate the anterior wall. 
 and cases are known in which it has caused death by perforation 
 of the left innominate vein. If insufficiently curved, the posterior 
 wall may become affected, and the oesophagus laid open. In 
 cases where a tracheotomy-tube has to be worn for a long time, 
 it may be advisable to make use of the indiarubber tubes intro- 
 duced by the late Mr. Morrant Baker, whilst Parker's tubes are 
 also well borne. 
 
 ih) Various fortns of septic trouble may arise in the wound, lead- 
 ing to cellulitis, and even secondary haemorrhage ; this is especi- 
 ally dangerous in the low operation, since the inflammation may 
 extend to the mediastinal tissues. In cases of diphtheria the 
 wound may also become affected with the disease. 
 
 {c) Inflammation of the trachea, bronchi, and lungs may result 
 either from the entrance of cold, or unmoistened air, or from the 
 inspiration of septic or diphtheritic material. 
 
 {d) Difficulty is sometimes experienced in leaving off the tube, 
 owing to the presence of granulations obstructing the lumen of the 
 trachea, or to stenosis of the larynx from contractions or adhesions j 
 of the vocal cords, or even to paralysis of the abductor muscles, 
 especially in diphtheritic cases. The trachea may also be kinked. 
 and its calibre thus diminished, by cicatricial union of the skin 
 and mucous membrane. The diagnosis of the cause at work in 
 any particular case can only be made by laryngoscopy, or careful 
 examination of the wound and upper portion of the trachea. 
 Granulations may be scraped away under an anaesthetic or| 
 destroyed by caustics, stenosis of the larynx overcome by dilata- 
 
SURGERY OF THE AIR.PASSAGES, LUNGS, AND CHEST 8ii 
 
 of bicarbonate of 
 Iso reniONed once 
 ledical attc'iidant. 
 Ilection of mucus 
 lown the tube in 
 : for such a con- 
 I. Attempts have 
 e lips to the tube, 
 owever, (^uite un- 
 3 have in this way 
 
 s kept in position 
 always be under- 
 leading to iiupair- 
 e inner cannula is 
 irt of the air nray 
 then breathe cor.i- 
 rance to i e tube, 
 
 he tube may give 
 
 correctly shaped. 
 
 the anterior wall. 
 
 ;ath by perforation 
 
 irved, the posterior 
 
 [us laid open. In 
 
 n for a long time, 
 
 •ubber tubes intro- 
 
 Parker's tubes are 
 
 in the wound, lead- 
 .ge ; this is especi- 
 inflammation may 
 
 of diphtheria the 
 .se. 
 
 lungs may result 
 ;d air, or from the 
 
 iving off the tube, 
 ig the lumen of the 
 [ctions or adhesions | 
 abductor nuiscles, 
 lay also be kinked, 
 union of the skin 
 cause at work in 
 ^oscopy, or careful 
 In of the trachea. 
 I an anaesthetic or] 
 Ivercome by dilata- 
 
 tion with an O'Dwyer's tube, whilst laryngeal paralysis must be 
 treated by the use of electricity. 
 
 6. Intubation of the Larynx is a means of treating laryngeal 
 obstruction which has been introduced in order to obviate the 
 i^isk always present in tracheotomy. It consists in the passage 
 through the mouth of a suitably curved tube into the larynx, by 
 means of a specially contrived introducer. The best patterns 
 to employ for the purpose are those known as O'Dwyer's tubes 
 
 Fig. 290. — O'Dwyer's Intubation Apparatus. (Down Brothers.) 
 
 [The cannulse are seen below on the right; a hinged inner tube passes 
 throughout the length of each, and the upper end of this is screwed 
 to the extremity of the introducer seen in the middle ; when it has been 
 inserted into the larynx, the trigger of the introducer is drawn, and by this 
 means the inner tube is loosened and can be easily removed, leaving the 
 cannula in position. To e.xtract the tuLo, the rectangular forceps repre- 
 sented at the top is utilized ; the point of the forceps is inserted into the 
 top of the cannula, and then by opening the blades the cannula is fixed 
 and can be withdrawn. A useful type of unilateral gag is also represented, 
 and a small gauge to indicate the size of cannula required at different ages. 
 
 iFig. 290). The lower end of the cannula is oval, and not 
 Icircular, and passes between the cords into the larynx, whilst the 
 j'jpper enlarged end lies over the entrance ; it requires changing 
 jfrequently in order to prevent erosion of the mucous membrane. 
 lit has been used with considerable success in cases of oedema of 
 Ik glottis and laryngeal stenosis, but is scarcely to be recom- 
 
 tiended for diphtheria, owing to the risk of carrying the false 
 
 |iienibrane down with it. . . 
 
8l2 
 
 A MANUAL OF SURGERY 
 
 f 
 
 Surgical Affections of the Lungs. 
 
 Wounds of the Lungs result from violence applied to the chest, 
 
 with or without fractures of the ribs, or in consequence of pene- 
 trating injuries. 
 
 Non-penetrating Wounds consist either of laceration or contusion. 
 
 Contusion of the lung often follows some injury which is nut 
 sufficiently severe to fracture the ribs. The symptoms produced 
 are severe pain in the side, with perhaps temporary shock and 
 slight haemoptysis. Some traumatic inflammation follows, both 
 of the lung and the pleura, as indicated by loss of resonance and 
 possibly friction sounds. The treatment consists in keeping the 
 patient quiet in a warm room, at the same time carefully regulating 
 the bodily functions. Possibly pain may be relieved by strapping 
 the side of the chest. 
 
 Laceration of the lung is usually secondary to fracture of the ribs. 
 especially from direct violence. The severity of the symptoms I 
 necessarily varies with the character and extent of the injury, 
 The patient suffers from marked shock in severe cases, associated 
 with pain in the side and dyspnoea. Evidences of hirnumhani 
 soon follow, either in the form of haemoptysis or haemothorax. 
 If the wound is a small one, the patient complains of an irritating | 
 cough, and brings up a good deal of blood-stained frothy mucus: 
 but if the laceration is extensive, involving some of the larger! 
 pulmonary trunks, a quantity of pure blood may be ejected, even 
 leading to death from syncope, or from asphyxia, owing to the 
 blood filling the larger bronchial tubes. Hamothovax may also be 
 so excessive as to cause the patient's death from compression of 
 the lung. It results in a gradually increasing area of dulness ex- 
 tending from below upwards, together with loss of breath sounds 
 and vocal fremitus, coming on soon after the injury without signs] 
 of inflammation. 
 
 Owing to the laceration of the pulmonary vesicles, air tends toj 
 escape either into the pleural cavity, giving rise to the condition! 
 known as pneumothorax, or into the cellular tissue of the body,! 
 constituting surgical emphysema. Pneumothorax is always asso- 
 ciated with more or less collapse of the lung, and is ahnost! 
 certain to lead to considerable interference with respiration, and! 
 possibly to severe dyspnoea, or even orthopncea. The air \vbicli| 
 finds its way into the pleura, having been filtered through the! 
 lungs, is free from organisms, and hence does not cause! 
 suppuration or putrefaction of the blood-clot present, unless! 
 bronchitis or some other suppurative condition has existed pre-j 
 viously. The physical signs of pneumothorax consist in a liigh-j 
 pitched tympanitic note on percussion, and on auscultation! 
 amphoric breathing and possibly metallic tinkling. As soon 
 the wound in the lung commences to heal, the amphoric sound^ 
 disappear, the effused air is absorbed, and the lung gradually 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 813 
 
 )lied to the chest, 
 sequence of pene- 
 
 ation or contusion, 
 jury which is not 
 'mptonis productd 
 iporary shock and 
 ation follows, hoth 
 5 of resonance and 
 ,sts in keeping the 
 carefully ref,fulatin},' 
 lieved by strapping 
 
 fracture of the ribs, j 
 / of the symptoms 
 :tent of the injury. 
 !re cases, associated ! 
 nces of htmoYrhiii 
 ;is or hasniothorax, 
 ains of an irritatini;| 
 ined frothy mucus; 
 some of the larger 
 lay be ejected, even 
 
 lyxia, 
 
 owinj:: to the 
 
 othorax may also be 
 Tom compression of 
 area of dulness ex- 1 
 ,s of breath sounds 
 njury without signs] 
 
 vesicles, air tends to 
 lise to the condition 
 tissue of the body, 
 \yax is always asso- 
 ing, and is almost! 
 ith respiration, and 
 :a. The air whichi 
 iltered through the! 
 le does not cause 
 |lot present, unless| 
 >n has existed pre- 
 lx consist in a high- 
 id on auscultation! 
 ikling. As soon as 
 [he amphoric sounds 
 the lung graduall) 
 
 expands — a process which may take four or five days. If blood 
 is also present in the thorax, a condition of haimopneumothorax 
 15 produced, recognised by a splashing or succussion sound heard 
 on shaking the patient. Surgical Emphysema almost always indi- 
 cates a wound of both pulmonary and parietal layers of the pleura, 
 which are slightly separated by air, constituting a localized pneumo- 
 thorax. At each inspiration a fresh amount of air enters this cavity, 
 and is expelled into the areolar tissues through the parietal wound 
 at each expiration, being forced perhaps to a considerable distance 
 from the spot where it commences, or even spreading over the 
 whole body. It is of no serious significance, disappearing rapidly 
 after the wound in the lung has commenced to heal, thus occluding 
 the opened pulmonary alveoli. It is recognised by the parts 
 hecoming swollen and puffy, and giving a sensation of fine crack- 
 ling crepitus when the hand is pressed over them. Occasionally 
 emphy.sema may arise as an intevstitial condition, when the parietal 
 pleura has not been injured, the air escaping from the alveoli 
 along the inter-alveolar connective tissue into the root of the lung, 
 and then appearing first at the lower part of the neck. 
 
 Such are the ordinary phenomena observed in the early stages 
 of a ruptured lung. The effects subsequently produced consist 
 in a localized traumatic pleuro-pneumonia, associated wath slight 
 elevation of the temperature, possibly rusty sputum, and often 
 severe dyspnoea. In the worst cases death may result from 
 asphyxia. 
 
 Penetrating Wounds of the Lung are followed by \ ery similar 
 effects, modified, however, by the fact that the external wound 
 j in the chest wall allows of the exit of blood, arising either from 
 an intercostal artery or from the wounded lung, whilst it also 
 I permits the entrance of septic organisms with the air into the 
 [pleural cavity, and thus may change the character of the result- 
 I ing pleuro-pneumonia from a simple to an infective inflammation. 
 1 Empyema is consecjuently a frequent sequela, whilst the inflatn- 
 [ ination of the lung may be of a spreading nature, possibly termi- 
 \ nating in suppuration or gangrene. Surgical emphysema is also 
 [induced by air being sucked into the wound during inspiration, 
 and failing to escape during expiration, owing to the lips of the 
 wound falling together. This condition may ensue even when 
 I the lung itself has not been damaged. 
 
 Treatment. — When the rupture of the lung is due to a sub- 
 
 i cutaneous injury, the patient should be kept quiet in a w-arm 
 
 room, and the side strapped. The compression of the chest wall 
 
 must sometimes be omitted in patients where the irregular ends 
 
 of fractured ribs, broken by direct violence, are driven inwards, 
 
 [for fear of increasing the mischief in the lung. 
 
 Persistent haemoptysis must be treated by keeping the patient 
 [absolutely quiet, and allowing him to suck ice continually. 
 t Ergotin may be injected hypodermically, or a mixture of ergot, 
 
Si4 
 
 A MANUAL OF SURGERY 
 
 opium, and sulphuric acid administered ; the opium is espct ialK- 
 needed when great restlessness and irritability are present. Stiinii. 
 lants are necessarily contra-indicated, for fear of again startiri" 
 the bleeding. Hivmothorax rarely needs special treatment, since 
 the blood soon clots and is readily absorbed ; but occasionally it 
 may be so abundant as to compress the lung and lead to dyspiiua, 
 and under these circumstances it may be necessary to open up 
 the pleural cavity and remove it. Such must ne\'er be under- 
 taken until sufficient time has elapsed to permit of thrombosis in 
 the wounded vessels. Decomposition of the blood in tlie pleural 
 cavity occasionally happens even in non-penetrating injuries, the 
 bacteria reaching it either from the blood or from tlie lacerated 
 bronchi ; the suppuration and fever thereby induced necessitate 
 the opening and drainage of the pleural sac. 
 
 Simple pneumothorax seldom recpiires surgical treatment, since 
 the imprisoned air is (juickly absorbed, and the lung re -expands; 
 but should it give rise to severe dyspnci-a, it may be adxisahle to 
 remove the air by aspiration. 
 
 Temporary dyspncxia may be overcome by the inlialation of 
 oxygen ; but when of a more decided character, and not due to 
 any condition which can be removed, the essential treatment is to 
 diminish the blood-pressure, and thus decrease the amount of 
 blood carried to the uninjured lung, so as to enable it to cope with 
 the work of blood-aeration. This may be accomplished by ad- 
 ministering antimonial wine (lo to 15 minims every four ur six 
 hours) combined with full doses of liquor ammonias acetatis ; but 
 in urgent cases, where the patient is becoming cyanosed, and life 
 is threatened by asphyxia, venesection must be adopted. The 
 blood is withdrawn from the arm rapidly and freely, and as it 
 flows the dyspnoea passes off. This may be repeated once or 
 twice in addition to the use of the medicine before the full effect 
 is obtained and respiration becomes unembarrassed. 
 
 The treatment of penetyating zvounds of the thorax, in\ol\ing the 
 lung, is always a matter of considerable difficulty. The skin 
 around the opening is carefully purified and shaved, if necessary, 
 and a limited exploration of the wound with a purified hnger or 
 probe is permissible, so as to determine whether portions of the 
 clothing have been carried in, or a rib comminuted ; all such loose 
 fragments must be removed, as also any penetrating foreign body, 
 such as a bullet, if accessible. The greatest gentleness must, 
 however, be employed, since it is easy to dislodge clots lyirif^ in 1 
 the pulmonary tissues, and thereby restart the bleeding. As a 
 general rule, it is unnecessary to syringe out the deeper parts with 
 an antiseptic, since if one of the main bronchi has been opened, 
 the lotion might then find its way into the air-passages. The 
 insertion of a drainage-tube is scarcely called for as a routine 
 procedure, but it is advisable to lightly plug the wound with J 
 gauze. 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 815 
 
 )ium is especially 
 present. Stimu- 
 of af^ain sl.irtin;,' 
 1 treatment, siiicf 
 •ut occasionally it 
 lead to dyspiKia, 
 5sary to open up 
 never be under- 
 of thrombosis in 
 ood in the pleunil 
 \t\n<^ injuries, the 
 from the lacerated 
 iduced necessitate 
 
 al treatment, since 
 
 lung re -expands; 
 
 ay be ad\isahle to 
 
 the inhalation of 
 3r, and not due to 
 tial treatment is to 
 ,se the amount of 
 able it to cope with 
 complished by arl- 
 s every t'oui ur six 
 ionise acetatis ; but 
 cyanosed, and life 
 be adopted. The 
 d freely, and as it 
 : repeated once or 
 efore the full effect 
 ,ssed. 
 
 \ioyax, involving the 
 .culty. The skin 
 aved, if necessary, 
 . purified hnger or 
 ler portions of the 
 lited ; all sucli loose 
 lating foreign body, 
 t gentleness must, 
 Mge clots lying i" I 
 lie bleeding. As ;i 
 le deeper parts with 
 has been opened, 
 lair-passages. The 
 Id for as a routine 
 |g the wound with 
 
 The chief danger arises from the loss of blood, and, as already 
 stated, this may come from di\ision of an intercostal artery, or 
 from the lung. If of intercostal origin, it should be treated as 
 described at p. 211. Piilmonaty hcrmoyyha>^c is, unfortunately, not 
 so reacUly controlled ; and much difTerence of opinion has i)een 
 e,\pressed as to the most satisfactory means to adopt in these 
 cases. Probably the best method consists in keeping the patient 
 ;d)Solutely quiet, and trusting to the application of cold to the 
 side, and to the administration of lucmostatics, as indicated above 
 for non-penetrating wounds. In bad cases the hainorrhage may 
 only cease when the patient is in a condition of profound collapse 
 or syncope ; intravenous infusion of saline solution may then 
 >uffice to tide him over the period of danger, and lead to a 
 successful result. 
 
 Two other plans of treating pulmonary hannorrhage which 
 have been recommended may be noted, viz., venesection from the 
 systemic circulation so as to reduce blood-pressure, and thus 
 obtain thrombosis ; and plugging the wound in the parietes so 
 as to cause the blood to accumulate in the pleural cavity, and 
 thus by its pressure lead to a similar result. Neither of these 
 methocls commends itself to us as scientific, although both are 
 uccasionally successful, and possibly would be the only plans 
 practicable in dealing with a large number of wounded. The 
 latter of the two has an additional objection in that it is almost 
 certain to be followed by suppuration and septic fever, necessitat- 
 ing the opening and washing out of the pleural cavity at a later 
 date. 
 
 The (question of opening the thorax by resecting a considerable 
 portion of rib, so as to deal directly with the injured lung, has 
 been raised of recent years, and se\'eral cases in which it has 
 been undertaken have been recorded. Whether or not such 
 practice is justifiable is a question that further experience can 
 alone decide ; at present all we can say is that a surgeon should 
 he prepared to do this operation, although only resorting to it in 
 exceptional circumstances. 
 
 The later treatment of these cases is much the same as for 
 simple non-penetrating injuries. Should symptoms of septic 
 pleurisy follow, the wound must be freely opened, a portion of 
 rib being excised, if necessary, and the cavity washed out and 
 1 drained, as for empyema. 
 
 Hernia of the Lung, or pneumocele, is a condition in which a 
 I portion of the lung protrudes through an opening in the thoracic 
 I parietes beneath the uninjured skin. It may occur suddenly, as 
 the immediate consequence of a laceration of the intercostal 
 muscles and pleura, or more gradually, being then due to the 
 yielding of a cicatrix. It is most usually seen about the fifth 
 intercostal space, but has been known to occur in the root of the 
 
8i6 
 
 A MANUAL OF SURGERY 
 
 lil 
 
 i 
 
 neck from a lesion in the dome of the pleura. It is exxeediiirrlv 
 uncommon, bein^' recognised by the appearance of a roundt'il 
 swelling, increasing in size on coughing or making expiiatorv 
 efforts, and possibly disappearing entirely on holding the breath. 
 It imparts a crepitant feeling to the fingers when compressed, and 
 on auscultation a loud vesicular murnuir is heard. As a rule, no 
 treatment is advisable in this condition beyond the application nf 
 a pad or truss. 
 
 A similar condition has been met witli as a complication of an 
 open wound, and is then termed a Prolapse of the lung. An 
 attempt should always be made to return the protruded \ iscus, 
 and to prevent its recurrence by suturing the aperture thioui,'li 
 which it has escaped. If left unreduced, it is very likely tu 
 become gangrenous from strangulation, and should then In- 
 removed by the application of a ligature, the wound being suli- 
 sequently closed. 
 
 Empyema, or suppuration within the pleural cavity, results nut 
 only from traumalisiu, but also as a sequela of a simple pUnirisv, 
 or as a complication of varif)us affections of the lungs, whilst a 
 basal empyema is not an uncommon result of intra-alHloiiiinal 
 suppuration. A description of the physical signs and syinptonis 
 belongs rather to the physician than to the surgeon. It will suiTice 
 to mention here that the affected side of the chest does not move 
 on inspiration, whilst there may be some bulging of the inter- 
 costal spaces ; on percussion the side is dull, except perhaps 
 immediately below the clavicle, where tympanitic resonance mav 
 be elicited. On auscultation breath-sounds are absent, except] 
 in the vertebral groove, where bronchial breathing may be heard, 
 The loss of vocal fremitus is also an important sign. A certain I 
 amount of fever and dyspncjea is usually present in cases of| 
 empyema, whilst the other thoracic viscera may be displaced, 
 Left to itself, an empyema usually finds its way to the surface,! 
 and perhaps most commonly bursts through the fifth or sixthj 
 costal interspace, though sometimes through the second in front,! 
 owing to the perforating vessels being larger here than elsewhere.! 
 Occasionally a localized empyema is met with, giving rise toj 
 similar effects, but on a smaller scale. 
 
 In the early stages the pleura is but little altered in structure,! 
 although a certain amount of lymph may be deposited on it;j 
 in old-standing chronic cases it becomes very dense and firin,| 
 owing to a development of fibro-cicatricial tissue, whilst the 
 surface is converted into a layer of granulation tissue, similar td 
 that found in all chronic abscesses. The lung collapses anq 
 retreats backwards towards the spine ; at first its alveolar textur^ 
 remains unaltered, and the early removal of the exudation enable^ 
 it to re-expand, as a result of the atmospheric pressure, h 
 chronic cases, however, there are two hindrances to this expanj 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 817 
 
 t is exceedingly 
 e of a rovindt'd 
 iking expiratory 
 ling the breath. 
 compressed, and 
 i. As a rule, no 
 he apphcation of 
 
 implication of an 
 ,f the kmg. An 
 protruded \ iscus, 
 aperture throu'^h 
 is very Ukely t>> 
 shovild then be 
 vound being sub- 
 cavity, results nut 
 a simple pleurisy, 
 ;he lungs, whilst a 
 of intra-abdominal 
 .gns and syniptoms 
 eon. It will suffice 
 lest does not move 
 llging of the inter- 
 11, except perbaps 
 itic resonance may 
 are absent, except 
 ling may be heard, 
 nt sign. A certain 
 resent in cases of 
 may be displaced. 1 
 vay to the surface, 
 the fifth or sixth 
 he second in front, 
 -re than elsewhere, 
 ith, giving rise to| 
 
 lltered in structure, 
 le deposited on it; 
 Vy dense and firm,] 
 tissue, whilst the 
 -on tissue, srmilar ti 
 llung collapses aw 
 Tits alveolar textun 
 
 3 exudation enable! 
 leric pressure. 1' 
 ,ces to this expaii' 
 
 sion, viz., the density of the thickened visceral pleura, wiiich 
 resists the atmospheric pressure, and the infiltration and sclerosis 
 of the lung tissue itself. Under these circumstances, even when 
 the exudation is entirely removed, the lung may remain collapsed, 
 md Nature then attempts in several ways to remedy the mischief 
 and obliterate the pleural cavity : (a) The opposite lung undergoes 
 expansion and hypertrophy, and together with the heart projects 
 over to the opposite side ; (b) the abdominal viscera and dia- 
 phragm are displaced upwards ; (r) the chest wall falls in, and the 
 spine becomes laterally curved, with its convexity to tlie sound 
 side ; and (d) there is an exuberant growth of granulation tissue 
 from the surface of the pleura. In a certain proportion of cases 
 these structural changes suffice to determine a cure, but in others 
 a cavity still remains, lined with thickened pyogenic membrane, 
 and discharging pus or serum, according to whether or not sepsis 
 is present. Under these circumstances extensive operative inter- 
 ference is necessary. 
 
 The Diagnosis of empyema is readily made by attention to the 
 
 physical signs, and confirmation of such an opinion can be obtained 
 
 by puncture with a sterilized hypodermic syringe. A medium-sized 
 
 needle should always be employed for this purpose, and it is well 
 
 to insert it along the top of a rib after drawing the skin up or 
 
 down, so that on removal a \'alvular puncture results. The 
 
 character of the organisms contained in the sample of pus thus 
 
 withdrawn should, if possible, be ascertained, since it has been 
 
 proved that the Prognosis depends much on this point. Thus, 
 
 an empyema due to the presence of pneumococci, presumably 
 
 following a pneumonia, runs a mild course, and is readily cured, 
 
 even by aspiration alone ; one due to the ordinary pyogenic cocci 
 
 is more acute, and requires drainage with or without resection 
 
 of a piece of rib. The presence of tubercle bacilli renders the 
 
 outlook much more serious, whilst the addition of septic organisms 
 
 to any of the above aggravates the process and much impedes 
 
 a cure. The chronicity or not of the affection is also a most 
 
 important element in the prognosis, since the later the treatment 
 
 commences, the denser are the adhesions which bind down the 
 
 |bg, and the less the chance of its re-expansion. 
 
 Treatment therefore should never be delayed ; the earlier it is 
 
 undertaken, the better the results. 
 
 Aspiration may be adopted in the first instance, but is generally 
 be regarded as of an exploratory nature, though a cure will 
 casionally follow when the empyema is of pneumonic origin. 
 lis, however, sometimes of value in order to relieve for a time 
 e pressure on the other lung and the resulting dyspnoea, and 
 lus allow of the administration of an anaesthetic for the more 
 rious subsequent operation. 
 
 Drainage of the pleural cavity through an external incision is 
 e treatment almost invariably necessary, and the opening is 
 
 52 
 
ttS 
 
 A MANUAL OF SURGERY 
 
 best made either in the niid-axillnry line or a little in front of it, 
 throujifh the fifth costal interspace. Under special circutnstaiids 
 it may be necessary to open the pleural cavity at a lower l(\t|, 
 and then the ninth or tenth interspace in the scapular liiic is 
 selected. Whether a portion of rib need be removed or not, is 
 merely a question of mechanical convenience ; if the draina},'e-tube 
 can be efficiently retained between the ribs without resection, wil! 
 and good ; but if, as in children, the space is narrow, then a 
 portion of rib must be removed. An incision is made alon;; tlif 
 course of a rib about i^ inches in length, and the periosteum 
 stripped up from both the superficial and deep aspects of the hone, 
 so as to enable a curved raspatory to be passed beneath it ; at 
 least I inch of the rib is then cut away with bone pliers. The 
 parietal pleura is opened sufficiently to enable the finger to he 
 introduced and the cavity explored. A large drainage-tvibe is 
 inserted, and the wound immediately covered, so as to prevent 
 as far as possible the entrance of unfiltered air. 
 
 Formerly it was considered desirable to thoroughly wash out 
 the pus ; but it has now been demonstrated that such is unneces- 
 sary, and occasionally dangerous. Several cases of sudden death 
 have followed this practice, probably due to reflex irritation of the 
 vagus. Where sepsis has been admitted, irrigation is often 
 beneficial, but the following points must be attended to : (i.) The 
 fluid employed must be unirritating, though sterile ; (ii.) it must 
 be at the temperature of the body, neither too hot nor too cold ; 
 (iii.) it must not be injected with such force as to impinge against 
 the pleura or against the upper surface of the diaphragm ; and 
 (iv.) free exit must be given to it, so as to prevent tension from 
 accumulation within the pleural cavity. 
 
 If such treatment is undertaken sufficiently early, the lung may 
 be expected to expand, the discharge steadily diminishing, and the 
 wound ultimately healing ; but, as we have already explained, such 
 does not always occur, and then a fistula persists, leading into a 
 cavity lined with a thick pyogenic membrane, discharging a variable 
 amount of pus. The best means of obtaining a cure in these cases 
 consists in removal of the rigid external wall, as by Estlandds opm- 
 lion, which is characterized by the excision of portions of ribs com- 
 prising the outer wall of the cavity. It is usually carried out 
 through a \ ti^ical incision in the axillary line, the ribs being freed 
 from their periosteal connections; the amount excised necessarily 
 varies according to circumstances, and is in some cases very 
 extensive. The fistulous track is enlarged, and the interior of the 1 
 pleura carefully curetted and washed out, so as to remove all 
 necrotic and degenerating tissue ; the parietes are then allowed to 
 fall back into contact, if possible, with the deeper layer, a drainage- 
 tube is inserted, and the side firmly bandaged. A modification 
 of this proceeding is known as Schede's operation, in which not 
 only are the ribs removed, but also the intervening tissues, soj 
 
tie in front of it, 
 al circutnst;uut:s 
 at a lower level, 
 : scapuliir liiu' is 
 iinoved or nut, is 
 the drain:it;e-tube 
 3Ut resection, wtll 
 s narrow, then ;i 
 s made alont; the 
 id the periosteum 
 spects of the hoiu', 
 sed beneatli it ; ;ii 
 bone pliers. The 
 2 the finger to be 
 e drainage-tube is 
 , so as to prevent 
 
 aroughly wash out 
 at such is unneces- 
 5es of sudden death 
 ftex irritation of the 
 irrigation is often 
 tended to : (i.) The 
 sterile ; (ii.) it must 
 p hot nor too cold ; 
 
 to inipinge against 
 le diaphragm; and 
 
 event tension from 
 
 early, the lung may 
 liminishing, and the 
 ady explained, such 
 sists, leading into a 
 scharging a variable 
 , cure in these cases 
 by Estlander's opcm- 
 )ortions of ribs com- 
 usually carried out 
 the ribs being freed 
 excised necessarily 
 [n some cases very 
 Id the interior of the 
 [o as to remove all 
 are then allowed to 
 ler layer, a drainage- 
 led. A modification 
 \atiou, in which not 
 evening tissues, sol 
 
 SUKCERY OF THE .URrASSACES, LUNCS, .IND CHEST 819 
 
 that the subcutaneous or muscular structures in the flaps Hr« 
 laid down upon tiie prepared surface of the dee[)er layer of the 
 pleura. 
 
 Necessarily, either of these methods of treatment is associated 
 witb considerable deformity, and also with a terrible weakening 
 of tiie side, and plans have been suggested to obviate this by 
 removing portions of a number of ribs before and behind, so as to 
 leave the intervening segment free to collapse without totally 
 destroying the osseous thoracic boundary. Another proceeding 
 that has been recently introduced and practised with success is 
 the stripping <>( the thickened pleura away from the collapsed 
 lung, so as to enable it to expand once more (pulmonary decortica- 
 tion). Further experience is needed before any final opinion as 
 to the merits of these operations can be given. 
 
 Various operative proceedings have been directed to the lung 
 substance itself, concerning which, however, we can but suggest 
 a few points. 
 
 Pneumotomy, or incision of the lung, has been undertaken for 
 not a few pulmonary lesions, and the results obtained have been 
 rather variable, i. For tuheycnlous cavities it is of little use. They 
 are usually situated at the apex of the lung and drain well ; 
 the original disease is not removed ; and the general health is 
 frequently so impaired that the shock of the operation hastens the 
 inevitably fatal issue. Hence it is only required in cavities located 
 in the lower half of the lung, which drain badly, and the difficulty 
 (it diagnosing such conditions is considerable. 2. Fox bronchiectases 
 pneumotomy, though pviind facie desirable, has given but little 
 benefit, since it is uncommon for only one dilatation of the bronchus 
 to exist. In suitable cases, however, where there is a good deal of 
 tatid secretion, which is with difficulty expelled, it may be useful. 
 3. In gangycne of the lung much benefit may be derived. 4. The 
 same is true as regards pulmonary abscess following pneumonia. 
 5, In hydatid disease of the lung, incision and drainage have so 
 considerably reduced the mortality, that this method of treat;Tient 
 should alone be adopted. 
 
 As to the technique of the operation, the first thing is to locate the 
 
 mischief, and this is efTectod partly by a careful attention to the 
 
 physical signs, partly by the use of an exploring needle or syringe. 
 
 An incision is then made, and a portion of one or more ribs 
 
 i removed. If the lung is adherent to the thoracic walls, and shows 
 
 I no signs of retracting, the operation may be continued ; but if no 
 
 [adhesions are present, it may be well to stuff the wound with gauze 
 
 for a day or two, so as to determine their formation and thus shut 
 
 off the pleural cavity. The lung itself may be punctured with sinus 
 
 forceps introduced along an exploring needle, and then opened, or 
 
 I may be incised with a cautery. The abscess or other cavity is 
 
 [thus emptied of its secretion, and a drainage-tube inserted. As 
 
 52—2 
 
8po 
 
 A MANUAL OF SURGERY 
 
 a general rule it is unwise to scrape or irrigate it, for fear of a 
 communication existing with any of the larger bronchi, 
 
 Fneumectomy, or excision of a portion of the lung, has been 
 attempted in a few cases of tuberculous disease limited to the 
 apex ; the operation is, however, quite unjustifiable, since, if the 
 affection is localized to the apex, it can often be cured by the 
 physician, whilst if it is more diffuse it cannot be extirpated. 
 Primary malignant tumours of the lung, moreover, are usually 
 central, and the diagnosis can rarely be made early enough to 
 warrant an attempt at removal. The only conditions under which 
 it is justifiable to excise portions of lung are : (a) when a hernial 
 protrusion has become strangled through a small opening, and 
 cannot be reduced ; and (b) when malignant disease of a rib has 
 invaded the superficial portion. In the former case, the base of 
 the protrusion is transfixed and ligatured prior to cutting it away; 
 in the latter, the disease is snipped away with scissors, and bleedinj^ 
 stayed by cautery, ligature, or plugging. 
 
 Wounds of the Heart. 
 
 Wounds of the Heart and great vessels are so usually fatal 
 either immediately or within a few hours, that it is unnecessary 
 to discuss them here in any detail. If the patient does not die 
 at once, he suffers from intense shock and prostration, combined 
 with a weak and turbulent action of the heart, great pain in 
 the chest and dyspnoea, whilst the pulse is scarcely to be felt. 
 Free haemorrhage occurs if there is an external wound, but if 
 the opening in the pericardium is small and valvular, the heari s 
 action may be brought to a standstill by the pressure of the blood 
 within. Should the patient survive, pericarditis generally super- 
 venes, and is often of a purulent type. As to Treatment, the great 
 essential is to keep the individual absolutely quiet, and with the 
 head low. The external wound should be purified, but durinii 
 the stage of primary shock no attempt should be made to explore 
 it, either by finger or probe, for fear of dislodging a clot. Later. 
 on should he rally, the question of exploration may be raised, and 
 more than one case has now been published in which the surgeon 
 was by this means able to suture a wound in the ventricle. Other 
 cases are reported in which a wound of the heart has healed 
 spontaneously, and the patient survived for many years. 
 
 Effusion into the Pericardium, whether serous or purulent, may 
 occasionally require surgical treatment in order to relieve syn^ptonis 
 of cardiac failure, due to the pressure of the exudation. For serous 
 pericarditis all that is needed is to aspirate the cavity. This is 
 usually undertaken close to the lett border of the sternum in 
 the fifth interspace, or i| inches from the left margin of that 
 bone through the fourth or fifth interspace, so as to avoid the j| 
 
mri'^^^.zt' 
 
 SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 821 
 
 3 it, for fear of a 
 
 onchi. 
 
 ; lung, has been 
 
 ;e limited to the 
 
 able, since, if the 
 
 be cured by the 
 Dt be extirpated. 
 over, are usually 
 
 early enough to 
 :ions under which 
 i) when a hernial 
 lall opening, and 
 ;ease of a rib has 
 
 case, the base of 
 o cutting it away ; 
 jsors, and bleedin^^ 
 
 •e so usually fatal 
 it is unnecessary 
 itient does not die 
 stration, coniinned 
 irt, great pain in 
 carcely to be felt. 
 nal wound, but if 
 Ivular, the bean s 
 ssure of the blood 
 lis generally super- 
 'reatment, the great 
 uiet, and with the 
 .rilied, but during 
 )e made to explore 
 ing a clot. Later. 
 lay be raised, and 
 Iwhich the surgeon 
 e ventricle. Other 
 heart has healed 
 |ny years. 
 
 Is or purulent, may 
 I relieve syr''ptonis 
 iation. For serous 
 le cavity. This is 
 If the sternum in 
 2ft margin of that ^ 
 lo as to avoid the 
 
 internal mammary trunk, which courses down about a finger's 
 breadth from the border. 
 
 For suppurative pericarditis an incision may be made in the 
 same situation after removing the fourth or fifth r 'Stal cartilage, 
 the cavity washed out, and even a drainage-tube inserted. Care 
 must be taken to prevent infection of the mediastinal tissues, and 
 this can sometimes be accomplished by stitching the pericardium 
 to the parietes before opening it. 
 
 Asphyxia. 
 
 Asphyxia, or Apnoea, is the term applied to indicate t'le condition arising 
 from interference with or stoppage of the respiratory -.ict. If this has not 
 proceeded to any great extent it is termed Dyspnoea; when, however, tlie 
 obstruction is so marked that the patient is obliged to maintain the upright 
 sitting position, the term Orthopnoea is applied to it. 
 
 Fig. 291. — Artificial Respikation by Sylvester's Method (First Stage). 
 
 The arms are grasp'd ju« above the elbows, and raised well above the head 
 
 ,0 .'.s to expand the thorax. 
 
 Ilie Cax^ijes of i siihyxia may be classified as follows : 
 
 1. Conditioi..=5 arising from the presence of abnormal contents within the 
 air-passages, e.g., >ore'-gn bodies, blood-clot, or pu' froT" the bursting of an 
 abscess or aneurism , serum, as in cudema of the lun; ..^ns or muco-pus, as 
 in bronchitis ; the consolidated exudation in pneumonia: diphtheritic mem- 
 brane; or irresfiribic gases, e.g., nitrogen, hydrogen, carbonic acid gas, etc., 
 as in siiftbcatior . Death by drowning usually arises from a similar cause, 
 viz., the replacenent of air by water in the respiratory passages. 
 
 2. CaiiL^es aiising in the walls of the air-pass.ages, such as diminution of 
 their lumen fro.n inflammatory congestion, a.^■ in oedema of the glottis, 
 cicatricia' stenosis ; the presence of newrjro'. ths, or the displacement of parts, 
 as in cat throat; or the falling back of iii." n u' oi the tongue after partial 
 excision of that org,\n. 
 
822 
 
 A MANUAL OF SURGERY 
 
 J. Extrinsic causes, or those .arising outside the air-passages, e.f;., in the 
 7iccb : stranghng, hanging, garrotting, etc. ; the presence of tumours, such as 
 goitres or aneurisms ; a retro-pharyngeal abscess or tumour, and, under excep- 
 tional circumstances, displacement backwards of the sternal end of the clavicle. 
 Within the tliorax gradually increasing obstruction to the respiration may be 
 caused by the presence of tumours, aneurisms, or effusion into the pericardium 
 or pleura. 
 
 4. Nervous causes, e.g. , paralysis or spasm of the larynx, and paralysis of the 
 diaphragm, either from peripheral lesions, such as the pressure of aneurisms 
 or tumours on the nerve trunks, or from central causes, such as a lesion in the 
 upper part of the spinal cord or medulla. It may also arise from paralysis of 
 the respiratory centre, as from an overdose of chloroform. 
 
 5. In many forms of cardiac disease the lungs may become engorged with 
 stagnant blood, leading gradually to dyspnoea, orthopnoea, and finally 
 
 Fig. 292. — Svivester's Method ok Artificial Respikatio.n. 
 
 (Second Stage.) 
 
 The arms are brought down to the side, and pressed firmly inwards agpi^ji >' ■ 
 thoracic parietes so as to expel the air. These two stages are altt'.iatei, 
 repeated about fifteen times in the minute. 
 
 asphyxia, owing to the increasing difficulty in eliminating the 
 accumulation of carbonic acid. 
 
 fXC 
 
 The Treatrn'^nt of the different conditions giving rise to asphyxia cannct hero 
 be dealt with /;; extcnso. We can only indicate tlie general plan of treatment 
 to be adopted. A rapid examination is at once made, to ascertain, if possible, 
 the cause of the mischief, and whether its onset has been gradual or '.uddeii 
 If it has been gradually developing, it is not uncommonly due to some :horacic 
 condition which cannot be relieved ; if, however, its onset has been sudden, 
 and not the result of any evident lesion, the neck and chest should lie bared, 
 and examined for any signs of traumatism, the mouth opened, the tons'iie drawn 
 forwards, and the glottis examined with the finger to see that the p-issapes nr-- 
 clear. The patient should, if necessary, be removed into fresh air, iti'l .1. tificial 
 respiration at once commenced. Breathing can sc;r«etimes be p\ i'e: ;. 
 
 I 
 
SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 823 
 
 alternately dashing hot and cold water over the thorax, whilst electric 
 stimulation of the phrenic nerve may also be undertaken, one electrode being 
 placed over the neck, and the other on the epigastrium. The administra- 
 tion of oxygen instead of air is useful during the earlier stages, whilst if the 
 condition is due to cardiac disease with distension of the right side of the 
 heart, venesection holds out the best hope of relief. Obstruction within the 
 larynx needs tracheotomy or intubation, as also other conditions associated 
 with pressure on the trachea. 
 
 In cases of threatened death from drowning, the first care must be directed 
 to clearing the air-pascages and mouth of water, weeds, etc., by rapid inver- 
 sion, drawing the tongue well forwards, and swabbing out the pharynx; or the 
 patient is turned on his face, with a firm pillow, or coat rolled up, placed 
 beneath the thorax ; and the chest is compressed so as to help in the evacua- 
 tion of the water, which runs out of the mouth. Artificial respiration can 
 then l)e commenced. 
 
 Artificial Respiration is required in a variety of surgical conditions, and is 
 best undertaken by what is known a-i Sylvester's method. In this the patient 
 Hes on his back, with a pillow beneath the shoulders, the mouth opened, and 
 the tongue drawn forwards. The arms are then grasped just above the elbows 
 and drawn upwards above the patient's head, so as to expand the chest through 
 the action of the great pectoral muscles (Fig. 291). This position is main- 
 tained for about two seconds, and then the arms are lowered to the side, and 
 pressed firmly against the ribs, so as to determine a forcible expiratory act 
 (Fig. 292). At the end of about two seconds more the arms are again elevated, 
 and tlie same cycle passed through. This should be repeated about fifteen 
 times a minute, and the operator must be careful not to use too great violence, 
 or to unnecessarily hurry over it, as harm rather than good thereby results. 
 
 .Vnotlier less satisfactory method consists in alternately compressing the 
 lower part of the thorax and abdomen with the hands, so as to drive out a 
 certain amount of air, and then by suddenly relieving the pressure the elastic 
 e.\pansion of the chest walls draws in a fresh supply. 
 
 \i. Resimkation. 
 
■ ■ '«■. 
 
 ■m 
 
 #' 
 
 '>ii;i 
 
 CHAPTER XXX. 
 
 DISEASES OF THE BREAST. 
 
 Congenital Malformations of the breast are much more common 
 than is usually supposed. One or more accessory breasts or 
 nipples are found either below the noimal one or just above it, 
 but sometimes they have been found in the axilla, on the outer 
 side of the thigh, oi other curious situations. They are often of 
 t rudimentary nature, but in a few cases they have secreted 
 milV. The existence of these structures probably explains the 
 occcijiunal origin of cancer in unusual situations, such as the 
 axilla. Very rarely the breasts are entirely absent. 
 
 Affections of the Nipple. 
 
 Fissures of the Nipple (cracked nipples) seldom occur apart from 
 lactation, and may usually be traced to a want of care and cleanli- 
 ness on the part of the mother, associated with a tender condition 
 of the skin, which might have been prevented by bathing the 
 parts during the later weeks of pregnancy with spirit, so as to 
 harden them. The actual lesion is brought about by leaving the 
 nipples wet after nursing. The superficial layers of epithelium 
 become macerated, and are easily rubbed off, thus exposing the 
 more delicate and sensitive deeper parts, which are irritated and 
 inflamed by the repeated acts of suction. As a result, nursinj^ 
 becomes painful, and if persisted in, the wound may he in- 
 fected, the inflammation spreading to the breast substance alon<( 
 the duct or lymphatics, or extending along the superticial 
 lymphatics to the axillary glands. 
 
 Treatment. — The best way to prevent the occurrence of cracks 
 is to bathe the nipples with some dilute antiseptic, such as boric 
 lotion, immediately after nursing, and then to dry them thoroughly. 
 If at all tender, a little powdered boric acid and starch may he 
 dusted over them in the intervals. When a fissure has formed, 
 it should be dressed with cooling or antiseptic lotions— f.^^, lotio 
 plumbi or lotio acidi borici. Sometimes more stimulating appH- 
 cations are required, such as a solution of sulphate of copper, 
 
DISEASES OF THE BREAST 
 
 US 
 
 :h more common 
 issory breasts or 
 or just above it, 
 cilia, on the outer 
 They are often of 
 hey have secreted 
 ably explains the 
 ions, such as the 
 ent. 
 
 or even of nitrate of silver. It is also recommended to paint 
 the sore w^ith equal parts of glycerine and sulphurous acid. 
 
 Eczema of the Nipple may be of a simple nature, needing nothing 
 but ordinary treatment, or it may take on special features, being 
 then known as Paget's Disease {dermatitis maligna), a condition by 
 some supposed to be due to the presence and action of psorosperms 
 (p. 138). It presents an excoriated, red, smooth surface, dis- 
 charging an abundant yellowish viscid fluid, and may occasion- 
 ally spread widely beyond the areola. It is almost invariably a 
 precursor of cancer, and, indeed, some authorities maintain that 
 from the first the disease is malignant, and not eczematous, in 
 nature. The cancerous tumour is usually located beneath the 
 nipple, and may resemble either a duct cancer, or an ordinary 
 scirrhus. No local treatment is of any avail, and the disease, 
 when once recognised with certainty, is best treated by remo\'al 
 of the breast and axillary glands. 
 
 Abscess of the Areola is not uncommon in young girls about 
 the age of puberty, arising in the sebaceous follicles, and requiring 
 no special notice. 
 
 Chancre of the Nipple is rarely seen in the mothers of syphilitic 
 children (Colles's law. Chapter XXXIX.), but much more com- 
 inonly in wet nurses. 
 
 Primary Tumours of the Nipple are met with, such as papilloma, 
 sebaceous cysts, and occasionally epithelioma. 
 
 . occur apart from 
 ■ care and cleanli- 
 a tender condition 
 d by bathing the 
 ;b spirit, so as to 
 )ut by leaving the 
 'ers of epithelium 
 bus exposing the 
 are irritated and 
 a result, nursing 
 und may he in- 
 t substance along 
 g the superficial 
 
 urrence of cracks 
 tic, such as boric 
 them thoroughly. 
 id starch maybe 
 Isure has formed, 
 lotions— c.^^, lotio 
 stimulating apph- 
 llphate of ropper, 
 
 Inflammatory Affections of the Breast. 
 
 Acute Mastitis is naturally most often obserxed in puerpeval 
 
 women, owing to the sudden establishment of function in the 
 
 breast after the birth of a child, and to its maintained activity 
 
 (luring lactation. It results most commonly from a sore or 
 
 cracked nipple, through which pyogenic organisms hnd their 
 
 way into the breast substance, either along the lymphatics or 
 
 the gland ducts. In the former case the inflammation is mainly 
 
 interstitial in character, the pus diffusing itself widely between 
 
 the lobules ; in the latter the pus forms primarily within the 
 
 alveoli of the glandular substance, but subsequently spreads 
 
 beyond it. Simple obstruction to one or more of the ducts from 
 
 inflammation of the nipple, without any external wound, also 
 
 determines inflammation, which is frequently non-suppurative in 
 
 character. In non-puerperal women acute mastitis may res: lit from 
 
 injury, or may be pyaemic in origin. Occasionally a metastatic 
 
 inflammation of the breast occurs after the disappearance of the 
 
 parotid swelling in mumps ; whilst in girls about the age of 
 
 puberty a subacute inflammation, involving both the breast and 
 
 areola, and even terminating in suppuration, has been observed. 
 
 In newly-born infants a similar inflammation, occasionally running 
 
 on to suppuration, has been seen, possibly resulting from an 
 
i m 
 
 8?6 
 
 A MANUAL OF SURGERY 
 
 infection of the gland ducts during birth with cocci from the^ 
 maternal passages. A slight enlargement, with congestion of the 
 breasts, often occurs after birth, and may be due to, or is certainlv 
 aggravated by, the foolish habit followed by ignorant midwives of 
 pulling or forcibly squeezing them in order ' to break the nipple- 
 strings.' 
 
 Signs and Symptoms. —An inflamed breast is characterized hv the 
 organ becoming swollen, acutely painful, and tender. The gland 
 lobules are felt to be enlarged and indurated, whilst if lactation is 
 progressing, the secretion is to some extent impaired ; but owin;; 
 to the inability of the mother to allow the child to relieve the 
 organ, on account of the pain produced thereby, considerable ten- 
 sion results from accumulation of milk. If suppuration follows, 
 the skin over the breast becomes red and oedematous, and, 
 according to the situation of the pus, three different forms of 
 acute abscess of the breast are described : (a) Supvamammayy 
 abscess is the term applied to a collection of pus in the sub- 
 cutaneous tissue ; it is often entirely unconnected with the organ. 
 or may originate in the superficial lobules. It is strictly limited, 
 and does not burrow deeply, coming readily to the surface. 
 (b) An intramammavy abscess is that most commonly met with, the 
 pus developing within, and distending the lobules, or inftltratini,' 
 the cellular tissue around them ; it is usually diffused widelv 
 thT.'ighout the organ, and may point at several spots. When 
 very acute, or in debilitated women, especially if it has been 
 allowed to progress without treatment, the inflammatory process 
 may actually determine gangrene of the glandular tissue, (c) A 
 submammary abscess is one forming in the cellular tissue beneath 
 the breast. It may spread from the deep lobules, but more 
 frequently arises in connection with disease of some of the 
 adjacent ribs or cartilages, or as a cellulitis. In these cases the 
 breast is pushed forwards, and becomes prominent, floating, as 
 it were, on a bed of pus. The abscess usually points at the 
 periphery of the organ, perhaps in several places, but most com- 
 monly at the lower and outer quadrant. 
 
 Inflammation of the breast occurs in women wdio are anamic 
 and weakly. E\en the simple forms are associated with some 
 fever and malaise, and this becomes greatly exaggerated if 
 suppuration ensues, owing partly to the severe pain thereby 
 induced, and partly to the absorption of toxins. 
 
 The Treatment of simple acute mastitis consists, in the first 
 place, in supporting the inflamed gland by means of a sling or 
 bandage, and in binding the arm to the side, so as to keep the 
 pectoral muscle, on which it lies, at rest. Fomentations are 
 then applied, and any tension due to retained secretion is relieved 
 by the breast-pump. The bowels are opened, and the patient 
 placed on a light and nourishing diet, whilst stimulants and 
 tonics, such as iron and quinine, may be judiciously administered. 
 
DISEASES OF THE BREAST 
 
 S27 
 
 As soon as the acute stage has passed, friction with warm 
 oil. and perhaps the inunction of a belladonna ointment, are 
 advisable. 
 
 When suppuration is threatening, the breast may be poulticed 
 until fluctuation is detected ; but under no circumstances must 
 the abscess be allowed to burst into the poultice, and thus become 
 septic. If such a practice is permitted, chronic suppuration 
 ensues, and the breast may become riddled with sinuses. The 
 most rigid asepsis must be maintained in these cases, and as soon 
 as pus is evidently present, an incision should be made to permit 
 of its escape. In the supvamammary variety it matters little in 
 which direction the cut is made, since the pus is always superficial 
 to the breast tissue. In the true intramammary abscess, the incisions 
 should radiate from the nipple. One or more may be needed, 
 and these should be made with a free hand, so as to allow of the 
 insertion of the finger, and the opening up of any pockets or 
 iobules which are distended with matter. A drainage-tube is 
 inserted for a time, and gradually shortened day by day, until 
 its entire removal is permissible. When the chief incisions are 
 needed above the nipple, it is often wise to make a counter-opening 
 in the lower half of the breast, and generally on the outer side, 
 to permit of more efficient drainage. With such treatment the 
 best of results may be attained, and it is interesting to note how 
 quickly the contour of the breast is restored, and how slight is the 
 permanent injury inflicted on the parts. The suhmammury abscess 
 is best opened towards the lower and outer side, but also at any 
 spot where pus points. 
 
 If septic sinuses persist after an abscess has burst, their orifices 
 should be enlarged, and their walls thoroughly scraped and dis- 
 infected; deep cavities should be efficiently drained and stuffed 
 with gauze, so as to ensure the wounds healing by granulation. 
 
 Chronic Mastitis occurs in two forms — one, a localized affection 
 of one segment of the breast (chronic lobar mastitis), the other 
 involving the smaller lobules and interstitial tissue (chronic lobular 
 or interstitial mastitis). 
 
 I. Chronic Lobar Mastitis is by no means unfrequent as a 
 result of imperfect involution of the organs at the cessation of 
 lactation, but may arise from blows or squeezes, and especially 
 in young women ; it may also follow a subacute or acute attack, 
 which has not ended in suppuration. It is characterized by 
 an enlargement of one or more lobes of the organ, which are 
 usually tender, and often excessively painful, the pain being of 
 I a neuralgic character, and increased during menstruation. The 
 condition is of comparatively little importance, but may gh\. rise 
 
 to a great deal of anxiety and worry. All that is necessary in the 
 [ shape of Treatment is to support the part and keep the arm at 
 I rest in a sling, whilst an ointment containing belladonna, or a 
 
 Wladonna plaster, may be applied. 
 
 ^i.^ \. 
 
828 
 
 A MANUAL OF SURGERY 
 
 2. Chronic Lobular or Interstitial Mastitis is an affection oM 
 much interest, which occurs most frequently in women with small 
 or atrophic breasts, who have passed, or are near to, the cHmactcric, 
 being then merely an exaggeration of the sclerosis which occurs j 
 normally at that epoch. It is, however, sometimes met witli at 
 an earlier age. Pathologically, it is characterized by diffuse o\er- 
 growth and infiltration of the connective tissue, which becomes 
 sclerosed and thickened. This by its contraction constricts the 
 gland ducts and lobules, and as a result cysts form within the I 
 latter, being due to an exudation from the hyperacute gland of) 
 serous fluid, which is unable to find an exit owing to the piessurel 
 of the interstitial growth. Such are known as ' involution cysts,'! 
 and the fluid contained therein is usually clear and limpid ; lnit| 
 may be brown and turbid, from admixture of blood ; intra- 
 cystic growths are not present. Sometimes in the earlier) 
 stages the acini are full of a thick cheesy material, which can! 
 be squeezed out in thread-like masses, and consists of prolifeiated 
 epithelium which has been cast off" into the alveoli and underj^'onej 
 partial liquefaction. 
 
 Clinical History. — The condition often passes unnoticed in tliej 
 early stages, until a distinct tumour has formed, which is nodular j 
 and indurated to the touch, and often very painful. The breastj 
 may be somewhat enlarged, and there is, perhaps, some retractioiij 
 of the nipple, owing to contraction of the interstitial tissue ; hut| 
 this is by no means an essential feature. A scanty serous dis-[ 
 charge from the nipple is sometimes noticed. The skin seldoiiij 
 becomes adherent to the swelling, whilst the lymphatic glands in| 
 the axilla may be enlarged and tender owing to sympathetic^ 
 irritation. On careful examination of the breast, the affection is 
 rarely limited to one particular region, for although a distinct! 
 enlargement of one portion may be present, yet the whole ors,'an 
 feels more or less ' lumpy,' and not unfrequently the other breasti 
 participates in the same change. There may be but little pain| 
 although this is sometimes one of the most marked features of the 
 case ; it is of a neuralgic type, and usually increased at thei 
 menstrual periods. 
 
 If left to run its course, the disease may remain much in the! 
 same condition for many years, and even in time disappear] 
 but more frequently it slowly progresses, and then results iq 
 one of three conditions : (a) General atrophy, the breast becoming 
 shrunken, hard, and nodular, {h) More frequently general (\m 
 disease follows, a condition in which the organ becomes transl 
 formed into a number of cysts held together by dense connecti\| 
 tissue, {c) There is some question as to whether or not cancer \i 
 a sequela of this disease ; but there is abundant evidence to provJ 
 that any continued source of irritation in an organ like the breasl 
 renders an individual with a cancerous tendency more liable tf 
 its development. 
 
 -4M^ 
 
DISEASES OF THE BREAST 
 
 829 
 
 is an affection ot 
 women with small 
 ■ to, the climacteric, 
 jrosis which occurs 
 3tinies met with at 
 zed by diffuse over- 
 ,ue, which becomes I 
 ction constricts the 
 its form within the 
 lypera-mic gland of 
 ving to the pressure] 
 3 ' involution cysts,' 
 !ar and limpid; butj 
 •e of blood ; intra- 
 nes in the eadierj 
 naterial, which can! 
 nsists of proliferated 
 veoli and underj^one 
 
 ses unnoticed in thel 
 ed, which is nodularj 
 minful. The breastj 
 laps, some retractionj 
 terstitial tissue; butj 
 f\. scanty serous dis-j 
 The skin seldonil 
 lymphatic glands in! 
 ving to sympathetick 
 east, the affection isj 
 although a distinct 
 yet the whole ori;ar 
 ntly the other breasti 
 y be but little pain^ 
 arked features of the 
 y increased at the 
 
 The Diagnosis is sometimes easy, but the condition often 
 himulates somewhat closely a scirrhous tumour. The chief 
 points of distinction, however, lie in the facts (i.) that the whole 
 I breast is more or less involved; (ii.) that the opposite organ 
 IS very often similarly affected ; (iii.) that enlargement of the 
 [axillary glands is less common than in scirrhus, and even if en- 
 jLuged they are not hard, as in the latter disease; (iv.) that the 
 jkin is usually free from the mass; (v.) that the tumour is 
 never adherent to the pectoral fascia, nor is it of the stony hard- 
 ness of a scirrhus; and (vi.) that it is often more disseminated 
 and less defined than a cancerous growth, (vii.) Moreover, 
 on careful palpation with the flat of the hand, it is often impos- 
 Isihletomake QUt any distinct lump, the so-called tumour merging 
 .into the surrounding tissues ; this never occurs in scirrhus, the 
 urowth always being easily detected with the flat of the hand. 
 Small cysts can also be felt as localized elastic spots in the in- 
 ilammatory mass. Of course it is possible for the two conditions 
 ;o co-exist, and in doubtful cases an exploratory incision, and 
 microscopic examination of a portion of the tissue, can alone be 
 depended on. 
 
 Treatment. — In the early stages friction with some sedative 
 
 [application may be used at the same time that the breast is 
 
 ^upported, and freed from the irritation of badly-fitting stays. 
 
 I Firm and equable pressure, as by strapping, is also useful m some 
 
 cases, whilst iodide of potassium may be administered. If a definite 
 
 I tumour is present, or if many cysts can be detected, and especially 
 
 if the patient is anxious and worried about herself, it is wise ta 
 
 I remove the affected portion, or even better to excise the whole 
 
 breast, especially when there is a family history of malignant 
 
 I disease. 
 
 Localized or Encysted Chronic Abscess is usually associated 
 
 [with pregnancy, and is characterized by the formation of an 
 
 indurated mass in the breast substance, which slowly softens, 
 
 hiving rise to a sense of fluctuation, although when the abscess 
 
 walls are very thick, as is often the case, it may be exceedingly 
 
 jdifficult to detect. Retraction of the nipple is not uncommonly 
 
 Ipresent, and the axillary glands may be somewhat enlarged. 
 
 The condition has frequently been mistaken for a tumour, but is. 
 
 recognised from it by its incorporation with the breast substance, 
 
 Ik its lack of definition, and by the fact that on careful examina- 
 
 Ition elasticity, or even deep fluctuation, can be felt at its centre, 
 
 iihich is almost always less resistant than the margin, whereas 
 
 Ithe opposite is the case with a tumour. In casos r' doubt the 
 
 jinsertion of a grooved needle or an exploratory incision will settle 
 
 jthe diagnosis. Some few of these chronic abscesses of the breast 
 
 |are of a tuberculous nature. 
 
 Treatment consists in opening the abscess ca\ity, scraping out 
 
830 
 
 A MANUAL OF SURGERY 
 
 its interior, disinfectinf; with pure carbolic acid, if tuberculous, and 
 draining or stuffinf,' it. 
 
 Diffuse Tuberculous Disease of the breast is \ery unconmion. 
 Scattered noduies of caseous material are developed in the intLi 
 acinous tissue, which break down into pus, and come to the surface 
 at various spots. The breast may thus become r Idled with sinuses 
 discharging^ caseous pus. It may be associated with tuberculou; 
 disease of the lungs, whilst a like afTection may arise secondarilv 
 in the axillary glands ; possibly in some cases the primary troiihlf 
 lies in the glands, the breast being subsequently involved. 
 
 Treatment should be carried out, if possible, by incision, scrapinj;, 
 and purification of the cavities ; but if the tuberculous foci art' 
 multiple, it is wiser to amputate the breast. 
 
 Occasionally a chronic tuberculous submammary abscess forms as a 
 result of a similar affection of the ribs or costal cartilages. It 
 develops slowly, pushing the breast forwards, and is easily recofj- 
 nised, although the causative lesion can only be ascertained by 
 exploration. It must be opened thoroughly, and its wall scrapeil 
 and disinfected, whilst attention is also directed towards the affected 
 bone. 
 
 Syphilitic Diseases of the Breast. — As already pointed out, a 
 primary sore may be met with on the nipple ; secondary mucous 
 tubercles, or condylomata, are found in a similar situation di 
 lieneath a pendulous breast, whilst superficial and deep gummata 
 have in rare cases formed in the tertiary period of the disease. 
 
 Cysts of the Breast. 
 
 When the structure of the breast, its abundance of ducts and 
 alveoli, and its complex lymphatic distribution are considered, it 
 is not surprising that many different forms of cystic changes are 
 associated therewith. The following are the more important : 
 
 I. Acinous or Retention Cysts arise, as the name suggests, from 
 some obstruction to the ducts or lobules, whereby the secretion ot 
 the organ is unable to escape. They are met with most fretjuently 
 in women during or after the puerperal period, a milk cyst, or 
 galactocele, being then produced. It usually results from compres- 
 sion of one or more of the ducts, connected with a sore nipple, and 
 contains inspissated milk ; it forms a rounded swelling, and is 
 located near the nipple. The wall is lined with cuboidal or | 
 columnar epithelium, according to whether a portion of the lobule j 
 or the duct itself is implicated; if, however, it attains any great, 
 size, the epithelium may become flat and squamous. This is 
 surrounded by a fibro-cellular layer, the thickness of which increast? j 
 with the chronicity of the case. It is treated by laying the part j 
 open, removing the contents, and stuffing or draining the cavity. 
 
DISEASES OF THE UKEAST 
 
 «J' 
 
 tuberculous, iim 
 
 \erv vmconiindn. 
 loped in tin- inttn- 
 onie to the surfai r 
 
 •Idled with simises 
 I with tuberculous 
 y arise second;irilv 
 [le primary trouble 
 y' involved. 
 ' incision, scraping;, 
 berculous foci aiv 
 
 I' abscess forms as ;i 
 istal cartila^'es. It 
 ind is easily retof^- 
 be ascertained l>y 
 xnd its wall scraped 
 towards the affected 
 
 ;ady pointed out, ;i 
 
 ; secondary mucous 
 
 similar situation or 
 
 and deep «iummata 
 
 of the disease. 
 
 dance of ducts and 
 n are considered, it 
 cystic chanf,'es are 
 nore important : 
 lame suf,'Sests, from 
 eby the secretion ot 
 vith most fre(iuently 
 od, a milk cyst, or 
 [suits from compres^ 
 Ih a sore nipple, and 
 td swellings and is 
 [ with cuboidal or 
 mrtion of the lobule 
 It attains any gr*^^^ 
 Iquamous. This is 
 \s of which increases 
 
 I by laying the part 
 raining the cavity. 
 
 Similar {^dandular cysts form, as already described, in the course 
 ot clironic interstitial mastitis, and are then known as involntion 
 cysts : in long-standing cases, general cystic disease of the breast 
 niay supervene. 
 
 Retention cysts have also been described as resulting from 
 irritation of the nipple, as, for instance, when a young non- 
 prej^nant woman constantly puts a baby to her breast ; the 
 or^'an becomes enlarged, the epithelium proliferates, and a thin 
 serous fluid is secreted, which does not entirely escape and by 
 its distension of the lobules gives rise to what may be termed 
 irritation cysts. They may in time undergo spontaneous absorp- 
 tion, but Erichsen describes a case of this nature in which the 
 swellings did not disappear until the patient subsequently became 
 pregnant. 
 
 Again, one frecpiently finds cystic dilatation of the ducts and 
 lobules arising in connection with certain tumours of the breast, 
 such as duct papilloma, duct cancer, or cysto-adenoma. In the 
 latter cases haemorrhage from the contained growth is often 
 seen, giving rise to a bl(;od-stained discharge from the nipple. 
 A scirrhous growth also occasionally starts from the wall of an 
 acinous cyst. 
 
 Ill most of these retention cysts, discharge from the nipple 
 occurs on scpieezing the organ. 
 
 2. Interacinous Cysts develop in the interstitial tissue of the 
 hreast. 
 
 (</) Serous Cysts originate, it is supposed, from a dilatation of 
 lymph spaces. They may be uni- or multi-locular, perhaps more 
 frequently the latter. They are lined by a smooth, shiny layer of 
 endothelium, and contain serum, perhaps blood-stained, and in 
 old-standing cases cholesterine ; being separate from the gland- 
 substance, they never give rise to a discharge from the nipple, and 
 iiitra-cystic growths are unknown. They are usually surrounded 
 by a wall of connective tissue which may become exceedingly 
 thick and dense. Occasionally, however, they project under the 
 I skin, and if the walls remain thin, fluctuation, and even trans- 
 liicency, can be observed, leading to the condition sometimes 
 badly termed a hydrocele of the breast. 
 
 The Diagnosis of a serous cyst, if the wall is thick, is often a 
 
 [matter of considerable difficulty, as it resembles in many ways a 
 
 scirrhus. It is recognised, however, by the facts that the growth 
 
 is incorporated with the breast substance, usually •». airring near 
 
 its under surface ; that on careful examination an d . v ic resistance 
 
 lis transmitted to the fingers, quite distinct from the stony hardness 
 
 lot' a scirrhus ; that there is no retraction of the nipple, and no 
 
 [enlargement of the axillary glands, whilst, as a rule, the patient 
 
 |complair«s of but little pain. The diagnosis in cases of doubt may 
 
 jbe readily determined by inserting a grooved needle, or by an 
 
 exploratory incision, which should be made of sufficient depth to 
 
If 
 
 m 
 
 83a 
 
 A MANUAL OF SURGERY 
 
 ensure the tliorouf^'h division of the mass, for fear that a small 
 cyst surroiiiKlecl by walls of fibrous tissue, half an inch, or even 
 an inch, in thickness, should be mistaken for a solid tumour. 
 
 Treatment. Althouj^'h it may suffice to lay the cavity open and 
 drain it, it is decidedly wiser to remow it completely. 
 
 (V;) True Hydatid Cysts are occasionally met with, manifestin;,' 
 the general i haracteristics described at p. 151. 
 
 3. Cysts may also arise in connection with cancerous or sar- 
 comatous tumours, from degeneration of tissue in the former case, 
 and from hainorrhage into the substance of the latter. 
 
 4. Dermoid Cysts are described ; but it is a little doubtful whether 
 old galactoceles have not been mistaken f' "^''em. 
 
 I« 
 
 Tumours of the Breast. 
 
 In investigating any case of tumour of the breast, the surgeon 
 must never arrive at a hasty conclusion, but only give an opinion 
 as to its nature after a careful and detailed examination. Thus, 
 the age and previous history of the patient should be considered. 
 as also the family history. Simple tumours generally arise at an 
 earlier date than the malignant, whilst the sarcomata usually 
 affect younger individuals than the carcinomata. There can he 
 little doubt, moreover, as to the occasional tendency of tumour^ 
 to run in families. The length of time for which the swellinj,' \u> 
 been observed should be ascertained, and whether or not it varies 
 in size at the menstrual periods. The general appearance df the 
 patient should be noted, as also the fact whether or not pain, 
 local or neuralgic, is experienced. It is r musual for pain to 
 be referred to that part of the shoulder s' d by the posterior 
 
 division of the second intercostal nerve, tlie anterior branch 0! 
 which goes to the brea^^t. A careful inspection of the orf^an 
 should then be made, comparing it with the opposite breast, so 
 that any signs of asymmetry may be noted. Dimpling of the skin, 
 projection of tl e tumour or of the whole gland, and the situation 
 and condition of the nipple, are the chief points to which attention 
 should be directed. Examination of the tumour with the flat of 
 the hand, accompanied by gentle pressure of the finger-tips, must 
 then be undertaken ; it is not enough to pick up the breast 
 substance between the fingers, as thereby false impressions are 
 obtained. The relation of the tumour to the gland, its shape, its 
 consistency, whether fluctuating or not, and its mobility on super- 
 ficial, deep and surrounding parts should all be investigated. To 
 this end the breast must also be examined with the arm raised 
 well above the head, so as to put the fibres of the pectoralis major 
 on the stretch ; transverse movement of the organ across the j 
 fibres is always possible, unless the growth is fixed to the thoracic 
 wall ; movement in the direction of the fibres is at once linv<^ed ii 
 the tumour has invaded the muscle, or even if the overlying tasciai 
 
DISEASES 01' TIJE BREAST 
 
 833 
 
 2ar tliat a small 
 an inili, or even 
 )licl tumour. 
 ! cavity open and 
 
 jtely. 
 
 with, manif<^stin'^ 
 
 :ancerous or sar- 
 
 [1 the former case, 
 
 latter. 
 
 ; doubtful whether 
 
 )reast, the surf,'eon 
 ly f^ive an opinion 
 amination. Thus, 
 uld be considered, 
 nerally arise at an 
 sarcomata usually 
 Lta. There can be 
 indcncy of tuniouv^ 
 ,ch the swelling ha> 
 ither or not it varies 
 appearance of the 
 lether or not pain, 
 nusual for pain to 
 d by the posterior 
 anterior branch of 
 ction of the organ 
 .opposite breast, so 
 .mpling of the skin, 
 , and the situation 
 to which attention 
 jur with the Hat of 
 te finger-tips, must 
 ick up the breast 
 ;e impressions are 
 ■land, its shape, its 
 mobility on super- 
 , investigated. To 
 lith the arm raised 
 le pectorahs major 
 organ across the 
 ^ed to the thoracic 
 [sat once linvted 1! 
 lie overlyini^; fascia 
 
 IS seriously involved. iMually, tiie lymphatic glands in the axilla 
 must be tart-fuUy examiiu'd, as also, in suspic ious cast's, the 
 supraclavicular j^'lancls and the opposite breast and armpit. 
 
 The chief types of tumour met with in the breast may be 
 arraiif^^'d in three groups : the adenomata, the sarcomata, and the 
 cancers. A few other conditions have been observed, but .ire so 
 rare that they need no special description, e.g., lip<jma, fibrouiii, 
 (hondroma, and osteoma. 
 
 Adenoid Tumours of the Breast. — Four different varieties of 
 
 uiinDur are included in this group, viz., the adenoma, adeno- 
 
 tibroina, the so-called adeno-sarcoma, and the cysto-adenoma. 
 
 Each of these is characterized patliologically by the following 
 
 conditions: {a) Spaces lined by cuboidal epitheliv. m are present in 
 
 all; tlu-y may be tubular or slit-like in nature, simul.iting normal 
 
 Inland tissue, or they may become distended and cystic, {h) The 
 
 tpithclium lining their walls is in one or more layers, but scarcely 
 
 ivor arranged so methodically or evenly as in the normal structure. 
 
 It is always limited by the basement membrane, and has no 
 
 undcncy to e-xtend beyond it. [c) The spaces usually contain 
 
 iluid, more or less abundant according to the amount of dilatation 
 
 prestiU, and generally serous in character, though perhaps brown 
 
 ur reddish in colour from admixture with blood, {d) Not un- 
 
 frefiuently intracystic growths are present, and in one form, the 
 
 cysto-adenoma, these are a specially prominent feature of the 
 
 case, [c] The alveolar spaces are surrounded by interstitial tissue, 
 
 which may vary considerably in amount, and be either simple or 
 
 complex in structure. 
 
 Pure Adenoma Mammae is said to exist when the proportion of 
 interstitial tissue to gland substance is similar to that which obtains 
 elsewhere in the breast. It is very uncommon and recpiires no 
 special notice, the clinical characters not differing from those of 
 libro-adenoma, and its pathological nature being only specifically 
 j recognised on microscopic examination. 
 
 Fibro-adenoma (or Adeno-fibroma) is the most common mam- 
 iHiary tumour met with in young people before the age of thirty ; 
 it is often attributed to a blow or squeeze, and doubtless correctly. 
 It occurs as a more or less rounded or oval mass, which, if placed 
 superficially, moves freely in the breast substance, and, indeed, 
 pay be described as floating in it (Fig. 293); if situated deeply, 
 jit still appears freely moveable, but its definition is less evident. 
 jSometimes several such growths are found in the same breast. 
 |A fibro- adenoma is usually firm, and more or less elastic in con- 
 sistency, of slow growth, whilst it may be either painless, or in 
 temic and neurotic women exceedingly painful, the pain often 
 Increasing at the menstrual periods. There is no concurrent 
 liiilargement of the axillary glands, unless arising from other 
 luses, and no retraction of the nipple, with which i^is entirely 
 jinconnected, whilst the skin over it does not dimple. 
 
 The general 
 
 53 
 
■ 
 
 834 
 
 A MANUAL OF SURGERY 
 
 health is unimpaired unless the patient is suffering from an 
 associated anaemia. On section after removal the tumour is of 
 a greyish-white colour, becoming pink on exposure to the air. 
 It is more or less foliated in texture, being compared by Virchow 
 to the section of a cabbage ; no juice can be obtained on scrapin;; 
 the cut surface with a scalpel, although on pressure some Huid 
 of a thick glutinous or mucoid nature may escape. Microscopi 
 cally, the tumour consists of imperfectly developed glandular j 
 elements, surrounded by a considerable amount of firm interstitial ' 
 tissue, but ducts are never present. The -tumour is distincth | 
 encapsuled, except at the one spot, through which vessels enter, I 
 and at which it is connected with the neighbouring manimarv 
 tissue. It is stated that fibro-adenomata are occasionally con- 
 
 Fig. 293. — FiBRo-ADENOMA Mamm^.. (From Museum of Rovai 
 College of Surgeons.) 
 
 verted into sarcomata, thus changing their type from simple tj 
 malignant ; the evidence, however, as to this is not conclusive. 
 
 The Diagnosis is readily made if the above signs are cunsideretj 
 An adenoma differs from chronic interstitial mastitis or a seroii 
 cyst by its exact definition and free mobility, whilst from malia 
 nant tumours it is distinguished by its slow rate of growth, aa 
 its freedom from adhesions either to the skin or to surroundii( 
 parts. 
 
 The Treatment consists in its removal, which is easily efiectd 
 by cutting down upon the tumour in a direction radiating frol 
 the nipple, until the capsule is reached, when the mass is enucleat| 
 from its surroundings with a few touches of the knife. 
 
 Diffuse Hypertrophy of the breast (Fig. 294) is usually fil"] 
 adenomatous in nature, and consists of a general enlar^eineiitj 
 the organ, both gland substance and interstitial tissue participatif 
 
 iin 
 (of 
 
 m 
 
 pia; 
 
 lapi 
 
 lir( 
 
DISEASES OF THE BREAST 
 
 835 
 
 affering from an 
 the tumour is of 
 )0sure to the air, 
 )ared by Virchow 
 :ained on scrapinjj 
 •e'ssure some fluid 
 ;ape. Microscopi- 
 veloped glandular 
 of firm interstitial | 
 .mour is distinctly 
 rhich vessels enter, 
 bouring mammary 
 3 occasionally con- 
 
 [USEUM OF R<'V 
 
 Al 
 
 in the process, and hence the breast becomes firm and indurated. 
 It may be uni- or bi-lateral, perhaps more frequently the latter, 
 and generally occurs in adolescents. The size varies considerably, 
 but the breasts may become enormous, hanging down by their 
 weight, and perhaps to such an extent as to rest on the knees of 
 the patient when sitting. They are asually painless, although 
 sometimes neuralgia Is noticed. Functionally they are useless, as 
 even if the patient becomes pregnant, secretion of milk but rarely 
 occurs. The only treatment is amputation. 
 
 type from simple tJ 
 
 5 is not conclusive. I 
 
 f signs are cunsidereJ 
 
 mastitis or a sero'J^ 
 
 f, whilst from nialig 
 iv' rate of growth, aii| 
 In or to surroundift 
 
 liich is easily eflectJ 
 >tion radiatmg trol 
 
 ithe mass is enucleati 
 Ithe knife. I 
 
 I294) is usually hoi 
 Ineral enlari^enien 
 
 fal tissue participate 
 
 Fig. 294. — Diffuse Hypertrophy of the Breasts. 
 
 [itdcciurcd in a girl aged sixteen and a half years, and both organs had to be 
 removed. The left breast weighed 9,^ lb., the right breast q lb. 
 
 The so-called Adeno- sarcoma is very similar in type to the 
 
 jadenoma, differing from it mainly in the increased rate of growth, 
 
 |in its soft consistency, and in the fact that the interstitial tissue is 
 
 [of a more embryonic character, and, indeed, is often of a mucoid 
 
 pature. It is really a soft fibro-adcnoma, and usually occurs in 
 
 *omen at a somewhat earlier period of life than sarcoma or 
 
 jcancer^viz., between the ages of twenty-five and thirty-five. It 
 
 nay consist from the first of a localized tumour, increasing 
 
 hpidly in size, or it may possibly commence as a simple hard or 
 
 pronic fibro-adenoma, which, after remaining quiet for a time, 
 
''5 r 
 
 836 
 
 A MANUAL OF SURGERY 
 
 III 
 
 '-"^>V<'-.v~ 
 
 takes on a more active development. It remains, however, 
 throughout its course strictly encapsuled, and when large may 
 lead to pressure atrophy of the true gland substance. It is soft 
 and elastic in consistency, usually painless, and freely moveable 
 on the surrounding breast tissue. The skin over it remains 
 healthy, although distended and atrophic when the tumour is of 
 large size ; the nipple shows no sign of retraction ; the axillary 
 glands are not involved, and there is no systemic invasion. On 
 removal the section is similar to that of a fibro-adenoma, but cysts 
 are often present, as also areas of mucoid softening, somewhat 
 resembling sago. It can be readily removed in its entirety, and 
 does not tend to recur. 
 
 Cysto-adenoma (Syn. : Cysto-sarcoma, Adenocele, etc.) is a con 
 dition characterized by a marked development of intracystic 
 growths, fibro-papillomatous in nature, within the dilated acini 
 of a newly-formed mass of a' jmatous tissue, or within the 
 smaller ducts (Fig. 295). It Ui^^ally has a definite capsule, and 
 then the normal gland tissue may be pressed aside, and perhaps 
 atrophies. Several cysts are, as a rule, present, and may i)e of 
 
 great size, the intracystic growths 
 also varying in amount. These 
 latter consist of branched processes 
 something like a cauliflower in 
 appearance, covered with cuhoidal 
 or columnar epithelium ; they are 
 exceedingly vascular, and h.xmor 
 rhage into the cavity of the cyst 
 frequently occurs, as also a blood- 
 stained discharge from the nipple. 
 They are due to a proliferation of 
 the interacinous tissue, which 
 pushes the epithelial wall of the 
 The cauliflower-like papillomatous duct or acinus before it. The 
 intracystic growths can be dis- tumour produced is irregular in 
 tinctly seen. outline, owing to the projection 
 
 of the cysts ; it is usually pain- 
 less, and unaccompanied by enlargement of the axillary glands; 
 if of large size, blue veins are seen coursing over it. In the later 
 stages the capsule becomes adherent to the integument, and, 
 finally, owing to the pressure of the tumour, the skin may give 
 way, allowing the growth to protrude. Such will be followed 
 the development of a fungating mass, which bleeds readily, anii j 
 becomes extremely offensive. With care a probe can be passed | 
 between the mtracystic portion of the growth and the thinned | 
 and stretched skin, which has merely given way, and is not in- 
 corporated with it ; this fact is a ready means of distinguishing I 
 this condition from a fungating encephaloid cancer. The tumour j 
 is essentially benign in nature ; it is never disseminated generally, 
 
 Fig. 295, — Cysto-adenoma 
 Mamm^. 
 
DISEASES OF THE BREAST 
 
 837 
 
 •emains, however, 
 I when large may 
 )stance. It is soft 
 id freely moveable 
 n over it remains 
 n the tumour is ot 
 ction ; the axillary 
 mic invasion. On 
 adenoma, but cysts 
 ottening, somewhat 
 in its entirety, and 
 
 >cele, etc.) is a con- 
 lent of intracystic 
 in the dilated acini 
 ;sue, or within the 
 lefinite capsule, and 
 aside, and perhaps 
 sent, and may be ol 
 intracystic growths 
 n amount. These 
 [ branched processes 
 e a cauliflower in 
 )vered with cuboidal 
 pithelium ; they are 
 iscular, and bfcmor- 
 cavity of the cyst 
 irs, as also a blood- 
 •ge from the nipple. 
 to a proUferation ot 
 lus tissue, which 
 ithelial wall of the 
 .s before it. 11?e 
 ,ced is irregular in 
 to the projection 
 it is usually pain- 
 the axillary glands; 
 ,ver it. In the later 
 >e integument, and, 
 , the skin may give 
 will be followed by 
 bleeds readily, anj 
 jrobe can be passed | 
 th and the thinned 
 , way, and is not «■ 
 ansof distinguishing 
 cancer. The tumour 
 ,seminated generally, I 
 
 and can be readily and completely removed, so that there is but 
 little tendency to recur. In the early stages it is unnecessary to 
 take away the entire breast if the tumour can be efficiently dealt 
 with otherwise, but in the later stages the whole organ should be 
 excised. 
 
 Somewhat similar in nature to the above is the condition known 
 as a duct papilloma. This is characterized by the development 
 of a soft polypoid papillomatous mass, generally of small size, in 
 the interior of one of the terminal galactophorous ducts, which 
 in consequence becomes dilated. A discharge of blood-stained 
 serum results, and there is usually but little tumour to be felt. 
 Occasionally, however, the nipple may be slightly pushed forwards 
 and rendered prominent. It is often the precursor of a duct 
 cancer. Amputation of the breast will in many cases be needed, 
 although it may be feasible in some to deal with the tumour 
 alone. 
 
 Sarcoma of the Breast is not a common disease. It originates 
 in the connective tissue of the organ, being deeply placed in its 
 substance, or perhaps more frequently developing in the outer 
 and upper quadrant. It is of two chief types : (a) The round - 
 idled sarcoma forms a soft, somewhat elastic swelling, which 
 grows rapidly, and although often limited at first by a fibrous 
 membrane, the capsule tends sooner or later to give way, allowing 
 the growth to become diffused through the organ. It sometimes 
 gives rise to secondary growths in the axillary glands, or becomes 
 disseminated throughout the body by means of the bloodvessels. 
 Cysts often occur in its substance, resulting either from haemor- 
 rhage or occasionally from the dilatation of an incorporated 
 glandular alveolus ; in the latter case the cavity will be lined 
 with epithelium. Myxomatous changes are also not unfrequently 
 observed, and in the more rapidly growing recurrent tumours 
 the mass is often a true myxo-sarcoma. It usually occurs in 
 women between the ages of thirty and forty, i.e., somewhat earlier 
 than scirrhus, whilst its rapid growth and the absence of 
 retraction of the nipple or dimpling of the skin are useful 
 diagnostic features. Should pregnancy follow, the tumour may 
 increase in size at an alarming rate. In the infiltrating forms it 
 is almost impossible to distinguish it from encephaloid cancer, 
 except on microscopic examination, (b) A spindle-celled sarcoma, 
 or fibro-sarcoma, is also met with, forming a rounded or oval 
 tumour, more limited than the above, and growing somewhat less 
 rapidly. It somewhat simulates an adenoma, but is more closely 
 connected with the breast substance. The axillary glands are 
 hut rarely involved, and the sarcomatous nature is recognised 
 hy the microscope and by the great tendency of the growth to 
 recur e\en after apparently complete removal ; on account of this 
 latter feature, the name of ' recurrent fibroid tumour' (Paget) was 
 formerly applied to it. The recurrences generally take place at 
 
838 
 
 A MANUAL OF SURGERY 
 
 gradually diminishing intervals, and the tumour may then become 
 softer and more vascular ; occasionally the tendency to recur seems 
 to wear itself out after the performance of several operations. 
 
 The Treatment of sarcoma mammae consists in the removal of 
 the entire organ at as early a date as possible, together with the 
 axillary glands. 
 
 
 Cancer of the Breast. 
 
 No organ of the body, with the exception of the uterus, is more 
 frequently the seat of cancer than the female breast : it also occurs 
 in the male subject, but is about a hundred times less common 
 than in the other sex. 
 
 etiology. — The breast is an organ subject to great changes 
 in functional activity, richly supplied with blood, and closel 
 associated by nervous connections with other organs of the body, 
 especially the uterus. At the climacteric its functions are at an 
 end, and as it always undergoes a certain amount of fibrosis or 
 degeneration, it can be readily understood that changes are 
 very likely to ensue which may result in the formation of 
 cancerous tumour. Such is usually met with after the age of 
 forty, although the disease may prove fatal at a much earlier 
 date. It equally affects women who have borne children and 
 nulliparae, and the question whether or not the woman has nursed 
 her children seems to have but little influence. The left breast 
 is more often affected than the right. It is frequently attributed 
 to some injury, such as a blow or squeeze ; whilst there is little 
 doubt that badly-fitting stays are responsible for a certain per 
 centage of the cases. It not uncommonly follows eczema ot 
 the nipple, especially that variety known as Paget's eczema; 
 chronic interstitial mastitis may also possibly be an occasional 
 precursor of this affection. The question as to heredity is one 
 exceedingly difficult to decide, and, although it may be a marked 
 feature of some cases, it is somewhat doubtful whether, as 
 general rule, it has any considerable influence. 
 
 Two distinct types of cancer are met with in the breast— viz. 
 acinous or glandular cancer (including scirrhus and enceplialoid 
 and duct cancer. Colloid degeneration of either of the fornieti 
 varieties has been observed, but is very uncommon. 
 
 I . Acinous Cancer is the form almost invariably seen ; tt(| 
 division into scirrhus and encephaloid is entirely artificial, depend 
 ing on the greater or less amount of fibrous stroma present in ar, 
 particular case. 
 
 Scirrhus (Fig. 296) usually commences as a hard circumscri 
 mass, situated most commonly in the outer half of the organ, 
 is closely united to, if not absolutely incorporated with, the brei 
 substance, and on careful digital examination its margin is c 
 so accurately defined as at first appears. In the early stages 
 
DISEASES OF THE BREAST 
 
 839 
 
 may then become 
 incy to recur seems 
 al operations. 
 ; in the removal of 
 :, together with the 
 
 the uterus, is more 
 
 ■east : it also occurs 
 
 times less common 
 
 ■t to great changes 
 'blood, and closely 
 organs of the body, 
 , functions are at an 
 mount of fibrosis or 
 d that changes are 
 the formation of a 
 ith after the age of 
 il at a much earlier 
 borne children an 
 ■he woman has nursed 
 Lee. The left breast 
 frequently attributed 
 • whilst there IS httle I 
 Die for a certain per 
 V follows eczema ol 
 as Paget's eczema; 
 ibly be an occasional 
 as to heredity is ont 
 \ it may be a marWI 
 .ubtful whether, as a 
 
 fth" in the breast-val 
 hus and encepbaloidj 
 
 either of the fonnetj 
 lommon. I 
 
 invariably seen;t(l 
 tirely artificial, depeni] 
 
 stroma present in anfl 
 
 a hard circumscrib 
 
 half of the organ. 
 
 prated with, the breas 
 
 tion its margin is « 
 
 [in the early stages 
 
 is entirely distinct from the skin, which moves freely over its 
 surface; but as growth proceeds, the stroma contracts, and, by 
 dragging on the suspensory ligaments passing from the mamma 
 to the skin, the latter structure becomes more or less fixed, and 
 hence, on attempting to move it upon the tumour, an appearance 
 of dimpling results. At the same time, the whole breast is acted 
 upon in a similar manner, so that the affected organ often seems 
 to be smaller than the other ; and, since the upper half of the 
 [(land is usually affected, the nipple may be drawn up so as to lie 
 at a higher level than its fellow, as well as being retracted from the 
 traction of the growth on the galactophorous ducts. The tumour 
 itself is rarely one of great size, so long as it retains its scirrhous 
 
 Fig. 296. — SciRRHUs Mamm.e involving the Skin, and causing 
 Retraction of the Nipple. 
 
 nature ; it is sometimes extremely painful and tender, but not 
 uncommonly tho pain is intermittent, and of a neuralgic type, 
 [extending to the shoulder, and perhaps only elicited on manipula- 
 Ition. As the growth increases in size, it becomes adherent to the 
 Ipectoral fascia, and may even infiltrate the underlying muscular 
 jsuhstance, so that, on examination, with the arm extended and 
 lahducted, it is found that, although moveable across the fibres of 
 |the muscle, the breast cannot be moved with them. 
 
 The lymphatic glands in the axilla soon become enlarged, the 
 disease rarely lasting many months without this complication. 
 Those running with the long thoracic vessels under cover of the 
 pectoralis major are first involved, and, as the case progresses, 
 |he remaining axillary and subscapular sets become similarly 
 |f^ected, and even after a time the supraclavicular. When the 
 
840 
 
 A MANUAL OF SURGERY 
 
 deeper part of the breast is attacked, the disease nia> "ipread to 
 the mediastinal glands along the lymphatics, which accompany 
 the nutrient vessels arising from the internal mammary trunk ; 
 and thus intrathoracic deposits develop, which even extend aloiii; 
 the subpleural connective tissue, and affect the pleural cavity and 
 lungs. In those cases where the primary growth is situated near 
 the inner border of the breast, the free 'ymphatic anastomosis 
 across the middle line allows of the transmission of the disease to 
 the glands in the opposite axilla, and sometimes a similar affection 
 of the opposite breast arises from this cause. 
 
 The skin may be implicated in many ways. We have already 
 mentioned the dimpling which is met with over the tumour in the 
 early stages. As the case proceeds, the cancer extends outwards 
 along the suspensory bands of fascia, so that the skin itself becomes 
 invaded, feeling firm and brawny, and looking congested and 
 purplish in colour, whilst a branny desquamation is usually present. 
 A crack or fissure at length forms, giving exit to a little serous 
 discharge, which at first scabs over, but finally leaves an ulcerated 
 surface, which slowly extends, and may attain considerable dinien 
 sions. A typical scirrhous ulcer is hollowed out and excavated ; \t> 
 surface, if kept clean, is covered with smooth granulations, dis 
 charging a considerable amount of sanious fluid, but if neglected, 
 it becomes sloughy and offensive ; it is surrounded by a projecting 
 elevation of the tumour substance, forming a sort of rampart around 
 it. Less commonly the disease becomes disseminated through the 
 skin, giving rise to a series of dusky-red, button-like masses of 
 cancer, surrounded by skin which is often apparently unaffected: 
 or the whole cutaneous surface of the organ may become infiltrated 
 and thickened, constituting the condition known as cancer a 
 cuirasse. In such cases the skin is dusky in colour, and so con- 
 tracted and indurated that it is impossible to wrinkle it ; the pores 
 become enlarged, giving a ' pig-skin ' appearance to the part, and 
 may exude an abundant secretion which becomes inspissated on 
 the surface into crusts or scabs, which are independent of any 
 ulceration. This process often extends widely beyond the limits 
 of the breast, invading the whole thoracic wall, and even running 
 over the shoulder to the back of the head or neck ; it is due to a 
 diflfuse extension of the disease along the cutaneous lymphatics, 
 and in its most typical form is slow in its development, the patient 
 perhaps living for many years. Occasionally one meets with a 
 nmch more rapid form of cancerous lymphangitis, in which the skin 
 becomes similarly affected, but the growth is not unfreciuently 
 associated with what is supposed to be a ' weeping ' eczema, due 
 in reality to the yielding of dilated lymphatics, that can be easily 
 seen on examining with a lens. The process spreads widely and 
 rapidly, and cancerous nodules appear here and there in the 
 infiltrated area ; the prognosis is of course very grave. 
 
 In the later stages, the patient passes into a state of cachexia, 
 
DISEASES OF THE BREAST 
 
 841 
 
 ase ma> spread to 
 which accompany 
 mammary trunk; j 
 even extend ulonj; 
 ! pleural cavity and 
 rth is situated near 
 phatic anastomosis 
 )n of the disease to 
 s a similar affection 
 
 We have already 
 X the tumour in the 
 sr extends outwards 
 B skin itself becomes 
 ring congested and 
 m is usually present, 
 it to a little serous 
 r leaves an ulcerated 
 considerable dimeii 
 t and excavated ; its 
 th granulations, dis 
 lid, but if neglected, 
 inded by a projecting 
 )rt of rampart around 
 jminated through the 
 utton-like masses of 
 parently unaffected; 
 ly become infiltrated 
 nown as cancer en 
 colour, and so con- 
 wrinkle it ; the pores 
 nee to the part, and 
 omes inspissated on 
 independent of any 
 ly beyond the limits 
 [11, and even running 
 neck ; it is due to a 
 taneous lympliatics, 
 llopment, the patient 
 y one meets with a 
 [is, in which the skin 
 lis not unfreciuently 
 leping ' eczema, due 
 ;, that can be easilv 
 spreads widely and 
 and there in the 
 ly grave. 
 la state of cachexui, 
 
 becoming emaciated and exhausted. Ulcerated surfaces of con- 
 siderable size may exist, and the tumour is fixed to the thoracic 
 wall, even invading the ribs. The arm on the affected side is 
 swollen and brawny, owing to the pressure of the enlarged glands 
 on the main lymphatics and veins of the limb, constituting a 
 condition of lymphatic or solid oedema. Secondary deposits also 
 develop in the viscera, and may lead to various symptoms, accord- 
 ing to the situations in which they are placed. Finally, death 
 from exhaustion ends the scene. 
 
 Encephaloid Cancer occurs less frequently as a somewhat soft, 
 rapidly-growing tumour, which quickly infiltrates the whole organ, 
 and gives rise to secondary lymphatic and visceral affections at a 
 much earlier date than scirrhus. It does not tend to cause retrac- 
 tion of the nipple or dimpling of the skin, the latter structure 
 being distended, and with blue veins coursing under it. The 
 breast becomes enlarged and prominent, the skin is gradually 
 invaded by the tumour, ulceration follows, and a foul fungating 
 mass sooner or later sprouts up through the opening. The cancer 
 that attacks young women is often of this type, and the prognosis 
 necessarily very grave. 
 
 Finally, in elderly women, a chronic form of cancer is met with, 
 known as Atrophic Scirrhus in which the disease lasts for many 
 years without much definite extension. Cases have been known 
 to persist for fifteen or twenty years, the patient at length dying 
 of some intercurrent malady, although in the great majority of 
 the cases dissemination has ultimately occurred. The special 
 characters are due to the excessive contraction of the stroma, as 
 a result of which the cellular elements become crushed and 
 practically destroyed. The nipple is deeply retracted, and the 
 tumour and breast substance in the most marked cases are scarcely 
 discernible. 
 
 2. Duct Cancer is a somewhat rare form of the disease, the 
 exact nature of which is still under discussion, and there is very 
 little doubt that several distinct types have been described under 
 this name. It is sometimes characterized by the development of 
 one or more nodules of a malignant papillomatous nature within 
 the dilated ducts, and usually situated not far from the nipple. 
 These growths are covered with columnar epithelium, and may, 
 I indeed, be looked upon as forms of columnar cancer. They are 
 exceedingly vascular, and a blood-stained discharge from the 
 nipple is usual. These tumours always grow slowly, and when 
 situated near the skin give rise to a round dusky-red swelling. 
 The nipple is not retracted, and lymphatic enlargement not 
 constant. In other cases the dilated alveoli are occupied by 
 masses of proliferated epithelial cells of a spheroidal type, which 
 arrange themselves into more or less definite papillomatous 
 [growths, whilst cystic degeneration also occurs. Either of these 
 Ivarieties may be associated with a development of ordinary 
 
i %: 
 
 842 
 
 A MANUAL OF SURGERY 
 
 scirrhus in some other part of the breast. The diagnosis can only 
 be estabHshed with certainty by microscopic examination after 
 removal. 
 
 The duration of cancer varies considerably in the different forms. 
 The encephaloid type runs a rapid course, and will proi)al)lv 
 destroy the patient's life in six to twelve months. Duct cancer 
 is very slightly malignant, whilst atrophic scirrhus is similarly 
 slow in growth, and in both death may be postponed for a con 
 siderable period, or is often due to some intercurrent malady, 
 Cancer en cuirasse is variable in its course, being sometimes 
 tolerably rapid, and at others chronic ; it cannot be cured by 
 operation, on account of its early and extensive dissemination. 
 A circumscribed scirrhous tumour is stated to end fatally, 
 on an average, in two or three years if no operative treatment 
 is undertaken, whilst removal of the mass will probably add 
 another year or eighteen months to the patient's life. These 
 figures are, however, derived from statistics of operations per 
 formed before the general adoption of the more exact and exten 
 sive measures which are now usually undertaken, and it is likelv 
 that they considerably under-estimate the benefits derived from 
 such interference. 
 
 The Pathological Anatomy of cancer is discussed in Chapter M, 
 
 The Diagnosis of scirrhus from chronic interstitial mastitis and 
 chronic abscess or cyst has been already considered (p. 829). From 
 tumours of the adenoid type it is easily distinguished. The stony 
 hardness of a scirrhus, its union with the breast substance, its 
 limited mobility, the dimpling of the skin, retraction of the nipple, 
 and enlargement of the axillary glands, are the chief local charac- 
 teristics to be noted. Non-malignant tumours are more elastic 
 to the touch, more moveable, and usually quite circumscribed in 
 outline, whilst the skin, though expanded, does not become 
 adherent ; the nipple is rarely retracted, and the axillary glands 
 remain of normal size. It is often impossible to distinguish a 
 cancerous from a sarcomatous tumour, except on microscopic examina- 
 tion ; a round-celled sarcoma closely resembles an encephaloid 
 cancer, although it is usually more circumscribed — at any rate, 
 in the early stages. The fibrosarcoma may sometimes be mis- 
 taken for scirrhus, but it is more defined in outline, does not cause 
 retraction of the nipple or dimpling of the skin, whilst lymphatic 
 enlargement is not a constant accompaniment. K cysto-adcmml 
 presents no difficulty in diagnosis if the skin is entire, and the cysts 
 prominent ; but when ulceration has taken place, and a fungating 
 bleeding mass protrudes, it is not unlike the later stage of an 
 encephaloid cancer or fungating round-celled sarcoma. It can 
 be distinguished, however, by the fact that a probe can some- 
 times be passed under the skin for some distance into thecavityj 
 of the cyst, whilst lymphatic enlargement is rare. 
 
 Treatment. — This necessarily consists in the removal of ' 
 
DISEASES OF THE BREAST 
 
 843 
 
 diagnosis can only 
 examination after 
 
 the different forms. 
 and will probably 
 iths. Duct cancer 
 :irrhus is similarly 
 :)stponed for a con- 
 tercurrent malady. 
 , being sometimes 
 annot be cured by 
 isive dissemination. 
 ed to end fatally, 
 operative treatment 
 
 will probably add 
 atient's life. These 
 
 of operations per- 
 )re exact and exten 
 aken, and it is likely 
 lenefits derived frcm 
 
 ussed in Chapter VI. 
 terstitial mastitis and 
 sred (p. 829). From 
 uished. The stony 
 ;reast substance, its 
 Taction of the nipple, 
 le chief local charac- 
 [urs are more elastic 
 lite circumscribed in 
 does not become 
 the axillary glands 
 ible to distinguish a 
 nicroscopic examina- 
 ibles an encephaloid 
 icribed— at any rate, 
 sometimes be mis- 
 itline, does not cause 
 \n, whilst lymphatic 
 nt. A cysto-adcnoml 
 „ entire, and the cysts 
 [lace, and a fungating 
 le later stage of an 
 id sarcoma. It can 
 a probe can some- 
 ;ance into the cavity 
 
 bare. , I 
 
 the removal ot tw 
 
 tumour by operation ; but in order to give the patient as good a 
 chance as possible of a permanent cure, the excision must include 
 the whole of the breast, the greater portion of the overlying 
 integument, the subjacent pectoral fascia, possibly a part of the 
 pectoral muscle, and the whole of the lymphatic and connective 
 tissues of the axilla. A full description of the operation is given 
 below, but we desire here to emphasize the fact that the pro- 
 ceeding should be very radical if the patient is to derive any real 
 benefit from it. In the old days, only the more prominent portion 
 of the breast was removed with the tumour, and consequently 
 recurrence was so exceedingly common that if 5 or 10 per cent. 
 of the patients were really cured, it was thought to be as much as 
 any surgeon could reasonably expect. Since we have learnt more 
 of the anatomy of the organ and of the pathogenesis of the disease 
 (for which we are mainly indebted to Heidenhain and Stiles), 
 more extensive proceedings have been undertaken, with a gradual 
 amelioration in the results, so that several surgeons have been 
 able to report 50 to 60 per cent, of their cases as free from recur- 
 rence at the end of three years. It was suggested by Volkmann 
 that any case that remains free from recurrence for three years 
 may be claimed as a cure, but this is generally considered too 
 short a period on which to base such an assumption, since experi- 
 ence tells us that the disease often reappears at a much later date 
 (even nine or ten years). 
 
 It has been proved that the breast is a much more extensi\e 
 organ than was formerly supposed, and if merely the projecting 
 portion is removed, many deep lobules are left, which may lead 
 to recurrence. Moreover, it has been shown that the deeper 
 lymphatics pass into the fascia covering the pectoralis major, and 
 so to the axilla ; lience, this structure should always be taken 
 away, as well as a thin layer of the muscular fibres in certain 
 cases. Again, lymphatics travel along the fibrous bands reach- 
 ing from the breast tissue to the overlying skin, and thus this 
 latter must never be dissected back from over the tumour. The 
 nipple should under no circumstances be left behind, since all 
 the interlobular lymphatics converge to a plexus around it, and 
 reach the axilla by three or four main trunks. The axilla itself 
 should be opened in every case, and entirely cleared of its lym- 
 phatic contents, since deposits in the glands are often found on 
 microscopic examination, where no clinical evidence of their 
 presence had been previously noted. It is also important to 
 remo\ e the breast and axillary tissues in one piece, so as to avoid 
 division of the lymphatics and possible infection of the wound 
 with their cancerous contents. 
 
 Of late years Halsted of Baltimore has been urging the neces- 
 sity of removing the pectoral muscles with the breast in all cases 
 : of cancer, in order to gain better access to the axilla, and also to 
 ; ensure the extirpation of the lymphatics which pass between or 
 
844 
 
 A MANUAL OF SURGERY 
 
 through them. This is often badly termed the complete operation, 
 and is being largely utilized. The clavicular portion of the great 
 pectoral is left, the sternal portion being removed from within 
 outwards, and the tendon divided close to the humerus. Whilst 
 admitting that this practice is good and desirable in cases where 
 the muscle is involved, or where there is much axillary infectio". 
 we do not consider it necessary as a routine procedure. 
 
 As to the cases in which operation should or should not be 
 undertaken, the following facts must be noted : Cancer en ciiiyds^i 
 should never be touched, since it is impossible to eradicate the 
 disease, owing to its wide dissemination through the cutaneous 
 lymphatics. Atrophic scirrhus also is often left alone, on tlie 
 plea that the prognosis is so favourable as to render operation 
 unnecessary ; if, however, the patient is fairly strong, there is no 
 objection to it, and it certainly seems wise to remove a cancerous 
 focus, however chronic it be. Apart from these, all cases in 
 which there is a reasonable prospect of eradicating the disease 
 may be subjected to operation. The following grave conditions, 
 however, require the most serious consideration : (i.) Where the 
 supraclavicular glands are enlarged, it seems hopeless to expect 
 that the whole disease can be eliminated, and yet one likes to give 
 the patient her only chance. The operation must then include the 
 supraclavicular fossa in its scope, as recommended by Halsted; 
 he indeed goes so far as to maintain that the posterior triangle 
 should be cleared of its lymphatic contents in all cases, whether 
 or not enlarged glands can be detected beforehand, and states that 
 in a considerable percentage of cases cancerous invasic i will have 
 already occurred. The cervical incision is a curved oi.e, extend- 
 ing along the posterior border of the sterno-mastoid, and outwards 
 along the clavicle. This flap is dissected up, and all the fat and 
 glands are removed from before backwards, the internal jugular 
 vein being the starting-point. Of course, the greatest care is 
 taken to avoid the thoracic duct or right lymphatic trunk, 
 (ii.) If the tumour is adherent to the thoracic parietes, no opera 
 tive interference is advisable, (iii.) Evidence of pressure on, or 
 implication of, the axillary nerves also precludes such treatment: 
 slight oedema of the arm due to pressure on the main vein need 
 not deter the surgeon from proceeding, since the whole vein ha^ 
 been successfully excised ; in such cases the collateral circulation 
 has evidently been opened up previously, (iv.) Profound cachexia 
 and evidence of visceral deposits also contra-indicate operation. 
 except to give relief to the local pain, (v.) Extensive ulceration i 
 and fungation, and general diffusion of the tumour through tlit 
 breast, are, as a rule, prohibitory signs, (vi.) Disease of botli 
 breasts, although rendering the prognosis more grave, is, catif! j 
 paribus, no hindrance, since both organs have been removed sue 
 cessfully, even at one operation. Speaking generally, rapidly 
 growing tumours in vigorous patients are exceedingly unfavourable 
 
DISEASES OF THE BREAST 
 
 845 
 
 complete operation, 
 artion of the ^leat 
 lOved from within 
 humerus. Whilst 
 [)le in cases wherf 
 I axillary infectio", 
 acedure. 
 
 [ or should not ht 
 : Cancer en ittiyas>i 
 )le to eradicate the 
 ugh the cutaneous 
 left alone, on tin 
 to render operation 
 ^ strong, there is m^ 
 remove a canceroib 
 these, all cases in 
 dicating the disease 
 ig grave conditions, 
 ion : (i.) Where the 
 s hopeless to expect 
 yet one likes to give 
 nust then include the 
 mended by Halsted: 
 he posterior triangle 
 ,n all cases, whether 
 hand, and states that 
 us invasic i will have 
 , curved Oi'e, extend- 
 'astoid, and outward^ 
 and all the fat and 
 the internal jugular 
 the greatest care is 
 t lymphatic trunk, 
 tc parietes, no opera- 
 .e of pressure on, or 
 des such treatment. 
 ^ the main vein neefl 
 3 the whole vein has 
 collateral circulatior. 
 .) Profound cachexia 
 [a-indicate operation, 
 Extensive ulceration 
 tumour through tlie 
 Ivi.) Disease of both 
 lOre grave, is, cttUml 
 been removed sue-' 
 generally, rapidh- 
 dingly unfavourable 
 
 it 
 
 cases to deal with, whilst slow growth of the tumour, and definite 
 limitation of its outline, are favourable signs. 
 
 Amputation of the Breast is an operation which is performed 
 not only for the removal of cancerous or sarcomatous growths, 
 Init also for diffuse hypertrophy, for diffuse septic or tuberculous 
 disease when the organ is riddlea with sinuses, and occasionally 
 tor interstitial mastitis. The proceeding is a very simple one in 
 non-malignant cases. The incisions usually employed are semi- 
 lunar, and placed oblif]uely, as on the right side in I'ig. 297 ; in 
 simple cases, however, there is no need to include quite so mucli of 
 
 rv 1^ 
 
 r 
 
 X^ 
 
 X^MNi^^- ^ 
 
 ^ 
 
 ^^___^^^ y^' Jt^ 
 
 
 
 '^VoHI^^V 
 
 l4..#^ 
 
 i^Ml^ 
 
 fe?? 
 
 'M 
 
 
 ^h(j^hhP^^\^ 
 
 
 ^^m 
 
 ^^B^'v ^^^vA 
 
 ^ 
 
 ^m 
 
 Fir,. 297. — Incisions for Amputation of the Breast in Cancer. 
 
 the integument. The skin is dissected up on either side from the 
 glandular tissue, and the organ freed from its attachments to the 
 pectoral fascia ; the axilla need not be opened. 
 
 Operation for Cancer. — The patient lies on the back, with the 
 head directed towards the opposite side, and the arm raised well 
 above it, so as to put the pectoralis on the stretch. The axilla 
 should be previously shaved, and the skin carefully purified. The 
 incisions employed vary With the size and position of the tumour, 
 one great essential being that no portion of skin which lies 
 immediately over the tumour should be left ; where it is located 
 in the outer and upper quadrant, as is so commonly the case, 
 incisions somewhat similar to those represented in Fig. 297 (right 
 side) will do very well. In other cases the incisions may be placed 
 horizontally, extending backwards as far as the posterior axillary 
 folds, and then the axilla is dealt with through a vertical incision 
 running up along its anterior border (Fig. 297, left breast). It is 
 
846 
 
 A MANUAL OF SURGERY 
 
 the usual custom to m.ike the lower incision first, so that the view 
 of the surgeon may not be interfered witli by the blood tricklinj,' 
 from the upper wound, but this is by no means essential or always 
 convenient. Tlie skin is dissected back on either side from the 
 glandular substance, keeping well clear of breast tissue. The 
 inner side is then dealt with first, the wound being carried th)\vri 
 until the pectoral is exposed, and the gland, together witli the 
 deep fascia, dissected off the muscle from within outwards until 
 its outer border is reached. Should the tumour be adherent to 
 the fascia, it is wise to take away a considerable mari^in of 
 nmscular tissue with the growth, or better still to remove the 
 sternal portion of the muscle ; the same practice is of course 
 followed if the pectoral is actually invaded at any spot. If the 
 clavicular segment can be spared, the subse(juent usefulness of 
 the arm is much increased. During this stage of the operation, 
 all bleeding-points are secured temporarily by Spencer- Wells' 
 forceps. The breast, together with the fascia, and perhaps part 
 of the muscle, is now lying turned outwards, merely connected 
 to the trunk by its axillary attachments. The surgeon then 
 carries on the dissection along the under surface of the pectoral 
 muscles, opening up freely the axillary cavity, and if need he 
 increasing the cutcmeous incision for this purpose. The axillary 
 vessels are first cleaned, the vein often coming prominently into 
 view. The apex of the space is then dealt with, all lymphoid 
 tissue and fat being removed, and finally the inner and posterior 
 walls are similarly treated, until when the dissection is complete 
 nothing remains within the cavity but the main vessels and 
 nerves ; whenever possible, the subscapular branches should be 
 spared. Having thus, it is hoped, eliminated the disease, all 
 bleeding-points are ligatured, the woimd is closed by a continuous 
 suture, aided by one or two deep tension stitches, and a draina^'e 
 tube is usually inserted for a day or two ; it may be placed with 
 advantage through a special opening made in the posterior axillary 
 wall. Where much skin has been removed there will be some 
 difficulty in bringing the edges of the incision together, but by 
 judicious undercutting and sliding an open wound can usually 
 be avoided. If, however, it cannot be closed, skin-grafting by 
 Thiersch's method must be resorted to. 
 
 The immediate results of this operation are exceedingly satis 
 factory, the mortality being slight, probnbly not 5 per cent, 
 Patients often used to complain of im^^airni ui the movements 
 
 of the arm when the axilla had 
 to heal with the arm bound ; 
 by keeping the arm away fi 
 body. Healing is assisted bj 
 facilitated and better pressure can V 
 and there is consequently less oozing. 
 
 pensd and 
 
 the case allowed 
 
 ■ide ; this entirely obviated 
 
 the side at j,ht angles to the 
 
 tliis p sition, since drainage is 
 
 exerted upon the wound, 
 
 Even when the pectorals 
 
 have been sacrificed, the patient is still able to lift the ar to the 
 
DISEASES OF THE BREAST 
 
 847 
 
 lack of the head. The final resuhs necessarily vary with the 
 period at which operation w.as undertaken, and with the cjire and 
 skill of the surgeon. Local recurrence after operation is always due 
 to incomplete removal of the growth, or to infection of the wound 
 (luring the operation. The operator must ever keep in mind that 
 altliDUgh in a healthy organism the implantation of cancerous 
 material has apparently but little or no effect, yet in a cancerous 
 individual positive results are only too certainly obtained. The 
 recurrence appears either in the neighbourhood of the cicatrix, 
 the most usual situation, or in adjacent lymphatic glands. The 
 prof^aess is often slow, but occasionally the disease spreads more 
 rapidly than if no operation had been undertaken. Another 
 attempt should always be made to remove the growth, if such be 
 feasible. 
 
 Recently a proposal has been made by Beatson of Edinburgh 
 to deal with inoperable cases of cancer by oophorectomy, com- 
 bined with the administration of thyroid extract, and two or three 
 cases of apparent recovery under this regime have been recorded. 
 Certainly, if the patient is made to fully understand what is 
 involved by such a proceeding, there can be no objection to 
 trying it, although our present experience seems to indicate that 
 the improvement, often unquestionable at first, is only temporary. 
 
CHAPTER XXXI. 
 
 ABDOMINAL SURGERY. 
 
 Injuries of the Abdominal Walls. 
 
 These may be divided into three main classes — contusions, non 
 penetrating and penetrating wounds. 
 
 Contusions of the abdominal walls vary in their results with 
 the cause and character of the injury, and with the condition 
 of the subjacent viscera. If due to a slight blow, the effects are 
 probably not serious, the patient merely suffering from pain and 
 bruising, as in any other part of the body. If the blow, althoufjli 
 slight, falls upon a distended viscus, such as the stomach or 
 bladder, the organ may be torn, and the contents extra\;isated 
 into the abdominal cavity, with fatal results from peritonitis. If 
 a solid viscus, such as the liver or spleen, is injured, alarinin;: 
 haemorrhage may occur into the peritoneal cavity, from which the 
 patient may die. An account of these visceral injuries is fjfiven 
 seriatim under the appropriate headings in this chapter. Any 
 sudden sharp concussion, especially if directed to the epigastrium, 
 is liable to be followed by severe shock from irritation of the 
 subjacent solar plexus of the sympathetic nerves, and life itself 
 may be destroyed in this way by syncope without the appearance 
 of any evident lesion. 
 
 If the injury is limited to the abdominal walls, rupture of one 
 or more of the constituent muscles, especially the rectus, may 
 occur. A hematoma of considerable size usually follows, and 
 such is especially liable to suppuration and the formation of an 
 abscess, which may point directly at the injured spot, or burrow 
 widely between the muscular planes. The smell of the pus is 
 always suggestive of the presence of the Bac. colt, and this orj.,Mnis!n 
 probably finds its way into the extravasated blood from some 
 slightly damaged coil of intestine in the neighbourhood. As a , 
 further complication, laceration of the parietal peritoneum may 
 be mentioned, causing shock and intraperitoneal extravasation ol 
 blood ; if the latter is abundant, as from a large vessel, peritonitis 
 is almost certain to follow. 
 
 Ifp^r 
 
ABDOMINAL SURGERY 
 
 849 
 
 alls. 
 
 js contusions, non- 
 
 1 their results with 
 with the condition 
 blow, the effects are 
 ering from pain and 
 :f the blow, although 
 as the stomach or 
 pntents extra\asated 
 from peritonitis. li 
 is injured, alarming' 
 ivity, from which the 
 iral injuries is ^iven 
 this chapter. Any 
 d to the epigastrium, 
 •om irritation of the 
 lerves, and life itself 
 :hout the appearance 
 
 Ualls, rupture of one 
 illy the rectus, may 
 [visually folloNvs,and 
 the formation oi an 
 ired spot, or burrow 
 f smell of the pus is 
 lo/i, and this ori^'imism 
 Td blood from some 
 lighbourhood. As » 
 kal peritoneum mav 
 neal extravasation ot 
 rge vessel, peritonitis 
 
 The Treatment of an abdominal contusion is always a matter 
 of some anxiety to the surgeon, as it is difificult at first to make 
 certain of the exact nature of the injury, and as to whether or not 
 visceral complications are present. In the more simple cases 
 ;ill that is needed is to put the patient to bed, combating shock 
 in the usual way by the application of warmth, but stimulants 
 should be avoided, if possible, for fear of restarting haemorrhage. 
 In tlie more severe cases, a decision has to be made as to whether 
 xpectant treatment is to be depended on, or whether an explora- 
 tory laparotomy is to be undertaken. No absolute rules can be 
 laid down as to when operation is necessary, but the surgeon 
 should remember that exploration in a doubtful case will probably 
 do far less harm than delaying operation until the diagnosis is 
 made certain by an outbreak of diffuse inflammation, providing 
 ilways that the patient is not so profoundly collapsed as to contra- 
 indicate all interference. The examination of the abdomen and 
 t the patient may bring to light facts which make operation es- 
 >t;ntial, such as (a) seven; intraperitoneal hfemorrhage, [b) general 
 ivirpanites or free air in the peritoneal cavity as indicated by loss 
 if the area of hepatic dulness, {c) blood-stained vomiting, or (d) the 
 phenomena due to a lacerated bladder. Under such circum- 
 stances, no delay is justifiable, and, even if severe shock is 
 .)resent, operation should be commenced, unless death is evidently 
 mniinent. A large intravenous injection of hot saline solution 
 will usually rally the patient sufificiently to warrant the surgeon 
 in proceeding, whilst freely washing out the peritoneal cavity with 
 •::e same hot solution has often a similar efTect. If, however, 
 wll-marked shock is present, with perhaps localized pain, but 
 with no absolute e\idence of visceral lesinns, expectant treatment 
 should be adopted. The patient is kept warm in bed; perhaps 
 a little opiu.'i is administered to allay pain and restlessness and 
 to check peristalsis, but as little as possible should be given, since 
 Aiiiptoms are so completely masked thereby. If there is any 
 [vomiting, rectal alimentation should be employed after the lower 
 [iwvel has been washed out. If, at the end of twenty-four hours, 
 the patient is still in a condition of collapse, and especially if 
 manifestations of intraperitoneal liaMuorrhage or ot commencing 
 peritonitis have made themselves evident, operation can still be 
 [undertaken with some prospect of success. 
 
 Non-Penetrating Wounds of the Abdominal Wall do not demand 
 
 |i>eparate attention, since there is no special significance about 
 
 Ithem, and if uncomplicated by contusions are treated on general 
 
 [principles. If the epigastric artery is cli\ided, extensive extrava- 
 
 Isation is likely to ensue ; the wound must then be enlarged, 
 
 and the bleeding-points secured. It must also be remembered 
 
 jthat the sheath of the rectus is di\i(led anteriorly i)y the linear 
 
 |transversa' into separate compartments ; but as these do not 
 
 uend through the whole thickness of the muscle, collections of 
 
 54 
 
850 
 
 A MANUAL OF SURGERY 
 
 blood or pus may be limited anteriorly, whilst behind they become 
 diffuse. If the abdominal muscles are widely divided, steps 
 should be taken, after thorough purification, to draw together ihe 
 severed muscular or aponeurotic fibres by deep stitches, so ;is to 
 diminish the tendency to a ventral hernia. 
 
 Penetrating Wounds of the Abdominal Wall may occur with or 
 without injury or protrusion of the abdominal viscera. In all 
 cases there is a certain amount of hemorrhage, greater or less 
 according to the size of the vessels divided, and of shock, which 
 latter is very marked when the viscera are injured, whilst mere 
 protrusion without injury may cause but little effect. Thus, cases 
 are on record in which a patient has walked to the surgeon for 
 treatment, supporting some coils of intestine in his hands. The 
 protruded viscera, usually small intestine or omentum, are often 
 large in amount compared with the size of the opening, causiiii: 
 them to be more or less congested, or even strangled. Neces 
 sarily, in all cases the great danger is that of diffuse septic 
 peritonitis, caused either by rupture of the intestine or bv 
 infection from without. It is an interesting point to note that 
 the peritoneum that co\ers the viscera has but little sensation 
 of pain, whilst the parietal peritoneum and that forming the 
 mesentery are very sensitive ; on the other hand, the viscera! 
 peritoneum is much more liable to inflammation from bacillar', 
 invasion. 
 
 The Treatment of these abdominal wounds has been entirely 
 altered in recent years, as a result of increased confidence in 
 antiseptic methods. The external wound is carefully cleanscii. 
 whilst protruding viscera are similarly purified. If omentum 
 escaped, it is wise to ligature and remove it, whether it is injured ur 
 not. Intestine should be carefully washed with weak antiseptL 
 lotions, such as boric acid lotion, carbolic (i in 60), or sublimate 
 (i in 2,000), and then replaced ; if slightly bruised, it may 
 returned, but the external wound should not be entirely closed 
 and a drainage wick of gauze inserted, so that if fa.'cal extrava>a 
 tion occurs a ready exit is provided. Small incisions or punctiir. 
 must be sutured, but when intestine is hopelessly damai;^: 
 enterectomy should be undertaken if the patient's general cur. 
 dition is sufiiciently good ; but if unfit to undergo such an open: 
 tion, the gut must be fixed in the wound as in colotomy. a: 
 the defect dealt with at a subsequent period. 
 
 In cases where it is not certain whether the peritoneum lu- 
 been implicated, the surgeon should always enlarge the wound- 
 as to make sure, and if the serous membrane has been iiivohcu. 
 he should carry his investigations still further, and ascertain. 
 possible, whether any damage had been done to the \ iscera. 
 
 The external wound must (with the exception mentioned aho.t 
 be carefully closed with sutures, so as to minimize the riskotj 
 subsecjuent ventral hernia. The peritoneum and divided muH.fj 
 
ABDOMINAL SURGERY 
 
 85' 
 
 behind they bectimt 
 iely divided, step> 
 ) draw to<,^ethei ihe 
 ;p stitches, so as Id 
 
 [ may occur with or 
 nal viscera. In all 
 lajre, greater or le^> 
 and of shock, which 
 injured, whilst nurv 
 : effect. Thus, cast> 
 d to the surgeon for 
 ; in his hands. Thi- 
 - omentum, are ofur. 
 the opening, caiisiii;; 
 n strangled. Ntct- 
 hat of diffuse septi< 
 the intestine or by 
 yr point to note that 
 iS but little sensatio:. 
 ind that forminj^ tlit 
 er hand, the viscera, 
 mation from bacillar;. 
 
 nds has been entireh 
 
 creased confidence r. 
 
 is carefully cleansa. 
 
 ,ed. If omentum ha- 
 
 kvhetherit is injured : 
 
 , with weak antisepi. 
 
 (I in 60), or sublinuo 
 
 ily bruised, it may i: 
 
 not be entirely clo^c. 
 
 -hat if f'l-'cal extravav. 
 
 11 incisions or puncturt> 
 
 ' hopelessly damai:.^ 
 .patient's general con 
 ndergo such an opera 
 as in colotoniy,aW 
 
 i- the peritoneum jH 
 p enlarge the wounds 
 [me has been invol«M 
 .rther, and ascertain. 
 lie to the viscera. ^ 
 3tion mentioned alK« 
 fninimi/e the nskon] 
 Im and divided nuisr 
 
 lire united by buried stitches of catgut or well-boiled silk, and 
 finally the skin is brought together with a continuous suture. A 
 drain-tube may need to be inserted for a time. 
 
 Tiiere are but few other conditions of the abdominal wall which 
 require notice. The rectus muscle may be torn as a result of 
 injury or tetanic con\ulsions, and a hernia is very likely to follow. 
 One of the segments may become spasmodically contracted, 
 constituting what is known as a ' phantom tumour,' usually 
 occurring in hysterical females, and disappearing under an anajs- 
 ihetic. 
 
 form 
 
 Affections of the Umbilicus. 
 
 al her 
 
 ibed 
 
 he various rorms ot umhilical nernia are described at p. 942. 
 
 Inflammation and IJlceration, perhaps running on to eczema, 
 nav arise from want of cleanliness after separation of the cord. 
 I'etanus neonatorum probably owes its infection to this source, 
 as also the erysipelas of infants, both of which diseases are ex- 
 ceedingly fatal, whilst the latter is often accompanied by sloughing 
 of the neighbouring abdominal parietes. The eczematous con- 
 dition merely requires cleanliness, and the application either of an 
 antiseptic dusting-powder or of some simple ointment. 
 
 Occasionally a Polyyoid Excrescence is met with growing from 
 the umbilicus, and is probably derived from the remains of the 
 umbilical vesicle. On microscopic examination, it is found to 
 -onsistof a number of tubular glands held together by connective 
 tissue. All that is recjuired is to ligature the base and cut it 
 away. 
 
 Warts and Navi are also found here, but need no special notice, 
 a^ also syphilitic and epitheliomatous disease. 
 
 Umbilical Fistulae not unfrecjuently occur, and may be congenital 
 
 : ac(iuired. Three varieties are described : 
 
 (ii) A Firciil Fistula of congenital origin arises from non-closure 
 111 the \ itello-intestinal duct, and either opens into the intestine 
 jdirectly, or by means of a passage of greater or less length, which 
 
 "rresponds U) Meckel's dixerticulum, and is connected with the 
 
 wer part of the ileum. Acquired cases are usually due to per- 
 
 ration of the bowel following strangulation of an umbilical 
 [itrnia, or to tubercuU)us peritonitis. 
 
 ill) A Congenital Urinary Fistula is due to non -closure of the 
 lirachus; occasionally merely a sinus persists, leading towards the 
 
 ikulder, but not opening into it. It may be dealt with by excision 
 )f the mucous membrane, its destruction by the gahano-cautery, 
 
 hy freshening the edges and subsecjuent suture. 
 
 A Jiiliary Fistula someUmes forms at the umbilicus, probably 
 
 esuliiiif,^ from the bursting of an abscess in connection with the 
 ■bladder. 
 
 In Ectopia "V^esicse the umbilicus is absent, the extroverted 
 
 54—2 
 
t iiO 
 
 852 
 
 A MANUAL OF SURGERY 
 
 portion of the bladder extending up to what should norniallv 
 be its situation. 
 
 A£fections of the Peritoneum. 
 
 Inflammation of the peritoneum, or Peritonitis, arises from 
 a variety of conditions, and presents many diverse manifesta 
 tions. It is a disease which may be limited to some particular 
 locality, or may involve the whole serous membrane. In dis 
 cussing the subject, we shall avail ourselves of the large mass ot 
 information gathered together by Mr. Frederick Treves in the 
 Lettsomian Lectures for 1894. 
 
 From an .etiological point of view, it may be stated that peri- 
 tonitis is almost invariably due to the action of micro-organisms, 
 the symptoms being largely those of toxic poisoning, death, 
 when it occurs, resulting from toxaemia rather than from t!;e 
 inflammation. 
 
 The following forms may be distinguished : 
 
 1. Peritonitis due to infection from the intestine, the organism 
 usually present being the Bacillus coli communis. Entrance to the 
 peritoneal cavity may be gained either through some actual breach 
 of surface, such as a penetrating wound or perforating ulcer, or I 
 through an intestinal wall, the resisting powers of which have 
 been diminished by inflanmiation or injury. The peritonitis 
 associated with appendicitis, or secondary to strangulated hernia,] 
 is of this type. 
 
 2. Peritonitis due to infection from without, the ordinaryj 
 pyogenic organisms being present, especially the Sti'cptocouiiX 
 pyogenes. Such occurs in penetrating or operation wounds wherrj 
 the bowel is uninjured, as also in puerperal peritonitis. 
 
 3. Peritonitis may be due to the gonococcus, which has travelleJ 
 up the Fallopian tube from the vagina. 
 
 4. Tuberculous peritonitis also occurs, and is usually chronic in| 
 
 5. There is a group of cases in which peritonitis is of doubtful 
 origin, possibly arising from chemical or local irritants, rheuniatis:.J 
 etc. ; but it is still a moot point whether such can be caused apart 
 from the activity of micro-organisms. 
 
 Clinical History. — From a purely clinical standpoint, the ori:;ii 
 of peritonitis is of comparatively little importance, since 
 symptoms produced are very similar in the diflferent groupj 
 indicated above. It may be practically discussed under twomaij 
 headings — the acute and the chronic. The acute is again diviiid 
 into the diffuse and localized, and the chronic into the simple ai| 
 the tuberculous. 
 
 Acute Diffuse Peritonitis. — The onset \aries somewliat wia 
 the cause of the affection ; but when due to traumatic intectioj 
 from without, the symptoms usually conuuence with abdomicl 
 
ABDOMINAL SURGERY 
 
 853 
 
 should normally 
 
 d is usually chronic^ 
 
 pain and distension, together with flatulence and vomiting. The 
 pain may at first be localized to some particular region, or referred 
 to the umbilicus ; it soon, however, becomes diffuse, and is 
 associated with exquisite tenderness and great distension. In 
 a typical case the phenomena are very characteristic. The patient 
 lies on his back with his knees drawn up, partly to relax the 
 abdominal muscles, partly to prevent the bedclothes touching the 
 jiody. The abdomen is distended, hard, and extremely tender ; 
 it is at first generally tympanitic, but later on, if effusion should 
 become marktd, dulness may be noted in the flanks, although this 
 is not a common feature. The pulse is quick, hard, and wiry in 
 tlie early stages, though later it becomes weak, rapid, and com- 
 pressible. The respirations are quick, shallow, and thoracic in 
 character. The temperature, raised at first, tends to become 
 subnormal from toxaemia before the end is reached. Vomiting is 
 usually a prominent symptom, associated perhaps with hiccough ; 
 to commence with, the contents of the stomach alone are expelled, 
 'lut later on they may be mixed with bile, or even fitcal material. 
 Though very constant and troublesome, it is much less distressing 
 than that whiv,h arises from intestinal obstruction, and, owing to 
 the pain induced by any sudden contraction of the abdominal 
 nuscles, the patient ejects the vomit with but little force. Con- 
 stipation and arrest of flatus are always present in peritonitis, 
 iiwing to the cessation of peristalsis induced by the inflammation. 
 As the case progresses, the patient's strength rapidly diminishes, 
 his face becomes pinched and drawn {fades Ilippocnitica), the 
 rxtieniities are cold, the temperature is usually subnormal, and 
 j lieath results from collapse and toxaemia. 
 
 When due to sudden perforation of the bowel, the onset of the 
 
 >ymptoms is associateu with profound shock, and the course is 
 
 very rapid if the opening is large, and the intestinal contents 
 
 tarly extravasated. Vomiting, too, is usually more marked than 
 
 hvhen due to other causes. If, however, the perforation is small, 
 
 hbere is much less immediate shock, and the symptoms progress 
 
 niore gradually. 
 
 The Post-mortem Phenomena of acute diffuse peritonitis consist 
 
 n an exudation into the peritoneal cavity of turbid serum or pus, 
 
 jniixed with flocculi of lymph. The serous coat of the intestine 
 
 lis roughened, and adjacent coils may be matted together by 
 
 [greenish semi-puriform lymph. The effusion is mainly found in 
 
 [the pelvis and lower part of the abdominal cavity, and is not 
 
 ilways very abundant ; it is intensely infective, and any wounds 
 
 paused during the performance of the post-mortem examina- 
 
 Ition are likely to be followed by severe cellulitis or even fatal 
 
 feptica-mia. The omentum sometimes forms a barrier shutting 
 
 pff the lower from the upper portion of the peritoneal cavity, and 
 
 limiting the mischief to one or other section. 
 
 Treatment of Acute Diffuse Peritonitis. — In former days treat- 
 
854 
 
 A MANUAL OF SURGERY 
 
 ment consisted in foinentinj^ the abdomen, and keeping tlie patient 
 fully under the influence of opium, whilst abstinence from loml 
 was enforced, and possibly calomel given as an absorbent : hui 
 smce peritonitis is very rarely idiopathic in nature, and usuallv 
 results from some very definite local lesion, such measures are 
 rarely ade(|uate. In difTuse peritonitis, expectant treatment of 
 this character is almost certain to be followed by a fatal issue: 
 and although treatment by operation has no great results to boast 
 of, it is the only rational and scientific plan to adopt. The \ irulent 
 nature of the toxins produced by the inflammatory process, and 
 the late date at which operation is usually performed, fully suffice 
 to explain the high death-rate associated with it. An exploratorv 
 laparotomy should therefore be undertaken as early as possible, 
 the incision being made in the linea alba, and usually below the 
 umbilicus, unless there is tolerably clear evidence that the causative 
 lesion is in the upper part of the abdomen. The effusion is allowed 
 to escape, and by gently separating the coils of intestine localized 
 pockets of fluid may be evacuated. Collections of blood or pus 
 should be swabbed out by gentle sponging, or possibly general irri 
 gation of the abdominal cavity with sterilized salt solution {o'f^ per 
 cent.) may be adopted. In this proceeding care must be taken to 
 maintain the fluid at a constant temperatiu'e (105" to no' F.), to 
 prevent abdominal distension, and not to allow the fluid to pLiv 
 on the under surface of the diaphragm for fear of causing respiratory 
 embarrassment. If the original lesion can be reached without 
 much difliculty, it must be dealt with according to the rules giien 
 hereafter, provided that the patient's general condition is siitti 
 ciently satisfactory. Drainage of the peritoneal cavity by a ,t,'lnss 
 drainage-tube, or perhaps better by strips of gauze passed anioni:; 
 the intestines in different directions, is usually essential. 
 
 In cases of threatening peritonitis following abdominal opera 
 tions, as indicated by pain, distension and \omiting {pcritonhnii 
 the chief causative factor is often a paralytic condition of the i,'iit. 
 which permits of the retention and decomposition of the intestirij 
 contents, thus assisting the activity of the Biu\ coli. In such case- 
 a smart saline purgative is often useful, in order to free tliej 
 intestine from its irritating contents. When, however, generaj 
 septic peritonitis is present, purgati\es can only do harm. 
 
 Acute Localized Peritonitis usually arises in connection with! 
 some limited lesion of the abdominal contents, which is of sucij 
 a nature as to permit of the general peritoneal cavity bein^^ shin 
 ofT by adhesions between adjacent coils of intestine, the proce;j 
 being thereby localized. It is usually, although not invariablvJ 
 followed by suppuration, the abscess being thus intraperitoneal 
 although not involving the general peritoneal ca\ity. li'l 
 abscesses arising in connection with appendicitis or pehic perl 
 tonitis are not uncommonly of this nature. They may InirNj 
 through the barrier of adhesions, and thus light up a difTuse ."T 
 
ABDOMINAL SUIiGERY 
 
 85s 
 
 ceepinf; the patient 
 Uincnce from loud 
 an absorbent ; Inn 
 ature, and usually 
 such measures are 
 ctant treatnu'iit of 
 d by a fatal issue: 
 •eat results to hoasi 
 Lclopt. The virulent 
 matory process, and 
 formed, fvdly sufluf 
 it. An cxploratnry 
 IS early as possible, 
 id usually below th. 
 ,ce that the causativt^ 
 he effusion is allowed 
 of intestine localized 
 tions of blood or pib 
 possibly ^'eneral 1111 
 salt solution (o''' F' 
 •are must be taken tti 
 > (105" to no' l'.),t.' 
 ow the fluid to pl;iv 
 of causing; respiraiovy 
 
 . be reached without 
 ling to the rules <iiven 
 ral condition is sutli 
 Ineal cavity by a k'la>- 
 Vau/.e passed anionjjN 
 [ly essential, 
 ■ing abdominal opera- 
 Nomiting {pentoumiK 
 condition of the >^ii;. 
 ;ition of the intestuu. 
 ir. coli. In such ca>c 
 in order to tree thr 
 [en, however, i^eneia 
 inly do harm. 
 's in connection wit' 
 '^nts, which is of sue: 
 eal cavity bein^^ shut 
 intestine, the proce- 
 oush not invanabiv. 
 thus intraperitoneal 
 itoneal cavity. ^.^ 
 dicitis or pelvic pen 
 ■e. They may m 
 light up a diffuse"' 
 
 llatnmation of the peritoneal sac, or they may burrow to the 
 surface and burst externally, or open into one of the hollow 
 viscera. 
 
 The Symptoms complained of are deep pain and tenderness, 
 more or less localized to the affected area, together with fe\er, 
 vomiting, and constipation. At first no swelling or tumour is 
 to be made out, but a feeling of resistance may be noticed in 
 the abdominal wall, which is held tense and rigid, as if guard- 
 ing some focal point of mischief. As the effusion increases in 
 amount, a tumour dull or tympanitic on percussion usually 
 becomes evident ; it is mainly due to a matting together of the 
 intestines, but associated with a variable amount of elfusion. If 
 the abscess tra\els towards the surface, the abdominal wall 
 becomes infiltrated, red, and trdematous, the component tissues 
 being brawny to the touch, and cutting lil<e bacon. I-'inally a 
 thictuating area presents itself in the midst of this indurated mass, 
 and tlie abscess either discharges itself or is opened. The pus con- 
 tained therein may be thin and ofTensi\e, or it may be free from 
 odour, and then is often somewhat inspissated, and like custard 
 in consistency. Of course this process is attended with con- 
 siderable increase in the pain and constitutional disturbance. If 
 the cavity is treated antiseptically, it rapidly contracts and a cure 
 is accomplished, although intraperitoneal adhesions may persist 
 and lead to trouble later on from hampering the intestinal mo\e- 
 nients. If a communication is established with the intestine, a 
 facal fistula is very apt to follow ; whilst if the cavity becomes 
 >eptic, chronic suppuration may result, and thereby the patient's 
 tiealth and strength are undermined. 
 
 Treatment of Acute Localized Peritonitis. — In these cases, 
 resolution can be obtained in favourable cases by keeping the 
 patient quiet and on a low diet, with perhaps a little morphia, 
 and by applying fomentations locally, whilst the lower bowel is 
 emptied by an enema. Such a course must, however, not be per- 
 Msted in for too long when suppuration is likely to have occurred, 
 for fear of the inflammation spreading to the general peritoneal 
 cavity, or of the abscess bursting into it. An early exploratory 
 laparotomy is advisable under such circumstances. The line of 
 treatment marked out for appendicitis (p. 901) is that which should 
 i always be followed. 
 
 Simple Chronic Peritonitis in itself rarely recjuires surgical 
 
 I attention, since it is to be looked on rather as a protective than 
 
 as a destructive process. It is characterized by infiltration and 
 
 thickening of the peritoneum, giving rise to aclhesions, whereby 
 
 the intestinal wall is strengthened, and bacterial in\asion limited. 
 
 jit is localized or diffuse in character, and arises either as a result 
 
 lof pre-existing acute inflammation or as a primary aflfection. In the 
 
 kore diffuse forms the intestines are hopelessly matted together, 
 
 land the omentum may be rolled up and contracted into a rounded 
 
A MANUAL OF SURGERY 
 
 cord-like mass, lyin^' transversely across the upper part ol ilu 
 abdomen ; chronic obstruction is almost certain to arise sooner oi 
 later from this condition. Occasionally the existence of persisting' 
 localized pain may indicate the presence of a solitary adlusioii, 
 passing between the abdominal wall and one of the viscera, sucli 
 as the anterior wall of the stomach. In sucli cases an exploratory 
 laparotomy is permissible, the adhesion if found bein^ divided 
 between ligatures. The importance of dealing with such adlu 
 sions, where possible, is evident from the fact that intt'rnal 
 strangulation beneath them, or acute kinking of the gut over 
 them, is one of the commonest forms of acute obstruction. 
 
 Tuberculous Peritonitis. — This disease is almost limited t. 
 young people, and is usually secondary to some other focus oi 
 intra-abdotninal tuberculosis, e.g., in the intestine, mesenterii 
 glands. Fallopian tube, etc. It is sometimes limited in it^ 
 development to a portion of the peritoneal cavity, especially when 
 it is of pelvic origin, but is more frequently diffuse. It manifesto 
 itself in several different ways: (i) In the ascitic variety the 
 peritoneum becomes thick and hypera^niic, and studded over \vit!i 
 tubercles, some of them small, grey and translucent, others larf,'er 
 and undergoing caseation. The effusion is generally abundant, 
 and consists of straw-coloured or opalescent serum, perhap:^ 
 blood-stained in the more active cases. Flakes of fibrin may In 
 found covering the membrane here and there, but there is n. 
 extensive matting of the intestines. Occasionally the effusioi; 
 becomes encapsuled, giving rise to cystic swellings shut in betwee!] 
 the coils of intestine. (2) In the fibvous variety the intestine- 
 become matted together by extensive adhesions, and between 
 them foci of tubercle are found. The mesentery may become 
 infiltrated and aluink, fixing the intestines i)ar1-: en bloc to tlie 
 posterior abdominal wall. The omentum is ofiiii invaded, am; 
 contracts upwards to form a sausage-like tumour lying transversely 
 above the umbilicus. There is but little effusion, and that b 
 usually encapsuled. It is obvious that such a condition ^ 
 extremely likely to lead to obstructive phenomena, due to kinkini; 
 of the intestine. (3) The nlcevoiis variety is characterized by an 
 exaggeration of the above phenomena. Tuberculous foci are 
 found between the coils of intestine, and open into them, givinj; 
 rise to various inter-intestinal fistulas {fistula binincosa), or even 
 opening externally. 
 
 In any of these varieties acute manifestations may develop at 
 any time as a result of infection from the bowel with the Bac. cck 
 and then the symptoms of acute diffuse peritonitis may supervene. 
 
 The ssrmptoms are very variable. Any and every form of di^'es' 
 tive disturbance may occur, including diarrhoea, or altematiK 
 attacks of constipation and diarrhoea, with some amount of colic 
 and vomiting. The onset is generally gradual, but intermissions 
 and relapses are of frequent occurrence. Wasting is, however, 
 
A BDOMINA L S L" ' G KR Y 
 
 «S7 
 
 .ipper part of tin 
 1 to arise sooner (ji 
 itence of persisting 
 solitary luUusioii, 
 f the viscera, sucii 
 ises an exploratory 
 unci being divided 
 i<r with such ailliL- 
 fact that internal 
 ifT of the gut over 
 obstruction, 
 almost limited i. 
 3me other focus ol 
 itestine, mesenterk 
 mes limited in \h 
 ity, especially when 
 iffuse. It manifesl> 
 ; ascitic variety the 
 d studded over with 
 lucent, others lari^er 
 generally abundant, 
 ent serum, perhaps 
 d<es of fibrin may bt 
 sre, but there is ik, 
 sionally the effusion 
 lings shut in between 
 ariety the intestine 
 ;sions, and between 
 .entery may become 
 barlv en bloc to tlit 
 i oft I. a invaded, and 
 3ur lying transversely 
 iffusion, and that b 
 ^uch a condition b 
 mena, due to kinking 
 characterized by an 
 uberculous foci are 
 |en into them, giving 
 a himncosa), or ever, 
 
 lions may develop at 
 /el with the Bac. di 
 jnitis may supervene, 
 A every form of difjes- 
 Trhcea, or alternatiiji 
 lome amount of colic 
 tial, but intermissions | 
 ^Vasting is, however, 
 
 always a marked feature. The abdomen is enlarged, perhaps 
 tender to the touch, and may contain free fluid or not. 
 
 Treatment in the early stages is often successfully undertaken 
 
 by the physician ; but if the condition is progressing, the surgeon 
 
 may be called upon to deal with it by laparotomy. When marked 
 
 ascitic accumulation is present, all that is needed is to remove 
 
 the fluid and close the wound with or without irrigation, and in 
 
 nearly 75 per cent, of the cases a cure may be anticipated. Where 
 
 diffuse or localized suppuration is present, adhesions which can 
 
 he reached may be gently broken down, exit given to the pus, 
 
 and the peritoneal cavity washed out ; but no prolonged search 
 
 after suppurating foci should be made, or the intestine may be 
 
 torn. The results of treatment in this \ariety are not nearly as 
 
 satisfactory as in the former, at least 40 per cent, of the cases 
 
 dying. As to the way in which cure is established, opinions 
 
 differ, some authorities considering that it is due merely to the 
 
 admission of atmospheric air, some to the alteration produced 
 
 thereby in the intra-abdominal tension, whilst others maintain 
 
 that it is simply in consequence of the removal of the exudation 
 
 and its contained toxins. The most plausible idea, however, 
 
 attributes it to a flushing of the intra-abdominal tissues with 
 
 blood serum (a well-ascertained fact after laparotomy) and the 
 
 eftect of the antitoxic substances contained therein, the tubercles 
 
 thereby having their vitality destroyed. In this connection one 
 
 may note the statement that too early a laparotomy does but 
 
 little good, an insufficient amount of antitoxin having presumably 
 
 developed in the system. 
 
 Par acentesis Abdomini s is _re (|uired i n cases of gen eral o r 
 encysted ascites. The usual plan adopted is to seat the patient 
 on a chair, and to encircle the abdomen with a flannel binder, 
 the ends of which are split to within 6 inches of the middle line. 
 The unslit portion is placed over the abdominal wall in frg pt, 
 whilst the divided portio ns cross behind, and are held_by assistant?, 
 so as to make "continuous pressure upon the abdominal content^. 
 The abdomen is carefully percussed, and a spot of absolute dul- 
 ness selected ; here a small skin incision is made with a scalpel, 
 and a suita ble troca r and cannula inserted. The median line 
 below the umbilicus is the place usually chosen for the puncture, 
 but there is no objection to inserting the trocar through the 
 flanks. Some surgeons prefer to withdraw the fluid more slowly, 
 so as to preve nt the sh u ck often experienced from its rapid 
 removal. Two or three Southey's trocars and cannula:; may then 
 be inserted. 
 
 Affections of the Stomach. 
 
 Rupture of the Stomach results from blows or falls upon the 
 epigastrium, especially after a heavy meal, and then usually in- 
 
S5S 
 
 A MANUAL OF SUh'GliliY 
 
 volvcs the pyloric rnd or ihc {greater riirv.ituro near the raidi.ii 
 orilicc, ll may also follow a pcnclralin;; injury, such as a sliih 
 or a fail upon a spiki; or railiiif^'s. Nei^^hbourinj,' viscera are ivn 
 iinfr('(pi<'iitly inxoKcil in the lesion, espe( iaily the liver or s|)lr(ii. 
 The Symptoms are tiiose of se\ere and prolonged slioek, wjdi 
 epi^faslric pain and \()nlitin}^^ the ejected material oftcMi eontaiiiini; 
 i)I()od ; acute septic jieritonitis usually ensues in a very short tinii, 
 destroyinj,^ the patient's life in a few days. ( )< casionally, wlim 
 the wound is small, or the orj^an empty at the time of the accident, 
 there is hut litth; or no extravasation, and then a localized intra 
 peritoneal absci'ss may form, shut off from the ^^eiu ral peritoneal 
 cavity h) adhesions, and sooner or later hurstin^^ and disehai),'iii- 
 into the stomach, colon, or one of the hollow \iscera, or else 
 lrackin}j^ alonjj; the parietal wound so as to reach the surface, ei 
 e\en sometinu-s hicakinj,^ down the banici' of adhesions, and 
 orif^inatinj^f a late j^eni-ral pei itonitis. If tlu' postci ior wall of tlu 
 stomach is alone injured, the resultin<,' phenomena are very siinilir 
 to those due to the perforation of an ulcer {q-v,). 
 
 Treatment. When a wound jierforatinj,' the alxlominal pariett^ 
 is present in the rej^ion of the stomach, it is always tlu^ suii^'eon^ 
 duty to eidarji^e the opening,', and ascertain what amount of internal 
 daniaj^e has been done ; hut if there is no external wound, or 
 •\ merely a superiicial one, a certain diagnosis cannot he iiiadf 
 
 ; unless hlood-stained Noniitinf^^ is present. In douhtful cases the 
 ! persistence of shock for some considerahle time and the onset nf 
 .' peritonitis indicate that an exploratory laparotomy should he 
 undertaken. No tiiue must, howe\er, he; lost in cases where ih 
 diajjfnosis is tolerahly certain, since th(^ only hope of savin;,' tl; 
 patient's life lies in early interference. A median incision is niadt 
 aho\e the uiuhilicus, the situation of the injury in the stomar!: 
 ascertained, and the aperture clamped iiy forceps so as to prevent 
 any further exit of the gastric contents whilst the peritoneum i- 
 being cleansed. All extravasated material should be carefully 
 sponged or swabh(>il away, and if the general caxity has not yd 
 become iniected, irrigation should be avoided for fear of carryii;, 
 infective material to other regions. The wound in the stoinac': 
 is closed by a row of Lenibert's sutures, which tuck the niartjiib 
 inwards, and these must extend a little beyond the lesion on either I 
 side (Figs. 305 and 306). If the posterior wall is also injured. a> 
 by a bullet woimd, an opening should lie made through the onici 
 turn so as to explore and cleanse the lesser sac of the peritoneiin I 
 If the case has been operated on early and there is but littU 
 peritoneal inflammation, it may be possible to close the parieta. 
 wound entirely ; but, as a rule, it is necessary to drain the upper 
 part of the serous cavity by inserting a plug of gauze down to and 
 around the site of the injury. If the general cavity is inflamed, thrj 
 treatment suitable to acute peritonitis must be instituted (p. 854. 
 It will probably be wise under these circumstances to place ai 
 
A H DOM IN. 1 1. SUKGllh' Y 
 
 »w 
 
 . nc;ir tlu' caiili,!, 
 iry, siuh ns ii slal 
 \\]tt viscciii .ire II ' 
 lu^livcr or splrcii. 
 lon^^ftl shock, with 
 ial ollcn containing 
 n ;i very slioil tinn. 
 ( )i ( :is'u)naUy, wlu n 
 inu- of tin- accident. 
 i-n a locali/ctl inti.i 
 (• n;(.n( ml pc^riloniiil 
 iiijj and tliscliarj^in^ 
 ()\v \isccra, ov i'Im; 
 each the svufacc, or 
 ■ of acUu'sions, ami 
 posterior wall ol llu 
 icna arc very similar 
 
 (. iihdominal paruKN 
 always the siUi^M'on'^ 
 ;it amount oi nilcrnai 
 ) external wound. -; 
 )sis cannot he uvmV 
 11 doubtful cases tbt; 
 time and the onscK'! 
 parotomy should W 
 ist in cases where ti 
 y' hope of savin;^ llv 
 /dian incision is made 
 |ijvny in the stomar' 
 ,ceps so as to pre\.i: 
 1st the peritoneum i- 
 shovild be carefully 
 ai cavity has not yri 
 h\ for fear of carrym. 
 lound in the stomach 
 ,ich tuck the niari^ub 
 iud the lesion on oitlw 
 vail is also injured. a> 
 de through the omen 
 lac of the peritoneun|. 
 'd there is but lmk| 
 to close the parietal 
 Lty to drain the upper 
 of gauze down to and 
 cavity is inflamed, the I 
 
 , be instituted (p. »54'' 
 umstances to place al 
 
 Iiainage tulu! in\m( diately abfiNC tlu; symphysis pubis, as well as- 
 ,a\in;4 tlie ii|)p(i- incision jiartly open. 
 Foreign Bodies in lli<; stomach consist eiihei ol those which 
 
 ha\(' 
 
 I retiiius, c. 
 
 ■-Ml 
 
 teen s\vallow(!(l accideii 
 
 tally 
 
 Ol intentional 
 
 Mans, woi 
 
 d, etc.. due to tl 
 
 !>■• 
 
 or Ol con 
 
 le constant ingestion ot 
 
 ill portions whic h remain in the \ is(ns, and nia\ after a time 
 Inrin large masses. 'I"lu; presence of tlu; former is known from 
 the history, whilst the latter may gisc ris(! to symjjtoms of gastric 
 
 irritation, 
 
 tl 
 
 le cause ol wliicii IS ine\ 
 
 j)licabl 
 
 !• until the mass has 
 
 iltained such a si/e as to suggest the |)resence of a tumour, 'i'he 
 >nl\ treatment possible wlieie the foreign body is i>\' an\ si/e is 
 ;i) (»|ien the organ and rc-nuni' it (gastrotomy ) ; wiiere, however, 
 It is of small dimensions, c./;., a (oin, it may 
 
 )e aii( 
 
 )U('(I to pass 
 
 (inwards. 
 
 Ulcer of the Stomach. I'ntil recently this ailection was con- 
 Mclciid as belonning e\( liisi\(dy to the realm of the physician, but 
 uitliin the last few years it has ftivpimtly come uiuler the care of 
 the surgeon. Into the a'tiology rmd sjx'cial symptoms of this con- 
 ilitinn, it is uiHKH-essary to enter ; they are described sulliciently 
 in oidinruy medical te.\t-bo(d<s. Then; are, howex'er, several 
 (()mpli( ations which may call for surgical treatm(;nt, \ i/.., e.\ces- 
 ■>ive ha-morrhag"', perforation, cicatric ial stenosis, and adhesions 
 hctween tin; stomach and parietes, whilst it must not be forgotten 
 that malignaiU diseas(t may coimiience at the site of an old- 
 ^tanding ulc:er, and that the mere persistence of the sxniptoms in 
 spite of treatment may endanger life. 
 
 1. Excessive (iiid I'cysisteut 1 1 iiiioyyha>^c \\v,\.y ■>() wi-aken the jiatient 
 as to lead to a fatal issue, li the lesion in the stonuK h cannot be 
 located, it is usually unwise to search for it, and a gastro-enter- 
 • istoniy will fullil the requirements of the case b\' putting tlu; 
 \isciis at rest and diminishing the hyper-acidity ol the contents, 
 which is often a harmful element, in a few recorded instances 
 the stomach was so distended that there could be no doubt that 
 the iilci-r was in the neighbourhood of the pylf)ric orifice, which 
 was becoming narrowed by cicatricial contraction. Kiister suc- 
 cessfully opened the stomach in two siu h cases, finding the ulcer 
 where he had expected it ; the base was carefully cauterized, and 
 no further bleeding ensued. In one of the i)atients a pluinstone 
 was found embedded in the sore. 
 
 2. Pcrfoi'titioii of the Ulcey is by no means an unconnnon occur- 
 rence, and is always fraught with the greatest danger. The 
 anterior wall is that most fretjuently imolved, owing to its greater 
 mohility, which prevents the formation of protective adhesions. 
 The cardiac end is more often affected than the pyloric. The 
 
 [character of the symptoms varies with the si/e of the perforation, 
 and with the distension or not of the viscus. If a large opening 
 is produced in the anterior wall, so that the gastric contents are 
 allowed a free entrance into the peritoneal ca\ ity, the patient is 
 
86o 
 
 A MANUAL OF SURGERY 
 
 m 
 
 seized with severe epigastric pain and profound sliock, and this 
 is followed by acute septic peritonitis, which rapidly proves fatal 
 if surgical interference is not at hand. When the perforation 
 is small, and only a gradual leakage occurs, the onset is subacute; 
 the primary shock is then inconsiderable, but epigastric pain anJ 
 tenderness are j)resent, and st(;adily increase until the characteristic 
 features of general peritonitis supervene. Occasionally, even with 
 the anterior wall, the ulcerati\e i)rocess ma^ extend so slowK 
 that there is time for protective aiiliesions to form, and tlien;h\ 
 shut off the general serous cavity from the inllannnatory process: 
 a localized abscess may then tlevelop, and fmd its way eitlifi 
 through the abdominal wall, or it may burst into one of the 
 hollow viscera in the neighbourhood. 
 
 When the ulcer involves the posterior wall of the stomach, tin 
 lesser sac of the peritoneum usually becomes obliterated by tin 
 formation of adhesions between the serous coats which lorm 
 its boundaries, and when perforation occurs, or when the ulcer 
 has extended deeply enough, the retroperitoneal tissues ari 
 thereby opened up, and the pus and gastric contents tra\('llin;^ 
 up between the liver and diaphragm may give rise to an abscess 
 containing pus and gas, which is known as a suhphrcnic /lo 
 pneumothonix. This usually extends forwards, and points on om 
 or other side of the ensiform cartilage ; the pleural cavity also 
 becomes invoked in the inflammatory process, either by pus 
 finding its way directly through the diaphragm, or by lym|)liaii( 
 absorption, gi\ ing rise to a basal empyema. In some cases iIk 
 pus is unaccompanied by gas, and instead of burrowing upwards, 
 finds its way down behind the peritoneum, so as to point just 
 above the iliac crest. The symptoms of a subphrenic pyo- 
 pneumothorax are simply those which always arise in connection 
 with a deep acute abscess, together with irregular areas of dulnts> 
 and resonance over tlie focus of mischief; the liver dulness may 
 be entirely obscured by the gas within the abscess cavity, and tlu 
 organ itself displaced downwards. 
 
 The Profj;nosis of gastric perforation is exceedingly gra\e, since, 
 unless active surgical interference is obtainable within a compara 
 tively short time, hopeless peritonitis ensues. Barling states that 
 95 per cent, of patients that are untreated are sure to die, whilst 
 the later the operation, the worse the results. 
 
 Treatment. — Should it be decided for any particular reason noil 
 to operate in a given case, the horizontal position, rectal feedinf;. 
 and the use of niorphia to check peristalsis, are the only inean> 
 which hold out any prospect of benefit. Operation, as alreadyj 
 indicated, must be undertaken at as early a period as possible, 
 although it is often wise to delay for an hour or two to allow thel 
 patient to recover in measure from the initial shock. The niedianf 
 incision is the best to employ, since it is not possible to be certainl 
 as to the situation of the lesion. The rules gi\en above as to thel 
 
AHDOMINAL SURGERY 
 
 86 1 
 
 I shock, and ihis 
 piclly proves fatal 
 1 the perforatum 
 mset is subatuti'; 
 )it,'astric pain ;m;l 
 
 the characteristic 
 ;ionally,even with 
 
 extend so slowK 
 form, and therd)} 
 nnnatory process ; 
 ind its way eitlur 
 L into one of tlu 
 
 ,f the stomach, tlu 
 
 obUterated by tlu 
 
 coats which form 
 
 or when the ulcer 
 
 toneal tissues an 
 
 contents travcllini; 
 
 ■e rise to an abscess 
 
 as a snhphvcnic p\v- 
 
 and points on om 
 
 pleural cavity also 
 
 :ess, either by pus 
 
 m, or by lyniphatu 
 
 In some cases tlu- 
 
 jurrowing upwards, 
 
 ^o as to point just 
 
 a subphrenic pyn- 
 
 arise in connection 
 
 liar areas of dnlius> 
 
 I liver dulness may 
 
 icess cavity, and tlu 
 
 Idingly grave, since. 
 ; within a conipJii^'^ 
 Barling states that 
 sure to die, whilst ! 
 
 Irticular reason not 
 Ition, rectal feedini;. 
 \re the only mean> 
 deration, as already 
 I period as possible, 
 3r two to allow the 
 nock. The median 
 hssible to be certain 
 ,en above as to the 
 
 treatment of a penetrating injury hold good in connection with 
 this subject, especially as to the use of swabs for the removal 
 of any extravasated gastric contents, and as to the value of 
 peritoneal irrigation. There is no need to excise the ulcer when 
 loiind ; all that is refpiired is to close the aperture; by means of 
 Leinbert's sutures, applied perhaps in a purse-string fasiiion, so 
 ,is to bury the ulcerated surface. In somt; cases it may seem 
 iiiiwise to attettipt closure of the lesion, and tiu'ii liio opening in 
 the stomach should be stitched to the abdominal wall, and a 
 drainage-tube inserted so as to relieve gastric tension. The 
 listiila thus formed is usually closed without jnuch diriiculty at a 
 subsequent date. 
 
 The treatment of subphrenic pyo-pneumothorax consists in 
 opening the abscess wherever it is most accessible. Opinions 
 ilitVer as to whether it is necessary to make a counter-opening 
 liehind ; in all probability, it is wiser not to attempt this at 
 first, but if the temperature still keeps up, and the cavity 
 does not seem to drain well after a few days, then further 
 interference will be required. The best situation tor a counter- 
 opening is in the mid-axillary line, a portion of the eighth or 
 ninth rib being excised. If, as often happens, there is also an 
 empyema, this is readily accomplished, and an additional opening 
 can be made through the diaphragm if one does not already exist ; 
 if, however, the pleural cavity is not afTected, then the serous 
 membrane c(wering the upper surface of the diaphragm must be 
 i^titched to the parietal pleura before the diaphragm is incised. 
 
 3. Stenosis is always liable to occur after ulcers of the stomach, 
 lis in other situations. If it is located near the pylorus, that 
 orifice may become contracted, giving rise to special symptoms, 
 and necessitating treatment of a particular character (p. 867). 
 Occasionally, however, the fundus may be chiefly involved, and 
 then an hour-glass contraction of the viscus may occur, which in 
 >onie cases is so marked as almost to divide the organ into two 
 halves, only a narrow neck persisting between the two. The 
 -yniptoms of such a condition are almost identical with those of 
 pyloric stenosis, and the treatment required consists either in 
 .xcision of the sulcus and reunion of the gastric walls, or in 
 establishing an artificial opening between the two segments, as by 
 a Murphy button. 
 
 4. In a few cases Adhesions may form between the anterior 
 wall of the stomach and the parietal peritoneum, owing to a 
 plastic peritonitis over the situation of an ulcer. Such will give 
 rise to a localized fixed epigastric pain, usually increased consider- 
 ably by distension of the organ. It may be treated safely by 
 abdominal section, and divisicm of the adhesion between ligatures. 
 If left alone, not only may it cause inconvenience by the pain 
 induced, but it may also determine internal strangulation or 
 obstruction. 
 
862 
 
 A MANUAL OF SURGERY 
 
 5. Finally, cases are met with in which the symptoms of linsu'u 
 ulcer persist or recur in spite of the most careful dietiniLj atid 
 treatment, and it is now considered ijuite justiliable to submit such 
 cases to operation. Two lines of treatment are possible. (<?) Thf 
 ulcer may be excised, if it be in a convenient position for such a 
 procedure, and if the infiltration around it be not too extensivf, 
 (h) In other cases f^^astro-enterostomy (p. .Sjo) may be undertaken 
 with a view to reheve symptoms by enabling,' the \iscus Mion 
 readily to empty itself after the inj^estion of food. The resiilt>- 
 of this latter procedure have l)een \ ery satisfactory. 
 
 Cancer of the Stomach. —Any part of the; stomach may hi 
 afiected with this disease ; at the cardiac end it is probably an 
 exter.sion from the lowest jjortion of the o-sopha^^ais, and mav he 
 of the nature of squamous epithelioma. Pyloric cancer will he 
 referred to anon (p. S()8). Cancer of the body of the \isciis 
 sometimes starts at the site of an ulcer, or may have no (jbxious 
 orif^in ; it is of the usual acinous type, varyin;^ in hardness accord 
 in{^ to the rate of {growth. It soinetimes constitutes a polypoid 
 
 mass ; at other times it is papillomatous in character ; but it 
 most fre(]uently a diffuse infiltration, which j^a'adually invohc^ 
 the whole orj^^an, and spreads to adjacent structures, after lixin:: 
 them by a pl-:istic peritonitis. Colloid degeneration is not aii 
 unusual occurence, the stomach and omentum together form 
 ing a huge mass of disease. The Symptoms at hrst are \('i\ 
 indefinite, nothing but a little dyspepsia being comi)laine(! dl. 
 accompanied perhaps by acid eructations. Loss of api)etit 
 follows, togt:ther with vomiting and wasting, and perhaps 
 tumour is detected in the epigastrium, mo\ing up and dow: 
 witii the resjMrations. If the stomach is washed out after il. 
 administration of a test meal, it is usually found that the seen 
 tion of hvflrochloric acid is much diminished, but this test ; 
 not infali .;ie. Sooner or later glaiulular troubles, and local c 
 general dissemination, lead to such interference with nutritii 
 as to cause the patient's death. Treatment is seldom practical)!; 
 beyond palliating tin; more promini'iit symptoms. In doubiti: 
 cases, however, an exploratory operation should be recommeiuleu 
 and if this i)roceeding were more c:onnnonly adopted, cases woiii: 
 be found by the surgeon ;i.t a sufficiently ej. ly c ate to enable bin 
 to excise the disease. Total gastrectomy is p'";sible only in rasr 
 where the stomach is not adherent in any marked degree t 
 adjacent viscera. 
 
 Operations upon tho Stomach. 
 
 I. Washing out the Stomach is needed in cases of poisoniiiL;. :: 
 chronic catarrh, in dilatation of the organ, and as a preliminar\i 
 operations in which its cavity is to be hud open. It may be attui' 
 plished by the ordinary stomach-pump, or by the simpler nietlia 
 of passing a long tube of good-si/ed calibre, to the upper end' 
 
ABDOMINAL SUliGERY 
 
 ^6r 
 
 i(^ Uie viscus Mior 
 
 The resulb 
 
 y'mptoms of Kii^ti" 
 iireful clii'tins^ :uul 
 ibU; to submit such 
 
 possible. (<i) Tlif 
 position for such a 
 
 not too exlensivf. 
 may be uiulert;il<cn 
 
 food. 
 :tory. 
 c stomach may Iv 
 d it is probably an 
 iha-^nis, ami may W 
 •loric cancer will b' 
 body of the viscu^ 
 ,ay have no obviou- 
 r in hardness accord 
 institutes a polypoid 
 character ; but it b 
 , ^rradually invnlu^ 
 ructmes, after tixuv.: 
 rcneration is not ;i; 
 itum to^^elher toini 
 )ms at tirst are \ei\ 
 )ein^' complainei! ui. 
 Loss oi api^etil- 
 ,..^, and perhaps . 
 u)\in;4 up and dow:, 
 Ivashed out after tlv 
 ■omul that the secrc 
 |hed, but this test i- 
 loubles, and local .: 
 jrence with nutntm; 
 \ seldom practicabl-. 
 hploms. In douhitv. 
 uld be recommenileJ. 
 adopti-d, cases wouk. 
 ly c ate to enable Inr 
 p'. -sible only in cum- 
 iiv marked de^aee t. 
 
 lach. 
 
 :ases of poisoning, ir] 
 ind as a preliminaryU 
 ni. It may be accoiii- 
 y the simpler methcK| 
 le, to the upper end > 
 
 which is attached a funnel. I'luid is introduced throuj^'h the 
 hinnel, and syphoned out by lowering it below the level (;f the 
 >tuinach. IJefore open (operations, a warm solution of boric acid 
 should be employed as the aj^ent for irrij^ating the \ iscus. 
 
 2. Gastrotomy, or opening the stomach, is recpiired for the 
 lenioxai of foreign bodies from it or from the lower end of the 
 ,rs()i)hagus, for exploratory purposes, and as a means of dilating 
 simple strictures of either the pyloric or cardiac orilices (Loreta's 
 operation). It has a,ls(i been employed with advantage for the 
 
 II.' 
 
 (.•moval of masses of cancerous disease by ciu(;tting. 
 
 Opnuttion. — When a foreign body can be distinctly felt within 
 the viscus, any incision that seems to promise ready access may 
 Ik: ''itiployed ; but it is generally made on the left side, parallel 
 
 li<; J S.- Incisions ctilizkh in X'akiocs Amdominai. ()1'i:kations. 
 
 A, ',l;i^i!'itniny ; A,, additional incision in I'rank's j^'asti' .toniy ; !•, incision 
 u./oNposiiif^ ^'idl bladdcTdr for pyloi;-ctoniy ; (', iliac coloii mi y ; D, incision 
 or operations on appendix; \-'., median incision for ovarioiunu or snpra- 
 niibic cystt)toniy : !•", for radical lurt; of in^idnal hernia i r \aricocele. 
 
 I ', aiul about a frnger's breadth from, ilu- edge of the costal 
 
 cartilages, and about 2J, inches in length (I'ig. J<;N, .\). The 
 
 "josition of the left lobe of the li\er nuist be prc-\ iously ascertained 
 
 -\v percussion, and the centre of the incision is best placed 
 
 about ^ inch below it. 'Hie abdominal wall is completely divided, 
 
 |aiKl the peritoneum (jpened. The lingers are then introduced, 
 
 nd the stomach soiglit for; it is recognised by its posilicjii im- 
 
 iiediutcly under the liver, and by the tliickness, pink colour, and 
 
 jpacity of its wall. If the omentum or transverse colon presents 
 
 in the wound, it must be pushed ilown, and the stomach looked 
 
¥i 
 
 864 
 
 A MANUAL OF SURGERY 
 
 for above. The spot where the stomach is to be opened is now- 
 decided on, and two silkworm gut sutures introduced throu<,^h 
 the serous and muscular coats, so as to enable the organ to he 
 kept against the abdominal wall, a careful packing with a known 
 number of sponges or gauze swabs being also interposed between 
 the visciis and the parietes, so as to prevent any escape of lUuu 
 into the general peritoneal cavity. An incision is made in the 
 long axie of the stomach, and the finger inserted. 1 .le remold 
 of a foreign body must be undertaken with great care, so as not 
 to inHict injury on the organ, the wound being enlarged, it 
 necessary. It is subsequently closed by the Lembert or prefer 
 ably the Czerny- Lembert suture. The stomach is now replaced 
 in position, and all traces of blood, etc., removed, the external 
 wound being closed in the usual way. 
 
 If the surgeon desires to reach the cardiac ovijice, a somewha; 
 larger opening in the parietes is needed, in order to allow n 
 greater space for the introduction of the hand into the abdoinei;. 
 since the orifice lies deeply just in front of the aortic openin;,^ ir. 
 the diaphragm. When this is accomplisiied, the opening nuu 
 be dilated by the fingers or by suitable dilators, and a forei<,'ii 
 body can by this means be removed from the lower end (i: 
 the o'sophagus. The utmost gentleness uuist be observed in tlii^ 
 proceeding, as serious symptoms may be caused by irritatio: 
 and damage of the pneuniogastric nerves, the ut: inations o! 
 which pass tlirougli this opening in the diaphragm. 
 
 The operations on the pyloric orijicc are dealt witii below. 
 
 3. Gastrostomy consists in the formation of a permanent artiliciai 
 opening into the stomach, through which the patient can be feii. 
 It is neeaed in cases of malignant disease or intractable sten()>i- 
 of the a;sophagus, where the patient is exposed to the risk 0: 
 starvation, owing to his inability to take nourishment. 
 
 Not man} years back the only operation a\ailable was one ir 
 which a diiect opening was made into the viscus without aii\ 
 attempt to form a \alve, trusting to various flanged tubes oi 
 umbrella-like plugs to close the aperture. The results were nios; 
 unsatisfactory, since even if the patient surxived, he usualh 
 suffered great inconvenience from the prolapse of the nuicoib 
 membrane, and from irritation and ulceration of the surroundiiii. 
 skin, owing to escape of the acid gastric juice and its digesti\' 
 powers. 
 
 During tlie last few years a number (jf excellent operations' 
 have been introduced so as to pre\ent these complications, most 
 of them depending on the formation of a muscular valve, aiiii 
 there can be no iloubt that the improxements thus effected hau 
 been very great. Two chief methods have been suggested — viz.. 
 Witzel's and I'rank's ; the latter of these is, to our niind.-. i 
 preferable, and the results gained thereby are so satisfactory a- 
 warrant us in describing it in detail. 
 
ABDOMINAL SURGERY 
 
 86s 
 
 le opened is imw 
 roduced throu-h 
 ; the organ to be 
 tig with a known 
 iterposed between 
 ny escape of llum 
 ,n is nnide in ihf 
 ed. 1 "'"' removal 
 eat care, so as not 
 being enhirgeil, ii 
 ^embert or preter- 
 ;h is now replaced 
 oved, the external 
 
 orijice, a soniewha; 
 order to allow oi 
 into the abdomen, 
 le aortic opening' in 
 the opening nra\ 
 I'tors, and a t'orei;4ii 
 1 the lower end »\ 
 be observed in thi- 
 ;aused by irritation 
 the I.C1 r. inations oi 
 
 ragm. 
 
 t with below, 
 permanent artilicia. 
 
 - patient can be ted. 
 intractable stenosw 
 osed to the risk oi 
 ishment. 
 
 vailable was one i; 
 viscus without ain 
 us flanged tubes '. 
 lie results were nio>: 
 urvived, he usually 
 :ipse of the mucor. 
 h of the surrouniluu 
 lice and its dig-'stU' 
 
 excellent opcratioib 
 
 compli^-'-^tions, most 
 
 Imuscular valve, and 
 
 is thus effected lia\f 
 
 ^een suggested -m;. 
 
 , to our mind.-, i 
 
 ; so satisfactory ai^w 
 
 I'lank's Operatum. — The usual oblique incision for exposure of 
 ihe stomach is first made, the viscus withdrawn and examined, 
 and a silk sling passed through the serous and muscular coats at 
 the site selected for the artificial opening, so that a cone-shaped 
 portion of the wall can he drawn up into the wound (Fig. 299, A). 
 Tlie parietal peritoneum is then .-^tured all round to the base of 
 the cone, so as to shut it ofT from the general serous cavity. A 
 second incision, about i inch in length, is now made on the outer 
 side of the first wound, parallel to it, and about lA inches from it. 
 The bridge of skin and subcutaneous tissue between the two is 
 separated from the subjacent structures, and the apex of the cone 
 
 A B 
 
 Fig. 299. — Frank's flAsTROsTOMV 
 
 i>f;,'astric wall drawn under the l)ridge into the second wound (H). 
 
 .\ small opening is then made into the \iscus through the apex, 
 
 I in which the silk sling is located, and ihe nmcous membrane 
 
 •-iitelud accurately to the skin in the centre of the incision. The 
 
 iivinaiiuler of this incision is then closed in the ordinary way, as 
 
 also the fust. Mealing readily occurs, and thus a vaKular open- 
 
 [in',Ms established, which passes in an angular fashion round the 
 
 lai^Mu of the costal cartilages, lending to prevent regurgitation 
 |i)f the gastric contents. The patient maybe fed by the artilicial 
 lopening at once. 
 
 W'c have somewiiat modified this operation of late, and 
 Itiir results lia\e been still better than when we utilized 
 
 iianls's original method. Instead of the obIi(|ue incision, a 
 Ltntical one (as suggested by Kocher) is emnloyed, extending tor 
 13 'T 4 inches downwards from the eighth costal cartilage and 
 
 55 
 
866 
 
 A MANUAL OF SURGERY 
 
 passing through the substance of the rectus muscle, which is split 
 l)y the fingers or handle of the knife into two portions. The peri 
 toneum is opened, and the stomach withdrawn ; a cone-shaped 
 portion is selected, and its base stitched to the parietal peritoncinn 
 and posterior layer of the sheath of the rectus, 'i'he apex ol the 
 cone may now be passed under a bridge of skin and subcutaiiiou- 
 tissue to emerge at a second opening a little above the loniicr; 
 but this is quite unnecessary, and indeed often impossible, owin^ 
 to the small size of the stomach ; it suffices to fix the apex in 
 the upper angle of the incision. Before this, however, a small 
 opening is made into it, and a piece of rubber drainagcUilK 
 without lateral holes is introduced and stitched firmly to thi 
 gastric wall, so that about lA inches project into its cavity; thi 
 stomach is then carefully sutured to the upper angle of the wound. 
 The halves of the rectus muscle are freed from tlie sheath oi. 
 either side and drawn together by sutures, so as to cover i;i a-^ 
 much of the stomach as possible, thus forming a definite sphiiu ler; 
 the incision in the skin is then closed. The results of this piu 
 cedure have been most satisfactory, not a drop of gastric juia 
 escaping. The amount of food at first administered is small, 
 and rectal feeding may be required in addition ; but it is gradualK 
 increased until perhaps 17 oz. can be retained four times a dav. 
 The patient should be kept in the recumbent posture for thro 
 weeks. ■• 
 
 W'iicel's Operation. — This consists in making a \alvular opciiiii- 
 into tlie stomacli by introducing and stitching a tube into it as in 
 the last proceeding, and then burying the projecting portion as far 
 as possible by suturing the serous and muscular coats to^^ttlui 
 o\er it. The stomach is tlien fixed to the abdominal parietcs aiiu 
 the skin closed. The functional result of this operation is vei\ 
 good, but the fixation to the abdominal wall is not so secure as in 
 I'' rank's method. 
 
 4. Gastrectomy. — A good many cases have now been reported 
 in which a limited portion of the gattric wall has been removed 
 successfully, either for simple or malignant ulcers or groutlh. 
 Incisions are made so as to include the mass, and the womul ^^ 
 subseciuently closed by Lembert or Czerny-Lembert sutures. 
 
 Total excision of the stomach is a proceeding wliich has only 
 recently been attempted, but several successful cases are now mi 
 record. It has been un.dertaken for extensixe malignant diseasf. 
 which, howe\er, has left enough of the o'sophageal end Irec in 
 allow of its apposition and fixation either to the upper end of thr 
 duodenum, or, if that cannot be brought across to it, to a suiialk 
 •coil of the jejunum. The actual union has been effected cithtr 
 by simple suturing, or i)y introducing a Murphy button. 
 
 * I'or further (I'itails, sec Ciiiltss, ' On Ciastrostoni) , ' Kiuf^'s (.■otieHC Jlusinul 
 Uepurts, vol. v., iSijy-iSy.S. 
 
ABDOMINAL SURGERY 
 
 867 
 
 icle, which is split 
 rtions. The ptii- 
 ii ; a cone-shaptd 
 irietal peritoiuum 
 
 The apex ol ihe 
 
 and svibculamoii- 
 
 ibove the tonnui ; 
 
 impossible, owinu 
 
 to fix tlie apex in 
 
 however, a small 
 )ber clrainat;t-tulH- 
 lied firmly to iht 
 iito its cavity ; th. 
 uif^le of the wniiiul. 
 ■cm the sheath or. 
 
 as to cover in as 
 :i definite sphincter; 
 results of this pm- 
 rop of gastric juio 
 ninistered is small. 
 ; but it is grachial.} 
 ed four times ii ilay. 
 It posture for ilnn 
 
 [V a \alvular openiiii; 
 \ a tube into it as in 
 ecting portion as l;ir 
 -ular coats tt)^t'tlur 
 lominal parietcs ami 
 is operation is very 
 s not so secure as in 
 
 i now been repurtal 
 
 has been reinoxni 
 ulcers or growtlb. 
 .,s, and the wt)UiHl i^ 
 lembert sutures. 
 Idin^' which has only 
 lul cases are now on 
 e malignant disease, 
 ^hageal end free M 
 khe upper end ofllid 
 |ss to it, to a suitable 
 
 leen effected eitbtrl 
 
 hy button. 
 
 KinKsCollcKell"SV'' 
 
 Affections of the Pylorus. 
 
 Simple Stenosis fzenerally results from the healing of a gastric 
 ulcer of the usual type, but situated at or close to the pyloric 
 oritice; it is sometimes due to the contraction of adhesions 
 around an inflamed gall-bladder (cholecystitis), and is occasionally 
 caused by hypertrophy of the muscular tissue of the spliincter. 
 The effects produced are hypertrophy and dilatation of tlie 
 stomach, which becomes enlarged downwards and forms a sac, in 
 which food collects perhaps for days, and undergoes fcrmentatixe 
 changes, being finally ejected in large {|uantiti'.'s, mixed with 
 frothy nuicus and a yeast-like scum containing an abundance of 
 ^arcina.'. The stomach may hi time almost reach the pelvis, the 
 
 I'li;, jOO. I'VLOROI'LASTV. 
 
 The contrncted bowel is divided l()nj,'itiidinally, and the aperture thus made 
 opened out, so that it can he brought toj,'eiiier lrans\i-rst'l\-. 
 
 pylorus being dragged down with it. Succussion or splashing 
 > )unds are heard on shaking the patient's abdomen. 
 
 The Treatment consists at first in washing out the stomach 
 regularly, but when that fails to give relief one of the following 
 proceedings may be undertaken, {a) Lordas Opinttioii consists 
 :ii dilating the stenosed orifice with the linger. The viscus vj 
 npencd midway between the curxatiues and about 2 inches 
 Irom the pylorus, and first one finger is introduced, slowly 
 and carefully, then twcj, and even perhaps three ; no \ iolence 
 s admissible, or the walls of the oiifice may be torn or rup- 
 tured. The results of this proredury have been on the whole 
 encouraging, but it is now being leplaccd by other more certain 
 .lid satisfactory metliods. (/*) J^.xiision of im lyionis can be under- 
 iiiken in suitable cases, and the results have been so much 
 mproved by the use of the Murphy button and other similar 
 V)iitri\ances that it need not ii<«w be greatly feared (.'. iiifya). 
 
 I A most ingenious proceeding has also been recently practised 
 b'ith good success in the shape (jf Pyloroplasty, an operation with 
 b.hich the name of Mr. IT. \V. Allingham is, in this country, 
 
 >noiirably connected. It consists in exposing the pylorus and 
 
 ^e.uiiig it from adhesions. A Icjngitudinal incision is then made 
 lirough the stricture, and by a little carefid manipulation this 
 iwtiiiiul can be opened out and brought together in a trans\erse 
 
 55-^ 
 
868 
 
 A MANUAL OF SURGERY 
 
 manner so as to ,L,'reatly increase the lutnen of the orifice (Fi<,'. 300). 
 Two rows of stitches are inserted, one throuj^li the niiuoiis 
 membrane, and the other througli the nniscular and serous coats, 
 (d) Where the pylorus is so intimately adherent to adjacent 
 structures, or so involved in cicatricial material as to render it 
 unsafe, or even impracticable, to expose it sufficiently to allow of 
 the above proceedinj^'s, Gastro-entcrostowy (p. 870) must be under- 
 taken as a last resource. 
 
 Pyloric Cancer usually occurs in the form of scirrhus, or as a 
 hard, slowly-f,'rowing columnar carcinoma, and since it involves 
 the whole circumference of the };ut, it causes {^^reat obstnution 
 to the onward passaj^e of its contents. The growth early extends 
 beyond the limits of the pylorus, becoming adherent to and im- 
 plicating the under surface of the liver, the head of the pancreas, 
 colon, and even, when of lafge size, the anterior abdominal wall. 
 The early symptoms consist of slight pain, followed by feeiiiiusui 
 discomfort, dyspepsia, and nausea ; but when typical, the) itiav 
 be grouped together as follows : i. Those due to pyloric obstruc- 
 tion, \iz., dilatation of the stoiuach, with sarcinous Noiniiin;,': 
 2, tlu' intrinsic signs of the growth, viz., the existence of a tuninur 
 a little abo\e and to the right of the und^licus, which is at lirs! 
 rounded and definitely limited, except on the left side, wIkiv it 
 shelves off into the stomach ; it is moveable in the earl}' stages, 
 but later on becomes fixed ; it is firm in consistence, and soiiit 
 what tender on manipulation and pressure, and may recei\i 
 pulsation from the underlying aorta : 3, conditions arising fn " 
 interference with surrounding parts, c.<^., jaunilice and as(iti- 
 from pressure on the bile-duct or portal vein respectively, \\\\\\>: 
 a^dema of the legs or varicosity of the superficial abdominal veiib 
 may arise from compression of the inferior vena cava : 4, genera! 
 cachexia and asthenia due partly to the cancerous growth, ()artly 
 to defective nutrition. J'^or fuller details we must refer to medical 
 text -books. 
 
 Treatment.— If the mass is comparatively mo\eable and llitp 
 are but few adhesions, as in the early stages, pylorectomy 1: 
 removal of the diseased portion of gut may be undertaken; U\\ 
 where the growth has extended beyond the bowel to ailjaccr! 
 viscera, or where massi\e adhesions are present, gastro-eniero- 
 tomy or the formation of an artificial communication between tl:t 
 stomach and intestine below the growth is alone practicable. 
 
 Pylorectomy is an operation which has been performed b'l 
 for simple and malignant stricture of the pylorus, but until iiuitcj 
 recently the mortality connected therewith was so great as t 
 render it almost a hopeless procedure. Thus, in seventy-tu 
 cases dealt with for malignant disease by the old plan of operatiii. 
 fifty-five died from the immediate eflects, whilst in ten ix*] 
 of simple stricture only four recovered. The latest statistics 0! 
 operations in which the Murphy button was employed aie, how 
 
ABDOMINAL SURGERY 
 
 869 
 
 ,e orifice (Fi^- }oo). 
 cnif^h the nuuous 
 r and serous coats. 
 herent to adjacfiii 
 rial as to render it 
 PTiciently to allow nt 
 I70) must be uiuld 
 
 of scirrhus, or as a 
 id since it involves 
 ;s }.(reat obstrnction 
 rrowth early extiMuls 
 ulherent to and in; 
 ead of the panncas, 
 ;rior abdominal wall. 
 llowed by feelin!.4s I't 
 n typical, they nia\ 
 le to pyloric obsliuc 
 sarcinous vonnlin^'; 
 'xistence of a tunnmr 
 cus, which is at Iiin 
 he left side, wlu iv 1; 
 e in the early stages, 
 )nsistence, and some- 
 e, and may receive 
 nditions arisin-; It"" 
 jaundice and asoli- 
 ,. respectively, whils 
 ("icial abdominal veiib 
 /ena cava : 4, ^'eneial 
 •erous growth, partly 
 [must refer to nuHlu;i! 
 
 ^ nuivcable and llnr. 
 ,aj;es, pylorecloniy ■'■ 
 Iv be undertaken ; Imt 
 liie bowel to adjacent 
 [csent, gastro-eniero^ 
 lunication between the 
 llone practicable. 
 
 been performed b'>tr. 
 
 dorus, but until quite 
 \\ was so great as t 
 
 rhus, in seventy nv 
 old plan of operating 
 whilst in ten c;u« 
 
 :he latest statistics o!| 
 
 LS employed aie, how 
 
 ever, much more encouraging, (a) In Billi-oth's operation the 
 al)domen is opened by an incision which suits the exigencies of 
 the case, though perhaps the best to employ is an obiitjue one 
 4 or 5 inches long, extending from the median line above down- 
 wards towards the right, nearly parallel to the right costal margin 
 (iMg. 298, B). The diseased area is now explored, and a final 
 decision made as to the practicability or not of remoxiiig it. If 
 an operation is determined on, the growth is carefully isolated 
 hoiH surrounding parts by dividing the attachments of the great 
 and lesser omenta, any enlarged glands being also enucleated. 
 Clamps are then applied to the stomach and dnodrnnm, and the 
 operation area well packed round with sponges. The mass is 
 now removed (I'^ig. 301) and the divided ends united (I*'ig. 302), 
 
 "ii. 301. — Malignant Crowth of 
 THE I'ylorus, and Incisions in 
 Stomach and Duodenum nki:di:i' 
 luR ITS Kkmovai (Tili.manns.) 
 
 I'lfi. .jOJ, Ml.lllon OK SUTURlNfi 
 
 THK I'NKyuAi. Wounds li-kt 
 ai-ti:r Kkmovai, ok tiik (Irowtii. 
 
 (Tll. I.MANNS ) 
 
 The iipptT end of the gastric incision 
 is first closi'd, so as to it'nder t!u' 
 openini^s in the stomach and ihio- 
 deiiiim of equal size. 
 
 luit tor exact details we must refer to larger text-books of opt^ratixe 
 surj;ery. The operation is prolonged and diflicult, and profound 
 shock is usually experienced. Carefully regulatetl stomach- 
 leeding should not be too long delayed after the operation, the 
 best results basing occurred in those cases where it was started 
 early, [h) When the Murphy hitttov. is employed, the same steps 
 are followed until the growth is isolated, and tiien the mass is cut 
 away at once, care being taken to also remove three-cjuarters of 
 an inch of sound tissue on each side. The gastric wonnd is then 
 entirely closed by a row of Czerny-Lembert sutures. The heavier 
 male end of a Murphy button is inserted into the open mouth of 
 ilie duodenum, and the purse-string suture tied, as detailed below 
 (p. SSS), whilst the female half is placed in a new opening made 
 for it in the posterior wall of the stomach, as for a lateral anaslo- 
 
870 
 
 A MANUAL OF SURGERY 
 
 
 inosis (p. 890). The two lial\es are united, and the operation i- 
 then completed by the usual toilette of the peritoneum and the 
 closure of the parietal incision. 
 
 Gastro-enterostomy may l)e undertaken by simple suturing; ni 
 the required viscera tof^ether (WoUler's operation), or by the use 
 of the Murphy button. The portion of bowel which is selected as 
 the site of the artificial openiuf^^ should be the upper part of tin 
 jejunum, since if the conmiunication is established too lov. , a 
 imich fi^reater absorbin},^ surface is isolated, with the result iliai 
 
 even if the operation !>- 
 successful the paiiLiii 
 j^aadually emaciates owin- 
 to lack of nutriment : aiu! 
 the rapidity of the eiuaii 
 atioii will increase as tlu 
 conununication is placed 
 further from tiie (Iud 
 denum. 
 
 The incision employed 
 is usually one in tin 
 middle line throuj^h tlu 
 linea alba. The stoniarh 
 is readily found, anil tlu 
 condition of the {^aowth 
 examined so as to deter 
 mine whether or not it i> 
 remo\able. Formerly ii 
 was the practice io iiniti 
 the bowel to the anterior 
 wal 1 of the stomach 
 (r'i}2[. 303), but there are two obxious objections to this method: 
 (a) The jejunum is drawn up o\er the trans\erse colon, and i^ 
 likely to constrict it and lead to obstruction ; and {!)) the necessar\ 
 dra}^f of the j^ut is apt to brin^f the two ends parallel to each otlm. 
 and thus produce a spur or kink, by means of which the hilt 
 is directed into the stomach insteatl of into the eOerent liiiili. 
 Severe bilious \omitin{f residts, which may prove fatal. 
 
 Hence the majority of surj^eons nowadays follow with ad\ anta>,'t 
 the plan recommended by N'on Hacker of utili/inj; tlie postcriin 
 {gastric w;ill for this purpose. It is accomplished in the followiii:, 
 manner : 'I'he transverse colon is withdrawn from the w (lund, 
 tof^ether with part of the omentum. ] Jy tracinj,' down the trans\ :si 
 meso-colon to its attachment to the posteri(.)r abdominal paiit'tt\ 
 the termination of the duodenum is reached as it crosses the niiddk* 
 line aloufj; the lower border of the pancreas, and with the su[)erior 
 mesenteric vessels lyin}^^ in front of it ; by this means the upper 
 portion of the jejunum is easily f(nmd, and a suitable spot toi 
 making the anastomosis selected. A hole is then made throu^li 
 
 Fk;. 
 
 JO J 
 
 Anteuiok (i.\sri<()-i;NTi:K()s- 
 
 TOMV. 
 
 A, Transverse colon ; 1?, jejiinnm (iraxKed 
 up over tlie colon and onientinn (pur- 
 posely omitted) to be brouf^lu into 
 apposition with the stomach. 
 
AUDOMINAL SURGERY 
 
 871 
 
 the operation i^ 
 itoncuin uiul ilic 
 
 mple sulurinK <ii 
 in), or by the usi' 
 liich is selected as 
 upper part of tlu- 
 lishecl loo low. a 
 th the result thai 
 the operation is 
 sful the patient 
 ly emaciates owiim 
 )f nutriment ; and 
 itlity of the eiuun 
 ill increase as tin 
 uication is plareJ 
 from the ilu.) 
 
 incision employed 
 ally one in lli' 
 line through tlu 
 Iba. The stonuuh 
 Uly found, ami ilu 
 .on of the ^'rowili 
 led so as to dttcr 
 vhether or not n is 
 xh\e. Formerly u 
 .c practice to uniie 
 Avcl to the antfiior 
 l,,f the stoniacli 
 ions to this methoa: 
 [averse colon, ami b 
 Ind {!>) the necessar\ 
 rallel to each oilu'. 
 of which the bili 
 the elTerent liml'. 
 love fatal. 
 How with ad\ anlai;r 
 llizinj^ the posieri.i 
 ;icd in the following, 
 li from the wound, 
 [down the trans\ vsi 
 abdominal pancJ<'N 
 t crosses the nmUHf 
 ,d with the supono: 
 IS means the uppti 
 a suitable spot t'J 
 Ihen made throu^a 
 
 the transverse meso-colon (FIjj;. 304), so as to open into the lesser 
 SIC of the peritoneum, and enable the postericjr wall of the 
 stomach to be reached. A 
 clamp is placed on either 
 side of the selected portion 
 iif bowel, so as to prevent 
 the escape of intestinal 
 contents when the ^ut is 
 opened; but, of course, it 
 is impossible to do the 
 same to the stomach ; the 
 hitter viscus ought, there- 
 tore, to be thoroughly 
 washed out with some 
 dilute antiseptic, such as 
 horic acid, before the 
 operation commences. 
 Sponges are also packed 
 aioiuid the site of opera- 
 tion, so as to receive any 
 iluid which may escape. 
 
 If W'ol tier's plan of 
 simply suturing is adopted, 
 two incisions about an inch 
 long are made, one in the 
 stomach and the other in 
 the jejunum, invoking at 
 tiist only the serous and 
 muscular coats. In the stomach it is made parallel to tlu> great 
 coinexity, and about i .', inches from its lower edge, whilst in tlie 
 ji-jimum the incision is longitudinal, and situated along the anti- 
 nusenteric border. l>oth of these wounds gape to such an extent 
 as to allow of the union of the divided coats on the lower side by 
 ;iie insertion of a row of fine catgut stitches. The nuicous mem- 
 hnuies are then incised, and a row of catgut sutures is introduced 
 ■ 1 unite them to the same extent, the knots being located within tlie 
 
 nt'n of the bowel. The surgeon then deals with the remaining 
 juiiconnected lateral and upper segments of the openings, taking up 
 the nnicous membranes and serous coats separately by a double 
 riiw of stitches, the knots being placed on the outer aspect of tlie 
 viscera. Thus, the deeper parts of the opening are sealed by 
 what is known as \\'(')ltler's suture (Fig. 309, p. ^^2), and the 
 iipper and more accessible portions by the Czerny-LeMd)ert stilcli 
 \'\'A. 307). 
 
 It the Murphy button is employed, one of meilium size should 
 IK' selected, and it is introduced according to the rules gi\en below 
 |p. ■'<yo) for lateral anastomosis. 
 
 The operation is completed by suturing the margins of the 
 
 Fir,. 304. roSTKRIOK (JaSTUO-IvNTKROS- 
 TOMV (\'()N HaCKKK's ( )|'KRATI()N) 
 
 A, Transverse colon tnrnod up to);etlu'r 
 with tlie omentum (which is omitti'd 
 from the drawinf,') ; i'>, coil of small 
 intestine, which is l)ro(ii,'ht into con- 
 tact with the posterior wall ot the 
 stomach thron^jh (,', a hole in the trans- 
 verse meso-colon, the margins of which 
 are fixed down by stitches to the back 
 of the stomach. 
 
872 
 
 A MANUAL OF SURGERY 
 
 opening in the meso-colon to the stomach, so as to prevent any 
 suhseciiuMit contraction, by cleansin},' the pcritoiieiun, and closing; 
 the parietal incision in tlie usual way. 
 
 The alter-treatnient consists in abstainin;^' from stoniarh-fe( din^ 
 for at least forty-eif^^ht hours, if practicable, rectal alimentaiinn 
 beinj,' resorted to in the interval. Not unfrefpiently there will he 
 some regurf^itation of bile into the stomach, and this may lead to 
 troublesome \omitin^' ft)r a few days ; but if the junction is satis- 
 factory, it soon passes ofT, especially when food is administcird 
 by the mouth, as may usually be undertaken on the third day. Ai 
 first only Huid nourishment should be permitted, but in a wci k s 
 time soft solids may be {^iven, and {gradually a more libtial diet ih 
 ordered. The effect of the operation is necessarily only palliative 
 when cancer is present, but the general condition often impnixe'- 
 considerably for a time, and the final exitus lelhalis is asscjciaied 
 with less suffering. 
 
 In comparing Wolfler's and Murphy's methods, the j^neat 
 ad\antage of the former consists in its introducing no foroi^'ii 
 body, which may give rise to trouble by slipping back intu tin- 
 stomach or by impaction lower down the gut ; hence it should 
 always be used in non-malignant cases. The proceeding,' \\ 
 howe\er, much more tedious, and the shock caused by tlu 
 prolonged operation is often sufficient in itself to turn the l)alaiKe 
 against a patient whose powers have been considerably diniin 
 ished by a malignant growth associated with semi-starvation, 
 Murphy's operation, though placing a solid body of some size 
 within the intestinal canal, has the great advantage of rapidity, 
 and, on tlie whole, we are inclined to recommend this pnxeid 
 ing as the better in malignant disease. The results hitluitj 
 obtained have been most encouragmg, Murphy being alilf tu 
 report twenty-nine cases, with only eight deaths, and we our- 
 selves have had several successful cases. The button, if al! 
 goes well, should appear in the motions about a fortnight afttr 
 the operation. 
 
 Ulcer of the Duodenum is occasionally met with after bums, a> 
 already described at p. 72. It may also occur in the same \va\ 
 as a gastric ulcer — i.e., more or less spontaneously, and witlum; 
 any apparent cause. The symptoms to which it gives rise art 
 deep pain in the right hypochondrium, worse after food, to^^etlur 
 with vomiting. Haemorrhage may be caused by the ulcer layin:.' 
 open some branch of one of the pancreatico-duodenal ves^tl?, 
 and this may prove fatal. Perforation is sometimes iiukim!, 
 and, according to its situation and size, it gi\es rise to acute or 
 chronic suppurative peritonitis, or if it opens posteriorly, to :i 
 subphrenic abscess, which tends, however, to come to the suifacf 
 to the right of the suspensory ligament of the li\ er ; in tact, tiic 
 symptoms and results are very similar to those of perioiatiii:; 
 
 
AUDOMINAL SURCF.KY 
 
 873 
 
 s to prevent any 
 mm, and closing 
 
 istonuicli-t'eiiliiii; 
 ictal JilinH'iilaliiin 
 ntly lliere will W 
 I this may U'atl tn 
 I junction is satis- 
 ,(l is aclministcixii 
 the tbirclday. At 
 ;tl, but in a wt'iV;'- 
 nore libfial dUl i^ 
 riiy only palliativt 
 ion often impnAc- 
 itlialis is associakcl 
 
 methods, the u'l^nt 
 ducinK "'> ft)rcMi,'ii 
 pinn back into tht 
 It; hence it slimikl 
 rhe proceedini; i>. 
 ck caused by thf 
 to turn the V)alaiue 
 considerably ilimir. 
 lith semi-starvatum, 
 body of sonif si/x 
 vantage of rapicVnv, 
 imend this proceed- 
 "he results hitluTtj 
 ,-pliy beinj,^ ablf t>^ 
 caths, and we (mt 
 The button, it iH; 
 mil a fortni^dit afur 
 
 , with after burns. a« 
 lur in the same \va\ 
 Tieously, and witlum: 
 ich it f,dves rise are 
 ' after food, to^^etkr 
 p by the ulcer laying 
 [co-duodenal vessel,. 
 sometimes induced. 
 jves rise to acute or 
 ^ns posteriorly, U' '^ 
 J) come to the surface 
 lie liver; in lad, tne ] 
 those of perloiatin^ 
 
 j;astrlc ulcer {q.v.). Stenosis of the duodenum may follow this 
 lesion. 
 
 Affections of the Intestine. 
 
 Congenital Conditions are occasionally met with afTectinj,' the 
 intislines, and perhaps },M\in{,f rise to serious complications. 
 ((II The most conunon of these consists in what is Known as 
 Makcl's diverticulum. It occurs as an outf^rowth fKjni tiu; lower 
 tiul of the ileum, which may be patent for i or 2 inches, terminat- 
 ini; possibly in a libroiis cord, wiiich floats free amonj^'st the iiites- 
 tiius, or may contract adhesions, and thus determine an internal 
 stian^(ulation ; sometimes it persists as an open tube as far as tiie 
 iinibilicus, gi\inf,' rise loaconj^enital fu'cal fistula. It is due to non- 
 obliteration of the oiuphalo-mesenteric duct, {b) Coiif^ciiilal stenosis 
 (it the duodenum also occurs opposite tl;e entrance to the common 
 bile-duct, and a similar condition may arise in the lower part of the 
 ileum at a spot corresponding to the site of Meckel's diverticulum. 
 
 Injuries of the Intestine. 
 
 Contusion of the Intestine may result from any serious blow on 
 the abdomen, and necessarily \aries in its effects with the nature 
 and force of the injury, the amount of distension of the gut, and 
 the strength and power of resistance of the parietes. In its 
 >iiiiplest form, it merely produces a little bruising ni the intestinal 
 wall, followed by a subacute or chronic enteritis, from which with 
 care the patient quickly recoNers. In the more severe cases, an 
 acute enteritis ensues, due to bacillary iinasion, which may even 
 mil on to ulceration or sloughing of the coats of the bowel. 
 The latter result is more likely to follow if the mesentery has 
 also been involved in the injury so as to produce thrombosis ol 
 the mesenteric vessels. Under these circumstances, the final 
 issue depends largely upon the rapidity of the inflammatory pro- 
 cess. If adhesions ha\e had time to form between the parietes 
 and the injured gut, the mischief is limited, and the patient may 
 recoxcr with an artificial anus or fa'cal fistula, the formation of 
 which has been preceded by a localized intraperitoneal abscess, 
 containing extremely offensive pus, owing tt) the presence of liie 
 Ike. eoli, which has migrated through the intestinal wall. If, 
 ho\ve\er, the inflammatory affection is rapid in its onset, and 
 adhesions have not had time to develop, acute diffuse peritonitis 
 is almost certain to follow. When the injured portion of bowel 
 is retroperitoneal, as in the duodenum or colon, a retroperitoneal 
 abscess may form. 
 
 The Symptoms of intestinal contusion consist primarily of shock 
 and pain. The amount of shock \aries necessarily with the 
 se\erity of the injury and the nervous susceptibility of the patient. 
 
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874 
 
 A MANUAL OF SURGERY 
 
 The pain may not be severe during; the period of shock, hut is 
 always very marked subsequently, and increased by examina- 
 tion, movement, or during violent respiratory efforts. To limii 
 such movement, the abdominal parietes are maintained in a 
 state of firm contraction, and can be felt hard and resistant. 
 Vomiting may be present, but is not a marked feature. The later 
 symptoms necessarily vary with the course taken by the case, and 
 need not be described in further detail. 
 
 Treatment is conducted along the same lines as that of contu- 
 sions of the abdominal wall (p. 849), viz., where there is no 
 absolute evidence of rupture, an expectant attitude must l)e 
 adopted. If, however, at the end of twenty-four or forty-eiiflu 
 hours signs of acuto peritonitis manifest themselves, an exploratory 
 laparotomy is justifiable. Acute enteritis induces diarrhcjea and 
 the passage of blood-stained mucus, and such symptoms will 
 indicate the use of bismuth, and perhaps a little morphia, whilst 
 a fluid diet is alone permissible. 
 
 Eupture of the Intestine follows abdominal injuries of a more 
 severe character than those causing contusion, such as when a 
 cart or cab has traversed the abdomen, or when the patient has 
 been tightly squeezed. The amount of distension of the gut is a 
 most important factor in the aetiology, since it is obvious that a 
 distended coil is much more likely to give way than one that 
 is empty ; in the latter case it is quite possible for a small 
 wound to occur, through which the intestinal contents are unable 
 to escape. The bowel does not always gi^■e way at the point of 
 impact, but occasionally at a distance from it ; under these cir- 
 cumstances the tear is more likely to be ragged and irregular, 
 whilst if it yields at the point struck, the gut may be cleanly torn 
 across. The parts most frequently affected by this form of injury 
 are the junction of the moveable jejunum with the fixed duodenum, 
 and the lower 3 feet of the ileum. In this condition also the effect 
 of the accident on the mesentery is of importance, since in the 
 first place it may give rise to considerable intraperitoneal hanior- 
 rhage, and later on may cause sloughing of the gut as a result of 
 thrombosis. 
 
 The Effects of rupture of the intestine a,re always extremely 
 serious, if extravasation of the contents follows, since acute difl'use 
 peritonitis is almost certain to be lighted up ; in a few cases a 
 localized intraperitoneal abscess has been known to result, but 
 such is by no means common. 
 
 The early Symptoms consist of severe and usually lasting shock, 
 accompanied by intense abdominal pain. Owing to escape of the 
 intestinal contents, a virulent form of acute peritonitis follows 
 immediately, from which the patient rapidly succumbs. Free 
 gas is sometimes, but not frequently, met with in the peritoneal 
 cavity, as in rupture of the stomach, and may be recognised by 
 
ABDOMINAL SURGERY 
 
 875 
 
 the existence of a resonant note on percussion in front of the liver. 
 In a few cases emphysema of the abdominal walls has been caused, 
 and in the absence of thoracic injuries or of diffuse cellulitis is an 
 absolutely certain sign of rupture of the intestinal tube. Vomiting 
 occurs, but not to an excessive degree ; if blood is found in the 
 vomit, it suggests that either the stomach or upper part of the 
 intestinal canal has been injured. Occasionally a blood-stained 
 motion is passed, but only late in the case. 
 
 The Diagnosis of a ruptured intestine is always a matter of 
 uncertainty in the absence of such symptoms as resonance in 
 front of the liver or emphysema of the abdominal walls, which are 
 very uncommon. The amount of shock is an uncertain guide, 
 although, if prolonged and severe, it is suggestive ; whilst the 
 presence of an area of deep fixed tenderness and pain with, perhaps, 
 a rigid abdominal wall over it, and the incidence of early acute 
 peritonitis are probably the only signs that we can depend upon 
 with any certainty. The history and nature of the accident are 
 important, and should be carefully investigated. 
 
 in the non-existence of any distinct signs of rupture, Treatment 
 in the early stages can only be expectant, and directed towards 
 combating the shock and relieving the pain. A small dose of 
 opium should be administered with this object, and also to check 
 peristalsis, and hinder further extravasation of the intestinal con- 
 tents ; but as little as possible should be given, since it tends to 
 mask symptoms. If the surgeon has good grounds for suspect- 
 in^f that the intestine is torn, he ought at once to undertake an 
 exploratory laparotomy, which in careful hands will do less harm 
 to the patient than waiting for the onset of acute peritonitis to 
 make the diagnosis certain. If severe shock is present, an injec- 
 tion of hot saline solution into a vein will sufficiently restore the 
 patient in the majority of cases to warrant such a procedure. 
 When a rupture is found, the same rules of treatment should be 
 fcllowed as those which have been enunciated for a ruptured 
 stomach. 
 
 In Punctures or Stabs involving the intestine, the results differ 
 considerably according to the amount of distension of the bowel, as 
 also with the fluidity of the faces and the direction of the incision. 
 Thus, a longitudinal cut (running parallel to the axis of the bowel) 
 is more likely to gape than a transverse one, owing to the greater 
 power of the circular muscle fibres ; a small puncture may be 
 almost closed by a protrusion of mucous membrane. Wounds of 
 the small intestine are more likely to be accompanied by extrava- 
 sation than when the colon is involved, owing to the contents of 
 the former being in a much more liquid state. 
 
 The Symptoms are very similar to those already detailed as 
 characteristic of rupture of the intestine. As far as regards the 
 immediate phenomena, there is nothing absolutely typical unless 
 
876 
 
 A MANUAL OF SURGERY 
 
 gas or faecal material is escaping either from the abdominal wound 
 or from a prolapsed portion of bowel. Shock is not necessarily 
 so severe as when the intestine is ruptured by violence without 
 penetration ; abdominal pain is always present, and the pheno- 
 mena of acute peritonitis quickly follow. 
 
 Treatment. — Every case of suspected penetration should be 
 carefully and thoroughly explored ; a probe is first passed, and 
 then the abdominal parietes divided on either side of the piohe, 
 so as to enable the extent of the mischief to be ascertained. If 
 the peritoneum is not opened, no harm has been done, since after 
 purification the different layers of the wall are sutured togefher. 
 If the peritoneum has been involved, the opening in it should 
 be enlarged, so as to explore the viscera and determine with 
 certainty whether or not the gut has been wounded. If a small 
 punctured or incised wound of the intestine is present, it is closed 
 by a purse-string stitch or by a row of Lembert or Czorny- 
 Lembert sutures. If a more extensive lesion exists, excision o' 
 the damaged portion may be necessary ; but if the patient is deeply 
 collapsed from the supervention of peritonitis, it may be wiser to 
 bring the divided ends to the abdominal wall, and form a tem- 
 porary artificial anus, which is subsequently dealt with when tht 
 patient's general condition has improved. As to the treatment of 
 the resulting peritonitis, we must refer to w'hat has been written 
 concerning rupture of the stomach (p. 858). 
 
 For Gunshot Wounds and their treatment, see pp. 166 and 16-, 
 
 Perforation of the Intestine arises from many different causes, 
 such as the impaction of a foreign body, or the yielding of an 
 intestinal ulcer, as occurs in tuberculous disease or typhoid fever. 
 or from that form of enteritis which follows strangulated hernia, 
 We have already discussed the phenomena resulting from tht 
 perforation of an ulcer of the stomach or duodenum (pp. 859 and 
 872), and another variety caused by perforation of the appendi.\ 
 will be alluded to subsequently (p. 8g8). 
 
 When the jejunum or upper portion of the ileum is involved, 
 perforation is usually due to the impaction of a foreign body, 
 such as a fish-bone, or to yielding of a tuberculous ulcer. In acute 
 cases, general peritonitis is almost certain to follow, and what \\t 
 have written as to the results and treatment of such a lesion in 
 the stomach applies here with equal force. Occasionally tlit 
 lesion is of a more chronic type, especially when due to tubercle, 
 and then adhesions may form, allowing an intraperitoneal abscess 
 to develop, and should it open externally, a faecal fistula follows. 
 In not a few cases the process of cicatrization may lead to a spon 
 taneous closure of the fistula, and no operation should be under- 
 taken until sufficient time has elapsed to determine whether or 
 not this will occur. A similar condition sometimes results from 
 
ABDOMINAL SURGERY 
 
 877 
 
 abdominal \vt)und 
 is not necessiuily 
 y violence without 
 it, and the pheno- 
 
 tration should be 
 s first passed, ;md 
 
 side of the probe, 
 be ascertained. If 
 en done, since after 
 3 sutured together. 
 jening in it should 
 ,nd determine with 
 ounded. If a small 
 
 present, it is closed 
 .embert or Czeruy- 
 n exists, excision 0' 
 the patient is deeply 
 1, it may be wiser to 
 ill, and form a tern- 
 dealt with when the 
 s to the treatment of 
 lat has been written 
 
 see pp. 166 and 167. 
 
 lany different causes, 
 
 ir the yielding of an 
 
 ;ase or typhoid fever, 
 
 strangulated hernia, 
 
 resulting from the 
 
 jdenum (pp. 859 and 
 
 :ion of the appendix 
 
 [a ileum is involved, 
 of a foreign body. 
 Iilous ulcer. In acute 
 follow, and what we 
 It of such a lesion m 
 ,. Occasionally the 
 /hen due to tubercle, 
 itraperitoneal abscess 
 [fffical fistula follows, 
 may lead to a spon- 
 [on should be under- 
 [etermine whether or 
 metimes results from 
 
 tuberculous peritonitis, the umbilicus being a common site for 
 such a fistula to develop. In other cases several coils of intes- 
 tine may be matted together by adhesions, amongst which an 
 abscess forms, which by opening into the bowel in two or more 
 pla'-es gives rise to a fistulous communication, known as tijisttila 
 [{mucosa , 
 
 In the lower portion of the ileum, typhoid fever is the most 
 u;;ual cause of perforation of the intestine. It generally occurs 
 about the end of the second or in the third week of the disease, 
 and rarely more than one perforation is present. The symptoms 
 are usually those of sudden collapse, as indicated by a falling 
 temperature and a quick and feeble pulse, whilst severe abdominal 
 pain followed by distension indicates the development of general 
 peritonitis. Even when the patient is already collapsed by the 
 disease, some slight fall of temperature with acceleration of the 
 pulse may occur, followed by abdominal pain and meteorism. 
 The only treatment which holds out any prospect of saving the 
 patient is operation, but owing to his depressed condition the 
 outlook is not particularly bright. Obviously, when he is mori- 
 bund, it is useless to interfere ; but the fact that at least seven 
 cases of recovery have been reported, out of rather more than 
 forty that have been subjected to operation, shows that in suit- 
 able circumstances a certain percentage of success may be 
 anticipated. The abdomen should be opened in the middle 
 line below the umbilicus, and if the lesion is not at once 
 obvious, the ileum is sought for at its junction with the caecunr, 
 and the bowel brought up and carefully examined inch by inch 
 till the perforation is found ; it may then either be closed by 
 sutures, or stitched to the margins of the wound so as to create 
 a temporary artificial anus. The peritoneum is cleansed and 
 drained in the usual way. 
 
 In the large intestine the most common cause of perforation is 
 ulceration due to chronic obstruction. Masses of faeces accumu- 
 late within the bowel, and by their pressure give rise to inflam- 
 mation of the walls, which runs on either to ulceration or to 
 actual necrosis. Most usually the peritoneum is by this means 
 laid open, and acute perforative peritonitis follows. In malignant 
 disease of the colon, perforation also results in some instances, 
 jjiving rise to a localized abscess, and subsequently to a faecal 
 listula. 
 
 Stenosis of the Intestine. 
 
 This arises from two main causes, viz., the contraction of 
 cicatrices, and the development of malignant growths. 
 
 Cicatricial Stricture usually results from the healing of ulcers 
 which have extended more or less circularly around the bowel. 
 After typhoid fever they are therefore rare, since the ulcers are 
 rather longitudinal than transverse, and, indeed, there is only one 
 
878 
 
 A MANUAL OF SURGERY 
 
 certain case of stricture arisinj^ from this source on record. In 
 the small intestine tuberculous ulceration is one of the commuiu'st 
 causes, since it always tends to travel round the fj;ut alon<^' the 
 line of tlie vessels ; it is usually found in the neif^hbourhood of 
 the ileum, and may involve an extensive portion of the bowel, di 
 be multiple. It also arises from syphilitic disease, or as a sef]iiela 
 of strangulated hernia, injury, or the separation of an intussus- 
 ception. In the large intestine dysentery is perhaps the iiiosi 
 important cause of stricture, whilst syphilis or pelvic cellulitis 
 may determine its occurrence in or near the rectum. 
 
 Owing to the contents of the small intestine being of a some- 
 what liquid nature, a stricture in this situation often exists for 
 some time before symptoms of any urgency arise. The patient 
 may complain of a certain amount of indigestion and discomfort, 
 but sooner or later the narrowed aperture of the gut becomes 
 blocked either by a fold of mucout membrane or by a portion ot 
 undigested food, and thus an attack of obstruction is induced. 
 In the early stages of the disease this can be overcome and 
 remedied by purgatives, but each recurrence is likely to increase 
 in severity, until finally an acute attack supervenes, which kills 
 the patient, unless relieved by prompt surgical interference. 
 
 In the large intestine very similar phenomena appear, but the 
 attacks of obstruction are of a somewhat different character, since 
 there is less pain and vomiting ; and aperients, instead of re- 
 lieving the patient, as they often do in the earlier attacks in the 
 small gut, always aggravate the symptoms ; there is also much 
 greater distension of the abdomen. The diagnosis of stricture, 
 though strongly suggested by the symptoms, can only be abso- 
 lutely confirmed by an exploratory operation, except when the 
 lower part of the rectum is in\ olved. 
 
 The Treatment in the earlier stages consists of suitable dietinj,', 
 and the administration of purgatives, or of large enemata, and 
 for a time such will be successful. Sooner or later, howe\er, a 
 more than usually serious attack of obstruction will call for 
 something m.ore radical, and we must refer readers to the chapter 
 on obstruction for details of the treatment to be adopted. If on 
 operating the stricture is found and recognised, enteroplasty or 
 enterectomy should be undertaken, if the small gut is involved, 
 For stricture of the caecum or ascending colon, some short- 
 circuiting method, whereby the ileum is implanted into the color 
 below the stricture (ileo-colostomy), is perhaps the best plan to 
 adopt ; in the transverse colon excision is possible, as also in the 
 sigmoid flexure, whilst in the descending colon enteroplasty may 
 be undertaken. FaiHng any of these radical measures, the 
 establishment of an artificial anus in the bowel above the stenosis 
 suffices to give relief. It must be remembered, however, that no 
 permanent opeiimg can be made more than a foot above the ileo- 
 caecal valve, since the absorption of nutrition is thereby so inter- 
 
ABDOMINAL SURGERY 
 
 879 
 
 :e on record. In 
 of the commonest 
 ;he ^nit aloiif^' tho 
 
 nei^li^^""'^^''^"^' of 
 n of the bowel, (ir 
 se, or as a secjuela 
 )n of an intussus- 
 perhaps the nmsi 
 )r pelvic ceUiilitis 
 turn. 
 
 : being of a some- 
 
 )n often exists for 
 
 .rise. The patient 
 
 on and discomfort. 
 
 the gut becomes 
 
 ; or by a portion of 
 
 ruction is induced. 
 
 be overcome and 
 
 is hkely to increase 
 
 irvenes, which kills 
 
 i interference. 
 
 :na appear, but the 
 
 ent character, since 
 
 ents, instead of re- 
 
 rher attacks in the 
 
 there is also much 
 
 ignosis of stricture, 
 
 can only be abso- 
 
 , except when the 
 
 of suitable dieting;, 
 jlarge enemata, and 
 |or later, however, a 
 iction will call for 
 .iders to the chapter 
 be adopted. If on 
 Led, enteroplasty or 
 [all gut is involved, 
 colon, some short- 
 Inted into the colon 
 )S the best plan to 
 iible, as also in the 
 ^n enteroplasty may 
 fical measures, the 
 ll above the stenosis 
 i, however, that no 
 foot above the ileo- 
 is thereby so inter- 
 
 fered with that death from asthenia is certain to follow in a very 
 short time. The intestinal t.ontents, too, are fluid and \ery acid 
 at this level, and gi\-e rise Uj much irritation of the skin. 
 
 Cancer of the Bowel is almost always primary in nature, and 
 is then usually a colunmar carcinoma, to which colloid degenera- 
 tion is sometimes added. Secondary growths are occasionally 
 met with, and are necessarily of the same nature as tlie original 
 tumour. The disease may occur as a localized plaque imbedded 
 in the mucous membrane, and undergoing the usual ulcerative 
 changes ; but more frequently it appears as a circular infiltration 
 lit the bowel. Secondary deposits arise after a time in the mesen- 
 teric glands, the liver, or e\en in distant parts ; the general history 
 of these growths suggests, however, that they are not so malignant 
 in type as cancer elsewhere. At first they merely gi\e rise to 
 dyspeptic Symptoms of varying character, according to the size 
 and situation of the mass, and then to these may he superadded 
 intermittent attacks of chronic or subacute obstruction, w'hich 
 udginally come under the care of the physician, but at length the 
 surgeon's assistance is needed to relieve or deal with an acute 
 attack. " Two other manifestations of the disease may determine 
 surgical action, viz. : (i) The existence of a tumour, which, 
 though at first readily moveable, soon becomes fixed owing to 
 the formation of adhesions to surrounding tissues ; and (2) the 
 development of an abscess due to an invasion of the growth by 
 the Bac. coli, which finds its way through the ulcerated surface of 
 the tumour. This complication is most likely to occur when the 
 colon is affected, and all the manifestations of an acute or sub- 
 acute intraperitoneal abscess supervene. In favourable cases it 
 Imrsts externally, or is opened, giving exit to exceedingly offensive 
 pus, and for a w^hile the patient's symptoms are relieved ; a faecal 
 fistula follows, and the disease runs a rapid course to its inevitably 
 fatal issue. 
 
 Treatment. — Whenever a diagnosis of malignant disease of the 
 bowel has been made or is suspected, an exploratory laparotomy 
 is justifiable in order to confirm or disprove the fact. Unfor- 
 tunately, physicians are only too liable to leave the case until 
 the progress of the disease has settled the question, and then 
 palliative treatment may alone be possible. If found early 
 enough, the growth, together with a good margin of healthy tissue 
 on either side, should be removed, and the intestinal canal re- 
 stored by enterorrhaphy. A \'-shaped portion of the mesentery 
 is included in the part excised, so as to remove if possible any 
 affected lymphatic glands. Should this be impracticable owing to 
 the extent or fixity of the growth, the following plans of treatment 
 may be considered, and that which best suits the requirements of 
 the particular case undertaken : 
 
 I. The growth may be shovt-civciiited by uniting portions of gut 
 ahove and below it. This is usually accomplished by one of the 
 
88o 
 
 A MANUAL OF SURGERY 
 
 forms of lateral anastomosis described hereafter ; thus, the carnin 
 may he attached to the sigmoid flexure in a case of cancer of the 
 transverse colon. 
 
 2. The bowel may be entirely divided above the tumour, and 
 the upper end implanted into the gut below it, the open end uf 
 the divided bowel being sutured. This lateral implantation is t!ie 
 best plan of treatment to employ for cancer of the caecum wliicli 
 cannot be extirpated ; the ileum is divided above the valve, and its 
 open end implanted into the ascending colon well above the growth 
 (ileo-colostomy), whilst the lower end is totally closed. 
 
 3. The affected coil of gat has been ixclitded from the intes- 
 tinal tube by dividing the bowel abo\e and below, and unitinj. 
 the divided ends, whilst the open ends of the diseased coil are 
 either entirely closed by sutures, or one end is closed and the 
 other is brought to the surface, and fixed there so as to establish 
 a fistulous track. The latter practice is probably the safer ti» 
 adopt, since there is always a certain amount of discharge from 
 the cancerous growth, and, at any rate, in the small intestine the 
 mucous membrane itself secretes, so that total closure would he 
 accompanied by danger. 
 
 4. Finally, if none of these measures are applicable, or if the 
 patient's condition is such as to make it unwise to attempt them, 
 and if the growth is situated in the colon, an artificial anus mav 
 be established. 
 
 Operations on the Intestines. 
 
 Before describing in detail the actual operations which are 
 undertaken upon the small or large intestine, it is essential that 
 the various Sutures employed in such work should be discussed, 
 The interior of the bowel is occupied by material which, as loiii,' 
 as it remains in its proper place, is innocuous enough ; but let 
 it once find its way into the peritoneal cavity, an acute and 
 usually fatal peritonitis is almost certain to follow. Hence, 
 every union made by the surgeon must be air- and water-tight, 
 and capable of accommodating itself to varying degrees of intra- 
 intestinal pressure. For this reason a continuous stitch must 
 never be employed except in the long axis of the bowel, or 
 unless there is some button or bobbin within it. Again, it is 
 essential that on its peritoneal aspect the line of union should 1 
 present nothing but serous membrane, as otherwise adhesions are 
 certain to form, and the comfortable action of the bowel will be 
 subsequently impaired. Hence, special forms of stitches have toj 
 be adopted, the more important of which are described below. 
 
 Lemherfs Suture, originally proposed at the end of last cen 
 tury, has for its object the bringing of surfaces of peritoneum i 
 together without encroaching on the mucous membrane; ami 
 stitch which involves the whole thickness of the wall is liable tol 
 
ABDOMINAL SURGERY 
 
 88 1 
 
 thus, the caTuii) 
 
 I of cancer of the 
 
 the tumour, and 
 , the open end of 
 'implantation is tlie 
 the cKCUtn whicli 
 e the valve, ami its 
 
 II above the growth 
 closed. 
 Jed from the intcs- 
 aelow, and uniting; 
 i diseased coil arc 
 
 is closed and the 
 5 so as to establish 
 l)ably the safer to 
 t of discharge from 
 ; small intestine the 
 i\ closure would i)e 
 
 applicable, or if the 
 se to attempt them, 
 1 artificial anus may 
 
 nerations which are 
 \e, it is essential that 
 should be discussed, 
 :erial which, as \oK 
 pus enough ; but let 
 [ivity, an acute and 
 to follow. Hence, 
 air- apd water-tight, 
 ring degrees of intra- 
 itinuous stitch must 
 ;is of the bowel, or 
 ichin it. Again, itis^ 
 line of union shoidd 
 lerwise adhesions are 
 'of the bowel will be 
 IS of stitches have to] 
 . described below, 
 the end of last cen- 
 rfaces of peritoneum 
 [ous membrane; any 
 the wall is liable to 
 
 be followed by leakage of the intestinal contents, and possibly 
 peritonitis. The needle is passed at right angles to the axis of 
 the wound through a small fold of the serous and nniscular coats, 
 (Toing down to the submucosa ; each fold is placed about one- 
 twelfth of an inch from the margins of the incision (Fig. 305). 
 On drawing up and tightening the stitch, the margins of the wound 
 are tucked in (Fig. 306), and only the serous coats brought into 
 
 ai 3-mS 
 
 4ff^Hw^[4-hf4 
 
 I'lG. 305. — Lemhert's Suture as applied for 
 A Longitudinal Wound of the Bowel. 
 
 Fig. 306. — Lemhkrt's 
 Suture seen in Section, 
 to show Character of 
 Appro.ximation. 
 
 The stitches are carried well beyond the ex- 
 tremities of tile incision, so as to obliterate 
 tlie groove always caused by this method of I., Suture; n, serosa; /;, 
 suturing. muscularis ; c, mucosa. 
 
 apposition. A series of similar stitches are inserted along the 
 whole extent of the wound, numbering about ten or twelve to 
 the inch. In closing a longitudinal incision in this way, a groove 
 will be formed at either end which must be obliterated by two or 
 three extra sutures. For a small puncture the same type of stitch 
 is utilized, but it may be introduced circularly around the opening 
 
 Tig. 307. — Czerny-Lembert Suture. 
 
 I ! .Stitch securing divided mucous mem- 
 brane ; II., ordinary Lembert suture, 
 for the serous coats ; it, serosa; 6, mus- 
 cularis ; c, mucosa. 
 
 Fig. 308. — Halsted's Mattress 
 Suture. 
 
 Ilike a purse-string, and by tightening it the margins of the 
 [aperture are turned in and buried. 
 
 The Czerny-Lembert Suture is very similar in its nature, but 
 Consists of two rows : the first has for its object the closure of 
 m wound in the mucous membrane (Fig. 307, I.), and in a 
 Bongitudinal wound this may be of the continuous type ; the 
 jsecond row consists of the ordinary Lembert stitches, con- 
 
 56 
 
88a 
 
 A MANUAL OF SURGERY 
 
 tinned or interrupted accordinfj to the requirements of the case 
 (I'lR- 3<^7> II')' I>y this means the l<nots of the first series of 
 sutures are covered over and Iniried by the second row. 
 
 Halsted's Mattress Sutuye (Im^- 308) is a very valuable one, 
 which has been utilized a f^ood deal of late. It consists practiculjy 
 of a double Lembert, a loop being thus formed at one end, wliilst 
 thei knot is tied at the other. It is introduced with exactly the 
 same precautions as the original Lembert. 
 
 Occasionally it happens that two segments of bowel have to be 
 stitched together, although the surgeon cannot reach the outer 
 coats owing to this portion being fixed. Thus, in dealing with 
 the posterior segments of the walls of the bowel, either in 
 pylorectomy or gastro-enterostomy, it is found that one can only 
 work from the front, and the stitches must then be inserted by 
 what is known as Woljic/s Method (Fig. 30(j). The sutures are 
 
 Fig. 309. — W(")lfler's Suture. 
 
 L.Stitcli through serous and muscular coats 
 applied and tied from within ; II., stitch 
 uniting divided mucous membrane over 
 the former, so as to cover it in ; a, serosa ; 
 b, muscularis ; c, mucosa. 
 
 Fir,. 310. — Paul's Tl-hk^ 
 (glass). Large and Small 
 Sizes. 
 
 first passed through the serous and muscular coats on either 
 side (I.), the knots being tied on the inner aspect — i.e., towards 
 the lumen of the open gut. The mucous membrane is then 
 secured by a second row of stitches (II.), so as to cover over the 
 first series of knots. Of course, only a portion of the circum- 
 ference of the bowel has to be dealt with in this way ; as soon as 
 possible, one changes to the Czerny-Lembert method. 
 
 Passing on now to the actual operations, the following have to 
 be described : 
 
 I. Enterotomy is a term which is only correctly applied to an 
 incision made into the intestine either for the removal of a foreiiln 
 body or for the examination of its interior. The wound should I 
 always be placed in the longitudinal axis of the gut, and along its] 
 anti-mesenteric border ; it is closed by a row of Lembert, Czerny- 
 Lembert, or Halsted stitches. 
 
 The same title, enterotomy, has, however, been often incor-l 
 rectly employed to denote the operation which is sometimes I 
 undertaken for the relief of intestinal obstruction wlien the! 
 
A BDOMINA L SUNG ER Y 
 
 SSj 
 
 nents of the rase 
 ,he lirst series of 
 nd row. 
 
 ry viiUuvhle one, 
 
 onsists practically 
 
 at one end, whilst 
 
 with exactly the 
 
 [ bowel have to be 
 
 )t reach the outer 
 
 as, in dealing; with 
 
 bowel, either in 
 
 that one can only 
 
 len be inserted by 
 
 The sutures are 
 
 JO —Paul's Tl-hks 
 ;s), Laroe ami Small 
 
 liar coats on either 
 aspect— ?.<;., towards 
 
 membrane is then 
 IS to cover over the 
 ■tion of the circuin- 
 ;his way ; as soon as 
 
 method. , 
 
 ,he following have to | 
 
 rrectly applied to an 
 removal of a foreiijn 
 d The wound should 
 Ihe gut, and along n? 
 of Lembert, Czerny- 
 
 pr, been often incor- 
 [which is sometimes 
 Sstruction when the 
 
 patient is almost moribund, and one is unabU- to make an exact 
 Ji;ij,Miosis of the cause. It is especially useful when liie obstriic- 
 ;i,)ii is probably due to some lesion located in the ca'cum or 
 iiscending colon. An incision is made, either in the middle line 
 i,r in the iliac region on the right side, somewhat similar to that 
 (iiiployed for removal of the appendix ; the first distended coil 
 which presents is drawn well out, and opened after carefully pro- 
 tecting the peritoneal ca\ity from faxal infection. A large trocar 
 and cannula are lirst introduced so as to allow the flatus and fluid 
 contents of the gut to escape ; the opening is then enlarged and a 
 Paul's (glass) tube tied in (Fig. 310), so as to carry away the 
 intestinal contents clear from the wound, to the margins of which 
 the bowel is fixed. This proceeding is often known as Nelaton's 
 iiperation, but should in reality be termed Entcyostomy. 
 
 2. Enteroplasty is a plan of treatment which has been devised 
 tor dealing with cicatricial strictures of the intestine, and is based 
 on the same idea as the operation of pyloroplasty for fibrous 
 ^tenosis of the pylorus (p. 867). A longitudinal incision is made 
 through the stenosed gut along the anti-mesenteric border ; this 
 is opened out, and converted into a transverse cleft, which is care- 
 fully sutured, the lumen of the bowel being thereby considerably 
 increased. 
 
 3. Enterectomy, or excision of a portion of the bowel, is called 
 lor in the following conditions : (a) For the removal of gangrenous 
 ;;ut after strangulation, whether internal or external ; (b) in the 
 treatment of multiple penetrating wounds, as after a stab or gun- 
 shot injury ; (c) in dealing with artificial anus ; (d) for the re- 
 moval of simple or malignant strictures ; and {e) in some cases 
 of intussusception. Not long ago the operation was but rarely 
 undertaken, and the results were most unsatisfactory ; but at the 
 present time a very considerable degree of success may be 
 expected, and enterectomy is frequently practised. Naturally, 
 the results vary largely with the condition for which it is per- 
 formed, and with the experience and skill of the operator ; a 
 much higher rate of mortality follows when the excision is done 
 for malignant disease, for gangrene following strangulation, or for 
 intussusception, than when performed for other causes. 
 
 Whenever practicable, the bowel should be thoroughly emptied 
 [prior to operation, and rendered as sterile as possible by the use 
 [of such drugs as calomel {gr. i. daily), salol, ^-naphthol, naphtha- 
 lene, bisnuith subnitrate, etc., for a few days previously. The 
 ibdomen is opened by any suitable incision, and the portion to be 
 removed clearly defined, the general peritoneal cavity being pro- 
 [ected by a careful packing with sponges or gauze. 
 The bowel must then be clamped on either side of the seat of 
 Operation, so as to prevent the escape of intestinal secretions or 
 Jces. Any of the forms of clamps figured in surgical instrument 
 italogues will eflfect this purpose, and amongst the best are 
 
 56—2 
 
<ls • < 
 
 ^ •: 
 
 m¥' 
 
 A MANUAL OF SURGERY 
 
 Makins' or Lane's. If, however, the surj^eon should lia\t.' fi 
 operate without th(! aid of these, the same result is attained hv 
 passing; a piece of draina^'e-tuhe throu^,di the mesenteric all.uli. 
 ment, and tyinj^ or clampinf,' it around the j^ut. 
 
 The affected portion is now removed by scissors, cuttinj^' tliiiiuf^'li 
 the bowel and takinj^f away a V-shaped portion of the mesentciv, 
 after securing; as far back as possible the main nutrient sesselstn 
 the diseased area, according to Murphy's reconunendation. It 
 must be remembered that the terminal vessels run circularly round 
 the gut, and ha\e but little lateral anastomosis, and therefore it i> 
 essential not to encroach too freely on the mesenteric attachment, 
 otherwise the projecting edge of the anti-niesenteric border is 
 certain to slough, and septic peritonitis will result. Some operator-. 
 recommend that the mesentery should not be cut into, but tluii 
 the gut should be detached from the mesenteric junction ; such 
 practice will suffice wdien merely a small segment of bowel is to W 
 removed ; but if a large portion needs resection, it would take a 
 much longer time to secure all the bleeding spots. The wound in 
 the mesentery is subsequently secured by sutures, and the divided | 
 ends of the bowel united by one of the many forms of enteror- 
 rhaphy described lielow. 
 
 4. Enterorrhaphy is required for any condition in which there is I 
 a solution of continuity of the canal, and necessarily the methods 
 employed must vary according to the character and situation of 
 the lesion. We have already alluded to the plans that are 
 utilized in dealing with longitudinal wounds of the gut. The 
 two chief methods that remain to be discussed are the end-t^ ^-ndj 
 union of a totally divided segment of the bowel, and the meansj 
 whereby lateral approximation or union is secured. 
 
 For end-to-end union the following are the chief plans that] 
 have been adopted : 
 
 A. Enterorrhaphy by simple suiiiving. In this the surgeon! 
 utilizes no special apparatus, but trusts to the deftness of liisj 
 fingers and the accuracy of his stitches. The gut is united l>yf 
 a series of interrupted Lembert or Czerny-Lembert sutures, in- 
 serted around the circumference at distances of about one-twelttlij 
 of an inch. The greatest care must be employed in dealinj( witlij 
 the mesenteric attachment, where the peritoneal layers separate 
 in order to enclose the bowel, and where there is a consider-l 
 able likelihood of the muscular coat being missed ; if this happens! 
 leakage is almost certain to ensue. This method in skilled hands 
 is very satisfactory in its results, but there is one great ohjectioij 
 to it, viz., the time .taken in its performance. 
 
 B. Maunsell's operation, in which a temporary invaginatioij 
 enables the coats of the gut to be accurately sutured together, 
 a most valuable proceeding. It may be described in stages 
 follows : (a) Two long horsehair sutures are passed through thj 
 whole thickness of the mesenteric and anti-mesenteric borders 1 
 
A BDOMIN A L S URG ER V 
 
 88S 
 
 n slioukl h:uf t- 
 iult is iitliuiuil In 
 mesenteric attuch- 
 
 )rs, cuttinj^ tlmni^li 
 1 of tlie meseiUcrv, 
 nutrient vessels in 
 cotnniendation. It 
 im circularly round 
 ;, and therefore it i^ 
 lenteric attachintnt, 
 esenteric border i> 
 It. Some opt-rulDi- 
 3 cut into, but thai 
 :eric junction ; sudi 
 ent of bowel is to he 
 ion, it would lake a 
 )ots. The wound in 
 ires, and the divkk'd ^ 
 ny forms of entemr- 
 
 ion in which there is 
 
 :essarily the methods 
 
 cter and situation ot 
 
 1 the plans that are 
 
 s of the gut. The 
 
 id are the end-t^^ndj 
 
 3wel, and the meansj 
 
 :;ured. 
 
 ;he chief plans thati 
 
 In this the surf,'eonl 
 the deftness of hisj 
 ^he gut is united hyl 
 JLembert sutures, in-l 
 |of about one-twelfthi 
 loyed in dealing witlj 
 )neal layers separateT 
 [here is a considerj 
 psed; if this happens] 
 [thod in skilled haiidj 
 one great objectioiJ 
 
 iporary invagination 
 
 vr sutured together, i^ 
 
 f scribed in stages a 
 
 passed through thl 
 
 lesenteric borders - 
 
 cacli end of the divided intestine, which are thus temporarily 
 approximated {I'ig. 311). {h) A longitudinal incision about 
 throe-quarters of an inch in length ( l-'ig. 311, A) is then made 
 
 l'i(. jii. — Maunseli.'s Otkration for uMf •■ , DivujED Segments 
 
 OF Gut. 
 
 I The mesenteric and anti-mesenteric traction stitches have been introduced, and 
 \ shows the situation of the lateral incision, anri its formation bi- ransfixion. 
 
 I through the anti-mesenteiic border of the b(nvjl, about an inch 
 ' •:■ 'le end of the upper or lower segment, according to con- 
 
 ivenience. {c) The horsehair ?utures (Fig. 312, D) are now tied, 
 passed within the intestine, and drawn out of fh-^ lateral opening. 
 
 ^jr^mmamsm 
 
 iHTEnmorSmtuEP 
 ^ X 
 
 StSMCNTOr OUT 
 
 miiiyiMi^lHijaiiiimmi 
 
 ■at 
 
 Intzrioh orUnunSESMtNT of Cur 
 
 Fig. 312. — Maunsell's Operation. 
 
 I), D, Traction stitches carried through the tube, aod out of the lateral 
 opening; A, serosa; B, muscularis; C, mucosa; F, mesentery. 
 
 JTraction upon these, assisted by a little careful manipulation, 
 [enables the surgeon to produce an artificial intussusception 
 IFig. 313). The divided ends of the bowel now present through 
 
886 
 
 A MANUAL OF SURGERY 
 
 
 the lateral aperture as two tubes one within the other (Fig. 314], 
 their serous coats being in contact, and the mucous coats lininf( 
 both the inner and outer aspects of the protrusion, (d) A sharp 
 
 Peritoneal coat 
 
 Fig. 313. — Maunsell's Operation, showing Position of Intestine 
 AFTER Invagination has been accomplished. 
 
 straight needle (Fig. 314, A) carrying after it a thread of tine 
 silk or catgut, is passed through one of the diameters of the 
 protrusion, transfixing the serous, muscular, and mucous coats, 
 The central portion of the suture as it passes across the innen 
 
 Fig. 314. — Method of inserting Stitches in Intestine in 
 Maunsell's Operation. 
 
 A shows the needle passed through both sides of the bowel, and through all 
 the intestinal coats, so that one passage of the needle places two sutures 
 
 tube is drawn out and divided, and the two halves are tied 
 on either side. Similar sutures are passed in other dianietersj 
 until some sixteen or more are present. By this means the twf 
 tubes are securely united together, (c) All the sutures are cuj 
 short, and the intussusception reduced. The bowel will be founif 
 
ABDOMINAL SURGERY 
 
 887 
 
 'eritoneal coat 
 
 'eritoneal coat 
 
 accurately sutured {Fig. 315, A), the knots of all the stitches being 
 placed within the lumen of the gut. (/) The lateral opening in the 
 bowel (Fig. 315, B) is closed by a continuous row of Lembert's 
 sutures, and if need be a row of the same is inserted around 
 the circular junction, as an additional safeguard in order to bury 
 the penetrating stitches, and so prevent leakage. The operation 
 can be rapidly performed, and gives excellent results. 
 
 Should it be necessary to unite unequal portions of intestine, the 
 larger segment is first reduced in size by the insertion of a row of 
 Lembert's or Czerny-Lembert's sutures, so as to make the opening 
 correspond in size to that of the smaller ; invagination may then 
 be accomplished through a lateral opening in the larger portion, 
 and the operation completed as before. 
 
 A modification of this method has been recently suggested and 
 practised with success by Ullman. After the invagination through 
 the lateral incision has been accomplished, a hollow bobbin made 
 
 Retrmted 
 
 Gut 
 
 IN Intestink in 
 
 I"' 315— Maunsell's Operation completed after tite Invagination 
 
 HAS keen REDUCEU. 
 
 A slicnvs line of union with serous coats turned well in, so that none of the 
 sutures appear outside ; B, longitudinal incision stitched up ; C, wound in 
 the mesentery secured by sutures. 
 
 of decalcified bone or carrot, and with a circular groove around its 
 middle, is inserted into the inner canal, lined by mucous mem- 
 brane. Around this the two tubes of gut are firmly tied by a 
 single silk thread. The intussusception is now reduced, the bobbin 
 being drawn into the bowel, and the operation is completed by 
 closing the lateral opening. The bobbin retains its shape and 
 texture sufficiently long to enable the segments of the intestine to 
 become firmly united by plastic lymph. If further use confirms 
 Ullman's experiences, we shall have in this method a most valuable 
 addition to our means of obtaining rapid and secure end-to-end 
 union. 
 
 C. Enterorrhapy by the use of special apparatus. Under this 
 heading various bobbins and Murphy's button must be included. 
 
 Murphy's Button is represented in Fig. 316. It consists of two 
 portions, a male and a female, which can be easily insinuated one 
 into the other and closed, but which can only be separated by un- 
 
888 
 
 A MANUAL OF SURGERY 
 
 twisting, the spring catches (S) seen in the side of the stem of the 
 male working along a screw thread in the interior of the female. 
 
 Murphy's Button. 
 
 A, Male half; B, female half; P, inner cup or flange of male half, governed 
 by c, spring ; S, spring catches working along a screw thread on the 
 inner aspect of the central stem of the female half. 
 
 Each half consists of a central stem, which is hollow for the passa^^e 
 
 of faeces, to the outer end of which is attached 
 a cup-shaped expansion. In the male half 
 there is an additional inner cup or flange (P), 
 separated from the former by a spring (c), so 
 that when the two halves are approximated, 
 the inner cup is kept constantly pressed 
 against the female half, and thus pressure- 
 atrophy of the tissues grasped between the 
 two segments results, ultimately setting the 
 button free. In the meantime, however, a 
 sufficient formation of lymph will have oc- 
 curred along the line of junction of the two 
 to prevent extravasation and to secure union. 
 In performing end-to-end anastomosis, a 
 running thread is inserted through each end 
 of the divided intestine in the manner shown 
 in Fig. 317. It commences at the anti- 
 mesenteric border (b), and traverses the 
 whole thickness of the gut two or three times 
 until it reaches the mesentery (a), when a 
 Fig. 317.— Method of return overstitch is introduced so as to gather 
 for'^End-to^E^nd without fail the two layers of the mesentery 
 Anastomosis with ii^to the grasp of the button. The same 
 Murphy's Button, stitch is continued along the opposite side of 
 
 a. Overstitch ; b, anti- ^^'^ ^"^^'. ^"^ brought out again at the anti- 
 
 mesenteric border mesenteric border. A half- button is now 
 
 and two ends of introduced into each end of the divided gut, 
 
 suture ; c, mesenteric and preferably the heavier male end into 
 
 attachment. ^^le lower segment ; the stitch is then 
 
 drawn tight and tied, so as to gather up the 
 
 gut wall round the central stem of the button (Fig. 318). The 
 
 two halves are now pressed together (Fig. 320), sufficient force 
 
ABDOMINAL SURGERY 
 
 889 
 
 of the stem of the 
 irior of the fein;ile. 
 
 of male half, governed 
 L screw thread on the 
 
 How for the passa<;e 
 of which is attached 
 In the male half 
 er cup or flange (P), 
 ;r by a spring (f), so 
 ;s are approximated, 
 constantly pressed 
 and thus pressure- 
 rasped between the 
 itimately setting the 
 antime, however, a 
 ymph will have oc- 
 junction of the two 
 and to secure union. 
 end anastomosis, a 
 d through each end 
 the manner shown 
 lences at the anti- 
 and traverses the 
 t two or three times 
 jentery {a), when a 
 luced so as to gather 
 ;rs of the mesentery 
 button. The same 
 the opposite side of 
 it again at the anti- 
 half -button is now 
 of the divided gut, 
 ier male end into 
 Ihe stitch is then 
 as to gather up the 
 Ion (Fig. 318)- Tlie 
 20), sufficient force 
 
 heing employed to bring the walls of the gut into accurate 
 apposition, but without exercising injurious pressure. 
 
 The button is generally set free about the seventh day, and 
 should pass downwards, and be expelled with the faces any time 
 from the fourteenth to the twenty-first day. Occasionally there 
 are difficulties in the onward passage of the button, which may 
 either be retained entirely, or may become impacted ; under 
 
 Fig. 31S. — Ai'1'EARANCE OF Intestinal Segments with Murphy's 
 Button tied in. (Down Brothers.) 
 
 these circumstances it has been known to ulcerate through the 
 walls of the gut, and cause fatal peritonitis. The results of the 
 operations undertaken by means of the button are very satis- 
 factory, as compared with ancient statistics ; but it is doubtful 
 whether they are any better than those obtained by many of the 
 methods introduced more recently. The one great adxantage of 
 diis appliance is the rapidity with which the anastomosis is com- 
 pleted. There are, however, several very grave objections to its 
 employment as a routine measure ; the fact of its being made of 
 metal is of itself a drawback, and fatal issues 
 have certainly occurred from sloughing, from 
 want of union due to the use of too large a 
 button, or of one badly constructed, and even 
 i from subsequent obstruction and perforation 
 I when it has passed lower down. On the 
 , whole, one would be inclined to use it when 
 I time is of value, and the patient's general con- 
 dition such as necessitates the utmost speed 
 I in operating ; under other circumstances one 
 would prefer Maunsell's operation when prac- 
 l doable. 
 
 Many other useful contrivances, such as 
 {]Iayo Rohsons bobbin (Fig. 319), AUingham's 
 [bobbin, Chaput's button, etc., have been 
 jintroduced of late, and with most of them good results can be 
 jobtained. The majority consist of a hollow tube of decalcified 
 [bone made of different sizes to fit the varying lumen of the gut. 
 [The ohject is not so much to bring about apposition of the 
 
 vided ends of the bowel as to act as an internal sphnt, steadying 
 [the part during and after the operation, facilitating thereby the 
 
 Fig. 319. — Mayo 
 Kobson's Bobbin. 
 (Down Brothers.) 
 
8go 
 
 A MANUAL OF SURGERY 
 
 introduction of the stitches, and shielding the line of union from 
 the irritation of faeces for some days. A continuous stitch, either 
 of the Lembert or Czerny-Lembert type, is utilized, and is tied 
 sufficiently firmly upon the narrowed central portion of the bolthin 
 to prevent it from slipping away. The material of which it is 
 composed (decalcified bone) is such as to do no subsequent harm 
 to the mucous membrane, since it becomes soft and pulpy in the 
 course of a few days. 
 
 5. Lateral Anastomosis of the intestine is usually undertaken in 
 order to effect the short-circuiting of some malignant growth, or 
 of a stricture which cannot otherwise be dealt with. It is some- 
 times employed instead of end-to-end anastomosis to unite divided 
 segments of intestine. The open ends are first entirely closed hv 
 Lembert or Czerny-Lembert stitches, and the portions of bowel 
 made to overlap. Corresponding lateral incisions are then mad- 
 into each. 
 
 The anastomosis may be effected in the following w^ays ; 
 
 (a) By Simple Suturhig, or, as it is sometimes called, hv 
 Wolfler's operation. This has been already described under 
 gastro-enterostomy at p. 871. The longitudinal openings in the 
 two portions of bowel lying exactly opposite each other are secured 
 by sutures, inserted in the posterior half by Wolfler's plan, and in 
 the rest of the opening by the Czerny-Lembert method. In order 
 to prevent subsequent contraction, it is absolutely essential that 
 the mucous membrane be continuous all round the aperture. 
 
 (/>) Murphy's Button is probably the quickest, and certainly the 
 most satisfactory, of all the plans that have yet been suggested. 
 The details of its insertion differ slightly from those employed in 
 effecting an end-to-end anastomosis. Incisions are made in the 
 two sections of bowel to be united, each incision being two-thirds 
 of the diameter of the button to be used. The wounds at hrsi 
 only involve the serous and muscular coats. A purse-strini; 
 suture is inserted round the incision, traversing the whole thickness 
 of the intestinal walls ; the mucosa is then incised, and the halt 
 button introduced. By drawing the stitch tight and tyin^^ it 
 around the stem of the button, the wall of the gut is gathered 
 into the hollow of the cup. This is accomplished on each side, 
 and then the halves of the button are pressed together in the 
 way shown in Fig. 320. Murphy recommends that after the 
 operation the bowels should not be confined, but should he kept 
 loose, so as to prevent any solid mass of faeces blocking the 
 channel through the button. 
 
 6. The establishment of an Artificial Anus has frequently to be 
 undertaken in cases of intestinal obstruction, where the onward 
 passage of faeces is prevented by some irremovable barriei. 
 It is sometimes required in the treatment of intussusception. 
 and for rupture or penetrating wounds of the gut. When the 
 small intestine is involved, enterostomy may be undertaken 
 
 ^ 
 
ABDOMINAL SURGERY 
 
 891 
 
 line of union hnm 
 uious stitch, eilhcr 
 tilized, and is tied 
 rtion of the bol)hin 
 srial of which it is 
 o subsequent harm 
 ft and pulpy in tlie 
 
 ually undertaken in 
 ilignant growth, or 
 with. It is Sdine- 
 osis to unite divided 
 ;t entirely closed by 
 e portions of bowel 
 sions are then made 
 
 Dwing ways : 
 metimes called, by 
 dy described under 
 nal openings in the 
 ach other are secured 
 V' olfler's plan, and in 
 rt method. In order 
 alutely essential that 
 ,d the aperture. 
 !st, and certainly the 
 . yet been suggested. 
 ^1 those employed in 
 ns are made in the 
 ;ion being two-thirds 
 he wounds at first 
 ts. A purse-strini; 
 r the whole thickness 
 cised, and the bah'- 
 tight and tying it 
 the gut is gathered 
 iplished on each side, 
 Jssed together in the 
 liends that after the 
 but should be kept 
 faces blocking the 
 
 has frequently to he I 
 where the onward] 
 lirremovable barrier. 
 of intussusception, 
 (the gut. When the I 
 Tinay be undertaken ] 
 
 as described above (p. 883) ; but it must be noted that life 
 is impossible for any length of time with an artificial anus 
 situated more than a foot above the ileo-ca^cal valve, on account 
 of the interference with nutrition owing to cutting off such a large 
 extent of absorbent mucous membrane. Some form of short- 
 circuiting operation, or some means whereby the continuity of 
 the bowel is restored, must therefore be subsequently undertaken. 
 Things are, however, different in the large intestine ; colotomy is 
 frequently employed in dealing with diseases of the lower bowel, 
 and is an extremely successful proceeding. 
 The character of the artificial anus varies considerably accord- 
 
 Fig. 320. — Method of closing Murphy's Button in Lateral Anasto- 
 
 MO.SIS BETWEEN GaLL-BlADDER AND DuODENUM. (DoWN BROTHERS.) 
 
 ing to whether or not it is intendfid to be a permanent condition. 
 If merely a temporary opening is required, the smaller the portion 
 of bowel secured to the parietes the better, since the subsequent 
 operation for its closure is so much simpler (Fig. 321). But 
 where a permanent aperture has to be established, the surgeon's 
 aim should be to totally deflect the course of the faeces ; and 
 hence it is desirable to entirely withdraw a portion of the gut 
 from the abdominal cavity, and to cut away a complete segment, 
 including also, if possible, a portion of the mesentery. By this 
 means the upper and lower openings are brought to the surface of 
 the skin, and separated from one another by an area of cicatricial 
 tissue representing the section of the mesentery (Fig. 322). 
 
892 
 
 A MANUAL OF SURGERY 
 
 Colotomy, or, as it should be correctly termed, ' colostomy,' is 
 an operation for the establishment of an artificial anus in some 
 portion of the large intestine. Any part of the colon may be tluis 
 dealt with through a median laparotomy ; but one usually prefers 
 to open the termination of the descending colon through the peri- 
 toneum in the left iliac region. Formerly the favourite method 
 was to open the descending colon in the left loin behind the peri- 
 toneum (left lumbar colotomy or Amussat's operation). Callisen's 
 name has also been associated with this proceeding, but he merely 
 proposed to do it through a vertical incision ; Amussat was the 
 first to perform the operation, utilising a transver'^^e incision, and 
 extending its applicability to both sides of the body. 
 
 Uses of Colotomy. — The operation is required under the followin<; 
 
 Fig. 321. — Diagram of Temporary Fig. 322. — Diagram of Permanent 
 Colotomy, showing the Single Colotomy, showing the Two 
 
 Opening on a level with the Openings separated one from 
 
 Skin, the passage to the Lower the other by a section of the 
 
 Bowel being merely blocked by Mesentery. The dotted por- 
 
 A spur of Mucous Membrane. tion indicates the amount of 
 
 Bowel CUT away; but, of cour.se, 
 such an extensive resection is 
 
 ONLY practicable WHEN THERK I^ 
 A VERY LONG MESENTERY, WHICH 
 
 IS unusual. 
 
 conditions : (i) For congenital absence of the rectum, when a 
 perineal incision has failed to discover it : (2) for chronic obstruc- 
 tion of the large intestine, which cannot be relieved by enemata 
 or medical means, such as that arising from simple or malignant 
 stricture, or from the pressure of pelvic tumours : (3) for carcinoma j 
 of the rectum or sigmoid flexure, whether obstruction is present 
 or not, if a radical operation is impracticable, or as a preliminary 
 to excision : (4) for some cases of syphilitic and other forms of I 
 ulceration of the large bowel, which cannot heal as long as theyj 
 are irritated by the passage of faeces : (5) for irremediable casesj 
 
'-"ff needed, not on v t'^"'?"^ «« 'S,' It'f "!''' ""ft'" ' 
 
 "P^vards from a n . P^°" '^ indicated l\ ^^ '^'"'"- 
 l.ne passin,°rro,VhT J;:!'^" inch thin' ^;;:-;;-i ^-e drawn 
 ^he centre of the in^ °'" *° ^^^^ Posterior .1 •^""'^ °^ '-^"other 
 ,^vay between the Ja.f ?'°" ''^°»^d corresnonH f "^' '"^''-^^ ^Pine 
 ''^ '"ade parl:,^To h "."^ '^' ^^^st ofTe -.f ^'^'s line fn?d 
 '"■-^y commence at the o„. ''', ''^^' ^"^^ ^r p ' "'"• , ^^ ^houJd 
 pass outwards for about . ^""'^'^ ^^ ^he eS'"' •P"''P°'^-'^ 
 ^h's mcision is carri^i i ""■ 5 inches (FiJT t^''''"^' and 
 '""■^cJes, dividing ™,1. ^^^°"&^h the lajerfof^n' ^^' P- ^019' 
 external oblique and ^ ''T^ dorsi and fsn. n ^''^ '-^bdomina 
 f^"^fernal obhql"',„^,««^^-th this the poste S^r^/"" «^ ^^e 
 ascia lumborum Thl«^. '',"/''^''^^^^'^^ muscled '^"^^^'^^ents of 
 ^".^th of the inc Lon h '^""^^ '^" ^J^^niv S^I '°"^^'t"ting the 
 '-n« usually included ^^^^^^ ^^^^ ^^rvlt'tji^r''''' '^'^oie 
 ^opened, and the outl «. ^ ^^^^^^^ of the nnn i "'"'^''^^ 'i^-tery 
 ^';,e deeper portions ortl^''"' °^i^^ "^"scle noS"V""^''«^""^ 
 Md the loose fitfv ! i ^. ^^""d are now ]ZJ ^^' '^ necessary 
 'he fingers a^dt^^eep'^^^r-^-^ ^'"-""Tentfer!/^^ ^P'-^tulS:; 
 ^'^^^"cy. The gut must h'^'''r^"°"^^"derably^n° " ''''°"S^^ ^^'^h 
 >:n^sed, if diste'ndeS^"! .^!" ^?>°ked for, aL" 'T?""^ -"d con- 
 
 ^'■^fency. The guVmusV f h'^'''K^^^°"^^"derabl7in"" "^'°"S^^ with 
 diste'ndeT buHf" m^°°^^^ ^^^^ and m^v^""' ^"^ ^°"- 
 
 ^nced, thllgh^th &f ^' ^ ^«°^ dTZS'',r ^" 
 ominal w.ir.^: . ^ ^"^ .^^ anassist^nf '°. ''^?^culty ,s 
 
 cognised, if 
 
 "ften experienced'^ h"" ' t"^ ^^ collapsld" Tlr'rf "^"^ .""^y '^^ readii;';;' " 
 ^'"terior abSnll ^'.f^ '^^ hand of an assist f"'"^ °^ difficult is 
 tl>e lower edg^ oT ,ret '""^ ^""^ ^^ into :S!""\P^-^-g back the' 
 
 cases It may be mad/ I °"^ ^^^^ 's usuallv [h ,*''^ P^^^^on of 
 
 iiscendintr or ri«o ^?- P®^ cent, of indK.,-^ , ^"'" with air 
 cumstanc'es tts n?^^"^' »^^«o- colon eSl"t ," ^^"^ P^^^one.j 
 '" °^der to bring the reo"^ !? °P-^ ^he'™' ""^ ^"^^ -^- 
 "on ^s then completed •^1',^'' P^^^'O" of |ut -nJn P.^'^^°"eal cavity 
 h\'^ not being opened "f '''' ^^'"^ ^^ay f s fo" ^Mi^"^ ', ^^^ opera^ 
 ,;Vhen, howei'r^Z'g^^ T' ""T ^^ Possib/'"^^ ^^^^^^^^^ ^he 
 
 ?S ^:-^ ~ay^S^ :^^^ ^-vestment. 
 
 If er on to prolapse T? '^"^^^'^ ^^ove the wn 'i'"^' '° ^^^^ no 
 
 ^7 or two befo^re bein P°^^^^^^^' ^^^ ^owel should' /° P^ ^^^'^- 
 Jsutureswhirhnvl I "^ opened, and i= I ^nould be left for a 
 
 feut mcised at a later date. 
 
894 
 
 A MANUAL OF SURGERY 
 
 ii 
 
 If, however, the patient is sufferirif^ from obstruction, and an 
 immediate openinj,' of the bowel is desirable, the best plan to 
 adopt is to pull the gut well out of the wound, which is then 
 carefully guarded by an antiseptic compress, and to tap it with 
 trocar and cannula, subsequently making a small incision into it, 
 in which a Paul's tube is at once tied, so as to allow the intestinal 
 contents to escape without soiling the wound. A few fixation 
 stitches are then introduced into the walls of the bowel, so as to 
 prevent it from retracting. The tube is probably set free about 
 the fourth day, but by this time the wound will be in such a state 
 that no great harm will come from the escape of faeces in trie 
 neighbourhood. If a Paul's tube is not to hand, the patient is 
 rolled over on to his back, and a large trocar and cannula inserted, 
 so that the first gush of flatus and fluid faeces may be clear of the 
 wound. On removing the cannula the mucous membrane of the 
 gut is stitched to the margin of the skin, whilst the anterior 
 portion of the incision is sutured, and the small cavity behind the 
 gut packed with gauze. By fixing the bowel as far back as 
 possible, this cavity will be diminished in size. An antiseptic 
 dressing is then applied over a piece of protective to the anterior 
 portion of the incision, and a pad of tenax is placed behind to 
 receive the faecal discharge. The old plan of fixing the gut by 
 transfixing it back and front with silk stitches, which are with- 
 drawn after opening the bowel and tied at the four corners, has 
 little to recommend it. 
 
 Lumbar colotomy is not much in favour at the present day, 
 It is always a difficult proceeding if the bowel is not distended; 
 and if an immediate opening is necessary, there is a considerable 
 risk of suppuration of the wound and cellulitis. It has been 
 almost entirely replaced by the iliac operation. 
 
 Iliac Colotomy, or Littr^'s Operation, consists in opening the 
 lower portion of the colon or sigmoid flexure through the anterior 
 abdominal wall. An incision 2 to 3 inches in length is made at 
 right angles to a line extending from the anterior superior spine 
 to the umbilicus, the centre of the incision corresponding to the 
 junction of the outer and middle thirds (Fig. 298, C). The 
 abdominal parietes are divided, and the peritoneum opened. Two 
 fingers are then inserted, and the sigmoid flexure sought for ; it 
 is recognised by the presence of the appendices epiploicae and the 
 longitudinal bands of muscle fibres. It is carefully examined, 
 and the upper part of it selected for fixation in the wound, so as 
 to diminish the risk of subsequent prolapse. It is desirable to 
 withdraw a coil about 4 or 6 inches in length, together with its 
 mesentery. Many different plans of fixing it are in vogue, but 
 the method we prefer is to pass a strong silk thread through the 
 parietes and parietal peritoneum on either side of the wound, the 
 stitch traversing the mesentery en route. It is then made to 
 traverse the same structures once more in exactly the same way, 
 
ABDOMINAL SURGERY 
 
 895 
 
 bstruction, and mi 
 the best plan to 
 id, which is then 
 ind to tap it with 
 ill incision into it, 
 lUow the intestinal 
 A few fixation 
 he bowel, so as to 
 ably set free about 
 be in such a state 
 36 of faeces in tile 
 and, the patient is 
 d cannula inserted, 
 nay be clear of the 
 s membrane of the 
 ,vhilst the anterior 
 il cavity behind the 
 /el as far back as 
 ze. An antiseptic 
 tive to the anterior 
 s placed behind to 
 .f fixing the gut by 
 es, which are with- 
 16 four corners, has 
 
 t the present day. 
 
 is not distended; 
 
 re is a considerable 
 
 itis. It has been 
 
 sts in opening the 
 hrough the anterior 
 length is made at 
 jrior superior spine 
 rresponding to the 
 ig. 298, C). The 
 cum opened. Two 
 ure sought for; it 
 ; epiploicse and the 
 irefuUy examined. 
 . the wound, so as 
 It is desirable to 
 I, together with its 
 are in vogue, but 
 iread through the 
 of the wound, the 
 is then made to 
 ;tly the same way, 
 
 but at a distance of about half an inch from the former (see Fig. 323). 
 The loose ends are then tied together, so as to bring the parietal 
 peritoneum and sigmoid meso-colon into close apposition. A few 
 additional stitches should be inserted, uniting the skin to the longi- 
 tudinal muscular bands at each end of the incision, so as to prevent 
 any subsequent retraction of the exposed bowel or escape of small 
 intestine. Some surgeons simply secure the parietal peritoneum 
 to tlie gut by a row of carefully inserted sutures ; others pass a 
 glass rod through the mesentery and stitch the peritoneum to the 
 skin, whilst it has also been suggested to make a hole through the 
 mesentery and suture the two edges of the incision through it, 
 ;'/,, beneath the bowel. The projecting portion of gut is then 
 covered with purified protective, and an antiseptic dressing 
 applied. At the end of four or five days the bowel is opened, no 
 anaesthetic being generally necessary for this proceeding. A 
 portion of the whole lumen of the gut should be removed, down 
 
 Fig. J23.— Iliac Colotomy to show Fixation Stitch passing through 
 Mesentery and Abdominal Parietes. 
 
 to and even including the mesentery, so as to completely separate 
 the upper from the lower end, and thus establish an efficient spur. 
 Should an immediate opening be necessary, the bowel should first 
 be very accurately sutured to the skin all round, and then an 
 opening made, and a Paul's tube tied in. 
 
 When cicatrization of the wound is complete, a protective 
 apparatus is required in order to keep the patient clean. This 
 should consist of a hollow oval cup, made of plated metal, vulcanite 
 or celluloid, with a rolled edge, and kept in position either by 
 a truss spring or an abdominal belt. This hollow cup should be 
 large enough to include a 2-inch margin of skin all round the 
 opening, and in the concavity a small portion of antiseptic dressing 
 is placed. Such an apparatus enables the patient to go about in 
 comparative comfort ; the bowels are encouraged to act thoroughly 
 every morning, so that no further disturbance need occur during 
 the day. 
 
 Comparison of the Two Operations. — As we have already stated, 
 the iliac operation has almost entirely superseded the lumbar pro- 
 
 si V'' 
 
896 
 
 A MANUAL OF SURGEKY 
 
 ceedinf^, and the reasons for this chanffeof attitude are as follows 
 (i) The operator is not hampered by lack of space, as si 
 frequently happens in opening' the loin. (2) A clean incision 
 can he made without tearing or bruisinfj; tlie subperitoneal fat, 
 (3) The si}j[moid flexure is readily identified, and no otiier viscus 
 is likely to be opened for it by mistake ; if the colon takes an 
 abnormal course in the loin, or is pro\ided with a complete meso- 
 colon, the peritoneum has usually, if not always, to be opened, 
 and thus the one advantaf^e which can be claimed for the lunilxii 
 proceedinjf is lost. {4) An artificial anus situated in the iliac 
 region can be attended to by the patient himself witiiout assist- 
 ance, and is more easily cleansed and protected. (5) It is occa- 
 sionally possible for a certain amount of sphincteric control to lie 
 de\eloped after the abdominal operation, owing to the muscles 
 of the abdominal parietes becoming adherent to the coats of the 
 gut. Of course, this can only be attained when these structures 
 are brought into accurate apposition, as by the fixation stitch 
 described above. (6) A more complete diversion of the fa.'ces 
 can be effected by the iliac operation than by the lumbar. In the 
 latter it is impracticable to withdraw the whole lumen of the gut; 
 an opening is merely made on one side, and one has to trust 
 to the formation of a valve or spur of mucous membrane for thr 
 blocking of the lower aperture ; in the former the two segments 
 of the bowel can be entirely separated. 
 
 The objections urged against the iliac operation consist in the 
 following facts: (i) That it involves the opening of the peri 
 toneum ; (2) that immediate relief to obstruction is more risky 
 than in the lumbar method ; and (3) that there is a somewhat 
 greater tendency to prolapse. The first of these objections must 
 now be entirely waived. The second is certainly valid, but by 
 a careful use of Paul's tube and by fixing the gut firmly to the 
 skin by additional sutures the danger is minimized. Certainly the 
 lumbar operation is not devoid of risk when an immediate openiiii: 
 of the gut is required. Lastly, if the surgeon is careful to see 
 that no slack portion of gut exists above that which he fixes in 
 the wound, i.e., if he opens the lower end of the descendiiii; 
 colon, there will be but little likelihood of any subsequent pro- 
 trusion. 
 
 Appendicitis. 
 
 Considerable discussion has arisen of late years as to the best 
 title to apply to the condition which is now to be described. 
 Formerly the terms typhlitis, perityphlitis, and paratyphlitis were 
 utilized, indicating respectively an inflammation of the caecum, of 
 its peritoneal coat, or of its retroperitoneal connections. It has 
 now been conclusively proved that although true typhlitis does 
 occur, yet in the vast proportion of cases the caecum plays no part 
 in the trouble, and that the appendix is the all-important element, 
 
ABDOMINAL SURGERY 
 
 897 
 
 Aide areas follows: 
 c of space, as su 
 ) A clean incision 
 ; subperitoneal tat, 
 i\u\ no other viscus 
 the colon takes an 
 :h a complete niesu 
 vays, to be opened, 
 nied for the kuiibar 
 ituated in the iliac 
 iself without assist- 
 ted. (5) It is occa- 
 ncteric control to be 
 ving to the muscles 
 t to the coats of the 
 hen these structures 
 y the fixation stitch 
 version of the faeces 
 the lumbar. In the 
 Die lumen of the gut; 
 ,nd one has to trust 
 us membrane for the 
 ler the two segments 
 
 oration consist in the 
 opening of the peri- 
 uction is more risky 
 there is a somewhat 
 .hese objections must 
 rtainly valid, but l^y 
 he gut firmly to the 
 iiized. Certainly the 
 ,n immediate openuisj 
 son is careful to see 
 lat which he fixes in 
 ^ of the descendins; 
 ,any subseciuent pro- 
 
 I years as to the best 
 
 low to be described. 
 
 ^d paratyphlitis were 
 
 Ion of the caecum, ot 
 
 connections. It has 
 
 t true typhlitis does 
 
 baecum plays no part 
 
 ■• -important element, 
 
 and therefore the title ' appendicitis ' has almost completely sup- 
 planted the former. Again, it has been shown that the caecum 
 and its appendix are in most cases completely surrounded with 
 peritoneum, and hence the distinction into peri- and para-typhlitis 
 is ([uite uncalled for; the inflammation starts in the appendix, 
 then involves its peritoneal lining, and only occasionally spreads 
 into the retroperitoneal tissues byi)urrowing through the posterior 
 liyer of the serous membrane. The importance of appendicitis 
 lies in the fact that the peritoneal envelope is always in\ olved in 
 the inflammation, and according to the character and extent of 
 this complication the symptoms and prognosis must necessarily 
 be largely influenced. 
 
 etiology. — Many different conditions contribute either directly 
 or indirectly in determining an attack of appendicitis, (i) The 
 organ is to be looked on, not as an actively functional structure, 
 but as a degenerated relic or renmant, which is apparently of 
 Httle value or importance. Hence, as in other similar structures, 
 it has but a poor blood-supply, derived in the male from the ileo- 
 colic artery alone, although in the female it has an additional 
 twig from the right ovarian trunk. The latter fact may explain 
 why the disease is less common in females than in males. (2) A 
 large amount of lymphoid tissue is present in its walls, so much, 
 in fact, that the title of ' abdominal tonsil ' has been applied 
 to it. Inflammatory processes are thus readily set up within 
 its walls as a result of the absorption of toxins or organisms, 
 [which are almost constantly present within it. (3) Its length 
 and direction vary considerably in different individuals. In length 
 it may measure anything between i^ and 11 or 12 inches, but 
 is usually 3 to 4 inches long, whilst, as to direction, it may lie 
 in any axis ; perhaps most frequently it is to be found behind 
 the cffcum, and pointing down towards the pelvis. The facility 
 with which the intestinal contents find their way into its lumen 
 thus varies in different individuals, and it seems probable that 
 jappendicitis is more commonly met with where it is so placed 
 las to readily admit material which is with difficulty expelled, 
 lu., when it is transverse or directed downwards. A long 
 {appendix is also more liable to become twisted on itself. 
 |(4) The communication with the caecum is usually a small 
 [one, and is guarded by a fold of mucous membrane, known 
 as the valve of Gerlach. Sometimes this aperture becomes 
 Iblocked, or the orifice stenosed, so that an accumulation of mucus 
 loccurs within the appendix. (5) Faecal concretions or foreign 
 Modies, such as pips, pins, etc., are also met with within it, and by 
 Itheir presence and irritation may determine an attack of inflam- 
 ption. Foreign bodies are much less common than was formerly 
 [magined, occurring most frequently in children and young people. 
 llie faecal concretions are usually the result of chronic constipa- 
 jtion, which is always to be looked on as a predisposing cause. 
 
 57 
 
IPR 
 
 898 
 
 A MANUAL OF SURGERY 
 
 iii 
 
 Other causes of appendicitis are occasionally described, su( h 
 rlieuniatistn, and in chronic cases tuberclt! or actinoiuycdsis; 
 typhoid ulceration is rarely met with in the appendix. I)ysciiitr\ 
 is sometimes associated with appendicitis, tliouf,di more cominoiilv 
 it leads to a true ulcerative typhlitis, involvinf,^ the ca'cum. 
 
 Injury in the shape of a strain or sudden twist is not nnfrc- 
 (piently mentioned as the cause of an outbreak, .and probablv ads 
 by dis|)lacin^' a lon^' appendix in such a way as to lead to its 
 kinkinfjf and possibly to obstruction of the nutrient artery. 
 
 Whatever the assi|^Mied cause tnay be, it must e\er be kept in 
 mind tliat appendicitis is an infective malady, due to invasior. 
 of the walls of the appendix by orf^anisms, especially by tlif 
 Bac, loli, thouf^h ordinary pyogenic cocci are often present in 
 addition. 
 
 Pathological Anatomy.— Bacteria find an entrance into the wall 
 of the appendix either through an eroded area of the mucoid 
 mend)rane due to the impaction of a foreign body or of a tacal 
 concretion, or else they are absorbed into the lymphoid lissiit- 
 so abundantly present, and at once commence to develop and 
 multiply. As a result of this the mucosa becomes gieath 
 swollen and thickened, and as it is surrounded by fairly stroii;' 
 muscular walls, constriction of the vessels follows, pre\entiii:,' 
 recuperative processes from being undertaken, and hence tlit 
 bacteria are enabled to continue their destructive work. In co;; 
 sef|uence, ulceration of the mucous lining supervenes, or inter 
 stitial suppuration in the wall. Sometimes the small terminai 
 artery of the appendix becomes thrombosed, or undergoes ai; 
 obliterati\e endarteritis, leading to sloughing of one or iiior 
 portions of the ' walls, generally at the apex. The \eins alsu 
 are liable to become thrombosed, and bacteria may find their 
 way into the thrombus, causing its disintegration, and if einlKil: 
 are detached, pylephlebitis or portal-vein-pya^mia, with possibly 
 hepatic abscess, may result. The most important changes, how- 
 ever, are those occurring in the peritoneum, which is always 
 inflamed, and, indeed, upon the condition of this structure depeiuis 
 to a large extent the prognosis of the case. It may merely be I 
 thickened by a deposit of lymph, giving rise to adhesions which 1 
 bind it down to neighbouring parts, or a localized sup[)urativej 
 afTection may ensue ; or, again, an acute diffuse and usually fatal 
 peritonitis follows, either as a result of rupture of the appendix,! 
 or as an outcome of sloughing or perforation of its walls. 
 The localized abscess is in reality intraperitoneal, but its ex- 
 tension is limited l>y the formation of adhesions between nei^li- 
 bouring coils of gut. When an attack of appendicitis has 
 passed ofi, some stenosis of the lumen of the tube is a common I 
 sequence, and as a result of this the terminal portion may becomej 
 distended with retained secretion, and the patient may suffer froml 
 intermittent attacks of colicky pain due to the efforts of the ap-j 
 
ABDOMINAL SUKGlHiY 
 
 899 
 
 ' clescril)wl, siuh iw 
 or iictinoinycdsis; 
 ptMuUx. Dyscmen 
 i^rh more cotiiMionly 
 ; the ca'ciim. 
 ' twist is 111)1 unfit 
 <, anil probabls :l(l^ 
 ly as to Iciul Id in 
 rient artery, 
 uist ever be kept ir. 
 dy, due tt) inva^iu: 
 IS, especially l»y tlu 
 ire often present in 
 
 ntrance into the wall 
 area of the nuicoib 
 ;n body or of ii facal 
 \he lymphoid lissm- 
 2nce to develoj) ami 
 sa becomes f^reatly 
 ided by fairly stroii- 
 5 folhnvs, preventing 
 aken, and hence the 
 ictive work. In co;, 
 Isvipervenes, or inter- 
 s the small terminal 
 ,ed, or underf,'oes an 
 of one or more 
 )ex. The veins also 
 teria may find tlieir 
 ^ration, and if cniliuli 
 ya?mia, with possibly 
 (ortant chan<;es, how- 
 im, which is always 
 his structure dcpeiicls 
 It may merely be 
 :; to adhesions which 
 localized suppurative 
 use and usually fatal 
 Aire of the appendix. 
 >ration of its walls.: 
 iritoneal, but its ex- 
 iions between neis;h- 
 of appendicitis has| 
 le tube is a common! 
 portion may become 
 tient may suffer trom 
 ■he efforts of the ap-' 
 
 pfiulix to relieve itself; it will also predispose the individual to 
 ret 1 1. rent inllammitiou. 
 
 Hence, from a clinical standpoint, the followin;^' vtii'itiit's of 
 ippcndicitis may be recoj,'nised : 
 
 I. Simple or catarrhal appendicitis, associated with a plastic 
 peritonitis. 
 
 J. Ulcerative or K-mf^renous appendicitis, accompanied by a 
 localized intraperitoneal abscess. 
 
 3. (ianj^'renous or perforative appendicitis, resultinj^f in an acute 
 ilitiuse sero-purulent peritonitis. Such a condition is freciuentiy 
 tiital, and constituted one of the commonest causes of the so-called 
 •idiopathic peritonitis' of the oUl days. 
 
 4. kelapsiii},^ appendicitis, in which ii.ttack follows attack, some- 
 times with \ery little inter\al. 
 
 Clinical History. — (i.) The mild variety of the disease, known 
 as a simple catarrhal appendicitis, to which is added mt;rely a 
 localized plastic peritonitis, usually commences somewhat sud- 
 denly, the patient being seized with pain in the right iliac fossa, 
 and accompanied by nausea, \omiting, more or less complete 
 constipation, and slight fever (101° or 102 l'\). An examination 
 of the abdomen re\eals definite tenderness in the right iliac 
 reijif 1 most marked at a spot corresponding to the base of the 
 appti. lix, i.e., \\ inches inwards from the anterior superior iliac 
 spine, along a line drawn towards the umbilicus (McHmney's 
 spot), whilst the right leg is usually drawn up in order to relax 
 the tension of the abdominal muscles. A swelling, generally dull 
 on percussion, may sometimes be detected by palpation, a little 
 below MclUirney's spot, and consists of coils of intestine matted 
 together over and around the inflamed appendix. Such symptoms 
 usually last three or four days, and then, if properly treated, 
 resolve satisfactorily without any abscess formation. 
 
 This simple form of the disease is exceedingly common, and t!ie 
 prof^nosis is, on the whole, favourable. Tofft, of Copenhagen, 
 found adhesions in ♦^he neighbourhood of the appendix in 35 per 
 cent, of all bodies subjected to post-mortem examination. 
 
 (ii.) The more serious variety, commonly resulting in a localized 
 abscess, coimnences in a similar way, but the symptoms are a 
 good deal more acute. There may be an initial rigor, and the tem- 
 perature soon runs up, even to 104 F. Some general abdominal 
 j tenderness and distension follow, and there is no abatement, but 
 I rather an increase, in the symptoms at the end of the first 
 three days. Constipation is often absolute, and fa>cal vcMuiting 
 may occur. The muscles on the right side of the abdominal 
 walls are held tense and rigid, and a well-marked swelling can 
 usually be detected in the iliac fossa. Under a careful regime this 
 may disappear, and the symptoms gradually abate in their severity, 
 the temperature and the pulse falling concurrently ; but it is very 
 [common for suppuration to ensue, and such is indicated by the 
 
 57—2 
 
900 
 
 A MANUAL OF SURGERY 
 
 
 temperature persisting at its original high level, or by the pulse- 
 rate increasing in rapidity, whilst the temperature falls. Fluctua- 
 tion is rarely to be detected in the early stages, and, indeed, it is 
 bad practice to wait for it before interfering, since there is a con- 
 siderable probability that the tension within the abscess may be 
 sufficient to break down the wall of newly formed and not too 
 strong adhesions, and the general peritoneal cavity may be thus 
 infected. The abscess develops at first around the appendix, and 
 is, of course, primarily intraperitoneal. Not imfrequently it 
 bursts into the bowel, and thereby relief is gained without the 
 assistance of surgery ; some authorities, indeed, maintain that this 
 occurs in every case of the more severe type which resolves. In 
 other instances it may point externally, either through the anterior 
 abdominal wall, which becomes congested and oedematous as the 
 pus approaches the surface, or through the loin, the pus havini;; 
 invaded the retroperitoneal cellular tissue. In the latter case, it 
 is sometimes found that the abscess burrows widely up and down 
 the back of the abdomen, and may even extend behind and above 
 the liver, constituting a subphrenic abscess. In other patients, 
 and especially when the tip of the appendix lies over the brim of 
 the pelvis, the pus travels downwards and forms a collection 
 behind the rectum ; the surgeon must never omit a rectal exaraina 
 tion in appendicitis, where the temperature is of such a nature as 
 to suggest the existence of an abscess, and yet no evidence of one 
 can be found. Should it burst into the peritoneal cavity, all the 
 phenomena of perforative peritonitis supervene, probably indicated 
 by a sudden fall of temperature, and followed by increased 
 abdominal pain and distension. In other cases the patient' 
 general symptoms improve after the first outbreak ; but the focaij 
 trouble persists, and gradually a fluctuating swelling forms, whicli,] 
 on being opened, proves to be a subacute or chronic abscess 
 some peculiarity in the type of organism present is the probahl^ 
 cause of this occurrence. A faecal fistula may follow the bursting 
 or opening of any of these abscesses. 
 
 A complication likely to occur in these more severe types of tli^ 
 disease is pylephlebitis, or infective thrombosis of the branches ( 
 the portal vein in the liver. Such would be indicated by recurren 
 rigors, and possibly by pain and tenderness in the hepatic areaj 
 Necessarily it is almost invariably fatal. 
 
 (iii.) Diffuse septic peritonitis results either from the ruptuij 
 of a localized intraperitoneal abscess, and will then be preceda 
 by the symptoms outlined above, or is present from the outsa 
 being then due to primary perforation or rupture of the appendj 
 itself. The ordinary signs of acute peritonitis are developed 
 p. 852), but possibly there maybe obtainable some history of pa 
 starting in the right iliac fossa, which will give a clue to t| 
 diagnosis. 
 
 (iv.) Relapsing appendicitis is characterized by recurrent attad 
 
^OMINAL SURGERY 
 
 of wiryintf LTa\i'f,r ; . ~ " — — — — _ 9oi 
 
 of the disease %" ''" '"^'■'vidual ^v^^ZT^ ~—~~^ 
 
 '- -^o frequent i ,? '"^'^>' ^^^"^ ""ly atnr ?'" "T^ ^^« ^"'^Jert 
 
 ^^-'^^- of the %%ZT^l-'. -"e ab;ornSj S'"^' ^^^ are 
 to I>ecome fixed TtheX^Jl, ') T ""-«'" 'Hon fothT °' ^°"- 
 excessive movements of hr ""[ ^''^ P^oas niusdl o ? '^PP^ndix 
 stenosis exists serrl "^ ^""'^ "^ay ]ic.ht „Tf ' ''"'' ^^>en any 
 
 |.-'>'"dthecon;tSot""ndr^^'"^"'^ bact^Sr.^^^f '^'-- 
 tro.n severe pain of n rAi , ^'^°'" ^""e to time fhl^^ ^^ P^"^ "P 
 
 "e to an atten^pt to 'f S^"f "^^ without eVe\r'""^ ^"^^^^ 
 '''-^ve been named ' annend'^- .''^' ^^^^^sof nucu ' TT^ '^ ^^ 
 pend.x becomes totX^ n- ''"^'''' ^"^'c-' In a^^! ^"^^' ^^"acks 
 '" a mass of .;, °i'^^'>^ "^^'terated after a t^n? ^"^^^ases the ap- 
 
 •™l ri«i<I "b<lo,„i-^ ; ;\<^» °f f" 'oca|i,ed swell i^benel 't'^ ^'^ 
 
 one can never I- ^^^^^ently alike in Tl ''''"^^ observers, the 
 
 '^- Morris o;W;;^^^7^''t course ti;e ^t t 'r^'^"'^--^"^ ^^«"'e 
 
 rvhich somWimlrna^s ' ''^'•' ' ^^' ^^Sei aCf ^^ f^^'^ - as 
 
 |an explosion ^^ i P ' ^°^"etimes fiash^^ j PP®"*^^-'^ is a can 
 
 Jtohappen ' ' a"'' "°"^ °^ "« can tell in ad'""^ sometimes causes 
 
 Ipalse. PeSstent hi "^ ^^/"Perature with „ ", '^'^"^ ^'^^^^^^ 
 I Treatment.!! So mueh"h^^ '1^^^° ^ bad sign.^'^^^^^ ^^^^ of the 
 
 P^nge. and n any auth v' ^"^^^^ bas broujht I P'°P"^^>' ^^ 
 K within thrrea,m°of ?h '°"^^^^^ ^bat aptldt^tf ' ^^^'^^^ 
 l^geon should al^^y "ha e ^^ '"'^^^°"' o^- af any ^ ! ^V"°^^ 
 fe physician. Ataivn. ^ ^^^Ponsibil ty of fr/f ' ^^'^^ ^ 
 Pwhat apnear fr. k^ ."foment complicatinn? treatment with 
 
 '"ak^ey^o ^t an/ff^ T^^' - wTicrsSr^'^^P -- 
 kery is the reco4^ld ?^' °^ '^^'^"^ the patienf 1 ^^''^^""^ 
 I'sease- in Hi,o "^ ^^^" treatment for ^\^.^- -^^ America 
 
 ^JJ 
 
ii^ 
 
 902 
 
 A MANUAL OF SURGERY 
 
 gaining ground, and that surgical interference is becominj; 
 recognised as the most appropriate means of treatment in nianv 
 cases. 
 
 In the milder form of appendicitis, where the temperature does 
 not run- above 101° and the symptoms are not severe, all that is 
 required in the majority of instances is to put the patient to bed, 
 and apply fomentations locally ; the lower bowel should be emptied 
 by an enema, and if it seems likely that there is an accumulation 
 of irritating faeces within the intestine, a dose of castor-oil or of 
 calomel may be administered. A fluid, unstimulating diet is all 
 that is permitted, and should there be much vomiting, rectal 
 alimentation may be resorted to. Possibly a little morphia may 
 be given with advantage to quiet the patient and check peristalsis; 
 but the less the better, since it tends to mask symptoms. 
 
 In the graver cases the same general treatment may be insti 
 tuted to start with, but the question as to the advisabiHty 0! 
 operation will soon have to be faced. There are certain conditions 
 in which all surgeons are agreed as to operation being essential, viz., 
 where general peritonitis is present, or when an abscess is pointiiif;, 
 In the former case the only hope that exists, and even that is of 
 the slenderest description, lies in opening the abdomen (usually 
 in the middle line), flushing it out with some weak antiseptic lotion, 
 or perhaps better wiih sterilized salt solution at a temperature 
 of about 108° F., and searching for the appendix. If found, it 
 should be removed, and drainage, either by Keith's tubes or bv 
 gauze wicks, must be arranged for. In the great majority of 
 cases death will ensue in spite of all our precautions, but the 
 more recent reports certainly show better results. 
 
 When an abscess is evidently present, being indicated either bv 
 fluctuation or by a commencing cEcIema of the abdominal wall 
 there should be no hesitation in cutting down. An incision is 
 made over the oedematous spot, and deepened carefully, since the 
 tissues are probably matted together, and cut like bacon or brawn. 
 The knife or index-finger will suddenly sink into the abscess 
 cavity, and a gush of foetid pus follows. The cavity is iiem\\ 
 explored, so as to ascertain whether or not the appendix can 
 felt ; no undue force should be used, for fear of breaking down 
 adhesions and thus opening the general peritoneal sac. If the 
 appendix cannot be readily found, it is best left alone ; the abscess 
 is thoroughly irrigated, drainage is provided for, and the incision 
 partly closed. Probably the case will go on well, the discliarne 
 losing its smell about the third day, and the remaining sinus wil 
 gradually heal by granulation. Should the appendix, however, 
 present itself, it should be removed. 
 
 It is, however, in those cases where neither of tie above cor 
 ditions are manifest, and yet the symptoms, both local and general, 
 point to the fact that a lesion of considerable gravity is present, 
 that the greatest difference of opinion exists. We are quite ready 
 
ABDOMINAL SURGERY 
 
 903 
 
 •ence is becomin>^ 
 treatment in many 
 
 ne temperature does 
 ,t severe, all that i? 
 ; the patient to bed. 
 el should be emptied 
 ; is an accumulation 
 ;e of castor-oil or of 
 imulating diet is all 
 jch vomitinf^j, rectal 
 . little morphia may 
 ind check peristalsis ; 
 : symptoms, 
 atment may be insti- 
 ;o the advisability 0! 
 are certain conditions 
 Ion being essential, viz., 
 an abscess is pointing;, 
 s, and even that is of 
 the abdomen (usually 
 weak antiseptic lotion, 
 :ion at a temperature 
 ppendix. If found, it 
 y Keith's tubes or by 
 (the great majority ot 
 precautions, but the 
 
 dsults. . 
 
 tng indicated either by 
 ]f the abdominal \vall.' 
 [own. An incision i> 
 led carefully, since the 1 
 [t like bacon or brawn. 
 ,ink into the abscess | 
 The cavity is tjently 
 the appendix can be 
 [ear of breakin^^ down 
 leritoneal sac. If the 
 left alone; the abscess 
 1 for, and the incision 
 [on well, the discharge 
 e remaining sinus uillj 
 le appendix, however, 
 
 Iher of the abo\ e cor- 
 [both local and general! 
 Tble gravity is present, 
 ' We are (luite ready 
 
 to admit that in many instances conservative or medical treat- 
 ment will suffice to bring about a satisfactory result ; but this can 
 never he depended on, and, unfortunately, only too many lives 
 have been sacrificed through an unwillingness to call in a surgeon, 
 except at the last moment. Under these circumstances, even if 
 acute peritonitis has not occurred, the patient is profoundly toxa-mic 
 or exhausted by preceding suffering ; hence any operati\e measures 
 are likely to fail through the asthenic condition of the individual, 
 even if the local phenomena are such as can be efficiently dealt 
 with. Personally, we are distinctly in favour of early operation, 
 and the general rule (to which, of course, there are exceptions) 
 which we should suggest as justifiable, is that, if in spite of snitahle 
 rest and medical treatment the symptoms, both general and local, are not 
 iommencing to abate at the end of forty-eight honrs, operation should 
 he undertaken. The great advantages we would claim for this pro- 
 cedure are : (i) That the patient is not in a state of collapse from 
 toxaemia, and hence can stand the shock of an intraperitoneal 
 exploration without much risk ; (2) that the appendix itself is not 
 so likely to be tied down by a mass of firm adhe.-ions, and can 
 thus be found, isolated, and removed ; (3) that such removal is 
 most desirable in order to secure the patient against the danger of 
 recurrence ; and (4) that a much smaller incision will be needed 
 under these circumstances, and therefore there is less chance of a 
 ventral hernia subsequently forming. 
 
 Operation. — Probably the best incision is an oblique one, crossing 
 McBurney's spot, or a little below it, and parallel with Poupart's 
 ligament, somewhat similar to that for ligaturing the external iliac 
 artery (Fig. 298, D). The whole thickness of the abdominal wall 
 is freely divided, and the peritoneum, if need be, opened, so as to 
 expose the caecum. The appendix is then carefully sought for, 
 after protecting the general cavity by sponges ; it may be necessary 
 to lift the caxum from its bed in order to find it, or to separate 
 agfj;lutinated coils of intestine. In cases of difficulty, the longi- 
 tudinal bands of muscle on the ascending colon should be traced 
 downwards to the appendix, where the three sets of fibres con- 
 verj^e. An abscess usually containing extremely offensive pus 
 may be opened in this way ; but if the operation is an early one, 
 there is often no pus around the appendix, although its walls may 
 be yellow from purulent infiltration. Whenever possible, the 
 appendix should be removed ; it is first freed from adhesions, and 
 the meso-appendix ligatured. If sufficiently healthy, a formal 
 amputation, as in the chronic cases, should be undertaken, but 
 such a procedure is often impracticable. A silk thread is then 
 tied around the base about half an inch from the ca'cum, and the 
 appendix cut off; the stump is, if practicable, buried by the inser- 
 tion of two or three sutures into the serous membrane covering the 
 [cscum. Not unfrequently, however, the tissues are too much 
 j infiltrated and matted together to admit of such proceedings ; all 
 
904 
 
 A MANUAL OF SURGERY 
 
 that can then be done is to stuff the wound with long strips of 
 fjfauze, and allow it to heal by ^granulation. In the earlier more 
 favourable cases, where actual suppuration has not occurred, the 
 cavity is washed out after removal of the appendix, a draina^re- 
 tube inserted, and the abdominal wall partly closed. After the 
 operation, the patient should be fed mainly per rectum for a few 
 days, stomach -feeding being gradually commenced about the third 
 day. A small amount of opium may be needed, and, if all is goiiif. 
 well, the bowels may be opened by the use of enemata in about 
 five days if they have not already acted. 
 
 For relapsing appendicitis, radical treatment must be instituted if 
 the attacks are at all frequent, and possibly it would be justifiable 
 to lay down the rule that operation should be undertaken in the 
 (juiescent period after the second attack. If left till many attacks 
 have occurred, the task may prove very difficult, owing to the 
 number and density of the adhesions which are then present. 
 They are dealt with in the best way practicable, and the 'vppendi.x 
 thus freed is amputated. This is accomplished by diviuing the 
 serous coat by a circular incision, and retractln^., a cufT of serous 
 and muscular tissues sufficiently to enable the mucous membrane 
 to be ligatured, divided, and then covered over and buried hv 
 stitching or ligaturing the cuff of serous membrane over the end, 
 
 Sequels. — A Fcrcal Fistula may result from a perforative ap- 
 pendicitis when the abscess has been merely opened, and no 
 radical treatment undertaken at the same time, or it may follow 
 an amputation of the appendix from sloughing or yielding of tliej 
 stump. It is usually small in size, and sinuous in its course, and 
 may in many cases close of itself. Occasionally it is necessary to I 
 deal with it by laying bare the caecum in the iliac fossa, and rej 
 moving the appendix or suturing the opening. 
 
 A Ventral Hernia sometimes follows from the yielding of the I 
 cicatrix in tlie abdominal wall after an abscess has been opened 
 and drained. Both omentum and bowel, perhaps matted together! 
 and adherent to the cicatrix, are found in the protrusion. In I 
 some cases it may suffice to cover it with the concave pad of aj 
 truss, but in others operation is required ; adhesions must hej 
 divided or broken down, and often the opportunity can be takeiij 
 of removing the appendix, if this has not already been acconij 
 plished. The margins of the divided muscles are then sought foi,j 
 and united by a row of buried sutures in the ordinary way. 
 
 Affections of the Liver. 
 
 Rupture of the Liver is produced by injuries to the abdoniiniil 
 wall, such as blows, kicks, or crushes, or it may be torn by tha 
 broken end of a rib. Penetrating injuries also occur, as froiij 
 sword or dagger thrusts, and the organ may be involved in a ;;unl 
 shot wound. The resulting lesion varies considerably ; the j,dan(f 
 
id with long strips of 
 In the earlier more 
 
 has not occurred, the 
 appendix, a drainaije- 
 :ly closed. After the 
 ^ per rectum for a few 
 lenced about the third 
 ded, and, if all is goinj; 
 
 of enemata in about 
 
 : must be instituted if 
 t would be justifiable 
 be undertaken in the 
 
 left till many attacks 
 ifificult, owing to the 
 ;h are then present. 
 ble, and the 'vppendix 
 shed by diviuing the 
 ;t:r:„ a cuff of serous 
 le mucous membrane 
 
 over and buried by 
 dirane over the end, 
 Dm a perforative ap- 
 rely opened, and no 
 ime, or it may follow 
 ng or yielding of the 
 ous in its course, and 
 ally it is necessary to 
 le iliac fossa, and re 
 
 r 
 (• 
 
 the yielding of the 
 2SS has been opened' 
 haps matted together 
 
 the protrusion. In: 
 le concave pad of a 
 
 adhesions must be 
 irtunity can be taken 
 dready been acconi- 
 1 are then sought for' 
 ordinary way. 
 
 ^BDOMW^,, 5f//,r;£;,j. 
 
 ti-nes Dnx],;r?.//""'^'-'^a'-elik-elv^toh;",:.^ case so 
 
 m 
 
 oUhe larger vemn,s7^;n^^'""Y^ *"'P'«'"ent, i^'SirV"^ '''"^^■' "' 
 '""es produces aJ nos b/T^l''^-«Jy to be di • , "'l T' ''^"'"^ 
 ."'J."'-y depends, to d ef/ .^'^"'■^'^"^'"^^ation ' Th" '^""^'^ ■^'^•"e- 
 
 FU'iant, as uonn ifc- .. • ^ '^st is n/Jt-i,.,„ , ' '^'^^l the 
 
 considerable intrS I '.""''""' ''''^''' ^"^1 I en il P' '''" '^^'^^t- 
 escapes i„to t e SlI^^^^^^ ^''^'-^ ''^ 
 
 t«'-"' '"traperitmi' , '^^'' °^ the Jixer \vm °" I' "°t unlikely 
 patient, thoi^' " ^ .'^^"^'""^rhage is sure tn " ^''^ ^'^P'^^ule is 
 '-S of' b?".!; , "^^"I"^^ fro-" all the ; enomen?V '' •^^•«^^'^' ^'^e 
 «ound in the ] e ZT^'- '^^ '^^""^ be nT "h ''^?'''^^^^^'-'-^tic of 
 ''>' '-^ certain a nnm. ?^''^'"f^- '^'his procei i^ '"'''f,^' ^"^^ the 
 "•■i^e is also n^rwlil^r!"^^'^^' ^"^^ ^ ^ tomiH"'^'^ f"^"^-^ 
 
 ^'^^-^cls clownu, , '!^ ll-PP- P-t of the ah",^Zn"T; ^^^^ '^'""^ 
 ensue, but not m r-t ' . ^ ''"^^^^ is unin.m- i ' "^ ^^'"aduaJiy 
 
 '^«. ^"t. w.drti;;^^^r:;:;^^,f-e is,on;e"Se"Snr- '"^' 
 
 ^'^ '"^^ rise to a localised or il '"^'f ^'"''^^ J^acten\a find ^h • ''"" ^^' 
 '"ore severe lesions ,,i ^^"^^aJ peritonitis rv ^''''' ^^y. 
 "'■'" o'- a portion hon . T P^^-^aps the ""ft tb ''""'''^^' '" tlie 
 
 "« Iwdy n, V v/"''''Se of a hanso,,, nbTrnT' however, l,e 
 
 ™Pt"red Jiver s tT^^ f'"°"^ ^^ses, where^h i' T^'''^ '^y 
 f ouid be underfai ^'-''^^y ^^^tain, an ex^1o!n ^/'-^^nosis of 
 r""d. Possfbiv '"' ^"^ ^" '-attempt m-fdef J ^'-^^otomy 
 F half of% V ''' '"^^'-'^n incision is 'IS ^ *° '^^^'^^ ^'th the 
 °' the Jn-er often bears S brunt'"?'.^ •'•"^' ^'"^^ ^^^ 
 I ""^ or tJie mjury. Qut- 
 
9o6 
 
 A MANUAL OF SURGERY 
 
 lying ragged portions of the gland may be totally removed, prefer- 
 ably by the cautery, though one usually has to depend upon 
 plugging the wound with gauze in order to effect ha-mostasis. 
 Clean linear cuts may be sutured with silk, but tliere is con- 
 siderable difficulty in preventing the stitches from tearing out of 
 the friable hepatic tissue ; it is wise to insert all the stitches first, 
 taking up a good margin of the gland substance before atteniptin*,' 
 to tie them. Very shallow wounds which it is impossible to stitch 
 or plug satisfactorily may be seared with the cautery so as to stop 
 bleeding, and then a gauze- wick drain is placed over them, and 
 brought out of the external wound. 
 
 Abscess of the Liver is due to a variety of causes. 
 
 1. Multiple Abscesses develop in cases of pyaemia, whether the 
 emboU are carried by the hepatic artery or by the portal vein. 
 In the former case, the condition arises as a complication of 
 general pyaemia of systemic origin ; in the latter, the originatin;,' 
 focus of mischief is located in the area of distribution of the portal 
 vein — i.e., in the intestinal canal. Thus, pylephlebitis, as it is 
 termed, is not uncommonly met with in appendicitis, and some- 
 times in typhoid fever, whilst suppurating piles may also lead to it. 
 
 2. Suppurative Cholangitis is another cause of multiple abscess of 
 the liver. It consists of an inflammatory affection of the biliarv 
 ducts and passages, and is due to the spread of organisms from 
 the intestine, or occasionally from the gall-bladder after an 
 operation. The biliary ducts in the liver become enormously 
 dilated, and filled with a mixture of bile and pus which looks 
 very like yellow ochre. It is accompanied by pain over the 
 gland and the general phenomena of pyrexia, but rigors are not 
 present. The patient is not usually jaundiced, but bile may be 
 found in the urine. Treatment is of little avail, but if a diagnosis 
 can be made, and the gall-bladder has not been already incised, it 
 may relieve tension to open and drain it. 
 
 3. Hydatid cysts may suppurate, and require treatment as for 
 an abscess of the liver. 
 
 4. The more important abscesses, from a surgical standpoint, 
 are single, and these, from their size, demand operative treatment. 
 They may result from traumatism in the way stated abo\e, 01 
 may arise in connection with hydatid cysts, but more commonly 
 are of the type known as tropical abscess. The latter usually occurs 
 in individuals who have traxelled in the tropics, and 75 per cent. 
 of the cases are attributed to dysentery. The exact mode of 
 causation has not yet been fully worked out, but it seems probable 
 that they are primarily of embolic origin. They are most fre- 
 quently situated at the back of the right lobe, but, of course. 
 any part of the viscus may be involved. Though single, the 
 cavity is often loculated, indicating that several original foci 
 of suppuration have united together. Any of the ordinary 
 
ABDOMINAL SURGERY 
 
 qo7 
 
 y removed, pretVr- 
 to depend upon 
 effect ha'tiiostasis. 
 but there is con- 
 rom tearing out of 
 ,1 the stitches iirst, 
 2 before attemptin<,' 
 impossible to stilch 
 autery so as to stop 
 ;ed over them, and 
 
 .uses. 
 
 ^^emia, whether the 
 by the portal vein, 
 i a complication of 
 tter, the originatin,:,' 
 ibution of the portal 
 ylephlebitis, as it is 
 lendicitis, and sonie- 
 s may also lead to it, 
 af multiple abscess of 
 fection of the biliary 
 \ of organisms from 
 all-bladder after an 
 become enormously 
 nd pus which looks 
 d by pain over the 
 , but rigors are not 
 -^ed, but bile may he 
 ail, but if a diagnosis 
 en already incised, it 
 
 lire treatment as 
 
 for 
 
 surgical standpoint, 
 
 operative treatment, 
 ray stated above, or 
 but more commonly 
 [latter usually occurs 
 lies, and 75 per cent. 
 [The exact mode ot 
 luit it seems prohahle 
 1 They are most fre- 
 
 lobe, but, of course, 
 Though single, the 
 
 Several original foci 
 ly of the ordinary 
 
 pyogenic organisms may be found within them, and not unfre- 
 (I'uently the Bac. coli is present. In a few cases the Aiiuvba coli, an 
 organism which is often found in the bowel in dysentery, has been 
 discovered. Occasionally the pus is sterile, the causative organisms 
 having probably been disposed of, possibly as a result of the 
 chronicity of the process. The abscess wall consists of dis- 
 integrating hepatic tissue in acute cases, Init may lia\ e a fibro- 
 cicatricial wall in the more chronic forms, and in an (jld-standing 
 abscess the limiting membrane may be as tough as leather. The 
 pus is sometimes of the ordinary type, but not uncommonly reddish- 
 hrown in colour, somewhat like chocolate, and of a most nauseating 
 odour. 
 
 The Symptoms are in some instances extremely slight, the 
 patient perhaps dying of peritonitis due to its rupture without 
 its presence having ever been suspected. The individual usually 
 complains of a sense of weight and fulness in the right hypo- 
 chondrium, and in the more acute cases this may be accompanied 
 hy severe pain and localized tenderness over the whole hepatic 
 region, the pain being also referred to the right shoulder. A 
 certain amount of febrile disturbance occurs, the degree of which 
 depends on the rapidity of formation of the abscess : in the more 
 acute forms the temperature is high and rigors may be present. 
 The pyrexial phenomena are associated with loss of appetite, 
 rapid and well-marked emaciation, and perhaps a certain amount 
 of icterus, though the latter is not usually a prominent phenomenon. 
 On physical examination a more or less evident enlargement of 
 the liver will be detected, with, perhaps, a feeling of elasticity, or 
 even of fluctuation at some spot. The dulness often extends up 
 towards the thorax rather than downwards, though when the 
 abscess is situated not far from the free margin of the liver, this 
 is not the case. A doubtful diagnosis can sometimes be con- 
 firmed by the aspirator or hypodermic needle, but this should 
 not be utilized unless one is fully prepared for immediate opera- 
 tion in the case of pus being found. Manson directs that the 
 aspirator needle should be introduced in the following situations : 
 (i) In the right axillary line through the seventh or eighth costal 
 interspace ; (2) just below the ribs in the right nipple line ; 
 (3) immediately below the lung in the line drawn downwards 
 from the angle of the right scapula. 
 
 Left to itself, several distinct courses are open for the abscess 
 to follow : it may become adherent to the anterior abdominal wall 
 and point in the epigastrium, its onward passage being indicated 
 by congestion and oedema of the parietes ; it may open into the 
 peritoneal cavity, or into one of the hollow viscera, such as the 
 colon or duodenum ; or, again, it may travel upwards, burrowing 
 through the diaphragm, and either bursting into the lung, its 
 contents being expectorated, or into the pleural cavity, leading to 
 an empyema. Occasionally it remains passive as a chronic encysted 
 
90S 
 
 A MANUAL OF SURGERY 
 
 abscess, and then the walls become very thick. One of us recently 
 opened an hepatic absc .?ss which had been diagnosed by a hypo- 
 dermic needle twelve years previously, and left alone. It contained 
 about two pints of pus, and the walls were fully ^ inch thick. 
 The patient came under observation because the swelling was 
 becoming more prominent, as the result of increased intra- 
 abdominal pressure, due to pregnancy. 
 
 Treatment. — Aspiration, repeated once or twice, has been fre- 
 quently employed, but is of little value, and not a few cases 
 are on record in which septic peritonitis or pleurisy has followed 
 the introduction of the needle from the front or side respectively. 
 Experience pro\es that the usual law of treating suppuration 
 ought to be strictly obeyed, viz., that the abscess should be 
 opened and drained. If pointing in front and adherent to the 
 parietes, there is no difficulty or danger in making an incision 
 over the most prominent spot and laying the cavity open ; it is 
 then well flushed out and a drainage-tube inserted. If on dividing,') 
 the abdominal parietes it is found that the liver is not yet adherent, 
 it is perhaps best to plug the wound with sterilized or antiseptic 
 gauze so as to determine the formation of adhesions to such an 
 extent as to cut off the general peritoneal cavity ; in a few 
 days the abscess can then be opened with safety. If there is no 
 great thickness of hepatic tissue between the surface and the pus, 
 a knife may be employed for this purpose ; but if the abscess liei 
 deeply, it has been suggested that the thermo-cautery should hi 
 employed so as to prevent bleeding by sealing the mouths of th 
 hepatic veins. When it is urgently necessary to open the abscei 
 at once, even though no adhesions are present, the general seroi 
 cavity must be carefully protected by sponges or pledgets of gau 
 before letting out the pus, and the assistant must keep the pariet 
 in close contact with the hepatic tissue. It may be possible 
 insert a few stitches through the liver substance, securing it th 
 to the parietal peritoneum ; otherwise one must trust to a carefj 
 packing of the wound. After opening the abscess, it is usua 
 advisable to wash it out, and this may with advantage be repeat! 
 subsequently. 
 
 When the abscess is in its most common situation, viz., 
 back of the right lobe, it is often most satisfactory to open^^ 
 from the side ; a similar proceeding is sometimes needed when 
 abscess has been opened from the front, and does not drj^j 
 properly. An incision is rr. tde a little behind the mid-axilli 
 line through the ninth or tenth intercostal space, and a portia 
 one of the adjacent ribs removed. The pleural cavity is ope: 
 and the costal pleura stitched carefully to that portion w 
 covers the diaphragm ; it will be found that this structure 
 nearly vertical in this position, and but little difficulty is 
 perienced in shutting off the general pleural cavity. The 
 
 phragm is then divided, and not unfrequently the pentolfjg 
 
RY 
 
 {. One of us recentU 
 diagnosed by a hypo- 
 ft alone. It contained 
 re fully ^ inch thick, 
 jse the swelling was 
 of increased intra- 
 
 twice, has been fre- 
 
 and not a few cases 
 
 nleurisv has followed 
 
 _^^0^//M^ 5^*C£^^ 
 
 cavity ,s opened • f —— - _^ _ 
 
 may be fou^.7.^^^ '-^^ready for L ''^' '"^ised ; j'' '^' '^^ ^s to 
 
I 
 
 1 
 
 i : 
 
 r 
 
 910 
 
 A MANUAL OF SURGERY 
 
 yM 
 
 The surf:(eon, however, usually has to content himself with 
 incision of the cyst, turning out the scolices or daughter-cysts, and 
 inserting a large drainage-tube. If adhesions to the anterior 
 abdominal wall are present, this can be accomplished at one 
 sitting ; but if, as more commonly happens, none have been de- 
 veloped, it is wiser to undertake the operation in two stages, as 
 for hepatic abscess, so as to make certain that the general peri- 
 toneal cavity is firmly sliut off. Another advantage which follows 
 the division of the operation into two parts is that the latter pro- 
 ceeding, viz., the incision of the liver and cyst, can be undertaken 
 without an anaesthetic, and the patient is enabled to help in the 
 remo\al of the cysts by coughing when required. 
 
 Formerly aspiration and electyolysis were largely employed in the 
 treatment of this affection. It has been found, however, that 
 although a considerable percentage of cases could be cured in 
 this way (more than a half), yet that it was not unaccompanied 
 by risk of peritonitis, and that recurrence was often observed. 
 ]\loreover, some of the fluid not unfrequently leaked into the 
 peritoneal ca\ ity, and probably from the absorption of some toxic 
 product present led to urticaria, and sometimes to even graver 
 phenomena of poisoning. Electrolysis merely acts by producing' 
 a puncture of the cyst wall and consequent leakage. Both of 
 these methods should be entirely discontinued. 
 
 A suppurating hydatid cyst is dealt with according to the same 
 rules of treatment as hold good for abscess of the liver. 
 
 Tumours of the Liver are rarely primary. Secondary sarcoma 
 and carcinoma are by no means uncommon, but of course nothing; 
 can be done for them. A few cases are on record of remo\al of 
 a tumour or gumma together with a portion of the tissue of the 
 organ, but such must necessarily be a matter of such rarity that 
 we cannot spare space tc discuss it. 
 
 Affections of the Gail-Bladder and Biliary Passages. 
 
 Bupture of the Gail-Bladder results from such injuries as blows, 
 crushes, kicks, etc., whilst it may also be produced by penetrating: 
 wounds or bullets ; occasionally it may follow ulceration from 
 within, as from a large impacted gallstone. It is probable that 
 in health the gall-bladder is occupied not by bile, but by mucus. 
 and its function is apparently not to act as a bile reservoir, 
 but as a pressure gauge regulating the flow of bile into the 
 intestine. Whenever the biliary passages are stenosed or blocked, 
 bile regurgitates, as also after death, and necessarily if the bladder 
 is ruptured, bile will find it easier to escape in this direction than 
 down the long and sinuous bile-ducts, and therefore extravasation 
 into the peritoneal cavity always follows. Pure bile is sterile. 
 but if any inflammation of the biliary passages has been present. 
 organisms are sure to have found their way into the gall-bladder, 
 
ABDOMINAL SURGEfiY 
 
 on 
 
 itent himself with 
 aughter-cysts, and 
 js to the anterior 
 :omplished at one 
 one have been de- 
 1 in two stages, as 
 Lt the general peri- 
 itage which follows 
 that the latter pro- 
 can be undertaken 
 bled to help in the 
 
 ed. . , 
 
 ely employed in the 
 und, however, that 
 ; could be cured in 
 not unaccompanied 
 was often observed, 
 itly leaked into the 
 »rption of some toxic 
 imes to even graver 
 ly acts by producing 
 t leakage. Both ot 
 
 d. 
 
 .ccording to the same 
 
 the liver. 
 
 Secondary sarconiii 
 but of course nothinji 
 irecord of removal ot 
 
 of the tissue of the 
 ir of such rarity that 
 
 lary Passages. 
 
 Ich injuries as blow?, 
 liuced by penetratmi; 
 few ulceration from 
 1 It is probable that 
 bile, but by mucus, j 
 Is a bile reservoir, 
 low of bile into the 
 Istenosed or blocked, 
 \sarily if the bladder 
 fi this direction than 
 Irefore extravasation 
 Pure bile is sterile, 
 es has been present. 
 lito the gall-bladder. 
 
 and thus complications may readily ensue. If a considerable 
 .juantity of bile escapes suddenly inio the peritoneal sac, acute 
 peritonitis is certain to follow, whether organisms are present 
 or not, owing to the irritating nature of the Ihiid ; jaundice is 
 also developed from al)sorption of bile by the peritoneum, and it 
 may also be found in the urine. A more gradual escape of the 
 secretion will probably lead to the formation of a localized 
 intraperitoneal abscess or collection of fluid, associated with 
 jiumdice and probably clay-coloured stools. In a penetrating 
 wound bile and blood will escape on the surface, and septic 
 peritonitis is almost sure to follow. 
 
 The immediate Symptoms are those of shock and severe 
 hypochondriac pain, and this will be succeeded by either acute 
 peritonitis or by the formation of a localized intraperitoneal 
 swelling, together with jaundice. When the existence of such a 
 lesion is suspected, Treatment always consists in an exploratory 
 laparotomy. The fluid within the abdomen is carefully removed 
 with swabs or washed away, and the gall-bladder carefully 
 examined. Should only a small injury be found, it is perfectly 
 feasible to close it by sutures ; a gauze wick should, however, 
 he passed down to the lesion for a few days so as to provide 
 a means of drainage should leakage occur. A more serious 
 rupture will necessitate removal of the gall-bladder, or else the 
 margins of the wound may be stitched to the abdominal parietes, 
 and a biliary fistula thus produced. Should the common bile- 
 duct be entirely divided, the ends should be closed by sutures and 
 a cholecystenterostomy undertaken ; a small wound in the duct 
 may be sutured. 
 
 Cholelithiasis is the term applied to the presence in the 
 gall-bladder of Gallstones. These consist mainly of crystals of 
 cholesterine, held together by mucus and coloured by the bile 
 pigment ; they are soluble in chloroform. When first passed and 
 moist, their specific gravity is a little higher than that of water, 
 and hence when immersed in it they sink ; after drying, however, 
 they are found to float. The number present varies immensely ; 
 sometimes a single large one exists, which is more or less barrel- 
 shaped ; more frequently they are multiple, scores or hundreds 
 heing present, and are then usually faceted, and with a satin-like 
 yellowish lustre. 
 
 The Origin of gallstones is not yet fully understood, but there 
 seems no doubt that they are primarily due to an inflammatory 
 condition of the walls of the gall-bladder or biliary passages ; 
 they occur most commonly in w^omen who have suffered long 
 from dyspepsia and constipation, and may be associated with 
 cancer, either as cause or effect. In a case dealt with by one of 
 us, the origin of the trouble seems to have been the swallowing of 
 a pin many years previously, which worked its way into the gall- 
 
<;I2 
 
 A MANUAL OF SURGERY 
 
 
 bladder, set up .in inflammation which resulted in the formation 
 of calculi, and only appeared a^^ain after a successful operaticjii, 
 when sixty-six stones had been removed. 
 
 The Symptoms produced are extremely variable. Their occur 
 rence is usually preceded by dyspeptic phenomena, which ha\e 
 perhaps lasted for years, and by constipation. Some pain is com- 
 plained of in the rij^ht hypochondrium, but possibly nolhin^,' vt ry 
 serious is noted, until a physical examination reveals the disteiul'd 
 gall-bladder, which forms a tumour projectiu}^' from under co\ rr 
 of the ril)s, usually the 8th or 9th, and tendinj,' to enlarge down- 
 wards towards the und)ilicus ; it is usually firm, elastic, and 
 perhaps fluctuating; it moves with the liver during respiration, 
 and there is never intestine in front of it. Such a condition 
 often yields to medical treatment ; the diet has to be carefuliv 
 regulated, and a sufficient amount of exercise ordered. Alkaline 
 purgative medicines are usually employed, and a well-to-do patient 
 may be sent to Carlsbad to drink the waters. Possibly mass>if;e 
 may be utilised to assist in the extrusion of the calculi, and 
 drinking considerable quantities of olive-oil is also beneficial in 
 effecting the same object. 
 
 There are several complications, however, which may call for 
 surgical treatment. 
 
 1. Inflammatory phenomena connected with the gall-bladder 
 (cholecystitis) may assume considerable proportions. Acute in- 
 flammation is usually due to infection with the Bac. coli, which 
 travels up the biliary passages from the intestine. It is evi- 
 denced by acute pain and tenderness in the right hypochon- 
 drium, together with vomiting, constipation, and fever. The 
 constipation may be of such a marked character as almost to 
 amount to obstruction, and arises mainly from paralysis of the 
 neighbouring coils of gut, e.g., the duodenum and transverse 
 colon. Suppuration may follow, the abscess either bursting ex- 
 ternally or into the peritoneal cavity, or possibly into one of the 
 hollow viscera. In other cases the inflammation subsides after 
 a time, but results in a considerable development of adhesions 
 which interfere with operative proceedings, and may also de- 
 termine an attack of intestinal obstruction. Should the inflam- 
 matory mischiei '?:-.tend up the hepatic duct into the liver sub 
 stance, diffuse suppurative cholangitis will result, and may lead to a 
 fatal issue. A cjndition of chronic peritonitis is likely to follow 
 whenever calculi remain lodged in the gall-bladder for some time. 
 
 2. Biliary colic is another most distressing complication, due to 
 the onward passage of gallstones along the ducts. The pain is 
 of a most acute character, doubling the patient up, and causinj,' 
 considerable shock ; it radiates from the right side, shooting over 
 the scapular region and into the back ; it commences abruptly, 
 and continues in paroxysms accompanied by vomiting until the 
 stone is either discharged into the intestine or slips back into the 
 
ABDOMINAL SURGERY 
 
 91.1 
 
 in the formation 
 cessful operation, 
 
 .■)le. Their occur 
 niena, wliich haw 
 Some pain is com- 
 ,siblv notlnnK very 
 veal's tlu' clistencl"(l 
 
 from under co\ rr 
 f to enlarge clown- 
 ^ firm, elastic, and 
 during respiration, 
 
 Such a condition 
 
 lias to lie carefully 
 
 ordered. Alkaline 
 
 a well-to-do patient 
 
 Possibly mass.iK*^ 
 
 of the calculi, and 
 
 is also beneficial in 
 
 which may call for 
 
 nth the gall-bladder 
 portions. Acute in- 
 the Bac. coli, which 
 intestine. It is evi- 
 he right hypochon- 
 ,n, and fever. The 
 ,racter as almost to 
 •om paralysis of the 
 ,um and transverse 
 , either bursting ex 
 Issibly into one of the 
 nation subsides after 
 •pment of adhesions 
 and may also de- 
 Should the inflam- 
 It into the liver sub- 
 X, and may lead to a 
 :is is likely to follow 
 [adder for some time. 
 complication, due to 
 Iducts. The pain is 
 ient up, and causin}^ 
 It side, shooting over 
 [ommences abruptly, 
 ly vomiting until the 
 ,r slips back into the 
 
 ^'all-itiaddcr, leading to a sudden cessation of the pain ; a sense 
 of ti'uderness and discomfort may, however, persist for some time, 
 and possibly a little jaundice, owing to the swelling of the mucous 
 membrane obstructing the passage of bile. These attacks some- 
 times come on at more or less regular inter \als, and may be so 
 freiiuent as to produce great exhaustion. At the time, they should 
 be treated by the application of fomentations to the side, and the 
 administration of opium ; sometimes a large dose of olive-oil by 
 the mouth may assist in the passage of the stone. If they recur at 
 all frecjuently, t iiolecystotomy must be undertaken. 
 
 3. A gallstone does not always escape into the bowel ; it may 
 become impacted, and then gives rise to a train of tolerably charac- 
 teristic symptoms, which vary somewhat with the site of obstruc- 
 tion. If the cystic duct is blocked, there is severe pain in the 
 side, and perhaps distension of the gall-bladder with mucus, con- 
 stituting a tumour which can be felt, but there is no jaundice. If 
 the calculus is lodged at the junction of the common and hepatic 
 ducts, there will l)e intense icterus, but the gall-bladder is not 
 necessarily distended ; the liver, however, is likely to be enlarged 
 from engorgement with bile. When the stone is impacted in the 
 common bile-duct, both jaundice and distension of the gall-bladder 
 will result. Sometimes the stone lodges close to the intestinal end 
 of the duct in what is known as the ampulla of Vater; it may then 
 ulcerate through into the bowel without much difficulty. If im- 
 pacted higher up, it may also give rise to ulceration, which either 
 extends into the duodenum, thus setting the stone free, or lays 
 open the retroperitoneal cellular tissue, leading to an abscess ; or, 
 ai,'ain, it may open the peritoneal cavity, and thus cause acute 
 peritonitis. In any case, stenosis of the bile-ducts is likely to 
 follow, giving rise subsequently to permanent icterus. 
 
 Operative Treatment of Cholelithiasis. — The conditions which 
 may call for operation in the course of a case of gallstones are as 
 follows ; {a) For recurrent attacks of biliary colic, which cannot 
 be prevented by medical treatment ; {h) for persistent jaundice ; 
 (() when the gall-bladder can be felt enlarged and tender ; and 
 (if) for acute cholecystitis. 
 
 Cholecystotomy consists in opening the gall-bladder for the 
 j removal of calculi, or for purposes of drainage. It is best per- 
 formed through an incision which runs parallel to the costal 
 margin on the right side, and about an inch and a half from it, 
 [extending upwards as far as the middle line (Fig. 298, B). The 
 peritoneum is opened, and the gall-bladder sought for, any 
 adhesions present being carefully divided ; it will sometimes 
 liappen that these are so abundant as to prevent the surgeon 
 Ifrom continuing the operation, the risk of opening the bowel 
 Ijiy mistake being too great. The liver is drawn up, and the 
 [intestines are pressed downwards out of the field of operation 
 [liy means of sponges or cloths held in position by a broad re- 
 
 58 
 
I -J 
 
 I 
 
 1 'I 
 
 ■■\ 
 
 
 1 1 
 
 
 h'l 
 
 !:ii 
 
 914 
 
 .] MANUAL OF SURGERY 
 
 tractor. The gener.1l peritoneal cavity is thus carefully }^'uarc!( 
 from infection. If the gall-bladder is much distended, it 
 advisahle to tap it with a trocar and cannula, and withdraw ll 
 chief portion of its contents ; the opening is then enlarged sull 
 ciently to allow of the introduction of a scoop, or even of tl 
 linger, and by this means the calculi are removed. The bil 
 ducts are carefully examined both by the finger passed insic 
 as far as possible, and outside along their whole length, and 
 means of a long probe passed down the duct. If the interi( 
 is tolerably healthy, it is advisable to suture up the wound in tli 
 bladder, the threads not being allowed, however, to encroach o 
 the mucous mend^rane. A gau/e wick should l)e inserted dowi 
 to the iniision before stitching up the abdominal parietes, so as ii 
 proxide for drainage should there be any leakage of bile. If 
 seems undesirable to close the wound in the gall-bladder, a full 
 sized drainage-tube without any lateral openings is introduce 
 and stitched to its walls, whilst tlie margins of the wound in 
 the gall-bladder are united to the parietal peritoneum. A biliaiv 
 fistula is thus produced whicli discharges for a time ; but a> 
 soon as the obstruction to the onward passage of bile into 
 the gut is overcome, the (istida closes. Occasionally tliis does 
 not occur, and then tiie discharge of bile continues, necessitat- 
 ing further treatment. If there is sufficient evidence of tht 
 existence of bile in the motions to indicate that the passaj,'es 
 are clear, a plastic operation for the closure of the fistula may he 
 undertaken ; but if complete and permanent obstruction to the 
 passage of bile is suspected, an artificial conununication with the 
 intestine (cholecystenterostomy) should, if possible, be established. 
 
 It is often very difficult to remove a stone impacted in the 
 bile-duct. Possibly it may be extracted by a lithotomy scoop, 01 
 pushed on from within, or squeezed forwards or backwards by the 
 finger and thumb from outside; or, again, it has been broken up 
 from within by means of a needle, or crushed from without hy 
 forceps, the blades of which are guarded by indiarubber, but these 
 are bad methods to adopt. In difficult cases of this nature it is 
 better to incise the duct and extract the stone, the incision beiii},' 
 subsequently secured by Lembert's sutures, long-handled palate 
 needles being employed for the purpose. Sometimes the calcuhis 
 is lodged in the bile-duct behind the second piece of the duodenum; 
 it is then sometimes possible to push the gut aside and get at the 
 duct behind it, or in other cases it may be necessary to incise the 
 duodenum longitudinally front and back, and after extracting' thf 
 stone, to make a fistula between the duct and the posteiior wall 
 of the intestine. In other cases the stone is left alone, and in iht 
 course of a few days it may become dislodged by natural means 
 as evidenced by the passage of bile nito the intestine. 
 
 Cholecystenterostomy, or the formation of an artificial con. 
 munication between the gall-bladder and the bowel, is recjuireii 
 
•RY 
 
 thus carefully {,auirdal 
 luuch (listendccl, it is 
 lulu, and withdraw tlic 
 
 is then enlarj,'ed suffi 
 
 scoop, or even of tlic 
 i removed. The hile- 
 i finj^a-r passed inside 
 r whole len<^ah, ant! hy 
 
 duct. If the interior 
 e up the wound in the 
 )wever, to encroach on 
 ould be inserted down 
 niinal parietes, so as to 
 leakaj^'e of bile. If It 
 ;he gall-bladder, a full- 
 )peninf<s is introducd 
 gins of the wound in 
 :3eritoneuni. A biliary 
 s for a time ; but as 
 
 passage of bile inhi 
 Occasionally this dots 
 
 continues, necessitat- 
 cient evidence (;f tlit 
 .te that the passaj^'ts 
 e of the fistula may h 
 ;nt obstruction to (he 
 innumication witli tln' 
 ossible, be established, 
 itone impacted in the 
 
 a lithotomy scoop, ei 
 's or backwards by the 
 t has been broken ii[) 
 shed from without by 
 indiarubber, but these 
 ;es of this nature it is 
 )ne, the incision beinj,' 
 ., long-handled palate 
 ometimes the calculus 
 iece of the duodenum: 
 X aside and get at the 
 lecessary to incise the 
 d after extractinj,' the 
 .nd the posterior wall 
 ) left alone, and in the 
 ed by natural means, 
 intestine. 
 
 if an artificial cor. 
 
 ABDOMINAL SUKCERY 
 
 in cases wliert» i-,.. i- ~ ————__ ^'5 
 
 the common ci.,ct/f', ^''''^'^''^ «^^'"n^' ^^^d^^^T~~~~~ 
 
 Juo.le„,„„ arrT,V,„ I, i'"^"'''".] .-iLove, tlo .'""l fir '''"^ 
 JhnphyV CI L '■' '^"'"P''>' '"'Won o ;' ; • :7^'' ■"'".^tomosis 
 
 
 unci in ■ , •' , ,"" ' "I away, the ( 
 biliary | ''•^' ''' ^''^"'^^^^ '-vv of sutures. 
 
 being secured 
 
 he bowel, is reijuire 
 
 ■il 
 
 Affections of the Pancreas. 
 
 ■'■he p.-increas i« nn '""«eas. 
 
 -i^i\S^":'}=^'- • -- - - 
 
 "'"«e(l or (lamaml it. I ' , '^ '^^P'^^^icd from ;,/' ""^. ''-w cases, the 
 i''^l'ete.s is ce. hi 'o f,,/;"'"' extirpation mus Tevlr r""''^"""^-^ however 
 .placed. "• '^"""vv; u sho„Icl therefore be ct r'n"'"'' '"■ ^'"^e 
 
 , Acute Purulent Pancreatitis i . ^^ ^ '""''"•'''^ ''^"'' 
 
 l'l""s, an,l,>ftenca ;'- '^ P'-"'>alWy fro n Z,?'"!'^''"'^ "f deep 
 
 •™vl)e opened fro wh 'f '^"^ ^'''■'''^"1 p^^ "' ^''^ ca3liac 
 
 awmst infectintr *L ''•'"it, but the irreate^ " "'^ P''^"'--'-c'atic abscess 
 
 -^^^eo„ ,rS KnSr tl"^' '^^^''>'- Tl^t^nSTr '"^^ '- ^'^ 
 W'el>ra; !„ t it mi,!f i '"^'^'"'^^'e can l)e made bv ihl /"^/'^'^'i^ verse c-.lon 
 
 "ice :887 that t? ■, '^ "^'e" "Iwerved an tt.!, 7 ''"'^■ 
 
 ''■'e obstruct „ tr •■' ''f'^^'^ ^'^ pretty de^rktf '" -' "^^ny ca.ses 
 ="«cient cause < „ /'l.''"^^ has l)een proved el ,- '"" '"^''iiple -om- 
 
 ^f« fl"icl with ', Ts ; ;.^;;f;7"^;"« "'eUbsorption """/'^-'^ -f 'he epiti,elium 
 ■action andrnn/J- , '^'> ' i«:h spec fie trravitv t ''^^'"'-^ture with 1)J(,(hI 
 
 ™^", <!f eSS ;;'';r"^s'^"' '- "--^^ bile u^ 
 
 ,,|'' - a roSe,f t^S^^S:^ ->nvertin, Jt;^^; -^;^^ ^ 
 ''"''™en, immovec'd)le I^' /'"^"'^tinfr or elastic swelUn.' nl . i ^'"-''■'■'' '■■'i" ^ 
 ' ■"ach lies direc V in r' l''-'''^'^P'^ ''•^"i^^">itti.i</tl e ^,. ?''''^'' ''^^P'>^ *" the 
 ^'is;as f' ; ^.'" ''"'"it -"'f il as r-,n i, ^ • ""'^ puisation Tl,« 
 
 ■ -^'-"'^'''^"■'n^'f'tf its contents 
 5«— 2 
 
 ira 
 
A MANUAL OF SURGERY 
 
 and draining it, tlie surgeon finding his way to the cyst between the ston 
 and transverse colon. A large tube is inserted, either througli the fron 
 from the back by the side of the vertebrae. The skin around usually beer 
 irritated by the discharge, owing to a process of digestion. The progr 
 with such treatment is very good, Treves having collected fifteen cures oi 
 sixteen cases thus dealt with. 
 
 Carcinoma of the Pancreas is met with either as a primary growtii 
 secondary to a similar disease of the pylorus. It is usually of a scirrhous t 
 and may lead to distension of the stomach from pressure on and constric 
 of the pylorus, and to jaundice and ascites by involving the bile duct 
 portal vein. In one or two cases removal has been undertaken with succ 
 although an exact diagnosis was not arrived at before the operation. ! 
 comata and other tumours are very rare. 
 
 Affections of the Spleen. 
 
 o 
 
 Rupture of the Spleen occurs as a result of injury, causing great shock, f 
 in the left hypochondrium, and internal haemorrhage, usually to such an exi 
 as to prove rapidly fatal. In less severe cases the blood collects in the 
 loin, and gravitates towards the pelvis, the right loin being often kept clear 
 the position of the mesentery. Laparotomy should be r.udertaken where 
 practicable, and, if much damaged, the organ i.s r.^mo'f-d, (he splenic vesi 
 being secured by ligature ; the results of such troatni^'-.u. ^ave been most sa 
 factory. In a few cases it lias been possible to stor Ibe blee. ng by insert 
 a gauze tampon, which is removed in a few da} s. 
 
 Abscess of the Spleen may develop in the course of py..?mia, or .""(^llow 
 injur}-, especiall)- if associated with a lesion of -i neiglibourmg coil of intesti 
 The symptoms are merely those of deep suppur^t'on in the left hyprchondriu 
 and tlie abscess either finds its way externallj , or bursts into tl e ^leriton 
 cavity. It may be opened and drained with tho same precautions as fdr 
 other intraperitoneal collection of matter, and he results Intherto ohtair 
 have been encouraging. In pyaemia the disea'ie i. oftpv. fa .al before tlie 1 
 phenomena are recognised. 
 
 Floating Spleen is occasionally congenital, but n:ore commonly acqiii 
 in consequence of tight lacing, injuries, or the presence of tumours, 
 known b)' tlie existence of a moveable intra-abdominal swelling, whose sli 
 is that of the spleen, and having a notch in its anterior border; its 
 increases after meals. It may be so displaced as to lie in the right iliac foj 
 or even in the pelvis, and then has a long narrow pedicle which has, in a! 
 cases, led to its torsion and strangulation. Splenectomy was fo":.r 
 only treatment, if the displaced organ caused discomfort or pain ; it li 
 found possible, however, to fix it, and several successful cases havr ti>\\ 
 recorded. Splenopiwy, as the operation is termed, is best unde- i ken '._, 
 paring a bed for the organ outside the peritoneum in the loo-i cji!u'.'* 
 beneath the floating ribs on the left side. The spleen is then ^lipj- ' '' 
 a small hole specially made for the purpose in the perito' ?um, n.'" i 
 by stitches, whicii pass through its capsule and anchor it .o the under '^ii 
 of the diaphragm. 
 
 Tumours of the Spleen are met with either in the fcrm of a general hv 
 trophy, as in lymphadenoma or malaria, or as new crowths, such as 
 (hydatid most frequently), or secondary carcinoma or sarcoma. The spl 
 also becomes enlarged in lardaceous disease, rickets, and many of the gene 
 fevers. An enlarged spleen constitutes a swelling vvhich extends downwa 
 from the left hypochondrium towards the umbilicus, the nrtch heinj; 
 anteriorly. The condition is recognised by the constant absence of inte; 
 in front of it, by the resonant note obtained in the flank, bv 'fs mol>i!!*y'> 
 respiration, and occasionally by its increased size after meals. T'je treatmei 
 where advisable, consists either of splenectomy, or, in the rai? • 
 incision and drainage. 
 
 •it. 
 
ABDOMINAL SUKGEKY 
 
 917 
 
 •vst betsveen the stomach 
 iJer through the ront^ .,r 
 ^ around usually becm., 
 igestion. The prognos.s 
 [lected fifteen cures out C 
 
 is a primary growth ■: 
 isually of a scirrhous lyp., 
 essureonandconstv.ct,.. 
 Solving the bile duct an,; 
 ; undertaken with suexe.. 
 efore the operation. Sar- 
 
 y.causinggreatshockp ; 
 «;, usually to such an ext 
 
 fe blood collects in the Id, 
 in being often l^ept clear Iv 
 Ul be o.Jertaken wherou-r 
 r mo'-d,1 he splenic ye.H, 
 ^;;':'.°, .avebeen^mostsan- 
 i" : ;i,. blee. ug by msenms 
 
 r^r of pv.cmia, or followffl| 
 Sghboinng coil of intes,.. 
 onin the left hype choncvu.^ 
 J bu.stsintotVe,.ento>.| 
 ' Ume precautions as lov a:, 
 he^esSlts Hitherto obtan. 
 ohP'. fa ^-al before the Val 
 
 ut 
 
 ,t ir.ore commonly acqmr,; 
 presence of ^"^7'^^^ i:! 
 ^inmal swelling, -^"-f ^ 
 ;ts anterior border, its ...| 
 \o Ue in the right ihac fo^ 
 ;v pedicle ^vhich has, in H 
 
 plenectomy was to ^ .'.J 
 scomfort or pain , •-^\- . 
 .ccessful cases hav...- 
 d is best unde- , ken ... 
 m in the loo '.c^-^,:,^ 
 spleen is then ^.-pr , 
 
 ^arr;sSuSer.;n. 
 
 the fcrm of a gereraUypj 
 
 , new growths, ^v^ch as j 
 bma or sarcoma The 4^ 
 tl-Pts and manyc't t"ef,tnH 
 
 le after meals, x.- 1 
 
 ■ or. in the r''-? • 
 
 SpUnectoiuy, or extirpation of the spleen, has been undertaken for a variety 
 of conditions, and its value and position, as a surj^Mcal procedure, are now 
 pretty well established. For traumatic lesions it is both safe and justifiable. 
 I'or primary hypertrophy, and for malarial enlargement, it may be performed 
 if serious discomfort is being caused, and cannot otherwise be remedied. If 
 drainage fails to cure cysts, excision may be performed. If malignant disease 
 is diagnosed sufficiently early, the organ may be removed. Splenectomy for 
 leucocytha^mia is absolutely unjustifiable, all the cases operated on having 
 died. The opei'atioii is performed through any suitable incision of sufficient 
 length. The peritoneum having been opened, the organ is carefully examined, 
 and if extensive adhesions are present, the surgeon will be wise to desist, since 
 fatal haamorrhageisvery likely to result from any attempt to break them down. 
 if the organ is freely moveable, it is carefully drawn out of the abdomen, the 
 pedicle being isolated, and secured temporarily by pressure forceps. It is then 
 cut away, and the pedicle tied after transfixion with silk ligatures, the ends of 
 which are cut short, and returneu into the abdomen. 
 
 General Remarks on Abdominal Operations. 
 
 Before concluding this chapter, it seems desirable to add a few 
 remarks dealing generally with the subject of abdominal opera- 
 tions. Formerly they were of rare occurrence, and perhaps this 
 wiis as well, since septic peritonitis frequently followed. At the 
 present time no competent operator hesitates to open the abdomen 
 whenever required, and the death-rate from preventible causes 
 has been steadily d'minishing. The peritoneum, which formerly 
 the surgeon dreaded to touch, is now one of his best friends, if 
 properly treated. Attention to minute details is essential if good 
 results are to be obtained, and the following are a few points 
 which may prove of service to those aspiring to success in this 
 important branch of work. 
 
 The patient should be carefully pvcpavcd, when circumstances 
 permit, by regulating the diet and bowels for some days previously, 
 so that the intestinal canal may be as free from organisms as 
 possible ; a course of internal antiseptics, such as salol, calomel, 
 /inaphthol, may be advisable. If there seems a likelihood of 
 streptococcal infection, the patient may be immunized to the 
 iictioa of such organisms by the previous injection for a day or 
 [two of a sufficient dose of antistreptococcic serum, as suggested 
 jhy H. E. Durham; 10 c.c. given twice or thrice a day for two 
 three days will suffice for this purpose. No food should be 
 
 I allowed by mouth for some hours, and immediately before being 
 placed on the table the bladder should be emptied. If the pro- 
 ceedings are likely to be protracted, it is advisable to give a rectal 
 injection of warm saline solution, or of beef-tea and brandy, half 
 an hour beforehand, and possibly a hypodermic injection of 
 Strychnine (gr. -, J^). 
 
 The patient should be warmly wrapped up and protected from 
 Cold, no unnecessary exposure being allowed. Chloroform is the 
 be U anaesthetic to employ in all abdominal cases, and the more 
 complete the anaesthesia, the less the shock. Intraperitoneal 
 
A MANUAL OF SURGERY 
 
 operations are not painless, as has iieen often stated, for althouf,'!) 
 the visceral peritoneum is not acutely sensitive, yet the parietal 
 layer is, and any handling of this structure gives rise to pain aiul 
 necessarily to increased shock, if the patient is conscious. 
 
 The skin of the abdomen, the hands of the surgeon, and the 
 instruments, are rendered aseptic in the usual way, special atten- 
 tion being directed to the umbilical cicatrix. As soon, ho\ve\or, 
 as the peritoneum has been opened, all strong antiseptics must be 
 discarded, since they are likely to irritate this delicate membrane, 
 thus doing more harm than good. Warm sterilized salt solution 
 is the best fluid to employ for irrigating the serous cavity, or for 
 washing out sponges, swabs, or cloths. If sponges are employed, 
 they should be counted both before the operation, and again before 
 closing the aixlomen. 
 
 Parietal Incision. — Formerly, whenever practicable, the incision 
 was made in the middle line through the linea alba, in conse 
 quencp of the fa^.s that there is less bleeding in this situation, 
 •lil parts of the abdomen are easily accessible from it, and 
 • I ' the wound is more rapidly closed. It has been found, how 
 CA c. , that ventral hernia is a not unconmion sequela, and hencr 
 the general practice at the present time is to make one's incision 
 in any suitable place, and preferably through vascular structure> 
 such as muscle, retaining the linea alba for cases where drainat^e 
 of a septic focus has to be maintained. Even in such operation 
 as ovariotomy, where the middle line gives the best access, it i 
 wise to go through the rectus a little to one side of the centre 
 rather than through the linea alba itself. The linea semilunar 
 again, is a bad situation fo'" an incision, since 
 muscles which are inserted into its outer side 
 hernia is very likely to follow. On the other hand, care must 
 exercised not to place the incisions too near the bony niarj^nn 
 of the abdominal cavity, or subsequent manipulations may U 
 hampered by the rigidity of one side of the wound. 
 
 The muscles should be cleanly divided, and it is wise to see 
 that all bleeding is stopped before opening the peritoneum 
 Directors are best avoided, since they are very likely to wount 
 the serous membrane, and are quite unnecessary in skilled hands 
 A small hole should be first made in the peritoneum, throui;!; 
 which a blunt-nosed pair of forceps is inserted, and by littin,;: 
 these up and allowing the blades to separate slightly, a convenient 
 and safe substitute for a director is obtained. If a long incision is 
 required, the left index and middle fingers are passed througii tlii- 
 opening ; the intestines and omentum are thus kept out of tlu 
 way, the peritoneum being well raised and divided by scissors tc 
 the required extent. 
 
 The intestines musr be most carefully guarded during llu' 
 intraperitoneal portion of the operation, as if they are exposal 
 to the air, the endothelial lining is quickly shed, and a'lliesioiis 
 
 rb 
 
 the traction of ilk 
 is so great that 
 
 'if 
 
ABDOMINAL SURGERY 
 
 919 
 
 slated, for although 
 /e, yet the parietal 
 ves rise to pain ;uul 
 conscious, 
 e surgeon, and the 
 1 way, special atten- 
 As soon, however, 
 antiseptics must be 
 delicate membrane, 
 ;rilized salt solution 
 serous cavity, or for 
 on^es are employed, 
 ion, and again lu'fore 
 
 tcticable, the incision 
 
 linea alba, in conse 
 
 [ing in this situation, 
 
 :essible from it, and 
 
 as been found, how- 
 
 1 sequela, and hence 
 
 o make one's incision 
 
 ■h vascular structures 
 
 'cases where draina;4e 
 
 ,en in such operations 
 
 the best access, it is 
 
 le side of the centre 
 
 The linea semilunaris. 
 
 e the traction of the 
 
 side is so great that 
 
 r hand, care must he 
 
 ar the bony niar.i,Mns 
 
 anipulations may he 
 
 lound. 
 
 md it is wise to see 
 
 ing the peritoneum, 
 very likely to wmir.J 
 
 sary in skilled Irands. 
 peritoneum, throuiih 
 ierted, and by Httm,^ 
 slightly, a convenient 
 If a long incision is 
 e passed through this 
 thus kept out of the 
 Llivided by scissors to I 
 
 guarded during the I 
 if they art exposed 
 shed, and a'lhesioib 
 
 may form from without, whilst bacterial invasion may be predis- 
 posed to from within. A series of clotlis wrung out of warm 
 sterilized salt solution must be kept wrapped round them by the 
 assistant, and no unnecessary handling should be permitted. 
 
 Closure of the Wound.— A careful toilette of the peritoneum 
 must be undertaken before the abdomen is closed. All blood-clot 
 is removed, sponges are counted, and, if there has been any 
 extravasation of infective material, it is well to wash the site of 
 operation with sterilized salt solution at a temperature of about 
 roS'^ F., a proceeding which often assists considerably in mini- 
 mizing shock. Many different methods of closing the parietal 
 incision have been adopted, but perhaps the best consists in 
 securing the serous and muscular coats by one set of deep inter- 
 rupted stitches either of purified silk or of silkworm gut, which 
 remain buried, and then in dealing with tlie skin by means 
 of a continuous suture, which is .subsequently removed. Tliere 
 is no advantage in taking up each of the layers separately, and 
 the integrity of the abdominal cicatrix is increased by leaving all 
 the deeper stitches in situ. 
 
 Drainage is not usually called for in abdominal operations. If 
 the surgeon is careful in his manipulations, and avoids measures 
 which are likely to lead to subsequent oozing, the peritoneum 
 may be closed with safety. Where an inflammatory focus has 
 been opened, or when adhesions likely to bleed have been divided, 
 or raw surfaces left such as occur after enucleating a paro\ arian 
 cyst from the broad ligament, some means should be provided 
 whereby any considerable effusion of fluid can escape. It is 
 found that capillary drainage along a strip of gauze is the best 
 that can be employed for blood or serum. Ordinary indiarubber 
 tubes are liable to become blocked by portions of the intestine 
 protruding into the lateral openings, whilst glass tubes, such as 
 l\eith's, are unyielding, and fail to accommodate themselves to 
 the sinuosities of the regions needing drainage. Strips of aseptic 
 j^'auze are therefore inserted like lampwicks, and along these, by 
 capillary action, the effusion finds its way into the general dressing 
 phiced over the wound. Of course a certain amount of adhesive 
 inflammation follows, and therefore the wick should be as small 
 as possible, consistent with efficiency, and is changed or removed 
 at the end of forty-eight hours. Where, however, put- is to be 
 removed, ordinary drainage-tubes must be employed. 
 
 After-Treatment. — After the completion of the operation, the 
 patient is replaced in bed, with the head low. If restless and 
 irritable, a small dose of opium may be administered, but the less 
 the better, since it induces intestinal paresis, and this in turn 
 assists bacterial invasion from the gut. No food is allowed to enter 
 the stomach for twenty-four hours, although the mouth may be 
 washed out with warm water or with still lemonade, and nutrient 
 enemata administered every four or six hours. The great essential 
 
9^0 
 
 A MANUAL OF SURGERY 
 
 is to avoid vomiting, and this is best accomplished by a complete 
 temporary cessation of stomach-feeding. At the end of twenty- 
 four hours, if all is going well, a little fluid nourishment may be 
 given, and this is gradually increased. The bowels are left to 
 nature, and unless constipation persists for some days no aperiem 
 is necessary. 
 
 If peritonitis is threatening, the patient complains of abdominal 
 pain and distension, whilst flatulence and vomiting are distressinu 
 symptoms (peritonism). Under these circumstances the adminis- 
 tration of a smart saline purgative may stop the process by 
 re-establishing peristalsis, removing bacteria and their products, 
 and lessening the vascular tension. Failing this, the outlook is 
 grave, though in some cases it may be justifiable to reopen the 
 abdomen, wash out, and drain. 
 
CHAPTER XXXII. 
 
 HERNIA . 
 
 By the term Hernia is meant the protrusion of some viscus from 
 its normal situation through an opening in the walls of the cavity 
 within which it is contained. This may affect not only the 
 abdominal viscera, but also the brain and lungs, giving rise to 
 conditions which we have already described. In this chapter 
 we merely deal with hernia as met with iu connection with the 
 abdomen. 
 
 The most common Situations at which hernia occurs are those 
 spots where the parietes are weakened by the transmission of such 
 structures as the spermatic cord and round ligament (inguinal 
 hernia), or at the entrance of the crural canal, where the main 
 vessels of the leg pass under Poupart's ligament (femoral hernia), 
 or at the umbilicus (umbilical hernia). Viscera may, however, 
 protrude through the obturator foramen, sciatic notch, the 
 diaphragm, and in various other situations. 
 
 iStiology. — A great many conditions may be associated, directly 
 or indirectly, with the production of a hernia. They may, how- 
 ever, be described for practical purposes under two main headings 
 —the conge nital and the acq u ire d. 
 
 Coiiganlal Causes are rather predisposing than exciting in nature, 
 and must be looked for amongst the many malformaiions and 
 conditions of imperfect development to which the abdominal 
 parietes and contents are liable. The following are the most 
 important of these : (a) The non -obliteration of the funicular 
 process of peritoneum, which in the male precedes and accom- 
 panies the testicle on its progress downwards from the abdominal 
 cavity to the scrotum, and in the female passes along the round 
 ligament. The so-called congenital inguinal hernia res- Its from 
 this, although it must be remembered that the rupture does not 
 necessarily show itself at birth, and, indeed, may not appear till 
 after puberty, the term being therefore a misnomer. In females 
 under the age of twenty-five, hernia into the canal of Nuck, as 
 this peritoneal tube is called, is the most frequent variety met 
 
 
922 
 
 A MANUAL OF SURGERY 
 
 with, (b) The late descent of the testis, whether it finfls its w;iy 
 into the scrotum or not, is usually associated with the formation 
 of an inguinal hernia of the congenital type, or of some form ot 
 interstitial hernia. (c) Inherited weakness of the abdominal 
 muscles and parietes, with unusual patency of the rings, will 
 certainly predispose to this condition, and, moreover, there is 
 no doubt as to the tendency of hernia to run in families. 
 (d) Abnormal length of the mesentery or omentum has also 
 been looked on as a causative factor ; but, although it may 
 have some influence when other conditions are present, it can 
 per se have but little effect, (e) Congenital phimosis, by inducini,' 
 forcible acts of micturition, acts as an exciting cause. (/) Con- 
 genital apertures occur in the linea alba or linea semilunaris, 
 especially opposite one of the nmscular intersections in the rectus, 
 and through these one form of ventral hernia may develop. 
 (g) The umbilicus is sometimes imperfectly developed at birth, 
 permitting the viscera to protrude into the base of the umbilical 
 cord (congenital umbilical hernia), (h) The diaphragm is also 
 occasionally defective, allowi. g the stomach or other viscera to 
 find their way into the thoracic cavity. 
 
 Acquivcd^Qauses_. — Hernia may result from any condition which 
 tends either to weaken the abdominal parietes, or to increase the 
 intra-abdominal pressure. Thus, all violent exercise, especially 
 when of an intermittent nature and accompanied by excessive 
 straining, as in lifting heavy weights, may determine its occur- 
 rence, and the more so if the individual is forced to maintain the 
 upright position, or wears tight bands or girths round the abdomen. 
 Pregnancy stretches the abdominal walls, and parturition, by 
 inducing violent muscular contraction, may originate a rupture. 
 either through a split in the linea alba or through the crural 
 canal. Prolonged and severe bronchitis also favours the occur- 
 rence of a hernia by the increase of intra-abdominal pressure due 
 to coughing, whilst the straining to pass water in cases of enlarged 
 prostate or stricture may act in a similar manner. Chronic con- 
 stipation is a frequent factor in its production, especially if fRe 
 patient makes use of a closet with a high seat, whereby the 
 inguinal canals are left unprotected ; in uncivilized races, where 
 defecation is performed in the squatting posture, the lower part 
 of the abdomen is supported by the flexed thighs, and hernia is 
 very uncommon. Patients with weak and bulging inguinal 
 regions may with advantage use a low commode. In old and 
 weakly people, an additional cause may be found in the slipping 
 downwards of the mesenteric attachment, causing the intestines 
 to occupy the lower part of the abdomen rather than the upper, 
 so that the former bulges out over the pelvic brim. This is 
 possibly due to weakening or relaxation of the unstriped mus- 
 cular tissue which normally exists behind the peritoneum, passing 
 from the posterior abdominal wall to the base of the mesentery ; 
 
HERNIA 
 
 923 
 
 ber it finds its way 
 with the formation 
 or of some form of 
 of the abdominal 
 of the rings, will 
 moreover, there is 
 ) run in families. 
 omentum has also 
 , although it may 
 are present, it can 
 limosis, by inducini; 
 g cause. (/) Con- 
 • Hnea semilunaris, 
 ctions in the rectus, 
 ;rnia may develop. 
 developed at birth, 
 ase of the umbilical 
 : diaphragm is also 
 or other viscera to 
 
 any condition which 
 s, or to increase the 
 exercise, especially 
 Danied by excessive 
 letermine its occur- 
 ced to maintain the 
 round the abdomen, 
 nd parturition, by 
 )riginate a rupture, 
 through the crural 
 favours the occur- 
 minal pressure due 
 in cases of enlarged 
 ner. Chronic con- 
 n, especially if the 
 seat, whereby the 
 ilized races, where 
 :ure, the lower part 
 ighs, and hernia is 
 bulging inguinal 
 mode. In old and 
 nd in the slipping 
 sing the intestines 
 ler than the upper, 
 vie brim. This is 
 he unstriped mus- 
 leritoneum, passing 
 of the mesentery; 
 
 it is sometimes called the wiiscle of Tjyjiz. Obesity is also a pre- 
 disposing factor io hernia, the accumulated fat being deposited in 
 the omentum, mesentery, and subperitoneal tissue, thus increas- 
 ing the intra-abdominal tension. 
 
 Structure. — A hernia consists of a sac and its contents, the 
 sac being formed of peritoneum, perhapsThickened by additional 
 coverings, derived from the abdominal parietes, and the contents 
 being the protruded viscera. 
 
 The sac ^, or peritoneal investment of an ac(]uired hernia, is in 
 the early stages funnel-shaped, small, and thin, being deri\ed 
 from that portion of the serous membrane which normally lies 
 ver the hernial aperture. As the rupture increases in si/.e, the 
 sac becomes larger, partly as a result of the stretching of that 
 portion of the serous membrane already protruded, and partly by 
 the drawing down of fresh membrane from the neighbourhood ; 
 in the groin this is derived rather from the iliac fossa than from 
 the anterior abdominal wall. The sac is described as consisting 
 of two portions — the neck and the fundus. The neck, sometimes 
 large and open at first, gradually becomes narrowed, and is 
 generally thickened from the irritation to which it has been ex- 
 posed, either from the wearing of a truss or from the pressure of 
 the contained viscera. The body, or fundus, varies nuich in si/.e 
 and shape, and may undergo considerable alterations in structure. 
 
 (a) The sac, which is at first easily replaced, soon becomes 
 irreducible from adhesions to surrounding parts, though it can still 
 he readily emptied of its contents, (b) Inflammation may occur as 
 a result of injury or pressure, constituting a form of localized peri- 
 tonitis. If this is of a chronic type, the sac becomes thickened 
 and opaque, with dilated vessels coursing over it, as seen especially 
 in old irreducible umbilical hernia. Acute or subacute inflam- 
 niation is also met with, resulting in the formation of adhesions 
 between its inner wall and the contained viscera, or between the 
 opposite sides of the sac if no other structures interpose. Natural 
 cure of a hernia may in this way be occasionally produced by 
 adhesions forming across the neck of the sac, or by an adherent 
 plug of omentum, thus occluding the communication with the 
 peritoneal cavity. The lower portion of the sac may in a similar 
 way be shut off from the upper, either by a band of adhesions or 
 by a septum of adherent omentum ; this isolated cavity is some- 
 times the seat of a serous effusion, known as a hydrocele of a hernial 
 sac. (c) Haemorrhage into the sac wall may result from violence, 
 and will cause it to become much thickened, and even pigmented 
 and leathery in appearance. 
 
 The coverings of the sac are indurated in old-standing cases, 
 and matted together in such a manner as to render it impossible 
 to recognise the constituent parts. This is specially noticeable at 
 the neck of the sac, where their union with surrounding structures 
 is often such as to constitute an important predisposing element 
 
924 
 
 A MANUAL OF SURGERY 
 
 in the production of strangiihition. The opening through which 
 the liernia jirotrucles loses its characteristic features and shape, 
 being enlarged, more or less circular, and displaced so that an 
 obli(iue passage, such as the inguinal canal, becomes straight, the 
 internal abdominal ring lying almost immediately behind the 
 external. 
 
 Contents. — Any viscus in the abdomen may be found in the sac 
 of a hernia, except, perhaps, the pancreas; as a rule, howextr, 
 one finds only small intestine or omentum. 
 
 An cntcyocclc is the name given to a hernia containing some 
 portion of the bowel. It is at first reducible; but if the gut 
 becomes adherent, either to the sac or to some other contained 
 structure, it is rendered irreducible. It may also participate in 
 an inflammatory condition of the sac ; whilst, if irreducible, 
 obstruction may ensue from impaction of its contents, and if its 
 vessels are constricted strangulation supervenes. For a descrip- 
 tion of these conditions, see p. 945. The small intestine is much 
 more frequently involved than the large gut. The amount of 
 bowel protruded varies from a few inches to several feet. 
 
 If omentum is found in a hernial sac, the condition is known as 
 an epiplocclc. As long as it remains reducible, it is likely to retain 
 its normal texture ; but when large in amount, and especially if 
 irreducible, it becomes thickened, brawny, and matted together 
 to such an extent as almost to constitute a solid tumour ; it is 
 often the seat of an excessive deposit of fat, and in consequence 
 of this overgrowth it may become irreducible, e\en when no 
 adhesions are present. Serous cysts sometimes develop v>itliin it 
 as a result of effusion between opposed surfaces. In some cases 
 openings are found in it of sufficient size to allow the gut to pass 
 through and become strangulated. When omentum and bowel 
 are present in the same sac, the condition is known as an cntci'o- 
 epiplocele. 
 
 Much discussion has been caused by the occasional presence 
 of the cacim in a hernial sac. It was formerly supposed that this 
 viscus was only partially surrounded with peritoneum, and hence 
 it was maintained that when found in a hernial sac the peritoneal 
 investment was incomplete. It is now, however, universally 
 acknowledged that a caecum has generally a complete serous 
 covering and usually a mesentery, so that it is freely moveable ; 
 consequently it may pass into a hernial sac in the same ^\■ay as 
 any other moveable part of the intestine, and several instances are 
 on record in which it has l)een found in children to occupy the sac 
 of an inguinal hernia on the left side. On the other hand, a few 
 indisputable cases have been related in which the serous en\'elope | 
 was incomplete in a so-called ' caecocele.' 
 
 The bladder m ay be assoc iated with a -h ernial sa c in two distinct! 
 ways, "and usualFy m tlie mguinal region, {a) The fundus may I 
 be dragged downwards by the traction of the peritoneum, whenj 
 
'^ '"<'"«■>!, and, „„.il ; Consiclerahlu ir i(. |f;,,""'»';''^ ""-' sac, 
 I""'' ••' PLosphat," mi ° •"•«"■"'■"" of ;,''">■;" til" vises 
 -«" «en re/no e<l h"'S"."" '"■\v f»r„, 1 ,-'" ""5 '"splace, 
 MonalJy a .saccule of d " ?" """""«!' Hic sen,' '' ""='' ''•'■•< 
 
 -associated i^it ^Sr •'"?>' ''^-^ce"^^ '^ '"to it 
 consists merely of tCS f "''''' ''''■tahiJ tv L/,*' '^'"all hernia 
 f'-'^sue, and is devoid of "''' '""^""'^ men I.Vn,; "' /^ P^otru.sion 
 "pen if an oner 'ti^n / '"V^^'^'ar fibres Tt', ^/"^ sul.mucous 
 -; accident 'h' pp:nV°[,,e" '"''^'''^' ^^^ V unl^/f '^' ^" '>e lau 
 ■''^!tures, which shSuJd'nn "P''"'"- '""st i,e f ^'''''"- , ^^" ''^uch 
 
 e-^Posed, and cause sMhf°"-'^ '"ay form on t" '"'/'''''""' °'''^''- 
 occasionaJJv h.r ' '^"'"^^^hat reseniMJn 
 
 ^P'PJoica^, which sSuT;'/ ?^' ""^^ o^" ore of'?,''- '^^''^">^ ''^'■' 
 f^'^^'n induced by S "^'^.''^^^«"'e enia 'ed f '^ ''^PP^' 'slices 
 
 -tc™s:rS'"v"-^""''' ??^^ ^ 
 
 •1 tympanitic note on "„c ^'""""- " ">ay I e '^ " Tl """"'* "" 
 rounded, and o„ Pi^reussion, wliilsf tL f l'°*sil)le to ol)tai„ 
 
 t^^'-^ Vurg'ie?" p^rr ^'^pf ^-ci' in o^ r^iiT " ^^"- -" 
 
 '^els soft and do.HrhVT ^"^ ^^Jicky pab'l ^^ ^° dyspeptic 
 
 - ^^"ghin^.^nd frL'^^^ '-- ^^S in.pnL""^"^''^^ ^'^^ 
 . cussion. VVhen aJIm, ^^"^ '^'^''°"t a ffuri^ ? . '• °' ^^'^^ "one, 
 ^ny.sudden impuJseT '° '"''^PP^'-^r, if dfes'.o ^f ^^"^^ °" Pe'- 
 
 , ^ T^e Treatment of P'^"^^^^^ ^^"^tendin-r "he t. ^ ^'^^^ '^'^^^n 
 trusses, or rp^;^ i P "ernia, whether r. ii- ^^- 
 
 *^ ™rious tm ';]; '"^^"^ °f opemtio';'"Si5>" '' ' ^^"^ of 
 |«parate,y. ™'' "«. u wi„ be" hetteT'to^'tc^ss S'^oti: 
 
 Special Forms of »«« • 
 , Inguinal Hernia -Th . "'*" 
 
 "s way through the 
 
 n 
 
w. ^ 
 
 926 
 
 A MANUAL OF SURCERY 
 
 external ubdoininal rin^^. If it extends into tlu' scrotum, it is 
 termed complete, or scrotal ; whilst if it does not pass beyond tht- 
 external abdominal rin^s it is known as a huhonocele or incom- 
 j)lete inj^aiinal hernia. The neck is alwa} -■■ in relation with tlu; 
 deep epi<,'astric artery, and the stnirtures of the cord are eithii 
 spread out over the sac or are in close proximity to it. In the 
 early stafj;cs, the pubic s[)ine can be felt to the outer side of the 
 ne'ck of the sac ; but as it increases in size it lies o\'er the spine, 
 which can only be felt after pushing,' the hernia upwards and 
 inwards. 
 
 Two main varieties of inj^aiinal hernia are ' '^ribed, viz., the 
 obliipie and t!ie direct. 
 
 An Oblique Inguinal Hernia (Fi},'. 324) is one which passes down 
 
 Fir,. J24.— DouiiLE OKLiyuE In- 
 
 CiL'INAL HeKNIA. 
 
 Fig. 325. — Diagram of AcyuiREi) In- 
 guinal Hernia, showing Sercius 
 Sac with Intestine coming down 
 TO THE Top of the Testis. 
 
 the whole lenj^th of the inj^aiinal canal, entering at the internal 
 and emerginff at the external ubdominal rinj^ ; the deep epij^astric 
 artery is thus placed to the inner side of the neck^ During; its 
 passage through the canal every form of oblique hernia pushes 
 before it and becomes covered by structures representing the 
 various layers of the abdominal pariete^ Hence, in cutting down 
 on such a sac, the surgeon will divide, in addition to the skin and 
 subcutaneous tissues, {a) the intercoluirmar fascia, derived from 
 the transverse fibres of the external oblique which pass across the 
 external abdominal ring ; (h) the cremasteric muscle and fascia, 
 representing and extending from the internal oblique ; (c) the 
 infundibuliform fascia derived from the fascia transversalis ; and 
 {d) finally, a layer of subserous tissue varying in thickness, and 
 closely surrounding the peritoneal sac. In practice, the surgeon 
 does not attempt to recognise these diflerent coverings, the only 
 
H URN I A 
 
 927 
 
 ic scrotum, it i^ 
 pass lH!yt)tul tin- 
 mocflf or incom 
 relation witli tlu- 
 t; cord are cithn 
 ity to it. In the 
 outer side of the 
 "S over the spine, 
 nia upwards and 
 
 I ■'"'ribed, viz., the 
 
 ^^liich passes down 
 
 ^GKAM OF AcyuiREn IN- 
 
 *NIA SHOWING SERiiL'S 
 
 [testink coming down 
 OF THE Testis. 
 
 ling at the internal 
 \ the deep epif^astric 
 i neck^ Durin<^ its 
 hque hernia pushes 
 L representing the 
 Ice, in cutting down 
 lion to the skin and 
 lascia, derived from 
 lich pass across the 
 [muscle and fascia, 
 ll oblique ; {c) the 
 jtransversalis; and 
 I in thickness, and 
 lactice, the sur^^eon 
 Coverings, the only 
 
 one of importance being the cremasteric, tlie muscular (ibrt-s of 
 which are often eviik-nt, and serve as a useful laiulniark. 
 
 Tiiere are three diflereiit forms of obM(|uc iu«;uiii;il hernia, viz., 
 llie accpiired, the congenital, and the infanlile or encysted. 
 
 I. An Aajitimi Iit<,'itiiial Hernia (Fig. 325) is tnie in which the 
 sac consists i-ntireiy of peritoneum protruded from within thi,' 
 abdomen, ll gradually increases in si/e, and linds its way along 
 the cord to the scrotum. The sac usually e.\tends as far as the 
 head of the epididymis, but if of a large si/c it may overlap 
 the testicle, which lies behind it. The structures of the cord are 
 freiiuently spread out over the sac. In old-standing cases the 
 internal ring is dragged downwards and inwards, and often lies 
 jieliind the outer, and thus it may l)edif(icult,ap;>rt from operation, 
 to determine whether any particular hernia is dircci or (jbliipie. 
 
 'X\v>»«»i 
 
 Fig. J26. — Congenital Inguinal Hernia. 
 \, Vaginal variety H, fiiiiiciilar type. 
 
 2. Congenital I nguinal Hernia (Fig. 326) is due to non-closure of 
 the funicular process of peritoneum, which passes down to the 
 scrotum with the testicle, and is usually obliterated completely 
 e.\cept below, where it forms the tunica vaginalis. As already 
 mentioned, the hernia does not necessarily appear in infancy, its 
 occurrence being often delayed until puberty, or when the patient 
 has to undertake heavy work. This form of hernia is much more 
 frecjuently met with on the right side of the body, owing to the 
 tact that the right testicle descends into the scrotum at a later 
 date than the left. It is always characterized by becoming com- 
 plete at once, and its development may be immediately followed 
 In- acute strangulation. 
 
 In the majority of instances the patent funicular process is 
 continuous with the tunica vaginalis, and the protruded viscera 
 lie in contact with the testis, and somewhat obscure it; this , 
 known as a congenital vaginal hernia (Fig. 326, A). Less fre- 
 quently the funicular process is patent only as far as the head 
 i of the epididymis, being shut off from the tunica vaginalis. The 
 
928 
 
 A MANUAL OF SURGERY 
 
 MM' 
 
 hernia under such circumstances exactly resembles the acquired 
 variety, being unrecognisable from it except by the fact that it 
 
 Fig. 327. — Infantile Inguinal Hernia. 
 
 A, Prehernial condition with tunica vaginalis e.vtending upwards to inguinal 
 canal; B, hernial sac coming down behind tunica; C, sac invaginatiny 
 the tunica vaginalis. 
 
 becomes complete at once. It is termed ^congenital fiiniailar hernia 
 
 (Fig. 326, B). 
 
 In every case of congenital hernia the structures of the cord are 
 
 spread out over the sac, and more intimately adherent to it than 
 
 in the acquired form. Phimosis is usually associated with this 
 
 condition in young boys. 
 
 3. The Infantile or Encysted Hernia is one occurring in indi\'idual? 
 
 in whom the funicular process, although shut off from the ali- 
 
 dominal ca\ity above, remains patent below, communicating ^vith 
 
 the tunica vaginalis, which cavity 
 extends, in consequence, as high 
 as the inguinal canal (Fig. 327, 
 A). The hernia has a distinct 
 sac, which passes down behind 
 the open process, or invaginates 
 it (Fig. 327, B and C). It can- 
 not be recognised except on 
 operation, when the surgeon i^ 
 apt to open the tunica vaginaHs. 
 whichjihough reaching upwards, 
 does not communicate with the 
 general peritoneal cavity ; on 
 removing or displacing this, the 
 true sac of the hernia is found 
 Fig. 328.— Direct Inguinal behind it. This is not so likely 
 
 ^E'^N'A. to occur at the present day, when 
 
 the high incision is made. 
 A Direct Inguinal Hernia (Fig. 328) is one which, though passim; 
 
HERNIA 
 
 enital funicular hei'iiid 
 
 tiirough the ext I ~~ ' ~~~~— ^^^ 
 
 passin/afsoaL /^'^^^'^^^ is often ar^^^^^^^ '""^'- ^^^e 
 
 Plo. 329 
 
 ^AimoMWAL Wall „„„ w„„,.. „ 
 
 direction nam 1 1^.1 f^ v "'"vessels. 
 
 The External Direct Si?" """"'^ coverin.' the sac 
 
 59 
 
930 
 
 A MANUAL OF SURGERY 
 
 outer side of the conjoined tendon, and has a less complete cover- 
 ing of the cremaster muscle. 
 
 The Internal Direct Hernia issues from the abdomen to the 
 inner side of the obliterated hypogastric artery, rupturing or 
 pushing before it the conjoined tendon, which in such a case is 
 poorly developed. The coverings are the same as for the external 
 variety. 
 
 Interstitial Hernia is the name given to an inguinal hernia whicli 
 does not follow its usual course, but develops ir some abnormal 
 relation to the abdominal wall. Three varieties are described : 
 (a) Where a sac exists between the transversalis fascia and the 
 peritoneum {intvapavietal form, or pro -peritoneal hernia), either with 
 or without a hernia in the usual position ; in the former instance 
 one form of ' hernia en bissac ' is produced. This abnormal pocket 
 of the sac is found either betwee* +he symphysis pubis and the 
 bladder (hernia inguinalis ante-\ .calls), or it extends outwards 
 towards the iliac fossa (hernia inguinalis intra-iliaca). As no ex- 
 ternal swelling is caused by this condition, it is usually impossible 
 to recognise its existence prior to operation occasionally it is the 
 cause of a continuation of the symptoms of strangulation, when 
 apparently successful taxis has been performed, owing to the 
 strangled bowel being pushed backwards from the superficial into 
 the deeper portion of the sac. {h) An abnormal expansion or 
 bulging of the sac is situated between the internal and external 
 oblique muscles {interparietal form). A swelling is thus pro- 
 duced in the region of the inguinal canal, covered by the external 
 oblique aponeurosis, and tending to spread upwards and outwards 
 parallel with Poupart's ligament. The sac is often shaped like an 
 hour-glass, a more or less complete septum existing at the level 
 of the external abdominal ring, formed either by adhesions or by 
 a mass of adherent omentum. The usual downward course of 
 the hernial contents is thus prevented, and the sac yields laterally 
 above the site of the obstruction, and passes between the muscles. 
 {c) The hernia escapes as usual from the external abdominal rinf(, 
 but travels outward along Poupart's ligament, somewhat simu- 
 lating a femoral hernia {extraparietal variety). This form is 
 generally associated with late descent of the testis, and a con- 
 tracted state of the scrotum, so that it is easier for the hernia, 
 which is always of a congenital type, to pass into the thigh, and 
 be guided by the fascia in the direction indicated ; in a case of 
 this character operated upon a few years back, the testicle was 
 found lying close to the anterior superior iliac spine. There is no 
 difficulty in recognising such a condition. 
 
 The Signs of an inguinal hernia do not require much special 
 notice here, as we have already described the general clinical 
 features of a rupture (p. 925). In the early stages, where merely 
 a bubonocele exists, a fulness is noted in the course of the 
 inguinal canal, which increases when the patient coughs ; it is 
 
 
HERNIA 
 
 9m 
 
 complete cover- 
 abdomen to the 
 ry, rupturing or 
 in such a case is 
 .s for the external 
 
 linal hernia which 
 r some abnormal 
 es are described: 
 lis fascia and the 
 lernia), either with 
 16 former instance 
 is abnormal pocket 
 ysis pubis and the 
 extends outwards 
 -iUaca). Asnoex- 
 , usually impossible 
 ccasionally it is the 
 itrangulation, when 
 ned, owing to the 
 I the superficial into 
 Drmal expansion or 
 riternal and external 
 elling is thus pro- 
 fered by the external 
 Lards and outwards 
 loften shaped hke an 
 existing at the level 
 by adhesions or by 
 iownward course of 
 i sac yields laterally 
 letween the muscles, 
 •nal abdominal ring, 
 it somewhat simu- 
 Ity) This form is 
 /testis, and a con- 
 Lsier for the hernia, 
 into the thigh, and 
 Icated; in a case ot 
 ck, the testicle was 
 spine. There is no 
 
 equire much special 
 the general clinical 
 tages, where merejy 
 J the course ot m 
 Ivtient coughs ; it is 
 
 best detected by a finger passed through the external ring into 
 the canal. When it descends into the scrotum, the swelling 
 increases in size from above downwards, and in the obli(]ue 
 variety is continuous with the fulness in the inguinal canal. 
 The structures of the cord are masked by the presence of the 
 hernia, but the testicle is to be more or less distinctly felt at 
 the lower and back part of the swelling. When of the direct 
 variety, the cord lies to the outer side, and although the hernia 
 can be felt projecting from the external ring, it passes directly 
 backwards, and there is no fulness along the course of the canal. 
 
 Inguinal hernia is usually met with in the male sex, the oblique 
 variety being more common in the young, and the direct in elderly 
 patients. In the female sex it is rare, except in girls and young 
 nulliparous women ; in such cases it is almost always congenital, 
 passing into the labium along the canal of Nuck, but rarely 
 attaining any considerable size. 
 
 The Diagnosis of an inguinal hernia is a tolerably simple matter 
 if it is uncomplicated by any other condition ; it may, however, 
 he difficult, and in old-standing cases it is practically impossible 
 to distinguish the oblique variety from the direct. The con- 
 ditions for which it may be mistaken are best considered in two 
 fjroups. 
 
 I. Whilst the hernia is still incomplete and in the bubonocele 
 stage, it has to be distinguished fronflhe following : (a) Encysted 
 hydrocele of the cord, which is recognised by its smooth globular 
 outline and tense walls ; the impulse on coughing is less distinct, 
 and, although freely moveable in the canal, the hydrocele cannot 
 always be entirely reduced into the abdomen, whilst the charac- 
 teristic gurgle of a hernia is absent ; traction on the testis, more- 
 over, fixes the tumour, and renders it immobile. The exact 
 limitation of the upper end of the swelling, if it can be reached, is 
 very characteristic of a hydrocele, (b) A chyonic abscess originating 
 in the abdominal parietes, or within the abdomen or pelvis, will 
 sometimes point through the external abdominal ring. In such 
 cases, although there is a distinct impulse on coughing, and 
 although the swelling is reducible, it has not the definite outline 
 and characteristic sensation of a hernia, being usually soft and 
 fluctuating. Other evidences pointing to the existence of the 
 original disease may also assist in determining the nature of the 
 tumour, [c) Enlarged glands in the groin which have become 
 adherent to the external oblicjue are sometimes mistaken for a 
 hernia, owing to the fact that on coughing a distinct impulse is 
 communicated to them ; it is, however, merely heaving in nature, 
 and not expansile, whilst on digital exploration of the inguinal 
 canal the absence of a hernia may be readily ascertained, (d) A 
 testicle retained in the inguinal canal is recognised by that side of the 
 scrotum being empty, and on pressing the swelling testicular 
 sensation may be elicited. The rounded upper end of the testes 
 
 59—2 
 
 lJ 
 
M 
 
 932 
 
 A MANUAL OF SURGERY 
 
 can often be detected, (e) Tumours consisting of fat or other tissm 
 are occasionally seen in the inguinal canal, but are characterizf 
 by the strict limitation of their upper border, and usually by til 
 absence of a distinct impulse on coughing. On the other han| 
 as described elsewhere, a mass of fat simulating a lipoma 
 sometimes present, resulting from a protrusion of the subper 
 toneal tissue, a hernial sac being found embedded in its interiol 
 (/) Hamatocele of the cord is recognised by a history of injur] 
 the presence of pain and ecchymosis, and the absence of ii[ 
 impulse on coughing, whilst reduction is impracticable. 
 
 2. When the hernia extends into the scrotum, less difficulty is eN 
 perienced in its diagnosis. By examination of the cord immediatell 
 outside the external abdominal ring, all purely scrotal swellingg 
 such as hydrocele or sarcocele, are readily eliminated, since ij 
 them the cord can, in the early stages, be felt perfectly free, 
 varicocele can also be similarly recognised from an omental herni; 
 by the condition of the cord in its upper region ; moreover, i 
 
 Fig. 330. — Inguinal Truss. (Down Brothers.) 
 
 the patient is made to assume the recumbent posture, the swelling 
 disappears in each instance, but if a finger is placed firmly over 
 the inguinal canal so as to prevent any protrusion of omentum, 
 and he is then directed to stand up, the swelling immediately 
 reappears if it is venous in character. To the practised finger, 
 the diagnosis is never a matter of difficulty, since the enlarged 
 veins of a varicocele and omentum are not at all alike to the 
 touch, the veins moving freely under the finger ' like worms in a 
 bag.' When a hernia is associated with a hydrocele or sarcocele, 
 a little more care is necessary in order to distinguish between the 
 two swellings. 
 
 The Treatment of inguinal hernia is either palliative by means 
 of trusses, or radical. 
 
 Palliative Treatment. — Many different trusses have been Intro 
 duced in order to prevent the descent of a hernia. No one form 
 is capable of dealing with every case, but the truss must be 
 applied with care, so as to suit the special needs of the particular 
 patient. It is impossible to describe a tithe of the varieties which 
 have been suggested, and hence we must refer our readers to 
 special works on the subject. Suffice it to indicate the essentials 
 
HERNIA 
 
 933 
 
 of fat or other tissues 
 it are characterized 
 , and usually by the 
 
 On the other hand, 
 ulating a lipoma is 
 jion of the subpen- 
 ;dded in its interior. 
 
 a history of injury, 
 
 the absence of ivn 
 racticable. 
 , less difficulty is ex- 
 
 the cord immediately 
 3ly scrotal swellinf^s, 
 
 eliminated, since in 
 i\t perfectly free. A 
 )m an omental hernia 
 region ; moreover, if 
 
 Brothers.) 
 
 t posture, the swelliii},' 
 
 I is placed firmly over 
 
 [otrusion of omentum, 
 
 swelling immediately 
 
 the practised finger. 
 
 , since the enlarged 
 
 at all alike to the 
 
 iger ' like worms in a 
 
 Ldrocele or sarcocele, 
 
 [tinguish between the 
 
 palliative by means 
 
 \scs have been intro- 
 lernia. No one form 
 the truss must be 
 ^ds of the particular 
 If the varieties wliich 
 lefer our readers to 
 Idicate the essentials 
 
 of a good truss. It should consist of a pad kept in position over 
 
 the hernial aperture by a steel spring; it must fit the patient 
 
 accurately, resting behind on the middle piece of the sacrum, and 
 
 passing laterally midway between the crest of the ilium and the 
 
 top of the great trochanter. If the hernia is unilateral, the spring 
 
 ends on the sound side just behind the anterior superior spine, and 
 
 is prolonged anteriorly into a leather thong or cross-strap, which is 
 
 secured to a stud on the pad. To prevent it from slipping up, an 
 
 under-strap passes from the affected side close behind the anterior 
 
 superior spine along the fold of the nates to the inner side of the 
 
 thigh, being fixed finally to a 
 
 second stud on the pad. The pad 
 
 may be rounded or oval in shape, 
 
 and usually consists of soft iron 
 
 protected by cork, but polished 
 
 vulcanite, wood, or an indiarubber 
 
 cushion filled with air, water, or 
 
 glycerine have been employed 
 
 instead ; it should be well covered 
 
 with leather, and the strength of 
 
 the spring must be so adjusted 
 
 as to retain the hernia under all 
 
 conditions of strain to which it 
 
 may be subjected, but without the 
 
 use of undue force. In ordering 
 
 a truss from an instrument-maker, 
 
 the only measurement required is 
 
 that around the body, following the 
 
 line taken by the truss, and reaching in front to the symphysis 
 puhis ; it is also advisable to mention the size of the hernia, and 
 whether the opening in the abdominal parietes is large or small. 
 In the earlier cases of oblique hernia, the pad should rest rather 
 over the inguinal canal than over the external abdominal ring, 
 the object being to restore the valve-like action of the canal by 
 approximating its sides. In a direct hernia, the pad must be 
 applied direcJy over the opening. If such an apparatus is 
 properly adjusted and continuously worn, a cure is sometimes 
 estahUshed in the course of a year or two, and in cases of con- 
 genital hernia in children a cure may be confidently expected if 
 the mother or attendants of the child coriscientiously carry out 
 the necessary details. If the hernia is once allowed to slip down, 
 even after six or twelve months' treatment, all the previous good 
 will have been undone. 
 
 In infants, an efficient support is afforded by a skein of wool 
 (specially known as ' fingering '), divided at one end, so that when 
 placed round the body the cut ends of the skein can be passed 
 through the loop, forming a knot over the inguinal canal, which 
 acts as the pad of a truss. The cut ends are now passed under the 
 
 Fig. 331. — Wool Truss for 
 Treatment of Hernia in 
 Children. 
 
934 
 
 A MANUAL OF SURGERY 
 
 perineum, and tied to the transverse portion behind (^"'g. 33 1| 
 This apparatus is changed night and morning when the child 
 bathed, and also, if need be, at shorter intervals, the niolliJ 
 being previously instructed as to how to support the hernj 
 whilst the apparatus is being removed. In addition to such tru| 
 pressure, it is important to remove all causes of intra-abdominJ 
 tension, as by circumcision, where phimo is is present, or Ij 
 regulating the bowels. 
 'sj The Radical Cure of inguinal hernia is an operation to whic| 
 • much attention has been directed of late years, since its value w; 
 brought prominently before the profession by the late Professi 
 John Wood and others. It is very largely employed at tlil 
 present day, though there are still surgeons who only advocatJ 
 its use under exceptional circumstances, appealing to the frequenl 
 recurrence after operation as an argument against its adoption 
 Whilst fully admitting that recurrences are more frequent thai 
 they should be, we look on them as either being due to an erroi 
 of judgment in the selection of the cases for operation, or as 
 resulting from imperfect technique, or from inefficient after-treat- 
 ment. 
 
 The selection of cases for an operation of this type, which is not 
 an essential, but only a desirable means of treatment (or, as it is 
 sometimes termed, an operation dc complaisance), is a matter reciuii- 
 ing considerable judgment and discrimination. In an individual 
 whose occupation does not subject him to heavy strain or exer- 
 tion, and who possesses a hernia which, under ordinary circum- 
 stances, is easily commanded by a suitably applied truss, no 
 operation is absolutely necessary ; although one is perfectly 
 justified in urging him to submit to it, since he will be thereby 
 freed from the irksomeness of wearing a truss, and from the risks 
 of possible strangulation. If, however, the subject is a labouring 
 man, exposed to injury and strain, and who may find it difficult 
 to provide a suitable series of trusses, the operation should always 
 be undertaken unless distinctly contra-indicated (i) by a general 
 inherited weakness of the abdominal muscles ; (2) by a relaxed 
 and atonic condition of the abdominal parietes, which is so 
 commonly associated in elderly people with slipping downwards 
 of the mesenteric attachment of the intestine (enteroptosis), so 
 that the hypogastrium obviously bulges ; or (3) by such con- 
 stitutional disease as precludes all unnecessary operative inter- 
 ference. (4) Again, in cases of extensive irreducible hernia, the 
 return of large masses of intestine which have lain for years in 
 the hernial sac so increases the intra-abdominal tension as tre 
 quently to determine recurrence locally or elsewhere, and therefore 
 operative interference, though very desirable owing to the great 
 risk of strangulation incurred by the patient, is often followed by 
 very bad results. 
 
 As to the best age at which to operate, statistics definitely 
 
1 behind (^'g. 33 M- 
 ig when the child is 
 itervals, the mother 
 support the hernia 
 ddition to such truss 
 s of intra-abdominal 
 is is present, or i)y 
 
 1 operation to which 
 s, since its value was 
 )y the late Professor 
 ;ly employed at the 
 5 who only advocate 
 baling to the frequent 
 against its adoption. 
 ; more frequent than 
 )eing due to an error 
 for operation, or as 
 inefficient after-treat 
 
 lis type, which is not 
 treatment (or, as it is 
 e), is a matter reciuir- 
 on. In an individual 
 heavy strain or exer- 
 der ordinary circum 
 y applied truss, no 
 gh one is perfectly 
 e he will be thereby 
 s, and from the risks 
 ubject is a labouring 
 may find it difficult 
 ration should always 
 fited (i) by a general 
 !s; (2) by a relaxed 
 .rietes, which is so 
 slipping downwards 
 ne (enteroptosis), so 
 ,r (3) by such con- 
 ary operative inter- 
 educible hernia, the 
 ,ve lain for years in 
 iinai tension as fre- 
 Iwhere, and therefore 
 owing to the great 
 is often followed by 
 
 statistics definitely 
 
 HERNIA 
 
 935 
 
 prove that it is essentially an operation of adolescence, the results 
 gradually getting worse as the age increases. Young children 
 should not be touched until careful truss pressure for a year has 
 failed, or unless it is impossible to keep up the hernia by such 
 treatment. In any case it is perhaps wiser to delay it until the 
 age of three, owing to the risk of infection of the wound from the 
 constant saturation of the dressings with urine. 
 
 Very many different operations have been described and 
 practised by various surgeons; in all probability some of them 
 are unnecessarily complicated, and can only be briefly alluded to. 
 The plan we now employ in almost all cases is known as Bassiiii's 
 opcvation ; it appears to us as one of the most scientific of all those 
 that have been suggested, since it reproduces more accurately 
 than any other the normal structure of the parts. The instruments 
 required are scalpels, forcipressure forceps, dissecting forceps, re- 
 tractors, transfixion needle, curved hernia needles, and scissors. 
 Tlie operation may be described in the following stages : (i) The 
 pubic regi on having been pre\'iously shaved and t horougHTy 
 prrrified TaiT incision is mad e in the directi on of the JngTunal canal 
 and cord,_ about 2^ mches in length, its centre being a little above 
 the external abdominal ring. This is carried through the skin and 
 subcutaneous tissues until the structures of the cord are reached, 
 the superficial external pudic artery being necessarily divided en 
 route ; the pillars of the ring are clearly defined, and the external 
 oblique aponeurosis slit up for about | inch beyond the apex of 
 the ring in the direction of the cord. (2) The sac has now to be 
 identified ; if the hernia is one of old standing, or contains adherent 
 omentum or intestine, it is easily recognised ; but if it is thin, 
 empty, and of recent formation, and especially in the case of a 
 bubonocele, its identification may be a matter of some difficulty. 
 The structures of the cord are lifted up out of the wound, spread 
 out over the fingers, the coverings divided, and the white convex 
 border of the fundus of the sac looked for. It is sometimes 
 necessary to induce vomiting by titillation of the fauces, in order 
 to cause the hernia to protrude, particularly when it is of the 
 direct type. {i\ If the sac is emntv . it is freed from its connection 
 with the structures of the cord without opening it, and isolated as 
 far as or beyond the internal abdominal ring, as indicated by a 
 collar of fatty subperitoneal tissue surrounding the neck. If the 
 hernia is irreducible, the sac is laid open, its contents freed from 
 adhesions, and the intestine returned into the abdomen, whilst 
 omental tissue is removed, and the stump replaced. The greatest 
 gentleness must be employed in dealing with the intestines ; if a 
 considerable amount is present, it must be surrounded by a cloth 
 wrung out of warm sterilized salt solution. Adhesions are care- 
 fully divided either by the finger or between ligatures ; if closely 
 adherent to the sac, it may be necessary to leave a small portion 
 of this attached to the gut, which is then returned. Omentum, 
 
936 
 
 A MANUAL OF SURGERY 
 
 whether adherent or not, should he removed, as the elongated 
 fringes are very liable to contract adhesions to the abdominal 
 parietes, and subsequently produce mischief. In removing' 
 omentum, it is not advisable to encircle a large mass with 
 single ligature, as the vessels are less securely commanded, and 
 a pocket or pucker may be produced, possibly leading to interna 
 strangulation at a later date. Small portions, including one or 
 
 
 Fig. 332. — Bassini's Operation for Radical Cure of Hernia. 
 
 A and A^, Spencer Wells's forceps, holding aside the divided portions of external 
 oblique aponeurosis ; B, arched fibres of internal oblique, continuous on 
 the inner side with the conjoined tendon; C, hook or retractor hokling 
 aside the spermatic cord ; D,D,D,D, deep silk stitches p'assed beT\ind the 
 cord through the deepest fibres of Poupart's ligament on the outer side, 
 and conjoined tendon on the inner^ E, neck of the hernial sac ligatured. 
 (The cutaneous incision and the incision through the external oblique are 
 here shown much greater than would actuallj' be undertaken, in order to 
 demonstrate clearly the deeper parts.) 
 
 more of the larger vessels, should be taken up one after another, 
 and tied separately and with advantage at different levels, so as 
 to assist in the subsequent return of the stump. The protruded 
 mass is then cut away below the ligatures, and the stump 
 replaced after seeing that no bleeding point remains unse- 
 cured. The sac, being now emptied, is isolated as far as the 
 internal ring. (4) The neck is then transfixed as high as 
 possible, and ligatured with sterilized silk, and the sac cut off 
 below the ligature, the stump retracting well above the internal 
 
HERNIA 
 
 937 
 
 as the elongated 
 to the abdominal 
 if. In removin'^ 
 arge mass with a 
 y commanded, and 
 leading to internal 
 ;, including one or 
 
 Cure of Hernia. 
 Ivided portions of external 
 ll oblique, continuous on 
 took or retractor holding 
 Vtches passed Dehind the 
 fciment on the outer side, 
 The hernial sac ligatured 
 ^ the external oblique are 
 undertaken, in order to 
 
 ap one after another, 
 iifferent levels, so as 
 Imp. The protruded 
 Tes, and the stump 
 {)oint remains unse- 
 lolated as far as the 
 Insftxed as high as 
 land the sac cut ot 
 ll above the internal 
 
 ring. (5) The tissues of the cord are carefully examined, and any 
 varicose spermatic veins removed, as also any downgrowths of the 
 subperitoneal fat and possibly portions of the creinaster. (6) The 
 opening in the abdominal parietes is closed by a row of sutures 
 passing through the arched fibres of the internal oblicjue and 
 transversalis muscles, or through the conjoined tendon on the 
 inner side, and through Poupart's ligament on the outer, the 
 stitches being all placed behind the cord. To effect this, the 
 cord is drawn up out of the wound and held aside by a retractor 
 (iMg. 332, C), whilst the divided margins of the external obliiiue 
 aponeurosis are grasped by pressure forceps (A, A^). G entle 
 traction on the lower pair enables the deepest portion of Poupart's 
 ligament to be defined and seen. The stitches must secure a good 
 hold of the tissues, but should not include the external obliciue 
 aponeurosis, and when dealing with Poupart's ligament the 
 proximity of the iliac vessels must not be forgotten. It is wise 
 to utilize interrupted stitches and not looped sutures as recom- 
 mended by some authorities, since the latter tend to strangle the 
 portions of tissue included in their grasp. The opening in the 
 ahdominal parietes is in this way commanded as far down as the 
 pubic spine, but sufficient room must be left at the upper end for 
 the passage of the cord, undue constriction of which would cause 
 atrophy of the testis ; sometimes it is desirable to introduce a 
 stitch above the cord, in order to command a spot where recur- 
 rence is not uncommon. When the three or four needful stitches 
 have been introduced and tightened, the cord is replaced, and the 
 divided portions of the external oblique are sutured together over 
 it. (7) The wound in the skin is closed by a continuous suture, 
 and usually no drainage-tube is needed. ; 
 
 After-Treatment. — The patient is placed in bed with the head 
 low, and the knees slightly flexed over a pillow. The wound, 
 as a rule, does not require dressing for seven or eight days, when, 
 on removal of the stitches, it should be found completely healed, 
 if asepsis has been maintained. The patient should turn to the 
 opposite side in order to pass water, and the greatest care must 
 be taken to prevent the dressing becoming soiled. Occasionally 
 retention of urine follows this operation, necessitating the use of 
 a catheter. In the case of children, it is well to seal the parts 
 down by a collodion dressing, and by preference the collodion 
 should be of the flexile type, but with the guncotton replaced 
 by celloidin [celloidin collodion). 
 
 The recumbent posture should be maintained for three weeks, 
 and nothing but the slightest work undertaken for at least six 
 weeks, and no violent effort until six months after the operation. 
 Under such circumstances the use of a truss is unnecessary, and, 
 indeed, we consider that it is undesirable, as its pressure is liable 
 to produce atrophy of the newly-formed cicatricial tissue. When, 
 however, the abdominal walls are congenitally weak, or if, unfor- 
 
II 
 
 i 
 ] 
 
 r 
 
 938 
 
 A MANUAL OF SURGERY* 
 
 tunately, the wound has suppurated, the deep stitches coniiii 
 away, it is advisable to use a hght truss for a time. 
 
 The treatment of con^cuital hernia differs in no particular froi 
 that already described, except that the sac must he divided belo 
 as well as abo\e, and the lower opening secured by suture ( 
 ligature, so as to close the cavity of the tunica vaginalis. Tli 
 operation often proves difficult owing to the intimate adhesioi 
 lietween the sac and the structures of the cord, and it is souk 
 times impracticable to completely isolate the neck of the sac. 1 
 many cases the old-fashioned Mitchell Banks' operation suffict 
 for a congenital hernia. 
 
 The other operations which require to be mentioned are a 
 follows : 
 
 (a) In Mitchell Banks' Operation, the sac is isolated and remove 
 as high as the internal ring without any division of the externc 
 oblique. Stitches are then introduced through the conjoine 
 tendon and Poupart's ligament respectively, including the extern; 
 oblique in their grasp, and passing in front of the cord. It i 
 obvious that by such a plan the deep ring cannot be closed a 
 accurately as in Bassini's operation. It may suffice, however, i 
 a few of the simpler congenital cases. 
 
 {b) Ball's Operation consists in freeing the peritoneum on th 
 inner aspect of the internal abdominal ring, and then the sac 
 after being isolated, is twisted into a tense cord, so as to thro\ 
 it into a series of folds, thereby producing a prominence internall 
 rather than an infundibuliform depression. To prevent untwisi 
 ing, a ligature is tied around it as high as possible, and it is als 
 transfixed below the ligature by a thread, the ends of whi -h ar 
 passed through the abdominal parietes. 
 
 {c) In what is known as Barker's Operation the neck of the sa 
 is isolated, ligatured, and divided, the fundus being left in sith 
 whilst the thread used in tying the neck is employed as tli^ 
 first suture to close the deep part of the canal ; by this mean 
 it is hoped that the neck of the sac will be displaced, an( 
 hence more satisfactorily occluded. It is very doubtful, however 
 whether this really occurs. 
 
 (d) MacEwen's Method consists in opening up the inguinal cana 
 by dividing the aponeurosis of the external oblique, freeing tin 
 under surface of the abdominal parietes for some distance arounc 
 the internal abdominal ring, and in placing therein as a pat 
 across the internal opening of the canal the sac, which has been 
 previously isolated and threaded through with silk in such a way 
 as to throw it into folds. The silk thread is then passed by 
 means of a needle through the abdominal parietes on either side, 
 and fixed by traversing the aponeurosis of the external oblique 
 once or twice. The canal is subsequently closed by looped 
 sutures, which are passed in such a way as to draw up Poupart's 
 ligament over the arched fibres of the internal oblique. 
 
: deep stitches coniiriL; 
 r a time. 
 
 in no particular from 
 must he divided below 
 
 secured by suture or 
 tunica vaginalis. Tiic 
 the intimate adhesions 
 B cord, and it is some- 
 lie neck of the sac. In 
 mks' operation suffices 
 
 ) be mentioned are as 
 
 s isolated and removed 
 livision of the external 
 hrough the conjoined 
 , including the external 
 vit of the cord. It is 
 Lj cannot be closed as 
 lay suffice, however, in 
 
 he peritoneum on the 
 ng, and then the sac. 
 e cord, so as to throw 
 , prominence internally 
 . To prevent untwist- 
 possible, and it is also 
 the ends of whi -h art 
 
 'on the neck of the sac 
 ndus being left in situ. 
 k is employed as the 
 canal ; by this means 
 vill be displaced, and 
 'ery doubtful, howe\ er, 
 
 g up the inguinal canal 
 al oblique, freeing the 
 r some distance aronnd 
 :ing therein as a pad 
 le sac, which has been 
 nth silk in such a way 
 ad is then passed byj 
 parietes on either side, i 
 if the external oblique 
 itly closed by looped 
 3 to draw up Poupart's j 
 nal oblique. 
 
 HERNIA 
 
 '^"twards throuL^h thi^ ',"^'.'^"'' ^''*' ^-"'d (lisp) ' 'V ^^'-' °"^^''" 
 P'^^rces the ahdomin "'^'^"'"^^ ^^^ that at U , ', /''''''^'■^■^ '»"'' 
 
 treatment, ^he m, ° . f'^- "'^'^^^'' ^^"^ in mr %'f^"''^'""/^^' ^^^^^l 
 
 recurrencp ic ^ 7- f^^^^'^t- Another not .,„ '-"^^-^t^ti peritonea 
 stitches are ^.^''"."^"^^""'"''^tion of he u^ "V"°" "^^''^'^ of 
 
 as nmSomen?,! ,'"'■'■""='' • '«"■:•= the n no hn "■■, ' ""'' """^ 
 around, either 1,1 ,? ^P""'"g or tearinf; of the ten,l;l Relapses 
 
 Femoral Hernia —A f i 
 
 III ' °" ''^^^"nt of the £r?eTflr ; "'' '"°^^ commonly 
 
 ■nner compartment of the ?e„,ori sS^Jt'h ?"" '=™^'""'^>' 
 
 i'Heath, a space usually 
 
940 
 
 A MANUAL OF SURGERY 
 
 (II 
 
 F"^' JJ3.— Femoral Hkunia. 
 
 occupied l>y fatty cellular tissue, lyiuj)hatic vessels, and perhap 
 a lymphatic j^dand. It is about \ inch in length anteriorly, aiu 
 i^ inches along its posterior wall ; it is closed above by 
 thickened portion of the subserous cellular tissue known as tht 
 septum crurale, and its lower end is formed by the sapheuou: 
 opening, and closed by the cribriform fascia. Hence a femora 
 hernia, as it passes downwards, receives the following coverings 
 
 (rt)_peritoneum ; (/>) subserous cc 
 lular tissue, including tKe septui 
 crurale, a layer sometimes know 
 as the fascia propria, and occa 
 siotially represented by a tliir 
 fatty envelope ; {c) the anteri 
 layer of the femoral sheath, deri\ c 
 from the fascia transversalis ; (d] 
 cribriform fascia ; {e) subcutaneous 
 tissue; and (/)skin. In its passaj^^e 
 it is situated inmiediately intern, 
 to the femoral vein, and pressur 
 upon this may produce oedema of 
 the leg, whilst Gimbernat's liga 
 ment lies to the inner side of the 
 neck of the sac. The spermatic cord or round ligament passes 
 just above and internal to it, but on a superficial plane, whilst 
 the epigastric artery is not very far from the outer side of the 
 neck. Occasionally the obturator artery arises from this latter 
 vessel (once in three and a half subjects) ; it either passes to the 
 inner side of the neck of the sac along the border of Gimbernat's 
 ligament (once in seventy-five times), but more commonly runs 
 between the neck and the femoral vein. When once it has 
 emerged from the saphenous opening, a femoral hernia tends to 
 pass upwards and outwards along Poupart's ligament towards the 
 anterior superior iliac spine, being guided by the attachment of the 
 deep layer of the superficial fascia; when of large size, it may 
 extend considerably above the level of Poupart's ligament. 
 I'^emoral hernias are less likely to contain omentum than the 
 inguinal variety : a portion of the ileum is most often present, but 
 occasionally the ovary or Fallopian tube may be found in the sac, 
 T.he Signs of a femoral hernia are very charact(!ristic. X 
 swelling with an impulse on coughing, and nidit ? 'essi 'ducible, 
 forms on the inner side of the thigh, in' < or anenurt of com- 
 munication with the abdomen 1' i.'ie inner side of the 
 femoral vessels, and to the outer i the pubii pine, which 
 can always be felt (Fig. 333). T - is usually but little diffi- 
 culty in making a diagnosis, althougi, occ :.ionally considerahle 
 care is needed, and especially in distinguishing it from the follow- 
 ing conditions : {a) From inguinal hernia, which is more conim 
 in young males, its neck occupying the inguinal canal, and ti c 
 
HERNIA 
 
 94 « 
 
 jsscls, Jincl perhaps 
 j;th anteriorly, Juul 
 losed above by :i 
 isue known as the 
 by the saphenous 
 Hence a fenioriil 
 jllowinf,' coverinf;s -. 
 ; (ft) subserous cil 
 eluding tli'e septum 
 r sometimes known 
 
 propria* ^"'^ °^9^* 
 sented by a thick 
 e; ((•) the anterior 
 noral sheath, derived 
 ia transversalis ; (</) 
 :ia ; (f) subcutaneous 
 ■)skin. In its passa^^e 
 immediately internal 
 al vein, and pressure 
 ay produce oedema of 
 ist Gimbernat's \'v^<^- 
 the inner side of llie 
 Dund ligaiuent passes 
 perficial plane, whilst 
 the outer side of the 
 irises from this latter 
 ,it either passes to the 
 l)order of Gimbernat's 
 more commonly runs 
 When once it has 
 ^loral hernia tends lo 
 ligament towards the 
 the attachment of the 
 of large size, it may 
 Poupart's ligament, 
 omentum than the 
 .ost often present, hut 
 y be found in the sac 
 [y characteristic. A 
 V i-ssreducihle, 
 
 . or ciP'Mure of com- 
 le inner side of the 
 e pubi' pine, which 
 -rally but little chfti- 
 .umally considerable 
 In- it from the follo\v- 
 lich is more comm 
 ;uinal canal, and t: . 
 
 saphenous opening being free ; whilst it is also aiioveand int«Tnal 
 to the pubic spine, and above Poupart's ligament at its point of 
 exit ; it tends to pass downwards into the scrotum, or in females 
 into the labium. Femoral hernia, on the otiier hand, usually (but 
 not invariably) occurs in women over twenty li\t! years of age; 
 the inguinal canal is free, whilst the neck is in the situation of the 
 crural canal, below and external to the pubic spine, and below 
 Poupart's ligament; moreover, it travels upwards and outwards, 
 the labium being unaffected, {h) An enliugcd lymphatic ^land o\er 
 the saphenous opening may simulate this condition very closely; 
 but the absence of impulse on coughing and of the usual hernial 
 signs is generally sufficient to distinguish it; when, however, tht; 
 hernia is purely omental and irreducible, the impulse is so sli^^htly 
 marked that correct diagnosis in a stout woman is often difficult 
 without an exploratory incision, {c) A small lipoma in the canal 
 somewhat resembles a hernia, but the limitation of the tumour, 
 its greater mobility, and the absence of an impulse on coughing, 
 siiould suffice to prevent any mistake. (d) A psoas ahscess 
 pointing at the saphenous opening resembles a hernia in the 
 existence of a reducible swelling with an expansile impulse on 
 coughing. It is distinguished from it by the facts tliat there is no 
 gurgle on reduction ; that the abscess, as it passes under Poupart's 
 ligament, lies to the outer side of rmd behind the vessels; and that 
 distinct fluctuation occurs between the swelling in the saphenous 
 opening and the tumour, which can always be felt in the iliac 
 fossa; the characteristic signs of spinal caries are also usually 
 present, (c) In varix of the saphetia, if a pouch or so-called ampulla 
 forms close to its entrance into the femoral vein, it may be mis- 
 taken for a femoral hernia on account of the marked impulse on 
 coughing, and because the swelling disappears on assuming the 
 recumbent posture. It is, hovt'evefj, usually associated with th^ 
 signs of varix below, an3 by the fact tliat, although pressure is 
 made over the upper part of the crural canal after the vein has 
 been emptied, the swelling regains its ordinary size when the 
 patient stands up. 
 
 Treatment. — When reducible and of small size, a femoral hernia 
 may be treated by the"use of a tmss; sirmldr' m nature to that 
 used for an inguinal hernia, except that the pad extends some- 
 what lower, so as to maintain pressure along the course of the 
 canal. A badly fitting truss may compress the femoral vein, and 
 lead to oedema of the leg. 
 
 Operative Treatment is undertaken either for tlie relief of 
 strangulation, or, if a radical cure is desired, as an operation de 
 complaisance. The remarks already made as regards the cure of 
 inguinal hernia, and the general principles there enunciated, apply 
 also to this variety. Two main methods of operating are em- 
 ployed : (a) The sac is exposed by a \ertical incision along the 
 course of the crural canal, emptied of its contents by reduction of 
 
942 
 
 A MANUAL OF SURGERY 
 
 intestin'^ and removal or reduction of omentum, and cut away 
 after transfixiuL' and tyinL' the neck. The deep ring is then coni- 
 manded by a suture passed vertical.ljjbetween jhe fasc ia oyer th e 
 pectineus and'lhe inner' end of PouparFs ligament"; "^h is 'niusT, 
 Tiowever, ■ not be tied too tightly, for fear of constricting the 
 femoral vein, (b) Watson Cheyne recommends that a portion 
 of the pectineus muscle should be dissected up, and fixed in the 
 crural canal by means of sutures ; and he claims thereby to have 
 had very satisfactory results. The same precautions as to after- 
 treatment must be adopted as in inguinal hernia. 
 
 Umbilical Hernia. — Three different forms of umbilical hernia 
 are described. 
 
 1. Congenital Umbilical Hernia, or Exomphalos, is an exceed- 
 ingly rare condition, due to imperfect closure of the abdominal 
 walls, as a result of which the intestine is not entirely withdrawn 
 into the abdomen at birth, but is found in a cavity at the base of 
 the umbilical cord, which is bulbous and enlarged. If the con- 
 dition is overlooked, it may be included in the ligature with which 
 the cord is tied, and fatal strangulation, or at the best a faecal 
 fistula, will result. If left untreated until the cord has separated, 
 the peritoneal cavity will be laid open, and septic peritonitis 
 ensue. The only treatment is immediate laparotomy, reduction 
 of the gut, and closure of the umbilical opening by sutures. 
 
 2. The Umbilical Hernia of Infants and Young People, or, as it 
 is commonly called, 'starting of the navel,' is due to weakness of 
 the umbilical cicatrix, which yields before the intra-abdominal 
 pressure. Its occurrence is often determined by chronic consti- 
 pation or phimosis, necessitating continual straining in order to 
 evacuate the bowels or bladder. The condition rarely persists 
 till adult life is reached, and it is readily amenable to treatment. 
 This consists in regulating the bowels, the performance of cir- 
 cumcision, if necessary, whilst the local condition is dealt with 
 by a pad and strapping applied to the umbilicus. In persistent 
 cases it may be necessary to lay the sac open and remove it, 
 suturing the parts together, as described in detail below. 
 
 3. The so-called Umbilical Hernia of Adults is usually due to a 
 protrusion of omentum or intestine through an opening in the 
 linea alba, either immediately above or below the umbilicus, the 
 former being the more common. It occurs most frequently in 
 women who have borne children, being sometimes due to actual 
 rupture of the linea alba and separation of the recti muscles. In 
 such cases it is possible that the peritoneum is also torn, and the 
 intestines extravasated, as it were, beneath the skin. A peritoneal 
 sac is, however, usually seen, but in old-standing cases it is ex 
 tremely attenuated, and so adherent to surrounding parts as to be 
 unrecognisable, whilst the contents may be matted together in 
 an almost inextricable confusion. In such old-standing cases 
 
HERNIA 
 
 943 
 
 1, and cut away 
 rinaisthen^i- 
 \e feia overjlu' 
 ;ii'ent-,'tfnr'nmst, 
 constrictinf; the 
 is that a portion 
 ), and fixed in the 
 IS thereby to have 
 Litions as to after- 
 
 f umbiUcal hernia 
 
 llos, is an exceed- 
 . of the abdominal 
 entirely withdrawn 
 avity at the base ot 
 
 Ugature with which 
 at the best a fecal 
 cord has separated, 
 d septic peritonitis 
 parotomy, reduction 
 m by sutures. 
 ,ung People, or, as it 
 ; due to weakness o 
 the intra-abdominal 
 ,(1 by chronic consti- 
 ■;training in order to 
 iition rarely persists 
 ■nable to treatment, 
 performance of cir- 
 idition is dealt with 
 ilicus. In persistent 
 ppen and remove it, 
 
 letail below. 
 iS is usually due to a 
 
 11 an opening m the 
 the umbilicus, the 
 , most frequently w 
 .times due to actual 
 ,e recti muscles. '^ 
 is also torn, and the 
 eskin. A peritoneal 
 ^ding cases it is ev 
 ending parts as to be 
 matted together in 
 old-standing case? 
 
 obstruction is very liable to ensue, and if combined, as is not 
 uncommon, with a subacute form of inflammation, it may even 
 run on to strangulation. Moreover, the skin over the tumour 
 becomes stretched, atrophic, and not unfrequently ulcerated, so 
 that perforation may threaten. The hernia is often lobulated 
 in character, and a considerable deposit of fat may sometimes 
 surround it. 
 
 Treatment.- -When of large size, and occurring in stout indi- 
 viduals, it should be supported by a bag truss, whilst the patient 
 is placed on such dietetic and hygienic measures as shall assist 
 in the reduction of excessive corpulency. In favourable cases, 
 operative treatment can be undertaken. A vertical incision is 
 made over the site of the tumour, and to effect this without 
 wounding the subjacent gut, it may be advisable to pinch up the 
 skin on either side, and cut it by transfixion. The sac is then 
 opened, the incision being enlarged, if necessary, so as to allow 
 the contents to be drawn aside and the opening in the abdominal 
 wall exposed. When the intestine has been reduced and omentum 
 removed, the sac is dissected up to the margins of the opening 
 into the abdomen, which is usually small in size and circular in 
 shape, whilst the edges are firm and thickened. The sac may now 
 l)e cut away close to the opening, and all bleeding-points secured. 
 Tlie aperture is then closed in the following way : Several deep 
 transverse sutures are passed through the wliole thickness of the 
 abdominal wall on each side, and tightened after a row of inter- 
 rupted sutures has drawn the peritoneal surfaces into contact. 
 By this means the circular aperture is obliterated and the margins 
 united in the median line. The external wound may now be 
 closed, any redundant skin being cut away ; it is usually safer to 
 insert a drainage-tube in the more extensive cases. 
 
 Most si rgeons recommend that the fibrous margins of the deep 
 opening should be freely removed by dissection before the passage 
 of the sutures, so as to expose the fibres of the recti muscles, and 
 permit of their approximation after the peritoneum has been 
 turned in and stitched ; the suggestion is a good one, since the 
 union of healthy vascular tissue must always be more faxourable 
 than that of two anaMiiic cicatricial edges. To accomplish this 
 satisfactorily, it is often necessary to prolong the incision up and 
 down for some distance, since the recti muscles are usually 
 displaced laterally and must be freely detached from their sheaths 
 iftiiey are to be brought together in the middle line. Silkworm 
 k'ut may be used with advantage in these cases for the deep sutures, 
 since it remains unabsorbed. 
 
 A Ventral Hernia is the term used in describing any protrusion occurriu),' at 
 I some spot in the anterior abdominal wall other than those already mentioned. 
 i Several forms may be met with : 
 
 I. It not uncommonly consists of a protrusion of subserous fatty tissue 
 through a congenital or acquired opening in the iinea alba, lineaj semilunares, 
 

 A MANUAL OF SURGERY 
 
 or lineae transversae, especially at the junctions of the former and latter. Tin 
 are more common above than below tlie umbilicus, and if, as not unfrequent 
 happens, the fatty tissue proliferates, a localized tumour resembling a Upon 
 is produced, and goes by the name of a ' fatty hernia of the linea alba, 
 portion of peritoneum is drawn through the opening into the centre of tiie- 
 masses when they have persisted for some little time, and a true hernia is thi 
 induced. A similar condition is met with in the inguinal and crural region 
 and probably most of the cases described as lipomata in these parts are of tli 
 nature. Considerable pain and abdominal disturbance (vomiting, colic, etc 
 accompany almost every movement of the body, being caused partly by tli 
 traction of the peritoneum, partly by the constriction of the neck of the s;i 
 against the sharp edges of the small opening. Treatment consists in tli 
 removal of the projecting mass, care being tal<en not to include any viscei 
 in the suture with which the base is surrounded. The stump is pushed bar 
 into the abdomen, and the opening closed by deep sutures. 
 
 2. After operations involving the division of the abdominal parietes, ventrn 
 hernia may be caused by the yielding of the cicatrix, especially if the wouin 
 suppurates, and the deep stitches come away or are removed, or if the openin 
 is left patent for the purpose of draining an intra-abdominal abscess. Treatiiu' 
 of such cases consists in dividing the skin and subjacent fibrous tissues, definini 
 and refreshing the edges of the parietal wound, and drawing them togethe 
 with buried sutures. The peritoneum need not always be opened in such ; 
 procedure, but it is sometimes wiser to do so. Especially is this tlie case whei 
 a ventral hernia forms after an operation for suppurative appendicitis ; the 
 appendix is rarely dealt with at the primary operation, and the surgeon ma\ 
 rightly take the opportunity of removing it during the operation required for 
 the cure of the hernia. 
 
 A Lumbar Hernia is a condition of considerable rarity, in which the abdominal 
 viscera protrude by the side of the erector spinse, coming to the surface between 
 the latissimus dorsi and the external oblique, in the space known as Petit s 
 triangle. The ordinary signs of a hernia are present, and with a little care 
 tlie condition is readily distinguished from a lumbar abscess. Treatment may 
 be conducted along the same lines as for a ventral hernia. 
 
 A Diaphragmatic Hernia is rarely recognised ante-mortem. A few cases of 
 strangulation have, however, been diagnosed. It is usually congenital in 
 origin, arising from imperfect development of one or both halves of the 
 diaphragm ; it is most common on the left side. It may, however, result from 
 traumatic lesions, such as stabs, involving the diaphragm. The transverse 
 colon or stomach generally protrudes into the thorax, and there is usually no 
 peritoneal sac. Treatment is impracticable in the majority of instances, 
 although one or two cases of traumatic hernia have been successfully operated 
 on through the chest wall and pleural cavity, thus permitting the closure of 
 the hole in the diaphragm. 
 
 Obturator Hernia consists in a protrusion of intestine through the upper 
 part of the thyroid foramen, and lias usually been observed in elderly females. 
 It is not often recognised in the living, except when strangulated, and even 
 then, unless of considerable size, it is likely to be overlooked. It has, how- 
 ever, been diagnosed by the fact that, in addition to the general signs of 
 strangulation, there was a sense of deep resistance and of fulness close to the 
 origin of the adductor muscles ; whilst pain was referred down the obturator 
 nerve to the inner side of the knee. Rectal or vaginal examination may throw 
 some light on the nature of the case. Treatment lias generally been confined 
 to cases of strangulation, and in such an incision is made over the inner aspect 
 of Scarpa's triangle, and the pectineus divided or displaced. The sac when 
 found should be opened, and strangulation relieved by cutting upwards, the 
 obturator vessels being usually situated below the neck of the sac. 
 
 Other forms of hernia, e.g., pudic, pudendal, vaginal, sciatic, etc., have been 
 described, but are so uncommon that they need no special mention. 
 
fJEHNlA 
 
 adhesions, either bet^^?^'th'' ^'"^^^">^ ^ue to the n 
 he contents themselves "hl^h "°"^^"t« and the ac Tf"""" °^ 
 large to pass tlirou-h ^h ^ ^'^ ^^us united in? ' "^ ''^^^^'^^n 
 ahdonien. This i« -11 ^^ aperture of coml, -^^ '^ '"^ss too 
 "*■ ^'^e sac, which', ^^««^iated with 00^^./"'"^'°" ^^'^^'^ the 
 
 f-essive depS^:f.t'%^ ?/ '""^ -ntenfs"?) t^^^?. i'J-fitting 
 
 "ot to operate onl^,^^ f^-^^^^H^y dieted %ff;,"^^^-over, the 
 
 preliminary treatment f ^J^"""'* ^^ this naturi ?f ^"^P^rtant 
 
 of a Jarge amoim of i''"' '^^" ""^ertai^en t ' }a '"'"« ^"c'' 
 
 -ponsile CtlTtl'hVf ° ^^.^ -^"omtrca'r^ 
 
 action. 2 \m^*-i ■ "eaths from inf-Prf^..^ .^'ty has been 
 
 '-^: hinged t^o fhTio^fe: lZf%'' '"^P-^^d n ^ u tahf"r^". ^ 
 "'aintamed by mean^nf ^ ^ ,°^ ''' ^^uss, upwarH T^^'^^ leather 
 other of these pSnsli '''"• ^^''^^^i'^ ^Prin^ Lv n ^^''"'^ '^^^'"g 
 ''"t ue are not n ?' ^^^"^^'o^ may after a"t;n^^,'^ "'^ ^^ one or 
 'ar^^e hernU°' 3" /^r^f ^"^ ^"ch proce ^^^i;^ ^accomplished 
 '^« Jarge, operaiion ^ ^^^^'^^ individuals, and f fh' "^''^P' ^n very 
 omentum bXTrl '"Preferable and mni ^ ^^^ ^^P^nre is not 
 ■^^"■^«d (p. '5) ^^"^°y«d and adhesions dS;j°^^ satisfactory 
 
 possible To suppttthh ' .'^^^^' ^e'-y aggrav^^^^^^^^^^ '"' ''^^f^'-^^y de- 
 , Inflamed H^ L^o'^h '^ ^" ^iSicYig' '^'"^' '^ ^^ -ly 
 
 |'^"ollen, and nerh^' ^'it P^''^ becoming C n? /T^ ^^""^^ o^' a 
 fceneral fever ^li^?' ^^^ "'^'in ONer it ?ed /hP/-"*"^' ^^"^e'", and 
 (is usually pr;senf '1' "^"^,^^.' -"d xonl^ng whll^r*^'"^^^ ^^'"^i^- 
 tembling stran!»r.-^ condition is thus ilf/j :^^"^ constipation 
 f'epresfncTofTvl?-''"' ^"^ ^^ ^^ dist nguisheH ^^^^ ^omey^lm re' 
 
 h ^nd the cla Icter^n 'h^ "' '^^^^'^ ^he ab enef oTl '^'- ^^"^'^ ^^ 
 Pnia is irredur?M °^ ^^'^ vomiting, which^f ^?"'°n in the 
 Fcoum of f K • ^^' ^t any rate for of '" not f^cal. The 
 hon : ^!,Pt ' t/' P^'^-n\^ ta is' th'"n fr^'°'^'^^ ^-^ - 
 
 » 60 
 
9^ 
 
 A MANUAL OF SURGERY 
 
 adhesions exist. Lymph is deposited on the serous surfaces, a 
 this usually leads to the formation of adhesions. Occasional 
 where omentum is alone present, an attack of this type m 
 result in a natural cure, especially in the umbilical variety. 
 
 The Treatment consists in putting the patient to bed and 
 stricting his diet to fluids, whilst fomentations are applied 
 the part. A little opium may also be administered to allay t 
 pain, and possibly the lower bowel emptied by an enema. 
 
 Obstructed Hernia is a condition in which the onward passa; 
 of faeces through the gut contained in a hernial sac is prevente 
 It is most frequently seen in the umbilical variety, and is of cour 
 irreducible. It is due to an accumulation of undigested food 
 faeces, the condition being aggravated by the presence of ftan 
 derived from the decomposition of the contents of the bo\v( 
 Nausea and vomiting are induced, the latter, however, rare 
 becoming faeculent, whilst constipation is usually present, althou;^ 
 the lower bowel may empty itself and flatus may pass. Locally 
 the tumour becomes distended, but not tense as in strangulatioi 
 and a doughy mass, which can be moulded and indented by th 
 fingers, is felt within the sac. There is no tenderness, but th 
 patient usually complains of a good deal of intermittent colick 
 pain. If unrelieved, a subacute form of inflammation may super 
 vene, and this may pass on to strangulation, and even death. 
 
 Treatment consists in the use of copious enemata, and tlit 
 npplication of an icebag to the hernia, followed by carefully appliec 
 taxis, so as to assist the onward passage of the impacted contents. 
 As soon as the obstruction is overcome, a brisk purge should lie 
 administered. 
 
 The term Incarceration is also used to indicate obstruction in 
 an irreducible hernia ; but it is somewhat misleading, and should 
 be avoided. 
 
 Strangulated Hernia. 
 
 A hernia is said to be strangulated when the contents are con- 
 stricted in such a way as to obstruct and ultimately arrest the 
 flow of blood in the vessels contained therein. Interference with 
 the passage of faeces is not an essential in this condition, since 
 omentum alone may be involved, or the intestine, if present, may 
 only have a portion of its lumen constricted, as in the form known 
 as Bichter's hernia, or in Littr^'s hernia, where a diverticulinnis 
 similarly affected. 
 
 Two chief varieties of strangulation are described : those 
 occurring within the abdomen, which are dealt with more fully 
 in Chapter XXXIII., and those which are extra-abdominal; iti> 
 only the latter to which we shall now direct attention. 
 
 External Strangulated Hernia arises in one of two ways : (ii) The 
 hernia becomes strangulated immediately after its formation: 
 
947 
 
 -— . ^SUNIA 
 
 frecjuentJy resujts fl ^^^^""&enital type /M /'^"^^^^^ents, the 
 
 s"dden violen eC ^^"ff . '"^o the sac a" thJ^'^^^f '-^'"ount 
 
 standing, hernia, the neck of t?"'^^'°" "^"aJ y ^S ' °^' ■^°"^^' 
 tliickened and contrn^f , • *^^^ ^ac havincr L "'.'^ams ,n oJd- 
 tl'e irritation of the ^mfr'/^ by the "^^ P^^^'^f ^ '>ecome 
 
 conditions is usi .M.^ ""^^"^ ^•''^^era. Tlw "" °^ ^ ^^uss or 
 subacute. "'""^^-^ ^^"^e in character the "I";?'' °^ ^'^^^^ ^wo 
 . The site of the constr.Vr • ' "^"'"' °^"t«" 
 
 .'Structures outside thi ' ^'"^ '" ^nioraJ in.f , u .^"''''^'"n "'s 
 
 '"ay also be nrnriM ^^'^^^"aJ cause of th^ "^ I ^f^ament or the 
 
 ^' ^C'ht adSsTo^'rihll^P--^- 'f ' cr:i"S-''''^-^^ '■' 
 contained in the sac T ^^ "" ^^'^ or aperturp 1 .i^'"^ ^'"^er 
 •mmediateJy aflr tL-^" ^^"^^^^rniaMvhich ' "" ^"^entum 
 
 variably th J reZat7j?u ''''''''' ^ ^he cons S' ^^^an^uJated 
 H'^^xiominal pS:. °' ^^^ ^'-"- --"nt ;ie"oSL-n "■ 
 Pathological Phenomena '1^ ^ ^ ^ '" 
 
 somewhat with the t.Vh?^^-^^ ^^ects of str.n i • 
 •s seldom entirely arrf./T' °/ '^'^ constriction tT'^'"-'^" ^'^^y 
 pressure affects fir J !? ^^ ^'^^ ^^^et of heT'n J'^ ^'^^^'Jation 
 1'}' the con4s fon '/""^ '"°^^ especial k th/ ^^'^^^^ ' ''"^ the 
 
 -teries is^C^M to. ^"'i"^'^" ^^"^^ P o'duced'tl"''.^^"^ ^^^^-. 
 are intenspiv . '^ '^ standstill. Henri .u' ^^^^ ^^^ in the 
 
 "'• ^-""nl' v'n;^^ ^"^- -•" anVpa'ss^of""^^^' ^■-'- 
 
 S;S fc^ ^t^-S:;^ t^^^^^ .nowin, chan.es 
 
 v-cular congesta^''^ •?'' ^J-^ocolate! or' i'r'eT'c'?'" ^^ ^^^^^^ 
 ■^-al^s, and'lS^ J- thickened .^^ ^W o^f ^^l,', ^ "^^ ^o 
 "^vinf< to the arrest of J ^- . ? ^^""ation of ras w.Vh '^^'?" '"^^ 
 '^nts. The sMrff peristalsis and the Lt f^^'"" ^^^ '"'"en, 
 
 ^■^"rfation Lo tlt't ""' ^''' ^^'^^"ns mooth anf^r'°" °^ '"^'^ ^^n- 
 '^ >nalJy^:^: ^^^f^--^' ^i- er^M^S^:'!^'^-}} - the 
 
 ^■^"clation i^to ;:; ""' ""''' ^^'^^^ns smooth an.. ."°" °^ ^'' ^on^ 
 'Occasional y some of '•'"'''^^^^' ^^^^ enShelhl •""^' '^"^ '^^^ ^he 
 
 , "^/njudicious ta^s thl '''^' ^"^^ances.and possib ""'^'i''"- '"'^'^e 
 ^^^'^'^s into the sac thT^-""'^^ ^-^s-^els cl^pTete ^'' '''" '^'^"^^ 
 intestine in rL? ' ^"^'^ '^ thus filled wfhi^^"'Pty tliem- 
 
 ^^^'owr. When tlf^^T'" ^^^^ominj^ at ^nV T^>'«°^'' ^he 
 ''''^'^owelsoon,. .'^'"'?n^'"Jation is rehe..'^^'. >'f ^.^^^^sh-^rey in 
 
 I '"ation occur, .t^""'"' '^^ ^^rmer health v. '" ^'^'^ ^^^^^^y stLe 
 
 6o — 2 
 
948 
 
 A MANUAL OF SURGERY 
 
 
 results partly from the prolonj^ed stagnation of blood, and pari 
 from the action of the Bac. colt, which, as soon as the vitality 
 the intestinal wall is sufficiently impaired, migrates through 
 and liy its development produces toxic bodies which still furth 
 assist the gangrenous process. As soon as it is established, t 
 intestine turns an ashy grey or black colour, usually at one 
 more spots which gradually spread, lose all lustre and polis 
 and after a time become soft, lacerable, and ofifensive. At i 
 point of strangulation the gut is completely anaemic and lial)le 
 ulceration, which may subsequently result in perforation ; a 
 hesions may, however, form between it and the neck of the s? 
 thus preventing contamination of the general peritoneal cavil 
 Tlie intestine above the site of strangulation becomes paralyzed, ai 
 peristalsis is entirely arrested, even in a Richter's hernia. Fac 
 material, accumulating and undergoing decomposition, gives ri 
 to a catarrlial enteritis, and even occasionally to stercoral ulcei 
 which may perforate and cause general peritonitis ; this, howevt 
 is not very common in external strangulation, since the small i 
 testine is usually involved, and solid faeces are absent. In mo 
 chronic cases gangrene of the gut may be induced by the pressu 
 of the accumulated contents and the action of the Bac. coli. Tl 
 portion of the bowel below the constriction may be affected in 
 similar manner, owing to the arrest of the peristalsis, but lo 
 slighter degree. 
 
 Omentum, when strangulated, is at first congested and of a da 
 red or purplish colour, and later on infiltrated and matt( 
 together. If, however, it has contracted adhesions to the sa 
 and no gut is present, the trouble may subside, since its \itali 
 may be mr.intained through the adhesions, and a natural cure 
 tlie hernia may result. Where such a condition is not prestii 
 gangrene supervenes, and the omentum then becomes ashy j^n 
 or brown in colour, and is pultaceous and friable. It does m 
 become offensive unless associated with intestine, since it does ik 
 contain any intrinsic source of putrefaction. 
 
 The sac is usually distended with fluid, which at the commenct 
 ment is serous in character, and perhaps blood-stained, whil; 
 subsequently it becomes turbid and mixed with lymph ; finally, 
 is dark brown or yellowish-green, with a marked and most olijt 
 tionable odour. Occasionally there is but little or no effusion i 
 fluid, a condition more often met with when intestine is absen 
 from the sac, and only omentum, or some solid viscus, such a 
 the ovary, is present. The serous lining of the sac is but s\\\<\\^\] 
 aftected in the early stages ; as, however, the case progresses ti 
 inflammation or death of the contents, it also becomes inflamed 
 and ultimately gangrenous owing to the action of the Bac. d 
 which by this time has penetrated to the turbid serum contained 
 within it. The surrounding tissues, including the skin, become 
 a-dematous, congested, and crepitant, and, finally, may determine 
 
HERNIA 
 
 949 
 
 3f blood, and partly 
 an as the vitality ot 
 nii?rates through u, 
 s which still further 
 it is established, the 
 r, usually at one or 
 1 lustre and pohsi. 
 d offensive. At the 
 tnseniic and hable to 
 
 in perforation; ad- 
 the neck of the sac, 
 ral peritoneal cavity, 
 comes paralyzed^ and 
 hter's hernia. 1"'A'^'11 
 composition, gives nse 
 [Iv to stercoral ulceis 
 tonitis ; this, however, 
 in, since the small m- 
 , are absent. In more 
 educed by the pressure 
 ^of iheBac.coh. Hh' 
 
 may be affected in a 
 le peristalsis, but to a 
 
 ongested and of a dark 
 nftltrated and matted 
 adhesions to the sac. 
 ibside, since its vitahty 
 s, and a natural cure ot 
 Edition is not present, 
 len becomes ashy },'re\ 
 ,d friable. U does not 
 :estine, since it doe^.^ not 
 
 iJhich at the commence 
 
 Is blood-stained, vM^ 
 
 1 with lymph; final),'' 
 
 larked and most ol.je. 
 
 , little or no effusion o, 
 
 len intestine is absen, 
 
 le solid viscus, such H 
 Tfthesacisbutsh^'btM 
 
 [the case progresses to 
 also becomes inflame 
 
 laction of the Bac. uM 
 urbid serum, contame 
 
 kding the skin, become 
 finally, may determ-ne 
 
 a natural cure by sloughing and the establishment of an artificial 
 anus. 
 
 After the relief of strangulation, even if no gan<rrene has 
 occurred, the patient is not free from risk, owinj,' to chan<;es which 
 may possibly follow the temporary arrest of the circulation. It 
 has been shown by placing a ligature around the ear of a rabbit 
 that the amount of reaction, when the constriction is relie\ed, 
 varies directly with the tightness with which the ligature has been 
 applied, and with the period of constriction. When applied 
 loosely and only for a short time, the restoration of circulation is 
 followed merely by a transient hypera?inia, but as the complete- 
 ness and duration of the obstruction are increased, the inflamma- 
 tion becomes more and more intense, and even gangrene may 
 follow. Similar results are met with after the relief of stranj^^u- 
 lated hernia. In the less severe cases the intestine merely 
 becomes temporarily congested, but in the more acute forms 
 the paralysis of the gut may persist, whilst inflammation, possibly 
 running on to gangrene, may be produced, either in the strangu- 
 lated portion or in that immediately above, and thus, although 
 the operation has been skilfully performed, a fatal issue may 
 ensue. 
 
 The Clinical History of a case of strangulation is usually 
 so characteristic that there can be but little uncertainty as to the 
 diagnosis. The general symptoms are similar to those described 
 at p. 961, as occurring in all cases of acute intestinal obstruction. 
 The patient during some sudden effort notices a severe pain, 
 localized at first to one of the hernial regions, or referred to the 
 umbilicus ; this is accompanied by the usual e\ idences of shock 
 —i.e., he feels faint, the pulse becomes slow and weak, the tem- 
 perature falls, and the surface is covered by a cold, clammy 
 sweat. This shock is often not very prolonged, and is associated 
 with or quickly followed by vomiting, at. first gastric, then 
 bilious, and finally stercoraceous or faecal. < As this continues, 
 the pain increases in severity, and radiates over the whole of the 
 abdomen, which becomes tense, tender, and tympanitic. Symptoms 
 of exhaustion supervene, caused partly by the pain and vomiting, 
 and partly by the inability to take food ; probably the absorption 
 of toxic material from the intestine also assists in its production. 
 Complete constipation is usually present, but the patient may pass 
 flatus or faices from the lower part of the intestine. The onset of 
 ^'angrene is generally accompanied by a sudden fall of temperature 
 and a cessation of pain, whilst the pulse becomes weak, rapid, 
 and intermittent", the surface is covered by a cold sweat, the 
 countenance becomes shrunken and drawn (the so-called ' facies 
 Hippocratica '), hiccough follows, and finally the patient dies, 
 usually as a result of toxaemia due to the absorption of products 
 developed either in the bowel wall or sac, or in consequence of 
 acute generalized peritonitis. Locally, the onset of the symp- 
 
950 
 
 A MANUAL 01- SURGERY 
 
 toms is associated with the formation of a tumour in one of t 
 usual sites of a hernia, or if already the subject of this conditic 
 the patient may notice that his rupture has suddenly becoi 
 larf^er. The swelling is irreducible, tense, extremely tender a 
 painful, and without impulse on coughing. It is hard 
 rounded if bowel is in\ olvtd, softer and more doughy to the tou 
 if omentum. When gangrene ensues, the tension within t 
 sac is reduced, pain and tenderness cease, whilst the skin o\ 
 the tumour becomes dusky, inflamed, and cedematous ; final 
 e\idences of gangrene show themselves externally, the pai 
 becoming dark in appearance, and soft and emphysematous to t 
 touch. If the patient sur\i\e, the necrotic tissues separate, ai 
 an artificial anus is produced either naturally or through the inte 
 \ention of the surgeon. Suppuration witliin the sac is uncommo 
 
 Occasionally, however, cases are met with in which the abo^ 
 described signs are considerably modified, and in one of oi 
 cases the patient complained of no inconvenience beyond sligl 
 pain, although incipient gangrene was present ; he walked inl 
 hospital saying that he never felt better in his life. 
 
 The early symptoms arising from strangulation of a portion ( 
 the lumen of the intestine {RicJitet''s heynia) are sometimes K; 
 marked than when a complete loop is constricted, but the latt 
 phenomena are always very se\ere. It is usually of the femor. 
 \ariety, and the ileum is most frequently involved. If less tha 
 half the circumference of the bowel is constricted, the obstructiol 
 is not always complete at first, flatus and faxes being sometime 
 passed ; but where more than half the circumference of the bowe 
 is engaged, complete obstruction from kinking or paralysis of tin 
 gut ensues. The vomiting is less marked than in other cases 
 and is not so commonly fa^culent. The tumour \, )duced i: 
 small in size, but tense and tender. The prognosis in thest 
 cases is always grave, partly from the difficulty experienced ir 
 diagnosis, partly from the tightness of the constriction, deatl 
 usually resulting from perforative peritonitis, which is occasional!) 
 due to wounding of tiie gut by the hernia knife. The mortalitj 
 in these cases is calculated at 62 per cent., which is in marked 
 contrast with that of about 35 per cent., which is usually said to 
 be characteristic of ordinary strangulated hernia. Our mortality 
 for all cases of strangulated hernia, admitted to King's College 
 Hospital during the years 1892 to 1897, o^'Y amounted to i6'6 
 per cent. 
 
 The occurrence of strangulation in a pure epiplocele is \ery rare ; the 
 symptoms are vague in character, and the diagnosis is often diffi 
 cult. The presence of a soft, doughy, tender swelling in any of the 
 hernial regions, combined with pain, bilious vomiting, and possibly 
 constipation, is always a significant feature. So long as no kink 
 ing of the bowel is caused thereby, the symptoms may remain in- 
 definite, the vomiting never becoming fajcal ; but as time goes on, 
 
HERNIA 
 
 95« 
 
 imour in one of the 
 >ct of this condition, 
 [s suddenly become 
 vctreniely tender and 
 It is Imrd and 
 doughy to the toucli 
 
 tension within the 
 
 whilst the skin oyer 
 
 a>dematous ; finally, 
 
 externally, the parts 
 
 mphysematous to the 
 
 tissues separate, and 
 
 or through the inter- 
 
 the sac is uncommon. 
 
 h in which the above 
 
 and in one of our 
 jnience beyond slight 
 sent ; he walked nito 
 
 lis life. . . 
 
 ulation of a portion of 
 a) are sometmies less 
 .stricted, but the later 
 usually of the femoral 
 nvolved. If less than 
 ricted, the obstruction 
 •ffces being sometimes 
 imference of the bo\vel 
 ing or paralysis of tlie 
 ^ than in other cases, 
 : tumour p, )duced is 
 le prognosis in these 
 ^hculty experienced in 
 lie constriction, death 
 I which is occasionally 
 [knife. The mortality 
 ., which is in marked 
 iich is usually said to 
 ernia. Our mortality 
 fed to King's College 
 nly amounted to ib'ii 
 
 ilocele is very rare ; the 
 
 liagnosis is often ditt- 
 
 swelling in any of the 
 
 'omiting, and possib y 
 
 So long as no Knik 
 
 itoms may remain in 
 
 but as time goes on, 
 
 arrest of peristalsis may lead to true obstruction, or even general 
 peritonitis. As already mentioned, strangulated omentum does 
 not per se become offensive ; but occasionally a neighbouring 
 coil of intestine may be dragged upon, and its circulation dis- 
 turbed sufficiently to enable the Bar. coli to escape, and then it 
 may find its way into the sac, and de\elop therein its charac- 
 teristic odour without any serious lesion of the intestine or peri- 
 toneum being conjoined. 
 
 The Treatment of a strangulated hernia consists in reducing the 
 contents by taxis, or by operation. 
 
 Taxis is the term employed for the manipulation by means of 
 which a hernia is reduced. In cases of strangulation, it must be 
 used with gentleness and great care, since the involved portion of 
 intestine is congested and easily torn. The patient is laid on a 
 couch with the head supported, and the thighs slightly flexed, so 
 as to relax the abdominal muscles. The fundus of the tumour is 
 then grasped with one hand, and steady pressure employed, 
 having for its object the emptying of the congested bloodvessels, 
 and consequently a diminution in the size of the hernia ; the 
 fingers of the other hand manipulate the neck of the sac, in 
 order that the part which has most recently been protruded may 
 he first returned. The direction in which taxis is made varies in 
 diflerent rases. In inguinal hernia, it should be directed upwards, 
 outwards, and backwards. In a femoral hernia which has ex- 
 tended beyond the saphenous opening, taxis is first employed 
 downwards and inwards in order to make the gut re-enter the 
 crural canal, and then finally backwards and upwards, the 
 margins of the saphenous opening being relaxed by flexing and 
 slightly inverting the thigh. In umbilical hernia, the pressure is 
 mainly directed backwards. In all cases, taxis should be employed 
 under an anaesthetic as well as without, since the patient often 
 resists the efforts of the surgeon on account of the pain. Hence, 
 if ordinary taxis is employed for a few minutes (certainly not for 
 more than five) and fails, the instruments required for an opera- 
 tion should be prepared, and the patient placed on the table. 
 Anaesthesia is then induced, and a final attempt to reduce it under- 
 taken, on the failure of which the operation is at once commenced. 
 The objections to making prolonged eftbrts at taxis are very 
 obvious, since even if successful one does not know the precise 
 condition of the bowel, whilst considerable injury may result from 
 the injudicious application of force, and the patient loses one of 
 the great advantages of operation, viz., the additional radical cure 
 which in favourable cases should always be undertaken. 
 
 In some of the slighter conditions of strangulation, and especially 
 if the patient has had similar attacks before which have been 
 relieved without operation, reposition may be induced by applying 
 fomentations for half an hour, followed by the use of an icebag, 
 reduction sometimes taking place spontaneously. The heat 
 
95t 
 
 A MANUAL OF SURGERY 
 
 Wk\ 
 
 relaxes the tissues around the neck of the sac, and the effect 
 the cold is not only to constrict these tissues, but also to indu 
 contraction of the intestinal l)lood\essels and muscles. 
 
 Persistence of Symptoms after apparently Successful Taxis, 
 occasionally happens that althouf,'h the surgeon may have app; 
 ently reduced the hernia satisfactorily, the symptoms of strangu 
 tion, viz., pain, vomiting, and constipation, persist. Such may 
 due to a variety of conditions, and considerable judgment is need' 
 in coming to a correct decision in any particular case, (i.) Tl 
 vomiting may possibly be due to the anaesthetic, but then d( 
 not usually last for any length of time, and soon loses its fai 
 character, (li.) The gut remains paralyzed from the effect of t 
 constriction ; inflammation may then supervene, involving eitli 
 the released coil of gut or the portions above or below it, ai 
 perhaps running on to ulceration, perforation, and death fro 
 peritonitis or toxjcmia. ^iii.) The rupture reduced may not 1 
 the one which has given rise to the symptoms, an internal herni, 
 or one in some other region, co-existing, (iv.) The strangulatio 
 may have been caused, not by the neck of the sac, but by a slit i 
 the omentum contained in the sac. Reduction in such a cib 
 would not relieve the symptoms, the whole mass being retunie 
 into the abdomen, (v.^ The hernial sac may have a diverticuhii 
 or pocket communicatmg with it at its upper end (intrapariet; 
 interstitial hernia), or it may be shaped like an hour-glass. It i 
 possible to reduce the intestine from the lower portion of tlii 
 so-called hernia en bissac into the upper pocket, and then of coursi 
 the symptoms persist. (\i.) Reduction en bloc or en masse mai 
 occur, but only when considerable force is employed ; in this tin 
 sac and its contents are together reduced from their superficia 
 position to the deep aspect of the abdominal parietes, the herni; 
 then lying between the muscular planes or in the subserous areolai 
 tissue, and the constriction remaining. The hernia gradual!) 
 disappears, but without the characteristic gurgle. In such a cai-« 
 the sac sometimes gives way, the intestine and the portion of tin 
 neck which compresses it being pushed upwards. When occurriii| 
 in the inguinal region it is recognised by the persistence c 
 symptoms, and l:)y the fact that a finger inserted into the cana 
 which is unduly patent, detects a tense rounded swelling at 
 upper end. It also occurs, but less commonly, in the fenion 
 region, and in either variety the hernia may slip down again 
 short time after its apparent reduction. 
 
 In any case where, after an apparently successful taxis, tl 
 symptoms of strangulation are still present, a most caret 
 investigation is needed in order to ascertain, if possible, the caui 
 Thus, the character and frequency of the vomiting must be co 
 sidered, since, when due to anaesthetics, it usually loses its fae( 
 character, and is less severe. If the vomiting is associated wi 
 a certain amount of local pain, and possibly with some bloc 
 
iHY 
 
 e sac, and the effect df 
 iues, but also to indiu c 
 ,nd muscles. 
 y Successful Taxis. 1 1 
 rgeon may have appar- 
 symptoms of stranj^ail i- 
 persist. Such may Ik 
 ible judgment is needi d 
 rticular case, (i.) The 
 esthetic, but then do( > 
 nd soon loses its fai mI 
 :1 from the effect of the 
 ;rvene, involving either 
 ibove or below it, and 
 ition, and death from 
 2 reduced may not lie 
 )ms, an internal herni.i, 
 (iv.) The strangulation 
 the sac. but bv a slit in 
 case I 
 
 f^ERNlA 
 
 y\ •) X uc ^Miaiigi 
 
 the sac, but by a 
 luction in such a case 
 e mass being returned 
 ay have a diverticulum 
 pper end (intraparietal 
 :e an hour-glass. It is 
 
 lower portion of this 
 cet, and then of course 
 t bloc or en masse mav 
 employed ; in this thi 
 
 from their superfici;i 
 lal parietes, the herni; 
 n the subserous areolai 
 The hernia graduailj 
 furgle. In such a can 
 and the portion of tin 
 ards. When occurrin 
 by the persistence c 
 iserted into the cana 
 Dunded swelling at i* 
 monly, in the femor; 
 lay slip down again 
 
 '-taiiied diarrh ^^ ^ — ~~ 
 
 rase are met by „■„„ ,1 .""""'iral x.irietv ,1" '""'^i"" of l'oi„„ '/ 
 
 ^.V«™ the sa^ Z%"'fT'>"f^ t[T&"S tr:""''""«>'"of ., 
 
 r successful taxi; 
 sent, a most caret 
 1, if possible, the cau^ 
 romiting must be coj 
 usually loses its faed 
 ting is associated wi 
 
 ihlv with cr>m*i [jlod 
 
 h^ Miner T, '? '^ons'iicted Z/T '"'' ''<'m one/. 7' '^■""' 
 
 h'd tor andd Wde°;;r'""'- I'he cause f./T'f"™ care i|/ '' 
 
 V^^to hand, an oM °"' * ^'"^^' fron^'t ^i?"'"^ ''^«de he ' 
 h^ '^ettfr Vhan"'P^3>'^^ ^o repress In:;''^^''"^^ ^^''J suffice r';'' 
 
 ,^ ^"?ount afd tcentfr^"!^^^ examined ' rf' '^^''^^'^^ at the 
 fe^'^? to remove iLP'"^. ma^be rSu?'J^?^^ 
 ixdentJy been i„ .h "^ congested portLn "^Z ''"^ h h better 
 
 h"vaJ has been Itl.T'' I""' ^omeUmT' Tu '^^'"^ ''^'^<^i^ >as 
 already described (p 936) ^' ""''^'^^ of its 
 
954 
 
 A MANUAL OF SURGERY 
 
 Accorditif,' to lli(! coiulition of the intestine, the further steps- 
 the operation arc niochlied as follows : 
 
 1. If the f^ut, th(ni^li conf,'t'stecl, shows no si^m of f^anf^Mc 
 or perforation, it may be safely reduced. This is not always 
 matter of ease, owinj^ to the fact that the efTusion into its w; 
 has made it stifH' and firm. Prolonged and steady pressure \v 
 the finj^^ers will, liowever, sufficiently remove the exudation 
 pertnit ol its reposition into the abdomen. All manipulati 
 directed to the intestine must, of course, In- of the gentlest natu; 
 since its congested state makes it more friable than usual. 
 
 2. If the gut has been tightly strangled and gangrene is tlireatc 
 ing, it may be advisable to resect it at once, the incisions bei 
 made well abo\e and below the sites of constriction ; the divic 
 ends are united by one of the plans detailed at p. 884. If, ho\ 
 e\er. the bowel is in a doubtful condition, but recoxery thougl 
 possible, it is gently replaced just inside the abdomen, after free 
 dividing the constriction, and a large drain tube is inserted dow 
 toil. There is no need to fix the bowel ; it is already inflanu 
 and ixual) /ed, and hence will not change its position, especial! 
 if a small dose of opium is subse(juently administered. In tlii 
 way, even if gangrene or perforation occurs, a track is left for th 
 escape of the contents, while a localized plastic inflammation w i 
 siuU off the general peritoneal cavity. A fajcal fistula may tliu 
 be formed, but it oftens closes spontaneously at a later date. 
 
 3. If the gut at the time of operation is evidently gangrenous 
 the treatment is always a matter of difficulty, and one concernini; 
 Avliich very different views are held. Two chief methods ha\t 
 been suggested : 
 
 ((r) 'i'he gangrenous loop of bowel is opened, or the perforation, 
 if such is present, is enlarged sufficiently to allow of the entrance 
 of tlie linger into the lumen of the gut. A free flow of faces 
 should result from this proceeding, but if the constriction at 
 the site of strangulation is considerable, a pair of dressing forceps 
 should be passed up the bowel, and the narrowed portion dilated, 
 if possible. Failing this, the adhesions which have formed at the 
 neck of the sac must be gently broken through, and the constric- 
 tion dixided ; but if this can be avoided, so much the better, since 
 by such means the general peritoneal cavity is exposed to the 
 risk of septic infection. Hence it may be wiser to divide the 
 constriction from the outside without freeing the adhesions. An 
 artificial anus is thus formed through which for a time the patient 
 can discharge the intestinal contents, and unless this desideratum 
 is at once attained, failure is very likely to follow the operation. 
 The wound is left open and a suitable dressing applied, into wliich 
 the faeces can be received ; possibly the best application is a layer 
 of protective with a sufficient hole in the centre to allow the fjcces 
 to pass, and then over it a thick layer of tenax. 
 
 (b) More recently primary enterectomy with suture of the 
 
ine, the further steps of 
 
 IlURNiA 
 
 'livicled ends has been 
 ;il>ie success, 
 'riu; selection oi ^ne 
 
 9SS 
 
 extensi\eJv nrir.; . i ". 
 
 '> P''^ct,secl, and with consider 
 
 '^f these two 
 
 v-^iences caus;;;f C'Z '\' ^^^'1 ^^m th;^'S ^nd ''"" " 
 uonnd Tli» .- i .• ^ "^ passatje of f-..^^,. ., '"''' "iicon- 
 
 I'eRinnini. Ti!? "", ""ificfal anus aV, h ."""^^ ""•"e'l 
 
 ..eati. imS^r-Th" oatf. f • ^'?"S"la.ed hernia K of „, 
 'ds to niaintJn .'^1'"' °P ""^ "^ed not 
 
 uuoNe. i his is usually indicated 
 
956 
 
 A MANUAL OF SURGERY 
 
 by localized pain, and perhaps the passage of mucus, which ma) 
 be so abundant as to amount to diarrhoea ; the vomiting, morr 
 over, persists, but is no longer stercoraceous. If ulceration oi 
 perforation ensues, peritonitis will follow, but whether this occurs 
 or not the case is very likely to terminate fatally from exhaustion 
 It is best treated by the administration of bismuth combined wit): 
 morphia, whilst all solid food is interdicted, and stimulants maj 
 be freely given. (4) T. ^ occurrence of Peritonitis, or of a certain 
 amount of peritoneal activity, is inevitable after all cases ol 
 strangulated hernia. In most instances it is productive of no 
 harmful results ; but where the vitality of the gut wall has been 
 so lowered as to allow of the passage of the Bac. coli, or where 
 Its integrity has been interfered with by laceration or perforation, 
 a:i acute form of inflammation is set up which is seldom localized, 
 and rapidly becomes gcneyal. Lastly, septic infection of the peri- 
 toneum may be derived from the external wound, or as a result ot 
 local contamination by dirty instruments or fingers. Tycatmcut.— 
 As soon as peritonitis threatens, the administration of a smart 
 saline purge is often beneficial, acting by unloading the intestines 
 and encouraging peristalsis. Subsequently opium in carefully 
 regulated doses may be ordered, whilst nutrition is maintained by 
 enemata, or by small quantities of fluid given by the mouth. 1 )is- 
 tension of the in'.estine should be prevented, if possible, by passinj; 
 a long tube, or by giving a turpentine enema ; puncturing the dis- 
 tended coils of intestine has been adopted, but is extremely 
 dangerous. The condition is necessarily one of the greatest 
 graxity, and as a last resource laparotomy may be performed, 
 and the peritoneal cavity washed out. 
 
 Localized Peritonitis may be looked on as a conservative measure, 
 whereby Nature isolates some focus of danger from the general 
 peritoneal ca*" . Occasionally localized suppuration follows as 
 the result of a limited ulceration or perforation of the gut; the 
 pus must then be let out at the earliest possible moment, hut a 
 fa!cal fistula is very likely to follow. ']( 
 
 It is impossible to describe in detail e\ cry form of strangulateil 
 hernia. A few facts, however, must be stated about the iimrc 
 important \ arieties. In StrangiUated laguinal Hernia the constric 
 tion most commonly occurs at the neck of the sac, usually close to 
 the external abdominal ring, as a result of the condensation of tin; 
 surrounding tissues. The signs are usually very characteristic, 
 and the condition can rarely be mistaken. Some difficulty may 
 be experienced in distinguishing it from inflammation of an udi 
 scended testis ; in this, however, there is no persistent vomitini: 
 or constipation, whilst the absence of the testis below, and the 
 existence of the peculiar testicular sensaticn, when the swelling 
 in the canal is compressed, should clear up the case. Occasion 
 ally the two conditions co-exist, and then a correct diagnosis 
 
HERNIA 
 
 957 
 
 mucus, which may 
 le vomiting, morr 
 ;. If ulceration or 
 whether this occvus 
 ly from exhaustion, 
 nith combined wuh 
 uid stimulants may 
 mitis, or of a certain 
 after all cases ot 
 is productive of no 
 e "ut wall has been 
 e Bac. coli, or where 
 ■ation or perforation, 
 1 is seldom localizecl, 
 infection of the p'Mi- 
 und, or as a result ot 
 ingers. Tveatmcni.- 
 listration of a snian 
 loading the intestnies 
 r opium in carefuly 
 ition is maintained by 
 1 by the mouth, l^is- 
 if possible, by passin;.' 
 a ; puncturing the dis- 
 ed, but is extremely 
 ' one of the greatest 
 y may be performed. 
 
 conservative measure 
 nger from the general 
 Lppuration follow? ;b 
 
 fation of the gut; the 
 )ssible moment, Inita 
 
 Iy form of strangulated 
 Tated ab.iut the nu« 
 Ll Heroic the constnc- 
 Ihe sac, usually close tu 
 
 Ve condensation ot tlw 
 Iv very characteristic ^ 
 ' Some difficulty may 
 Vflammation of an »«.(.• 
 Vo persistent vomitnii 
 I testis below, and the 
 -n, when the swell.n? 
 p the case. Oaasion ' 
 Y a correct dia^no* 
 
 apart from an open exploration, may be almost impossible. 
 Torsion of the testis, and subsequent strangulation of the organ, 
 <;i\e rise to a swelling not at all unlike a strangulated hernia,' 
 but the absence of constipation and facal vomiting should pre\ent 
 mistakes. 
 
 Division of the stricture in the course of the operation is 
 always performed in a vertical direction, the surgeon cutting 
 directly upwards, the reason being that it is impossible in old- 
 standing cases to be certain whether the hernia is oblicjue or 
 direct, and thus the liability to injury of the epigastric artery 
 is diminished. 
 
 In Strangulated Femoral Hernia it is more common to find bowel 
 than omentum, and it is us this situation that partial hernia' 
 (Richter's) are most frequently met with. A tense painful swelling 
 is felt, situated in the neighbourhood of the saphenous opening, 
 and the diagnosis from inflamed lymphatic glands and phlebitis of 
 a \aricose saphena vein may not be altogether easy, particularly 
 if omentum alone is present. The history of the case, and a 
 careful consideration of the physical signs and symptoms, should 
 •generally be sufficient to clear up the diagnosis. The constriction 
 is usually met with opposite Gimbernat's ligament, and to divide 
 it the surgeon must cut directly inwards, so as to incise that 
 structure. The plan already mentioned of nicking it in two or 
 thrtie places, rather than freely dividing it, is especially useful in 
 this situation, on account of the occasional abnormal course of 
 the obturator artery, which is stated to be wounued once in every 
 150 cases. The accident would be recognised by the occurrence 
 '.)i free haemorrhage after the use of the hernia knife. In such a 
 case, the rupture is first reduced, the wound enlarged upwards, 
 and both ends of the divided vessel secured, if possible; failing 
 this, carefully adjusted pressure may be employed. Where the 
 constrictioii is very tight, so that it is almost impossible to pass 
 a directo*- bttween Gimbernat's ligament and the intestine, the 
 plan ahe\dy mentioned of dividing the constriction from without 
 ina\ '>! utilized with advantage. 
 
 In cases of gangrene where enterectomy is feasible, it will often 
 he necessary to open t)i;i abdomen by an additional incision above 
 the pehic brim, and 'hen haxing dixided the constriction at the 
 neck of the sac, the affected coil must be slipped back and pulled 
 out of the upper wound, the greatest care being taken not to 
 contaminate other coils of intestine. The shortness of the mesen- 
 tery renders it impossible to perform the necessary manipulations 
 through the W'ound in the groin. 
 
 Artificial Anus is the only means wlierehy Nature relieves the obstruction 
 (liif tn strangulated hernia One applies the term to a condition in which 
 an opening into the gut has been produced in such a wav that the greater 
 piirtKin of the feces finds an exit through it. It may arise from the sloughing 
 ot tlie intestine and c .erlying skin apart from ;>peration; or from tiie surgeon s 
 
958 
 
 A MANUAL OF SURGERY 
 
 interference, either by his opening,' tiie fjiit in mistake for the sac, or by 
 incising it when ^anRrenous ; or it may slouch snbse(iuently, if left in .w 
 when K''^»Krene is threatening. If no operation is undertaken, the surroun 
 ing pcirts settle down after a time and heal over, the diversion of the far>( 
 from their natural course becoming more and more complete, owing to the fi 
 mation of what is known as a .</>»;■ of mucous meml)rane, which lies across ar 
 blocks the entrance to the lower portion of the bowel (I'ig. 3^i) This sp, 
 arises partly as a result of the kinking of the gut, partly from «he inti 
 abdominal pressure which pushes the exposed inner wall of ti^'j intesti: 
 forwards. The effects produced by an artificial anus on the individual v, 
 with the portion of the bowel involved. If the jejunum or upper part of tl 
 ileum is thus opened, the patient soon loses ground and becomes einaciati 
 owing to the escape of the intestinal contents, before the nutritive elements 
 the food have been absorbed. liczema of the skin in the r.^-iuhbourhood 
 usually produced, resulting from the irritation of the f.rces. The artificial an, 
 made in order o prevent the flow of faeces over an ulcerated surface, as 
 colotomy for rc.tal cancer, is of ipiite a different character, since the surgt- 
 desires to P'-.tdblish such an efficient spur as shall prevent all passage of fa t. 
 down the knver part of the tube. 
 
 The curative Treatment of an artificial anus, where desirable, ccnsist-. 
 
 Fui. 3JJ — Dui'uytren's Enterotome. (Down Brothers.) 
 
 the re-estal)lishm'-nt of the lumen of the gut, and the closure of the e\tern.il 
 wound. To effect this, two chief methods have been recommended : (i) Tlie 
 old-fashioned ])lan necessitates the repression or removal of the spur as the 
 first stage in the proceeding, whilst the closure of the external woiiml is 
 eflected subsetpiently In some cases it may suffice to pass a large riil)l)er 
 drainage-tube into tlie gut, extending for some inches above and below the 
 opening, stitching it in position for a time by a fine catgut suture, which will 
 be absorbed in the course of a few days, and thus set the tube free, to lie 
 subsetpiently passed /i*- anum. The edges of the wound are pared after its 
 insertior, and the opening doseil, either by simply l)ringing the margins 
 together, or by turning in from tlie neighbourhood, and stitching into pnsition, 
 a reversed iiedunculated flap of skin, which exactly fits the opening in the 
 mucous membrane, and with its skin surface inwards. The raw surface 4 
 this flap is covered by another raised from the opposite side of the wound, 
 and fixed by sutures with its cutaneous surface outwards. In more chrcnic 
 cases, Dupuytren recommended that the spur should Ix' destroyed bydraggins 
 it outuards and grasping it by an enterotome (l"ig. jj j), which consists of two 
 blades fitting into one another, whicli are maintained in apposition by a screw 
 The portion thus grasped sloughs slowly away, tlie peritoneal cavitv l>eiii? 
 protected by a plastic inflammation. After destruction of the spin-, the 
 external wound may be closed as descrilied above. Such treatment of an 
 artificial .inns is tedious and uncertain ; whilst even if successful, the patient 
 probably sutlers from recurrent colic, owing to the adhesion of the intestine 
 to the afxiominal wall, a condition which may also expose him later on to 
 the risk of intestinal obstruction (2) A much better method of treatment b 
 that by means of an open operation In this a semilunar incision is made en 
 
HERNIA 
 
 959 
 
 for the sac, <>r by Ins 
 squentlv, if left in s,t,t 
 ilertaken. the surround- 
 . diversion of the laH.fs 
 inlete, oNvinKtothefor- 
 ,e which hes across ami 
 1 '(l-if.-. 321). This spur 
 
 iiartly from ^lie intra- 
 r wall of ti-. intestine 
 3 on the individual vary 
 im or upper part of il>e 
 iml becomes einaciai..!. 
 the nutritis-e elements ot 
 in the r.f^iuhbourhood ^ 
 rces The artificial anus 
 
 idcerated su;-face, as m 
 tracter, since thesuruiMi 
 vent all passaK'^ of l-'^ ''^ 
 
 tere desirable, ccnsisis in 
 
 
 either side of the artificial anus, by deepening which the peritoneal cavity is 
 freely opened, and the artificial anus, together with the surrounding' tissues 
 can be lifted up, exposing the coil of adherent intestine This is now clamw(i 
 above and below, tl.vided .is near to the openin;,' as possible, a V-shapeil 
 portion of mesentery removed, and the continuity of the intestinal canal 
 restored by some form of enterorrhaph , It is then returned to the abdomen, 
 and the external wi>uiul closed by sutures In the inj^uinal and femor.d 
 rcj^ions it is sometimes impracticable to undertake such an operation, owini,' 
 1(1 the important nature of the surrounding structures, ami then DupuMn-n s 
 method may be followed, or a lateral anastomosis established throii).jh a 
 separate incision into the abdomen between the portions of intestine f^joini,' to 
 find returninf; from tlv opening I the external aperture is subsecpientlv closed 
 In a plastic operation 
 
 Fsecal Fistula occasionally results from a strangulated hernia, owing to a 
 perforative innammation of the gut after the relief of strangulati(jn, wlietlu r 
 ;a the site oi constrictiim or above or below it, in the latter case arising from 
 a stercoral ulcer. Though the le ion may be intraperitoneal, it bv no means 
 tollows that general peritonitis need result, since sudicient j)lastic material 
 may be formed around it to shut off the general peritoneal cavity, and to 
 allow the extravasated cont' iiL.s of the bowel to find their way outwards 
 through a sinuous tract to .he external wound. It may l)e some days bef>>re 
 any evidence of the existence of this condition appears. Not uncommonlv the 
 (ipening will close natural'y as a result of cicatricial contraction, and hence 
 no steps need be taken to ileal with it until all hopes of such a result have 
 faded. Where, however, it persists, attempts may be made to effect this 
 purpose by injecting stimulating lotions, or by applying the actual cauterv to 
 the interior of the fistula; but more frequently an operatiim to expose, if 
 practicable, the wound in the gut, and to close it by suture, wi'I \^e necessary. 
 
 )OWN Brothurs ) 
 
 ;he closure of the eMeral 
 pn recommended: (1) TK 
 lemoval of the spur as the 
 lof the external wound .^ 
 U to pass a large ml >lHr 
 ches above and below He 
 \ catgut suture, which \m. 
 |s set the tube free to t^' 
 Ivound are pared after u^ 
 UViy bringing the mari,Mr~ 
 [and stitching into pnsui-' 
 11 V fits the opening m tlu 
 Vrds The raw surlace '■ 
 iposite side of the wound, 
 twards In more chn -vo 
 h be destroved by drangu.. 
 5jl), which consists olt\^ 
 d in apposition by a screw 
 L peritoneal cavity I'ein, 
 Irucli.m of the spur, t.ie 
 Such treatment "I ^ 
 if successful, the patu::: 
 adhesii)n of the intostir 
 , expose him later I'n ; 
 .-r method of treatment - 
 flunar incision is made •• 
 
CHAPTER XXXIII. 
 
 INTESTINAL OBSTRUCTION.* 
 
 By Intestinal Obstruction is meant a condition in whicli tl 
 onward passage of the feces is prevented. In arute cases it 
 often associated with strangulation, owing to the circulati< 
 through the vessels being impeded and finally arrested. 
 
 Many different types of classification of this condition have bee 
 suggested, and many of them are more or less valuable. Tin. 
 may be described as congenital or acquired- under the forme 
 term grouping together congenital stenosis, congenital adhesion- 
 etc., and under tlie latter all the ordinary conditions ; or they ma 
 be divided into classes according to whether the obstruction i 
 due to causes within the gut, to changes in the structure or relati\ 
 position of the intestinal wall, or to pressure from without, 'lln 
 most useful division is the clinical, grouping together those case; 
 which present a similarity in the symptoms ; and tliis methoc 
 will be employed here, the subject being discussed under tht 
 three headings — acute obstruction, chronic obstruction, and in 
 tussusception. 
 
 Acute Intestinal Obstruction. 
 
 The following are the chief Causes which gi\e rise to tliis 
 condition : 
 
 1. Strangulation by bands or adhesions, or through aper- 
 tures, etc. 
 
 2. \'ol\ iilus. I 
 
 3. The impaction of foreign bodies. 
 
 4. Strangulation over a band or acute kinking of the gut, hot ' 
 \ ery rare conditions. 
 
 5. Acute intussusception. 
 
 6. It may be the termination of a chronic obstruction. 
 
 * I'or much of the material incorporated in this chapter we beg to ackm 
 ledfje our indebtedness to Mr. Treves' classical text-book on tlie siibjec 
 (published by Cassell and C^o.), than which nothing better has appeared 
 which we have freely utilized. 
 
I. 
 
 PION.* 
 
 ondition in whicli the 
 . In arute cases it iv 
 ilie circulation 
 
 localized or ? iff *•'',"> '"'^h as th., :, , — ^^ 
 
 », *-«..i:.ut:n^ r""= ""«i. tis,"^ ■•'™'^ peri,;;;;,;: 
 
 atp ,64,'^' "^ "-™- in origin'" 'ff -;j-_e,,e„ ;,^,;;--e;o 
 
 tion. 
 
 licli </i\ii rise to tli 
 
 [IS, or through aper 
 
 iking of the gut, h 
 
 : obstruction. 
 
 ;hapter we beg to acknr 
 text-book on tlie siibji 
 ; better has appeared 
 
 l;'""'':y and .some 01,!' •"' "'"■ meWnierv- f°" "'""^t'o'i 
 
 t"n>ethods „f pnfd, r"'""= «'»■"' «i In '' ?''"','= ■'I'l'endi.x), 
 N under the arch o'"*"' '^''■••'"frniation e st . n"'' '^^toniii 
 
 Jesuit from union 
 6i 
 
96a 
 
 A MANUAL OF SURCKRY 
 
 between its fimhri.itod extremities and some part of the viscera 
 parietes, forming,' at first a l)road band-like adhesion, whicli 
 }j[radually moulded into a rounded cord by the constant draj^'f^ni 
 and puHing to which it is subjected. Tiiey are usually coars( 
 and thicker than those due to peritonitis, 'i'lie incchimisni 
 strangulation is identical, the noose Ibrm beiuj^^ perhaps the uk 
 connnon, since tile adhesions are likely to be lonj^er. (< ) Mccka 
 divciticuluw (p. .S73) is liable to cause strangulation when its In 
 end becomes adherent either to tlie parietes or to the \is(era; 
 is attached most fre(]uently to the mesentery of the ileum, an 
 after that to the neighbourhood of the umbilicus. Occasional 
 the diverticiduni ends in a fibrous cord, which may remain fi\( 
 to the umbilicus, or floats free in the abdominal cavity, and siil 
 se(|uently becomes adherent to some other structure, thus pii 
 ducing a hbrous cord. .Strangulation may be effected by bowt 
 
 passing under the loop, formed by th 
 adherent diverticulum. {d) The vevniiftn: 
 (ippiiiiiix, apf^cndices epiploidc, or Fallopian tult 
 may contract abnormal attachments, aiu 
 thus form arches or loops under which bowc 
 may pass and become strangled. (<•) .S7//5 
 pouches, and apcHiin's in the peritoneal invest 
 ment, whether normal or abnormal, may K>;ui 
 to strangulation. .\ll external hernia' may 
 be grouped under this heading, as also those 
 rare conditions known as internal hernia, in 
 which the abdominal contents fitul their way 
 into pouches in ihv posterior wall of the 
 peritoneum, f.^^, into the lesser sac of the 
 omentum, or tiie so-called fossa duodeni)- 
 jejunalis. Slits may also be found in the 
 omentum or mesentery, either congenital, traumatic, or the result 
 of operations. 
 
 Phenomena. — This form of obstruction usually occurs in youiij; 
 people, and is rare after forty; it constitutes above one-fourth of 
 all the forms of internal obstruction, .and the lower 2 feel of 
 the ileum are most frefi'iently involved. There is commonly a 
 previous history of peritonitis, but the onset is usually suildcii, 
 and the symptoms of strangulation, as detailed above, are of a 
 typical character. The abdomen is l1ac( itl at first, and not temlfi 
 until peritonitis ensues, on about the third or fourth day. Their 
 is generally no ob\ ious tumour, and no peristalsis or dilated coil> 
 of intestine are to be seen. The average duration is about fiu 
 to se\en days, the patients dying of exhaustion or toxa'tnia follou 
 ing peritonitis. 
 
 2. Volvulus is the most connnon cause of acute priiuaiy 
 obstruction of the large intestine. Hy it is meant a rotatici 
 of the gut upon its own mesenteric axis in such a way a^ '' 
 
 •■"■ M5 — Stramiu 
 i.ATioN Hv Hand 
 
 (TlLLMANNS.) 
 
INTESTINAL OBSTRUCTION 
 
 963 
 
 :vrl of the viscera cr 
 
 luUu'sion, whicli is 
 e constant drat^^Mii'^ 
 
 :ue usually coarser 
 
 The mcchanisiu nt 
 if,r perhaps the m«.U' 
 lon^'er. {c) Mcckd'^ 
 iliition when its fiw 
 or to the viscera; n 
 -y of the ilevuu, ami 
 ilicus. Occasionally 
 eh may remain lixcd 
 linal cavity, and sub 
 
 structvire, thus pro 
 be etVected by bowel 
 op, formed by th. 
 ((f) The venuiforii: 
 nar, or FoUopinu tuU. 
 ,;il iittacluuents, aiul 
 ns under which bow.l 
 ; strangled. (0 Sliiu 
 
 the peritoneal invest- 
 or abnormal, may U-;ul 
 
 external hernia> may 
 headint;, as also tlios. 
 
 ■IS internal hernia, m 
 ontentsimd their wav 
 posterior wall of tlif 
 
 the lesser sac of tlu' 
 -ailed fossa duodenn 
 
 tlso be fomul m tlu 
 
 aumatic, or the resini 
 
 ,uallv occurs in yoim:^ 
 es above one-fourth nt 
 
 the lower 2 teel it 
 iThere is comnionlv '. 
 ^ct is usually suckk'ii. 
 I ailed above, arc ot a 
 lit Inst, and not tcmld 
 
 [or fourth day. H'^';! 
 
 listalsis or dilated coii> 
 
 [luration is about tn. 
 
 Ion or toxaMUia lollov 
 
 ,e of acute primal)! 
 
 is meant a rotation 
 
 (in such a way a- iM 
 
 interfere not only with the passa.tje of the intestinal contents, but 
 
 also, sooner or later, with the circulation, dcterininin-,' a condition 
 
 of stran},'ulation. Occasionally a similar result is brouj^ht about 
 
 by the intertwining,' of one coil with another. The si^'moid (Irxure 
 
 is the part mainly aflected, althou^di it occurs in the c;rcum or 
 
 small intestine. In the former situation it is predisposed to by a 
 
 loiif; narrow sif,nnoid meso-colon, so that the two ends of the loop 
 
 are lirouf,dit closely together ; this condition may be of con^'enital 
 
 origin, but is usually due to the traction induced by prolonged 
 
 ( hronic constipation ; a distended sigmoid hanging into the pelvic 
 
 cavity drags upon and elongates the meso-colon, tending to 
 
 approximate the two ends of the loop, and necessarily causing a 
 
 slight obstruction at these spots. Some irregular movement of 
 
 the gut or of the aixlominal walls suffices to cause rotation of the 
 
 pedicle, and thus brings about the \ olvulus. When once present, 
 
 plastic peritonitis soon fixes the coil, whilst the pressure on the 
 
 vessels causes venous congestion and such obstruction to the 
 
 arterial supply of the gut as almost certainly to end in its death. 
 
 Distension of the coil with gas from decomposition of the retained 
 
 feces also aggravates the condition. 
 
 Symptoms. — Volvulus is rare before the age of forty, and 
 apparently occurs more often in the male sex. A history of 
 chronic constipation precedes it, but the acute symptoms start 
 abruptly. Pain is always present, at first intermittent, but finally 
 constant, and there is usually early tenderness o\er the sigmoid 
 riexure. The pain, vomiting and collapse are not so se\ere or 
 marked as in other forms of strangulation, but abdominal dis- 
 tension from excessive flatus, and resulting dyspncea and thoracic 
 cinbarrassment, are very distressing. Tenesmus is occasionally 
 present. A localized peritonitis is usually developed, but it some- 
 times becomes diffuse. Natural cure is unknown, the patient 
 cither dying in five or six days from collajise and interference with 
 respiration, or at a somewhat later date from peritonitis. 
 
 3. Impacted Foreign Bodies, causing intestinal obstruction, may 
 be of three types : gallstones, foreign bodies that have been 
 swallowed, or intestinal concretions (enteroliths). 
 
 Gallstones can only cause obstruction when of large si/.e, and 
 such usually gain entrance to the intestine by ulceration from the 
 i,'all-l)ladder into the duodenum. A coating of f;ecal material is 
 likely to form around them, and thus they increase in size as they 
 pass downwards, whilst the intestine gradually diminishes in 
 calibre from the duodenum to the ileum ; the usual site of im- 
 paction is in the lower ileum. Women over fifty are most often 
 the subjects of this condition, and there may be only a history of 
 some inflammatory condition in the region of the gall-bladder, 
 and none of biliary coli(-. Such patients frequently suffer from 
 intermittent subacute attacks of incomplete obstruction, which, 
 thouf^h severe for a time, are relieved by purgatives. If the gall- 
 
 61 — 2 
 
964 
 
 A MANUAL OF SUKC.HRY 
 
 stone IS not passed, a final acute attack supervenes, which begins 
 suddenly witii the typical si^'ns of acute obstruction, although the 
 pain and collapse are not so marked as in cases of strangulation, 
 ileath resulting from peritonitis or exhaustion. 
 
 When the oi)struction is due to jovci^n bodies which have been 
 swallowed^ the symptoms are usually subacute to start with, but 
 may lead to perforation if of irregular shape. 
 
 Enteyoliths are of thiee classes : {a) Calculi of phosphate 
 lime or inspissated faeces form around some foreign body as a 
 nucleus, (b) Masses of indigestible vegetable material may he 
 matted together with inspissated faxes, mucus, etc. ; they are said 
 to be not unconnnon in Scotland (the so-called aveiiolitli), beiti^ 
 mixed up with the husks of the coarse oatmeal there eaten. They 
 have also been known to consist of hair, or of cocoanut fibre in a 
 patient engaged in mat-making, (c) Calculi have l>een fmuid 
 consisting of insoluble mineral salts, c.)^'., carbonate of magnesia 
 or chalk, taken as medicine. "Whatever their origin, such entero 
 liths are usually impacted near the ca.'cum, and if causing acute 
 obstruction the symptoms are similar to those produced by a 
 large gallstone, being preceded by chronic attacks and severe 
 colicky pain. In thin persons their presence may be detected i)y 
 palpation of the abdomen. 
 
 4. Acute obstruction ensues when a coil of intestine lod^^'es 
 across a tightly drawn adhesion, the lumen at each end beinj,' 
 thereby entirely occluded, and the circulation arrested. Tlie 
 usual acute symptoms follow, which may, however, be relieved 
 spontaneously. Sudden kinking of the gut may lead to the same 
 result, being due to the contraction of fibrous adhesions or the 
 dragging of diverticula. 
 
 5. For Acute Intussusception, see p. qyi. 
 
 6. When acute symptoms are developed at the termination ot 
 a case of chronic obstruction, the pain from being intermittent 
 becomes constant, the vomiting more violent and faecal in char- 
 acter, and the fatal termination is due to acute peritonitis or to 
 exhaustion and toxaemia. Absolute constipation is always present, 
 and the abdomen is much distended. 
 
 The Diagnosis of acute obstruction is not pev sc a matter di 
 much difficulty, since the phenomena are extremely characteristic ; 
 but it is usually impossible to make certain of the cause of the 
 obstruction apart from an exploratory laparotomy. 
 
 Some care is also needed in distinguishing true obstruction tnmi 
 the obstructive symptoms associated with acute localized enteritis 
 or peritonitis, such as is seen in appendicitis, when the intestina 
 walls are paralyzed. This pseudo-obstruction is sometimes \ery 
 marked, and even fa-cal vomiting may occur, but by a careful 
 attention to the history and general condition of the patient a 
 correct diagnosis should be reached. We append a table ilhis 
 trating the chief diagnostic points between acute strangulation 
 
INTI-STINA L OliSTRUCTION 
 
 965 
 
 nes, which begins 
 tion, although the 
 i of stran^^ulatiun, 
 
 which have betn 
 to start with, Init 
 
 i i)f phosphate of 
 foreik'n hody as a 
 a material nmy hv 
 
 etc. ; they are said 
 ed avenolith), beiuK 
 there eaten. They 
 
 cocoanut libre m a 
 1 have l^een fnini'l 
 bonate of magnesia 
 
 origin, such entero 
 md if causing acute 
 hose produced by a 
 attacks and severu 
 
 may be detected In- 
 
 of intestine lodj^es 
 
 n at each end barifj 
 
 .tion arrested. I'h" 
 
 [lowever, be relieved 
 
 may lead to the same 
 
 lus adhesions or the 
 
 lat the termination ol 
 
 \n being intermittent 
 
 ]t and fffical in char 
 
 nite peritonitis or to 
 
 [ion is always present. 
 
 her se a matter' 't 
 
 imely characteristic ; 
 
 of the cause of the 
 
 tomy. 
 
 [rue obstruction trum 
 iite localized enteritis 
 when the intestinal 
 nn is sometimes very 
 Kr, but by a careful 
 lion of the patient a 
 Impend a table ilUis- 
 ' acute stranguhitmn 
 
 and acute appendicitis associated with peritonitis, one of the 
 coi iinonest causes of pseudo-obstruction : 
 
 
 Acivri-: Inikknal 
 
 ACUTK AnKNDICITIS WITH 
 
 
 SXRANliCLATlON. 
 
 I'hkitomtis 
 
 Onset - 
 
 Abrupt. 
 
 May be preceded by local pain. 
 
 Kigor - 
 
 Absent. 
 
 Often present 
 
 Temperature 
 
 Subnormal at first, rising at 
 
 High at first, falling later from 
 
 
 onset of leritonJMs. 
 Severe ; re erred to the um- 
 
 exhaustion or tox.imia. 
 
 1 'ain - 
 
 Severe ; irimarilv referred to 
 
 
 bilicus 
 
 the right iliac fossa 
 
 Tenderness - 
 
 Absent till peritonitis comes 
 
 Present over ca-cum even in 
 
 1 
 
 on. 
 
 early stages, and gradually 
 spreading 
 
 Vomiting 
 
 Early, marked, and soon 
 
 Less urgent, and seldom f.Tcal. 
 
 1 
 
 facal. 
 
 except as a late symptom 
 
 Abdominal 
 
 I'laccid till peritonitis is 
 
 Tense and rigid from the first. 
 
 parietes - 
 
 present. 
 
 
 'Hie Treatment of acute obstruction is practically included in 
 one word — Laparotomy. The condition of the gut is in most 
 cases identical with that found in a strangulated hernia, and 
 although a few patients may recover by palliative measures, e.s;., 
 enemata, opium, ice, etc., yet the majority would be gravely 
 injured in the delay caused by their employment. The danger 
 of laparotomy increases directly with delay ; hence, the sooner 
 it is undertaken, the better for the patient. Whilst prepara- 
 tions for the operation are being made, an enema may be 
 administered to clear the lower bowel, ice being given to 
 suck, and a small dose of opium to relieve urgent pain. Two 
 main objects must always be kept in mind in the operative 
 treatment of such cases, viz., {a) to empty the distended bowel, 
 and (b) to remove the cause of the obstruction. The second of 
 these requisites is always most desirable, but unless at the same 
 time the putrid contents of the upper portion of the intestine are 
 removed, but little real good has been accomplished, since the 
 patient is being slowly poisoned by septic absorption. The late 
 Mr. Greig Smith has declared most emphatically that 'no opera- 
 tion for intestinal obstruction is complete if the patient leaves the 
 operating table with a greatly distended abdomen.' Moreover, it 
 must be remembered that the formation of an artificial anus is 
 often insufficient to give relief, owing to the paralyzed and dis- 
 tended condition of the intestinal wall above. Hence, in many 
 cases, it is desirable to deal with the engorged bowel tirst, and 
 to leave the search for the obstructing body till a later date. A 
 very high death-rate must always be expected in these cases, but 
 
966 
 
 A MANUAL 01- SURGERY 
 
 ar^' 
 
 statistics prove that, in cases where the cause of the ohstructic 
 is not at once obvious, primary enterostomy, if followed by 
 satisfactory discliarj^e of the intestinal contents, gives results i 
 many instances ecjual to, or even better than, treatment direct( 
 towards the cause of the trouble. 
 
 In the most urgent cases, where the patient's abdomen is acutel 
 distended, and fjLcal vomiting has been present for some time, i 
 is not advisable to administer a general anasthetic : if such i 
 attempted, the patient's life is often lost from stoppage of tli 
 respiration, precipitated possibly by a severe attack of fan a 
 vomiting. A few drops of cocaine may be placed under the skii 
 and a small incision made through the linea alba below ili 
 umbilicus ; the first presenting coil of intestine is withdrawn, am 
 after protecting the peritoneal cavity with gauze or sponges, 
 tapped with a large trocar and cannula so as to allow the tirs 
 gush of flatus and faeces to be carried away from the wound 
 The opening is then enlarged sufficiently to allow a Paul's tiilu 
 to be introduced and tied in, and whilst the bowel is emptying: 
 itself, it is fixed by stitches to the abdominal wall. The stomach 
 should always be thoroughly washed out with warm water before 
 or during the operation. 
 
 In less severe cases, the stomach should be washed out as a 
 preliminary measure before administering the anaesthetic. The 
 abdomen is then opened in the middle line below the umbilicus. 
 and a definite search made for the cause of the obstruction, 
 The hand is first passed to the hernial regions, and then to 
 the right iliac fossa, so that the ciccum may be examined. If 
 this is distended, the cause necessarily lies below it ; if collapsed, 
 above it. In the former case, the condition of the sigmoid 
 flexure should next be investigated, and finally, if this viscus 
 is collapsed, the hand should be run along the colon, special 
 attention being directed to the splenic flexure. If the cacum 
 is collapsed, perhaps the best method to adopt is to gently with- 
 draw from the abdomen successive portions of gut, about a foot 
 at a time. These are carefully examined, and replaced by the 
 assistant whilst the next portion is being withdrawn. The 
 remainder of the intestines during this process are protected and 
 kept back by the application of towels which have been dipped in 
 hot sterilized salt solution. The obstruction is in this way sooner 
 or later discovered, and may be dealt with according to circum- 
 stances. If the intestines are too distended to allow of such 
 manipulation, it may be advisable to open or tap one or more 
 of the dilated coils, and thus reduce the distension before pro- 
 ceeding with any methodical search for the obstruction. 
 
 Omental bands or peritoneal adhesions should be divided 
 between ligatures. The vermiform appendix or Meckel's diverti 
 culum may be excised according to the method described at 
 p. 904. A volvulus should be untwisted, if possible ; but this is 
 
INTHSTINA L OnSTlU'CllOS 
 
 ')(>7 
 
 of the obstruction 
 , if followed by a 
 ts, gives results in 
 \ treatment clirecttd 
 
 Eibdomen is acutely 
 nt for some timi-, \i 
 tisthetic : if such is 
 Dm stoppage of the 
 ire attack of taial 
 aced under the skin, 
 lea alba below ihc 
 ne is withdrawn, ami 
 jrau/.e or sponges^, is 
 as to allow the hrst 
 ay from the wound. 
 
 allow a Paul's tube 
 e bowel is emptying; 
 
 wall. The stomach 
 th warm water before 
 
 be washed out as a 
 the anaesthetic. I he 
 . below the umbilicus, 
 [e of the obstruction, 
 regions, and then to j 
 iiay be examined, t 
 .,elow it ; if collapsed, 
 lition of the sigmoid 
 I finally, if this viscus 
 La the colon, special 
 ',^re. If the caecum 
 jpt is to gently with 
 /of gut. about u fool 
 and replaced by he 
 hrr withdrawn. inf 
 ess are protected and 
 Ih have been dipped m 
 I is in this way sooner 
 according to circum , 
 ded to allow of such 
 or tap one or more 
 istension before pro- 
 ibstruction. , 
 
 IS should be divided 
 X or Meckel's diverti- 
 method described at 
 possible ; but this is| 
 
 usually impracticable, owing to peritoneal adlu-sions, and in such 
 cases it is advisable to withdraw the (oil from tiu- ai)d()nien, and 
 it the large intestine is involved, an artificial anus slunild he made. 
 I'oreign bodies are, if possible, ilisplaced lorwaids or backwards 
 to a more healthy portion of the bowel, and then removed by a 
 longitudinal incision along the antimesenteric border, the wound 
 being subsetpiently closed by a row of Lembert's sutures. Of 
 course, volvulus of the small intestine or gangrene of the gut, if 
 present, may necessitate an enterectomy. 
 
 Chronic Intestinal Obstruction. 
 
 The Causes of chronic obstruction are very numerous, and, 
 looked at from an anatomical standpoint, may be divided into the 
 following groups : 
 
 1. Intra-intestinal conditions, ci^., impaction of faces, foreign 
 bodies, etc. 
 
 2. Affections of the intestinal walls, such as stricture, new 
 f,'ruwths, adhesions or matting together of coils of intestine, con- 
 traction or kinking of the gut from mesenteric gland disease, etc. 
 
 3. Compression of the bowel by tumours, cicatricial bands, 
 etc., developing outside the intestine. 
 
 Tile General Symptoms of chronic obstruction are more or less 
 as follows : The patient suffers from gradually increasing con- 
 stipation, alternating occasionally with watery diarrhu^a, spurious 
 in nature, and set up by a catarrhal enteritis due to the irritation 
 of retained faeces. At irregular intervals more severe symptoms 
 arise, consisting of pain, colic, vomiting, and absolute constipation, 
 owing to some temporary complete obstruction, as by a mass of 
 undigested food or freces becoming impacted, assisted perhaps by 
 a valve-like fold of mucous membrane across the passage. These 
 attacks usually pass off after a time, a copious evacuation of the 
 iiowels taking place either naturally or as the result of the 
 administration of a purgative. Finally, one of these seizures 
 persists and destroys the patient, either by exhaustion, or perfora- 
 tion followed by peritonitis, unless suitable treatment is promptly 
 adopted. The vomiting is never such a marked feature as in 
 acute obstruction, until the final stage, when it becomes f;ecal. 
 The abdomen is always more or less distended and tympanic, 
 and its contour varies with the site of the obstruction ; if this is 
 situated above the ileo-ca'cal valve, the swelling is mainly central, 
 whilst if in the rectum or lower portion of the colon, it is most 
 I marked in the flanks. Distended coils of intestine can be plainly 
 seen through the abdominal walls in thin subjects, as also evident 
 peristalsis. When arising from simple stricture, no tumour is 
 to he felt ; Init if due to malignant disease, and if the abdomen is 
 [Dot very distended, the growth may possibly be detected. 
 
 Faecal Impaction occurs in adult females who have previously 
 
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 (716) 872-4503 
 
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968 
 
 A MANUAL OF SURGERY 
 
 suffered from chronic constipation. The caecum and sigmou 
 flexure are the most common seats of obstruction, and a dough} 
 tumour may often be felt at one of these spots, which can ii 
 some cases be indented with the fingers, whilst in others it ma\ 
 be of stony hardness. The surface of the mass is usually more 
 or less nodulated, and tlu intestine tender from the accompanying 
 inflammation. The acute symptoms are always preceded by ; 
 prolonged period of malaise and ill-health, the appetite bein< 
 defective, the breath offensive, and the tongue foul. On recta 
 examination the presence of scybala may often be detected. 
 
 The special symptoms arising from the other conditions whicl 
 give rise to chronic obstruction, such as stenosis of the bowel 
 have been already referred to (p. 877). 
 
 The Diagnosis of chronic obstruction is obvious, but it is oftei 
 by no means easy to ascertain the exact cause of the trouble. A 
 thorough investigation of the case, according to the plan giver 
 hereafter, must be undertaken, and by this means some con 
 elusion may be arrived at as to "the nature and seat of the 
 obstruction. 
 
 The Treatment of chronic obstruction is always a matter 
 difficulty and anxiety, owing to the uncertainty often felt as to the 
 diagnosis. It ought to be possible, however, to decide whether 
 the block is located in the large or small intestine, since the 
 character of the abdominal distension and the symptoms are 
 tolerably distinctive in the two forms. 
 
 If the case is not of the most urgent type, the patient is put to 
 bed, the diet restricted to fluids, and belladonna, combined with 
 small doses of calomel, administered. At the same time copious 
 enemata should be given two or three times daily, but purgatives 
 are studiously avoided, as also opium ; probably the patient has 
 taken plenty of the former before coming under observation, 
 whilst the latter, although it may check vomiting and relieve 
 pain, is certain to mask symptoms, and thus prevent the true 
 course of the disease from being watched. Should the symptoms 
 be urgent from the commencement, or the treatment fail, the 
 question of operation has to be faced. If the obstruction is 
 located in the small intestine, a laparotomy must be undertaken, 
 using the same precautions as in acute cases. If the cause of the 
 trouble is easily found, a coil situated just above is withdrawn 
 from the abdomen, opened, and a Paul's tube subsequently tied 
 in so as to allow retained faecal material to escape. It is wiser 
 not to deal with the local trouble (unless strangulation is present) 
 until the urgent symptoms have disappeared. If, however, the 
 patient's condition is serious and the site of obstruction cannot 
 readily be found, any distended coil may be withdrawn and 
 opened. The practice of allowing numerous coils of intestine to 
 escape in order to facilitate the exploration of the abdomen is not 
 to be recommended. 
 
INTESTINAL OBSTRUCTION 
 
 969 
 
 eecum and sigmoid 
 ction, and a doughy 
 spots, which can in 
 ilst. in others it may 
 lass is usually more 
 -n the accompanying 
 ways preceded by a 
 the appetite being 
 rue foul. On rectal 
 'n be detected, 
 her conditions which 
 enosis of the bowel, 
 
 vious, but it is often 
 ;e of the trouble. A 
 ig to the plan given 
 Is means some con- 
 :ure and seat of the 
 
 ; always a matter of 
 ity often felt as to the 
 ■er, to decide whether 
 il intestine, since the 
 d the symptoms are 
 
 ;, the patient is put to 
 onna, combined \yitli 
 he same time copious 
 daily, but purgatives 
 fbably the patient has 
 g under observation, 
 vomiting and relieve 
 thus prevent the true 
 Should the symptoms 
 le treatment fail, the 
 If the obstruction is 
 must be undertaken, 
 If the cause of the 
 . " above is withdrawn 
 [ube subsequently tied 
 ;o escape. It is wiser 
 ■angulation is present) 
 red. H, however, the 
 [of obstruction cannot 
 y be withdrawn and 
 Is coils of intestine to 
 of the abdomen is not 
 
 When the cause of the obstruction is located in the large intestine, 
 colotomy is usually required. The lumbar operation may possibly 
 be undertaken ; but the majority of surgeons at the present time 
 prefer the iliac proceeding, although the peritoneum has to be 
 opened, and the risk of faecal contamination is thus increased. If 
 the rectum or sigmoid flexure is clearly the seat of the trouble, 
 tlie usual incision on the left side can be made ; but if there is no 
 indication as to the part of the colon involved, a median lapar- 
 otomy is perhaps preferable, a distended portion of the gut being 
 withdrawn and tapped, and a Paul's tube tied in. 
 
 In chronic peritonitis, where the intestines are hopelessly matted 
 together, but little can be done beyond the administration of 
 enemata, and possibly abdominal massage. The history of the 
 case will generally suffice to suggest its nature, and operative 
 treatment should then be avoided. 
 
 Faecal impaction requires the regular and repeated administra- 
 tion of large enemata, given through a long tube, whilst belladonna 
 and calomel may also be administered. Should hard scybala be 
 lodged in the rectum, it may be necessary to break them up in 
 situ, and remove them piecemeal. 
 
 Intussusception. 
 
 By Intussusception is meant the protrusion or invagination of 
 one part of the intestine into another, giving rise to the condition 
 illustrated in Fig. 336. The constituent parts are seen more 
 diagrammatically in Fig. 337. The upper portion is always pro- 
 lapsed into the lower, except occasionally during the irregular 
 peristalsis which takes place during the death-throes. The 
 invaginated portion (a) is known as the intiissnsceptmn , whilst the 
 lower portion (b) into which it is protruded is known as the intns- 
 siiscipiens. An intussusception, then, consists of three layers — the 
 outer or ensheathing layer (i.), an inner or entering layer (iii.), and 
 between the two the returning layer (ii.). Not only does the 
 intestine enter, but with it a certain portion of the mesentery ; 
 and it is to the constriction of the vessels contained therein, and 
 later on possibly to their complete obstruction, that the more 
 serious phenomena are due, e.g., gangrene, perforation, or rupture 
 of the gut. In addition to this, actual obstruction to the passage 
 of the intestinal contents may be brought about by the traction 
 of the mesentery, which renders the orifice of the intussusceptum 
 slit-like, by the swelling and congestion of the intestinal wall, or 
 perhaps by the impaction of a portion of undigested food within 
 the lumen of the gut. Peritonitis usually follows, being possibly 
 due to the invasion of a portion of the damaged intestinal wall 
 by the Bac. colt. If limited in extent, it may merely lead to 
 irreducibility of the intussusception, owing to adhesions forming 
 between the serous coats of the entering and returning layers. 
 
970 
 
 A MANUAL OF SURGERY 
 
 In other cases, and especially when ulceration or gangrene 
 present, a diffuse peritonitis may be lighted up, and this mi 
 result in the death of the patient. The bowel above the site 
 invagination becomes dilated, and possibly stercoral ulcers m; 
 be formed, particularly in the more chronic cases. 
 
 The Cause of intussusception is generally stated to be irregul 
 and violent peristalsis, however induced, whether by the presen 
 of irritating ingesta, or by the existence of polypoid tumoui 
 malignant growths, or possibly worms : the presence of scybalo 
 masses of faeces may also lead to its occurrence. In a few cas 
 
 Fig. 336. — Intussusception. (From Specimen in College of Surgeo 
 
 Museum.) 
 
 injury, e.g., blows on the abdomen, or severe strains duri 
 jumping, have been held responsible for its onset. 
 
 Intussusception is met with in four chief situations: (i) T 
 ileo-ccecal variety is much the commonest, constituting 44 j 
 cent, of all cases (Treves). In it the ileum is protruded into t 
 colon, the apex of the intussusceptum being formed by the il( 
 caecal valve. Owing to the great mobility of the ileum, a cc 
 siderable portion of gut may be thus invaginated, and a go 
 many cases have been observed in which it has actually project 
 through the anus. (2) The enteric variety involving the sni 
 intestine comes next in order of frequency, being met with 
 30 per cent, of the cases. It is most often seen in the lev 
 jejunum, and is rarely of great size. (3) The colic form m 
 
INTESTINAL OBSTRUCTION 
 
 971 
 
 tion or gangrene is 
 d up, and this may 
 wel above the site of 
 stercoral ulcers may 
 
 ases. 
 
 stated to be irregular 
 3ther by the presence 
 3f polypoid tumours, 
 presence of scybalous 
 ence. In a few cases 
 
 occur at any part of the colon or rectum, and, owing to the fixity 
 of this portion of the gut, is Hmited in extent. It is met with in 
 about 1 8 per cent, of the cases. (4) The ileo-colic only occurs in 
 8 per cent. ; in it the ileum is protruded through the ileo-ca^cal 
 valve, which for a time retains its normal position ; hut after the 
 intussusception has attained a certain size, the valve and cjEcum 
 are also invaginated into the ascending colon. In each of these 
 varieties, except the last, the intussusception grows at the expense 
 of the external or ensheathing layer, the apex of the protrusion 
 being always formed by the same portion of gut ; but in the ileo- 
 colic variety, as just stated, it increases by the passage of more 
 
 m 
 
 f\ 
 
 <j 
 
 |,N COLLEGE OF SURGEONS 
 
 severe strains during 
 
 Is onset. / \ Til I 
 
 lief situations: (i) ^^^\ 
 
 1st, constituting 44 Pf I 
 
 Vm is protruded into the 
 
 Lff formed by the ileo- 
 
 [itv of the ileum, a con^ 
 
 tvaginated, and a good 
 
 lit has actually projectej 
 
 Ity involving the small 
 
 Incy, being met with 10 
 
 te seen in the lowe. 
 
 [3) The colic form nia\ 
 
 Fig. 337.— Diagra.,- of Intussusception. 
 
 a, Intussusceptum ; b, intussuscipiens ; I., ensheathing layer ; 
 II., returning layer ; III., entering layer. 
 
 and more of the ileum through the valve ; after a time this stops, 
 
 and is replaced by the ordinary form of growth. 
 Intussusception is occasionally met with as a post-movtem 
 
 phenomenon, due to the irregular intestinal movements occurring 
 [during the death crisis. The condition is recognised as being 
 I of this nature by the absence of inflammatory signs, by the fact 
 
 that it is sometimes due to a reverse peristalsis, and by more than 
 [one intussusception being present. 
 
 The Clinical History varies according to whether the condition 
 |is acute or chronic. 
 
 Acute Intussusception occurs most frequently in young children, 
 Ithe onset being usually sudden. The child is attacked with 
 Isevere pain, possibly localized and more or less paroxysmal at 
 [first, but rapidly becoming continuous and diffused over the 
 
 ibdomen. This is followed by vomiting, which, however, is less 
 
972 
 
 A MANUAL OF SURGERY 
 
 severe than in acute stranf^ulation, and not so often taecul 
 The patient rarely suffers from absolute constipation, diarrl 
 and the discharge of blood-stained mucus, perhaps associa 
 with tenesmus, being common. Collapse soon supervenes, 
 in the worst cases this may be so severe as to kill the pat: 
 within twenty-four hours ; otherwise a fatal issue from exhaus 
 or peritonitis is reached within a week. On examining 
 abdomen, but little distension or tenderness is noted, unless ac 
 peritonitis is present ; in about half the cases a distinct tum 
 can be felt, cylindrical in outline, and sometimes descri 
 as * sausage-shaped,' following the course of the intussuscept 
 and generally curved, owing to the traction of the mesent( 
 In the ileo-caecal variety it extends from the right iliac fo 
 across the brim of the pelvis to the left, the colon being dragj 
 downwards. This may be associated with an absence of resista 
 in the right fossa, which feels empty, constituting what is kno 
 as the 'signe de Dance.' In other cases the tumour may 
 more limited, and distinctly moveable. 
 
 A natural cure occasionally follows, resulting either fr 
 spontaneous reduction, or from sloughing of the intussuscepti 
 whilst the peritoneal cavity is shut off by a circle of plastic lyn 
 uniting the ensheathing and entering layers of the gut. Wl 
 the latter takes place, the subsequent condition is not very sa 
 factory, owing to the formation of a fibrous stricture. 
 
 Chronic Intussusception occurs more frequently in adults th 
 in children, the onset being gradual and the course varyi 
 widely in different cases. The patient complains of intermitt( 
 attacks of pain of a colicky nature, which recur at inter\'£ 
 the attacks becoming more frequent and prolonged as the c; 
 progresses. Vomiting is often but little marked during the 
 termissions. The bowels are irregular in their action, and th( 
 is sometimes a blood-stained mucous discharge. The gene 
 condition is not at first much affected, but as the case progress 
 emaciation and general asthenia may superv^ene. On examii 
 tion, the abdomen is found to be flaccid and free from tenderne 
 although visible coils of intestine may be observed in soi 
 cases, and perhaps a tumour felt. The symptoms are rati 
 those of subacute enteritis and chronic obstruction than 
 strangulation, and the case may be brought to a fatal termir 
 tion either by an acute attack of obstruction or by peritonii 
 It may, however, last a long time before being recognised. 
 
 Treatment. — In the most acute forms of the disease but lit 
 can be done, owing to the extreme prostration of the patier 
 but in the less severe and in the chronic cases much can 
 attempted to prevent a fatal issue. 
 
 In acute intussusception the patient should be at once plac 
 under the influence of opium, in order to still peristalsis and pi 
 vent the increase of the tumour. Inflation of the bowel with a 
 
rEKY 
 
 '. not so often taeculent. 
 2 constipation, diarrhaa 
 cus, perhaps associated 
 le soon supervenes, and 
 "e as to kill the patient 
 tal issue from exhaustion 
 k. On examining the 
 5ss is noted, unless acute 
 cases a distinct tumour 
 d sometimes described 
 e of the intussusception 
 ction of the mesentery, 
 m the right iliac fossa 
 the colon being dragged 
 an absence of resistance 
 istituting what is known 
 es the tumour may be 
 
 .a^Iffla^^^^OBSTliUCTlON 
 
 as 
 Dervene. un examina- 
 ad free from tenderness, 
 
 be observed in some 
 ; symptoms are rather 
 c obstruction than of 
 ght to a fatal termina' 
 ction or by peritonitis, 
 eing recognised, 
 if the disease but little 
 )tration of the patient; 
 ic cases much can '" 
 
 S if Th ' '"practicable, owin<? to th. ^''°'" ''"'f 'he cases' 
 toss s ep^ilriSJurb*"" °" *: pa^STf^il ="'^!f°" 
 
 mesenteric border rf the inJJIf'™ '^'"S made (KT* f "?" 
 condmon of profound hU all h„t°"''"r' "'e paS„t ? 'T„"^ 
 
 "anTiatn VuTLT r 'f^ "'™°- '-y be ;:duc°edr """'/ 
 
 resulting either from 
 
 of the intussusceptum, 
 a circle of plastic lymph 
 'ers of the gut. When 
 ndition is not very satis- 
 IS stricture. 
 
 requently in adults than 
 nd the course varying 
 jmplains of intermittent 
 lich recur at intervals. 
 
 prolonged as the case 
 
 marked during the in- 
 
 1 their action, and there |manipuraIion"Vut"L''^'^' *^ ^""^^^^ ^^^Vhe redZ/K^'^''^^^^ 
 ischarge. The general | Excision of the 1.? ? 7^ *°° ^"any adhesfo " !, ^ ''"'P^^ 
 : as the case progresses Jgained have been ve' . '^'" ^' ""derTatn and th ^"''T 
 
 Dervene. On examina- ■ "^^"^^^ encouraging. '^"' ^"^ the results 
 
 nd free from tenderness, ■ Invnoti^o*- 
 
 Wi^tion Of a Caae „r i„t.ti«a. 0>,st,„etioa 
 
 ready mdicatfiH fi.^ . . "^°- 
 
 lould be at once piata 
 till peristalsis and pre- 
 1 of the bowel with air, 
 
 ■^^ already indicated th OS^truction. 
 
 I, means always a matter n?""* °' '"'estinal obstruction i« h 
 
 J. f .td-r-ce^:^„- iH^p 'r-refuliy «on 
 
 id pre-| 2. Ihe History of the Present A^fit,'^^'f"^^'">'' etc 
 ith air,| * ^ ^- ; "®^®°* Attack should then be 
 
 ■ ^'^'^''^^^^'"''^. January 18, X896 
 
 be 
 
 con- 
 
974 
 
 A MANUAL OF SURGERY 
 
 sidered, noting especially the manner of onset, whether aci 
 or gradual, the duration of the symptoms, and whether or r 
 preceding subacute attacks have occurred from time to tin 
 By this means it is possible to ascertain whether the patie 
 is suffering from acute or chronic obstruction, as also whetl 
 the causative lesion has been in existence for some time or not. 
 3. The more prominent Sjonptoms must then be considered. 
 
 (a) Collapse is due partly to reflex nervous disturbance, part 
 to the absorption of loxic materials, and partly to withdra^^ 
 of fluid from the body as a result of the vomiting ; the port 
 area is also much engorged, and this adds to the want 
 fluid in the systemic circulation. The nervous cause is mc 
 active in the early stage of acute obstruction, especially in infan 
 whilst the toxic is largely responsible for the exhaustion seen 
 the end of an acute attack or in the chronic variety. Hen 
 collapse is early in acute cases, late in chronic. Moreover, tl 
 higher the lesion, the greater the shock, owing to the fact th 
 the upper portion of the bowel is more intimately associated wii 
 the sympathetic nervous centres. 
 
 (b) Pain is a very marked symptom, being usually referrc 
 at nrst to a little above the umbilicus, and is more severe ; 
 lesions of the small intestine than in the colon. It varies great 
 with the completeness or not of the obstruction. This matt( 
 has been especially emphasized by Treves, who has pointed 01 
 that when the obstruction is but partial the pain is intermitten 
 whilst when the block is complete the pain becomes continuouj 
 Hence in acute strangulation pain is almost invariably constant 
 whereas in stricture it is markedly intermittent and of a colick 
 nature. The amount of pain, moreover, varies with the nervou 
 excitability of the patient ; it is increased by anything whici 
 induces peristalsis, e.g., food or purgatives, and it is diminishei 
 on the supervention of gangrene. 
 
 (c) Abdominal tenderness is rarely observed in the early stages 
 being caused by the onset of inflammation of the peritoneum. 
 
 (d) Vomiting is an almost invariable accompaniment of obstruc 
 tion. Its cause is still a matter of some doubt, since somf 
 authorities claim that it is due to a reverse peristalsis, whilst 
 others maintain that the ordinary onward movements of the 
 bowel are quite sufficient to explain it ; the intestinal contents 
 are urged forwards against the face of the obstruction, and, 
 being unable to pass, an axial regurgitant stream is produced. 
 It is a little difficult to see how this could occur when the lower 
 end of the colon is the part affected. Whatever the mechanical 
 explanation, there is no question as to the influence of the nervous 
 system in its production, or as to its being chiefly reflex in 
 character, which is evident from the fact that it occurs equally 
 when omentum or bowel is strangled. Hence, it is easy to under- 
 stand that it commences early in children and sensitive women, on 
 
INTESTINAL OBSTRUCTION 
 
 975 
 
 .nset, whether acute 
 and whether or not 
 from time to time, 
 whether the patient 
 ion, as also whether 
 r some time or not. 
 len be considered. 
 IS disturbance, partly 
 partly to withdrawal 
 vomiting; the portal 
 idds to the want of 
 ervous cause is most 
 1, especially in infants, 
 he exhaustion seen at 
 ronic variety. Hence 
 ironic. Moreover, the 
 )wing to the fact that 
 mately associated with 
 
 being usually referred 
 
 ind is more severe in 
 
 3lon. It varies greatly 
 
 truction. This matter 
 
 s, who has pointed out 
 
 le pain is intermittent, 
 
 n becomes continuous. 
 
 St invariably constant, 
 
 littent and of a colicky 
 
 aries with the nervous 
 
 id by anything which 
 
 ,, and it is diminished 
 
 ed in the early stages, 
 of the peritoneum, 
 ipaniment of obstruc- 
 ae doubt, since some 
 erse peristalsis, whilst 
 d movements of the 
 ;he intestinal contents 
 the obstruction, and, 
 it stream is produced, 
 occur when the lower 
 latever the mechanical 
 ifluenceof the nervous 
 
 ,eing chiefly reflex m 
 that it occurs equally 
 ice, it is easy to under- 
 id sensitive women, on 
 
 mi 
 
 account of the greater irritability of their nervous centres, whilst 
 it is also more marked when the small intestine is involved. 
 Anything that increases peristalsis naturally intensifies its occur- 
 rence. When the obstruction is situated in tiie jejunum or upper 
 part of the ileum, the vomiting is never really fa-cal in character, 
 although, if it has been temporarily checked by opium, the ejecta 
 may be exceedingly offensive and dark in colour, owing to decom- 
 position ; true faecal vomiting can only come from an obstruction 
 to the lower ileum or colon. 
 
 (e) Constipation, although usually present, is not necessarily 
 absolute, as it is possible for the lower bowel to be emptied in 
 cases of obstruction, whilst the patient sometimes passes a motion 
 as gangrene supervenes or death is approaching. 
 
 4. A most careful Physical Examination must now be instituted. 
 
 {a) An inspection of the uncovered abdomen should first be 
 made. The amount and character of the distension is observed, 
 and whether or not it is situated in the centre, as when small 
 intestine is involved, or in the flanks when the obstruction is 
 
 the rectum or sigmoid flexure. The existence of visible peri- 
 
 in 
 
 stalsis or enlarged coils of intestine should be noted ; such are 
 rarely seen in the acute cases, but may be very evident in the 
 chronic forms. The rise and fall of the abdomen during respira- 
 tion should be watched to ascertain whether the movements are 
 ecjual on both sides, or if any prominence, such as would be 
 caused by a tumour, is noticeable. The general condition of the 
 patient, whether emaciated or not, as also the appearance of the 
 face and the position in which he lies, should be obser\ed. 
 
 (b) All the normal and abnormal hernial apertures are 
 thoroughly investigated, as also the rectum and vagina. 
 
 ((•) The abdomen is carefully palpated, so as to ascertain the 
 existence of any tumour or increased resistance of the abdominal 
 \^aTIs. ~~~~" 
 
 -(rf) Percussion may also throw som e light onl fae-ease. 
 
CHAPTER XXXIV. 
 RECTUM AND ANUS. 
 
 Congenital Malformations. 
 
 'I'liE lowest portion of the intestinal canal, 4 inches in length 
 which is commonly known as the rectum, arises from the unioi 
 of two separate divisions. The upper, developed from the lowes 
 portion of the primitive hind-gut, is originally in communicatior 
 with the bladder, and forms a joint cavity or cloaca, the two 
 however, being early separated; the posterior segment, whici 
 becomes the rectum, extends down into the pelvis, to be joinec 
 
 ABC 
 
 Fig. J38. — Three Varieties of Malformation of Rectum. (Tillmanx.s) 
 
 In A, the bowel ends at the brim of the pelvis in a cul-de-sac, and there is no 
 evidence of an anus ; in B, the anus is also absent, but the bowel opens 
 into the bladder ; in C, the anus and bowel are only separated by a small 
 space. 
 
 by an epiblastic pit or involution growing in from the perineum, 
 known as the ' proctodeum.' Failures in typical development 
 may be due either to the proctodeum being absent or stenosed, to 
 the rectum either being absent (Fig. 338, A) or retaining in 
 measure its cloacal condition and opening into some other viscus 
 —e.g., the bladder, urethra, vagina, or vulva (Fig. 338, B) — or to 
 want of union between the upper and lower segments (Fig. 338, C). 
 The following are the chief clinical varieties of malformation met 
 with : 
 
RECTUM AND ANUS 
 
 977 
 
 JS. 
 
 s. 
 
 , 4 inches in length, 
 arises from the union 
 loped from the lowest 
 ,lly in communication 
 y or cloaca, the t\yo, 
 erior segment, which 
 le pelvis, to be joined 
 
 C 
 
 Rectum. (Tillmanns) 
 icul-de-sac, and there is no 
 fsent, but the bowel opens 
 1 only separated by a small 
 
 L from the perineum. 
 
 I typical development 
 
 [absent or stenosed, to 
 
 A) or retaining m 
 
 ito some other viscus 
 
 i (Fig. 338, BHor to 
 
 legments(Fig. 33'^'^'' 
 
 ■ of malformation met 
 
 (i.) Absence of the anus, with or witliout development of the 
 rectum, which, if present, may open in some abnormal situation. 
 In such cases, the important (juestion to he settU-d by the 
 practitioner is the existence or not of a rectum, and this, unfor- 
 tunately, cannot always be determined without an open t-xpiora- 
 tion through the perineum ; if, however, during crying and 
 straining there is a distinct bulge in the middle line at the 
 spot where the anus should be, there is e\ery likelihood (if tlie 
 viscus being present. If so, it is always expanded in a club-like 
 extremity, usually lined with peritoneum in front, and often below. 
 If the rectum is absent, it usually ends near the pelvic brim, 
 and is merely represented by a fibrous cord below that level 
 (I'i^'- 33'^> ^^)> whilst the bony pelvis is often atrophic and 
 imperfectly developed. 
 
 (ii.) A membranous septum may persist between the upper and 
 lower segments, placed about an inch from the anus, and allowing 
 the retained meconium to push it downwards. This is the type 
 of malformation most commonly observed (Fig. 338, C). 
 
 (iii.) An anus is occasionally present, whilst the rectum ends 
 Mindly above the pelvic brim, or opens elsewhere. 
 (iv.) The anus, though present, may be contracted. 
 Tlie Treatment of these cases must be instituted at as early a 
 date after birth as possible, so as to prevent intestinal obstruction. 
 Anal stenosis is readily dealt with by regular dilatation with 
 bougies. 
 
 Where a membranous septum persists between the proctodeiun 
 and rectum, a large trocar and cannula may be passed through 
 it, and the meconium allowed to escape ; the aperture thus made 
 is enlarged, and maintained by the subsequent passage of bougies. 
 Where the anus is absent, whether there is any indication of 
 the presence of a rectuiu or not, a perineal incision is first made 
 through the site of the anus, and carried upwards and backwards 
 along the concavity of the sacrum strictly in the middle line for 
 not more than 2 inches, though it is justifiable to proceed further 
 by removing the coccyx and part of the sacrum (Kraske's opera- 
 tion, p. 990). If found, the dilated and bulbous cul-de-sac is 
 drawn down as far as possible, and opened towards its posterior 
 aspect ; the mucous membrane is then, if feasible, stitched all 
 round to the skin so as to leave no surface to granulate, thereby 
 preventing subsequent stenosis. In cases where no rectum is 
 i present, colotomy must be performed, and by preference the iliac 
 I operation, since the space between the crest of the ilium and the 
 last rib is exceedingly small in an infant. When once a passage 
 tor the faeces is established, abnormal openings into the bladder, 
 [etc., usually close without difficulty. 
 
 Various malformations in connection with the post-anal gut 
 have been already described (p. 610). 
 Inflammation of the Rectum (Proctitis) causes pain of a bearing- 
 
 62 
 
978 
 
 A MANUAL OF SUIiGEHY 
 
 down character, a sensation of fulness, constantly recurri 
 tenesnuis, accompanied by a discharj^e of niiicus, niuco-pus, 
 blood. It may arise from any local source of irritation, c 
 the introduction of forei^m bodies, or the presence of a polyp 
 parasites, or piles ; ^'onorrlura is an occasional cause — in won 
 possibly owinj^ to infection from the \a^nnal discharj^'e, in n 
 probably from direct infec*';.ii. In dysentery the rectum is oil 
 in\()l\ed as well as the colon. If the inthunmalion becon 
 chronic, a simple fd)rous stricture may result. Tycatwcnt. — Inji 
 tions of lead and opium or of borax may be used locally, wlii 
 the patient is kept in a recundient position and on a low diet, t 
 bowels bein<( regularly opened by the administration of laxati\ 
 or enemata. 
 
 Thread-worms [O.xyuris vcrmiculavis) are the most const;i 
 source of irritation of the rectum in infants and children, 'ili 
 give rise to pruritus ani, a discharge of muco-pus, and many rctl 
 phenomena. In treating such a case, a sharp purgative m.iy 
 given every morning {e.g., pulv. scamm. co., grs. v.), and salt ai 
 water or an infusion of quassia used as an injection. 
 
 The Bilharzia hsematobia is occasionally found in the rectum 
 well as in the urinary passages (p. 1041). It gixes rise to fihr 
 adenomatous polypi, in which the ova can be readily demonstrate 
 they are rounded or oval bodies, differing from those found it^ ti 
 urine in that they possess a lateral spine-like projection, whilst 
 the latter it is terminal. Considerable tenesmus, dij;i ;'i(ia ar 
 discharge of blood are present, and the haunorrhage may becoii 
 so abundant as to destroy the patient's life, especially when urinai 
 symptoms are coexistent. They occur in children who have bee 
 in Africa, and unfortunately, no satisfactory treatment is known 
 
 IscMo-Rectal Abscess. 
 
 Suppuration in the ischio-rectal fossa [localized periprodii:. 
 is very frequently met with, and, from the fact that it coninuml 
 results in a fistula, is of considerable surgical interest. It ma 
 arise from a variety of causes, but for convenience may b 
 described under the three following headings : 
 
 I. Acute Ischio-Rectal Abscess is due to infection of the loos 
 fatty tissue filling the ischio-rectal fossa (Fig. 339, I.R.A.) wit!i 
 some pyogenic organism, reaching it either through the perineiin 
 or from the bowel. In the latter case some solution in the 
 continuity of the mucous membrane occurs, such as follows its 
 penetration by a fish-bone or other foreign body, or some form ^ 
 ulceration ; the Bac. coli is thereby set free, and in conseciuenw 
 the pus has the usual characteristic offensive odour. If tht 
 infection is derived from the perineum, the usual cocci of siip 
 puration are present, and the pus has no objectionable smell. 
 red, painful swelling is noticed on one side of the anus, which 
 
RECTUM AND ANUS 
 
 979 
 
 constantly recurrin- 
 mucus, nuico-pus, or 
 xe of irritation, <'.;.'.. 
 rrsence of a polypus, 
 ii:il cause— in wonu-ii 
 ,al (lischar^'c, in nuT 
 ry tlu' rectinn is oluii 
 ;i11annualion beconu- 
 It TmUiiicut. — InjiT 
 i^e used loyally, \vhilsi 
 and on a low diet, ih 
 inistration of laxative^ 
 
 - the most conslan; 
 ^ and children. Tlu\ 
 :o-pus, and many pn. 
 larp purgative may b. 
 1., s^"^. v.), and salt aiu. 
 injection. i 
 
 found in the rectum a- 
 It f,nves rise to hl'i' I 
 ie readily demonstniUji: 
 from those found w t'- 
 ike projection, whilst ir: 
 enesmus, dij: ■ : h"'ii ^i"' 
 rniorrhaRe may becom,] 
 especially when urinai) 
 children who have Ih.:. 
 ry treatment is known. 
 
 IS. 
 
 |a (localized pmproctitl_ 
 |e fact that it conini"nH| 
 Krical interest. It ma) 
 Ir convenience may I' 
 
 tlf infection of the \oc4 
 
 (Fig. 339, I.R.A-)^^'" 
 
 r through the pennei I 
 
 t some solution in tliej 
 
 [urs, such as follows itf 
 
 li body, or some form cj 
 
 lee, and in consequencj 
 
 Pensive odour. It ^ 
 
 the usual cocci oi^^A 
 
 1 objectionable sniell. j 
 
 ie of the anus, which 1 
 
 al first hard and brawny, but soon becomes soft and tluctuatini,'. 
 Pefa^cation is exceedingly painful, as also digital exploration of the 
 bowel ; and the patient is unable to sit with any comfort. If left to 
 itself, \t may burst internally or externally, or in both directions, 
 and. a fistula-in-ano is very liable to follow. Treatment.- In the 
 early stagi'S the part should be well fomented, but wiien there is 
 no doubt that pus is forming, a free opening should be made, the 
 cavity washed out, and stulTed with some antiseptic dressing. If 
 taken early enough, rapid recovery may ensue without the bowel 
 becoming involved, but when the mucous membrane has been 
 encroached upon or perforated, the wound will not heal without 
 division of the sphincter. 
 
 Occasionally a more diffuic type of acute suiii)uration occurs in 
 llie ischio-rectal fossa, constituting a rcllulilis, and not uncommonly 
 
 Fill. j39. — Diagrammatic Section' of Lower Exn <w Rectcm, Anus am> 
 
 Isciiio-Rectal FoSS/K. 
 
 LA., Levator ani ; E.S., external sphincter; LK.A., ischio-rectal abscess; 
 A. A., anal abscess ; F.LA., fisuila-in-ano ; A. P., superficial anal listuia 
 
 resulting in gangrene {gaiigiriioits pci'iproctitis). It is most likely to 
 be seen in weakly individuals and old people, and the symptoms 
 are very asthenic in type. The suppuration may extend above 
 the levator ani, and lead to deep fistulous tracks. The parts 
 must be freely opened up, the gangrenous tissue scraped away, 
 and the raw surfaces treated with peroxide of hydrogen. The 
 wounds are then stuffed with iodoform gauze, and subsequently 
 well irrigated twice a day. Free stimulation is always required in 
 these cases, but the prognosis is \ery bad, death being probably 
 caused by acute toxaemia or pyeemia. 
 
 2. Chronic Ischio-Rectal Abscess is usually met with in run- 
 down or tuberculous individuals during young adult life, and is 
 not unfrequently a complication of phthisis. It arises from injuries 
 to the perineum or bowel, and may even be induced by exposure 
 
 62 — 2 
 
98o 
 
 A MANUAL OF SURGERY 
 
 to wet or cold, as by sitting on a damp stone. A deposit of tub 
 culous material replaces the fat ordinarily occupying the isch 
 rectal fossa, and this after a time undergoes caseation or forms 
 abscess, which gradually spreads without pain or other infla 
 matory disturbance, until it may extend very widely and aim 
 entirely surround the bowel. After it has burst, the orifices 
 sinuses may be found at a considerable distance from the an 
 The Signs and Symptoms are those of a chronic tuberculc 
 abscess. An indurated and painless mass may be first felt in 1 
 fossa, and this slowly spreads, softens, and is transformed int( 
 more or less extensive abscess sac. The Treatment is as for 
 tuberculous deposits, viz., in the early stages, and even befc 
 suppuration has occurred, incision, removal by a sharp spoon 
 all tuberculous tissue, the application of pure carbolic acid, a 
 dressing the wound with gauze infiltrated with iodoform. Wh( 
 extensive sinuses or fistulas exist, treatment as for fistula-in-a 
 must be adopted. 
 
 3. Suppuration in the ischio-rectal fossa may occasionally 
 dependent on disease of neighbouring or distant structures, c. 
 the sacro-iliac or hip joints, the pelvic bones, the spine, prosta 
 pelvic cellular tissue, etc., the pus finding its way down by t 
 side of the rectum and burrowing through the levator ani, to rea 
 the surface. The usual treatment of such condition must 
 adopted, but if practicable the abscess is opened elsewhere, as, 
 course, the existence of a sinus near the anus is a fertile source 
 septic contamination. 
 
 Anal Abscess. — This term is applied to an abscess formii 
 immediately under the anal integument, and superficial to tl 
 sphincter (Fig. 339, A. A.); it is usually due to inflammation 
 one of the numerous sebaceous follicles in that locality. It m; 
 be acute or chronic, in the latter case being usually tuberculoii 
 and is one of the most frequent causes of fistula-in-ano. It mii 
 be freely opened throughout its whole length, and stuffed. 
 
 Fistula-in-Ano. 
 
 The term fistula-in-ano is somewhat loosely applied to all thoi 
 conditions in which suppurating tracks are found in the iieigl 
 bourhood of the anus and the lower end of the rectum. Manyi 
 these are merely sinuses which have but one opening. 
 
 The Cause of fistula is usually some suppurative condition, c.§ 
 an ischio-rectal or anal abscess, in the neighbourhood of th 
 bowel ; but it is sometimes the result of a stricture of the gut, th 
 inner opening being either above, in the substance of, or beloi 
 the cicatricial mass. This is more likely to be the case whe 
 multiple fistulae exist. 
 
 Varieties. — i. The Complete Fistula (Fig. 340) is one in whid 
 
■y 
 
 RECTUM AND ANUS 
 
 981 
 
 . A deposit of tuber- 
 occupying the ischio- 
 caseation or forms an 1 
 pain or other inflam- 
 ry widely and almost 
 ; burst, the orifices of 
 stance from the anus. 
 I chronic tuberculous 
 may be first felt in the 
 i is transformed into a 
 Treatment is as for all 
 :ages, and even before 
 1 by a sharp spoon of 
 pure carbolic acid, and 
 vith iodoform. Where 
 ent as for fistula-in-ano 
 
 ja may occasionally be | 
 distant structures, eg- 
 nes, the spine, prostate, 
 » its way down by the 
 the levator ani, to reach 
 uch condition must be 
 opened elsewhere, as, of 
 nus is a fertile source of' 
 
 to an abscess formind 
 and superficial to the 
 due to inflammation of 
 n that locality. It may 
 ng usually tuberculous, 
 iistula-in-ano. It must | 
 th, and stuffed. 
 
 Isely applied to all those 
 Ire found in the neighl 
 f the rectum. Manyofj 
 fne opening. 
 Lpurative condition, f.^. 
 ] neighbourhood of thel 
 stricture of the gut, the 
 substance of, or beloivl 
 to be the case whenl 
 
 there are openings both externally and into the bowel. When 
 following an anal abscess, they are both close to the anus, and 
 the track lies immediately beneath the skin and mucous mem- 
 brane (Fig. 339, A.F.). When following an acute iscliio-rectal 
 abscess, the external opening is a variable distance from the anus, 
 and the inner about i inch up the bowel, being situated just above 
 the so-called internal sphincter (Fig. 339, F.I. A.) ; occasionally 
 blind extensions are met with branching ofT from this, but not so 
 frequently as when the fistula follows a chronic abscess. In the 
 latter case the skin may be extensively undermined, looking blue 
 and congested, and the fistulous tracks may burrow widely, open- 
 ing even on the thigh, or in the perineum or buttock. Another 
 variety is that in which it passes round the bowel either superficial 
 to the external sphincter or beneath it, and opens also on the other 
 side, constituting the so-called horseshoe fistula. Again, the mucous 
 membrane of the bowel is often undermined, and stripped from 
 
 
 U- :^- -S^S 
 
 Fig. 3^o. — Complete 
 Fistula -IN- An'o with 
 External and In- 
 ternal Openings. 
 
 (TlLLMANNS.) 
 
 Fig. 341. — ^Incomplete 
 External Fistula. 
 
 (TlLLMANNS.) 
 
 Fig. 342. — Incomplete 
 OR Blind Internal 
 Fistula. (T i l l- 
 
 MANNS.) 
 
 340) is one in 
 
 \vhicli| 
 
 the muscular coat for some distance above the internal opening 
 by sinuses or an abscess cavity. 
 
 2. The Bliud External Fistula (Fig. 341) is the term applied to a 
 sinus resulting from the opening of an ischio-rectal abscess in 
 which no communication with the bowel can be discovered. A 
 probe passed into the wound can often be felt by a finger in the 
 rectum with only the thickness of the mucous membrane between. 
 In dealing with these external fistulae the possibility of the 
 
 , original cause being at a distance must not be overlooked. 
 
 3. The Blind Internal Fistula (Fig. 342) is constituted l^y a sinus 
 j opening into the bowel just above the anus. Attention is usually 
 
 drawn to the condition by the passage of pus with the motions or 
 independently, and perhaps by preceding inflammatory disturb- 
 ance. The orifice can sometimes be felt by digital exploration, 
 and on the insertion of a speculum may perhaps be seen and care- 
 fully examined by a straight probe or one bent in the form of a 
 hook; it is often associated with considerable undermining of the 
 j mucous membrane, and if chronic with stenosis of the bowel. 
 In all these conditions it is very difficult to obtain healing, 
 
982 
 
 A MANUAL OF SURGERY 
 
 owing to the state of unrest in which the parts are kept by tht 
 continuous movements, voluntary and involuntary, of the sphincter 
 hence division of this muscle is almost always necessary. It may, 
 however, be advisable to leave the case alone when the fistula 
 complicates the later stages of phthisis, or when a small blind 
 internal fistula exists in elderly people, causing but little incon- 
 venience and no injury to the general health. 
 
 Operation. — The bowels must have been completely evacuated, 
 both by means of castor-oil or some suitable purgative, and about 
 an hour previous to operation by enema, a most important 
 preliminary, not only for the comfort of the operator, but also 
 because it is very desirable that no further action should be 
 required for some days. The patient is placed in the lithotomy 
 position, and the perineal and anal regions shaved and purified. 
 A probe is passed along the fistula into the rectum, and guided 
 by it a grooved director, along which a curved pointed bistoury 
 is introduced, and the intervening structures divided ; this will in 
 most cases include the external sphincter. A careful search is 
 made for pockets or tributary branches of the main track, and 
 such, if found, are opened up and scraped out, undermmed and 
 unhealthy skin being snipped away with scissors; bleeding-points 
 are, if necessary, tied, and the cavity carefully powdered witli 
 iodoform, and lightly stuffed with oiled lint or gauze soaked in 
 iodoform and glycerine. Pressure by a graduated antiseptic wool 
 compress should be applied by means of a T-bandage. The wound 
 is allowed to granulate, and care taken that irregular healing does 
 not lead to a re-formation of the fistula. With this object in view, 
 it is often advisable to pass a moderate-sized bougie from time to 
 time at the end of a fortnight. 
 
 When a sinus extends for some distance under the mucous 
 membrane from the upper end of the original fistula, it may not 
 be always desirable to lay it open to its whole extent, since such 
 might involve serious haemorrhage at a spot where it cannot wel 
 be checked. It will often suffice to partly divide and scrape it, 
 and then, if the main fistula has been satisfactorily dealt with, it 
 will probably heal without difficulty, especially if syringed out 
 occasionally with stimulating lotions. 
 
 In the case of a horseshoe fistula, the sphincter need only be 
 divided at one spot, and that usually in the middle of the horse- 
 shoe. The whole track must, however, be opened up, the cavity 
 scraped, loose tags of skin removed by the scissors, and an 
 ordinary dressing applied. 
 
 After-Treatment. — The bowels should, if possible, be prevented 
 from acting for four days, and most scrupulous care taken to keep 
 the parts clean. The deep dressing need not be changed for the 
 first twenty-four or forty-eight hours, provided that the surround- 
 ing skin is well flushed with a warm carbolic solution. When the 
 plugs are removed, fresh small strips of gauze soaked in iodoform 
 
RECTUM AND ANUS 
 
 9»3: 
 
 and glycerine are introduced night and morning after the wound 
 has been syringed. On the fourth day a good dose of castor-oil 
 should be given, and subsequently care taken to secure an action 
 of the bowels daily. 
 
 Fissure of the Anus. 
 
 This is a most painful and troublesome complaint, met with 
 most commonly in women of a neurotic temperament, or in 
 individuals whose health has been broken down by long resi- 
 dence in the tropics. It is occasionally due to injury or to a 
 polypus, but more often to the passage of large scybalous masses 
 in patients suffering from chronic constipation. The fissure is 
 usually single, extending through the posterior border of the anus 
 towards the coccyx ; a ' sentinel ' external pile is often situated 
 immediately over it, and the crack may lead to a definite ulcer 
 ]ust within the external sphincter. According to Hall of Dublin, 
 it is due to one of the valve-like tags, left at the junction of the 
 proctodeum and rectum, being caught by a scybalous mass, and 
 torn from its upper connections. Each time a motion passes the 
 -ore place is reopened, and the valve pushed further on, until 
 tinally, having become swollen and fjcdematous, it appears at the 
 irifice as the ' sentinel ' pile, with an ulcerated surface behind or 
 1 beside it. Sometimes several fissures are met with in the same 
 individual, and then a syphilitic cause is probable, especially if 
 they are placed at the side or front of the anus. 
 
 The Symptoms of this condition are very distressing, cf)nsisting 
 
 jOf hurning pain during defalcation, which often lasts for some 
 
 [hours. The pain is usually associated with tenesmus, and may 
 
 radiate down the thighs or up the back, and not uncommonly to 
 
 I the left sacro-iliac joint ; it may be so severe as to lead the patient 
 
 to refrain from defaecation for prolonged periods. The faices may 
 
 he streaked with blood or pus, and there is a certain amount of 
 
 I discharge from the anus. On examining the part, the sphincter 
 
 s found to be spasmodically contracted, and the entrance of a 
 
 :iiit(er is forcibly resisted. 
 
 Treatment is, in the earlier stages, undertaken by regulating 
 
 [the action of the bowels by suitable laxatives, by the use of 
 
 [cocaine suppositories prior to defa'cation, and by improving the 
 
 ;!eneral health. In confirmed cases the sphincter has been 
 
 I forcibly dilated by the thumbs, and the crack or ulcer cauterized ; 
 
 hut by far the most efficient treatment consists in dividing its base 
 
 with a straight probe-pointed bistoury, the incision at the same 
 
 time including the external sphincter. The ulcer and the edges 
 
 jof the wound are snipped away with scissors, to facilitate the 
 
 dressing and healing of the wound. The lower bowel should in 
 
 |all cases be carefully explored with the finger, especially with a 
 
 Iview to the possible existence of a polypus, which, if undetected, 
 
984 
 
 A MANUAL OF SURGERY 
 
 would cause a recurrence of the mischief. Rest being thu: 
 obtained, healing soon follows. 
 
 Fibrous Stricture of the Rectum. 
 
 One of the most important conditions associated with o 
 resulting from inflammatory lesions of the lower gut is stenosis 
 It is usually met with in advanced life, especially in womei 
 over forty years of age, and is most often situated 2 or 3 inche 
 from the anus, or as high as its junction with the sigmoid flexure 
 In this position, it is usually due to the cicatrization and con 
 traction of ulcers following prolonged diarrhcea and dysentery 
 although occasionally due to tuberculovts or syphilitic ulceration 
 Any form of chronic proctitis, e.g., gonorrhoea, may also lead t( 
 it. It occurs sometimes a? a sequela of pelvic cellulitis anc 
 suppuration, from the contraction of fibrous bands which nia; 
 bind the rectum backwards to the sacral wall, or may mere!] 
 constrict it ; the stricture is in these cases usually at a lower poin 
 than in the former. Repeated attacks of inflamed piles may als( 
 lead to stenosis at or just above the anus. A stricture sometime: 
 results from traumatism, or follows operations involving the wholi 
 or at any rate the greater portion of the circumference of thi 
 bowel. As already mentioned, it may be associated with a fistula 
 especially if the latter has existed for long ; the inner openin' 
 may then be found in the substance of the stricture, as pointei 
 out by the late Mr. Henry Smith. 
 
 The earliest Symptoms of stricture are often alternating attack 
 of diarrhcea and constipation, in which the constipation is primary 
 and the diarrhoea due to a catarrhal enteritis arising from th 
 irritation of the retained faeces. Gradually the difiPiculty ii 
 passing motions becomes more and more marked, ond th 
 faeces themselves become narrowed, flattened, and elongated 
 something like pipe-stems, or small masses like shrimps ma 
 alone succeed in passing. This is associated with pain and un 
 easiness referred to the lower bowel ; a certain amount of bloo( 
 and mucus may be mixed with the excreta, and sooner or late 
 marked dyspepsia and abdominal distension supervene. If th 
 case is allowed to run on without treatment, absolute obstruc 
 tion of a chronic type may result, and lead to a fatal issue 
 or the mucous membrane of the bowel abo\'e the strictun 
 becomes ulcerated, an abscess forms, and subsequently a fistula 
 through which a certain small amount of faecal material passes 
 If several of these fistulae are established, the patient may finalh 
 succumb to chronic septic poisoning and exhaustion. 
 
 An examination of the bowel with the finger may reveal ; 
 smooth, regular constriction of the gut as if a band had been tie( 
 round it, the fibrous mass and the aperture in it feeling somethin! 
 like an os uteri. In other cases, the bowel is stenosed foi 
 
RECTUM AND ANUS 
 
 985 
 
 Rest being thus 
 
 .urn- 
 associated with or 
 wer gut is stenosis, 
 specially in women 
 :uated 2 or 3 inches 
 
 the sigmoid flexure, 
 catrization and con- 
 •huea and dysentery, 
 
 syphilitic ulceration. 
 Ea, may also lead to 
 
 pelvic cellulitis and 
 IS bands which may 
 wall, or may merely 
 sually at a lower point 
 iflamed piles may also 
 A stricture sometimes 
 ,ns involving the whole 
 
 circuiTiference of the 
 jsociated with a fistula, 
 ,cr ; the inner opening 
 e stricture, as pomted 
 
 ten alternating attacks 
 :onstipation is primary, 
 eritis arising from the 
 tially the difficulty in 
 ore marked, rnd the 
 tened, and elongated, 
 ses like shrimps may 
 ted with pain and un^ 
 rtain amount of blood 
 ta, and sooner or later 
 ion supervene, it t>ie 
 -lent, absolute obstruc- 
 lead to a fatal issue; 
 1 above the stnctiire 
 subsequently a fistula, 
 fsecal material passes, 
 he patient may finally 
 chaustion. 
 
 B finger may reveal 
 ff a band had been tied 
 . in it feeling something 
 bowel is stenosed tor 
 
 some distance, and its surface more or less ulcerated ; whilst if 
 due to pelvic cellulitis, it may be drawn up and fixed to the 
 posterior pelvic wall. When the stricture is too high for the 
 finger to reach, the gut may appear normal, though somewhat 
 dilated (ballooning). Sometimes the stricture is smooth, and free 
 from nodular irregularities and excrescences ; often, however, it 
 is ulcerated and irregular, the examination causing great pain. 
 The gut above the contraction is hypertrophied, distended, and 
 if filled with retained fa;ces, the mucous membrane may show 
 signs of inflammation, or even stercoral ulcers. The gut i)elow 
 the stricture is usually dilated (ballooned), partly from paralysis 
 of its walls, and partly by invagination of the mass from above. 
 
 The Treatment in the early stages consists in keeping the 
 
 bowels regular and the motions soft by means of laxatives, such 
 
 as castor-oil or salines, whilst the passage of the excreta is assisted 
 
 by enemata. The diet is regulated, and the strength maintained, 
 
 if need be, by tonics. Locally, the stricture, if within reach, 
 
 should be dilated by means of bougies passed in increasing sizes 
 
 every two or three days, care being taken that tlie point of 
 
 the instrument engages the stricture, and is not caught against 
 
 folds of mucous membrane or turned backwards. The utmost 
 
 gentleness must be used, in order, as far as possible, to stretch 
 
 the mucous membrane, and not tear it. Laminaria or compressed 
 
 sponge tents are of use in some cases, followed subseciuently 
 
 by bougies. When situated low down, the stricture may be 
 
 notched posteriorly, or slightly nicked in several places with a 
 
 probe-pointed bistoury, and bougies then passed. There is 
 
 always a great tendency in these strictures to contract again, and 
 
 the patient should be instructed to pass a bougie for himself at 
 
 short intervals. If the stricture is out of reach, or signs of 
 
 obstruction manifest themselves in spite of treatment, colotomy is 
 
 the final resource. 
 
 Syphilitic Disease of the Bectum and Anus. 
 
 The rectum and anus are attacked by syphilitic disease in a 
 variety of ways, the most prominent being as follows : 
 
 (a) The initial lesion or primary chancre is occasionally met 
 with in the neighbourhood of the anus, but presents no features 
 that demand special attention. 
 
 {b) In the secondary stage mucous tubercles or condylomata 
 are frequently seen, being placed either at the anal margin or 
 symmetrically on either side of the gluteal fold, the sores on one 
 side having evidently infected the other. They are of the usual 
 type (p. 1 1 29), and are treated by dusting with powdered 
 calomel, and keeping a piece of dressing between the lips of the 
 fold. 
 
 {c) In the tertiary period diffuse syphilitic disease of the rectum is 
 
986 
 
 A MANUAL OF SURGERY 
 
 not uncommon, occurring most usually, but not solely, in youi 
 married women amongst the poorer classes, and especially 
 hospital patients. It is a somewhat early tertiary manifestatic 
 and usually commences within easy reach of the finger, abo 
 3 inches from the anus. It starts as a diffuse gummatous inf 
 tration of the rectal mucous membrane and submucous tissi 
 which become thickened and indurated, ulceration soon foUowir 
 These phenomena are not limited to the rectum, but frequent 
 spread up the intestine towards the sigmoid flexure and do\ 
 to the anus, and likewise involve the recto-vaginal septum ai 
 vagina, passing down the latter canal to invade the perineum ai 
 neighbouring structures, so that in a neglected case the whc 
 external genitals and anus may be involved in an irregular hype 
 trophic mass, somewhat resembling elephantiasis. In additic 
 the ulcerative process may extend more deeply, leading to t 
 formation of fistulae, not only between the rectum and neighbor 
 ing viscera (e.g., vagina or bladder), but also communicating wi 
 the exterior. From the cicatrization occurring in the submuco 
 tissue, contraction of the gut results, causing a syphilitic strictu 
 which may extend for some distance up the bowel. The symptoi 
 consist in pain, increased on defaecation, irritability of the bow( 
 and discharge of blood and pus by the anus, whilst obstructi 
 phenomena, or alternating attacks of constipation and diarrhci 
 may also be present. On examination, the diffuse ulceration ar 
 infiltration of the part are suggestive of malignant disease, but tl 
 patient's age and history, and the course of the case, are usual 
 sufficient to determine the diagnosis. The general health r 
 mains good in the earlier stages of the affection, but later c 
 may be undermined by the pain and constant purulent di 
 charge. 
 
 Treatment consists in administering mercury and iodide < 
 potassium, the former perhaps in the shape of suppositorie 
 whilst locally dilatation by bougies is necessary. In advance 
 cases colotomy is essential in order to secure rest to the part: 
 and give them a chance of healing. Possibly in a few instance 
 only a temporary opening of the bowel may be required, bi 
 where much contraction exists and a considerable tendency t 
 obstruction, the artificial opening must remain permanentb 
 Sometimes the ulceration persists in spite of colotomy, and car 
 must then be taken to prevent the retention of discharges by tli 
 occasional passage of bougies. 
 
 Tumours of the Rectum. 
 
 Poljrpus Recti occurs most frequently in children, and consist 
 usually of an adenoma of Lieberkiihn's follicles, but occasionall; 
 of simple fibrous tissue covered with mucous membrane. The; 
 are commonly found within easy reach of the anus, and presen 
 
RECTUM AND ANUS 
 
 98^ 
 
 not solely, in young 
 s, and especially m 
 jrtiary manifestation, 
 of the linger, about 
 use gummatous infil- 
 id submucous tissue, 
 ration soon following, 
 sctum, but frequently 
 ,id flexure and down 
 )-vaginal septum and 
 ade the perineum and 
 ected case the whole 
 in an irregular hyper- 
 mtiasis. In addition, 
 leeply, leading to the 
 ectum and neighbour- 
 o communicating with 
 ring in the submucous 
 ing a syphilitic strictui'c, 
 )Owel. The symptoms 
 ritability of the bowel, 
 nus, whilst obstructive 
 .tipation and diarrhua, 
 - diffuse ulceration and 
 iignant disease, but the 
 ^ the case, are usually 
 e general health re- 
 aff"ection, but later on 
 -onstant purulent dis- 
 
 lercury and iodide of 
 hape of suppositories, 
 cessary. In advanced 
 ;ure rest to the parts, 
 i^ibly in a few instances 
 may be required, but 
 isiderable tendency to 
 remain permanently, 
 of colotomy, and care 
 3n of discharges by the 
 
 ,. children, and consists 
 
 jlicles, but occasionally 
 
 3us membrane. Ihey 
 
 the anus, and present 
 
 ) 
 
 an appearance something like a small cherry with a long pedicle, 
 pendulous and freely mobile. The Symptoms caused nre irri- 
 tability of the bowel and the passage of blood by the anus, which 
 latter when occurring in a child without symptoms of obstruction 
 is almost pathognomonic of polypus. The tenesmus excited may 
 lead, as mentioned elsewhere, to prolapse or to the occurrence 
 of an intussusception. It is occasionally associated with a fissure 
 of the anus, which probably arises as a secondary result of the 
 irritation caused by the partial extrusion of the polypus during 
 defaecation. A natural cure can be effected by rupture of the 
 attenuated pedicle, which is at first attended by a certain amount 
 of haemorrhage. Treatment. — The polypus is cut away after tying 
 or twisting its pedicle, or the clamp and cautery may be employed. 
 
 Papilloma of the rectum is a rare disease, and gi\es rise to 
 ha'morrhage from and irritability of the bowel, or, if large, even to 
 obstruction. This condition is not always limited to the rectum, 
 hut may extend through the greater portion of the intestine, and 
 then proves fatal from haemorrhage. Treatment consists in renioval 
 hy ligature or wire snare, where practicable. 
 
 Sarcoma is another uncommon disease in the rectum. It occurs 
 in the shape of a large fleshy tumour growing from the submucous 
 tissue, and projecting into the lumen of the gut so as to cause 
 obstruction. It is less painful than cancer, and usually occurs at 
 an earlier age. The symptoms are much as in the latter disease, 
 and the treatment, where feasible, is the same, viz., extirpation of 
 the growth, but it will very probably recur. 
 
 Epithelioma of the Anus {i.e., of the skin covering the anal 
 margin) occurs as a primary development similar to that on the 
 lip, and is then of the squamous type. It presents the usual 
 features, viz., an indurated nodular mass, which readily ulcerates, 
 and runs the typical course of such a disease, infecting the 
 inguinal glands. It is readily dealt with in the earlier stages 
 hy an operation somewhat similar to that for excision of the 
 rectum. 
 
 Cancer of the Rectum appears in the form of columnar epithe- 
 lioma, consisting, as des .'ibed elsewhere (p. 143, Fig. 37), of an 
 overgrowth of Lieberkiihn's follicles, not only into the lumen of 
 the gut (centrifugal or papillomatous type of growth), but also 
 invading the deeper portions of the bowel wall, infiltrating the 
 submucous and muscular layers (centripetal growth). A cer- 
 tain amount of vascular fibro-cellular stroma is found between 
 the glandular elements, and, according to the relative amount of 
 these structures, two types of the disease are described : (a) The 
 nodular variety commences at one spot in the form of a localized 
 malignant wart-like mass, which is hard in consistency, and con- 
 tains an excess of fibrous stroma. This type becomes ulcerated 
 [after a time, and does not grow very rapidly, (b) The annular 
 Uwiety is characterized by the mass being more cauliflower- like, 
 
988 
 
 A MANUAL OF SURGERY 
 
 t( 
 
 growinpf more quickly, and tending early to involve the whi)l 
 circumference of the gut. This latter form ulcerates early, bleed 
 freely, and causes greater destruction of tissue, so that obstruc 
 tion to the onward passage of fajces is much less likely to occii 
 in it than in the former type, where cicatricial contraction is 
 marked feature. 
 
 Both varieties sooner or later involve neighbouring structure 
 and hence lead to fixation of the mass, either to the pelvic wall 
 or to the bladder, vagina, or prostate ; sometimes the iliac vessel 
 or sciatic nerves are compressed, causing oedema or neuralgi 
 respectively. Fistula; may develop in connection with th 
 bladder, in which viscus the growth may actually form a con 
 siderable mass. Secondary deposits, similar in microscopi 
 structure to the primary growth, are found in the lumbar glands^ 
 or, if the anus is secondarily affected, in the inguinal region 
 they commonly involve the liver, and may even be dissem 
 nated throughout the body. The peritoneal cavity may also 1: 
 invaded. 
 
 The Symptoms of the disease are often so slight and the onse 
 so insidious as to raise no suspicions of the existence of an 
 growth until it has attained considerable size. It then leads 
 recurring attacks of constipation, alternating with diarrhoea, anc 
 to the discharge of large quantities of mucus, often blood-stained 
 A sense of weight or dragging pain is noticed in the rectum, anc 
 the patient after defaecation feels as if there is still something to h( 
 passed. This sensation increases until true tenesmus and strain 
 ing at stool are present, together with constant pain, which ma} 
 radiate up the back and down the legs, causing sitting on an} 
 hard substance to be painful. At first a blood-stained discharge 
 may be seen on the faeces, which become flattened and pipe-like 
 but later it passes independently of the motions. On examina 
 tion, an ulcerating, crateriform mass is met with, which may eithei 
 be limited to one segment of the gut wall, and is then usual!} 
 firm, and perhaps associated with stenosis, or it may surround the 
 bowel, and feel soft and spongy, readily breaking down under the 
 nnger, and bleeding freely. This examination is generally painful, 
 as also the process of defaecation, and sometimes the patient 
 abstains from the latter for lengthened periods on account of the 
 exquisite agony caused thereby. Marked cachexia supervenes, 
 the digestion becomes impaired, any meal causing pain and flatu- 
 lent distension ; natural sleep is impossible, and if a recto- vesical 
 fistula forms, the patient's troubles are further aggravated by the 
 passage of faeces and flatus by the urethra. 
 
 The case runs a more or less rapid course to the fatal issue, 
 which on an average ensues about seventeen months after the 
 onset of symptoms, if no operation has been undertaken (Jessop*), 
 and may be due to a variety of causes. Faecal obstruction 
 
 * British Medical Journal, 1889^ ii., p. 407 
 
^CTVM AND ANUS 
 
 ^'""t^ tne perforation 
 
 " tIS Tr:^^^^- ^ ~ -'' ^^- the -^;;i; 
 
 :Z:^' -^^- ^^^---/i-^^t;^ ^" ^'^e raCicai 
 Excision of the Re.f, ' °P"^^^^'o« of 
 
 ^se cases in which 1""' °' P^^^tectomy, ,s onlv ,• 
 disease bein^ ehn -n^J ?'^ ,'f ^ '^-^asonabJe nro^n ^/^PP^^^'^^'^e to 
 Jealthy bowel Co^i'^-, ^^'^en the finge? can'l °' '''' ''^'^^- 
 'i-^ecl anteriorJy soTs ,, , ^'°^^^^^' '^"d fvhere fh ^'''^'"^ ^"^« 
 or bladder, the case M ^"/^"§er other viscera / T''' '' "ot 
 «f the mass LTrTu ^ ^^^ourable one for ?' ^■^'•' ^^'^ P^^^tate 
 ^vhere expensive f^ °' ^"^'"^ ^^ not so i,?'''^""" ^'^'^^tion 
 
 any -ason^?o^'::3;ecf ::co°S^--^"^ o^on'^^V If^^^^^^ 
 
 i'^er. it is needle^rto '^fy deposits in th^ 1 i ^ ^^'^^^ is 
 
 ordeal of excfsionVn ^"', '^^ P^^ient t Wh^r'''^' 8^^'^"^^ o^ 
 ;o avoid opentg\tet//--consid^^^^^^^^^^ trying 
 
 , requently doner and wkh n'""' ' ^^"^ ^^ the p e^ent J'^''- "'" 
 
 'ons are taken • so tZl uu ""^^ard result ff? ^^^ '^ '^ 
 
 ,'"^da up, if it^'i; freet ' M-"^ '^'^ fe^rowtr'„,^L^^"^ P^^^au- 
 
 secondary denosiff cf^ moveable, and there I ^ ' ^. "'^"^ted 
 
 ' ^t must be £ ' ' , " ^^^""^Pt should be m?^ "° evidence of 
 
 ! reached on theTn^-''"^ '^^' ^" "he 4Te .h '° ''^' '' '^^^^^^ 
 anus with nn i?"°' ''^Pec^ of the /ut^hi . f • P^^^oneum is 
 
 -otheTincrwInTaf '■ '^^^^^-' ^iisuf ^LV",^,^- ^-^^ the^ 
 toneum is sif,,! i^ , ^^ ^^^^us s full • Jn h 7 ^'^ Pushed up 
 
 ^othe^o te Lfatet°"/ t ^"^^^^ ^o- the anus "b"'' ''' ^"^ 
 4 or 5 inches nfff ^^^ ^^^^'^^ "teri pZT'- T^ reflected 
 •n hoti sexe^ °' ''^ '^^"^^ -e uncove";d b^^.^^' '^^ ^wer 
 
 J ^t is good nrarti , membrane 
 
 i inches or more tt'"" °' ">^ bowe has i't'^ °"'- ^^'^^e 
 |«"ly a source of en/'""'^^" °' ^^^ throLL (f! '""'"'^'^ for 
 
w 
 
 »^>£ 
 
 990 
 
 A MANUAL OF SURGERY 
 
 sacral glands, and of ascertaininj^ the extent of the growth up tin 
 bowel. 
 
 Two forms of operation are described, according to whethci 
 the growth is situated high up or low down. The latter, ot 
 low operation, sometimes known as Langenbeck's, is performed 
 through the perineum; the former, for dealing with cancer situ 
 ated higher up, necessitates partial removal of the sacrum 01 
 coccyx, and is known as Kraske's. 
 
 1. Low operation. — The rectum having been thoroughly wasluul 
 out and emptied, and the patient placed in the lithotomy position, 
 the perineum is shaved and purified, and the posterior wall of tho 
 rectum and anus slit open in the middle line as far as the tip ol 
 the coccyx. An incision is now made all round the anus at the 
 junction of the skin and mucous membrane, if the anus is healthy ; 
 when diseased, the incision is extended beyond the margin so as 
 to include the growth. The rectum, together with the tumour, 
 is then separated from surrounding structures by scissors and 
 fingers, conmiencing posteriorly, where this is readily effected. 
 dividing the levator ani on each side, and working gradually 
 upwards and to the front, where greater care must be taken to 
 ensure the vagina, prostate or membranous urethra from harm. 
 In the male, a bougie or catheter may be passed into tlie urethra 
 with advantage. IMeeding-points can be secured during thi^ 
 process by pressure-forceps. The upper attachments of the f,uii 
 are divided either by scissors, ecraseur, or clamp and cautery. 
 Haemorrhage, which is generally very free, is arrested by ligatun 
 or cautery, and the gaping wound powdered with iodoform, and 
 plugged for twenty-four hours with gauze, the posterior incision 
 not being closed by suture, and no attempt made to drag down 
 the mucous membrane. Subsequently the wound may be left 
 without any internal dressing, an external pad of salicylic wool 
 sufficing ; it is thoroughly washed out two or three times a day 
 with some dilute antiseptic, such as sanitas (i in 10), Condy's 
 solution, or carbolic acid lotion (i in 60), which may be used 
 alternately ; granulations gradually cover the surface, and, a> 
 cicatrization progresses, the mucous membrane is by degrees 
 approximated to the skin margin, and the patulous cavity dimin- 
 ished in size until healing is complete. 
 
 If the growth affects one side of the gut alone, the opera 
 tion is modified by only removing that half. If fixed pos- 
 teriorly, the coccyx, and even a part of the sacrum, may be 
 taken away without hesitation to facilitate the extirpation of the 
 mass. 
 
 2. Kraske's or the High Operation. — The patient reclining on his 
 right side, an incision is made in the median line from just behind 
 the anus to the middle of the sacrum, but without opening the 
 bowel. The coccyx is excised, and the great sacro-sciatic liRa 
 ment and gluteus maximus detached from the left side of the 
 
RECTUM AND ANUS 
 
 991 
 
 the growth up tin- 
 
 orchnfi to whether 
 n. The latter, ox 
 .eck's, is pertormcHl 
 ,r with cancer situ 
 i of the sacrum 01 
 
 I thoroughly washed 
 
 ; hthotomy position, 
 
 posterior wall of the 
 
 as far as the tip nl 
 
 und the anus at Uu: 
 
 the anus is healthy; 
 
 ,nd the margin so as 
 
 er with the tumour, 
 
 ires by scissors and 
 
 s is readily effected, 
 
 i working gradually 
 
 tre must be taken K. 
 
 3 urethra from harm, 
 
 assed into the urethra 
 
 secured durmg thb 
 
 ttachn-ients of the ^ui I 
 
 - clamp and cautery. 
 
 IS arrested by hgaliuv 
 
 1 with iodoform, and 
 
 he posterior incision 
 
 made to drag down 
 
 . wound may be lett 
 
 pad of salicylic wool 
 
 or three times a day 
 
 Ls (I in 10), Condys 
 
 ■^ which may be used 
 
 the surface, and, a> 
 
 ,brane is by degree^ 
 
 latulous cavity dinmv 
 
 jut alone, the opera 
 half. If fixed pos- 
 ~|the sacrum, may be 
 Ithe extirpation ot tne 
 
 latient reclining on Ills 
 
 ■ line from just behind 
 
 without opemng tiie 
 
 ireat sacro-sciatic hjH 
 
 ^ the left side of the 
 
 t 
 
 sacrum. Part of the left wing of the latter bone is now removed 
 by chisel and hammer, the incision being curved, and extending 
 from the median line below, through or <'il)()\(; the fourtli pos- 
 terior sacral foramen to the under border of the third, and then 
 to the left border of the bone at tliat level (Fig. 343, a /;). The 
 loose cellular tissue surrounding tin; upper part of the rectmn is 
 thus exposed, and the gut, together with the tumour, is freed from 
 its connections, and aniputattid from the souiul gut ahove, the 
 peritoneum being usually encroached on in this stage of the pro- 
 ceedings. If the growth extends to the anus, the wliolc leiigtli of 
 tlie rectum below is excised ; but if the sphincter and lower inch 
 or two are free from disease, they are left in situ, and not divided 
 posteriorly, whilst the upper end of the gut is in all cases drawn 
 
 Fig. 343. — Pelvis seen from Behind to in'dicate the Lines of Section 
 OF THE Sacrum and Coccyx in Kraske's Operation. 
 
 a b, Kraske's original operation ; a c, Bardenheuer's modification. 
 
 down, and fixed by a few points of suture either to the anal portion 
 along its anterior wall, or to the skin. The wound is carefully 
 washed out, and stuffed with gauze sprinkled with iodoform ; even 
 if the peritoneal sac has been opened, no harm will usually come 
 of it, since a careful packing of the wound will close it off in 
 twenty-four hours. The results which have followed this severe 
 operation are, on the whole, encouraging, always provided that a 
 preliminary colotomy has been performed. 
 
 Various modifications of Kraske's proceeding have been 
 suggested, one of the best being that performed by Bardenheuer. 
 The sacrum is exposed, sawn across just below the third fora- 
 mina (Fig. 343, a c) and the portion thus detached is totally 
 removed. By this means a much more extensive view is obtained 
 of the pelvic contents, and the scope of the operation increased.- ■ 
 
99a 
 
 A MANUAL OF SURGERY 
 
 Excision of the rectum is a proceeding' only pructiciible in con 
 pjinitively few cases of the disease (Jessop states 15 to 20 p( 
 cent.), and fatal results are not uncommon from sliock, li.x'mo 
 rhage, or peritonitis. The tendency to recurrence is considerabl 
 but the disease is not then so painful as before, since the ner\ 
 terminals have been removed. In the cases that are cured 
 certain amount of inconvenience is certain to follow either froni 
 patulous or stenosed condition of the anal orifice, and it is sti 
 a moot point wheMier in many cases a simple colotomy is not 
 valuable as excisior;. 
 
 As already stated, if the radical operation is not feasibu 
 Oolotomy is the only means whereby the patient's condition ca 
 be temporarily ameliorated. The surjjjeon should not wait unt 
 urfjent symptoms develop, but should operate at the earlies 
 possible date, and for the following reasons: {a) It allows tli 
 patient to indulge in solid food, and thus assists in mahitainiii] 
 the general health ; (b) it frees him frotn the pain arising from th 
 passage of faeces over the ulcerated surface ; (c) it retards tii 
 growth of the disease by eliminating the irritating action of tli 
 faxes ; (d) it removes all chance of intestinal obstruction fron 
 the growth itself; and (e) it diminishes the absolute risk of tli^ 
 operation by doing it when the patient is comparatively well am 
 hearty, and when there is no urgency. Formerly, when under 
 taken for obstruction alone the death-rate was about 30 or 40 pe: 
 cent. ; in an early iliac operation it is now practically nil, or a 
 most 3 or 4 per cent. 
 
 Should the patient refuse colotomy, or should it be for any 
 reason contra-indicated, treatment consists in limiting the diet 
 to such materials as strong broths, arrowroot, etc., with some 
 stimulant, so as 10 give as little faecal remains as possible, and to 
 enable him to do without an action of the bowels for about a week 
 at a time. The strength is husbanded by keeping him in bed, 
 and pain is checked by the administration of morphia. 
 
 Haemorrhoids, or Piles. /\\. / 
 
 'I ■ r ■ I r • - II rriii i ' r-|>iniW: ' I 
 
 By the term Piles is meant a varicose condition of the \eins 
 surrounding the anus and lower inch or two of the rectum. 
 
 The character of the blood-supply of this portion of the bowel, 
 and the conditions under which it is carried on, go far to explain 
 the frequency of this affection. The circulation in the lowest 
 portion of the colon is similar to that in the intestine generally, 
 the vessels being distributed transversely around the gut ; but in 
 the rectum they run in longitudinal series along the bowel, being 
 connected by transverse branches, which form a plexus around 
 and just above the anus. Their situation in the loose submucous 
 tissue, where there is but little support, necessarily exposes them 
 to great and sudden variations of pressure before and after 
 
RECTUM AND .IS'i'S 
 
 '>9J 
 
 r practic;il)le in corn- 
 states 15 to 20 per 
 from shock, lucnior- 
 cnce is considcrublf, 
 lore, since the nervi- 
 es that are cured ;i 
 , follow either from ;i 
 )ril\ce, and it is still 
 le colotoniy is not as 
 
 tion is not feasible, 
 tient's condition can 
 should not wait until 
 erate at the earliest 
 is: {a) It allows the 
 Lssists in niahitainin-; 
 pain arising from the 
 ce ; {c) it retards tiie 
 rritating action of the 
 inal o\>struction from 
 i absolute risk of tin 
 omparatively well and 
 'ormerly, when under- 
 ^as about 30 or 40 per 
 V practically nil, or al 
 
 should it be for any 
 s in limitinf; the diet 
 /root, etc., with some 
 ins as possible, and to 
 Dwels for about a week 
 keeping him in bed, 
 if morphia. 
 
 I. , X / 
 
 Condition of the veins 
 
 of the rectum. 
 „ portion of the bowel 
 fd on, go far to explain 
 lulation in the lowest 
 ,16 intestine generally, 
 Iround the gut ; but in 
 Vlong the bowel, being 
 form a plexus around 
 h the loose submucous 
 [essarily exposes them 
 lure before and after 
 
 ilif.fcation. Their depriulcni position at tlif lowest part of the 
 portal area, together with tli<- absi-nce of valves, ;uul tlu' tact that 
 tliey constitute an important coinmunit ation between the portal 
 
 an 
 
 (1 general systems, and thus alionl the chief means of 
 
 tl 
 
 escane 
 
 linni a liiock on tiie portal trunk all these reasons niav be looked 
 
 oil 
 
 as PrediapoBing Causes of the condition. In aildition to tl 
 
 lese 
 
 ic excess, 
 
 we must also mention a sedentary occupation, alcohol 
 aiul chronic constipation, which, by leading; to congestion of the 
 liver, are fretpient precursors of piles. 'I'lu-y uk; e>ceedinglv 
 common in yo"ng p(u)ple, especially in men iihout twenty year's 
 of age forced to lead' a sedentary life ; np to middle age the 
 tendency diminishes, but in elderly individuals many conditions 
 
 wiiich fi 
 
 tl 
 
 arise wmcn lavour tneir development. Young women are re- 
 markably exempt from piles, owing probably to the regularity of 
 the menstrual discharge ; but uterine conditions, such as preg- 
 nancy, displacements, or tumours, which cause obstruction U) the 
 venous return, are liable to be associated with them. Many forms 
 (if abdominal tumour, e.g., aneurisms, may also determine their 
 existence. 
 
 A varicose condition of the xeiiis in the neighbourhood of the 
 i.iuis is often present without being recognised by the individual ; 
 hut many different circumstances may bring the symptoms into 
 prominence, such as the use of drastic purgati\es, espc. ially aloes, 
 local exposure to damp and cold, as by sitting on a cold wet stone 
 or in a draughty closet, or sudden congestion of the liver, as by 
 alcoholic excess, or a chill. 
 
 Two chief varieties of piles are described, viz., the external and 
 internal ; but frequently a combination of the two conditions is 
 present. 
 
 External P iles are found at the margin of tlie anus, and are 
 covered wiTTir^MtirT" They consist of a small central vein in a vari- 
 cose state, surrounded by a development of subcutaneous hbro- 
 cellular tissue, which latter is much more abundant than the 
 vascular element ; in fact, they practically consist of longitudinal 
 folds of skin of a dark brown colour radiating from the anus, and 
 superficial to the sphincter. In the usual relaxed state in which 
 they are found they give rise to no Symptoms beyond a little 
 pruritus, and perhaps a sense of fulness and irritation imme- 
 diately before and after defalcation. They are \ery liable, 
 however, to become inflamed from local irritation or cold, and 
 then appear as tense, bluish, rounded swellings, exceedingly 
 painful and tender, and often preventing the patient from walking 
 or sitting in comfort. In such a state the vein contained in the 
 pile is distended with blood-clot. Under suitable treatment the 
 swelling subsides in a few days, usually leaving the fleshy fold 
 more bulky and harder than previously, owing to the partial or 
 complete organization of the thrombus. 
 The Treatment of external piles, when uninflamed, is very 
 
 63 
 
994 
 
 A MANUAL OF SURGERY 
 
 simple. Constipation must be relieved ; the parts should be ke 
 clean and well washed ; a hamamelis ointment or extract may 
 occasionally applied, and great care taken not to irritate the an 
 after defaecation by the use of hard paper {e.g., newspaper). Ve 
 soft curl paper, well crumpled, should be employed, or preferab 
 absorbent wool. It is but rarely that operative measures are i 
 quired in a simple case of external piles ; where, however, e 
 ternal and internal piles coexist, it is advisable to complete ai 
 operation undertaken for the latter condition by the removal 
 the more prominent fleshy folds surrounding the anus. This 
 accomplished by grasping them with forceps, and snipping the 
 away by scissors in a direction radiating from the centre of t 
 anus. We would warn the practitioner, however, against a t( 
 free use of the scissors, wHereDya~sub5equenfCohtracti'on of t 
 anus may be induced. For inflamed external piles the patiei 
 should be kept in bed, the bowels opened by a copious wan 
 enema, and fomentations applied. If the pain and tension ar 
 very great, the tumour should be incised and the clot turned out 
 the margins of the fold may then be cut away, and the woun 
 dressed wnth iodoform and salicylic wool. 
 
 Internal Piles consist of dilated veins held together by a certaii 
 
 '"^^^ " "" amount of connective tissue, and coverec 
 
 by mucous membrane. At first they art 
 quite soft and compressible, and easil\ 
 emptied on pressure ; but when the\ 
 have existed for some time the connec- 
 tive tissue may be increased in amount, 
 and arterial twigs are often found run- 
 ning into the mass. 
 
 The condition is limited to the lower 
 2 inches of the bowel, and may present 
 very varied appearances in different 
 cases. Thus, there may be a general 
 varicosity of the veins in the submucous 
 tissue without the formation of any dis- 
 tinct tumours. The mucous membrane 
 is then of a deep claret colour, somewhat thickened, and liable 
 to protrude during defaecation. There is a certain amount of 
 mucous glairy discharge, and the faeces may be streaked with 
 blood ; but, as a rule, the haemorrhage is not great. Such a 
 condition is usually followed by a definite formation of haemor- 
 rhoidal tumours, and not unfrequently runs on to^rola_gse. 
 
 When distinct haemorrhoidal masses form,"'fhe"y"ma3rbe of two 
 types : (a) The longitudinal or fleshy pile (Fig. 344), consistins^ of 
 broad sessile masses, dusky in colour, soft and compressible in 
 consistency, and usually covered by mucous m.embrane, which, 
 although thin and stretched, still remains smooth and shiny, like 
 the skin of a black grape. Between the piles depressions are 
 
 \h\\\ 
 
 Fig. 344. — Internal 
 Piles. 
 
RECTUM AND ANUS 
 
 995 
 
 parts should be kept 
 snt or extract may be 
 )t to irritate the anus 
 ., newspaper). \'ery 
 iployed, or preferably 
 'ative measures are re- 
 where, however, ex- 
 ;able to complete any 
 ,n by the removal of 
 ig the anus. This is 
 5, and snipping them 
 om the centre of the 
 lowever, against a too 
 infCohtraction of tlie 
 rnal piles the patient 
 i by a copious warm 
 pain and tension are 
 d the clot turned out ; 
 iway, and the wound 
 
 . together by a certain 
 ive tissue, and covered 
 ane. At first they are 
 mpressible, and easily 
 ure ; but when they 
 ome time the connec- 
 
 increased in amount. 
 
 are often found run- 
 
 „ limited to the lower 
 
 >wel, and may present 
 
 arances in different 
 
 e may be a general 
 
 _;ins in the submucous 
 
 formation of any dis- 
 
 le mucous membrane 
 
 thickened, and liable 
 
 a certain amount of 
 
 lay be streaked with 
 
 not great. Such a 
 
 formation of hamor- 
 
 m toprqlaRse. 
 
 'fhey'maybe of two 
 
 ,. 344), consisting of 
 
 and compressible in 
 
 IS m-embrane, which, 
 
 looth and shiny, like 
 
 liles deoressions are 
 
 found, in which small portions of faeces may lodge and produce 
 irritation. This form usually bleeds but little. (/;) The globular 
 or bleeding pile is single or multiple, and usually somewhat pedun- 
 culated ; the surface of the tumour is roughened and granular, 
 like a strawberry, due to the existence of dilated capillaries'. 
 When, however, a portion of it has been repeatedly protruded, 
 the exposed mucous membrane becomes hard, and practically 
 converted into skin. The haemorrhage is often abundant, and 
 comes either from the dilated superficial capillaries, or occasion- 
 ally from a central arterial twig. 
 
 The Symptoms arising from internal piles are often not very 
 marked until haemorrhage occurs; but there is usually a sense 
 of weight or fulness about the anus, with sometimes pain, which 
 is increased before and after d( faecation. The patient feels as 
 if a foreign body were present in the bowel, and the mass not 
 unfrequently protrudes, giving rise to much pain and incon- 
 venience until replaced by the patient, owing to the grip of the 
 sphincter. Sooner or later haemorrhage is almost certain to he 
 noticed, coming on at first after defaecation, and only a few drops 
 being lost. After a time, however, the flow increases, and may 
 continue to such an extent as to cause marked anaemia. If the 
 case remains untreated, the pain and inconvenience increase ; a 
 blood-stained mucous discharge from the rectum is noticed, soiling 
 the linen ; reflex irritation of neighbouring organs is produced, 
 and a condition of nerve prostration from pain and haemorrhage 
 may result. In cases where the piles are due to portal obstruc- 
 tion, as in cifrlibsis of tile liver, the bleeding may be beneficial, 
 -and musFrToTalways be checked. ' Moreover, when the menstrual 
 flow Ts 'diniinished, a vicarious discharge of bloodfrtjm' the piles is 
 somet imes - observed. 
 
 Complications of Piles. — Infianimation of the venous ampullae 
 contained in piles leads to what is popularly termed an ' attack 
 of piles,' although this is much less common with the internal 
 than the external variety, and the fleshy form is that usually 
 affected. Evidences of a localized phlebitis manifest them- 
 selves in the shape of a painful distension and swelling of the 
 parts, which become blue 'n colour and exquisitely sensitive. 
 They subside with or without suppuration ; in the latter case a 
 spontaneous cure may result, whilst in the former general blood 
 contamination may follow, death from pyaemia having even 
 occurred. Strangulation of the piles by the sphincter ani may 
 follow protrusion where reposition is not effected, the mass then 
 becoming painful, tense, swollen, and livid in colour ; inflamma- 
 tion running on to ulceration and even sloughing follows, the 
 patient suffering meanwhile from sickness, pain, and toxaemia. 
 Pyjemia is likely to ensue unless the case is effectively treated, 
 preceded by pylephlebitis {i.e., septic inflammation of the branches 
 of the portal vein in the liver). On the other hand, a spontaneous 
 
 63—2 
 
996 
 
 A MANUAL OF SURGERY 
 
 cure may be effected. Prolapse may become chronic, and Jissii 
 of the anus develop. 
 
 The Diagnosis of piles from other swellings which occur in tl 
 neighbourhood is not difficult. From prolapse they are recognise 
 by their irregularity, the swelling not being of a rounded smoo 
 annular variety, as in the former case ; the two conditions at 
 however, often associated. From polypus piles are distinguish( 
 by being multiple rather than single, by being softer and mo 
 compressible, by their situation close to the anus, and by tl 
 haemorrhage being usually more marked. Mucous tubercles ar 
 condylomata are often mistaken for external piles, but are easi 
 recognised by being symmetrically placed, owing to infection 
 one lip of the gluteal fold from the other, by their moist surfac 
 and their situation at a little distance from the anus. Tl 
 consistency, appearance, and history of an epithelioma shoul 
 effectually prevent any error in diagnosis. 
 
 p^^anum Trom many other conditions besides _^gi[es..^^_Jn_J;.b 
 latter case the bfnnd' is' of a KngHf YprTfffnn ^rQlnnr, and nf te 
 coats the faeces, whereas' if tf bf igmales higher in the inte; 
 "tihal canal it is dark or tarry" "ifit;ot5uFW(fj^ 
 intimately mixed* wini' the excreta. A digital examination c 
 Ihe rectum will also in the latter case eliminate the presence c 
 piles. 
 - The Treatment of internal piles is both general and local. 
 
 General Treatment consists in removing all possible sources o 
 venous congestion, in regulating the bowels and assisting tin 
 functions of the liver. The latter may be effected by the judiciou; 
 administration of natural mineral waters, such as Hunyadi Janoi 
 and Friedrichshall, or by the use of .some such mild aperients a; 
 the confections of senna and sulphur, or castor-oil. These inaj 
 be given daily, whilst at the same time the food and drink of thf 
 individual are regulated, all excess of alcohol being avoided, anc 
 suitable exercise enjoined. In weakly and debilitated individual; 
 it is advisable to adopt a more stimulating and tonic plan o 
 treatment. Aloes should generally be avoided. When dependeni 
 on the pressure of a gravid uterus, but little more can be dom 
 than attend to the regular action of the bowels until the child i; 
 born. 
 
 Local Treatment in the earlier stages consists merely in pallintivi 
 measytfelS/ 'Thus "fh'e parls rnust be protected from injury and 
 ^col4.; only soft paper or cotton- wool used SfteT "^eTgecaliQn .;. . and, 
 when protruding, the piles should be sponge J With cold-water 
 and gently returned. An ointment con taming "anfextract ol 
 witch-hazel (hamamelis), or the injection of a hazeline lotion 
 (i in 8) is also advisable, and bleeding firohf piles can often be 
 arrested by this means. The ung. gallae c. opio of the Pharma- 
 copoeia is recommended, but is not so efficacious. , 
 
RECTUM AND ANUS 
 
 997 
 
 chronic, and Jissuyc 
 
 s which occur in the 
 ; they are recognised 
 oi a rounded smootli 
 ; two conditions are, 
 les are distinguished 
 ing softer and more 
 le anus, and by the 
 Mucous tubercles and 
 piles, but are easily 
 Dwing to infection of 
 y their moist surface, 
 •om the anus. The 
 an epithelioma should 
 
 Dlood. may. 1?§- P.^-ssed 
 
 orlEIcaiuu]:^-aIltLDfteIl 
 "higher in the mtes- 
 KaaJT'aniJrSmore 
 ligital examination ot 
 linate, the^resence of 
 
 ;neral and local, 
 all possible sources of 
 lels and assisting the 
 [fected by the judicious 
 ich as Hunyadi Janos 
 ich mild aperients as 
 istor-oil. These may 
 ■ food and drink of the 
 |ol being avoided, and 
 lebilitated individuals 
 ig and tonic plan of 
 led. When dependent 
 ittle more can be done 
 rels until the child is 
 
 ists merely in J>allidii'( 
 tcted from injury^ ancl 
 
 kfteT 'Sefxc^m 1 . .^M. 
 tged'wTth cold-water 
 laimng "an"'extract of 
 lof a hazeline lotion 
 Irii piles can often be 
 ] opio of the Pharma- 
 lious. , 
 
 \yhen there is much pain or bleeding, and the piles have 
 attained some size, Radica l Treatment by operation is necessary. 
 Care must be taken l^eTi^ie tah'iyhij.^' it" to ascertain the condition 
 of the liver, as the bleeding may be beneficial in relieving hepatic 
 congestion, and an operation is then injudicious and liarniful. 
 In all cases the bowels are thoroughly emptied by a dose of 
 castor-oil given the night before and an enema on the morning of 
 the operation, whilst the patient sits over hot water for halfan 
 hour beforehand. The lithotomy position is adopted, the perineum 
 is shaved and cleansed, and the surgeon thoroughly stretches the 
 sphincter by introducing the two index-fingers and then separating 
 them forcibly, by this means bringing into view the whole of the 
 diseased area of mucous membrane, which never extends beyond 
 2 inch es from the anus. The following plans of treatment are 
 
 those"Thiefly*"usfid '. "' 
 
 I., Removal by clamp and cautery, as introduced by the late Mr. 
 Henry Smith. The mucous membrane having been everted, as 
 just described, each of the haemorrhoidal tumours is grasped by a 
 pair of ring-ended catch forceps, and thus temporarily secured , 
 by this means the scope of the operation required can be readily 
 gauged. The clamp is then applied to each mass successively in 
 a direction corresponding to the long axis of the gut, great care 
 being taken not to include the external skin. The clamp is 
 lightened by the screw attached to its handle, and the projecting 
 mass of the pile removed by scissors. The cut surface is then 
 thoroughly seared by a cautery at a dull red heat, and the pressure 
 of the clamp slowly relaxed, so as to ascertain that all bleeding 
 has ceased. External piles may be snipped away, as^indigated^ 
 above (p. g94X the mucous "membrane re-inverted, Ihe parts 
 (Tusted with iodoforni, ancj a careTiilly graduated compress of anti- 
 septic woor'apptied _wdth. a. Tt bandage. The parts are bathed 
 "eacli My wftli some mild antiseptic lotion, and should be healed 
 in ten to fourteen days. The use of the catheter may be necessary 
 for the first forty-eight hours after a severe case, owing to 
 retention of urine. The bowels are not opened until the fourth 
 or fifth day, and then a good dose of castor-oil {e.g., i ounce in 
 adults) should be administered. It is better to allow the patient 
 to sit on a commode for the evacuation of the bowels. From a 
 very large experience of this operation, gained both at hospital 
 and in private, we have no hesitation in maintaining that, if 
 efficiently carried out, and combined with the use of a powerful 
 and properly constructed screw-clamp, it is absolutely safe and 
 free from danger ; that any complications from sepsis, haemorrhage, 
 etc., are due to the carelessness of the surgeon, and not to the 
 character of the operation ; and that for all practical purposes it 
 is the best means of dealing with internal piles. 
 
 2. Ligature is also an operation much in vogue for the treatment 
 of piles, and as now carried out with due antiseptic precautions, 
 
999 
 
 A MANUAL OF SURGERY 
 
 ■^ 
 
 W 
 
 a large amount of success attends its use, although it is doi 
 whether recovery is as speedy or painless as alter the cai 
 T he haemorrhoidal tum ours are graspe d by forceps, the mi 
 membrane divided arou nd the m, and the base ligatured with 
 tliVmass is then snipped^off, and the ligature cut short,' tHe' 
 being altDWed^6 'separate by subsequent ulceration. 
 
 -J. Cy?«A^/«/o' by" means" of ia powerful clamp has also 
 
 recommended by Benham, Allingham, and others, the ba 
 the mass being thoroughly compressed, and the pile ther 
 away. We think it safer to combine such treatment wit) 
 styptic and antiseptic qualities of the cautery. 
 4. Where the veins of the lower inch or 
 membrane are in a varicose condition, but 
 rhoidal tumours are present. Whiteh ead's g^a^jm^i^^y 
 .ployed. It consists in the total removalof this pile-bearing 
 in the same way as for excision of the rectum. An incisi 
 made round the margin of the anus at the jurctr n of the 
 and mucous membrane, and the latter "ssected up fron 
 muscular coat of the bowel by successive snips of the scissoi 
 is then cut away, all bleeding-points are secured, and the 1 
 end of the divided mucous membrane united by suture to the 
 the stitches passing deeply under the surface of the wound 
 not merely through the margins. Excellent results have foil 
 such treatment in suitable cases. 
 
 two of the 
 no definite 
 
 mi 
 ha 
 be 
 
 Bectal Prolapse. 
 
 A certain tendency to eversion of the mucous membrane o 
 bowel is a constant and normal accompaniment of the a 
 defaecation ; if, however, this becomes abnormally increased 
 condition may be maintained after the evacuation of the be 
 is concluded, constituting a condition of prolapse. At first 
 the mucous membrane is protruded, and this is known a 
 incomplete prolapse ; if, however, the condition persists, the "v 
 thickness of the bowel may become involved, mucous memb 
 submucosa, and even the muscular and serous coats, giving 
 to the complete variety (Fig. 345). The former condition (s 
 times badly termed a prolapsus ani) is more commonly met 
 in adults, and the latter (the so-called prolapsus recti) in chik 
 but it must be understood that the latter is always precede 
 an incomplete stage, limited to the mucous membrane, and 
 in adults complete prolapse is occasionally observed. 
 
 Causes. — i. It may be produced by a simple relaxation o 
 tissues, as met with in weakly individuals, and those who 
 been much exposed to the debilitating effects of residenc 
 tropical climates, especially when chronic constipation or diar 
 has caused the evacuation of the bowels to be accompanie 
 straining efforts. 2. Conditions which have led to chronic tene 
 
ERY 
 
 although it is doubtful 
 ss as alter the cautery. 
 ..hyJorceps, the mucous 
 base hgatured with silk ; 
 iture cut sliort; ttie "knot 
 ulceration. 
 
 1 ' clamp has also been 
 and others, the base of 
 , and the pile then cut 
 such treatment with the 
 
 tery. , 
 
 h or two of the mucous | 
 
 but no definite h»mor- 
 
 Vs o^iiikiL.xa^y_ be em- 
 
 fof'this pile-bearing area 
 
 rectum. An incision is 
 
 the jurcti- n of the skin 
 
 r '"'ssected up from the 
 
 e snips of the scissors; it 
 
 •e secured, and the lower 
 
 lited by suture to the skin, 
 
 surface of the wound and 
 
 Uent results have followed 
 
 mucous membrane of the! 
 iipaniment of the act oil 
 abnormally increased, the 
 evacuation of the bowelsl 
 ,f prolapse. At first only 
 md this is known as anl 
 idition persists, the wholel 
 olved, mucous membrane! 
 serous coats, giving risel 
 ! former condition (soniel 
 more commonly met witkl 
 •olapsus recti) in children; 
 tter is always preceded byl 
 [cous membrane, and tliail 
 lly observed. I 
 
 , simple relaxation of thel 
 lals, and those who havel 
 Ig effects of residence iri 
 c constipation or diarrhceal 
 :1s to be accompanied li;| 
 ,ve led to chronic tenesmus 
 
 RECTUM AND ANUS 
 
 999 
 
 or violent expulsive efforts, e.g., piles, chronic constipation, diar- 
 rhoea, rectal irritation, as from worms in children, or diseases of 
 neighbouring organs, such as vesical calculus, stricture, enlarged 
 prostate, may also determine prolapse. 
 
 Symptoms and Diagnosis. — The anal orifice is occupied by a 
 smooth rounded swelling, red or purplish in colour, covered by 
 mucous membrane ; this protrusion in the early stages can be 
 easily replaced by a little pressure, but returns if the patient 
 strains or coughs. When the swelling is of large size, reduc- 
 tion is increasingly difficult and painful from infiltration and 
 fibrous overgrowth of the submucosa, and it is very liable to 
 become inflamed and ulcerated from friction. Incontinence of 
 fa'ces is also a common result. When 
 the whole thickness of the gut is 
 protruded, the serous lining may 
 accompany the tumour, but is usually 
 limited to the anterior surface, and 
 into the sac thus formed small intes- 
 tine may pass, and even become 
 strangulated (Fig. 345, X). The 
 prolapse itself may also be con- 
 stricted if allowed to remain for 
 long unreduced ; the mass is then 
 livid, swollen, and intensely painful, 
 and if left to itself may slough away, 
 and thus lead to a spontaneous cure, 
 although severe septic symptoms 
 may supervene, and even perforative 
 peritonitis. 
 
 There should be but little difficulty 
 in recognising a prolapse ; the only 
 condition for which it can be mistaken 
 is an intussusception protruding from 
 the anus ; in such, however, tb ; finger 
 or a probe can be inserted into the rectum by the side of the pro- 
 truding gut, which is impossible with a prolapse. 
 
 Treatment. — In the earlier stages, all that is needed is the 
 removal, if possible, of the cause of the tenesmus, e.g., dilata- 
 tion of a urethral stricture, removal of a vesical calculus, or the 
 regulation of the bowels so as to check either chronic diarrhoea 
 or constipation. When piles are present, they should be treated 
 as described above, and the prolapse will, as a rule, subsequently 
 disappear. Thread-worms must be dealt with by suitable means 
 iq.v.). Beyond this, cold or astringent injections may be employed, 
 e.g., sulphate of iron (i to 3 grains to i ounce), and it is advisable 
 for the individual to acquire the habit of having the daily motion 
 at bedtime, whilst children are made to defalcate lying on the 
 side, one buttock being pulled up for the purpose. The prolapse 
 
 Fig. 345. — Longitudinal Sec- 
 tion OF Complete Prolapsus 
 Recti. (Tillmanns.) 
 
 X indicates the serous sac in the 
 anterior wall due to protrusion 
 of the peritoneum. 
 
lOOO 
 
 A MANUAL OF SURGERY 
 
 g 
 
 is carefully washed, reduced by pressure with the fingers, 
 retained by strapping the nates together, particularly in child 
 or by applying some suitable pad and a T-bandage. The 
 hope of obtaining a cure in this way consists in never allo\ 
 the prolapse to remain unreduced for any length of time. 
 
 When such palliative measures fail, Operative Treatment i 
 be undertaken. 
 
 In the slighter cases of incomplete prolapse, it will suffic 
 diminish the size of the anal orifice by snipping away radia 
 folds of skin and mucous membrane, and allowing the woi 
 thus produced to cicatrize. In the worse cases it may be ne 
 sary, in addition, to remove strips of the mucous membrane 
 longitudinal direction i ly means of the clamp and cautery ; 
 larger area of the posterior wall of the prolapse may be deni 
 of its mucous covering, and the edges brought together by ( 
 stitches. Where such has failed, or is thought undesirable, 
 prolapse may be dissected away by incising the circumferenc 
 the anal orifice at the junction of the skin and mucous membr 
 and turning down the outer layer of the mucous coat like a 
 A finger inserted in the bowel suffices to draw down all the s 
 inner lining, and to ascertain that nothing is present but 
 mucous membrane. The whole of the prolapsed portion is 
 moved by scissors, all bleeding-points being secured as divic 
 the upper edge of the mucous membrane is then united by su 
 to the cutaneous margin of the anal orifice. 
 
 In cases of total prolapse of the bowel in children, not! 
 but palliative treatment is generally necessary ; but in adul 
 modification of the above described operation is required, 
 patient's buttocks are well raised, so as to prevent any protru 
 of intestine if the peritoneal cavity is opened. The base of 
 prolapse is divided anteriorly on a level with the anus, the o] 
 ing in the peritoneum plugged with a sponge, and the remair 
 of the mass removed by scissors, bleeding-points being secure 
 divided. The serous cavity is then carefully closed by sutu 
 and the divided end of the bowel united to the skin at the a 
 No motion is allowed to pass for a week, but the anal orifice 
 lower gut should be thoroughly washed out twice or thrice c 
 to prevent accumulation of septic material. Control over 
 bowel is usually regained, though often somewhat slowly, and 
 "fter- treatment is likely to be prolonged. 
 
 In obstinate cases where the prolapse recurs again and a] 
 after operation, the sigmoid flexure should be cut down u 
 from the groin and anchored by sutures to the abdominal 
 {colopexy), or even a temporary colotomy performed. 
 
iV 
 
 with the fingers, and 
 articularly in children, 
 -bandage. The great 
 ists in never allowing 
 mgth of time. 
 srative Treatment must 
 
 .lapse, it will suffice to 
 aipping away radiating 
 d allowing the wounds 
 ; cases it may be neces- 
 nucous membrane in a 
 amp and cautery ; or a 
 rolapse may be denuded 
 -ought together by deep 
 bought undesirable, the 
 ng the circumference of 
 
 and mucous membrane, 
 
 mucous coat like a cuft. 
 
 draw down all the slack 
 tiing is present but the | 
 
 prolapsed portion is re- 
 ding secured as divided; 
 ^is then united by suture 
 
 -e 
 
 wel in children, nothmi 
 cessary; but in adults a 
 ration is required, ihe 
 o prevent any protrusion 
 )ened. The base of the 
 with the anus, the open- 
 Dnge, and the remainder 
 -points being secured as 
 
 iuUy closed by sutures, | 
 I to the skin at the anus, 
 but the anal orifice and 
 out twice or thrice daily 
 prial. Control over the 
 [omewhat slowly, and the 
 
 recurs again and again! 
 
 )uld be cut down uponi 
 
 to the abdominal wall I 
 
 [performed. 
 
 CHAPTER XXXV. » 
 
 SURGICAL AFFECTIONS OF THE KIDNEYS. 
 
 Congenital Affections of the Kidney.— Many different malformations and dis- 
 placements are met with affecting these organs. 
 
 The chief Malformations are as follow : (a) Complete absence of one organ, 
 a very rare condition, and (i) congenital atrophy of one kidney, it being repre- 
 sented by a mass of fatty tissue : in both cases the other organ is correspond- 
 ingly enlarged and hypertrcphied. (c) The kidneys may be fused together, 
 either constituting one large organ in the median line, and more or less 
 normal in shape, or sometimes constituting the so-called horseshoe-shaped 
 variety, the convexity being directed downwards. (</) Deep lobulation of 
 the kidney, as in some animals, is sometimes seen, especially if the organ 
 is displaced ; occasionally this is carried to such an extent as to divide it 
 into two or more portions, (c) The ureter and pelvis may be double, this 
 malformation affecting the pelvis alone, or extending as far as the bladder. 
 (/) The renal artery may arise from the aorta in two or more main branches. 
 
 The majority of these malformations are of very little clinical importance, 
 except in the operation of nephrectomy, when they may necessitate a slight 
 modification of the usual proceedings. 
 
 Congenital Displacement of the Kidney occurs about once in every thousand 
 individuals, the organ being either depressed, so as to lie over the sacro-iliac 
 synchondrosis or sacral promontory, or raised above its normal position. The 
 left kidney is more frequently affected in this way than the right, and, when 
 lying in the iliac fossa, the descending colon is usually displaced inwards, so 
 that the rectum starts to the right of the middle line. The adrenal bodies 
 retain their normal position, and do not move with the kidney. 
 
 Cystic disease, sarcoma, and hydronephrosis may also occur congenitally, 
 and will in tTirn'be~H5scribed below. V ^ 
 
 Floating and Moveable Kidney. — The term Floating Kidney has r -^ 
 
 [ been appireHTo'a "supposed congenital condition in which theorgar^|f , 
 lis attached to the posterior abdoffiifiarwair by a meso-nephron or 
 [■pfefitoneal liga^nient ; it is, however, more than doubtful whether 
 jstKh an""aBfiofniaiity really exists. By Moveable Kidney is 
 Imeant an acquired condition in which the kfdney moves within 
 [the perinephric fatty tissue, which forms a loose capsule around 
 lit. It occurs more frequently in women than in men, and more 
 [often on the right than on the left side, partly because the renal 
 Ivessels are longer on this side than on the other, and partly 
 jbecause the descending colon is more fixed than the ascending. 
 
 Causes. — Parturidoj n accounts for majnXSaSPS.^ firstly, because 
 k)f the sudden (iiniTnutioiroF iKe Intra-abdominal pressure, and 
 
 K^r.. 
 
I002 
 
 A MANUAL OF SURGERY 
 
 spcf^nflly . owing to the resulting pendulousand relaxecl^_^igj 
 the abd Q.n1iiTtt l muscles, especially iF the patient too earl^ rest 
 the erect _£osture, of "uhdertaliSspliy sical ' wofT<* wTtTiVnir eHfic 
 Extern aTs^uppprt^i hence it is more t'reqvieTTt am on father 'p'cT&T' 
 atiiongst the rich. It may also follow the removal of 1 
 abdominal tumours or rapid emaciation, whilst tight-lacin 
 traumatic influences may be responsible for some cases, 
 frequently associated with that form of displacement downw 
 of the abdominal viscera which is known as Glenard's disi 
 or enteroptosis. This is perhaps due to accumulation of fi 
 in the transverse colon, whereby the lesser omentum and c 
 peritoneal ligaments become stretched, and in consequence 
 intestines, stomach, and even the liver may slip downwards 
 become moveable. The right kidney participates freely in 
 displacement. 
 
 The Ssnnptoms arising from a moveable kidney consist ch 
 in pain referred to the back, or perhaps shooting along the ui 
 to the groin, testis or labium majus ; it is increased by pressut 
 or manipulation of the abdomen. Vomiting is a significant : 
 and the surgeon should never omit to~eXiimiTie tTie loins~lirc 
 of obstinate vomiting with no apparent cause. Periodical ex; 
 bations of these symptoms, with a temporary diminution in 
 amount of urine, result from kinking of the ureter ; sudden r 
 followed by an increased flow of urine possibly containing s 
 muco-pus, indicates that the organ has returned to its no 
 situation. On examining the abdomen, a moveable tumour 
 often be observed with ease if the abdominal parietes are 
 loaded with fat, and on manipulation pain and vomiting ms 
 induced. If the patient is lying in the prone position on a 
 couch, a distinct loss of resistance is noticed external to 
 erector spinae on the affected side. 
 
 Treatment consists in wearing an abdominal belt, sui 
 padded, or in the operation of nephrorrhaphy (p. 1022). 
 
 Injuries of the Kidney are usually due to crushes of the I 
 as between the buffers of railway cars, or when a cart p 
 over the abdomen, or from blows or falls. Considerable hae 
 rhage follows, both into the substance of the kidney or its p< 
 and into the perineph»-'o fatty tissue, and this even when 
 capsule has not been torn. The integrity of this structure 
 point of great importance, since it limits to some extent 
 bleeding and prevents urinary extravasation ; the kidney 
 be crushed to a pulp without any external haemorrhage, 
 under these circumstances clots are likely to pass down 
 ureter, and may obstruct it and lead to its subsequent occk 
 When the anterior portion of the capsule is torn, the peritoi 
 may also be involved, and then evidences of intraperiti 
 bleeding may manifest themselves, and, indeed, if the kidn 
 
s and relaxecl^'da.of 
 tienrtocTeaiJ^^^^sumeij 
 
 -wHrR-wmiout^i^riLi 
 
 the removal of large I 
 whilst tight-lacing or 
 for some cases. It is 
 isplacement downwards 
 n as Glenard's disease, 
 . accumulation of faeces 
 ;er omentum and other 
 ind in consequence the 
 nay slip downwards and 
 articipates freely in this 
 
 ,le kidney consist chiefly 
 ^looting along the ureter 
 increased by pressure on 
 itin'^ is a significant^sign, 
 T^mme the loins In cS^\ 
 :ause. Periodical exacer- 
 porary diminution m the 
 the ureter; sudden relief, 
 possibly containing some 
 IS returned to its normal 
 a moveable tumour can 
 dominal parietes are not 
 lain and vomiting may be 
 prone position on a nat 
 noticed external to the| 
 
 labdominal belt, suitably| 
 laphy (p. 1022). 
 
 le to crushes of the body, 
 Is or when a cart passes 
 lis Considerable ha?mor- 
 If 'the kidney or its pelvis, 
 
 land this even when the 
 Irity of this structure is al 
 Imits to some extent the 
 \sation ; the kidney niav 
 hcternal haemorrhage, anj 
 Flikely to pass down the 
 [ its subsequent occlusioa 
 lie is torn, the peritoneuttl 
 Idences of intraperitoneal 
 ■i indeed, if the kidney i| 
 
 SURGICAL AFFECTIONS OF THE KIDXEYS 
 
 1003 
 
 extensively lacerated, fatal haemorrhage may result, though this 
 is unusual. Rupture of the posterior surface of tlie kidney opens 
 up the retroperitoneal cellular tissue, which becomes intiilrated 
 with blood and urine, and suppuration is almost certain to follow 
 resulting in pyaemia or at a later date in exhaustion from chronic 
 septic poisoning. 
 
 The_,fiyn«»toin&,.cfocluced c in severe shock, combined 
 
 with pain in the loin, shooting clowri"hito the Yestisor thio^h aui3 
 iiicreasedTreeiuency of micturition, tne urme voided being usually 
 mixed with blood. The amount of blood lost in this way varies 
 considerably; in the slighter cases the haMiiaturia is of short 
 duration, but in more extensive lesions it may be severe and 
 so persistent as to threaten life. The passage of clots down the 
 ureter gives rise to renal colic, and obstruction of that duct may 
 lead to total suppression of the secretion on the affected side. 
 The bladder may in some cases become greatly distended with 
 clots, the blood coagulating after it has enter(?d the viscus. 
 H.Tinorrhage into the perinephric tissues is indicated by the 
 formation of a swelling in the loin, and laceration of tlie peri- 
 toneum is shown by distension of the abdomen and the existence 
 of fluid within it. The development of a perinephritic abscess is 
 recognised by fever, rigor's, increased pain in the loin, and the 
 usual phenomena of deep suppuration. 
 
 The Treatment usually required is to keep the patient quiet in 
 bed, with an icebag applied to the loin ; pain may be relie\ed by 
 strapping the side or by applying a firm bandage. Persistent 
 haemorrhage necessitates the administration of ergot, tannic acid, or 
 turpentine ; but if it is threatening the patient's life, an exploratory 
 incision is required, and, if need be, removal of the organ, although 
 it is sometimes possible to stitch up a limited rent. Any disten- 
 sion of the bladder must be relieved, the clots being washed out 
 through a large-eyed catheter. The occurrence of peritonitis or 
 of a perinephritic abscess will call for suitable surgical measures, 
 the injured viscus being dealt with according to circumstances. 
 
 Rupture of the Ureter is a rare ac ciden t, usually due to direct 
 violence, but occasionally happening during' "peirTC" operations, 
 such as removal of the uterus. When due to a subcutaneous 
 injury, if cannot be recognised at once, but extravasation of urine 
 takes place, resulting in the formation of a perinephritic abscess. 
 This is incised sooner or later, and on exploring the cavity it may 
 be possible to detect the rent in the ureter, but more frequently its 
 situation cannot be found, and then a doubt will necessarily exist 
 as to whether the lesion involves the ureter or the pelvis of the 
 kidney. In either case a urinary fistula in the loin results, which 
 may possibly close after a time ; if the fistula persists, nephrectomy 
 will be required, and then the sooner such an operation is under- 
 taken the better. In a few favourable cases it has been possible 
 to suture the rent in the ureter by the following plan : the lower 
 
1004 
 
 A MANUAL OF SURGERY 
 
 end of the divided ureter is closed, the exposed mucous mend) 
 being tucked in by sutures passing through the muscular 
 the upper end is then implanted into a longitudinal opening ma 
 the side of the lower segment, and accurately stitched in posi 
 
 We have recently had two cases probably of this nature under treatmt 
 hospital. Both occurred in young btjys, and both were flue to cab accic 
 In the first, alter the preliminary shock had passed off, nothing specia 
 noted for about ten days, when on sitting up sharp pain was experienc 
 the side, and this was followed by a retroperitoneal collection of fluid tog 
 with some amount of fever. On incision a large (luantity of limpid 
 escaped, with but very little pus — an interesting illustration of the fact 
 healthy urine does comparatively little damage to tissues into which 
 extravasated, Tlie finger introduced into the wound passed beyonc 
 middle line, and the ureter could be felt traversing the cavity ; but tlu 
 could not be found. Drainage was provided, and for a time a urinary f 
 persisted ; finally, the wound healed completely. In the second cast 
 inflammatory piienomena were more marked, but an incision was not 
 until the twelfth day ; here also the lesion could not be found, and dra 
 was resorteil to, but without avail, nephrectomy being subsequently reqi 
 Both cases recovered. 
 
 Hydronephrosis is a condition characterized by distensio 
 the pelvis and calyces with urine, as a result of some obstruc 
 to its exit. 
 
 Causes. — (i.) It may be, though very rarely, congenital in or 
 It must be borne in mind that the body of the kidney is devek 
 from the metanephros, and that the ureter unites subseque 
 with it to form its excretory duct ; such union is occasior 
 defective at the upper end, well-marked obstruction occurring 
 the junction of the ureter with the infundibulum of the pe 
 Similar trouble sometimes arises from the ureter becoming kir 
 over an abnormally placed renal artery. It is, however, r 
 frecjuently due to an impervious condition of the urethra or to 
 existence of a membranous septum therein ; both kidneys 
 then necessarily afi'ected. The amount of distension in son' 
 these cases is such as to seriously interfere with parturition i 
 the abdomen has been tapped. The infants are often born d 
 or succumb shortly after birth, (ii.) Acquired forms of obstruc 
 are by no means uncommon, and may be arranged vmder 
 following headings : (a) Blocks within the urinary passages 1 
 the presence of stones, parasites, foreign bodies, or even blood ( 
 (b) changes of structure affecting the walls of the urinary passa 
 e.g., inflammatory swelling of the mucosa, cicatrices, stenosii 
 tumours ; (c) kinking of the ureter in cases of floating kidi 
 and (d) the pressure of extrinsic tumours or cicatrices, as i 
 pelvic cellulitis. Hydronephrosis may be unilateral or bilate 
 in the former case the obstruction arises within the ureter 
 from some vesical condition involving its entrance into 
 bladder ; in the latter case the cause is generally to be lookec 
 below this spot. 
 
 It must be clearly understood that a sudden and absolute b 
 
seel mucous meinbram 
 •h the muscular coat, 
 vuUnal opening,' made in 
 ;ly stitched in position, 
 i nature under treatment at 
 were due to cab accidents 
 ,ed oft, nothing special w.is 
 rp pain was experienced in 
 I collection of fluid together 
 e .luantity of limpid unne 
 illustration of the fact that 
 to tissues into which it is 
 wound passed beyond tl>e 
 ng the cavity; but the rem 
 1 for a time a urinary fistula 
 >, In the second case the 
 ,t an incision was not made 
 I not be found, and drainage 
 being subsequently required 
 
 SURGICAL AFFECTIONS OF THE KIDNEYS 
 
 IC05 
 
 I 
 
 terized by distension of 
 isult of some obstruction 
 
 arely, coHf^ciiital in origin 
 )f the kidney is developed 
 :eter unites subsequent y 
 tch union is occasionally 
 I obstruction occurring at 
 undibulum of the pelvis 
 ureter becoming kmked 
 f It is, however, more 
 n of the urethra or to the 
 lerein; both kidneys are 
 of distension in some ot 
 ,re with parturition until 
 ints are often born dead, 
 Lyed forms of obstruction 
 be arranged under the 
 le urinary passages from 
 ,odies, or even blood-clot; 
 s of the urinary passages, 
 la, cicatrices, stetiosis, or 
 ases of floating kidney; 
 ,rs or cicatrices, as atter 
 unilateral or bilateral; 
 ■s within the ureter, or 
 its entrance mto the 
 ;enerally to be looked for 
 
 idden and absolute block 
 
 never leads to hydronephrosis. Should it occur as the result of 
 impaction of a calculus in one of the ureters, tiie secretion on that 
 side is totally suppressed as soon as the tension within the pelvis 
 and calyces is sufficiently high. Should, however, the obstruction 
 he intermittent or incomplete, so that some of the urine escapes, 
 thereby relieving the pressure, hydronephrosis develops. Sudden 
 and complete occlusion of the urethra likewise res'ilts in dilatation 
 of the bladder and rupture either of that viscus 01 of the urethra, 
 whilst a gradually increasing obstruction is always likely to lead 
 to hydronephrosis. 
 
 Pathological History. — The earliest result of obstruction to the 
 (low of urine consists in dilatation of the ureter and pehis, which 
 is soon followed by expansion of the calyces. The pyramids 
 are Hattened, and the cortex expanded and thinned, so that thf 
 whole kidney looks larger 
 than usual. Acertain amount 
 of interstitial infiltration of 
 the cortex is always present ; 
 the urine secreted in the 
 early stages is usually abun- 
 dant and of a low specific 
 j,aavity. 
 
 If the obstruction con- 
 tinues, the renal tissue 
 hecomes more and more 
 jatrophied, until finally it dis- 
 appears entirely, the kidney 
 [being represented by a thin- 
 hvalled multilocular cyst. At 
 lany stage septic phenomena 
 [may supervene, giving rise 
 to pyonephrosis {vide infra). 
 
 The Clinical History varies 
 ;onsiderably with the method 
 )f onset and the cause of the 
 trouble. Frequently all that 
 lappens is a slight painless 
 
 jnlargement of the affected organ ; if both are involved, there 
 nay be at first some increase in the amount of urine secreted, 
 ihich is pale, limpid, and of a low specific gravity ; after a 
 [ime the quantity diminishes, and finally anuria and uraemia 
 lay follow, especially if septic changes supervene, as is so 
 bonimonly the case. When only one kidney is affected, the 
 pcretion may remain normal in quantity and quality, owing to 
 bompensatory hypertrophy of its fellow. Not unfrequently a 
 luctuating swelling of considerable size is produced by hydro- 
 kephrosis; it presents all the physical signs of a renal tumour 
 S. 1016), and its formation is often associated with pain, vomiting, 
 
 Fig. 34G. — Hydronephrosis. (From 
 Specimen in Bristol Hospital 
 Museum.) 
 
ioo6 
 
 A MANUAL OF SURGERY 
 
 and increased fre(|uency of micturition. I'inally, a perinep 
 abscess may develop, owinj; to ulceration of the pelvis or u 
 and the cyst may thus discharj,'e throuf^h the loin. Occasio 
 the size of the tumour varies considerably from time to 
 owing to the obstruction being temporarily overcome b; 
 pressure of retained urine behind it. 
 
 The Treatment of hydronephrosis should in tlie first pla( 
 directed to removal of the cause, if practicable, and wlien 
 obstruction exists in the prostate or urethra, no other treat 
 is feasible. In some cases of congenital hydronephrosis d 
 malformation of the upper end of the ureter, it is possih 
 transplant it and thereby relieve the obstruction. Unih 
 hydronephrosis must be dealt with by aspiration as a tempi 
 measure ; but this is rarely satisfactory, and usually needs 
 followed by an exploratory incision (nephrotomy), by mea 
 which it may be possible in a few cases to reach and deal 
 the obstruction. In the majority, however, the block is siti 
 so low down that it cannot be reached, and nephrectomy 
 then be undertaken. 
 
 Inflammation of the Kidney and its Surroundings.— It i« 
 
 necessary to discuss the many varieties of inflammation o 
 kidney ; they are dealt with in medical text-books. The folic 
 conditions are, however, of surgical importance : 
 
 I. Pyelitis is the term applied to an inflammation invc 
 the pelvis of the kidney, the calyces, and perhaps the ureter, 
 chief causes from which it arises are : {a) The presence 
 calculus, or the passage of uric acid crystals in gouty Individ 
 {b) tuberculous disease, either starting primarily in the ki 
 or extending upwards from the bladder ; {c) extension of i 
 inflammation from the bladder and urethra ; {d) malignant d 
 of the kidney ; {e) occasionally in floating or moveable ki< 
 (/) the ingestion of irritating drugs, e.g., cantharides, turpe 
 and occasionally cubebs or copaiba ; {g) the presence of fc 
 bodies, such as needles, bullets, and parasites, e.g., the Bil 
 haviatolui or the Strongvlus gigas ; (h) a pyaemic embolus 
 (i) possibly cold. 
 
 \\'hale\ er the cause, the pathological phenomena are the 
 consis'.irg in the lining membrane becoming congestec 
 thickened, and secreting a muco-purulent, or even purulen 
 charge. Owing to the swelling of the mucous membran 
 entrance to the ureter is encroached on, and a certain amo 
 distension of the pelvis and calyces (hydronephrosis) fo 
 Where micro-organisms are present, as in cases due to ext( 
 from the bladder, the kidney is likely to be involved in the p 
 (pyelonephritis), or the condition may be followed by a u 
 abscess in the loin or suppurative perinephritis. 
 
 The Ssrmptoms of pyelitis consist of pain and tenderness 
 
HY 
 
 SURGICAL AFFECTIONS OF THE KIDNEYS 
 
 1007 
 
 n 
 
 finally, a perinephr tic 
 of the pelvis or ureter, 
 the lohi. Occasionally 
 ,ly from time to timr. 
 arily overcome by th.- 
 
 Id in the first place b. 
 :ticable, and where tlu 
 hra, no other trea meiu 
 , hydronephrosis due u 
 
 ureter, it is P^f ^! ^\^^;;; 
 obstruction. Unilater.d 
 .spiration as a temporary 
 and usually needs to be 
 phrotomy). by means ..t 
 is to reach and deal w.tl, 
 .ver, the block is situated 
 i, and nephrectomy must I 
 
 Surroundings-It is un- 
 .s of inflammation of the 
 ext-books. The following 
 
 jortance: . , . 
 
 n inflammation mvolv r..' 
 perhaps the ureter. Ibe 
 • ia) The presence ot a 
 stals in gouty individuals; 
 primarily m the kidne , 
 .r- ic) extension of sepuc 
 ihr'a(rf) malignantdise.se 
 ting or moveable kidney 
 ',cantharides, turpentine, 
 a< the presence of foreign 
 firasites! e.g. the B. /mm- 
 ^ a pyemic embolus , and| 
 
 ll phenomena are the same 
 b'Lcoming congested aj 
 lent, or even purulent, d 
 le mucous membrane, U 
 In, and a certain amounto 
 
 ■ (hydronephrosis) foUo^ 
 IS in cases due to extensd 
 
 , be involved in the procej 
 be followed by a unnanj 
 
 '' p^a^n^and tenderness om 
 
 tlie affected kidney, increased fre(]uency of micturition, and the 
 intermittent discharge of pus in acid urine. The intermissions are 
 due to the inflammatory sweUingof the mucous membrane, which 
 temporarily blocks the upper entrance to tlie ureter, and neccssi- 
 liites a certain degree of pressure of the urine and pus accuinulated 
 in the pelvis of the kidney in order to overcome the obstruction. 
 Necessarily, where pyelitis follows chronic cystitis, the acid re- 
 action of the urine is neutralized by the changes occurring in the 
 l)laddet ; in such cases a nocturnal elevation of temperature is 
 usually noted. 
 
 The Treatment of pyelitis is mainly directed tf) the cause. 
 Where such is removable, c.^., calculus or foreign bodies, an 
 ojieration is advisable. In septic cases originating in the bladder, 
 treatment should first be directed towards the latter \iscus. If 
 no cause is evident, the patient is kept warm, his diet restricted 
 to the simplest solids and bland fluids, and salol, alkalies, and 
 sedatives prescribed. If these measures fail, the afTected kidney 
 should be explored. 
 
 2. Pyelonephritis, or inflammation of the pelvis of the kidney 
 together with the renal parenchyma, is almost invariably suppura- 
 tive in type and commonly due to extension upwards from the 
 lower urinary organs, constituting the chief element in the more 
 serious cases of what used to be badly termed 'surgical kidney.' 
 
 This condition may supervene suddenly and with acute symp- 
 toms, and then probably results from some surgical operation or 
 simply from catheterism in a patient whose bladder is in a highly 
 septic condition. The organisms find their way upwards along 
 the lymphatics in the mucous lining of the ureters, and soon infect 
 the pelvis, giving rise to a suppurative pyelitis ; the walls of the 
 ureters may in such cases be studded with miliary abscesses. 
 The presence of septic matter in the pelvis always lights up a 
 certain amount of irritation in the renal substance, constituting a 
 jsubacute interstitial nephritis; but in addition to this bacteria 
 [invade the pyramids and travel upwards along the lymphatics or 
 the renal tubules, giving rise to abscesses, either scattered through 
 the connective tissue of the organ or within its tubules, in either 
 case seriously damaging its excretory function. In both in- 
 [stances it is possible for many of these minute foci of pus to run 
 [together and form a large collection, which in time becomes 
 recognisable from outside ; but more usually the patient dies of 
 toxaemia or uraemia before that stage is reached. Sometimes the 
 ;ondition develops more chronically, and then the phenomena of 
 )yonephrosis are more prominent. 
 
 The Clinical History of pyelonephritis is a little vague. In 
 icute cases the symptoms probably commence with a severe rigor 
 ^hortly after the operation which has called the trouble into 
 Existence. This is associated with pain in the loins or back, 
 Jcadache, vomiting, and probably some amount of drowsiness^ 
 
looS 
 
 A MANUAL OF SURGERY 
 
 perhaps passing,' into a condition of coma. Tli« i\'^()V ma) 
 repeated, or the fever may remain lii;^h witliout cxactThati 
 The urine is usually diminished in amount, and, indeed, ma) 
 supj)ressed entirely ; if any passes, it is hi^di -coloured and cont 
 albumen and perhaps blood, tojjjether with some amount of 
 which is probably derived larj^^ely from the lower portion of 
 urinary track. The prof^mosis in these cases is nearly hope 
 the patient beinj^^ almost certain to die of ura-mia, cspcciail 
 both kidneys are generally aOected, although in the more hr 
 type, if the cause of obstruction is removed, lie may recoxer. 
 
 Treatment.- -The cause of the affection in the lower urir 
 passages nuist be attended to ; septic urine is drawn off, an 
 need be the bkadder washed out; all causes of obstiuction n 
 also be removed, if practicable. The patient is, of course, kep 
 bed ; tlu* loins are cupped or fomented ; the patient is encoura 
 to drink |)lenty of bland fluid, whilst stimulants are, if possi 
 avoided entirely, as also opium. When the temperature rem; 
 high, (piinine is administered. 
 
 3. Pyonephrosis is the name applied to a distension of the pe 
 of the kidney when associated with suppurative pyelitis. I 
 always secondary, either to pyelitis or to iiydronepluosis. In 
 former case, the inllanunation of the ureter causes partial obstr 
 tion to the How of urine, and hence leads to dilatation ; in 
 latter, supinnation extends to tlie previously dilated pelvis fi 
 the bladder, or as a result of the local cause. It is always as 
 ciated with a certain amount of pyelonephritis, from which ind 
 it is only distinguished by the greater degree of dilatation. 
 
 Pathological Conditions. — 'i'he lining menilirane of the pel 
 is indameil, thickened, and perhaps ulcerated. A consideni 
 (juantily of decomposing urine, mixed with muco-pus, is alw 
 present in the dilated pel \ is and calyces, and rugged calculi 
 tuberculous masses may also be found, giving rise to a chronic 
 subacute interstitial nephritis, which may run on t(^ sup[)urati 
 A certain amount of perinephritis is always associated with I 
 condition. 
 
 Clinical Signs.-— The kidney is found to be enlarged and ten 
 on palpation, whilst more or less constant pain is present in 
 loin. The temperature is usually somewhat raised, especi; 
 at night, from the absorption of septic products ; the pati 
 steadily loses groimd, and becomes emaciated ; the tongue 
 dry, the appetite diminished, and nausea is sometimes presi 
 The urine is usually scanty in amount, and loaded with nuico-p 
 which may be constant or intermittent. If both kidneys 
 involved, the excretion of urine gradually diminishes, leading 
 a fatal issue from uraemia, unless the patient dies previously fr 
 toxaemia or pyaemia. 
 
 Treatment. — Where both kidneys are involved as a resu't 
 some urethral or prostatic affection, no special treatment direc 
 
m^i^^^ti' 
 
 SURGICAL AFFECTIONS OF THE KIDNEYS 
 
 1009 
 
 Tlv li^or nuiy U 
 'itlunit ('\:ui'rl>:itions. 
 , :uul, iiulewl, miiy j><' 
 .r,ol()iuc<l iuul conliuns 
 
 some amounl of pus, 
 > lower portion ot the 
 ses is nearly hopeU^ss, 
 uraMnia, especially as 
 jrh in the more hronir 
 Jie may recover. 
 
 in llie lower urmary 
 u: is drawn olT, ^nd it 
 ^cs of obstruction must 
 -nt is, of coinse, kept ui 
 ie patient is encoura|,'c(l 
 ndants are, if possd)lc, 
 he teniperatm-e remanis 
 
 L distension of the pelvis 
 
 purative pyelitis. It is 
 
 hydronephrosis. In the 
 
 r causes partial obstruc- 
 
 ds to dilatation ; m the 
 
 usly dilated pelvis trom 
 
 aiise. ItisaKvaysasso- 
 
 Lritis, from which indeed 
 
 ree of dilatation. 
 
 Iiienibrmie of the pelvis 
 
 :erated. A considerahK 
 
 lilh muco-pus, IS alwa}> 
 
 I and ruSk^ed calculi 01 
 
 ving rise to a chronic 01 
 
 run on to suppuration, 
 
 lys associated with this 
 
 be enlarged and tender 
 |t pain is present in t le 
 Vvhat raised, especially 
 products; the patieni 
 iciated; the tongue is 
 is sometimes present, 
 loaded with nuico-pus, 
 If both kidneys arc 
 , diminishes, leading; to 
 2nt dies previously from 
 
 Involved as a resu't ot 
 Bcial treatment directed 
 
 10 tile kidneys is feasible; but if the condition is unilateral, and 
 )t secondary to disease of the lower uriiiar\' organs, nephrotomy 
 
 -I'ould be undett.'iken, and any removab..; cause dealt with. 
 I'ailing tiiis, tlu^ cavity may be drained, or even nephrectomy 
 pcrfornHul. 
 
 4. Abscess in the Kidney may follov any of the conditions 
 
 .'ilrcady alluded to, in which bacteria gain access to the organ from 
 
 below. It also occurs in connection with pyannia and after the 
 
 general infective fe\ers, biiing then more O)- less of a pya'inic type. 
 
 Ill acute interstitial lutphritis the abscesses are multiple and at 
 
 first small, being located between the lubales or sometimes within 
 
 tlu;m ; the pyramids then liaxe a streaky white appearance due 
 
 to their iniiltralion with pus, and the abscesses form in the 
 
 cortical substance at their base. Larger collections are caused 
 
 by the amalgamation of several of the smaller. In pya-mia the 
 
 abscesses are preceded by infarcts which appear immediately 
 
 beneath the capsule as wedge-shaped areas of a chocolate colour, 
 
 wliich turns to yellowish white as suppuration occurs. Symptoms 
 
 are not produced unless the abscess is large enough t(j be detected 
 
 from outside ; the mere presence of pus in the urine associated 
 
 with an enlarged and tender kidney is not sufficient evidence (^f 
 
 abscess formation. When the collection is large enough, the 
 
 organ can be distinctly felt, and perhaps fluctuation detected. 
 
 Possibly pyuria is absent, but a perinephritic abscess is very 
 
 likely to form. Treatment of an abscess of the kidney consists 
 
 in nephrotomy for drainage purposes, or perhaps nephrectomy. 
 
 The more chronic varieties are probably tuberculous in origin, 
 and may then attain considerable dimensions, all that is noted 
 i icing the lumbar swelling, whilst pyuria is not necessarily 
 present. 
 
 5. Perinephritis cannot be recognised unless suppurative in 
 nature, resulting either from septic wounds or from ulceration 
 involving the walls of the pelvis and calyces, or from the trans- 
 mission of micro-organisms from the interior of a suppurating 
 kidney or ptJvis ivitb.out any breach of surface. A perinephritic 
 abscess m? v a. 10 arise from inflammation spreading from the 
 intestine, p'eural cavity, ribs, or elsewhere. 
 
 The cymntoms may be acute or chronic in nature. In acute 
 pmnrpnyitis s'gns of deep suppuration i loin are produced, 
 
 vi/,., an i.iJurated painful swelling, associated with fever, and 
 perhaps pr ?ceded by rigors. Fluctuation may sometimes be 
 detected vhsn pus has formed, but the abscess is often so deeply 
 placed that it is difficult to recognise it at first ; it tends to point 
 at the side of the erector spina', or rr^.ay barrow forwards between 
 jtlu; p.bdominal muscles, and find a' exit on the anterior abdominal 
 Avail. Occainonally it bursts i;Uo -Wz p,:ritoneal or pleural cavities, 
 |or into the intestine. If it convs to U^c surface, it is preceded by 
 ongestion ana oedenia of l^e ';kir... Chronic perinephritis gives rise 
 
 64 
 
lOIO 
 
 A MANUAL OF SURGERY 
 
 to no characteristic symptoms until an abscess forms whicl 
 large enough to be felt. 
 
 Treatment in each case consists in giving exit to the pus throi 
 an incision at the outer border of the erector spina; ; the cavit 
 then carefully examined, and the cause of the suppuration 
 possible, determined, and treated according to the requisites 
 the case. 
 
 Tuberculous Disease of the Kidney occurs in one of t\: 
 forms, (a) It may arise in the course of acute general tul 
 culosis, when miliary tubercles are found studding the orgj 
 but giving rise to no special symptoms. Tr^ "Iment, of course 
 impracticable. 
 
 (b) It may extend upwards from a similar affection of the blad( 
 and then almost invariably involves both kidneys. The muc 
 
 membrane of the un 
 becomes thickened ; 
 tra:jsrc;m»;d into cedei 
 lous ^.anu^ation tis 
 co'"'aii:ing ubercles, i 
 thai of .he pelvis ; 
 c ci i y c e :j is s i m i 1 a 
 affected; finally, the re 
 parenchyma itself 
 conies iifihrated v 
 I ' iberculius tissue spre 
 ii.;; Iron the pyram 
 ClirJcaKy, enlargemen 
 both kidneys is noti( 
 arising partly from 
 deposit of tubercle wit 
 the organ and partly fi 
 the obstruction \ i. 
 ureter. The bv",!,;): 
 caused by thp ■'enr'l 
 chief cannri a. vr^v 
 distinguished iio' 
 due to th vesical !r.j 
 Fig. 347. -Tuherculous Kidney, ^^"owing pg^inephritic pbsti 
 TmcKENiNG OF Mucous Membrane of • f',, (r.Wnxv^ 
 
 Pelvis and Ureter. (From Specimen in occasionally toUows, 
 College of Surgeons' Museum.) the parent dies troni 
 
 haustion, sep'ic absc 
 tion, or uraemia. Treatment in these cases is of no a\ ail. 
 
 {c) Primary Tuberculosis of the kidney is generally unilate 
 and commences as a deposit of tubercle in the cortex or at 
 base of one of the pyramids. A caseous mass forr .-, which r 
 extend widely, causing disintegration of ^\\e kidney subsipnre 
 .may burst into the pelvis and infect t'.iat cavity. A ; ' er> 
 
f'^e same ai n o-Cnc ^""""f'^'ons is im,)rm^^H . ''"' t^^^'" '" tht 
 
 t-ons may occur.' t1 °'" °' ^^'^^ consC a fh^'"'''''^">^ «^ ^n 
 I'^^V^P"^' in which on el'^"' "'"^% contains 'r'f.^-^'^^^«^'>a- 
 1"^^ cletected. H-^^lul; "'"'^'"'"ation tJie Ba li>,. 7^^"" P^^nx)r- 
 
 '"^ ^^ "ot tender, 1x00^7,^^^ ^' ^"""^^ ^^ ^^ i^d r"' .'"^ ^^"• 
 --r o. considera^f -'-- -^^^^^^^^ 
 
 Tl>e Diagnosis of pri,„.r„ , , , ' ''' '•■"■«'^ 'l""nlity 
 
 calculus T]J] f>'"^Ptoms are very si nW ''""''^ ^^^ ^'^mon- 
 of importa:! :SZ°^^•^^ P^^'enTa"':/,,^^^ f''"- "^ -ni;, 
 symptoms are ess nfl f P°'"ts of dist^nr '"'>' '"^y he 
 
 ''^-''"aturia or rfn, " "'""f^ '^>' «ercise ofr"/ "" ff ^''''^^ ^^e 
 t!'e kidney is usualh ^^ '''''^" ^^'hen a calcuinf ' '''"'' '''^''"^' ''^ '^'ss 
 t''econditbnismfL"°^ '° ^^"^er on n i i"-P'"''^^'"*' ^inlst 
 cases the a ri?.K \^^^^ ^^^^mon than t nt ? ''''°" ' ''^ ^""'"■^e. 
 
 -^ incision n^tho-f^^T^ ''''''' ^^V^oCJ";;:'' ^" ^-'^^^"1 
 •" colour and ^ • , ^^^^ ^nf^erciJous I ,V n^ """"^''^n throuLd, 
 "ochdes m,;" e 'felt t °^^^'"- whilst",' ^"^^Jl^-aHy '-mred 
 cision give exit t. . ''''^' '^^^^n^e fluid on ,f '^^^^^^^''. caseous 
 
 '^'•ten sSn.ewhat thick?°"f P"^' ^he u^perp^rr?^' ''' ^" '"- 
 is iniiformlv ev^n ^\^"f^ and indurated In? f ! ^'^^ "^^^^r is 
 
 present, theVa' J'"1 ,''^^^ ^^^^ ^^ any If" ""^ '^'' '^"'face 
 of the ureter ,1,?. "^ ?^"'^^^-^ed colour the '' h • ""^ 'f'''^^^^ are 
 
 '' i^e strictly li,„ ted and ^h''^'""! °/ ^'^^ i^'i^ney the dise-.. • r 
 
 ^0 treat it in th'l ^^"^ P^^^'i^ unaffected 7 ""^^as"^ ''' '^^nnd 
 
 ^•i^-' I^y scraoini . ""^ .'^^^^ ^^^ tubercufous W r ''^' '^^ '^'^'''^^'^^ 
 'he cavityT M^, '"^^^^^^ ^i^^ased tSu^ ,?ff' ""^^i«ewhere, .^^ 
 fhus formed ^ /^^"^^^ carbolic acid S T'^- Pn^i^cation o ^ 
 shaped aTeas of H^^^"' ?^^^ i^ "lay I e "ossR ^T'"^^ '^' ^^"^nd ^^ 
 
 "Hied too ex S • 'V tances, however the d «^ ^ounus .;y sutures. 
 pus. U th^ ;'-'^"ng of a ser es of rv«fo > ,, ? "t, the kidney 
 
 64--2 
 
^-^ . 
 
 I0I2 
 
 A MANUAL OF SURGERY 
 
 the loin, and through this opening the kidney can be expk 
 and, if necessary, removed. 
 
 ' Renal CalQuIy,§c^Ren,sil,,Calci^^^^^^ usually met witli in i 
 viauaFs' suffering from litliiasis, as indicated l^y the passage 
 sand or gravel in the urine. The general causes of this ( 
 dition are detailed elsewhere (p. 1039). All renal concretions 
 primarily excreted in a crystalline form from the renal tubi 
 but under ordinary circumstances are sufficiently small to 
 their way into the pelvis of the kidney, and thence along 
 ureter to the bladder. If, however, they are obstructed in t 
 onward course, either on account of their size or shape, or s( 
 narrowing of the tubules, they may become lodged in the kid 
 
 Fig. 348. — Calculous Kidney. (College ok Surgeons' Museum 
 
 substance or in one of the calyces, and by the gradual deposi 
 the same material increase in size until large enough to give 1 
 to symptoms (Fig. 348). Renal calcuU are not often of gr 
 bulk, rarely exceeding that of a Barcelona nut ; occasiona 
 however, the whole of the pelvis, and some of the calyces, may 
 occupied by a concretion, which takes the shape of the cavit) 
 which it lies. When many calculi are present in the pelvis of 
 same kidney, they are usually faceted. Chemically they con: 
 either of uric acid or urate of ammonium ; sometimes, howe\ 
 they are composed of oxalate or acid phosphate of line. 
 
 The Pathological Phenomena connected with renal calculi vi 
 with their size, shape, number, and position. If situated in 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 
 
 lOI 
 
 Iney can be explored 
 
 ily met with in indi 
 ed by the passage ol 
 U causes of this con 
 I renal concretions arc 
 om the renal tubules 
 ficiently small to hml 
 and thence along th. 
 ire obstructed m then 
 size or shape, or some 
 .e lodged in the kidney 
 
 OF Surgeons' Museum.) 
 
 l)V the gradual deposit ot 
 large enough to give rise 
 I are not often of great I 
 llona nut; occasional y. 
 leof the calyces, maybe 
 
 L shape of the cavity M 
 lesent in the pelvis of the 
 
 Ichemically they consist 
 in; sometimes, however, I 
 Isp'hate of lime. , 
 
 ■iwith renal calcuh van 
 tion. If situcxted in tlie| 
 
 substance of the renal parenchyma, they give rise to but little 
 change, being more or less encapsuled in a cavity lined by 
 granulation tissue. When occupying the pelvis of the kidney, 
 they set up pyelitis, and from the obstruction to the flow 
 of urine, caused partly by tlie thickening of the mucous 
 membrane, and partly by the calculus engaging tlie orifice of 
 tlie ureter, produce dilatation of the pelvis of the kidney, and 
 ihe phenomena of hydro- or pyo-nephrosis. If on account of 
 their shape or size they become imprisoned in one of the calyces, 
 ulceration of the wall and suppurative perinephritis may follow ; 
 the calculus may even find its way into tlie abscess cavity, and be 
 discharged spontaneously or removed through the loin, a urinary 
 fistula often resulting. If the calculus passes down the ureter, 
 it gives rise to the symptoms of renal colic. When small and 
 smooth, it usually reaches the bladder without much difficulty, 
 and is then voided with the urine, or remains as a vesical calculus. 
 Occasionally, owing to its size or irregular shape, it becomes 
 impacted in the ureter, usually at its upper end, giving rise to 
 acute obstruction and the cessation of the urinary secretion on 
 that side, followed by disorganization. If the kidney thus affected 
 is the only one available for excretory purposes, the patient, if 
 unrelieved, dies in a few days from suppression of urine (calculous 
 anuria). In other cases the stone ulcerates through the wall of 
 the ureter, giving rise to a retroperitoneal urinary abscess, or 
 possibly to suppurative peritonitis. If the ureter is only partially 
 ohstructed by the calculus, the changes which take place in the 
 kidney are more gradual, and result in hydro- or pyo-nephrosis. 
 
 The. t^p^ical Symptoms arising from renal calculus are as follows: 
 The patient .complains of pain in the loin, more or less persistent, 
 Jind often .paroxysmal "In nature, which is, however, ahvnys in- 
 creased jQji exercis^ or jolting ; it is frequently referred to distant 
 regions, but" most commonly follows the course of the genito- 
 crural nerve, giving rise to pain in the front of the thigh, accom- 
 panied by. J.^i;^^t)pQ,.Qf..the.^ testicle ;ih'^tli(; FeittSlfelt Is' also 
 experienced in the labium majus. "Sometimes it extends down 
 the back of the thigh, and it has even been said that pain in the 
 heel is pathognomonic ! It is almost invariably associated with 
 haematima,. ai)(j[7^]fl^.with pyuria, the amount of l.lpod or pus 
 heing increased on exertfon. "F^requency of micturition is a pro- 
 minent sy'ihptoiTi, whilsfif the pelvis is enlarged the kidney may be 
 tender, and distinctly felt on palpation. If the calculus is lodged 
 in the renal parenchyma, the urinary secretion may be but little 
 influenced, although the characteristic pain is well marked ; the 
 patient also finds that at night he can only gain relief by lying 
 on the affected side, and on manual examination the kidney, 
 though somewhat tender, is not much enlarged. When the 
 calculus lies in the pelvis or one of the calyces, the typical 
 phenomena described above are produced ; but it is then noticed 
 
IOI4 
 
 A MANUAL OF SURGERY 
 
 Si? 
 
 that at night the patient hes on the sound side, since the organ is 
 both enlarged and tender. On the other hand, it is an undoui)ted 
 fact that stones even of large size may exist for years in the kidney 
 without gixing rise to any symptoms whatever. 
 
 The passage of a calculus down the ureter is accompanied 
 by the symptoms known as Renal Colic. They consist of 
 excruciating pain of a paroxysmal natufe, wTvrcTr""Corrtes— on- 
 suddenly, and is referred both to the loin and along the course 
 of the genito-crural nerve. It is always associated with vomiting 
 and severe shock, the patient often lying on the floor writhing in 
 agony, with cold perspiration standing in beads on his forehead. 
 The, teniperature..iS'Stibnormal, and the pulse. weak and- rapid. 
 IStrangury is usually present, the patient suffering from frequent 
 paroxysmal efforts to pass water, but only succeeding in evacuat- 
 ing a small amount, and that generally blood-stained. After 
 lasting for a variable period, the pain suddenly ceases, as a result 
 of the passage of the calculus into the bladder,. or of its slipping 
 back into the pelvis of the kidney. 
 
 Calculous aiiuria is the term applied to a cessation of the 
 urinary secretion which results from blocking of one or both 
 ureters with calculi, the opposite kidney in the former case being 
 absent, atrophied or diseased. The condition is usually lighted 
 up by some physical effort, which presumably dislodges the 
 calculus. It is ushered in by sudden pain in the loin, which 
 often passes away in the course of two or three days. The 
 anuria is rarely complete at first, a few ounces of pale limpid 
 urine being passed at intervals, whilst occasionally distinct poly- 
 uria is present. Sooner or later definite uraemic phenomena 
 supervene ; the most usual period is seven or eight days after the 
 onset, but incomplete obstruction or a pre-existing condition of 
 hydronephrosis may delay matters. The onset of uraemia is 
 indicated by vomiting, a slow, full pulse becoming irregular, 
 contraction of the pupils and muscular tremors. Coma is rarely 
 deep, and the temperature is subnormal. Possibly the calculus 
 can be detected per rectum or vaginam if it is impacted low 
 down. 
 
 The Diagnosis of renal calculus is often a matter of uncertainty 
 in the absence of a history of the passage of gravel, or of the 
 occurrence of renal colic. It is most likely to be mistaken for 
 tuberculous disease ; the differential diagnosis between the two 
 conditions has already been considered (p. loii). Some assistance! 
 may perhaps be obtained by the use of the X rays, and Mr. Heniy 
 Morris has pointed out that too long an exposure is undesirable, I 
 since the calculi are not very opaque, owing to their containini; 
 so much organic material. Phosphatic calculi are more easily 
 detected than those consisting of oxalate of lime, whilst the uric[ 
 acid stones are only seen with difficulty. 
 
 Treatment. — In the early stages treatment is directed to the cure! 
 
SURGICAL AFFECTIONS OF THE KIDNEYS 
 
 1015 
 
 the organ is 
 1 vindoubted 
 1 the kidney 
 
 iccompanied 
 r consist of 
 p-comes- -on- 
 er the course 
 nth. vomiting 
 r writhing in 
 his forehead, 
 k and- rapid, 
 rom frequent 
 ig in evacuat- 
 ained. After 
 es, as a result 
 )f its sHpping 
 
 5sation of the 
 
 : one or both 
 
 ner case being 
 
 usually lighted 
 
 dislodges the 
 
 he loin, which 
 
 :e days. The 
 
 of pale limpid 
 
 y distinct poly- 
 
 lie phenomena 
 
 "^ days after the 
 
 ig condition of 
 
 of uraemia is 
 
 ning irregular, 
 
 poma is rarely | 
 
 \\y the calculus 
 
 impacted low 
 
 of uncertainty 
 ivel, or of the 
 
 mistaken for 
 Itween the two 
 lome assistance ' 
 and Mr. Henry 
 [is undesirable, 
 leir containing! 
 Ire more easily 
 
 whilst the uric I 
 
 :ted to the cure I 
 
 of lithiasis (see p. 1039). The patient's diet and general habits 
 of life must be suitably regulated, and he is instructed to make 
 use of alkaline purgatives, such as Carlsbad or Vichy waters, or 
 ciTfat'e'cirnthia and sulphate of soda maybe administered in a 
 mixture. Plenty of bland fluid shoidd be ordered, such as boiled 
 or distilled water, in the hope of dissolving the stone or assisting 
 its onward p^issage to the bladder. Sometimes it may beccime 
 encysted, if the patient is kept absolutely at rest ; the symptoms 
 will then gradually ameliorate, and finally disappear. 
 
 Attacks of renal colic are treated by the use of hot hip baths, 
 warm drinks, and hypodermic injections of morphia ; in the more 
 severe cases chloroform must be administered. 
 
 If, in spite of the above-mentioned measures, the pain persists 
 or increases in amount, or if one kidney is considerably enlarged 
 and very tender, an exploratoyy operation is required, especially it 
 a considerable amount of blood or pus is being passed in the 
 urine, and the patient's temperature raised. It must also be 
 undertaken if a perinephritic abscess forms or a calculus becomes 
 impacted in the ureter. Pain in both kidneys is no contra- 
 indication to operation, since there is no objection to exposing 
 and even removing calculi from both organs ; it must not be 
 forgotten, howe\'er, that sympathetic pain in a sound kidney may 
 be induced by calculi on the opposite side. Naturally, the organ 
 in which most pain is complained of is dealt with first, unless the 
 existence of a calculus in the opposite kidney is indicated by the 
 X rays. The constant passage of gravel, moreover, need not 
 det:er one from operating, since when once the kidney has been 
 relieved by removal of the larger masses, the tendency to 
 recurrence may be checked by suitable diet or drugs. The 
 amount of urea excreted daily should always be estimated in 
 these cases, and if it is much diminished no operation should be 
 undertaken. For details of the technique of nephro-lithotomy, 
 see p. 1020. 
 
 Where the organ is totally disorganized nephrectomy may be 
 required, but such treatment is not always advisable, especially 
 when sinuses have resulted from a suppurative perinephritis. In 
 such cases the renal tissue has often entirely disappeared, and 
 disintegrating calculous material may occupy the pelvis, which is 
 surrounded by a mass of dense fibro-cicatricial tissue, the removal 
 of which is impracticable and even dangerous. All that should 
 be attempted is the extraction of the stone and the purification of 
 the cavity ; the patient must resign himself to the i..convenience 
 of a suppurating sinus in the loin. 
 
 A diagnosis of calculous anuria should always determine an 
 operation, as such is the only means of saving life. After explor- 
 ing the kidney and its pelvis in the usual way, the ureter is 
 exposed by prolonging the incision downwards and forwards in 
 front of the anterior superior iliac spine, and parallel to the outer 
 
ioi6 
 
 A MANUAL OF SURGERY 
 
 end of Poupart's ligament. The peritoneum and its cont( 
 are displaced forwards, and the ureter can then he expk 
 from end to end, except in its lower portion in females. An 
 pacted stone is cut down on and removed through a longitud 
 incision in the ureteral wall, which is subserjuently closed 1 
 Lembert's suture. When the lower end of the female uretc 
 l)Tocted,th'6 calculus can often he detected pcy vaginain, and i 
 he removed by that route. 
 
 Tumours of the Kidney. — The General Characters of re 
 
 tumours are as follows : A swelling is noticed in the loin, wl 
 
 
 
 V 
 
 ^ 
 
 ^ 
 
 ■'v: 
 
 JIB ■ -^ -^ ^ A. -...^ ,<Ji. V M jm-.i 
 
 ^^: 4: 
 
 \ 
 
 w -' 
 
 Fig. 349. — Cystic Disease of Kidney. (King's College Museum. 
 
 is shaped more or less like the kidney, a notch being occasions 
 felt on the inner border, and the outer margin being round 
 The flank is always dull on percussion, the note remaining 
 altered whatever the patient's position, and intestine never find 
 its way behind the tumour. The passage of the colon in from 
 the kidney not unfrequently gives rise to a hand of resonance o 
 its anterior surface ; the bowel, however, soon gets pushed as 
 by the growth of the tumour. On the right side it is not unus 
 for the renal dulness to be continuous with that due to the li\ 
 
SUI^GIC^^ AFFECTION, OF 
 
 '^'HB KIDNEYS 
 
 ng's College Museum ) 
 
 ' "e mass moves sUfk+i ~ 
 
 '''antheJiv.rorspK^^^^ thnu^hTT , . 
 
 -;arcls the peJvis.^ '" ' ""^ "" P^-'^"'c]e can I, 7e k m' '^'''T'^y 
 
 , . J 'le different varieties of ^ '^ '^'''''' 
 
 . ■■ Cystic Disease (or ,1 i, h T '■"■'" ' 
 
 -feeding „,,, of^f'^he ^v '^f ' ^•''""S in si4''\ •'';'=^'^ 
 winch js Kenerallv fl,,. T' ""=> are lined „;,i , ""^'''y 
 
 tl^e sulstlnce '"?."" ''^ ^^'^ '"^^onephr'or^or U T^'P^l"^ ^" ^^^ 
 
 from .i:S:y;^3im:r;„"["°-'<'--Wesizeare found™ • 
 .taal bodies.^' TlT4 . ; ,oo7S'"^ '° "'^ -"'" fcdc"llr„ah? 
 cce.ssoryand mispla/ed adrenals Z "' ''t"™^** g"-ring llom 
 
 *™, and consist of rLSTo^slt'^'""}''''"'''' spreaTove? 
 fctarTh™"™' '««">MngZf„ft'!' ''7 '"ir^ often sl,o " 
 \ -)■ ^''^^«"-oagrea1si|f,:^d~^«,^.-^^^^^^^^^^ 
 
loiS 
 
 A MANUAL OF SURGERY 
 
 but pain and lia^maturia are absent. Death results from ge 
 dissetnination or from exhaustion, or niay follow media 
 obstruction to the circulation, as by the detachment of a s 
 matous embolus, which travels upwards and blocks the pulmc 
 vessels. Treatment by nephrectomy has gi -en most unsati 
 tory results, recurrence within a short period occurring ev( 
 those few cases which escape death from shock. When 
 kidneys are affected, nothing can be done. 
 
 2. The Sarcomata of Adults occur between the thirtieth 
 fiftieth years, and are of the spindle-celled variety. Onlj^ 
 kidney is generally involved, giving rise to a rapidly gro 
 swelling, associated with pain and haematuria. Calculi are 
 found in the pelvis of such organs. Secondary deposits 
 in the viscera, and death is usually due to exhaustion, 
 results of nephrectomy have not been very encouraging. 
 
 3. Carcinoma is an uncommon form of tumour in the kii 
 It presents the same clinical features as a sarcoma, and can 
 be recognised on microscopic examination. One symptom, 
 ever, requires special mention, since it is extremely suggesti 
 the presence of cancer, viz., the development of a varicocele 
 is due to the pressure of enlarged and cancerous lymphatic g 
 upon the roots of the spermatic veins, and hence, whenev( 
 elderly person develops a varicocele, a careful examination 
 kidney on the affected side should always be instituted. 
 
 Various Cystic Conditions of the kidney nuist be noted in 
 tion to the general cystic disease, already described. 
 
 {a) Hydatid Disease affects the kidney, as it may involve 
 other organ in the body. It starts either beneath the ca 
 or in the glandular substance ; in the former case it is likt 
 form a rounded projection, which may be detected on palpat 
 the loin ; in the latter it expands, or even destroys, the wh 
 the glandular tissue, and may burst into the renal pelvis 
 cysts being passed along the ureter, accompanied by mc 
 less colic. Suppuration may complicate matters, but, unle; 
 cyst has ruptured into the pelvis, diagnosis is scarcely fe 
 apart from an exploratory incision. 
 
 Treatment consists in cutting down on the kidney, 
 enucleating the mass, if possible. Failing this, drainage m 
 undertaken, but in bad cases nephrectomy is necessary. 
 
 {b) Dermoid Cysts have also been found. 
 
 {c) Serous Cysts are occasionally met with, arising possil 
 a result of obstruction to some of the ducts. Rounded swe 
 single or multiple, are produced, growing outwards fror 
 cortex, and containing a thin fluid with a small amoii 
 albumen and saline substances in solution. They give rise 
 symptoms except from their size, and rarely icquire trea 
 other than simple aspiration or drainage. 
 
 {d) Not unfrequently a number of small cysts develop ii 
 
?y 
 
 SURGICAL AFFECTIONS OF THE KIDNEYS 
 
 1019 
 
 th results from K^nern 
 ay follow mechanical 
 Ifctacbment of a sarc- 
 I l,locks the pulm()nary 
 cri.en most unsatistar- 
 ,riod occurring' even in 
 n shock. When both 
 
 tween the thirtieth and 
 lied variety. Only one 
 ;e to a rapidly growing 
 turia. Calculi are often 
 ;econdary deposits form 
 ue to exhaustion. Hie 
 :y encouraging. . 
 ,f tumour in the kidne , 
 , a sarcoma, and can only 
 on One symptom, how- 
 ,s extremely suggestive ot 
 pment of a varicocele, t 
 °ncerous lymphatic glands 
 
 and hence, whenever an 
 -areful examination of the 
 ''s be instituted, 
 aey must be noted in addi- 
 ilv described. 
 \l as it may involve am 
 ilier beneath the capsu I 
 
 ormer case it is hkely 
 detected on palpation 
 
 .ven destroys, the wholeo;i 
 
 linto the renal pelvis, tlu 
 accompanied by more « 
 
 te matters, but, unless J 
 crnosis is scarcely feas.li 
 
 iwn on the kidney, a 
 ling this, drainage may 
 [my is necessary. 
 
 " with, arising possihlv 
 
 Ts Rounded swelling 
 )wing outwards from t^ 
 Lith a small amount 
 ion. They give rise to 1 
 rarely require 
 
 Inall cysts develop in cofl 
 
 ncction with chronic granular nephritis, but they are of no clinical 
 importance. 
 
 Operations on the Kidney. 
 
 The kidneys are placed on either side of the middle line, and 
 extend from the nth rib above, to midway between the last rib 
 and the iliac crest below, the rif,dit kidney bcinj,' somewhat lower 
 than the left, owing to the presence of the liver. The lulus is 
 situated opposite the spinous process of the first lumbar \ ertebra, 
 and the upper ends of the orj^'ans are nearer to the spine than the 
 lower. 
 
 The kidneys may be exposed by two chief routes, viz., the 
 lumbar and the abdominal. 
 
 The Lumbar incision (Fig. 350, B) commences at a point cor- 
 
 treatmei^ 
 
 Fig. 350. — Diagram to Illustrate Lumbar Incisions 
 A, For lumbar colotomy ; B, for exposing the kidney. 
 
 responding to the outer border of the erector spina, and J, inch 
 pelow the last rib, extending downwards and outwards in the 
 prection of the fibres of the external oblicjue for about 4 or 5 
 Qches towards the anterior superior iliac spine. The posterior 
 bortions of the abdominal muscles and the in"' i: lumborum are 
 livided seriatim, and the fatty tissue surrouruiir^ the kidney is 
 aus easily reached and opened. 
 
 The Abdominal incision is made along the linea semilunaris, 
 l^hich is divided, and the peritoneal cavity opened. If the colon 
 es over the kidney it is displaced inwards and held aside, as also 
 ^e other intestines, by cloths soaked in warm salt solution ; the 
 entoneum covering the posterior abdominal wall is incised to the 
 liter side of the colon, and the organ thus exposed. 
 A third method has been advocated by some surgeons, known 
 
I02O 
 
 A MANUAL OF SUHGEJiY 
 
 as the Lateral or Lumbo-abdominal. The incision extends 
 cally from the tip of the hist ril) to tlie iUac crest, and, if lu^c c 
 a cross-cut is made l)ack\vards at right angles to it. 'llx 
 toneum is stripped forwards from the kidney, the operation 
 tiuis retroperitoneal. The ad\ai age o\et the ordinary 1 
 incision has, however, yet to he di luonstraled. 
 
 The following are the chief operations undertaken upo 
 kidney : 
 
 1. .Nephrotomy ^c onsists in exposure of the kidney, exploi 
 of itssun?n!ana?|and, if need be, incis" 'nto it for the rei 
 of some abnormal condition. It shou nerally be undc 
 through the loin. W'lien exposed, the kidney is partially 
 from its connections, and ilrawn up into the wound. Its 
 stance is then carefully pal[)ated between the fingers, any abnc 
 softening or hardening being noted. It may next be exj 
 with a fine round needle, such as is used for knitting, 
 must be taken not to mistake the sensation imparted t 
 lingers by striking the pyramids with the needle for a ; 
 If nothing abnormal is detected, an incision should be 
 through the convex border of the kidney substance into the p 
 r^ree luemorrhage follows such a proceeding, but soon stops 
 the finger is inserted. This incision through the renal parcMic 
 must always be undertaken in preference to one through the p 
 since the latter heals with difificulty, and is liable to leave a fi 
 The pel\ ic cavity is then civrefully explo A by the finger, an 
 upper part of the ureter examined by robe, although tl 
 better accomplished by making a tiny in the pelvis thr 
 which the probe is introduced, the opening being subsequ 
 sutured without difficulty. Should a stone be detected, it m; 
 removed by dressing forceps or a scoop through the renal p 
 chyma, as also any foreign body ; a papillomatous growth c; 
 scraped away, and the base carefully cauterized, whilst if the o 
 tion is performed in order to drain a suppurating pelvis, a drai 
 tube is inserted into its interior. The wound in the cort 
 usually secured by one or more catgut sutures passed throu; 
 substance, unless the condition of the lining membrane c 
 pelvis renders such a step inadvisable, or if permanent drain; 
 required. The external wound may then be closed, the mus 
 planes being carefully united by a series of buried sutures. 
 
 2. Nen2y[§at|||ny. or total removal of the kidney, is perfc 
 for tITe~ followmgconditions : (a) For tuberculous (fee as r , - 
 conservative measures are impracticable, or when the pelvi 
 ureter are involved ; [b) for calculous pyonephrosis, whei 
 renal parenchyma is disintegrated ; (c) for hydronephrosis, 
 palliative measures or drainage have failed to give relief ; {c 
 malignant disease ; (e) for traumatic lesions, such as disint 
 tion or rupture, especially if complicated by laceration o 
 
 peritoneum ; and (/) for some cases of ruptured uretsr. 
 
 sV^^vJ*' 
 
 t/ 
 
 !V 
 
 ,V^vM«/' 
 
 /\. 
 
 ^ 
 
 ^ 
 
 1 3- 
 
 '\T-' 
 
iRY 
 
 i incision extends verti- 
 crest, and, if neiessiirv, 
 uigles to it. The pen- 
 v-y the operation bemu 
 ei the ordinary hnnbar 
 
 \ted. , 
 
 IS undertaken upon tlic 
 
 the kidney, exploration 
 
 •nto it for the removal 
 
 .neruUy be undertaken 
 
 kidney is partially freed 
 
 to the wound. Its sub 
 
 the \\n\iiivs, any abnornia 
 
 t may next be explorrd 
 
 used for knitting. Care 
 
 nsati(m imparted to the 
 
 the needle for a stone. 
 
 incision should be niade 
 
 ' substance into the pelvis. 
 
 dinLS but soon stops v.hen 
 
 ugh the renal parenchyma 
 
 .to one through the pelvis, 
 
 is liable to leave a fistula. 
 3 A by the finger, and the 
 robe, although this is 
 in the pelvis throu^^hl 
 ening being sul^sequently 
 one be detected, it may be 
 D through the renal paren- 
 ^illomatous growth can be 
 .terized, whilst if the opera- 
 airating pelvis, a drainage- 
 . wound in the cortex is 
 futures passed through Ji 
 lining membrane ot the 
 ,r if permanent drainage is 
 in be closed, the nniscularl 
 of buried sutures, 
 the kidney, isperfovmj 
 uberculous (tiseaser w«<* 
 ,e, or when the pelvis 
 pyonephrosis, when tlie 
 for hydronephrosis, wto 
 iiled to give relief ; [d) m' 
 sions, such as disintega 
 ited by laceration ot ttw 
 
 SURGICAL AFFrXTIONS or THE hIDNFA'S 
 
 I02I 
 
 •uptured ureter. 
 
 tar. 
 
 Htj' ore unde rtaking liie excision cjI any kidney, li()\vev(<r disensec!, 
 
 it jis""<sssent ial" "ffiat the surgeon sliould .afjsfy himself .ig.ti) Ih^' 
 
 i-'sTstence" oTanotlier, and also, if possiMf, ascertain thiU it Is 
 
 rnpaT>Te'"(Tr undertaking the inereasfd duties wliich u itT sur)se-' 
 
 q^ieuUy fall .upon_.it. Many diOerent plans of doing this have 
 
 l)(-en sujigested, but it is often dilTicult to lie absolutely certain. 
 
 Ill d()ul)trul cases "ttifi" best course is to prrforni an exploraloiy 
 
 tir£)TrroToiWrT)y ni"e?l"ns nf vchicti not oTily i ?m tho e\istonet> oPa 
 
 seconiFkTuney T)e' determined, but also its condition investigatctl, 
 
 and the size of the renal artery ascertained. An examination of 
 
 the diseased organ can also be made; if it is of large size, the 
 
 operation may l)e at once completed from the front ; but if it is 
 
 small enough to be dealt with from the loin, the abdomen is 
 
 dosed, and the nephrectomy i)ut off for a week or ten days, 
 
 until the first incision has healed. It is sometimes possible to 
 
 prove the existence of a second kidney by means of the cysto- 
 
 iicope, little gushes of urine being seen to escape from the ureter ; 
 
 in females catheterism of the ureter is practicable. Another 
 
 method suggested is to compress the orifice of one ureter and 
 
 collect the urine from the other; but these plans are difficult to 
 
 accomplish and cannot be depended on. 
 
 Nephrectomy may be undertaken through the ahdomen or 
 thn)ugh the loin ; but sundr' combinations or modifications of 
 these operations have been rec ommended by various authorities. 
 
 The Abdominal Operation is chiefly utilized wlien the organ is 
 I mucTienfeTged; OTT"a:ccount of the readier access obtained, espe- 
 rciatly "to tTie pedicle. The main objection lies in !he fact that the 
 periton eimi is opened , and thereby exposed to septic contamina- 
 Uon, esj^clallj^^wdienthe j5elX-tg"a-nd ;t+re-tippcr pnrf'df -ttii; '\ireter 
 are" 3istenae 3 jyitK_ tfec6m as is frequ'eiifly"' the crigiS"" 
 
 iToreoveir, no satisfactorycTrainage is obtalned^'for thd~ Chvity left 
 by the removal of the organ, unless a counter-opening is made 
 through the loin. Of course, a great advantage, as before stated, 
 is that the other kidney can be first examined, and its condition 
 ascertained. As to the technique : after exposing the kidney in 
 the manner already described, the organ is freed from its adhesions 
 to surrounding tissues, the surgeon being careful to keep outside its 
 true capsule, but inside the layer of condensed perinephric tissue. 
 Special precautions must be adopted in dealing with the posterior 
 aspect of the tumour, particularly on the right side, where it is 
 occasionally adherent to the inferior vena cava. The mass is now 
 [lifted from its bed, and its pedicle, consisting of the ureter and 
 |renal vessels, isolated. These latter are secured separately by 
 ligature and divided, a clamp being applied to the distal ends. 
 ^tie ureter is dealt with in the same way, small pieces of sponge 
 )eing packed round so as to receive any secretion which may 
 escape ; the exposed mucous membrane in the portion which is 
 left is carefully touched over with pure carbolic acid. The 
 
I022 
 
 A MANUAL OF SURGERY 
 
 kidney thus freed is removed, and the wound in the postei 
 parietal layer of the peritoneum brought together, if possible, 
 sutures, provision for drainage having been previously m; 
 either through the loin or by the insertion of a gauze drain fr 
 the front. The abdominal cavity is carefully cleansed from 
 blood-clot, and closed in the usual way. Considerable shock 
 always experienced from this operation, and the death-rate fr 
 this cause is somewhat high. 
 
 The Lumbar Method can only be employed when the kidney 
 not much enlarged. The organ is exposed by the incision ahea 
 described, enucleated from its surroundings, and the pedicle de 
 with as in the abdominal operation. If the condition of 
 opposite organ has not previously been ascertained by laparotoi 
 Kocher recommends that the peritoneum should be incised 
 the outer margin of the wound, so as to enable the hand to 
 inserted across the middle line, and thus allow an explorati 
 of the opposite loin, and there is no reasonable objection to t 
 proceeding. 
 
 3. Nephrorrhaphy is the title given to the operation for fixin< 
 moveable kidney. The usual lumbar incision is adopted, a 
 if the organ is found to move freely within its fatty capsule, t 
 latter should be always drawn into the wound, and a consideral 
 portion excised. Two or three silk stitches of medium thickne 
 are then passed through the muscles, and also through t 
 cortical portion of the kidney, securing a good hold of it. 
 tying these the kidney is fixed to the posterior abdominal wa 
 and the wound is then closed. The results of this operation ha 
 not always been satisfactory, the symptoms returning. It appea 
 from experiments that sutures passed through the renal pare 
 chyma are very quickly disintegrated and removed ; and henc 
 although the kidney may seem to be efficiently immobilized at tl 
 completion of the operation, it readily becomes loose again. 1 
 obviate this it has been suggested to leave the parietal incisi( 
 open, merely stuffing it with gauze, so that a firm mass of cic 
 tricial tissue may develop, extending from the kidney to the su 
 face, and thus anchoring it. Some, again, have recommendi 
 that the true capsule should be partially stripped off and stitchf 
 to the abdominal parietes, the raw surfaces thus formed unitir 
 securely, and fixing the organ; whilst otheis advise the isolitic 
 of one of the tendons of the spinalis dorsi, which is passed fro: 
 above downwards under the capsule, as a support on which tl 
 kidney is slung. (See report in Clinical Joitvnal, I-'ebruary 
 1896.) , 
 
und in the posterior 
 irether, if possible, by 
 sen previously made 
 of a gauze drain from 
 illy cleansed from all 
 Considerable shock is 
 \ the death-rate from 
 
 ;d when the kidney is 
 [ly the incision already 
 , and the pedicle dealt 
 the condition of the 
 rtained by laparotomy. 
 I should be incised at 
 enable the hand to he 
 5 allow an exploration 
 nable objection to this 
 
 .e operation for fixing a 
 icision is adopted, and 
 in its fatty capsule, this 
 und, and a considerable 
 3S of medium thickness 
 and also through the 
 I good hold of it. By 
 »sterior abdominal wall 
 s of this operation have 
 ,s returning. It appears 
 rough the renal paren- 
 1 removed; and hence, 
 jntly immobilized at the 
 :omes loose again. To 
 ve the parietal incision 
 at a firm mass of cica- 
 the kidney to the sur- 
 in, have recommended 
 tripped off and stitched 
 es thus formed unitiii;,' 
 iis advise the isolation i 
 ., which is passed from | 
 support on which the ; 
 JoHvnaU February 3, 
 
 CHAPTER XXXVI. 
 
 BLADDER AND PROSTATE. 
 
 Congenital Affections of the Bladder. 
 
 I Ectopia Vesicse, or Extroversion of the Bladder, is the term siven to 
 denote total absence of the anterior wall of the bhulcler and of the lower 
 portion of the abdominal parietes, as a result of which the mucous membrane 
 nf the posterior vesical wall is exposed and rendered somewiiat prominent 
 by the pressure from behind of the abdominal contents (Fij,'. 351, \\). This 
 surface is usually irregular, and covered with papilliform processes ; the 
 
 llg^g^^™ 
 
 Fig. 351. — Ectopia Vesict:. (Tillmanns.) 
 
 H, Exposed mucous membrane of bladder ; U, U, orilices of ureters; 
 H, H, projections of pubic rami on either side. 
 
 orifices of the ureters (U, U) are easily recognised below, urine being occa- 
 [sionally emitted from them in forcible jets. The condition is necessarily one of 
 j the greatest discomfort, not only from the constant dribbling of urine causing 
 [excoriation and eczema of the thighs and surrounding parts, but also from the 
 1 pain and irritation due to friction of the clotlies against the exposed mucous 
 I membrane. The symphysis pubis is always absent, and the horizontal ramus 
 
I024 
 
 A MANUAL OF SURGERY 
 
 of the pubic arch terminates on either side in the inguinal region (H, H). 
 innominate bones are usually rotated outwards, and the sacrum is con 
 anteriorly from side to side instead of being concave. In consequence of 
 pelvic malformation, the patient's gait and powers of progression are c 
 siderably impaired. The penis is cleft, and in a condition of comp 
 epispadias; it is drawn upvvards and backwards over the trigone, so th: 
 requires pulling down (as seen in the illustration) to expose the uret 
 orifices. The testes are often found in the inguinal canal, or, if in 
 scrotum, are accompanied by congenital hernia;. No umbilicus is pres 
 The condition is due to impaired development of the anterior wall of 
 allantois and the lower segment of the abdominal pu.fietes. At birth 
 lower portion of the umbilical cord is expanded over the raw surface, ( 
 stituting the anterior vesical wall. When the cord separates, the poste 
 vesical wall is necessarily exposed. 
 
 The Treatment of this distressing malformation is most unsatisfact 
 The majority of the cases are treated by the application of a urinal, 
 unfortunately, the instruments hitherto devised are not particularly efhci 
 Various operative measures have a'-'-, been practised with the object 
 covering the exposed surface, and ^ .mg, if possible, a reservoir in wl 
 the urine may be retained, (a) Trent jien burg's operation consists in divis 
 of the sacro-iliac ligaments from behind, so as to enable the lateral halve 
 the pelvis to be compressed together. By this means the posteripr ves 
 wall is thrown backwards and its tendency o protrude lessened, 
 wounds are allowed to granulate, and, if successful, the bladder wall fin 
 lies at the bottom of a sulcus, which can usually be covered over by a pla 
 operation without much difficulty. The main objections to this method 
 that it involves a very severe operation, and also leads to a further weaker 
 of the pelvic arch, the integrity of which is already much impaired by 
 absence of the pubic symphysis, (b) Plastic operations without interfei 
 with the pelvis have been introduced and practised by the late Professor J< 
 Wood, Thiersch, and others. For full details, we must refer to larger ti 
 books. Suffice it here to state that a skin flap is turned down from 
 anterior abdominal wall above the breach of surface, and sutured on eit 
 side to the margins of the defect. The cutaneous surface of this flap c 
 stitutes the anterior wall of the newly-formed bladder, if such it can 
 called, whilst its raw outer surface is covered in either by flaps derived fr 
 either side, or by undercutting the neighbouring skin and sliding it upwa 
 to the middle line, where it is united by sutures, as suggested and succcissfi 
 carried out by Mr. Boyce IBarrow. The after-treatment is always proloii] 
 and tedious, and the patients are likely to experience much subseiju 
 inconvenience owing to the growth from the under surface of the abdonii 
 flap of hairs, which become encrusted with phosphates. 
 
 2. An Umbilical Urinary Fistula is sometimes met with as a result 
 imperfect closure of the urachus. 
 
 3. Occasionally in cases of malformation of the rectum the Primit 
 Cloacal Condition may in part persist (see p. 976). 
 
 Traumatic Affections of the Bladder. 
 
 Rupture of the Bladder may be produced in several wa) 
 (i) It may be due to direct violence applied to the lower part 
 the abdomen, especially when the viscus is distended. (2) 
 may complicate a fracture of the pelvis, either as a direct result 
 the violence, or from penetration of a spicule of bone from the 
 pubis. (3) The bladder may be opened by a penetrating wour 
 (4) Apart from traumatic lesions, rupture may occur from sini[ 
 over-distension, especially if destructive ulceration of its walls 
 
^LADDEJij,^^ Pj^OSTATE 
 
 the rectum the Primitive 
 
 present: or it ma,, f n '025 
 
 Phospha'tic conS:?;/:""" "''^^'''"°" "f a saccule inT" • 
 
 . Rupture of the bladder ,•= a- : ""'''""^ •'■ 
 
 >ns to whether or „„? u *"<''=<' »to two „,,•„ ,, 
 
 peritoneum covers fh. *" P^'oneal cav>v '"■""'• ''"ord- 
 
 reflected anterLrfv 1"^^? ='"<' ''''•ck part df II °^'"""^- The 
 
 'iterated hypo^atl tTefie '^nT ""^' '^\^l '^^ 
 
 The symptom'^J^dSceVL'e"^ ™™'/™° Sultl?"'" "- 
 
 ^'atesfi-1-S^sV^^^^^^^^ 
 passing a catheL thi^hL^"'""^ treatment s not "h ^^'f 'J'-^P'dly 
 a little blood-stafn^H , • "^^^ '" "^"^Uy found pmL°P^'^''- O" 
 instrument is ns nuated th "^^ ^' withdrawn ^V '^°^^^'^'>^ 
 cavity, a considerabt n^^'°V§^^ ^^^ ^^Pture "nto 'fh '^^'^''■' *^« 
 drawn off and the ni^ quantity of blood stain pH • P^^'^oneal 
 
 anterior abdlL'aVwS V"' ^^^^ -^ be fdr^nd"'" .^ 
 injecting a mea^.,r«^ ^ "^eful dia^no^hV • '"'^^^ the 
 
 and noting how mf if "V'^"^ °^ ^oric add lott" P ,'°"''^t^ ^n 
 considerable Zr^nf "^ ^^- '^*"^"s ' when a ""/"''' '^'' ^'^^^^'^' 
 .uantities/^ '^"^ "^^^ ^^^^^^^^ ^-o^^XrverSeT^ 
 
 The Treatment of thp ^^'° 
 
 loremo«a„v ex,.?'!^ """^ '" ^' "verted for //* ''''^^^Se-wick 
 •he usual waT and rhe"- ^^' ^""■"inal wallilTh^""?' '=° »' 
 either drawn^off at J^ F*"?"' P"' back to bed rf" "'"^'^ '" 
 
 .o»mb r;XS P'\t ^^""'"■^' ^vWch^s usu'arfll'^^"' 
 pelvic hrirv, t'y^mia. Abscesses tend m ,.^- "^H^^V ratal from 
 
 65 
 
:, ' T, 
 
 1026 
 
 A MANUAL OF SURGERY 
 
 : Foreign Bodies introduced into the bladder from without ar 
 various natures, such as portions of catheters or bougies, f 
 etc. They give rise to symptoms of chronic cystitis and usu 
 become encased with phosphatic deposit. They should 
 removed as early as possible with a lithotrite, but if of large 
 or thickly covered with phosphates, must be treated by peri 
 or suprapubic cystotomy. In the female digital dilatation of 
 urethra is the best means of gaining access to the interior of 
 viscus. 
 
 Methods of Examining the Bladder. 
 
 When a patient presents himself complaining of increased frequenc 
 micturition and other evidences suggestive of chronic disease of the biac 
 a systematic examination of the individual and his urinary passages 1 
 always be instituted. The history of the case, the character of the sympt 
 and the condition of the urine are carefully gone into. At the first inter 
 it is advisable to ask the patient to void his urine, after which, providin 
 tight stricture exists, a medium-sized catheter-a-boule, or one of rubber, sh 
 ,be gently introduced, and the amount, if any, of the residual urine estim 
 
 ^^ 
 
 Fig. 352. — Leiter's Electric Cvstoscope. (Tillmanns.) 
 
 a, Electric lamp in beak ; b, glass window for illumination purposes; 
 f d, switch for opening or closing current. 
 
 and tested. Having gained all the information possible from this sourc 
 examination of the bladder should then be made, or perhaps at a subsei 
 visit, (i) The patient is laid on a couch, and the lower part of the abd 
 uncovered. The hypogastrium is then examined by inspection, palpation 
 percussion, so as to ascertain whether or not the bladder is distended, 
 any abnormal resistance can be felt, either from thickening of the wall 
 presence of a tumour. (2) A sound is then passed according to the me 
 described at p. 1048, and the interior of the viscus explored ; by this mc 
 calculus may be detected, and even sometimes a tumour, as also a rough 
 irregular condition of the mucous membrane. (3) The finger is inserted 
 the rectum, or, in the female, into the vagina, before the sound is withJr 
 so as to enable the condition of the posterior vesical wall to be investi 
 between the point of the finger and the sound. Enlargement of the prosta 
 of the vesicular seminales can also be detected in this way. (4) As menti 
 elsewhere, Bigelow's evacuator is useful, not only to wash out the bladder 
 also to detect the presence of very small calculi which the sound may 
 missed. (5) Of recent years a new means of examining the interior of 
 bladder has been introduced in the shape of the cystoscopc (Fig. 352). 
 consists of a straight tube with a short end bent at an angle, in whic 
 electric lamp is placed, the wires leading to it being carried within the t 
 A small window covered with glass is situated close to the angle, and a p 
 is here inserted in such a manner that, when the surgeon looks thn 
 an eyepiece placed at the end of the instrument, he is able to see the portii 
 the vesical wall illuminated by the electric lamp. To use it the bladderi 
 
^^DEH AND PROSTATE 
 
 be previously washed on f . ,7 ' — ~~ '027 
 
 the anterior nnH "'^'' ^°'" ^""le time n ^''''"^'^ -^vavs bep^n, u — -*' 
 in spite of f.i.!ii"!'"y' '" cases uhpr« *^'. ^° .^he condition '/'.""''^"'"ent, 
 
 membrane (6) Fin-S"'-^ '"^^^ ''-^-^^'iTL''V''^ ^^oi'^lS^'"''' '' 
 
 H-^nneal. is justifiable. " ''^'Ploratory 
 
 Inflammation of the m.AA . 
 
 Acute Cystitis o ' a -Bladder. 
 
 injury to the viscn.wf ' ''^" ^^'^ Presence of f • " ^°'"etimes 
 'I^ently as a comnli^ ?"^ operation. ?ni ) /°''"^^" ^o^^>"es, or 
 
 extensL of'th^Tnfcation ^^^^^'^^ - "^ to"n"°^^ ^-- 
 are often very severe Tv'T.' """"^ '" ^"^^ cases th. "P'^'^'^ 
 "■ntating poisons such . ^ ^ .""^^^ ^^^^^t from tL I '>'"^Ptonis 
 -superxene if a dtrf • ''' ^^ntharides. A-?i- I ^^^orption of 
 but iittle doubt /ha^.^jf''"'"^"^ '-^ int od ced ?'',' "^^''''^'^^ '^ay 
 chief in times p^t^' ■^' ^^^^ ''^ '"ost prX ' "^ '""T ^^^ '^^ 
 
 is paralyzed in^TaVe. '? ''"'^^ ^'^'^^^ ^o occm- "r' .f ^'^^ '"'■^- 
 -stances infect on t^ °^ 'P^"''^^ injury inH ''", ^^^^ ^^^^^der 
 .nents are Xiov^d'^ '"P'^'^'^"^ ^^en^' ^hen sf 1'''. '''''^^^ 
 urethra, aIon"whfrb' '"^-"^ *° ^^^^ presence ,.f^^^^'^ ^"^t^"" 
 
 external meatus h,. ^"^"'^ '^"d urethr- ^n^i ^^' ^''^ "n- 
 
 ^'-c^ '-> "eL^^l ?^ ,--P^^c dressing m^^-^ ^he 
 
 ^^f^SPi^^^^^ red „., ... 
 
 , -ladder is' sc^^^^^^^^^cUon^l, Z the' meT"r^^'- -'- 
 anety of cystitis is not nrfl '' ''"^ Probably in „vi "°^^' '^ reaches 
 
 'lirect infection from thSM "^"^"'^'t may 'b fl, ""^'^.-'n whom this 
 P"es associated wUh k nT '" ^''^ vulva, a vul- f "'■'"':^'->- organs b 
 
 rectal mucosa is liabe to h.f,^'''' ''^'^^ been ^-n f ;?^''"''''* '^«^4 some- 
 
 \ ^'^e Symptoms of arnt^n .-.• • ^ ' 
 
 65—2 
 
''S 
 
 1028 
 
 A MANUAL OF SURGERY 
 
 modic nature being made to pass water (strangury) ; but 1 
 urine is voided at a time, for as soon as any amount has colle 
 it is ejected forcibly. It generally contains blood and pus, 5 
 becoming alkaline, and teeming with bacteria. Some amour 
 fever is usually noted, as also vomiting, whilst tenesmus ma; 
 induced as a result of the proximity of the rectum to the infla 
 bladder. The usual termination of the case is in resolution, 
 sometimes chronic irritability may perbist. In rare instances 
 inflammation is of such a virulent nature as to cause death, 
 urine in these cases is often exceedingly foul, and the fatal i 
 is due to exhaustion, peritonitis, suppurative pyonephrosis 
 even acute toxaemia ; occasionally the whole mucous lining oi 
 viscus may slough. In some patients, however, when the intl 
 mation is concentrated at the neck of the bladder, retention, 
 tension, and atony may ensue. 
 
 Treatment. — The patient should be kept in a warm atmosph 
 and preferably in bed, and fomentations applied to the lower 
 of the abdomen ; hot hip-baths twice daily, maintained for s 
 time, are very advantageous. The diet should be restri 
 to fluid, and the patient encouraged to partake freely of bai 
 water and other bland liquids. Alkalies and henbane maj 
 administered, and morphia and belladonna suppositories are 
 ful to allay the pain and irritability. As a rule, no instrun 
 should be passed during the acute stage, unless retentio 
 present ; but if the urine becomes very foul, the bladder ma 
 gently washed out. In the worst cases salol (10 to 20 gn 
 and boric acid (15 to 20 grains), administered by mouth, ma 
 some good. 
 
 Chronic Cystitis is much more common than the acute var 
 The usual cause is some irritation of the walls of the viscu! 
 from calculi, tumours, foreign bodies, tuberculous ulceratioi 
 retention and decomposition of urine, especially if associated 
 obstruction to the outflow, as by a stricture or enlarged pros 
 It may also follow acute cystitis, whilst impairment of the nen 
 mechanism, as in various forms of injury or disease of the sf 
 cord, may induce trophic changes and predispose to its occurre 
 
 The Symptoms are those of irritability of the bladder, the pat 
 constantly desiring to pass water, and having to rise at ni 
 perhaps several times, for this purpose. The urine beco 
 turbid, and on standing deposits a variable amount of mi 
 or muco-pus, mixed with epithelial cells, crystals of triple p 
 phate, and a granular sediment of phosphate of lime. I 
 usually alkaline, perhaps foul-smelling and ammoniacal, ( 
 taining an abundance of micro-organisms. There is often 
 little pain, though when a calculus exists, or the neck of 
 bladder is ulcerated, this may become a prominent symptom, 
 patient's general health is not at first affected, but if the sympt( 
 
tERY 
 
 ''«»marte--f-"gfrom nocTu;„:!'^,.W'-"y from hTP"™ °< 
 
 actsof mVf • °^ uncommon tu^ and even vnt ^"^^and 
 
 marked when th^ "^/^sciculated • Jh- T '^Jadder wp i . ^^ 
 outflow of urLVT^^'^ '"^ ^^'olL^L'^.r' '^ of cou e':i'^h 
 
 applied to the lower part I e Jned^ P.^^osphatic concretLf"'"^ ^'^^ to pouch rf ""'"''''^"^^ 
 tily, maintained for ^onAlcc^^^^^^ ^^^^"Jes, 
 
 iet'should be re^r-^^^^^^^^^^ . Perforat '■ "^'. ^"^ ^h, 
 
 partake freely of barley- ■ bJadder and fh '^'''^'°" of urine r, P^^^^nitis or 
 
 r (strangury) ; but little 
 my amount has collected 
 ,ins blood and pus, soon 
 cteria. Some amount f)f 
 whilst tenesmus may be 
 le rectum to the inflamed 
 :ase is in resolution, but 
 ;t. In rare instances the 
 as to cause death. The 
 ' foul, and the fatal issue 
 urative pyonephrosis, or 
 hole mucous lining of the 
 owever, when the intlam- 
 le bladder, retention, dis- 
 
 5t in a warm atmosphere, 
 
 lily, mamtamed tor someB occasion oiT'TM^^'^^^goes dernm„"*-''.''"'"6finies fom^'j ""'^'^ 
 ■ should be restricted I l^^frL^^^^^^^^'Origina^^^^^^ Perforin ', ^"^ 
 
 .take freely of barleyJ w^^^/t^avasation^T^^^^^ ^^j^a PeritonitTs :';:,"^'-^V,- 
 
 es and henbane may be ■ compression '!h°''''§^^°^^t^ o^ts 1' '°"^^^oted sTate'of' i" 
 suDDositoriesareuse.Ifh„.;„l'°",o^ ^^^ openings af \) "^"^cuJar suhsf^!. , '^^ ^^e 
 
 .age, u Lr r^r;|s„°4 -' ^' t:!s^-^P&'^'S':r^ 
 
 foul the bladder may I J The Di. " ''^P'^'^ misS f '°/'=r'' "i* tec er n ^ '"° "-e 
 :s salol (xo to .0 grain Jd.ararte^S"''^' "' =''™"ic c'";*; Wdney. ''•^='"« causes an 
 .tared by mouth, may <l.|„„diei„„ of thI'ZnT" ,°' 'm'atio„"of''?h''''>', ,"«* ^om ,|, 
 
 »!fnsio„ of tte-s™ r/Xr^^ '"f-'ed with 
 :s salol (lo to 20 grain-rtararterJ^'of °f chronic ^'"ti*' ^'''"^J'- 
 .tared by mouth, may <l.|„„dieio„ of thI'ZnT" ,°' 'm'ation"of''?h''''>', ,""'* ^om „,, 
 
 e 
 e 
 
 n than the acu 
 he walls of the 
 
 he walls ot the viscus, awie Jnwor • "® Patient \xrV>;\ ^ considered K„* i ' "' 
 
 uberculous ulceration oI,J„^red """^''^^ P'-^^Vs musf , ^- '^^^^^^^h e\^n n ? '^'' 
 3ecially if associated uitlineS^^^^^ The L''" ^"^tituted, and ?''''°" °^ 
 
 ure oJ enlarged prostatle CUt 'a^^ ' ^"^ '^^^'-'i^^^^ ' .^^^^"- o'^^nd 
 
 mpairmentof the nervo*p. ro26. '^'° ^-^-^"^'ned by the different '^" "^^^^ra, S 
 y or disease of the sp.n| n. Treatment of ch. • '"''^^^^ ^e c^S 
 
 edispose to its occurrenc* cause if c u chronic cvstih'c • 
 
 of the bladder, the patie»ouJd hJ.T ^^" ^^^ discoverf^H iu "^^uraUy directed f^ 
 having to rise at ^„i,|er^i;: S^ t n^-t" "-"^^s'd a^ed^'S""^"^^"* 
 
 . .rv.f»k r.f frinlp „!,* ■ .' f'^^^y^ be sterili:,^^ i^V.^^'heters and nfh™ :.f ^n^ed 
 
 h^'^ *« caurtn^-t" r*'"-'*ra?ed"?n'r ^"^•^" 'SS 
 
 "septic prepartttn 'f,H '"'^'■<= "'^^ and&'^f i"^'™™ente 
 r/»^ '°. ^eme^r" l^fl^-H'c oiult"^ n:™h.so.e 
 
 se. The urine beconi 
 
 riable amount of muci»ou]d al»ro° V^ "^^ '^iadder r\^'".""' "^'^"ent wiJ] i-,^ j' ~'^ 
 s, crystals of triple 9;M4tp%lt^'''"''^^ before use""?,-"! "'"er in'ltS 
 bosphate of hme ^ fportimt '^oTeSem'!' '"'1' « carbofc oil ,"''"'=^"=d with "o™ 
 ; and ammoniacal, cofsiy indnc^H f^f^ber that sensis if '' ™ ^o) ; for it u"^ 
 
 ms. There is often j|4 tt?;.^"'' """ ■>^ P^eseSeV /e^s' t^^"^ ^-'^"^ I 
 Cists, or the neck ot mru^ ui , . ^- ^"uers the ra^^ .... , ' '- 
 
 rominent symptom 
 
 ^ , ..'^^ bladdeTis best .. "°"= ">^ ^"-"'uch mor 
 
 rominent symptom, ifct. to fh« « j r^ '^rigfated h,, „ • 
 
I030 
 
 A MANUAL OF SURGERY 
 
 material employed is poured. By raising the funnel the Huid i 
 into the bladder, whilst on depressing it below the bed or co 
 the fluid returns on the syphon principle. The patient's sei 
 tions must guide the surgeon as to how much flvud can be be 
 in any particular case. Various solutions are employed for 
 purpose, but perhaps the most useful are weak Condy's fl 
 sanitas (i in lo), boric acid (20 grains to i ounce), perchlorid 
 mercury (i in 2,000), or a neutral solution of quinine (2 grain 
 I ounce), and they may be used alternately with advant; 
 The frequency with which the injections are made must \ 
 with the severity of the symptoms ; it is not often necessar 
 perform the operation more than once or twice a day. 
 
 At the same time that this local treatment is being adop 
 the patient's general habits of life must be regulated. The 
 should be bland and unstimulating ; alcohol is better avoi( 
 but if essential for other reasons, well-diluted gin or whisky 1 
 be given. Tea and coffee should be prohibited, whilst a 1 
 diet is perhaps the best which can be employed. As to medici 
 there are none which can alter the reaction of the urine f 
 alkaline to acid, but perhaps salol, boric acid, or benzoic ; 
 may be of some assistance. Hot infusions of buchu, uva i 
 and triticum repens, act as mild diuretics, and as alterative: 
 the vesical mucous membrane ; full doses, however, such r 
 pint or a pint and a half in the course of the day, are nee( 
 Where much muco-pus is excreted, copaiba, cubebs, turpent 
 or sandal-wood oil may be advantageously exhibited, whilst 
 jections of dilute astringents have been advised, but must be i 
 with caution. 
 
 In cases which do not improve, and if the patient is becon 
 exhausted from the constant interference with his rest, etc., 
 only means of treatment left is that of opening the bladder thro 
 a perineal incision. Perineal Cystotomy is undertaken not onl} 
 the draining of a chronically inflamed bladder, but also to exp 
 the mucous lining of the viscus, to remove growths and fori 
 bodies, as also sometimes to deal with prostatic enlargements 
 calculi. The bladder is first thoroughly washed out, a few oui 
 of antiseptic solution being left within it. After anaesthesia 
 been induced, a staff with a median groove is passed into 
 bladder, and then the patient is placed in the lithotomy posit 
 and the perineum shaved. An incision is made in the iiii( 
 line of the perineum, from a point 2i inches in front of the a 
 to about I inch from that opening. The knife divides the det 
 structures of the perineum, and, guided by the left index-finge 
 the wound, is made to enter the groove in the staff at a p 
 corresponding to the membranous portion of the urethra, 
 then carried upwards and backwards along the groove, inci; 
 the prostate and entering the bladder. The knife is caref 
 withdrawn, the finger gently inserted into the bladder, 
 
BLADDER AND PROSTATE 
 
 I03t. 
 
 . funnel the lluul runs 
 ovv the bed ov coucli 
 
 The patient's sensa- 
 ,ch fluid can be borm. 
 are employed for ^ 
 
 weak Condy s fluid 
 ounce), perchloride ot 
 jf (uiinme (2 grains to 
 ,tely with advanta<ge. 
 
 are made must vary 
 not often necessary to 
 
 .vice a day. 
 
 nent is being adopted, 
 e regulated. The chet 
 ohol is better avoided. 
 
 ated gin or whisky may 
 'habited, whilst a mdk 
 [oyed. As to medicines, 
 'tion of the urine from 
 ;c acid, or benzoic acid 
 ,ons of buchu, uva ursi, 
 .cs, and as alteratives to 
 ses, however, such as 
 
 of the day, are needed, 
 laiba, cubebs turpen me, 
 Kly exhibited, whilst nv 
 [dvised, but must be used 
 
 the patient is becomb^ 
 be with his rest, etc., the 
 Lng the bladder thi-ou^li 
 Is undertaken not only for 
 Vdder, but also to explore 
 love growths and foreign 
 lostatlc enlargements arul 
 Lashed out, a few oun ^ 
 t \fter anesthesia lia^ 
 roove is passed into the 
 \n the lithotomy positio • 
 L is made in the middle 
 ches in front of the amis 
 * knife divides the deeper 
 w the left index-hngeriD 
 ^\r. the staff at a po-n 
 \on of the urethra. In 
 llong the groove, incisij 
 * The knife is carefull 
 into the bladder, anJ 
 
 the stafT removed. After digital exploration of the bladder, a 
 full-sized gum-elastic catheter (No. 16 or iS) is passed in through 
 the wound and fixed, a long piece of rublier tuhini,^ being attaclu'd 
 to allow of the constant escape of the urine, as well as to permit 
 of occasional irrigation. The catheter is removed and changed 
 at the end of forty-eight hours, and in favourable cases may be 
 discontinued altogether at the end of a week, and the perineal 
 wound allowed to heal ; in, severer cases a permanent opening 
 may have to be maintained. V, J 
 
 Tuberculous Disease of the Bladder may be primary or secondary, 
 the latter extending from similar disease in the kidney, prostate, 
 or testicle. It is much more common in men than in women, 
 and is most frequently seen in young adults. It commences in 
 tlie submucous tissue as a deposit of miliary tubercle, which 
 caseates and suppurates, breaking down, and giving rise to ulcers 
 with undermined edges ; these are rarely of large size, are usually 
 multiple, and situated in or near the trigone. The Symptoms are 
 those of chronic cystitis and haematuria, the irritability of the 
 viscus being very marked. The diagnosis is made by demonstrat- 
 ing the bacillus of tubercle in the urine, and by the cystoscope. 
 The course of the case is unfa\ourable, death resulting from 
 general infection, phthisis, or extension to the kidneys. 
 
 Treatment. — The case is usually treated for some time as one 
 of chronic cystitis before its nature as a tuberculous affection is 
 ascertained. In the milder cases it may sufBce to attend to the 
 general health and hygiene of the individual, and to wash out the 
 hladder with some antiseptic two or three times a week, leaving 
 a drachm or two of a 10 per cent, solution of iodoform in olive 
 oil or glycerine within the viscus. In more advanced cases 
 cystotomy may be undertaken, preferably by the suprapubic 
 method, and the ulcerated surfaces scraped and disinfected by 
 applying the galvano-cautery or pure carbolic acid. To effect 
 this the method suggested by Mr. Hurry Fenwick, of using a 
 suitable speculum as a caisson through which to work, is 
 especially to be recommended. 
 
 Very similar Symptoms may be induced by the presence of a 
 [Simple Ulcer of the Bladder, which, according to Fenwick, occurs 
 [not unfrequently. It is usually single, and situated near the neck 
 or trigone, giving rise to great irritability of the viscus and haema- 
 turia, although the urine remains clear. The diagnosis is best 
 made by the cystoscope. Phosphatic deposits sometimes form 
 over the ulcerated surface, and may suggest the existence of 
 la stone. The treatment now recommended consists in washing 
 lout the bladder with lactic acid {\ to 3 per cent.), or in scraping 
 land cauterizing the base of the sore through a suprapubic 
 lincision. 
 
1032 
 
 A MANUAL OF SURGERY 
 
 Tumours of the Bladder. 
 
 New growths from the vesical wall are not \ery unconimo 
 they may he simple or malignant. 
 
 Simple Tumours occur in the form of fibroma and myxoma, I 
 that most often seen is the Papillomatous or Villous Tumoi 
 which appears as a soft flocculent. mass, usually situated near t 
 
 trigone, and close to the ope 
 ing of one of the urete 
 {^\- 353)- Tlie floating tu 
 or villous processes consist 
 an extremely delicate co 
 necti\e tissue, coxered w 
 a layer or two of epitheliu 
 similar to that lining 
 bladder, and traversed 1 
 bloodxessels. Occasionally 1 1 
 growths ha\e a narrow bas 
 and are pedunculated, l>i 
 more frequently are sessili 
 They may be single, or ma 
 multiply rapidly, and sprea 
 all over the bladder by ii 
 fection from the primar 
 growth. 
 
 The Symptoms I'-e thosi 
 of recurrent hajmorri age, thi 
 blood being of a Bright rec 
 colour, followed later on by irritability of the bladder. At firs 
 the hemorrhage is intermittent, considerable intervals occurring 
 between the attacks ; but subsequently it becomes more con 
 tinuous. The irritability of the bladder is generally induced h\ 
 chronic cystitis, and when the urine has undergone alkalint 
 changes, there is a copious exudation of ropy mucus which 
 mixing with the urine, causes considerable difficulty in mic 
 turition, leading in some cases to strangury. On standing, thi; 
 deposit becomes so tenacious and jelly-like as to be poured witl 
 difficulty from one vessel to another. The urine may also contair 
 portions of the tumour which have been set free, and o_ cpas ionally 
 if situated near the neck of the bladder, some of the fimbriatec 
 ends may be swept into the urethral orifice, and interfere witl 
 micturition. In the same way the opening of one or both ureter; 
 may be encroached upon, leading to hydronephrosis. On examina 
 tion of the bladder with a sound, nothing definite can be detected 
 unless the surface of the growth becomes encrusted with phos 
 phates, and no abnormality is noticed on rectal examination 
 Occasionally a small portion of the growth may be caught in the 
 eye of a catheter. 
 
 F'fj- 353- — Villous Tumour of the 
 Bladder. (From King's College 
 Museum.) 
 
ERY 
 
 ier. 
 
 e not \ery uncommon ; 
 
 roma and myxoma, but 
 ►us or Villous Tumoui, 
 
 sually situated near the 
 :, and close to the open- 
 ■ one of the ureters 
 53). The floating tufts 
 >us processes consist of 
 tremely delicate con- 
 ! tissue, coxered with 
 r or two of epitheHuin 
 
 to that lining the 
 ', and traversed by 
 issels. Occasionally the 
 s ha\e a narrow base, 
 re pedunculated, but 
 frequently are sessile, 
 nay be single, or may 
 y rapidly, and spread 
 r the bladder by in- 
 
 from the primary 
 
 Symptoms z. ^e those 
 •rent haimorr^ age, the 
 3eing of a bright red 
 the bladder. At first 
 3le intervals occurring 
 t becomes more con- 
 generally induced by 
 s undergone alkaline 
 F ropy mucus which, 
 ble difficulty in mic- 
 y. On standing, this 
 as to be poured with 
 urine may also contain 
 free, and ojccasionally, 
 )me of the fimbriated 
 ce, and interfere with 
 of one or both ureters 
 phrosis. On examina- 
 finite can be'detected, 
 encrusted with phos- 
 1 rectal examination, 
 may be caught in the 
 
 ..^^^«4W^p«0,,,^^, 
 
 Tlic Prognosis of the r=» ■ ' — — — __ '°» 
 
 f.'ro«lh is not at fiAt ,?,r " ""•«"''factorT3 — 
 
 Lymphatic glands are of.^' ''^"^ "^''^'^ invadi fn ^'^.'"'^^"■'^'""•S 
 cancer o AlK-^r^ ^,^, i;''*-^, - a;f S 'll?;*'^- "»- 
 
 f"' i54 -CA.VCER or BlaDOE,^ ^ ^ 
 
 ■spread to it from thp 
 
 wmmences Jn ., °^""'"^^ type. Most Z 'T^''^^ ^'-^"^er, the 
 
 .fonvarTs"o%hene:/°??r(?^^" ^w' hr^dl^^^^ ^^^^^o^ 
 l^uperricial nro," . ^^^ bladder. The Jr. S"^' ^^^ending 
 
 
1034 
 
 A MANUAL OF SURGHRY 
 
 (Fif^'. 354), the raw surface often heromin^' mated in places 
 a phosphatic deposit. A cancerous j^'rowth in the hladde 
 always more or less likely to beconir papillated. The ilisea; 
 much more conunon in men than in women. 
 
 The Symptoms \ary somewhat in these two forms, altho 
 the conspicuous features of each are iia'maturia and irritab 
 of the bladder. In the slowly f^aowinj,' superficial \ariet}, 
 tumour often attains a considerable si/e before cau'^ini,' 
 trouble, beyond possibly some slight irritability of tlie blad 
 A severe attack of ha^maturia, unaccompanied by pain, is usu 
 the first symptom of importance, and may be induced by s( 
 injury which causes a crack or fissure in the j,'rowth. This p; 
 less lucmaturia closely simulates the early symptoms of a sin 
 villous tumour, but is more persistent, and yields less readil 
 treatment. After one or more of such prolonged attacks, cys 
 follows, and the subsequent history resembles that of the har 
 and more rapidly growing infiltrating tumours. In sucli 
 symptoms of vesical irritability precede those of ha^matu 
 Dysuria and se\ere pain referred to the bladder and perine 
 are complained of, and the urine early becomes alkaline ; 
 putrescent ; shreds of the growth may also be found in the ui 
 on microscopic examination. If the tumour involves the inter 
 meatus, micturition may be considerably impaired, whilst if 
 orifices of the ureters are obstructed, hydronephrosis resu 
 On passing a sound, the tumour can be detected as an irregi 
 mass projecting into the bladder, whilst the posterior vesical v 
 may be felt per ycctimi to be hard and resistant ; its ulcera 
 surface may also be seen with the cystoscope. 
 
 The course of the case is similar to that of a somewhat rapi 
 growing carcinoma, leading to early and marked cachexia, 
 creased by thgsleeplessness resulting from the vesical irrltatic 
 secondary depostts^^Sfe found in the viscera and lumbar glan 
 whilst perforation of the wall may occasionally follow, cans 
 urinary extravasation, septic cellulitis, and death. Another m 
 distressing complication is the establishment of a recto-vesi 
 fistula, through which the urine makes its way into the recti 
 thus intensifying the sufferings of the patient. 
 
 The Diagnosis of a vesical tumour can only be made w 
 certainty by the cystoscope, or by disco\'pring fragments of 
 substance in the urine, though in th t is easy to dil 
 
 the urethra, and explore the blac fer .ith th.c miger, Whene 
 haemorrhage is associated ^ '" aked \esi' 1I irritability, i 
 cannot otherwise be explaine tumour of bladder may 
 
 suspected. The question as whetber or not it is malij^m; 
 can only be determined by a careful e> mination of the symptor 
 In simple papilloma, and the supeilicial type of epithelior 
 haemorrhage precedes the irritability ; but whilst it is us illy i 
 possible to detect the villous growth either by examination w 
 
pia5-^-cA, Y 
 
 Hxy^-A^^ 44^''-^ 
 
 >-V 
 
 roated in places with 
 th in llu' bladder is 
 lated. The disease is 
 
 ■ two forms, although 
 iaturia and irritability 
 uperiicial \anety, the 
 . before causmi,' any 
 ability of the bladder, 
 lied by pain, is usually 
 V be induced by sorni" 
 le growth. This pain 
 
 symptoms of a simple 
 c\ yields less readily to 
 jlonged attacks, cystitis 
 bles that of the harder 
 umours. In such the 
 . those of ha'maturui. 
 ' bladder and permeuni 
 
 becomes alkaline and 
 so be found in the unne 
 our involves the internal 
 ^ impaired, whilst if the 
 hydronephrosis results, 
 [detected as an irregular 
 he posterior vesical wal 
 ' resistant ; its ulcerated 
 
 •ope. , . ,, 
 
 t of a somewhat rapidly 
 \ marked cachexia, in- 
 n the vesical irritation; 
 era and kimbar glands, 
 fsionally follow, causin,^ 
 d death. Another most 
 ment of a recto-vesical 
 Its way into the rectum, 
 
 lent. , . , 
 
 Ian onlv be made wuh 
 /ering fragments ot it= 
 ,, > is easy to dilate 
 the iinger. Whenever 
 vesi. nl irritability, and 
 of bladder maybe 
 
 or not it is mah^nant 
 Ination of the symptoms, 
 d type of epithelioma, 
 t whilst it is us iHy i"i- 
 [er by examination ^vltn 
 
 HLADDllR AND riiOSTATE 
 
 I nma^Aw/k*^X^*- 
 
 1035 
 
 the sound or from the rectum, a fungating malignant growth may 
 sometimes be recognised by the sound, in the infiltrating type 
 of malignant disease, on the other hand, pain and dvsuria .'dwavs 
 precede the bleeding for a considerable interval, whilst definite 
 ( \ idence of the existence of the growth can usually be made out, 
 both by the sound and on rectal examination. A worn and 
 exhausted appearance must not he looked on as necessarily the 
 outcome of advanced cancerous cachexia, since the loss of rest 
 and sleep due to chronic vesical irritability can of itself lead to a 
 somewhat similar condition. 
 
 Treatment of Tumours of the Bladder. In the early stages, 
 when the diagnosis of a tumour has not been conlirmed, the 
 lurmaturia may be treated with ordinary hanuostatic remedies, 
 such as a mixture containing dilute sulphuric acid and ergot, or 
 turpentine administered in capsules (10 minims three times a day). 
 When once a diagnosis has been established, removal by operation 
 is the only plan which holds out any hope to the patient, and such 
 can only be undertaken with any prospect of success in benign 
 (jrowths, or in the very earliest stages of the superficial form of 
 malignant disease. The bladder is laid open either In' perineal 
 or suprapul)ic cystotomy, and the growth removed by the curette. 
 The suprapubic operation is certainly preferable, in that it gives 
 one the opportunity of definitely seeing the interior of the bladder. 
 The plan already mentioned of employing an expanding speculum 
 as a caisson will be found useful ; when all moisture has been 
 sponged away or sucked up, the vesical wall is seen at the bottom 
 of this tube by means of an electric lamp fitted to the surgeon's 
 head. In default of a better instrument, a Fergusson's speculum 
 can be utilized. Growths may be removed by means of long- 
 handled instruments specially adapted for the purpose, and the 
 base from which they spring must be carefully cauterized. 
 
 permanent suprapuKicl3r perineal opening may be established 
 
 Functional Derangements of the Bladder. 
 
 Incontinence of Urine. — A patient is said to be suffering from 
 incontinence when the urine escapes invohmtarilv, dribbling awaj^_ 
 either constantly or intermittently from nieurellira. 
 
 I. Active Incontinence is often present in young children, mostly 
 boys. It results from some condition of increased excitability of 
 the urinary apparatus, and is looked on by some as of a choreic 
 [nature; in other instances, it is probably due to weakness of the 
 [sphincter vesicae, which is unable to resist the pressure induced 
 by even a small amount of urine. The chief sources of irritation 
 are phimosis, ascarides in the rectum, a rectal polypus, or urine 
 
1036 
 
 A MANUAL OF SURGERY 
 
 of high specific gravity, containing uric acid crystals in susp( 
 sion. The affection is most obvious at night, and, indeed, rr 
 only occur during sleep ; it has been known to persist till ad 
 life is reached. Somewhat similar in nature to this is the irri 
 bility of the bladder induced by calculus, inflammation, or ulce 
 tion, where frequent calls to micturition are experienced ; to tl 
 however, the term ' irritability of the bladder ' is applied, ' inc( 
 tinence ' being only used where no active disease of the viscus 
 present. 
 
 Treatment of the nocturnal incontinence consists in the remo 
 of all sources of irritation, such as a tight foreskin, whilst 1 
 child is waked from sleep at regular inter\'als in order to p 
 water, so as to break him of the bad habit. Tonics, e.g., ir 
 arsenic, and quinine, may be administered, and tincture of bel 
 donna should also be given in full doses. Instruments have be 
 used for compressing the urethra at night, and are stated in so 
 cases to have effected a cure. 
 
 2. Passive Incontinence is .said to be present when the neck 
 the bladder is relaxed, so that as soon as any urine is secreted 
 flows out of the urethra, the bladder in this way never becom 
 distended. It arises mainly from two causes : (a) Paralysis 
 the sphincter vesica^, as a result of some injury or disease of 
 spinal cord, which may either temporarily or permanently imp 
 its function. Thus, in severe shock, the bladder is unconsciou 
 evacuated from relaxation of the sphincter ; but if the luml 
 cord is not compressed or destroyed, the function is soon regain 
 Any lesion involving the centre for the sphincter necessa 
 destroys its future utility, and results in permanent incontiner 
 It is quite possible for the detrusor centre to be damaged with 
 injury to the sphincter, and in such a case distension of the blad 
 with subseijuent overflow supervenes. Paralytic incontine 
 occasionally follows overdistension of the female urethra for 
 removal of a calculus. Nothing can be done for either of th 
 conditions, if permanent, beyond the application of a suita 
 urinal, (b) Mechanical Incontinence sometimes results from 
 impaction of a calculus in the internal meatus, or from 
 dilatation by a pedunculated growth from the prostate. 
 
 3. False Incontinence, or Distension with Overflow, is due 
 any condition in which the outflow of urine is impeded to s 
 an extent as to lead to a certain quantity being left in the blad 
 after every act of micturition, although the patient imagines t 
 tlie organ has been completely emptied. This so-called resic 
 urine gradually increases in amount until the bladder becoi 
 filled, and then some of it dribbles away involuntarily so a.^ 
 wet the patient's clothes. In old-standing cases the bladder 
 be detected as a tense, rounded swelling in the hypogastri 
 This condition is usually met with in patients with neglec 
 stricture or enlargement of the prostate, and in the latter cast' 
 
ERY 
 
 cid crystals in suspen- 
 night, and, indeed, may 
 )wn to persist till adult 
 ture to this is the irrita- 
 nflammation, or ulcera- 
 re experienced ; to this, 
 ider' is applied, 'incon- 
 disease of the viscus is 
 
 ! consists in the removal 
 'ht foreskin, whilst the 
 ervals in order to pass 
 abit. Tonics, e.g., iron, 
 , and tincture of bella- 
 Instruments have been 
 , and are stated in some 
 
 esent when the neck of 
 any urine is secreted, it 
 his way never becoming 
 causes : {a) Paralysis of 
 I injury or disease of the 
 ^ or permanently impair 
 bladder is unconsciously 
 :ter ; but if the lumbar 
 unction is soon regained, 
 le sphincter necessarily 
 permanent incontinence, 
 ; to be damaged without 
 distension of the bladder 
 
 Paralytic incontinence 
 I female urethra for tliel 
 done for either of these 
 .pplication of a suitable 
 !times results from the 
 al meatus, or from itsj 
 1 the prostate. 
 vith Overflow, is due i 
 rine is impeded to suet 
 
 being left in the bladdej 
 :he patient imagines 
 
 This so-called nsidm 
 il the bladder becoiiK 
 y involuntarily so as tj 
 ig cases the bladder c; 
 ig in the hypogastriui 
 
 patients with neglecte 
 and in the latter case tl 
 
 ft^^l^r, P,osTArB 
 
 result of obqfr„or causes are- (t\ ri '^ smip y fro,,, , ^^ °! . 
 
 "voluntary iver*s,e" M; & ? ^'"ffle^'^&f ^ro,U:Z 
 "I a nouse-surtreon ^ •' *°^ '"stance m. • ^ ° ^^^untarvnr 
 operation for va^ricocefe f '^'f * ^"^enng C"^ ^ ^^^ °versLn 
 [^,7 hours, whereby ;:^:;^^«ftunreJieidTrr'"^?^ ^ftert 
 f<^iows cystitis, espedajU°7 ,^^^ ^"^"ced rT?. '^''" '^^^^ 
 
 I he Treatment should h T^ "^^"^^ retent on """.P^^'^'^" ^o 
 ;'>struction which ex i ."^r^cted to r.movrn '"'"^ ^" ^ 
 ^'"les a day wi'II r, ^' ^^^'^st re^uJir l^,u ^^ ^"y source ^f 
 
 r ^*"^P^°ve the exn^/c- "'""' Phospho^fc acid ^^f ^^^^' ^^^ ho 
 
 Constant current^^^Xr^^'" °^ ^he vSs '"t,°'^^^ ^°"'- 
 three times a we^t V ^^^^^"city may aJsn h ^^'^ Passaire of 
 
 He is inserted t'to^heT^;/ '^^^ntJa^r 17''^'' ^-' of 
 Wastrium. ^° ^^'^ '^^^dder, and the oth,? f ' ' °"^ e'ec- 
 
 Betention of Urine ^\v^ ^^^""^ ^^'^^ ^he 
 
 ^ congenital occlusion L^f' "''^ «''^^/'''«/ cauS ^°"ditio„s. 
 pound the Deni^ ,-^ ^ ^^^ urethra a Hrrff ' '■^•' Phimosis 
 
 Ptured urethra, ;tc^^7,VJ''"^^' "^^thraJ or 0^^^,'^^^^^ ^' 
 ^scess, tumour hvn * ". H ^''O'tatic causes .^-'".^^^ ^'^scess 
 (7. paralysis 'efe°Phy. ^^^cuJus ?' 3 ' ^£ -^-n-ation 
 Fh as occurs ^fr«. ' ^""lours, etc ■ (X^ ^ causes, cc 
 
 I (5) %*..,.■ (6) p;:;:;°f^^;;; 
 
I038 
 
 A MANUAL OF SURGERY 
 
 neighbouring organs or external tumours, e.g., uterine fibre 
 or retroversion of the gravid uterus. In investigating 
 particular case, the age and condition of the patient mus 
 taken into consideration, and also the character of any precei 
 urinary symptoms, whilst a careful examination should be m 
 Speaking generally, one may state that the most common c; 
 of retention in infants is phimosis; in children, impacted calci 
 or a ligature around the penis ; in young men, gonorrhoei 
 one of its complications ; in young women, hysteria, or for 
 bodies in the bladder ; in adult men, stricture ; in adult wor 
 some uterine condition ; and, in old men, hypertrophy of 
 prostate. 
 
 If left unrelieved, the urine accumulates and the bla< 
 becomes distended, giving rise to much pain and discomfort. ' 
 of two conditions is ceitain to follow : (a) In cases of reten 
 from stricture the dilated urethra behind the seat of obstruc 
 gives way, resulting in extravasation of urine. If, however, 
 bladder wall is weakened by the presence of sacculation, rup 
 of a saccule may follow, causing pelvic extravasation, (b) W 
 the retention arises from atony or paralysis, or from some 
 struction which can be to some extent overcome, distension i 
 overflow is produced. 
 
 Inasmuch as retention is merely a symptom, the treatn 
 necessarily varies with the cause. 
 
 Ujv, 
 
 v:^ 
 
 Abnormal Conditions of the Urine. 
 Urinary Deposits. — Uric or lithic acid is eliminated in 
 
 r^ YA.A fof"^ of ' cayenne-pepper ' granules, usually known as gra 
 
 — -— -C ^^^ microscopic examination, the granules are found to coi 
 
 Ajl^/V^\) ^^ ^'^^ rhomboidal, lozenge-shaped plates, or masses of acic 
 
 crystals (Fig. 355). They are of a dusky brownish-red colour, 
 
 ' to the absorption of urobilin, the normal pigment of the ui 
 
 / The secretion in these cases is always acid, and usually of 1 
 
 •^' specific gravity. The deposit is not soluble in boiling water, 
 
 readily so in alkaline fluids ; and on reacidulating such a s 
 
 tion, the uric acid is precipitated in the shape of white nee 
 
 shaped crystals. 
 
 Urates or litliates of potassium, sodium, or ammonium ar 
 frequent occurrence in the urine, appearing as a deposit 
 amorphous granules of variable colour, according to the anir 
 of urinary pigment present, and this is often known as a ' hit 
 tious,' or brick-dust sediment. The ammonium salt is someti 
 found in the shape of spiculated globular bodies (Fig. 3 
 Urates always occur in acid urine of high specific gravity, 
 are freely soluble in boiling water ; on the addition of di 
 hydrochloric acid the uric acid is precipitated. The mnrcxidc 
 may be applied either for uric acid or its salts ; it consist^^ 
 
BLADDER AND PROSTATE 
 
 1039 
 
 err., uterine fibroids, 
 In investigating any 
 the patient must be 
 Lcter of any preceding 
 ition should be made, 
 e most common cause 
 ren, impacted calculus, 
 a men, gonorrhea or 
 I hysteria, or toreign 
 :,;,e ; in adult women 
 .n, hypertrophy of the 
 
 lates and the bladder 
 ^n and discomfort. One 
 A In cases of retention 
 the seat of obstruction 
 urine. H, however, the 
 . of sacculation rupture 
 ;travasation. (b) When 
 lysis, or from some o> 
 vercome, distension with 
 
 symptom, the treatment 
 
 the Urine. 
 
 uid is eliminated in tk| 
 
 ually known as gravel. 
 
 lies are found to cons.; 
 
 ts or masses ot acicuU 
 ^brownish-red colour, du. I 
 
 .1 pigment of the urine 
 LFd^nd usually of hi^. 
 
 'blein^^o^^^"-r'''' 1 
 acidulating such a solu 
 
 shape of white needk I 
 
 L or ammonium are u;! 
 
 L'aring as a deposit 0. 
 :;:cording to the anuju.1 
 Vften known as a Uteri 
 Cum salt is sonietun. 
 Liar bodies (tig- 33 , 
 Igh specific gravity, jUK 
 P tlJ addition of clH 
 Itated. The murcxidc te 
 its salts ; it consists .r 
 
 mixing the substance to be tested with a little nitric acid and 
 evaporating to dryness, when an orange-red discoloration is pro- 
 duced, which on the addition of liquor ammonia! changes to a deep 
 purple-red. '^ ' ^ 
 
 A deposit of uric acid or urates is either a temporary condition 
 dependent on some trivial derangement of the system, or is a 
 phenomenon constantly recurring and due to too great an in- 
 dulgence in nitrogenous food, too little fresh air and exercise or 
 imperfect digestion, the result of some hepatic disturbance. ' It 
 is also noted in conditions where great tissue change is occurrin<f 
 as after violent exercise or in fevers. Under these circumstances 
 the materials which should be changed into urea are transformed 
 into uric acid or its salts. When such a tendency is continually 
 
 ''i'i«i.«,it',;'.; 
 
 
 •V- 
 
 
 Fig. 355. — Uric Aciij Crystals. 
 
 Fig. 356. — I'rati; ok Ammonium 
 IN Amorphous Granules and 
 Hedgehog-siiai'ed Bodies. 
 
 present, the patient is often said to be suffering from Lithiasis or 
 Lithaemia. Should the individual be incapable of eliminating the 
 material thus formed, an attack of gout or rheumatism is likely 
 to supervene, whilst it must always be borne in mind that the 
 formation of a uric acid calculus is merely a manifestation of the 
 same diathesis, which needs careful treatment after the removal 
 of the stone, if a recurrence of this painful aft'ection is to be 
 prevented. 
 
 The Treatment of litluemia or lithiasis consists mainly in atten- 
 tion to the personal hygiene. The patient's diet is regulated, all 
 I sweets, pastry, and alcoholic stimulants (with the exception, 
 [perhaps, of a little whisky well diluted with lithia or potasli 
 i water) being avoided. Regular habits are enforced, and plenty 
 of outdoor exercise recommended. Thg, hepatic secretion is 
 stimulated, and the bowels regulated by the administration of 
 saline purgatives, especially natural mineral waters, e.g., bVied- 
 Irichshall, Carlsbad, or Hunyadi Janos, whilst an occasional 
 Iclose of blue pill or podophyllin is advisable. Lithia salts and 
 |pipera/cine have also been employed with advantage. 
 
 Oxalate of lime usually occurs in the urine of dyspeptic and 
 Ihypochrondriacal patients, who are pale, nervous, and irritable. 
 
I040 
 
 A MANUAL OF SURGERY 
 
 V 
 
 It is supposed to arise from the incomplete oxidation of 
 hydrate foods. The urine is of low specific gravity, pa 
 abundant in quantity, and slightly acid in reaction ; an ex 
 mucus is usually present, causing the crystals to adhere 
 irregularities in a test glass. On microscopic examinatio 
 are found to be regular octahedra, or in the shape of dum 
 (Fig. 357). The treatment of oxaluria consists in regulat 
 
 J.I i 
 
 \ 
 
 
 Fig. 357.— Oxalate of Lime in Octahedral Crystals and Dum 
 
 SHAPED Masses. 
 
 the diet, which must be light and nourishing, all heav] 
 being avoided, as also rhubarb, which contains large quant; 
 oxalates, and the patient is directed to drink only boiled ( 
 tilled water. Tonics, such as mineral acids, iron, and qi 
 may be ordered, but the best treatment consists in change 
 and removal, if possible, from causes of anxiety and worry. 
 Phosphatic deposits in the urine occur in three forms : (i 
 triple phosphate, or ammonio-magnesic, is found in alkal 
 
 Vi> 
 
 "^MJ 
 
 \-V\r- 
 
 N 
 
 UJH 
 
 Fig. 358. — Crystals of Triple Phosphate in Urine. 
 
 decomposing urine, and is always vesical in origin. It ex 
 the form of hexagonal prisms, three of the sides, however, 
 very narrow ; the ends also are bevelled off, so that the a 
 ance of a ' knife-rest ' is produced (Fig. 358). (ii.) The amoi 
 phosphate of lime is exceedingly common, forming the 
 mass of any phosphatic sediment. It is always present in c 
 cystitis, and is not unfrequently met with a few hours i 
 meal, constituting what is known as the 'alkaline tide.' 
 condition is often observed about twelve o'clock in the mc 
 especially if an alkaline salire purgative has been taken 
 breakfast. The phosphatic material is voided at the end 
 act of micturition, and may give rise to considerable a 
 
ERY 
 
 BLADDER AND PROSTATE 
 
 104 1 
 
 Dlete oxidation of carbo- 
 leciiic gravity, pale and 
 n reaction 
 :rystals to . _ 
 ,scopic examination they 
 the shape of dumb-bells 
 consists in regulation ot 
 
 an excess of 
 adhere to any 
 
 ^j.» 
 
 ^L 
 
 Crystals and Dumb-bell 
 
 ourishing, all heavy food 
 contains large quantities o!| 
 o drink only boiled or dis 
 il acids, iron, and quinine 
 It consists in change ot ai:| 
 ^f anxiety and worry. 
 
 three forms: (1.) Hn 
 found in alkaline 0; 
 
 lir in 
 ic, is 
 
 ) 
 
 l^HOSPHATE IN UrINE. 
 
 ical in origin. It exists 
 [f the sides, however, beii 
 led off, so that the appeal 
 .cS). (ii.) The amorphov 
 kmmon, forming the mai 
 Is always present in chroi 
 with a few hours after 
 the 'alkaline tide.' n\ 
 Ive o'clock in the morninj 
 ive has been taken betoj 
 is voided at the end ot ta 
 to considerable anxief 
 
 on the part of the patient, who mistakes it for seminal fluid. 
 (iii.) The most usual condition in which phosphates are met with 
 in urine, is a mixture of the two varieties described above. Which- 
 ever form is present, the deposit becomes more evident on boiling, 
 disappearing, however, on the addition of a few drops of acid', 
 riie treatment of phosphaturia is always directed to the vesical 
 condition, except in those unusual cases where it is due to some 
 constitutional error. 
 
 2. Haematuria, or the admixture of blood with the urine, is 
 best descr oed according to the source from which the blood 
 is derived. 
 
 (a) Renal haematuria results from acute inflammation, conges- 
 lon, calculus, tumours, or injuries of the kidney. The urine is 
 
 [sometimes deeply coloured with the blood, and may be as dark 
 s porter. Blood casts of the renal tubules are often observed, 
 nd even long sinuous clots, corresponding to the shape of the 
 ureter. 
 
 (b) Vesical haematuria is due to injury, calculus, tumours, ulcera- 
 lon, simple congestion of the bladder with varicosity of the 
 esical vei.is, or the presence of the Bilhavzia hamatohia. The 
 lood is intimately mixed with the urine, but is more abundant 
 ,t the end of micturition, and clots are often present. 
 
 The^_Bilhav2ia is a parasite which inhabLts_SQme of the rivers 
 
 Tid ,p.QoLs Qf..SQiitll.Afrjca- It is taken into the system by the 
 
 pouth, and may develop either in the urinary track, or sometimes 
 
 the lower bowel (p. 978). The adult worms are found in the 
 
 ody inhabiting the radicals of the portal and vesical veins, and 
 
 ischarge their ova through the mucous membrane of the bowel 
 
 r bladder, giving -ise to haemorrhage. By an extension to the 
 
 idney, pyonephrosis may be induced. No specific treatment 
 
 as at present been discovered, but in most cases the disease 
 
 fter a time disappears spontaneously. 
 
 (r) Prostatic haematuria may be caused by congekion, calculus, 
 
 keration, or malignant disease ; the blood passes back into the 
 
 ladder,. and hence the phenomena simulate the \esical condition. 
 
 xamination of the prostate from the rectum may, however, give 
 
 clue to the source of the mischief. 
 
 (rf) Urethral haematuria arises from acute gonorrhu-a, laceration, 
 instrumentation. The blood often flows from the urethra in- 
 pendently of micturition, whilst the first few drops of the stream 
 e also coloured. 
 
 [i) Haematuria is occasionally of constitutional origin, arising 
 ni purpura, scurvy, or haemophilia ; other evidences of these 
 tseases will be observed, and render the diagnosis evident. 
 Microscopical examination of the urine should always be made 
 ascertain whether or not blood corpuscles are present, since 
 condition may be simulated by that known as ' paroxysmal 
 moglobinuria,' in which corpuscles are absent. The latter 
 
 66 
 
I042 
 
 A MANUAL OF SURGERY 
 
 condition is supposed to be due to vaso-motor spasm of the 
 vessels, and is not unconnnonly associated with Raynaud's dis 
 
 The only certain test for the presence of blood is by spec 
 analysis ; but that most usually relied on consists in m 
 together equal parts of tincture of guaiacum and ozonic e 
 The suspected urine is subsequently added, and sinks to 
 bottom of the test-glass ; a copious precipitate forms at the 
 of junction of the two fluids, which on standing becomes a i) 
 blue colour if blood is present. 
 
 The investigation of a case of ha^maturia in order to asce 
 its origin should be conducted in the following way : {a} 
 history of the patient and of his urinary trouble should be tc 
 
 (b) The character of the urine should be investigated, notin 
 colour, and whether or not the blood is intimately mixed wi 
 
 (c) The relation of the passage of the blood to the act of mic 
 tion should be noted by making the patient pass the first anc 
 portions of the urine into separate vessels from that in whic 
 passes the bulk ; if the urine in all three vessels is equally 
 coloured, the ha;morrhage usually comes from the kidney; 
 most of the blood is in the first vessel, it comes from the ur( 
 or prostate, whilst if the bulk of it is contained in the last vt 
 it is probably derived from the bladder, (d) Microscopica 
 amination of the urine may lead to the discovery of shrec 
 tumour, epithelial cells, or blood-casts, which could be r 
 derived from some special part of the urinary track. By t 
 means the source of the haemorrhage, whether from kid 
 bladder, prostate, or urethra, may be detected, and an opi 
 formed as to the nature of the disease. 
 
 3. Pyuria is the term applied to the admixture of pus or ni 
 pus with the urine. It always results from inflammatory a 
 tions of the mucous membrane lining the urinary passages, 
 may be renal, vesical, prostatic, or urethral in origin ; the met 
 of investigation, in order to ascertain its exact source, are 
 same as for haematuria. 
 
 Pus in urine is mainly recognised by the microscope, whil;: 
 the addition of litiuor potassae it becomes ropy. 
 
 4. Chyluria arises from distension or rupture of the lympl 
 vessels in the vesical mucous membrane, and is usually du 
 the presence of the Filaria sanguinis hominis (p. 288). The i 
 is milky in colour, and on microscopical examination this is k 
 to be due to the presence of an emulsion of fat. 
 
 5. Albuminuria, or the escape of some of the albumii 
 contents of the blood with the urine, is a condition of ! 
 frequent occurrence, and so important in its results, that 
 precaution should always be adopted of testing the urine of e 
 patient before attempting any operative proceedings ; and th 
 the more essential because it is well known that this condi 
 often exists quite unexpectedly and entirely apart from symptc 
 
GERY 
 
 motor spasm of the renal 
 d with Raynaud's disease. 
 3 of blood is by spectrum 
 d on consists in mixinj^ 
 liacum and ozonic ether, 
 added, and sinks to the 
 cipitate forms at the hue 
 tanding becomes a brij^'ht 
 
 :uria in order to ascertain 
 following way ; (a) The 
 
 ^^^DDER^^^ PjiOSTATE 
 
 '043 
 
 loiiowmg way ; [^a) 1 m 
 trouble should be taken, 
 )e investigated, noting its 
 intimately mixed with it. 
 ood to the act of micturi- 
 ent pass the first and last 
 !ls from that in which he 
 ■ee vessels is equally dis- 
 les from the kidneys ; if 
 it comes from the urethra 
 ntained in the last vessel, 
 r. {(i) Microscopical ex- 
 le discovery of shreds of 
 ;, which could be alone 
 urinary track. By these 
 3, whether from kidnev. 
 detected, and an opinion 
 
 dmixture of pus or nuico 
 from infiammatory affec- 
 he urinary passages, and 
 ral in origin ; the methods 
 its exact source, are the 
 
 the microscope, whilst oc 
 5 ropy. ' 
 
 rupture of the lymphatic 
 le, and is usually due to 
 ninis (p. 288). The iirinfj 
 examination this is founiij 
 I of fat. I 
 
 lome of the albuminooil 
 , is a condition of siicir 
 : in its results, that m 
 testing the urine of c\wj 
 proceedings; and thisii 
 :nown that this conditioJ 
 ely apart from symptonisJ 
 
 •Tests Man v r If ff ~ '""^ 
 
 forms, lit\o",,;.;-Py '/°.^'-^^ the urnei":;;? '7'- '^— '« 
 ^he latter, ho vever'diln ''' ''^^"^^^ by Tn excl^ /"'l'^^ ^^P"^it 
 ^Jrop of d Jute acefi'r 'fP'^'^ entirely on "he "flir^ ''''^■'^P^^''^^^''^ -• 
 '^cid gives Jh! f'^'' '^^''^^t the former ^ ^^•^'°" "^ '"^ ^'n^'le 
 
 ^•^cess, as the deposi?L^ ^'^'^' '-^"^ ^'^e acid ^"h P'-^^'P'^'-^te. 
 consists in pounW H ^ ,^^^ re-dissolxed T '^^^^d- nit not in 
 adding the acic..^ ^^^ ^°^^ "''ine into a 'teswT' '^""^'^^^^ test 
 
 '•ne of jt.:ct,o 'onlTe t^"^ -tratunVVeW^te u?i' ^^'^^^^"'/^ 
 present. (:>) Whh ' ^ ^^^'te film is form i /,""'' '^^ the 
 
 ascertained if^ .^ existence of albumen in fi, 
 
 A carefu mSorcooic f"^ ^^^ -^-^^"i^can e "nu T 1.^^"' ''''' '^^-" 
 as to determ nf. wi P., ^' ^-^amination of the s^;^ '"^est.gated. 
 
 «f the puJse shnnif 1 '^^oodxessels in the limh«? ? V ^'^^ ^"n- 
 
 patient.^ '^°"^^' ^^^ "«ted, as also he p^evion k'-^' '^'''''''^' 
 
 Albuminuria an. f ^''°''>' ^'^ '^'^ 
 
 »" early*' "S of 'if" '" ^°'°". "nd with b f f"""' '^ "' '°^' 
 
 66-2 
 
I044 
 
 A MANUAL OF SURGERY 
 
 diet so to diminish it as to warrant the performance of shg 
 operations ; init where the condition is at all advanced, i 
 operations de complaisance are al)Solutely contra-indicated, and on 
 the chief surgical emergencies should be knowingly dealt wit 
 viz., haemorrhage, asphyxia, intestinal obstruction or strangul 
 tion and retention of urine. In cases of severe injuries, amput 
 tion is generally indicated under circumstances where in a healtl 
 individual conservative measures would be adopted. Operati( 
 for malignant disease may be undertaken at the express wish 
 the patient, if the increased risks associated with it ha\ e been e 
 plained to him. The importance of not operating on these patien 
 depends on the facts that they tolerate an anaesthetic badly, th 
 the tissues are in a condition of lowered vitality, and hence tl 
 process of repair is hindered, septic inflammations and erysipel 
 are very prone to develop, whilst secondary haemorrhage is like 
 to follow, owing to tlie liigh pulse tension. Again, boils ai 
 carbuncles are \ery common in these patients, and where sue 
 conditions are met with, and especially if they recur, the urii 
 should always be examined. (4) Albuminuria may arise 1 
 extension of inflammation to the kidneys from surgical affectioi 
 of the lower urinary organs, and a fatal result from shock or su] 
 pression of urine may be induced by operations under these coi 
 ditions. (5) It is occasionally the result of cardiac disease, owir 
 10 valvular incompetence and regurgitation into the system 
 veins, and it is then advisable to delay all operative measun 
 until digitalis has been administered in sufficient doses to allevia 
 the urgent symptoms. 
 
 6. Diabetes. — Thf^ presence of sugar in the urine is also a matt( 
 of the greatest importance from a surgical stand[ int, and i 
 existence or not should always be carefully ascertained. Tl 
 chief tests employed are as follows : (i) Equal parts of liquc 
 potassae and solution of copper sulphate are boiled together, an 
 then a few drops of the suspected urine added ; if sugar is presen 
 a yellowish-red precipitate forms by the reduction of the cupr: 
 salt to cuprous oxide. (2) The same result follows the use c 
 Fehling's solution. It is better to keep the copper solutio 
 separate from the potash ; equal parts of them are boile 
 together, and a few drops of the urine added ; if sugar is presen 
 a red deposit occurs. (3) Picric acid and liquor potassae ar 
 mixed and boiled, and the urine added ; the presence of sugar i 
 indicated by the solution turning to a dark, blackish-red coloui 
 The admixture of 2 grains of sugar to the ounce is sufficient t 
 determine this discoloration to such an extent as to render th 
 fluid quite opaque. 
 
 The effecjj if diahntnn i" very similar to that of albuminuria, i: 
 
 Jljat-iLieaJstorlimimsllfid. vitality of th e tissues,^ arid consequentl; 
 
 predisposes to_ the occurrence of sepsis, and oT" suc!r"TriTectiv( 
 
 mHamn:jatlQn&-a& KATIaanff 7-ffrKnnyips.l ^'^"p^^^^^ nPiTniFk am 
 
 <^iw!ili- 
 
BLADDER AND ['HOST ATE 
 
 1045 
 
 •formance of sUrM 
 
 all advanced, an 
 .indicated, and only 
 oNvingly dealt with, 
 action or stranguU- 
 •re injuries, atnputa- 
 .^ where in a healthy 
 aoopted. Operation 
 
 the express wish ol 
 with it have been ex- 
 ing on these patients 
 "neesthetic badly, that 
 tality, and hence the 
 ations and erysipelas 
 
 hemorrhage is hkel, 
 n Again, boils and 
 ents, and where such 
 
 the; recur, the urine 
 anuria may arise I'V 
 
 om surgical affections 
 ,ult from shock or sup- 
 aions under these con- 
 
 cardiac disease, onmh!^ 
 ion into the systennc 
 ' ai operative measures 
 
 den\ doses to alleviate 
 
 [e urine is also a matter 
 ':al standi >nt and it 
 lUv ascertained, me 
 
 Ire boiled together, and 
 ed ; if sugar is present, 
 eduction of the cupnc 
 Ith follows the use ot 
 b the copper sohn_>.. 
 '^of them are boiler 
 ^ed ; if sugar is present^ 
 
 nd liquor potasss are 
 fepre^sence of sugar . 
 
 rk blackish-red colour. 
 
 founce is sufhcient M 
 ,xtent as to render tne| 
 
 that of albuminuria, in 
 
 tSres"andconsequenl)l 
 |sueSiau_^^ .^1 
 
 [and ot sucn _i". , 
 VpEiTarHiiSTtis and 
 
 ^erit 
 
 sclerosis of the smaller vessels are also induced by this disease 
 in tlie later stages, a.ndJigiicc-Kan^reue of the extremities is likely 
 t.o-o€C»r, especially in chronic cases and in elderly penple; -The 
 essential cause of troul)le, liowever, is se psis, and hence if the 
 most rigid aseptic precautions are taken there is no reason why 
 operative proceedings should not be undertaken in conditions of 
 danger and urgency. Thus several cases have been reported 
 lately in which such serious proceedings as total removal of the 
 breast and axillary contents for scirrhus, or appendicectomy, have 
 been safely undertaken in confirmed diabetics. 
 
 Stone in the Bladder. 
 
 Varieties. — A vesical calculus may be formed of almost any of 
 the unnaFy deposits commonly met with, and each has its own 
 special characteristics. " " 
 
 (a) The lii'ic m/'^rcalculus (Fig. 359) is usually an oval, flattened 
 
 A 
 
 Fig. 359. — Uric Aciu Calculus in 
 Section. 
 
 H 
 
 Fig. 3G0, — Ox.\LATE ok Lime 
 Calculus from Outside ami 
 ON Section. 
 
 ibody of considerable density, with a smooth or slightly nodular 
 
 surface, and of a nut-brown colour. On section it is distinctly 
 
 I laminated, and it may be surrounded by a crust of phosphatic 
 
 ImaferialT . 
 
 [b) The imitc of ammomnm calculus is of very similar structure, 
 
 but of a lighter colour, and the lamination is less distinct. 
 
 , (f) The oxalate of lime or mulberry calculus (Fig. 360, A and 13) 
 
 is a rough, irregular body, sometimes evenly nodular, but not 
 
 lunfreciuently tuberculated, or even spiculated. It is extremely 
 
 Ihard and dense, laminated, and of a dark red-brown colour, or 
 
1046 
 
 A MANUAL OF SURGEIiY 
 
 sometimes black, owinfj; to admixture with blood. It is tare 
 }^'reat size, on account of the irritation caused by its presence, 
 its slowness of },aowth. 
 
 (d) A pure phospliatic calculus is very vincouimon, but any i 
 or foreign TK3tty~ts certain to become coaied with a phosp 
 deposit when chronic cystitis has resulted in alkaline deronipos 
 of the urine. Occasionally concretions of a similar nature 
 ff]")Ontaneously in saccules of the bladder ; such bodies are \ 
 and chalky in appearance, friable in consistency, with no evidt 
 or but little, of lamination, and on removal are exceedi 
 offensive. These concretions consist of a mixture of the t 
 phosphate and phosphate of lime. Less commonly an exce 
 the triple phosphate is present ; if in the proportion of two f 
 of the latter to one of phosphate of lime, a laminated and sc 
 what denser calculus is produced, which is sometimes ternn 
 fusible calculus, owing to the fact that it fuses to a bead under 
 blowpipe flame. Occasionally a phosphate of lime calculus oc 
 in the upper urinary passages, e.f^., the pelvis of the kidney, 
 has a crystalline appearance on drying. 
 
 (e) Cystine forms the basis of a rare calculus which is 1 
 yellowish-green colour and waxy appearance. 
 
 (/) Xauthiue, or xanthic oxide, occurs very exceptionally 
 calculus of a reddish colour. 
 
 Striictiire of. _a Calculus. — A calculus usu^ajly; consists _i}f 
 following parts : i. The nucleus, which may be formed^ by a por 
 of J.)lQD4-GlQt, insp|ssated__muciis, a renal calculus, or some for 
 substance introduced from wjthout. 2. The iJocly, which con: 
 of superposed layers of uric acid or oxalate of lime, or of whati 
 substance the stone is composed ; not unfrequently the comj 
 tion of adjacent lamina' differs, leading to what is known a.' 
 alteynating calculus. Each lamina consists of myriads of mii 
 crystals, held together by vesical mucus, with which a cer 
 amount of phosphatic material is often mixed, whilst layers of 1 
 phosphatic deposit may be interposed. 3. The crust consists 
 variable amount of soft, friable phosphatic material, the cjuar 
 of which is the measure of the degree of chronic cystitis origin 
 by the calculus ; in some cases it is entirely absent. 
 
 The Number of calculi present in a bladder varies gre; 
 Sometimes there is only one, but a considerable number, cou; 
 perhaps by hundreds, may exist ; in such circumstances they 
 never of great size. Multiple calculi are not unfrequently fac 
 as a result of mutual friction. 
 
 The Causes of vesical calculus must be looked for in som 
 those constitutional conditions already described as predispo 
 to lithiasis or oxaluria. They are very common in children du 
 the first decade of life, especially amongst the lower classes, 
 children of the rich rarely suffering from stone. It diminishe 
 frequency from childhood to the age of twenty-five, and t 
 
blood. It is rarely of 
 id by its presence, and 
 
 ;oniuion, but any stcmc 
 
 Led Willi a pliosphalu' 
 
 alkaline deccnnposition 
 
 a similar nature torni 
 
 such bodies are white 
 
 tenry.Nvithnoevidencj', 
 
 noval are exceedmK > 
 I mixture of the triple 
 commonly an excess oi 
 proportion of two parts 
 a laminated and some- 
 is sometimes termed u 
 ises to a bead under th( 
 e of lime calculus occurs 
 lelvis of the kidney, and 
 
 calculus which is of a | 
 
 mce. . n 
 
 very exceptionally as a 
 
 usually consists. fll the 
 av be formecTby a portion 
 Calculus, or someiojreign 
 The Tw^;', which consists 
 ie of lime, or of whatever 
 'nfre(iuently the composi 
 to what is known as ar 
 6ts of myriads of minuit 
 ,;, with which a certair 
 \ed, whilst layers of pure I 
 . The crust consists ot a I 
 'ic material, the quantity 
 ^hronic cystitis ongmalei.| 
 
 [ely absent. 
 
 bladder varies greatly. 
 lerable number, countid 
 li circumstances they are 
 ' not unfrequently facetec 
 
 Le looked for in some oi 
 lescribed as predisposing 
 Immon in children durmJ 
 Ist the lower classes, tl;^ 
 (stone. It diminishes It 
 If twenty-five, and thw 
 
 BLADDER AM) rROSTATE 
 
 1047 
 
 [gradually increases until it is fairly common in elderly men. 
 The condition is c()uiparati\(ly rare in women, owing to 
 the fact that the shortness and large si/e of the urethra allow 
 small calculi to be murh more readily passed. Possibly the 
 character of the drinking water, or the amount imbil.ed', is a 
 matter of importance, as indicated by the fact that tlie occurrence 
 of calculus is very unetpially distributed in ditferent parts of the 
 (ountry ; tl.us, it is most frecpiently met with in tlie [eastern 
 counties. It is also very common in India and Arabia, a fact 
 which may be e\[)lained by the large amount of lluid withdrawn 
 from the body by perspiration. 
 
 Symptoms. -The effects produced by vesical calculi vary in 
 
 (liffeient individuals, according to the shape of the stone, and 
 
 the tolerance of the mucous membrane. In children and young 
 
 adults, where the parts are \ery sensitive, even a smootli calculus 
 
 <,Mves rise to seveie symptoms, whilst old men often tolerate a 
 
 hirge stone without much inconvenience ; catevis paribus, an oxalate 
 
 of lime calculus is always more irritating than one composed of 
 
 uric acid. The classical symptoms of a vesical calculus may be 
 
 preceded by a history of the patient ha\ ing passed ' gravel ' for 
 
 a long time, on the cessation of which the calculous symptoms 
 
 conimenred. They consist of pain in the perineum and neck 
 
 of the bladder, which radiates to the back and down the thighs, 
 
 hut is especially noticed at the end of the penis immediately after 
 
 micturition. The stone is th m pressed down against the sensitive 
 
 neck of the bladder by the contraction of its muscular walls. 
 
 Increased fref]^ie;jicy of micturition is also present, and perhaps 
 
 ha;maiurTa'6F a vesical type, though this is not a prominent 
 
 fj;atu«i^_ All these phenomena are increased in se\erii\ bv jolting, 
 
 jumping, or any form of exercise, and hence are moii' marked 
 
 during the day than at night. (Occasionally the patient complains 
 
 that the flow of urine suddenly ceases before the bladder lias been 
 
 completely emptied, and that some change in the position of the 
 
 hody is needed in order to allow him to complete tlie act. In 
 
 addition to these characteristic symptoms, he may suffer from 
 
 various phenomena secondary to the irritability of the bladder, 
 
 and depending on the straining induced by the calculus. Thus, 
 
 tenesmus, followed by piles or prolapsus ani, may be produced 
 
 hy sympathetic irritability of the rectum, especially in children ; 
 
 whilst a hernia may also be caused, and not unfrecpiently 
 
 priapism. 
 
 The symptoms are somewhat modified in children, leading to 
 irritability of the bladder, as evidenced by wetting of their clothes 
 and of their beds at night, and pulling at the prepuce and penis. 
 These manifestations are very similar to those caused by a tight 
 foreskin, with which condition, indeed, a stone is often associated ; 
 hence, it is important always to sound the bladder of a child after 
 jcircumcision for phimosis. 
 
1048 
 
 A MANUAL OF SUHGERY 
 
 Tlie iictual Diagnosis of \esical calculus can only be made 
 sounding. In order to accomplish this, the patient is laid 01 
 couch with the head low, and the buttocks raised on a pill 
 placed beneath them. The bladder should always contain a 
 ounces of Muid, so as to obliterate any folds produced by lax 
 of the mucous membrane, as well as to facilitate the introducti 
 of the instrument. A soured of suitable size, w.irmed and lul 
 cated by some antiseptic oil or ointment, is then gently pass 
 along the urethra, and depressed betwt en the separated lej^s so 
 to enable it to enter the bladder. The handle of the i'lstrume 
 which should be cylindrical in shape and tinted, with the make 
 name or some mark to indicate the direction of the beak, is tb 
 lightly grasped between the index-finger and thumb, and rota 
 from side to side, whilst at the same time the whole instrum« 
 is drawn forwards or backwards in the urethra, li^ach side 
 the bladder is thus carefully investigated, and, finally, if no st( 
 is detected, the beak is turned directly downwards, so as 
 examine the pouch which often forms behind a slightly enlar<j 
 prostate. The presence of a stone is recognised by a metal 
 click, which can be felt, and even heard, when the end of t 
 instrument taps it. The character of the click is some guide 
 the size and density of the stone. The presence of two or \m 
 calculi is indicated by the surgeon being able to touch them 
 rotating the instrument alternately to each side of the middle lii 
 or by seizing one stone with a lithotrite, and using it as a sou 
 for the other. In doubtful cases, a still more delicate test than t 
 sound is obtained by passing a medium -sized tube of a Bigelov 
 evacuator, and washing out the bladder. The calculi may 1 
 this means be washed out even from sacculi, and be felt to rati 
 against the end of the instrument when the pressure upon t 
 indiarubber bulb is relaxed. When the calculi are multif 
 and of small size, they may be even removed in this way 1 
 an examination which was only intended to be diagnostic 
 chariicter. The surgeon must not forget that a hypertrophi 
 bladder with projecting fasciculi may somewhat resemble a c< 
 cuius, especially when coated with phosphatic material, 
 some rare instances a calculus may be so completdy hidden 
 one of the saccules as to render its detection impossible by the 
 means. 
 
 Course of the Case. — A patient suffering from vesical calculus 
 certain, sooner or later, to de\elop symptoms of chronic cystit 
 and septic changes in the urine are etjually sure to follow- 
 possibly as a natural sequence, but more probably as the resi 
 of the introduction of septic instruments. The bladder is hyp« 
 trophied, and if the stone is not removed, the mucous mei 
 brane becomes ulcerated, and the inflanunation ex*^ends to t 
 kidneys ; the patient's life is thus destroyed partly by exhaustic 
 and partly by septic or urannic poisoning. Occasionally a cak ui 
 
HLADDF.R AND I'HOSTATE 
 
 1049 
 
 xn only be tuade by 
 patient is laid on a 
 s raised on a piUow 
 always contain a lew 
 s produced by Uixi^y 
 itate the introduction 
 t;, Nv armed and lubn- 
 s then j^ently passed 
 e separated le^'s so as 
 lie of the instrument, 
 ited, with the maker s 
 n of the beak, is then 
 nd thumb, and rotated 
 the whole instrument 
 irethra. l':ach side ol 
 nd, tonally, if no stone 
 downwards, so as to 
 nnd a slik'htly enlarged 
 ■o^nised by a metal ic 
 when the end ot the 
 click is some guide to 
 resence of two or more 
 able to touch theni on 
 side of the middle hue, 
 ,ul using it as a sound 
 Ire delicate test than tlie 
 .ed tube of a Bigelow s 
 ' The calculi may by 
 uli, and be felt to rattle 
 , the pressure upon tht 
 e calculi are multiple 
 Loved in this way by 
 d to be diagnostic in 
 ' that a hypertfopbied 
 ,ewhat resemble a ciil- 
 )sphatic material. In 
 io completdy hidden m 
 
 lion impossible by tliese 
 
 Ifrom vesical calculus i> 
 Ims of chronic cystitis 
 lually sure to follow-- 
 1 probably as the result 
 i The bladder is hyper- 
 led, the mucous meiii- 
 Imation extends to lH^; 
 t partly by exhaustion. 
 
 [occasionally a calculus 
 
 becomes encysted in the saccule of a dilated bladder; it increases 
 in si/.e only on that part of the stone wliich is exposed at the 
 mouth of the saccule, and hence may become . — —.^ 
 more or less mushroom-shaped. It is recog- 
 nised by the sound always striking it in the 
 same situation. 
 
 The Treatment of \esical calculus is a matter (>• 
 which has exercised the judgment and nianipu- 
 lati\e dexterity of surgeons f(jr many generations. ^ 
 
 A large number of operations have been made 
 use of, hut at the present day only three are 
 employed, \iz., lithotrity, lateral lithotomy, and 
 suprapubic cystotomy. 
 
 Lithotrity was formerly conducted at several 
 sittings, the stone being crushed, and tlv: patient 
 allowed to pass the debris subsecjuently ; this 
 process was repeated at intervals of a few 
 clays, until the bladder was clear. Such a 
 proceeding took a considerable time, and was 
 exceedingly painful, irksome, and dangerous to 
 the patient. The introduction of Higelow's 
 evacuator completely revolutionized this opera- 
 tion, and enables it to be completed at one 
 
 silting, constituting the proceeding sometimes 
 
 termed Litholapaxy, 
 Operation. — fhe patient is carefully prepared 
 
 by keeping him under observation for a few 
 
 days, regulating the bowels, and, if possil)le, 
 
 reducing any inflammation of the bladder by 
 
 suitable diet and drugs, and by washing it out. 
 
 On the preceding night a dose of castor-oil is 
 
 administered, and an efficient enema a few hours 
 
 before the operation. The patient should be 
 
 warmly clad, and the legs enclosed in thick 
 
 worsted stockings reaching nearly to the groins. 
 
 After anaesthesia has been induced, the head is 
 
 kept low, and a pillow placed beneath the 
 
 buttocks, so as to slightly raise the pelvis. The 
 
 bladder is carefully washed out with some bland 
 
 antiseptic, such as a solution of boric acid, and 
 
 about 6 ounces of lotion left within it, in order 
 
 not only to obliterate all folds of mucous mem- 
 brane, but also to facilitate the seizure of the 
 
 stone, and to prevent injury of the walls during 
 
 the operation. 
 The lithotrite is then introduced. The best instrument to 
 
 employ is Thompson's modification of Civiale's (Fig. 361), the 
 
 male blade of which is solid, and the female fenestrated. Other 
 
1050 
 
 A MANUAL OF SURGE NY 
 
 forms are sometimes used in which the female blade is solid, al 
 is either the same size or larger than the male, in order to prot( 
 the walls of the bladder from injury. The male blade slic 
 eiisily up and down a groove in the stem of the female blade, a 
 after the stone has been seized, the blades are forcibly press| 
 together by a screw action, brought into play by the mechanic 
 in the handle, which can be put in and out of gear at will. It 
 absolutely essential that the instrument should be made of wel 
 tempered steel, so a to prevent any risk of breaking during tl| 
 operation. To introduce it some skill is needed, since the cur\( 
 end is short, and consecjuently the handle must be well depresst 
 between the legs, in order that the beak may pass under til 
 pubic arch. The position of the stone is next ascertained if 
 
 Fig. 3G2. — ICvACL'ATOK i>t Position in tiii: r>i.,\nin:R 
 
 rotating the mstrument ; the blades are opened, ami the stone 
 caused to roll between them by a sliglit jerk of the handle. This 
 is better than attempting to pick up the calculus by invcrtini,' 
 the blades, and is less likely to injure the mucous membiaiiL', 
 If fairly grasped, the blades when screwed up crush it into 
 several fragments, each of which is subse(juen.ly cealt with in a 
 similar fashion. If only the margin of the stone is gripped, tlie 
 ap|)lication of screw pressure may cause it to slip away, and the 
 mand'uvre must then be carefully repeated. When the surgeon 
 is satisfied that the fragments are sufficiently small, the largest 
 evacuator-tube that can be safely introduced is passed into the 
 bladder. To effect this, it is sometimes necessary to incise the 
 urethral orifice with a bistoury in a downward direction. The 
 evacuator is attached to the tube, and tie bladder thoroUf^lilv 
 washed out by alternate pressure upon, .'uul relaxation of, the 
 rubber bottle. l>y this means the fragments of the stone are 
 
BLADDER AXD PROS r ATE 
 
 lOsI 
 
 e blade is solid, and 
 :, in order to protect 
 e nude blade slides 
 le female blade, and 
 are forcibly pressed 
 f by the mechanism 
 .f ^rear at wdl. It is 
 uld be made of well- 
 breakin^ during' the 
 Jed, since the curved 
 jst be well depressed 
 may pass under the 
 next ascertained by 
 
 pened, and the stone 
 [of the handle. This 
 lalculus by inverting; 
 mucous membrani'. 
 ^d up crush it into 
 [endy cealt with in a 
 Istonc IS gripped, thf 
 Ito slip away, and the 
 When the surt,'("(ni 
 [ly small, the lari;cst 
 [d is passed into tiu' 
 pessary to incise tlir 
 v-ard direction. 'I'l'^' 
 bladder thorou^^hly 
 id relaxation of, tin' 
 Its of the stone arc 
 
 collected in the glass receptacle which forms part of the appar- 
 atus. The washing is continued until no more fragments are 
 heard or felt to rattle against the end of the tube. It is often 
 necessary to reintroduce the lithotrite in order to crush some 
 larger portions of the calculus still remaining; tlie old practice 
 of withdrawing small fragments within tl.3 grasp of a litht)trite 
 is to be condenmed. It is scarcely necessary to re-sound the 
 bladder after the efficient use of the evacuator. A certain amount 
 of bleeding is indispensable from these manipulations, but it is 
 not excessive in careful hands. Should, ho\ve\er, considerable 
 bleeding follow, the bladder is likely to become subse(iuentlv dis- 
 tended with clots, necessitating the use of a large-eyed catheter 
 for their removal 
 
 After-Treatmeut. — The patient is placed in bed as soon as the 
 operation is completed, and kept warm ami quiet, and suitable 
 measures nuist be taken to combat shock. The diet is restricted 
 to fluids for a few days, whilst pain, if complained of, may be 
 relieved by a little morphia. If all goes well, he may be allowed 
 to get up at the end of the week. 
 
 N'arious SequelfC may follow this operation. Cystitis results 
 partly from mechanical causes, but more fre(|uently from imper- 
 fect asepsis. The symp*;oms are usually subacute in character, 
 and may pass away after a few days; but if due to sepsis, 
 considerable; constitutional disturbance arises, and a large amount 
 of viscid muco-pus is excreted, whilst the urine becomes alkaline 
 and ammoniacal. In such a case it is absolutelx' essential to 
 wash out the bladder once or twice a day, as if left to itself 
 the condition is very liable to spread up to the ureters, and may 
 destroy the patient's life by suppurative pyelonephritis. Atony of 
 (he hladdcr is occasionally induced, either by the operation or by 
 a consei[uent cystitis, and is especially conunon in elderly indi- 
 xidua''^ It must be treated by regular and aseptic catheterism. 
 W'hc.i ti e patient's kidneys are already afTe' '''d prior to the 
 operation, any of the conditions described under urinary fcvcy 
 'n. 077) may be originated by it, even including suppression of 
 urine. 
 
 Lateral Lithotomy is an operation which has always been of 
 l^reat interest to the surgeon, although at the presimt day it is 
 comparatively seldom performed. The patient, ha\ ing been suit- 
 ably prepared, is ana-sthetized, and the perineum sha\e(l. A 
 sound is passed so as to make certain of the presence of the 
 calculus, and the bladder washed out, about (> or 7 outices of an 
 antiseptic solution being left in. A hilly curved stafV, grooved 
 on the left side, is introduced and handed over to the care of a 
 trustworthy assistant. The patient is then, and not till then, 
 placed in the lithotomy position, i.e., his hands and ankles are 
 approximated and held together by bandages or suitable shackles ; 
 a Clover's crutch is usehd when the surgeon has not plenty 
 
1052 
 
 A MANUAL OF SURGERY 
 
 of help. The staff is held in the assistant's right hand, the 
 hand being used to support the scrotum ; the operator usi 
 prefers the staff to be held well up under the arch of the pi 
 As a final preparation before commencing, the le*"t index-finge 
 inserted into the rectum, partly in order to ascertain the d 
 of the perineum, and partly to see that the bowel is empt>, 
 to induce contraction of its walls, and thus minimize the 
 of injury by the knife. Of course the finger is aL..'rwards c 
 fully purified before placing it in the wound. 
 
 The superficial incision (Fig. 364) commences at a poin 
 
 X= 
 
 1 
 
 Fig. 3GJ • -Knifk, Staff an'o roucEPs used in Lateral Lithotomi 
 
 (Down Bkcthers.) 
 
 J^nchesijiij:Qjlt_QLt]ie_anuSj a little to the left of the central rap 
 "and extends downwards and oufwards" to a spot just external 
 jlie middle of a line from the anus to the tuber ischii, be 
 deeper behind than in front, and dividing the skin, subcutane 
 tissue, and inferior lia^morrhoidal vessels and nerves. The 
 cision is carefully deepened by the section of any resisting ba 
 until the transverse perineal nerves and vessels are cut throu 
 as also the deeper layer of superficial fascia and anterior layei 
 the triangular ligament, which are continuous around the tra 
 versus perinei muscle. The left index -finger is then pushed 
 into the wound, so as to ascertain the position of tlie staff, ; 
 the knife is carried on towards it, and made to enter the groi 
 at a pcjint corresponding to the membranous portion of 
 urethra (I'^ig. 3^\5). When once the knife is felt to be well 
 
RY 
 
 BLADDER AND PROSTATE 
 
 »oSJ 
 
 t's right hand, the left 
 ; the operator usually 
 the arch of the pubes. 
 the le'^t index-finger is 
 to ascertain the depth 
 le bowel is empt> , and 
 hus minimize the risk 
 ger is a*.jrwards care 
 
 id. 
 
 imences at a _point_ i ^ 
 
 ^imm 
 
 IN Latkral Lithotomy 
 
 left of the central raphe, 
 a spot just external u 
 the tuber ischii, beind 
 the skin, subcutaneous | 
 fs and nerves. The in- 
 [1 of any resisting bands 
 essels are cut throuKli- 
 ia and anterior layer oil 
 uous around the traiii- 
 nger is then pushed or I 
 osition of the staff, an- 
 lide to enter the groovf 
 iranous portion of ihfi 
 fe is felt to be well ii 
 
 the groove it is puslied on into the bladder, the handle being 
 depressed, and the blade somewhat lateralized. It is most 
 important that the point and back of the knife sliould never leave 
 the groove in the staff, or the rectum is likelv to be wounded : 
 
 Fig. 364. — Sui'ERFiciAL Lnxision in Lateral Lithotomy (FicRorssoN ) 
 
 as it is passed onwards, the membranous portion of tlie urethra, 
 together with the deep constrictor, is divided, as also the capsule 
 of the prostate, whilst the left lateral lobe of th'u organ is freely 
 notched. The knife is then carefully withdrawn. The left 
 
 Fig. 365.— Deep Incision in Latkral Lithotomy. (1'ergusson.) 
 
 I index-finger may now be inserted along the urethra into the 
 bladder, keeping the finger-nail in the groove. The opening in 
 the prostate is enlarged by twisting the hnger once or twice as 
 
 jit lies in the wound. If possible, the surgeon feels the calculus 
 
i'i' 
 It- 
 
 1054 
 
 A MANUAL OF SURGERY 
 
 :f-' 
 
 with the tip of the finger, or, at any rate, satisfies himself 
 lie has entered the bladder before the staff is withdrawn, 
 its removal the wound is still further dilated by rotation of 
 finj^er, so as to facilitate the entrance of the lithotomy fore 
 which is the next step in the proceedinj^. These are insertet 
 slidinj,' them alonj,' the back of the index-finger, and when 
 introduced the finger may be withdrawn, being usually folio 
 by a gush of lotion, which may carry the calculus into the g 
 of the forceps. As a rule, however, it is necessary to fee 
 the stone, and grasp it by opening and closing t^ip blades, 
 surgeon must then endeavour to manipulate tlie calculus, si 
 to have its shortest diameter presenting. The forceps, with 
 stone in its grasp, is tlien gently withdrawn by pulling 
 down along the axis of the pelvic outlet. Great care must 
 exercised not to use any undue \iolence, for fear of bruising 
 lacerating the neck of the bladder ; gentle side-to-side m( 
 ment is perhaps the best to employ. Should the calculus 
 larger than was at first expected, the urethra and prostate r 
 be notched with a probe-pointed bistoury on the right side, 
 
 JcoMcir^ 
 
 Fig. jGG. — Lithotomy Scoor, and TosiTroN of Fingkr in 
 
 EXTRACTING StoNK. 
 
 as to enlarge the aperture, or the tissues may be gently pusl 
 back with the index-finger, whilst steady traction is exercis 
 If the calculus breaks into several pieces or if many calculi 
 present, the fragments may be removed by means of the fini 
 and lithotomy scoop (Fig. 36^). The bladder is now once nn 
 thoroughly searched, washed out with an antiseptic, and all evid 
 haemorrhage stopped. In most cases it is advisable to introdi 
 through the wound a gum-elastic vaginal tube or a large cathei 
 which is left in position for a few days. 
 
 The After-Treatment consists in keeping the patient (juiet, w 
 his legs tied together, a pad of wool being placed against I 
 perineal wound, which is syringed out once or twice a c 
 through the tube. When the wound begins to granulate, 1 
 tul)e may be remo\ed ; the urine escapes for a time througli 1 
 perineal opening, which, however, contracts gradually, and clo 
 in most instances in the course of two or three weeks. T 
 patient should i)e kept on a light non-stimulating diet, with plei 
 of diluent drinks, such as barley-water. 
 
 Complications and Dangers of Lateral Lithotomy. — (i) Htnu 
 I'hage may arise from three sources ; the superficial arteries ot t 
 
Ry 
 
 BLADDER AND PEOSTATli 
 
 >05S 
 
 satisfies himself that 
 is withdrawn. After 
 ted by rotation of the 
 the lithotomy forceps, 
 These are inserted by 
 -finger, and when once 
 being usually followed 
 :alculus into the grasp 
 s necessary to feel^ for 
 )sing thp blades. The 
 late'^the calculus, so as 
 The forceps, with the 
 irawn by pulling well 
 . Great care must be 
 for fear of bruising and 
 ntle side-to-side move- 
 Should the calculus be 
 :thra and prostate may 
 y on the right side, so 
 
 ; ( 
 
 ITION OF FlNGEK IN 
 
 ,-; may be gently pusheil 
 V traction is exercised. 
 ir if many calculi are 
 by means of the fin^'er 
 ,dtler is now once more 
 ntiseptic, and all evident 
 ; advisable to introduce 
 ube or a large catheter, 
 
 the patient (juiet, with 
 fing placed against ihcl 
 
 once or twice a dav 
 bgins to granulate, thei 
 [for a time through the 
 |ts gradually, and close^ 
 
 or three weeks. The 
 idating diet, with plenty| 
 
 lithotomy.— (i) Hifinor- 
 Iperficial arteries ot the 
 
 perineum, the deep branches of the pudic, especially that which 
 passes to the bulb, and tiie veins of the prostatic plexus. The first 
 of these are divided in the superficial incision, and may be readily 
 secured, if neccsary, by forceps and ligature. The artery to the 
 bulb is not likely to be wounded if the incision is limited anteriorly 
 according to the directions gi\en above ; if, however, this trunk 
 or its branches in the bulb are cut, free arterial iuemorrhage 
 follows, which is usually stopped without difticulty by openin*' 
 up the wound and seizing the bleeding-points with forceps. The 
 internal pudic artery runs but little risk of injury except in those 
 cases where it follows an abnormal course ; it is readily treated 
 on general principles. \'enous luemorrhage from the prostate is 
 a more serious matter, and is especially prone to occur in elderly 
 persons with prostatic hypertrophy. It is recognised by venous 
 l)lood welling up from the de])ths of the wound, or possibly, if 
 not evident at the time of the operation, by the bladder becoming 
 distended with clot, considerable pain being therebv induced. If 
 noticed during the operation, it is treated by syringing out the 
 wound with iced lotion, and the insertion of an air tampon or 
 a petticoated tube. The former contrivance consists of a gum- 
 clastic catheter, the deep portion of which is surrounded by an 
 indiarubber bag, which can be inilated with air througi; a small 
 tube fitted with a stop-cock, to which a force-pump can be 
 attached. The petticoated tube is used when the latter is not 
 obtainable or fails to act ; it is made by tying a petticoat of lint or 
 gauze around the distal end of a vaginal tube; this is tlien passed 
 into the bladder, and the space between the petticoat and the t\ibe 
 packed with gau/.e. If tlie bladder becomes filled with blood- 
 clot, this must be broken up and removed by syringing with hot 
 water through a large-eyed catheter, and the wound subsequently 
 plugged around a catheter. (2) A Wound of the Rcctiiui may be 
 caused by carrying the superli ial incision too far backwards, or 
 by keeping it too near the middle line behind ; or it may occur 
 later in the operation by not maintaining the point of the knife 
 strictly in the groove. It is more lu'.ble to happen, howe\er, whilst 
 witiidrawing th.e knife, the point being swept backwartls, thus 
 opening the bov.el ; it most frequent. v happens to boys. It is 
 often not recognised until fiatus and fa'ces are passed through 
 the wound at a later date. If of small size and situated low 
 down, it will proliably close by cicatrization without special treat- 
 ment ; but when high up and more extensive, a recto-vesical 
 fistula is likely to follow. The treatment usually recommended 
 in such a case is to divide the sphincter, and thus lay the lower 
 end of the rectum and the lithotomy wound into one cavity, the 
 connnunication being sometimes closed by the contraction of the 
 j,'ranulation tissue which fills up the wound. In suitable cases it 
 may be possible to stitch up the opening from the rectum after 
 paring its edges. (3) Pelvtc Cellulitis is caused by cutting beyond 
 
r 
 
 1056 
 
 A MANUAL OF SURGERY 
 
 ? ^ 
 
 c 
 
 the limits of the prostate, and thus opening up the recto-ves 
 fascia, or by bruisinfj; and over-distension of the neck of 
 bladder by draf^ginff through it too large a stone. In tit 
 case urinary extravasation and diffuse septic inflammation 
 likely to follow, resulting in grave constitutional disturbanc 
 a septic nature, and possibly in the death of the patient. '1 
 treatment suggested is to support the general health by suita 
 diet and stimulants, whilst local tension is relieved by extendil 
 the wound backwards, even into the rectum. (4) Septic Cysti 
 and extension of the inflammation to the kidneys, occasiona 
 supervenes, whilst life may be also destroyed by shock, suppr 
 sion of urine, or pya-mia. 
 
 Lateral Lithotomy in Boys was formerly considered one of t 
 most successful major operations in surgery, but at the prese 
 time it has been proved that lithotrity can be equally well pr; 
 tised, provided suitable instruments are employed and the extern 
 meatus is incised. Should a cutting operation be required, t 
 high position of the bladder lends itself most favourably to t 
 suprapubic method, which is now extensively practised. T 
 chief peculiarities of lateral lithotomy in boys consist in the ru 
 mentary nature of the parts involved, and in the fact that t 
 bladder is an abdominal rather than a pelvic viscus. Hence t 
 deep incision always travels beyond the limits of the prostal 
 whilst the knife has to pass relatively higher than usual in orch 
 to reach the bladder. Considerable difficulty is also experienc 
 in touc hing the stone with the finger, and if much force is use( 
 the neck of the bladder may be torn through, and fatal celluliti 
 ensue. Atrophy of the left testis has happened as a sequela c 
 this operation owing to section of the ejaculatory duct in tli 
 prostate. 
 
 Suprapubic Cystotomy is an operation which has been exten 
 sively practised of recent years, and with considerable success 
 The chief difficulty consists in displacing the anterior reflectioi 
 of the peritoneum, so as to expose the bladder without injuriii; 
 it. This is, however, readily accomplished by the use of 'rrenddcn 
 burg's position. The bladder is washed out, and 8 or 10 ounces 
 lotion left within it ; the patient is then placed with the peivii 
 raised well above the head, the intestines being thus allowed tc 
 gravitate to the postero-superior part of the abdomen ; ns soon as 
 the abdominal parietes are opened, air rushes into the connectivt 
 tissue behind the symphysis (cavum Retzii), and the peritoneum 
 is thus pressed back. 
 
 Operation. — The pubes ha\ing been previously sha\ed, and the 
 hypogastrium purified, an incision is made in the median line 
 reaching from the top of the symphysis upwards for about z or 
 3 inches ; the lower part of the linea alba is divided, and the 
 retro-pubic cellular tissue opened up. The entrance of atmo- 
 
BLADDER AND PROSTATE 
 
 IOS7 
 
 r VI p the recto -vesical 
 of the neck of the 
 a stone. In either 
 tic inflammation are 
 tional disturbance of 
 of the patient. The 
 al health by suitable 
 ■elieved by extending,' 
 1, (4) Septic Cystitis, 
 kidneys, occasionally 
 ;d by shock, suppres- 
 
 :onsidered one of the 
 y, but at the present 
 
 be equally well prac- 
 loyed and the external 
 ation be retiuired, the 
 lost favourably to the 
 lively practised. The 
 )ys consist in the rudi- 
 1 in the fact that the 
 'ic viscus. Hence the 
 limits of the prostate, 
 er than usual in order 
 dty is also experienced 
 
 if much force is used, 
 ^di, and fatal cellulilis 
 
 pened as a sequela of 
 
 aculatory duct in tin- 
 
 [hich has been exten- 
 
 considerable success. 
 
 Ihe anterior reflection 
 
 [dder without injurin;^ 
 
 )y the use of TvendcUn- 
 
 ivnd 8 or 10 ounces of 
 
 [laced with the pelvis 
 
 leinf,' thus allowed to 
 
 labdomen ; as soon as 
 
 is into the connective 
 
 and the peritoneum 
 
 [usly shaved, and the 
 in the median line 
 
 Ivards for about 1 or 
 
 is divided, and the 
 
 entrance of atmo- 
 
 spheric air into this cavity further assists in the depression of the 
 peritoneum. The tense rounded outline of the bladder can now 
 he readily detected with the fin«rer, and a couple of lateral silk 
 sutures or slings are passed through its walls so as to steady it 
 and prevent its subsecjuent retraction. An opening is then made 
 into it in the middle line, through which the index-finger is passed 
 and the stone examined. vSuitably curved lithotomy forceps are 
 introduced, and the stone grasped and withdrawn. The after- 
 treatment of the wound is a point on which much difference of 
 opinion has been expressed. Some leave it open, allowing it to 
 heal by granulation ; this is especially advisable if much cystitis 
 is present. When, however, the bladder is tolerably healthy, it 
 may be closed by sutures, which only pass through the muscular 
 and :;ubmucous coats, and thus when tied do not project into its 
 ia\ity. The external wound may then be left open or closed, 
 except at the spot where a drainage-tube or gauze wick is passed 
 down to the vesical wound, so as to allow exit to any urine which 
 may accidentally become extravasated. The urine is eitlier 
 drawn ofT by a catheter at regular intervals, certainly not less 
 than three or four times daily, or the bladder is drained by tying 
 ill a catheter. 
 
 C hoice o fPperation fQtJVes^caJMgajfiiilliiH— /U jh^ present day 
 
 Jithotnty has been broiiijlU to such a staiicliird of excellence that 
 
 there is no dolifliras to the general fuTe which should be followed, 
 
 I \iz., that untcss SOilvrj[pjitya-imruiUion is present, all cases of vesical 
 
 ^dilciilus should be treated by titli'oTrify. 
 
 The Oontra-indications to Lithotrity are as follow : (i) Conditions 
 of the Stone. If the calculus exceeds i^ inches in diameter, it is 
 not advisable to attempt lithotrity on account of the damage 
 which may be inflicted on the vesical wall. Moreover, some 
 stones, especially those consisting of oxalate of lime, are so hard 
 ihat no lithotrite can crush them. Phosphatic concretions, on 
 the other hand, are so soft that a litiiotrite becomes clogged, 
 ;uul crushing is impracticable. An encysted stone will also pre- 
 clude lithotrity on account of its iixed position. There is no 
 objection to dealing with multiple calculi by this means, but if 
 only of small size, they may be removed by simply using the 
 ovaniator. (2) Conditions of the Urethra. The existence of an 
 nr^'anic stricture, or an enlarged prostate, may render lithotrity 
 impracticable from the impossibility of passing large enough 
 instruments, whilst false passages may make it exceedingly 
 ilithcult. Excessi\'e irritability of the urethra, as e\idenced by 
 I the occurrence of se\ere rigors after instrumentation, may also 
 I render the operation unadvisable. (3) Conditions of the Bladder. 
 The existence of severe cystitis or tlie presence of sacculi, as 
 j indicated by the cystoscope, will usually suggest the performance 
 
 ut lithotomy; whilst a contracted bladder, which will only hold a 
 
 67 
 
I058 
 
 A MANUAL OF SURGERY 
 
 few ounces of urine, materially increases the danj^ers and difli- 
 culties of lithotrity. 
 
 Havinj; tluis described the conditions which contra-indicate 
 lithotrity, a choice nuist be made between entcrinj,' the bladder 
 from tlie perineum or above the pubes. 
 
 Indications for Lateral Lithotomy. — (i) Where cystitis and 
 great irritability of the bladder are present, the incision facilitatin;,' 
 the process of draininj^f and washinj^ it out ; (2) the presence of a 
 phosphatic concretion ; (3) a contracted and hypertrophied con- 
 dition of tile bladder. 
 
 Suprapubic Lithotomy should be undertaken under the followinj,' 
 conditions : (i) Where the stone is too large to be dealt with by 
 crushing; (2) where the stone is encysted; (3) where a stricture 
 or enlarged prostate is present ; (4) where lateral lithotomy is 
 rendered impracticable on account of pehic conditions, such as 
 rachitic contraction or the existence of a tumour, or where the 
 left hip-joint is ankylosed, preventing the patient from assuming,' 
 the lithotomy position. Suprapubic cystotomy is only absolutely 
 contra-indicated by two conditions, viz., severe septic cystitis and 
 contraction of the bladder. 
 
 Calculus in the Female. — As already mentioned, \esical calcuhis 
 is very rare amongst women, owing to the shortness and greater 
 size of the urethra, so that small stcMies passing downwards from 
 the kidneys are easily voided. Phosphatic concretions are not 
 uncommon, and are then formed around a foreign body usually 
 introduced by the patient. Many of the symptoms are \ery 
 similar to those in the male. 
 
 Treatment. — If the calculus does not exceed ^ to ^ inch in 
 diameter, it can usually be extracted by dilating the urethra with 
 the finger, the sphincter being also nicked in two or three place- 
 if necessary. It is never wise to totally divide the sphincter, as 
 incontinence is almost certain to follow. For a somewhat lar;,'ei 
 stone lithotrity can be undertaken, whilst for those of really liirj,a 
 size suprapubic cystotomy is the best procedure. It has been 
 recommended to open the bladder through the anterior vagina 
 wall, and thus remo\e a stone ; but this is scarcely desirable, for 
 fear of the persistence of a vesico- vaginal fistula. 
 
 / 
 
 Affections of the Prostate. 
 
 Pros t atitis arises most usually as a sequela of gonor rhda, 
 its acute or chronic stage, by direct extension Dack\vanf> 
 
 Acute 
 eitlier in" 
 
 of the inflammatory process ; it is also occasionally met with a- 
 a result of stricture arising from the irritation of retained aini 
 decomposing urine, or from the passage of instruments. It i? 
 also said to be induced by the application of cold or damp to tlie 
 perineum, as by sitting on cold stones or damp grass, but probaMv 
 
Li LAUD Eli AND PROSIAIE 
 
 «0S9 
 
 dan^'ers and lUfli 
 
 h conti-a-mcUc:iti 
 Lcrin^' the blacUU r 
 
 'here cystitis and 
 incision facihtatm^' 
 ) the presence of a 
 jypertrophied con 
 
 under the following 
 to lie dealt with hy 
 where a strictvire 
 •itcral Utiiotoniy is 
 conditions, sucli as 
 mour, or wiiere thf 
 tient from assnnun- 
 ,y is only absolutfh 
 :e septic cystitis and 
 
 ,„ed, vesical calculu. 
 liortness and f,'reatL'i 
 in!,' downwards Ironi 
 
 concretions are not 
 foreij^m body usually 
 
 symptoms are \ory 
 
 •eed A to i{ inch ill 
 injr the urethra with 
 two or three plact- 
 -,ide the sphincter, a^ 
 )r a somewhat lai},an 
 ■^ those of really lar^'t 
 :edure. U has been 
 the anterior vai^nial 
 scarcely desirable, for 
 ula. 
 
 Teduela of ^onorrhda 
 
 jror 
 niDa 
 
 extension bacT<waT* 
 isionally met with a^ 
 tion of retained ami 
 [f instruments, b l^ 
 cold or damp to t e 
 .p grass, but prohaM) 
 
 this has been preceded by bacterial in\asion of tlie posterior part 
 of the urethra. Suppuration follows in not a few cases, bein^^ due 
 to the infection of the prostatic fcjjlicles with pyoj^^cnic or^'anisnis. 
 .jometimes merely one or two follicles are enlar;,'ed, causing; wiiat 
 is termed a folliciday abscess ; occasionally the mischief extends 
 much more widely, invoKinf^ the whole of one lobe, or perhaps 
 tlie whole orj^^an, and constitulinj; a purcmhynnitous absii'ss. 
 
 T he Sym ptnm a rtm sist of de ep-seated pain referred to the neck 
 
 (if^the. bladder,, with p_erlii:ips a sense of weight and fulness about 
 
 the perineum, M jcturiUon beconieji J're'P'eni :" k1 painful, and 
 
 (lefa'cation may cause consicTerable distress. As tTienni^an 
 
 increases in size, the pain becomes more and more severe, and all 
 
 movements of the body, as also the act of sittin<^f, are increasinj^ly 
 
 difficult. On rectal examination the or^^an can be felt enlarf^^eil, 
 
 liot, and tender. Suppuration is likely to follow, and retention of 
 
 urine maybe thereby induced. A follicular abscess bursts into the 
 
 urethra spontaneously, or is ruptured by the passaj^e of a catheter 
 
 for the relief of retention ; the openinj,', however, is often of a 
 
 valvular nature, and only a small portion of the pus escapes. 
 
 The process may then continue to spread, and the pus may find 
 
 its way into the rectum, or come to the surface throuj^'h the 
 
 perineum, in either of the latter conditions, a rectal or perineal 
 
 fistula is liable to result. Considerable constitutional disturbance 
 
 is usually associated with this affection, whether suppuration 
 
 occurs or not. The formation of a parenchymatous abscess is 
 
 always attended with much more acute symptoms, both j,'eneral 
 
 and local. The or^an is lari^^er and produces more rectal irrita- 
 
 uon ; a considerable (juantity of pus may form, and suppuration 
 
 may extend beyond the capsule into surroundiu}^ parts. 
 
 Treatment. — The patient should be kept in bed on a restricted 
 diet, and the bowels freely opened by saline pur},'es, combined 
 witli small doses of antimony, and perhaps full doses of hyoscyamus. 
 Local depletion may be undertaken by cupping the perineum, or 
 by applying ten or twelve leeches to it. Hot hip-baths are also 
 very valuable, and linseed-meal poultices may be placed on tiie 
 perineum after the leeches have been removed. Extreme pain 
 should be relieved by the use of morphia suppositories, and if the 
 urine needs to be drawn ofT, a soft rubber catheter of small size 
 should be used. If an abscess forms and is not opened by the 
 passage of a catheter, or if the natural opening is of a valvular 
 character, so that the cavity cannot completely empty itself, an 
 incision must be made into it through the middle line of the 
 perineum, being guided by a finger placed in the rectum ; pus 
 may not be reached until the knife has entered to a depth of 
 about 2 inches. Urine will sometimes escape from this opening, 
 and may continue to do so for some considerable time. If 
 j,'onorrhcca is also present, suitable treatment must be adopted in 
 order to check the discharge. 
 
 67 — 2 
 
ICjO 
 
 A MANUAL OF SURGERY 
 
 Ohronic Prostatitis is perhaps one of the most coininoii cause 
 of chronic {^leet after ^^fonorrhcra. It is sometimes left as ; 
 secpiela of an acute attack, or may arise as a result of stricture. 
 
 The Symptoms prochiced by it are a sense of weij^ht and fulnes 
 about the perineum, comi)inecl with irritability of the bladder 
 and pain referred to the extremity of tlie penis at the end a 
 micturition, owinf,' to the bladder contracting^ upon the hyperaimi( 
 and sensitise or,<(an. A j^dairy discharf^e of viscid m.'iterial 
 similar in appearance to uncooked white of v^^ {prostatorrhoca) 
 is often present, whilst fuie threads of mucus are usually see! 
 fUvitinf,' in the urine, beinj,' due to the formation of mucous casti 
 of tile prostatic ducts. On exaiuination through the rectum, th( 
 organ can bo felt enlarged and tender, and tiie xesicuhe an 
 usually in the saine condition. Chronic suppuration may follow 
 the abscess bursting into the urethra or rectum, or pointing ir 
 tiie perineum. 
 
 The Diagnosis from tuberculous disease can usually be madt 
 by careful attention to the history and physical signs. 
 
 Treatment consists in counter-irritation of the surface of tlit 
 perineum, as by blisters or iodine paint, care being taken th.ii 
 the reagent employed does not extend either to the anus or 
 scrotum, lielladonna suppositories may be of value, whilst the 
 occasional passage of a cold metal bougie may do good. In 
 suitable cases, where a long-standing gleet is present with iid 
 suspicion of suppuration, a cure may occasionally be brought 
 about by the administration of iodide of potassium, or of the liij. 
 ferri perchloridi (Illxv. or more, t.d.s.), combined with sulphate 
 of magnesia. The local application of a solution of nitrate of 
 silver by a porte-causticjue is also sometimes recommended, but 
 we are not nuich in fa\our of such a proceeding. Probably the 
 best treatment consists in forcible dilatation of the prostatic 
 urethra, as suggested by Oberli'inder, the follicles being therein 
 emptied of their secretion ; massage of the prostate per rectiiw 
 against a sound held in position may also be useful. Should an 
 abscess form, it is incised through the perineum. 
 
 Tuberculous Disease of the Prostate is usually met with as a 
 result of extension from similar disease in the epididymis, the 
 seminal \esicles being also invaded ; occasionally, however, it 
 may arise as a primary affection. In either case, it rapidly 
 spreads to the bladder, and thence to the ureters and kidneys. 
 The prostate is found to contain caseous masses in the early 
 stages, but later on these break down, leading to extensive ulccia 
 tion, and sometimes the organ is riddled with ragged cavities. 
 The symptoms are those of irritability of the neck of the bladder, 
 combined with pain referred, perhaps, to the end of the penis, 
 or mainly noticed in the back or perineum. Ha;maturia is occa 
 sionally produced, whilst pyuria is almost constant. The urine 
 
BLADDER AND PHOSTATl': 
 
 in6l 
 
 )St common causes 
 )metimes left as a 
 esult of stricture. 
 f weifiht and fulness 
 ity of the bladder, 
 ,enis at the end ol 
 ipon the hyperacmu- 
 of viscid material, 
 e^K' {prostatoYvUm), 
 us are usually seen 
 ion of mucous casts 
 lugh tlie rectum, thu 
 kI the vesicula; an- 
 puration may follow, 
 :tum, or pointmg m 
 
 :an usually be made 
 :al sif;ns. 
 
 )f the surface ot tlic 
 are bein^' taken that 
 ther to the anus ..r 
 . of value, whilst the 
 e may do f,^ood. In 
 X is present with no 
 iasionally be brought 
 assium, or of the liM- 
 nbined with sulphate 
 Solution of nitrate d 
 bs recommended, but 
 feding. Probably the 
 ion of the prostatic 
 jlUcles being therebv 
 ,e prostate per m/»"; 
 be useful. Should an 
 um. 
 
 Lually met with as a 
 \ the epididymis, the 
 Isionally, however, n 
 Ither case, it rapully 
 ureters and kidneys 
 masses in the eailv 
 to extensive ukeia 
 Ivvith ragged cavities 
 ^ neck of the bUuUlei, 
 [he end of the pe'm^. 
 Hematuria is occ:i 
 constant. The urine 
 
 is feebly acid or neutral, and, on examination of tlie pus which 
 is deposited on standing, the tubercle bacillus may be detected. 
 Kectal examination will demonstrate an irret,'ular enlargement of 
 the organ, whilst if the vesicuhe are iinailed, they (an also be felt. 
 Treatment consists in attending to the general health, and 
 the administration of tonics. Possibly, if the disease is not too 
 extensive, benefit may be derived from sciaping the tuberculous 
 tissue away through a perineal incision. 
 
 Prostatic Oalculi are of unfrci|uent occurrence, being usually 
 met with in cases of chronic prostatitis, especially that n-sulting 
 Irom stricture of the urethra or previous attacks of gonorrho-a. 
 They are generally multiple, and of small size, consisting mainly 
 of carbonate of lime. They develop primarily in the glandular 
 crypts, and may remain emberldeil in the organ, giving rise to 
 but little inconvenience. When large and protruding from the 
 gland into the urethra, symptoms of obstruction to the tlow of 
 urine are produced, whilst on passing a catheter or sound a 
 distinct click or grating may be noticed. In the latter case, great 
 irritability of the neck of the bladder is induced. Sometimes a 
 number of them are found in a pouch or pocket, formed by the 
 amalgamation of several of the crypts. It is in some instances 
 possible to remove the cal- 
 culi through the urethra, 
 
 hut more fretjuently a peri- .^ ^^^^B^IFi '- ^ 
 
 neal incision is re(iuired. 
 
 Hypertrophy of the Pros- 
 tate is a condition rarely 
 met with, except in patients 
 over fifty years of age. 
 There is a general enlarge- 
 ment of the tissues of the 
 part, involving either the 
 j^landular and the muscular 
 elements ecjually, or espe- 
 cially limiting itself to one 
 or other of these tissues ; 
 more frequently the muscu- 
 lar element is considerably 
 in excess. Another variety 
 is due to the development 
 of localized tumours in, or 
 outgrowths from, the organ, 
 which are usually fibro- 
 niyomatous in nature, par- 
 ticularly if embedded in the 
 prostatic substance ; when of this type they are almost exactly 
 
 Fif.. 367 — IlNLAKciKi) I^kostatk; Middle 
 
 LOBK KKl'I.ACKD liV ICnuKMOLS I'MIRO- 
 MVOMA (l-KDM COLLEGE OK SURGEONS' 
 MUSKCM.) 
 
IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 / 
 
 .// 
 
 ,<° m. 
 
 ,<-' #?. 
 
 :<? 
 
 
 :/ 
 
 
 1.0 
 
 I.I 
 
 1.25 
 
 f IIIIIM 
 
 Si? 
 
 32.5 
 
 
 IIIM I Z2 
 
 12.0 
 
 1.8 
 
 U 111.6 
 
 Photographic 
 
 Sciences 
 Corporation 
 
 m 
 
 V 
 
 ^9> 
 
 V 
 
 4i>^ 
 
 
 
 
 '^'h^ 
 
 33 WEST MAIN STREET 
 
 WEBSTEK.N.Y. 14580 
 
 (716) 872-4503 
 
,<° m. 
 
 ,,'v %jr 
 
 :<? 
 
 ?, 
 
 
 C/s 
 
 ^.^ 
 # 
 
 J 
 
I062 
 
 A MANUAL OF SURGERY 
 
 analogous to the so-called fibroid tumours of the uterus, since 
 they originate in the walls of the sinus pocularis, the male analogue 
 of that organ. These tumours are rather denser than ordinary 
 prostatic tissue, and are often completely encapsuled. They an 
 primarily developed in the substance of the prostate, but ma^ 
 project backwards, when large, towards the rectum, or grov 
 upwards into the bladder (Fig. 367), or may even become pedun 
 culated, constituting a polypus in the dilated urethra. Occasionalb 
 these new growths consist mainly of glandular tissue with distinc 
 ducts, and possibly concretions may be found in the tubules 
 There are thus, pathologically speaking, three main forms of th( 
 so-called 'chronic hypertrophy of the prostate': the diffuse en 
 largement, the fibro-myomata, and the adenomata ; not unfre 
 quently they are combined one with the other. 
 
 Fig. 368. — Effect of Enlargement of the Middle Lobe of the 
 Prostate on the course of the Urethra. (Diagrammatic.) 
 
 The left-hand figure represents the normal curve of the urethra ; that on tli 
 right side the barrier caused by an enlarged middle lobe. 
 
 The changes produced in the prostatic urethra and neck of tli 
 bladder vary consideralily according to the character of the out 
 growth in any particular case. A certain amount of obstructio 
 is always present, except in a few instances in which the intern; 
 meatus becomes unduly patent, possibly from a tumour in tli 
 median portion being wedged in between the two lateral lobe; 
 The prostatic urethra is increased in length in all cases 
 this disease. When the lateral lobes are enlarged, the lunie 
 of the urethra is diminished from side to side, being narrow 
 or chink-like instead of circular; its vertical measurements an 
 however, increased. The urethra is, moreover, rendered m 
 or less tortuous, owing to irregular enlargement of the varioi 
 portions. Thus, if the median lobe i^ especially promineii 
 a rounded barrier extends across the urethra, which become 
 
BLADDER AND PROSTATE 
 
 1063 
 
 )f the uterus, since 
 is, the male analogue 
 enser than ordinary 
 ;apsulecl. They are 
 J prostate, but may 
 e rectum, or grow 
 even become pedun- 
 rethra. Occasionally 
 ir tissue with distinct 
 und in the tubules, 
 e main forms of the 
 ate': the diffuse en- 
 momata ; not unfre- 
 r. 
 
 B 
 
 ImiDDLE LOBli OF THE 
 
 (Diagrammatic.) 
 
 . the urethra ; that on the 
 red middle lobe. 
 
 Irethra and neck of the 
 character of the out- 
 icimount of obstruction 
 Is in which the internal 
 from a tumour in the 
 the two lateral lobes, 
 >ngth in all cases of 
 J enlarged, the lumen! 
 ^o side, being narrow 
 [cal measurements are, 
 Ireover, rendered more 
 gement of the various 
 especially prominent, 
 ethra, which becomes 
 
 almost S-shaped (Fig. 368, B). If one lateral lobe is enlarged 
 more than the other, the urethra is pushed over towards the 
 unaffected side. The shape of the internal meatus is also con- 
 siderably modified : when the median lobe is enlarged, it becomes 
 crescentic, the convexity looking upwards and forwards; when 
 one lateral lobe is of larger size than the other, the orifice is also 
 crescentic, the convexity being directed towards the smaller lobe ; 
 when all three lobes are affected, the entrance to the bladder may 
 be Y-shaped, the limbs of the Y passing on either side of the 
 median lobe. Not unfrequently the prostate may project into the 
 bladder as a rounded, collar-like elevation, encircling the meatus. 
 
 The Symptoms are also modified by the nature and position of 
 the enlargement. The patient at first finds some difficulty in 
 micturition, especially at the commencement of the act ; straining 
 often hinders rather than assists. The stream is not necessarily 
 smaller than formerly, but is projected with less force. Gradu- 
 ally irritability of the bladder ensues, and the patient has to pass 
 water very frequently, a trouble especially noticed during the 
 night. Some degree of pain and a sense of weight and fulness 
 about the perineum are also experienced, whilst tenesmus, and 
 even hernia, may be subsequently induced by the straining. 
 Intermittent attacks of increased pain and difficulty in micturition 
 occur from time to time, being generally induced by exposure to 
 cold and wet, and presumably due to congestion of the prostate. 
 After lasting for a few days the more acute symptoms slowly 
 disappear, if judiciously treated. 
 
 As the obstruction increases, a certain amount of residual urine 
 remains within the bladder after each act of micturition, the 
 vesical muscles gradually losing power and becoming atonic. 
 Gradually well-marked distension and atony of the bladder ensue 
 in neglected cases, the utine dribbling away and wetting the 
 clothes, whilst decomposition of the retained fluid follows, and 
 causes cystitis with increasing vesical irritation and muscular 
 spasm. The urine becomes alkaline after a time, containing 
 niuco-pus and phosphates, the result of chronic cystitis. This, if 
 neglected, is certain to lead to hydronephrosis and pyelonephritis. 
 The general health of the patient is slowly undermined by the 
 constant irritation produced by this process, as also by septic 
 absorption, and the final chapter may be ushered in by symptoms 
 of uraemia from the mischief inflicted on the kidneys. 
 
 Occasionally the early symptoms may pass unnoticed for a 
 considerable time, the patient imagining that the frequent calls to 
 pass water are good signs rather than evidences of disease. In 
 such cases the bladder may become over-distended, and the con- 
 dition unsuspected until, owing possibly to some exposure to cold 
 or over-indulgence in alcohol, complete retention is induced, and 
 then, to the surprise of the patient, an enormous amount of urine 
 is withdrawn on the passage of a catheter. Priapism is some- 
 
Wk 
 
 1064 
 
 A MANUAL OF SURGERY 
 
 times a troublesome condition, and the effect of this on the mora 
 sense may be very serious, and leads in some cases to acts of grosi 
 indecency. 
 
 The Diagnosis of enlarged prostate is made partly by a con 
 sideration of the symptoms complained of, but mainly by ai 
 examination of the urethra and rectum. The age of the patient 
 the increasing irritability of the bladder, by night and day, th< 
 fact that straining hinders rather than helps the expulsive act 
 together with evidence of vesical distension — all these fact; 
 indicate that the seat of obstruction lies in the prostate. A recta 
 examination is then instituted, and some idea gained of the size 
 and condition of the organ ; it must not be forgotten, however 
 that the size, as recognised by a finger in the rectum, cannoi 
 measure in any way the amount of obstruction to the passage o 
 the urine, and, in fact, it often happens that where the gland does 
 not feel especially large from the rectum, the obstruction is tht 
 greatest. The careful introduction of a catheter will assist in 
 making the diagnosis, inasmuch as the barrier at the neck of the 
 bladder is easily detected, and sometimes with difficulty passed. 
 
 Treatment. — All that is required at first is regular catheterisiu, 
 in order to prevent the bladder from becoming over-distended, 
 
 «f 
 
 'zl 
 
 Fig. 369.— Catheter Coude and Bicoude. 
 
 and this the patient may sometimes be taught to do for himself. 
 To pass a catheter in a case of enlarged prostate is not always 
 easy, owing to the fact that the middle lobe (Fig. 368, B) projects 
 across the urethra, and bars the onward progress of an instrument 
 of the ordinary shape. The surgeon should therefore use eitlier 
 a catheter coude or bicoude (Fig. 369), which consists of a soft, 
 straight instrument of the usual French type, the end of which 
 is bent or doubly bent at an angle, so as to enable it to ride 
 over the obstruction ; or he may employ an English gum-elastic 
 catheter, the stilette of which is drawn out a little so as to increase 
 its curve ; or he may utilize the silver prostatic catheter, which 
 is longer and more curved than usual, depressing it well between 
 the thighs after clearing the pubic arch. Whichever method is 
 adopted, no force is required, since with a little skill the point 
 of the instrument will pass round the obstruction and enter the 
 bladder. Every precaution must be taken to ensure the efficient 
 sterilization of all instruments employed, and it should be remem- 
 bered that as a general rule large rather than small instruments 
 will pass most easily. 
 
BLADDER AND PROSTATE 
 
 1065 
 
 f this on the moral 
 ises to acts of gross 
 
 e partly by a con- 
 but mainly by an 
 I age of the patient, 
 night and day, the 
 i the expulsive act, 
 n — all these facts 
 
 prostate. A rectal 
 L gained of the size 
 forgotten, however, 
 
 the rectum, cannot 
 m to the passage of 
 vhere the gland does 
 le obstruction is the 
 itheter will assist in 
 r at the neck of the 
 h difficulty passed. 
 
 regular catheterisni, 
 ming over-distended, 
 
 JlCOUDK. 
 
 /ht to do for himself, 
 trostate is not always 
 [Fig. 368, B) projects 
 ress of an instrument 
 therefore use either 
 |ich consists of a soft, 
 )e, the end of which 
 to enable it to ride 
 English gum-elastic 
 ittle so as to increase 
 Itatic catheter, which 
 king it well between 
 Vhichever method is 
 little skill the point 
 [uction and enter the 
 ) ensure the efficient 
 it should be remem- 
 in small instruments 
 
 During the first fortnight of catheter life the patient must be 
 carefully guarded from cold and exposure, to avoid the occurrence 
 of constitutional disturbance. Not un frequently a certain amount 
 of fever (to which the name of Catheter Fever was gi\en by the 
 late Sir Andrew Clark) is produced, which either passes ofT in the 
 course of a few days, or may increase, together with symptoms 
 of chronic cystitis, running on to a fatal issue at the end of three 
 or four weeks. The origin of this condition is still somewhat 
 doubtful; it may certainly arise from the absorption of micro- 
 organisms or their products from the urethra, or from the use of 
 impure instruments, but possibly reflex nervous disturbance plays 
 some part in its production. The only treatment required in the 
 simpler cases is to keep the patient warm in bed, to limit his diet, 
 to administer quinine and opium, and to keep the bowels well open. 
 During the continuance of catheter life, the patient must be 
 warned to live quietly, and abstain from all excesses, especially 
 as regards eating and drinking ; sexual excitement should be 
 avoided, and horse-exercise forbidden ; precautions must also be 
 taken to ensure protection from cold and damp. The adminis- 
 tration of alkalies is desirable if the urine is highly acid, so as to 
 diminish the irritability of the bladder. 
 
 Under such a regime, it is possible that the patient may live 
 in comparative comfort perhaps for years, the progress of the 
 affection being entirely checked in some instances. In others, 
 the patient suffers from intermittent attacks of congestion of the 
 prostate with increased pain and irritability of the bladder, and 
 augmented difficulty in micturition. The introduction of a catheter 
 is then very likely to cause bleeding, but a few days' rest in bed 
 usually brings about considerable improvement. The progress of 
 the case depends, to a large extent, upon the bladder remaining 
 free from septic contamination, and the surgeon must realize ancl 
 impress upon his patient that such is generally due So infection 
 from without, and hence the most scrupulous care must be taken 
 to sterilize all instruments before and after use. In cases where 
 the relief given by regular catheterism is but temporary, and the 
 irritability of the bladder increases seriously, further measures 
 are absolutely imperative. 
 
 Two chief plans of operative treatment have been adopted in 
 this affection, both directed to reducing the size of the organ, and 
 thus removing the obstruction to the passage of urine : in the 
 one, the gland itself is attacked, and portions of it removed or 
 divided (prostatotomy or prostatectomy) ; in the other, the diminu- 
 tion in size is attained by indirect measures. 
 
 Prostatotomy, or incision of the prostate, is usually undertaken 
 from the perineum. The ordinary incision for median cystotomy 
 is made after the passage of a staff with a median groove. The 
 membranous urethra and prostate are divided in the middle line 
 to a sufficient extent to allow of the introduction of the finger 
 
1 066 
 
 A MANUAL OF SURGERY 
 
 into the bladder, and an elastic tube is then inserted for drainage 
 Any projecting nodules or masses of prostatic substance that 
 can be detected are removed. The drainage is maintained for 
 a week or ten days, and considerable improvement is said to 
 follow in some cases. The chief objection to this plan is that the 
 perineum in these patients is often so deep that it is impossible 
 to insert the finger into the bladder; considerable haemorrhage 
 may also take place, whilst it is difficult to remove tumour masses 
 that might be easily enucleated by other means. The chiet 
 indication for its use is when cystitis is present to such a degree 
 as to necessitate continuous drainage. 
 
 It has also been proposed to divide the obstruction at the neck 
 of the bladder by a concealed knife, to destroy it by a galvano- 
 cautery (Bottini's method), or snare it when pedunculated ; such 
 proceedings are uncertain, and not free from risk. 
 
 Prostatectomy, or removal of the prostatic enlargement, has 
 been introduced as a means of treatment during the last few years. 
 It is usually conducted through a suprapubic incision into the 
 bladder, the patient being previously placed in the Trendelenburg 
 position. The enlargement at the neck of the bladder can be felt, 
 and, by the use of suitable illuminating apparatus, seen. Pro- 
 jecting growths may be incised and shelled out without much 
 difficulty or haemorrhage ; whilst if the whole organ is enlarged, 
 the mucous membrane over it may be divided by a circular in- 
 cision, the gland substance cut through in front and behind with 
 scissors, and the whole mass enucleated by the use of a suitable 
 scoop, or with the fingers. The passage of a catheter along the 
 urethra enables the surgeon to ascertain that the whole of the 
 projecting growth has been removed. Most satisfactory results 
 have followed this operation, although sometimes severe haemor- 
 rhage has occurred. It is most suitable in cases where a pedun- 
 culated or encapsuled tumour exists in the middle lobe. 
 
 The chief measures which have been employed for reducing the 
 size of the prostate by indirect means are as follows : 
 
 (a) Double Castration. — This plan was first suggested by White 
 of Philadelphia, in 1894, ^"^ '^^^ "O'^^ been followed to a suf- 
 ficient extent to enable us to come to some decision as to its 
 utility. It has long been known that uterine fibroids diminish in 
 size after removal of the ovaries, and the similarity between such 
 growths and an enlarged prostate would lead one to anticipate that 
 if the testes are excised a similar shrinking of the prostate might 
 follow ; such, in certain instances, has been found to be the case. 
 The conditions most favourable to double castration are those in 
 which the whole gland is enlarged, soil and vascular, bleeding 
 readily on the introduction of a catheter ; on the other hand, hard 
 prostates, or those in which fibroid tumours are present, are not 
 likely to be much improved by this proceeding. It is also interest- 
 ing to note that the tone of the muscular wall of the bladder can 
 
 II 
 
BLADDER AND PROSTATE 
 
 1067 
 
 lerted for drainage, 
 tic substance that 
 is maintained for 
 ivement is said to 
 his plan is that the 
 lat it is impossible 
 jrable haemorrhage 
 ove tumour masses 
 means. The chief 
 It to such a degree 
 
 :ruction at the neck 
 jy it by a galvano- 
 pedunculated ; such 
 
 isk. 
 
 c enlargement, has 
 g the last few years, 
 ic incision into the 
 1 the Trendelenburg 
 ; bladder can be felt, 
 )aratus, seen. Pro- 
 l out without much 
 3 organ is enlarged, 
 ed by a circular in- 
 Dnt and behind with 
 he use of a suitable 
 . catheter along the 
 at the whole of the 
 satisfactory results 
 limes severe haemor- 
 ses where a pedun- 
 Jdld lobe. 
 
 yed for reducing the 
 lUows : 
 
 luggested by White 
 followed to a suf- 
 le decision as to iis 
 fibroids diminish in 
 larity between such 
 le to anticipate that 
 the prostate might 
 jund to be the case, 
 itration are those in 
 vascular, bleeding 
 e other hand, hard 
 .re present, are not 
 It is also interest- 
 of the bladder can 
 
 be largely regained, even after considerable distension and atony 
 have occurred. 
 
 (b) In order to overcome the natural objection of patients to 
 the removal of their testes, vasectomy, or the excision of a portion 
 of the vas deferens on each side, has been practised. In suitable 
 cases the results have been good, but are attained more slowly 
 than after castration. 
 
 (c) Ligature of the internal iliac arteries has also been employed 
 in order to starve the gland, and certainly in a few instances with 
 success. 
 
 The actual treatment to be adopted in any particular case nmst 
 be determined by its special features. Catheterism will suffice 
 for a time, but when this fails operation should be undertaken. 
 For localized outgrowths projecting into the bladder, and recog- 
 nised by the cystoscope, suprapubic prostatectomy is to be recom- 
 mended ; but for general enlargement of the organ, especially if 
 it is soft and succulent, vasectomy should first be performed, and 
 may be followed up by double castration, or even by prostatectomy, 
 if necessary. 
 
 Finally, if the patient refuses these operations, or if his general 
 condition prevents them from being undertaken with safety, and 
 catheterism is insufficient to give relief to his symptoms, a pev- 
 manent fistula either above the pubes or through the perineum must 
 be established, necessitating the use of a portable urinal. This 
 is effected by introducing a trocar and cannula into the bladder, 
 and leaving it there until a sufficient track has been formed. 
 
 Cancer of the Prostate occurs in elderly men, but is not com- 
 mon ; it is usually of a scirrhous type, though sometimes it is of a 
 soft nature ; in either form it early progresses beyond the limits of 
 the capsule. The symptoms produced are those of obstruction to 
 the flow of urine, together with pain, which may be very severe, 
 and at a later date haemorrhage. The progress of the disease is 
 much more rapid than in senile hypertrophy. On rectil examina- 
 tion the hard mass is readily detected, whilst secondary deposits 
 may be found in the lumbar and abdominal glands on palpating 
 the abdomen. Occasionally phenomena referable to pressure on 
 the abdominal vessels and nerves arise, and the symptoms of 
 general cachexia soon manifest themselves. Palliative treatment 
 alone can be adopted. 
 
CHAPTER XXXVII. 
 
 \ 
 
 
 AFFECTIONS OF THE URETHRA AND PENIS. 
 Affections of the Urethra. 
 
 Congenital Malformations. — Total Absence, or Occlusion, of tl 
 
 urethra has been met with, the urine under such circumstance 
 being sometimes retained, and leading to dilatation of the bladde 
 ureters, and kidneys, a condition rapidly fatal, even if the chi 
 be born alive. In a few cases the urachus remains patent, ar 
 a congenital urinary fistula is established at the umbilicus, whil 
 in others the cloacal condition persists, the urine passing in 
 the rectum. 
 
 Epispadias is a deformity in which the urethra is partially i 
 wholly exposed along the upper surface of the penis. Accordir 
 to Mr. Henry Morris, it is not, properly speaking, a division 
 deficiency in the upper wall of the urethra, but in its floor, whi( 
 has been transposed to the dorsum by torsion of the penis. ' 
 is thus, in fact, a hypospadias reversed, i.e., upside down.' 
 rare instances, the external meatus is situated just above tl 
 glans, which is cleft and deeply grooved superiorly. Mo 
 commonly the urethra opens at the root of the penis, just 
 front of the symphysis, and in such patients the organ is alwa 
 rudimentary and stunted. Complete epispadias is only prese 
 when associated with extroversion of the bladder (p. 1023). '^' 
 incomplete form has been treated with success by the use 
 reversed flaps dissected up from the side of the penis. For detai 
 of the operations on this and the following conditions, see larg 
 text-books on operative surgery. 
 
 Hypospadias, or defective development of the lower wall of tl 
 urethra, is a much more common malformation than the for 
 going. Three varieties are described. In (a) hypospadia glam 
 the opening of the urethra corresponds to the position usual 
 occupied by the fraenum, and is thus directed downwards inste; 
 of forwards. The prepuce in these cases is always voluminou 
 and hangs like a hood over the glans, which is bent down ov 
 the orifice, (b) Hypospadia penis is characterized by the ureth 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 1069 
 
 AND PENIS. 
 
 or Occlusion, of the 
 >r such circumstances 
 iatation of the bladder 
 atal, even if the child 
 s remains patent, and 
 t the umbihcus, whilst 
 the urine passing into 
 
 urethra is partially or 
 the penis. According 
 ipeaking, a division or 
 but in Its floor, which 
 ;ion of the penis. ^ 'It 
 l.e., upside down. In 
 ituated just above the 
 ted superiorly. More 
 
 of the penis, just in 
 nts the organ is always 
 padias is only present 
 kladder (p. 1023). IhM 
 [success by the use of 
 
 the penis. For details 
 conditions, see larger 
 
 If the lower wall of the 
 
 rmation than the fore- 
 ti (a) hypospadia glaim 
 to the position usuallv 
 [ted downwards instead 
 1 is always voluminous, 
 tch is bent down over 
 bterized by the urethra 
 
 opening somewhere along the under surface of the body of the 
 penis, which is often small and stunted. Considerable discom- 
 fort may arise in the act of micturition owing to the urethral 
 orifice looking downwards; it is also sometimes so small as to 
 require incision and dilatation, (c) Complete hypospadias, or 
 hypospadia perinealis, is a somewhat complicated condition, in 
 which the lower wall of the urethra is defective as far back as 
 the perineum, the scrotum being cleft, and thus resembling the 
 vulva. The penis is always small, imperfectly developed, and 
 bound down by adhesions between the scrotal segments, looking- 
 not unlike a hypertrophied clitoris. Under such circumstances 
 it is not surprising that the sex of the child has been mistaken, 
 ;iiid not a few cases are on record where it has been educated as 
 a female until the age of eighteen or twenty. Non-descent of 
 the testes is often associated with this malformation. 
 
 In the incomplete varieties, where the deformity is slight and 
 the urethral opening well in front of the sci otum, no interference 
 is necessary ; but where it encroaches on the scrotum, causing 
 inconvenience and discomfort, and threatening to prevent effective 
 sexual intercourse in the future, the restoration of the urethra 
 may be attempted by the use of reversed flaps obtained from 
 either side, or from the redundant prepuce. In the complete form 
 the penis must first be liberated from its adhesions and set free ; 
 the integument lining the scrotal cleft is then dissected up and 
 turned inwards to form the posterior part of the urethra, whilst 
 the lateral halves of the scrotum are brought together with 
 sutures ; the anterior portion of the urethra may then be dealt 
 with as for the incomplete variety. 
 
 Traumatic Laceratioa of the Urethra usually results from 
 violence applied directly to the perineum, as by falling astride a 
 stile, fence, or beam ; it has also been caused by severe jolting in 
 the saddle, or by a kick in the perineum. In fractures of the 
 pelvis it may be produced by a spicule of bone puncturing the 
 canal, and the membranous portion is that generally affected. 
 The whole circumference of the urethra may be involved, the 
 two segments being entirely disconnected, or only a portion may 
 he ruptured, and that most frequently the floor. 
 
 The Symptoms consist of pain in the perineum and shock, fol- 
 lowed by great distension of the scrotum from hemorrhage, 
 whilst blood trickles from the urethral orifice. If the patient is 
 ahle to restrain himself from passing water, and is successfully 
 treated, no extravasation of urine results, since the lesion is below 
 the sphincter vesicae ; if, however, he attempts to micturate, the 
 : urine finds its way into the perineal and scrotal tissues. Whether 
 the rupture is complete or not, an organic stricture of considerable 
 [density is almost certain to follow, and great difficulty is subse- 
 [quently experienced in keeping it dilated. , • 
 
I07O 
 
 A MANUAL OF SURGERY 
 
 Treatment. — In the slij^hter cases, where it is probable that tl 
 mucous membrane has alone been torn and there is no perine 
 swelling, the patient should be kept quiet in bed, and no attemp 
 made at instrumentation. If urinary affection of the wour 
 occurs and an abscess forms, it can be dealt with by incision at 
 later date. 
 
 Where, however, it is thought that the urethra is partially 
 wholly divided, no temporizing measures such as tying in 
 catheter, even if that be possible, should be adopted. An incisic 
 ought to be made at once into the perineum so as to expose tl 
 divided ends of tlie urethra, which it is the surgeon's aim to unit 
 The blood-clot is removed, bleeding points are secured, and if tl 
 ends of the urethra can be identified, a soft catheter is introduc( 
 into the bladder, and they are sutured together around it wi 
 fine catgut. When the ends are nmch torn, it is wise to c 
 aw.iy the bruised extremities so as to have clean, smooth surfaces 
 deal with. Under all circumstances the catheter must be kept 
 for five or six days, if possible, and subsequently an instrume 
 nuist be passed every day for some time. 
 
 If a catheter cannot be introduced, or if extravasation has o 
 curred, free incisions must be made into the scrotum and perinea 
 to give exit to the blood and urine, and to expose the seat of injur 
 A catheter is passed as far as possible, and its point felt for, c 
 down on, and guided into the bladder ; a prolonged attempt und 
 ana.'sthesia may be necessary to accomplish this, and even th( 
 it is useless to attempt to stitch up the urethra, as the sutures a 
 certain to cut out. Occasionally, and especially if treatment h 
 been delayed, the swelling of the parts is so great as to rend 
 the passage of a catheter impossible. The patient must then 1 
 put to bed for a few days until the blood-clot has disappeared, t 
 urine in the meantime escaping through the perineal wound ; 
 as soon as possible another attempt must be made. When on 
 the catheter is passed, it must be retained for several days, so 
 to establish the continuity of the tube. 
 
 Foreign Bodies are sometimes found in the urethra, usual 
 consisting of a portion of a catheter, pipe-stem, or in children 
 piece of slate-pencil. Their presence gives rise to partial or cor 
 plete obstruction to the flow of urine, followed by ulceration 
 the mucous membrane, the formation of a peri-urethral absces 
 or even extravasation. They are readily detected on the passa; 
 of a sound or catheter, and may be removed by suitable force 
 if situated near the orifice. Should this fail, the urethra may 1 
 incised and the body extracted ; a troublesome urinary fistula 
 apt to follow this proceeding, even when the wound in the ureth 
 has been carefully sutured. 
 
 Impacted Calculus is a not unfrequent cause of retention 
 children. It can usually be felt through the walls of the cam 
 The symptoms and treatment are much the same as for foreij 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 1071 
 
 is probable that the 
 
 there is no perineal 
 
 ,ed, and no attempts 
 
 :tion of the wound 
 
 with \)y incision at a 
 
 rethra is partially or 
 such as tyinf; m a 
 Ldopted. An incision 
 m so as to expose the 
 argeon's aim to unite. 
 ,re secured, and if the' 
 catheter is introduced 
 rether around it with 
 )rn, it is wise to cut 
 ■an, smooth surfaces to 
 heter must be kept in 
 quently an instrument 
 
 extravasation has oc- 
 scrotum and perineum 
 ^pose the seat of injury, 
 d its point felt for, cui 
 -olonged attempt under | 
 sh this, and even then 
 thra, as the sutures are 
 
 cially if treatment has 1 
 so great as to render 
 patient must then he 
 
 ,ot has disappeared, the 
 
 le perineal wound ; hut 
 
 [be made. When once 
 
 for several days, so as I 
 
 the urethra, usually 
 -stem, or in children a 
 B rise to partial or corn- 
 flowed by ulceration ol 
 L peri-urethral abscess, 
 ietected on the passage 
 Jved by suitable forceps 
 |ail, the urethra may be 
 Bsome urinary fistula 15 
 fe wound in the urethra 
 
 I cause of retention in 
 [the walls of the canal. 
 Vhe same as for foreign 
 
 bodies. When near the neck of the bladder, it should be pushetl 
 hack into that viscus, if possible, and treated hy lithotrity. 
 
 Simple Urethritis may arise from a variety of causes apart from 
 gonorrhcx'a, e.g., the presence in the female of an irritating \ aginal 
 discharge, such as leucorrh(i.'a, and possibly due to the Inxc! coli. 
 It also occurs after the passage of an instrument or of a calculus', 
 and is occasionally excited in gouty individuals by highly acid 
 urine. The symptcMUs are much the same as those of gonorrhd'a, 
 but the discharge is thinner in character, and on microscopical 
 examination rio gonococci are detected. The treatment consists 
 in the adininistration of a simple saline purgative, all forms of 
 alcohol being interdicted. In more severe cases oleo-balsams 
 may be prescribed, and even mild injections. 
 
 Polypoid Tumours, similar in character to the caruncle met 
 with in the urethra of women, have been observed at the orifice 
 of the male urethra. They are red, vascular, and sometimes ex- 
 ceedingly painful, and are best dealt with by excision, followed 
 by the application of the galvano-cautery, so as to stop the 
 bleeding, which is always copious. If of large size, the base may 
 be ligatured, and the growth cut away. 
 
 Stricture of the Urethra. — By stricture of the urethra is meant 
 a condition in which the onward passage of urine is hindered, 
 owing to some change in the walls of the urethra, which prevents 
 them from dilating. When at rest, the urethra is merely a 
 potential canal, the walls of which are in complete apposition, 
 and it is only converted into a tube when urine is passing along 
 it. When, owing to some change in the structure of its walls, 
 this functional dilatation is impracticable, the patient is said to 
 suffer from stricture. Three forms of stricture are described, \\z., 
 the spasmodic, congestive and organic. 
 
 Spasmodic and Congestive Strictures frequently co-exist, although 
 either congestion or spasm may be the predominant feature in any 
 particular case. Thus, in acute gonorrhoea the mucous membrane 
 often becomes engorged and thickened to such an extent as to 
 interfere with the act of micturition. Spasm is the chief element 
 under the following conditions : (i) When a patient, suffering 
 from slight organic stricture, is exposed to wet or cold, especially 
 after heavy drinking ; (2) after operations on the rectum or sper- 
 matic cord ; (3) as a result of catheterism ; and (4) from perineal 
 irritation of the urethra, as by a blow or kick in this region, or 
 from prolonged riding on a bicycle with a badly-fitting saddle or 
 on horseback. Temporary retention is the usual result of any of 
 these conditions, and, as a rule, no treatment is required beyond 
 placing the patient in a hot bath, and unloading the lower bowel 
 by the use of a large warm enema. If such fails, catheterism 
 will be necessary, and must be conducted with the greatest 
 I gentleness, owing to the congested and lacerable condition of the 
 
IC72 
 
 A MANUAL OF SUIiGEIiY 
 
 mucous membrane. Full-sized soft Instruments shoiild first 
 used, and will usually succeed ; if not, a silver instrument mi 
 be substituted. 
 
 Organic Stricture is the term applied to an undilatable condit 
 of the urethra, resulting from the development of cicatricial tisj 
 within its walls. 
 
 The Causes of organic stricture are : {a) the long continual 
 of a urethral discharge, following gonorrlui^a, or the frequent 
 currence of this affection. Chronic infl:v.iimatifins are alvv. 
 characterized by a tendency to sclerosis of the tissues involv 
 and the urethra is no exception to this rule, its walls under th 
 circumstances becoming thickened, indurated, and contract 
 {})) The cicatrization of a urethral chancre, or of an ulcer cau; 
 by the impaction of a stone, or the contraction produced by 
 healing of a urethral abscess, may also lead to stenosis, {c) 1 
 most intractable forms of stricture are those due to cicatrizat 
 after rupture or laceration of the urethral wall. 
 
 The usual Situation is within the bulb, i.e., just in front of 
 triangular ligament ; but the orifice and body are not unfrequer 
 affected. It occurs in the membranous portion only as a res 
 of traumatism, and never in the prostatic. To find more tl 
 two strictures in any particular case is unusual, although three 
 four have been met with. 
 
 Various terms are applied to a stricture according to i 
 physical conditions present ; thus, it is termed annular, if 
 involves the whole lumen of the urethra ; bridled, if it affects o 
 a portion of the circumference of the tube. A ribbon-shaped st 
 lure is one in which a considerable extent of the wall is contrac 
 {i.e., as if a ribbon had been tied around the urethra). It is tern 
 tortuous, if the resulting passage is not straight ; indurated, if 
 walls are very hard and thickened ; and resilient, when the stricti 
 though readily dilated, rapidly re-contracts. The terms impassi 
 and impermeable are applied to strictures through which, on the ( 
 hand, a surgeon is unable to pass an instrument, or along whi 
 on the other hand, urine cannot find its way ; it is doub 
 whether the latter condition ever occurs, whilst the numbei 
 impassable strictures met with by the surgeon diminishes with 
 experience and ability in passing instruments. 
 
 The Symptoms of urethral stricture vary according to the c; 
 The patient generally complains of difficulty in the act of mict 
 tion, the stream becoming small, and perhaps forked or twist 
 It takes p, longer time than usual to empty the bladder, and e 
 when apparently successful a few drops of urine may trickle a^\ 
 wetting the patient's clothes. Irritability of the viscus folk 
 leading to frequent attempts to pass water at short inter\ 
 during the day and night. The urine under these circumstar 
 often becomes alkaline, and loaded with muco-pusand phospha 
 As the obstruction increases, more and more residual urine is 
 
AFFECTIONS OF THE URBTHRA AND PENIS 
 
 '07J 
 
 ents shovilcl iirst be 
 ,er instrunient must 
 
 ancUlatal)le condition 
 It of cicatricuvl tissue 
 
 the lonf^ continuance 
 x, or the frequent re- 
 .matirns are always 
 the tissues involved, 
 its walls under these 
 ated, and contracted 
 
 o^se°due to cicatrization 
 
 vail. 
 
 just in 
 
 in the bladder, which may in time form a tense, rounded, dull 
 swelHuK in the liypof^astriuni. The (luantily of urine trickling 
 away also increases, so that the patient's garments are always 
 wet, K'viuf,' him an unpleasant urinous otiour. A certain amount 
 ol gleety discharf^e is present, wliilst if tiie individual takes an 
 excess of alcohol, or is exposed to wet and cold, complete reten- 
 tion may ensue. Sometimes the onset of symptoms is so insidious 
 that such an attack of retention is the first marked feature in the 
 case. 
 
 The Pathological Conditions arisinj,' from a stricture are best 
 considered under the followinj; five headinf,'s : (i) The uvcthya 
 antcrioy to the stricture is usually in a perfectly normal state, 
 of an ulcer caused E although possibly the orifices of false passages may be seen. A 
 • °- produced by the ft few granulations are sometimes present, projecting at the com- 
 a to stenosis. (0 'l'*^*^ I inencement of the stricture. (2) The styiciuyc itself \s characterized 
 
 hy the development of fibro-cicatricial tissue immediately under 
 
 tlic mucous membrane, and intimately adherent to it. it extends 
 
 front of the K for a variable distance, and is often associated with i good deal 
 
 t' "'re'not'unfretiuently Bof peri-urethral infiltration. (3) The urdnra behind th' 4nctnye is 
 
 t" on only as a result ■ dilated, and the mucous membrane velvety and f . iable ; the 
 
 ?°'' rpQ fjjjj more than Borifices of the lacunie and other glands are somewhat enlarg' J 
 
 ^' 1 ilthough three or Band more than usually evident, and perliaps r - ^ration nr>y be 
 
 '^^^'^'^ ' ' Bpresent around them. In the lattr stages the inflammntion may 
 
 o.^^r,rflin<' to theBextend to the p:*-i-uretliral tissue owing to lymphatic .'bs .ption, or 
 "ture accoi'-i"»f-> t •.■ 1 ^ \ c c 1 ,• • 11 
 
 L . ^.^ed annnlav, n U ■perhaps to the escape ot a tew drops ot urine; a permcal abscess 
 
 ; 'died if it affects onlyBthen results, leading subsecjuently to perineal f'lstuhe. When the 
 
 A. nhhon-shaped stricBohstruction becomes almost absolute, this portion of the urethra 
 
 'f the wall is contracted fciay give way, leading to extravasation of urine into the perineum 
 
 " thra"). It is termedBind scrotum. (4) The bladder invariably manifests considerable 
 
 ^ ^^ I f in'dui'atcd, if theB;hanges in structure. At first the \esical wall undergoes a com- 
 
 ^.'^^^, .Ay^en the stricture, B)ensatory hypertrophy of its muscular elements and is thickened, 
 
 'TUg terms i«t/'^ss(iWi Bn order to overcome the obstruction to the onward passage of 
 
 ^' »h which, on the oneBjrine (Fig. 370). The lattice-work arrangement of the muscular 
 
 '^° °^ Qj. along whicli,B)ands becomes coarse, thickened, and evident, causing the vesical 
 
 •^ wav • it is doubtfulBvall to assume a fasciculated appearance. As the pressure in- 
 
 \ ilst' the number otBreases, the mucous membrane protrudes between the muscular 
 
 diminishes with hisBisciculi, giving rise to sacculation ; it is also thickened and con- 
 
 ®° "ested as a result of chronic cystitis, the superficial veins being vari- 
 
 se, and the surface perhaps ulcerated. The urine becomes alka- 
 
 e and decomposes, containing muco-pus and phosphates. It is 
 
 ely to stagnate in any sacculi which exist, and may then 
 
 termine the formation of phosphatic concretions ; or the walls 
 
 the sacculi become ulcerated, and after a time perforation and 
 
 travasation of urine into the cellular tissue lead to a fatal 
 
 ue. Occasionally the bladder, instead of being thickened, is 
 
 ated and atonic with very thin walls. (5) Consequent on the 
 
 langes in the bladder, the conditions already described as 
 
 dronephrosis, pyonephrosis, or pyelonephritis may develop 
 
 ■68 
 
 ints. 
 
 :, according to the case, 
 Itv in the act of mictur j 
 hips forked or twisted,| 
 tv the bladder, and e^ 
 
 I urine may trickle away,| 
 
 IV of the viscus folio 
 
 'fater at short intervaij 
 
 ider these circumstanced 
 
 uco-pus and phosphate 
 
 bre residual urine is leti 
 
I074 
 
 A MANUAL OF SURGERY 
 
 ■'tm 
 
 partly as the result of the backward pressure, and partly from 
 extension of septic matter along the ureter to the pelvis of 
 kidney and calyces. 
 
 Physical Examination. — The actual diagnosis of a stricture 
 only be confirmed by a careful physical examination of the uretl 
 
 Fig. 370. — Stricture of the Urethra. (College of Surgeons 
 
 Museum.) 
 
 At A and B strictures are seen, under which glass rods have been passed, 
 bladder is somewhat dilated, and its walls are thick and hypertro} 
 and with commencing sacculation. 
 
 which is usually made by the introduction of a full-sized catln 
 or a solid bougie, e.g., No. 9 or 10 (English), so as to asceit 
 where the obstruction is situated. If this cannot be pas; 
 smaller instruments, and even filiform bougies, are inser 
 until one is found which will enter the bladder. 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 lO'/S 
 
 3, and partly from the 
 : to the pelvis ot the 
 
 osis of a stricture can 
 ination of the urethra, 
 
 r-A 
 
 -B 
 
 (College of Surgeons 
 
 rods have been passed. J 
 1 are thick and hypertroph.t 
 
 3n of a full-sized cathete: 
 
 rlish), so as to ascertar 
 
 'this cannot be passe 
 
 bougies, a.e insert^ 
 
 idder. 
 
 A great variety of catheters is in use ; in old days only metal 
 instruments were obtainable, and even now the silver catlieter 
 is the favourite with many surgeons of eminence. In selecting 
 such an instrument, care must be taken that it is suitably 
 curved, and that the ' eye ' is sufficiently large and bevelled 
 inwards, so that no projecting rim lacerates the urethral mucous 
 membrane. The great advantages of the metal instrument are 
 that it is easily kept aseptic, and that the point can be located 
 and thus guided more readily along the urethra. Of late years 
 many different forms of flexible catheters have been introduced, 
 and are now extensively employed, inasmuch as they give rise to 
 less irritation than those made of metal. The objections to them 
 are that the materials of which they consist are readily attacked 
 and injured by antiseptics, whilst they are less easily directed 
 through a stricture on account of their flexibility, it being impos- 
 sible to know with certainty the situation of the point. Probably 
 the best means of sterilizing a soft instrument is to expose it to 
 the action of steam, which should be made to act not only on the 
 exterior, but also inside the tube ; many appliances to obtain this 
 object have been devised. Amongst the best flexible instru- 
 ments are the English or gum-elastic catheter, the French olive- 
 headed or catheter-a-boule, and others made of silk-web coated 
 with shellac, etc. Some varieties are now polished and prepared 
 inside as well as out, and they should, if possible, always be 
 selected. 
 
 Bougies or solid instruments are preferred by some surgeons 
 for the examination and treatment of strictures. Those known 
 as Lister's bougies are the best, consisting of solid metal rods, 
 curved like catheters, the bulbous ends of which are three 
 S sizes smaller than the shanks, thus enabling each instrument 
 passed to prepare the way for the next. Flexible bougies are 
 also made, whilst for finding a way through a tight and tortuous 
 stricture a filiform or a long graduated whip-lash bougie, made 
 of whalebone or catgut, may be employed ; in the latter variety, 
 the fine end is passed through the stricture, and coils up in the 
 bladder, whilst the thicker portion is thus brought to bear on the 
 stricture. 
 
 In order to introduce a silver catheter or bougie, the patient is laid 
 [on his back, the surgeon standing on his left side. The umbilicus 
 should always be exposed, as also the upper parts of the thighs. 
 The catheter, which has been previously sterilized, warmed, and 
 Icovered with some antiseptic oil or grease, is taken in the right 
 land, and inserted into the urethra, with the handle directed 
 iver the left thigh and slightly downwards. The point of the 
 instrument is guided as far as the perineum, and then the handle 
 carried round to the middle line of the body towards the 
 imbilicus ; it is then raised to the vertical, the penis being held 
 m the left hand, and gently depressed between the patient's 
 
 68—2 
 

 ■\ 
 
 '^^ 
 
 A- 
 
 '% 
 
 IC76 
 
 A MANUAL OF SURGERY 
 
 thighs, the so-called tour-de-maitre. The catheter finds its ■ 
 along the urethra into the bladder rather by its own weight t 
 by any forcible action of the surgeon. The chief points at wl 
 difificulty may be experienced are : [a) The orifice, which maj 
 small and contracted ; {b) the lacuna magna, which is avoidec 
 keeping the point of the instrument against the floor ; and {c) 
 opening in the triangular ligament, which is best entered 
 keeping the point against the upper wall of the canal. 
 
 Some authorities recommend that the patient should stand 
 with the back resting against a wall or firm support, the surg 
 sitting in front, and manipulating, it is said, with greater accur; 
 The objections to this position are : {a) The liability of the pat 
 to faint, and (b) the existence of greater muscular tension t 
 obtains in the horizontal posture. 
 
 When a flexible instrument without a stilette is used, i 
 passed by pressing the point on with a littlu rotatory moven 
 until the bladder is reached, withdrawing a little, and pusl 
 on again, if any obstruction is met. In some instances, howe 
 the use of a stilette is absolutely necessary. 
 
 The chief Dangers of catheterism are as follow : i. A consii 
 able degree of shock is sometimes experienced, especially in se 
 tive individuals, and if an instrument has not been passed bef 
 It may be obviated to a large extent by first introducing at 
 half a drachm of the 5 per cent, solution of cocaine into 
 urethra. 
 
 2. Hamoyyhagc may be induced by laceration or abrasion of 
 mucous membrane, even though no false passage has been m^ 
 it is best avoided by gentleness and the use of well-finis 
 instruments. In spite of these precautions, when the mu( 
 membrane is soft and congested, and in many cases of strict 
 some bleeding cannot be avoided. It is rarely sufficient to 
 for special treatment, but if very abundant may be arrestee 
 injections of hazeline or of iced boric acid lotion. 
 
 3. False passages are frequently produced in the treatmen 
 strictures. The point of the instrument is most likely to It 
 the canal at some spot in the floor, travelling for a vari 
 distance, according to the force employed, under the mu( 
 membrane, occasionally re-entering the dilated urethra be 
 the stricture, which it avoids altogether, or perforating 
 posterior wall of the bladder by tunnelling under the prostatt 
 accident which can only occur in unskilful hands. The oc 
 rence of a false passage is indicated by the sudden onward m 
 ment of the instrument, combined with pain and haemorrh; 
 the point is usually deflected from the middle line, as is pi; 
 seen by the obliquity of the rings at the end of the shaft ; no i 
 comes unless the urinary passages are opened behind the stric 
 On rectal examination, the instrument can be felt out of 
 middle line, and nearer the rectum than is normal, and in i 
 
 / 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 1077 
 
 theter finds its way 
 'its own weight than 
 
 chief points at which 
 orifice, which may be 
 , which is avoided by 
 the floor ; and (0 the 
 ^ is best entered by 
 
 the canal. 
 
 .tient should stand up, 
 a support, the surgeon 
 with greater accuracy 
 lUability of the patient 
 muscular tension than) 
 
 I stilette is used, it is 
 ttlu rotatory movement 
 
 Ifme instances, however,| 
 
 iS 
 
 exceptional cases has even been found in it. False passages are 
 not necessarily matters of great importance, but when extensive 
 may lead to peri-urethral suppuration and extravasation of urine, 
 possibly followed by fatal results. 
 
 4. Inflammatory phenomena may be lighted up in the prostate 
 and acute epididymitis induced by extension along the vas 
 deferens ; these are almost always due to sepsis. 
 
 5. Urinary Fever, or, as it is somet'mes termed, urethral or 
 catheter fever, is always liable to develop as a result of the intro- 
 duction of instruments. It may occur as a solitary rigor even in 
 individuals with healthy urinary organs, but is much more fre- 
 (]uently observed in those with damaged kidneys. As to its 
 causation, there has been much discussion, but there can now be 
 little doubt that it is essentially septic in origin. Possibly the 
 instrument employed may be dirty, or the urethra itself contains 
 septic material, especially in its deeper parts. It is quite sufficient 
 
 rtfl'^^'and* pushingl for a slight abrasion to occur near the neck of the bladder, to allow 
 
 ' ' ■ of the absorption either of toxins or of bacteria, and then general 
 
 phenomena show themselves at once. If merely toxic products 
 are absorbed, probably a passing febrile condition, such as one or 
 more rigors, will develop, with no more serious phenomena ; but 
 if bacteria find their way into the submucous tissues, they are 
 likely to develop rapidly in the lymphatics, extending to the 
 bladder and thence up the ureters owing to the continuity of 
 lymphatic supply, giving rise finally to pyelonephritis (p. 1007). 
 brasion of thtB Formerly reflex congestion of the kidneys was thought to be an 
 ration ^'^ been ma'leBimportant factor in these cases ; probably the congestion which 
 passage ^ ^g\\.finisheiSoccurs is due to the direct irritation of bacteria, and not to nervous 
 
 phenomena. 
 
 The clinical manifestations vary considerably, according to the 
 [character of the case and the type of infection, [a) The simplest 
 oiin consists in the development of a single rigor, the temperature 
 erhaps running up to 105° F. ; the patient shivers and feels very 
 11, and the head aches, but when the temperature falls he soon 
 ecovers, and within a few hours is all right again, {h) Sometimes 
 he temperature does not fall to the normal after the initial rigor, 
 ut remains elevated a few degrees for a day or two, and there 
 ay even be a repetition of the rigor. The patient, however, 
 ecovers perfectly, and no permanent harm is done, {c) In the 
 ore serious cases the symptoms of pyelonephritis supervene, 
 ,nd are very likely to prove fatal, the patient perhaps dying in 
 van or eight days, (d) General pyaemia may appear as a com- 
 plication of the last condition, {e) In patients who are com- 
 encing the regular passage of catheters for enlarged prostate a 
 
 ..follow: I. A consider! 
 
 A ^Qneciallv in sensi| 
 need, especid,ii> , r I 
 
 3 not been passed betorel 
 ; first introducing abou,| 
 ;ion 
 
 of cocaine into tht 
 
 the use of 
 
 Tarlly sufficient to c4 
 ant may be arrested bj 
 
 lotion. ^ ^. 
 
 ced in the treatment 
 t Ts most likely to leaJ 
 travelling for a vanabl 
 
 ^aated urethra beht 
 
 Ither or perforating l^ 
 
 ng under the prostate, 
 
 Hful hands. The-c 
 le sudden onward 
 'Vain and hannorrh| 
 
 middle line, as 1 ^^ '^-.^^ of phenomena' develop, which have been already alluded 
 
 '"^Si VVndthestrictu*) (p. 1065), and though often mild, are of a similar nature. 
 
 ened ^^"^"^^^ ^^t of •) Finally, suppression of urine may accompany any of the 
 
 |n?s"normal, and in so#nditions alluded to above. 
 
 occul 
 movl 
 
I07S 
 
 A MANUAL OF SURGERY 
 
 Treatment. — Whenever it seems probable that the kidneys are 
 damaged, the greatest care must be taken in order to avoic 
 septic infection. The instruments employed, whether bougies or 
 catheters, must be thoroughly sterilized, and it would also be wel 
 to irrigate the urethra with a mild antiseptic lotion. It is perhaps 
 better to use soft, elastic instruments rather than silver ones, as 
 the latter give rise to more irritation than the former, and are 
 more likely to abrade the mucous membrane. 
 
 For the single rigor following catheterism, the patient must be 
 kept warm, plenty of hot diluent drinks given, and quinine 
 (2 grains) and opium (^ to i grain) administered in a pill, although 
 the latter drug must be sparingly used if any evidences of uraemia 
 are existent. If the febrile symptoms continue, the skin anc 
 bowels are freely acted on, and a milk diet prescribed, although a 
 certain amount of stimulant may be given if necessary ; all 
 operative measures must be avoided, unless it is essential to 
 relieve obstruction, as they are almost invariably fatal. Should 
 suppression of urine ensue, the loins should be cupped in the 
 hope of relieving renal congestion, a free action of the bowels 
 obtained by the use of watery purgatives, and the patient made 
 to sweat freely, either by the use of hot-air baths or by the in- 
 jection of pilocarpine. Uraemic symptoms may sometimes be 
 relieved by copious and repeated intravenous injections of 
 normal saline solution, which encourage diuresis and a watery 
 diarrhoea ; several successful cases treated in this way have been 
 recorded. 
 
 The Treatment of Passable Strictures is conducted either by 
 dilatation or by a cutting operation (internal or external ure- 
 throtomy). 
 
 Treatment by Dilatation is effected in various ways, according 
 to the nature of the stricture and the urgency of the symptoms. 
 Where the obstruction is not serious, and an instrument can be 
 easily passed, gradual dilatation should always be employed ; this 
 consists in the use of instruments once or twice a week, steadily 
 increasing the size until a No. 12 is reached. If the intervals are 
 too short, the urethra may become irritated, spasm be induced, and 
 the lumen of the canal temporarily diminished in size ; by keeping 
 the patient quiet for a few days on a bland diet, and the bowels 
 well open, the spasm disappears. In cases where time is an 
 object, rapid dilatation may be undertaken by the passage of several 
 sizes of bougie at one sitting ; for this purpose, Lister's instru- 
 ments are particularly useful. Where only a very small catheter 
 can be introduced, and that with difficulty, contimwus dilatation 
 may be adopted by keeping the patient in bed, tying in the small 
 instrument for forty-eight hours or more, at the expiration of 
 which period a catheter several sizes larger can be substituted, 
 This in turn may be tied in if the patient can bear it ; but the 
 presence of a catheter within the urethra for any length of time 
 
AFFECTIONS OF THE URETHRA AND PENIS 1079 
 
 hat the kidneys are 
 in order to avoid 
 whether bougies or 
 t would also be well 
 »tion. It is perhaps 
 than silver ones, as 
 he former, and are 
 
 ;he patient must be 
 given, and quinine 
 id in a pill, although 
 svidences of uraemia 
 ;inue, the skin and 
 ascribed, although a 
 1 if necessary ; all 
 is it is essential to 
 iably fatal. Should 
 i be cupped in the 
 ction of the bowels 
 \d the patient made 
 baths or by the in- 
 
 may sometimes be 
 snous injections of 
 uresis and a watery 
 
 this way have been 
 
 onducted either by 
 al or external ure- 
 
 is not always tolerated, and may give rise at the end of two or 
 three days to considerable constitutional disturbance and fever. 
 Forcible dilatation is a plan which has now but few advocates. 
 It consists in the passage of an instrument, the shaft of which 
 is made in two portions, which can be separated from one 
 another in such a way as to destroy the stricture either by dis- 
 tension or rupture of its substance. It is but little used, on 
 account of the great tendency, when cicatri;iation is complete, to 
 the formation of an even more intractable stricture than before. 
 
 By whichever of these methods dilatation is accomplished, it i ^ 
 essential that either the surgeon or the patient should subsequently 
 pass an instrument through the stricture at first every week or 
 two, and then at longer intervals, to overcome the tendency to 
 recontraction which is ever present. 
 
 The Treatment of Passable Stricture by a Cutting Operation is 
 conducted either by internal or external urethrotomy. 
 
 Internal Urethrotomy is a valuable means of treatment when 
 rightly employed, but in careless or inexperienced hands may be 
 attended with considerable danger. It has been performed either 
 
 ^^^—f ^ ^^^^nn -i. 
 
 r 
 
 OOWtJ^ BROS LONDON 
 
 HALr SIZE 
 
 Fig. 371.— Civiale's Urethrotome. (Down Brothers.) b 
 
 by passing an instrument through the stricture, and dividing it 
 from behind forwards, or by passing an instrument down to the 
 stricture, and dividing it from before backwards. The latter plan 
 of treatment, though recommended by some skilled authorities, 
 is not an operation which commends itself to our judgment, inas- 
 much as it is almost impossible to gauge the amount of tissue 
 divided. The former plan of incising a stricture from behind for- 
 wards is of course only called for under special circumstances, 
 since if the urethrotome can be passed through a stricture, ordi- 
 nary dilatation is in the majority of cases practicable. It is use- 
 ful, however, [a) in the treatment of very old and dense carti- 
 laginous strictures, as also (b) for resilient strictures, and (c) when 
 the urethra is excessively irritable. It should only be employed 
 when the obstruction is situated in the anterior two-thirds of the 
 urethra. Many forms of urethrotome have been devised, but 
 perhaps the most useful is that known as Civiale's (Fig. 371), 
 which can only be used for a stricture which will admit the passage 
 of a No. 5 catheter. The end is bulbous, and contains a hidden 
 knife, worked by means of a button in the handle. The instrument 
 is passed through the stricture, the cutting blade projected, and by 
 withdrawing it the cicatricial tissue is notched to such an extent 
 
 /.. 
 
 r' . . - '■-...•' 
 
io8o 
 
 \' r i 
 
 \ /] MANUAL OF SURGERY 
 
 m 
 
 m 
 
 as to allow a full-sized catheter to be inserted at once, and, if 
 possible, tied in. Where the deeper part of the urethra is being 
 dealt with, the incision should be made along the roof so as to 
 avoid the bulb. Care must be taken not to cut 
 beyond the limits of the cicatricial tissue, other- 
 ^ wise haemorrhage, peri-urethral suppuration, or 
 Jg even extravasation of urine, may ensue. It is 
 X also advisable to sterilize the urethra as far as 
 o possible by washing it out with weak antiseptic 
 m solutions before operating. 
 
 z External Urethrotomy, or Syme's Operation, is 
 o required under circumstances similar to those 
 needing internal urethrotomy, if the stricture is 
 . situated in the posterior third of the urethra, but 
 s is chiefly employed where perineal fistulas are 
 H present. It is performed by passing a special 
 « shouldered staff (Syme's, Fig. 372), the distal end 
 H of which is small enough to pass through the 
 ^ stricture, and grooved in the middle line, whilst 
 J the shaft of the instrument is of larger size, and 
 < ends abruptly, so that the shoulder rests against 
 g the face of the stricture ; the groove extends on 
 X to the larger portion for about -| inch. The 
 ^ patient is then placed in the lithotomy position, 
 o and the surgeon, seated opposite the perineum, 
 ^ which is shaved and well purified, incises it in 
 i5 the middle line, carrying his dissection carefully 
 c^ downwards so as to reach the groove in the staff 
 
 behind the stricture. The knife is then carried 
 K forwards to the anterior extremity of the groove, 
 Q and inasmuch as it extends on to the shaft of 
 g the instrument, the stricture is completely divided. 
 K Any fistula: which exist are laid open into the 
 yj median wound, and thoroughly scraped and puri- 
 "1 fied. A full-sized soft catheter is then passed 
 > into the bladder, through either the penis or the 
 
 1 perineum, according to circumstances, and re- 
 fj^ tained in position for some days, the urine being 
 "^ syphoned off in the usual way, whilst the perineal 
 2 wound, after all haemorrhage has been stopped, 
 
 is packed with strips of antiseptic gauze, and 
 allowed to heal by granulation. The catheter is 
 removed early or late according to the amount 
 of general disturbance caused thereby, and subsequently a fiill- 
 siztd instrument can be passed into the bladder daily. Some 
 surgeons have recommended the use of the so-called self-retaining 
 catheters, in the hope of preventing urine from finding its way 
 through the external wound ; several varieties have been suggested, 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 1081 
 
 i at once, and, if 
 le virethra is being 
 the roof so as to 
 
 taken not to cut 
 •icial tissue, other- 
 il suppuration, or 
 may ensue. It is 
 
 urethra as far as 
 th weak antiseptic 
 
 yme's Operation, is 
 s similar to those 
 if the stricture is 
 of the urethra, but 
 lerineal fistula; are 
 7 passing a special 
 372), the distal end 
 ) pass through the 
 s middle line, whilst 
 s of larger size, and 
 loulder rests against 
 e groove extends on 
 bout i inch. Tbe 
 3 lithotomy position, 
 )Osite the perineum, 
 lurified, incises it in 
 dissection carefully 
 |e groove in the staff 
 nife is then carried 
 ;mity of the groove 
 on to the shaft of 
 completely divided, 
 laid open into the 
 ,ly scraped and puri- 
 eter is then passed 
 jher the penis or the 
 umstances, and re- 
 lys, the urine being 
 , whilst the perineal 
 ' has been stopped, 
 tiseptic gauze, and 
 ,n. The catheter is 
 litig to the amount 
 subsequently a full- 
 adder daily. Some 
 -called self-retaining 
 jom finding its way 
 lave been suggested, 
 
 but they are of little practical value, since the escape of urine along 
 the side of the instrument can never be totally prevented. 
 
 Excision of a Stricture has been undertaken with success in 
 several cases \yhere dilatation and urethrotomy had failed to give 
 permanent relief. As much as one inch of the urethra has been 
 removed, and the ends sutured together with successful primary 
 union. 
 
 The Treatment of Impassable Stricture varies according to 
 whether or not the condition is complicated with retention of 
 urine. 
 
 If no retention is present, it is possible that the inability to pass an 
 instrument is due to some temporary spasm or congestion induced 
 by errors of diet or drink, 
 or perhaps by exposure to 
 cold. Hence the patient 
 should rest in bed for a 
 few days, his bowels be 
 well opened, the diet 
 regulated, and a mixture 
 containing some alkaline 
 purgative and tincture of 
 henbane administered. 
 Further attempts at in- 
 strumentation should then 
 be made, if necessary, 
 under an anaesthetic, and 
 if the stricture still remains 
 impassable, Wheelhouse's 
 opeyation (Fig. 373) is in- 
 dicated. This consists in 
 incising the urethra in 
 front of the constriction. 
 
 Fig. 373. — Wheelhouse's Operation for 
 Impassable Stricture. (Bryant's ' Sur- 
 gery.') 
 
 tracing the passage backwards, and dividing it. A Wheelhouse's 
 straight staff with a median groove and a blunt hook at the end 
 is inserted down to the stricture, and the urethra opened just in 
 front of it by cutting down on the groove. The staff is then 
 twisted round, the upper end of the incision drawn up by the 
 projection of the hook, and the sides of t.ie urethra held apart 
 with artery forceps. The orifice of the stricture is thus exposed, 
 and granulations may often be seen projecting from it. A fine 
 probe-pointed director can generally be insinuated along the 
 urethra through the stricture, which is then divided. A full-sized 
 instrument is passed into the bladder and retained for a few days, 
 whilst the wound is allowed to heal by granulation. 
 
 If retention of urine is present in a case of impassable stricture, 
 no ame must be l-^-t. If seen at an early stage, and the 
 symptoms are not urgent, the patient is given a hot bath, 
 and the bowels are opened by a warm enema, whilst a moderate 
 
I082 
 
 A MANUAL OF SURGERY 
 
 
 dose of opium or preferably a morphia suppository is adminis- 
 tered. If the urine is not passed naturally in the bath, and 
 the bladder is becoming distended, being felt in the lower part of 
 the abdomen, suprapubic aspiration, or puncture with a trocar 
 and cannula, should be undertaken, and temporary reliji" thus 
 obtained. Probably, when tension has been removed from the 
 posterior part of the urethra, a catheter will be introduced without 
 much difficulty. Failing this, aspiration may be several times 
 resorted to, but it is generally wiser to open the urethra in front 
 of or behind the stricture, and drain the bladder, since the risks of 
 septic troubles, extravasation of urine, dangerous pressure upon 
 the kidneys, and urinary infiltration along the lines of puncture, 
 are thereby lessened. 
 
 Cock's Operation, or Perineal Section, is sometimes adopted 
 when no guide can be passed into the bladder (Fig. 374). The 
 
 Fig. 374— Cock's Operation of Perineal Section. 
 (Bryant's ' Surgery.') 
 
 patient is placed in the lithotomy position, and the situation of the 
 membranous urethra ascertained by inserting the index-finger 
 into the rectum. A median perineal incision is then made, and 
 after dividing the cutaneous structures, the surgeon plunges the 
 scalpel boldly in towards the apex of the prostate, guided by his 
 finger in the rectum. He must keep strictly in the middle line, so 
 as to avoid the important vascular and other structures which are 
 so abundantly present in the perineum. As soon as the urethra 
 is opened, a gush of urine often escapes ; the upper urethral wall 
 should not be damaged with the knife, for fear of opening up the 
 deep pelvic cellular tissue. 
 
 This operation may be tolerably simple if the urethra behind 
 the stricture is dilated, as is not uncommonly the case ; but 
 sometimes it is extremely difficult, especially if the urethra has 
 been displaced laterally. If the stricture is not situated too far 
 from the incision, it is always wise to complete the operation by 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 1083 
 
 sitory is adminis- 
 in the bath, and 
 I the lower part of 
 ure with a trocar 
 porary rehjf thus 
 removed from the 
 introduced without 
 f be several times 
 e urethra in front 
 r, since the risks of 
 ous pressure upon 
 lines of puncture, 
 
 sometimes adopted 
 jr (Fig. 374)- The 
 
 ill Section. 
 
 the situation of the 
 kg the index-finger 
 I is then made, and 
 |urgeon plunges the 
 state, guided by his 
 n the middle line, so 
 [tructures which are 
 loon as the urethra 
 1 upper urethral wall 
 of opening up the 
 
 the urethra behind 
 Uly the case; but 
 [ if the urethra has 
 I not situated too far 
 
 te the operation by 
 
 dividing it, and a full-sized catheter can then be passed into the \ 
 bladder, and the perineal wound allowed to granulate. If the ^ 
 stricture cannot be dealt with during the operation, and is of a 
 dense cartilaginous nature, a tube is inserted into the bladder 
 through the perineum ; probably at the end of a few days the 
 tissues will yield sufficiently to allow of the passage of a catheter, 
 or Wheelhouse's operation can be subsequently adopted. 
 
 The chief complications of stricture other tlian those already 
 mentioned are perineal abscess, perineal fistula, and extravasation 
 of urine. 
 
 A Perineal Abscess consists in a focus of peri-urethral suppura- 
 tion, which is due either to a limited extravasation of urine, or to 
 the absorption of septic material through an ulcerated surface. 
 It is indicated by the formation of a hard, brawny swelling in the 
 perineum, which is tender to the touch. As it approaches the 
 
 Fig. 375. — Perineal Fistul.t; (Bryant's 'Surgery.') 
 
 surface, fluctuation can be detected, and the skin over it becomes 
 congested and oedematous. Constitutional disturbance and fever 
 of an asthenic type are also present. Left to itself, it bursts and 
 usually gives rise to a perineal sinus or fistula, discharging either 
 pus, or urine mixed with pus. One or many of these fistulae may 
 occur (Fig. 375), and the openings are not limited to the perineum, 
 but may also be found in the thighs, buttocks, or even the groins. 
 In chronic cases, the scrotal or perineal tissues become infiltrated 
 and of an almost cartilaginous consistency. 
 
 Diagnosis. — Every abscess in the scrotum or perineum is not 
 necessarily associated with stricture, for simple irritation of the 
 skin may lead to a superficial abscess ; suppuration in the lacunar, 
 or Cowper's glands, may follow gonorrhoea ; a prostatic or ischio- 
 rectal abscess may point in the perineum ; whilst the injury 
 inflicted by the passage of instruments, or the existence of false 
 passages, may lead to a similar result. 
 
 The Treatment of a Perineal Abscess consists in the application 
 
1084 
 
 A MANUAL OF SURGERY 
 
 of fomentations during the early stages ; as soon as pus is present, 
 it should be let out througli a free incision, and it is often advisable 
 to take the opportunity of dealing radically with the stricture by 
 section at the same time. Perineal fistulae can rarely be cured 
 without operation, since, although the stricture may be completely 
 dilated, the discharge of urine and pus continues. Under these 
 circumstances Syme's or Wheelhouse's operation is the proper 
 treatment. 
 
 Extravasation of Urine is a condition due to a solution of con- 
 tinuity of the urethral walls, allowing the urine to find its way 
 into the perineal and scrotal tissues. It usually results from over- 
 distension of the urethra behind a neglected stricture ; during 
 some violent effort at micturition, the patient experiences severe 
 pain and a sensation as if something had given way in the 
 perineum, followed by a feeling of relief. This, however, is of 
 short duration, as it is soon succeeded by the local and constitu- 
 tional effects of extravasation. The same phenomena are pro- 
 duced in cases of traumatic laceration of the urethra if the patient 
 attempts to empty his bladder. Occasionally the onset of 
 symptoms is more gradual, being preceded by a peri-urethra! 
 abscess, which bursts into the urethra ; at each act of micturition 
 the cavity becomes more and more distended with urine ; finally 
 the wall yields, resulting in diffuse extravasation. 
 
 The membranous urethra is almost always the site of the rupture, 
 the urine finding its way subsequently through the anterior layer 
 of the triangular ligament, and being guided towards the an- 
 terior abdominal wall by the arrangement of the fasciae. The 
 root of the penis, covered by its appropriate muscles, lies in an 
 interfascial cul-de-sac, formed by the anterior layer of the 
 triangular ligament above, and the deep layer of the perineal 
 fascia (or fascia of Colles) below ; these two layers are con- 
 tinuous, passing round the transversus perinei muscles, and are 
 both attached laterally to the ischio-pubic rami. Into this space 
 the urine finds its way, after the anterior layer of the triangular 
 ligament has yielded, and owing to the fact that its passage back- 
 wards and laterally is checked by the attachment of the fasciae, it 
 is necessarily forced forwards, infiltrating in order the perineum, 
 scrotum, and body of the penis. If more extensive, it travels 
 along the spermatic cords to the anterior abdominal parietes, its 
 passage downwards into the thighs being prevented by the attach- 
 ment of the deep layer of the superficial fascia of the abdomen to 
 the fascia lata just below Poupart's ligament. In the most severe 
 cases the urine may even find its way as far as the axillse. 
 
 The Effects of extravasation of urine are always serious, 
 Possibly, if the urine were pure and aseptic, part of it might be 
 absorbed ; but even then prolonged infiltration of the tissues is 
 likely to result in suppuration and sloughing. In cases of stricture, 
 however, the urine is almost certain to be foul and alkaline, and 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 io8; 
 
 as pus is present, 
 t is often advisable 
 1 the stricture by 
 in rarely be cured 
 nay be completely 
 aes. Under these 
 tion is the proper 
 
 a solution of con- 
 ne to find its way 
 J results from over- 
 stricture; durmg 
 experiences severe 
 given way in the 
 his, however, is of 
 local and constitu- 
 ihenomena are pro- 
 rethra if the patient 
 nally the onset oj 
 by a peri-urethral 
 'h act of micturition 
 I with urine ; finally 
 
 ion. 
 
 le site of the rupture, 
 rh the anterior layer 
 ed towards the an- 
 oi the fasciae. The 
 3 muscles, lies in an 
 terior layer of the 
 lyer of the perineal 
 wo layers are con- 
 lei muscles, and are 
 mi. Into this space 
 yrer of the triangular 
 ■^.at its passage back- 
 ient of the fascia, it 
 order the perineum, 
 extensive, it travels 
 idominal parietes, its 
 rented by the attach- 
 la of the abdomen to 
 In the most severe 
 ^s the axillse. 
 lare always serious, 
 part of it might be 
 ion of the tissues is 
 In cases of stricture, 
 ,ul and alkaline, and 
 
 hence wherever it travels it gives rise to a gangrenous cellulitis. 
 The parts at first become infiltrated and brawny, but soon emphy- 
 sematous crackling and putrefaction are observed, owing to necrosis 
 of the cellular tissue. The congested and u-dematous skin turns to 
 a dusky purple or black colour, and finally gives way or separates, 
 allowing exit to a mixture of pus, urine, and decomposing slougli 
 of a most offensive and penetrating odour. The superficial loss of 
 substance may be so extensive as to lay bare both testicles, and 
 even the body of the penis, or part of the anterior abdominal wall. 
 The inflammatory process is necessarily associated with severe 
 constitutional disturbance, at first characterized by higli fever and 
 a quick, bounding pulse ; but later on the temperature may become 
 subnormal, and the patient profoundly collapsed from toxaemia. 
 
 The Treatment consists in early and free incisions, so as to give 
 exit to the urine and pus, and to prevent, if possible, the sloughing 
 of the skin and subcutaneous tissues. Every part that the urine 
 has infiltrated must be dealt with in this way ; thus, the perineum 
 sliould be incised in the middle line ; the scrotum similarly 
 divided, if need be, down to the urethra, the testicles being laid 
 on either side ; the penis should be incised, if necessary, on either 
 side of the urethra, and along the dorsal surface. It is often 
 possible to expel a large portion of the urine, especially in the 
 scrotum, by firmly squeezing the infiltrated tissues. A full-sized 
 catheter must be passed into the bladder, and to effect this the 
 urethra has often to be laid open and the stricture divided ; 
 perineal drainage is always preferable for these cases. The parts 
 should be subsequently dusted over with iodoform, and dressed 
 with warm antiseptic applications, e.g., a charcoal or carbolic 
 linseed poultice, or boracic fomentations. Frequent hip-baths 
 should be employed, and, if practicable, a continuous sitz-bath 
 would be the very best means of treating the case. As soon as 
 the wounds become clean, they should be dressed in the ordinary 
 way to allow them to granulate. The general health of the 
 patient must of course be attended to, plenty of easily assimilated 
 nourishment, stimulants, and quinine being administered. 
 
 Urinary Fistulae are most commonly found in the perineum, 
 scrotum, or body of the penis. They usually result from peri- 
 urethral suppuration in connection with a stricture, but are occa- 
 sionally due to other causes, e.g., a lacunar abscess after gonor- 
 rhoea, or a prostatic abscess. They vary much in size and 
 number ; when the result of a stricture, many may be present 
 (Fig. 375), and great infiltration of the surrounding tissues is 
 usually produced. The Treatment of perineal fistula? has been 
 already in measure described, external urethrotomy being neces- 
 sary if a stricture exists. Occasionally the perineal wound does 
 not close after such an operation, even when the stricture has been 
 divided ; the edges of the fistula should then be pared, and the 
 wound brought together by deep quilled sutures. A catheter 
 
io86 
 
 A MANUAL Of BVMMKf 
 
 should l)e kept in the bladder for a few days, and tlie urine regu- 
 larly drawn off after its removal. 
 
 When of small size, and situated either in the perineum or the 
 penis, cure may be determined by cauterizing the passage either 
 with a probe coated with nitrate of silver or by a galvano-cautery, 
 but in other cases some form of urethroplasty is necessary. 
 
 Affections of the Penis. 
 
 Phimosis, when complete, is a condition in which the prepuc( 
 is so long, and the orifice so narrow, that it cannot be retracteil 
 behind the corona. It is usually Congenital in origin, and may 
 exist to such a degree as to render micturition impossible. Moro 
 frefjuently the opening is a very small one (pinhole prepuce) 
 permitting micturition, but leading to irritability of the bladder 
 from the obstruction. In such cases the prepuce is usually 
 adherent to the glans, and considerable irritation is caused by 
 the retention of the smegma secreted by Tyson's glands ; this 
 may collect and become so inspissated as to give rise to definite 
 concretions. The child pulls at the foreskin, owing to the itchinj,' 
 produced, and thus the symptoms of vesical calculus may be 
 simulated. Attacks of balanitis are also frequent, and should the 
 prepuce be withdrawn, paraphimosis is almost certain to follow. 
 If allowed to remain untreated long enough, distension of the 
 bladder, and even hydronephrosis, may supervene. Not only is 
 this condition in itself a cause of irritation and even danger to the 
 individuals affected, but it is often provocative of masturbation, 
 whilst it tends to aggravate the symptoms of venereal disease, 
 and there is but little doubt that it acts as a predisposing cause to 
 epithelioma of the penis. Phimosis also occurs as an Acquired 
 condition, resulting from the cicatrization of venereal sores. 
 
 The Treatment of phimosis consists in circumcision. Other 
 methods have been suggested — e.g., dilatation of the prepuce, and 
 merely slitting it up — but they are not satisfactory. 
 
 Circumcision should always be performed on children with a 
 long prepuce within the first year of life, since at that time the 
 parts are but slightly developed, the operation is a trifling one, 
 and but little inconvenience is svibsequently experienced ; the 
 longer it is postponed, the more troublesome does it become. 
 The best method of operating is as follows : The dorsal aspect 
 of the prepuce is put on the stretch by grasping it on either side 
 of the median line with a pair of catch forceps ; a director is then 
 introduced between it and the glans, and held exactly in the 
 middle line, and the prepuce slit up with a curved pointed 
 bistoury or scissors. The lateral halves are now separated from 
 the glans, adhesions, if necessary, being broken down ; this must 
 be very thoroughly attended to, so as to enable all retained 
 smegma to be removed, and the corona glandis defined. The 
 
AFFECTIONS OF THE URETHRA AND PENIS 
 
 1087 
 
 kI the urine regu- 
 
 le perineum of tlie 
 the passaf,'e either 
 a jfalviino-cautery, 
 3 necessary. 
 
 which the prepuce 
 :aiinot be retracted 
 in origin, and may 
 impossible. More 
 (pinhole prepuce), 
 ility of the bladder 
 prepuce is usually 
 tation is caused by 
 yson's glands ; this 
 give rise to definite 
 owing to the itching,' 
 al calculus may be 
 uent, and should the 
 St certain to follow, 
 h, distension of tlie 
 ;rvene. Not only is 
 i even danger to the 
 ve of masturbation, 
 of venereal disease, 
 .redisposing cause to 
 curs as an Acciuired 
 venereal sores, 
 ircumcision. Other 
 of the prepuce, and 
 
 Ictory. 
 on children with a 
 ,ice at that time the 
 on is a trifling one, 
 ]y experienced; the 
 e does it become. 
 The dorsal aspect 
 ling it on either side 
 ;''a director is then 
 eld exactly in the 
 a curved pointed 
 .now separated from 
 |en down ; this must 
 enable all retained 
 ndis defined. The 
 
 redundant preputial tissue, botli skin and mucous membrane, 
 is cut away on eacii side by scissors, special attention being 
 directed to the rtMiiovai of sullicient tissue on tiie under side to 
 prevent the unsiglitly projection so fretiueutly seen just below the 
 fr;enum. In adults several vessels will l)U;ed and reciuire to be 
 ligatured, especially that in the fr.i'num, but in a child tiie haemor- 
 rhage is trifling. Having carefully trimmed up the edges, and 
 snipped ofT all ragged corners so as to render the margins of tlie 
 wound regular, catgut sutures are inserted to prevent any raw 
 surface being left exposed ; in children only a few are reciuired, 
 hut possibly a considerable number in adults ; a continuous suture 
 should never be employed. The wound is dressed with strips of 
 gauze or lint dipped in carbolic oil, and around this, again, a wisp 
 of antiseptic wool ; no bandage or tape is retjuired. In adults 
 considerable after-trouble may be experienced from nocturnal 
 erections, which may be so marked and prolonged as to tear 
 through the stitches; to control this the patient's bowels should 
 he freely opened, and he should be kept on a low and mistimulat- 
 ingdiet, and bromide of potassium or other sedatives administered. 
 The stitches'afe" usually refnoved at tiie iend of five days, and'flVei 
 parts are then dusted over with a mixture of powdered boric acid, 
 zinc oxide, and -tarch, so as to reduce their sensitiveness. 
 
 When a phi. osed prepuce is completely retracted, the patient 
 often finds it impossible to replace it, thus giving rise to a condition 
 known as Farapbimosis. It is due to 
 the narrow orii-;«. a (f the prepuce 
 getting behind t)v^ corona, and is 
 characterized by great cedema and 
 congestion, not o: 'y of the exposed 
 mucous membrane, imt also of the 
 glans itself. If left untreated, ulcera- 
 tion takes place along the line of con- 
 striction, and the parts become fixed 
 in their deformed position, the vessels 
 sooner or later accommodating them- 
 selves to the new conditions, and the 
 (fidema slowly disappearing. In 
 some cases sloughing of the glans 
 may occur. 
 
 Treatment consists in forcible re- 
 placement of the prepuce. This is 
 
 accomplished by grasping the penis between the first and second 
 finger of each hand, and compressing the glans penis with the 
 thumbs so as to empty the vessels and diminish the amount of 
 itdema present, and thus reduce its size (Fig. 376). At the same 
 time the fingers draw the prepuce forwards, and thus finally re- 
 position is effected. When the oedema of the prepuce is very 
 marked, it should be punctured in several places to permit the 
 
 Fig. 370 
 
 Reduction of 
 Paraphimosis. 
 
\^ / 
 ) I 
 
 I 
 
 1088 
 
 A MANUAL OF SURGERY 
 
 escape of serum and diminish the tension previous to reducti 
 as just described. In more advanced cases reposition becom 
 impossible, and then the narrow constricting band caused by t 
 orifice of the prepuce must be divided on the dorsal aspect. Tl 
 will free the parts, which can be subsequently drawn forwarc 
 and after the oedema has been reduced by applying lotio plum 
 for a few days, circumcision may be advantageously undertake! 
 
 Balanitis, or inflammation of the prepuce, arises either as 
 simple inflammation from want of cleanliness in persons with 
 long foreskin, or more frequently as an accompaniment of gonoi 
 hcea or soft chancres. 
 
 It is characterized by swelling and oedema of the prepuce, ai 
 a muco-purulent or purulent discharge. If the surface of t 
 glans is also involved, the term Balano-postMtis is sometim 
 applied to it. Occasionally, when a considerable degree 
 phimosis exists, the under surface of the prepuce may becor 
 ulcerated, and even perforated ; whilst in very neglected cas< 
 and especially if phagedena is present, the prepuce will sloug 
 and allow the glans to protrude, usually through its upper surfac 
 
 Treatment. — In simple cases, all that is required is to thorough 
 cleanse the parts by washing beneath the foreskin, and then app 
 lead lotion on lint between the glans and the prepuce ; but whi 
 there is much discharge, and the foreskin is long and swollen, or 
 perforation is threatening, the prepuce must be slit up, and, aft 
 the parts have been restored to a healthy state, the redunda 
 tissues should be cut away by a modified circumcision. 
 
 Herpes not uncommonly affects the prepuce and glans. It m 
 result from simple local irritation, more especially in gou 
 individuals ; but is most frequently seen in patients who ha 
 suffered from syphilis, and is then likely to be somewhat intrac 
 able. It manifests itself as a crop of small vesicles on a hyperaen 
 base, which become abraded, leaving a number of small ulce: 
 It is preceded by pain of a neuralgic type, and accompanied 
 much itching and irritation. The only treatment required is 
 keep the parts clean, and dust them over with powdered oxide 
 zinc and starch. In the majority of cases the disease lasts fron 
 week to ten days. During the heahng of the herpetic ulcers 
 patient is very liable to be inoculated with the virus of either t 
 soft chancre or syphilis if he exposes himself to the risk of infectic 
 Warts often arise on the penis in the shape of red, vascu 
 excrescences, usually pedunculated, and sometimes of consideral 
 size. They are met with most frequently as a sequela of gone 
 rhoea, and must be carefully distinguished from mucous tuberch 
 They should be treated by snipping them away with scissors, a 
 cauterizing the base with. a galvano-cautery. 
 
 Horns are also occasionally seen arising from the body of t 
 penis. They are of the usual sebaceous type, as described 
 p. 332, and should be excised. 
 
AFFECTIONS OF THE URETPrr> . 
 ~~ '__^^^_URETHRA AND PENIS 
 
 1089 
 
 Epithelioma of the JT""^^ " ^^:^^;^____^o85 
 
 and rapidJy spreads to \h ^ '"^^"^ ^^^ind thrco^onJ 1 ^^Y-^' 
 either as an irVl 1^° *^^ .surroundinir oarf. 1^?'?"^. ^^^n^'^s. 
 
 itseJf 
 
 .'n^uinal glands are earJy^ffecS^f t "'"^"^ ^apid pJo^retj "^Th^ 
 
 i.s«SF?';«t:r;;;:;:f 
 
 rtery to the septum The urethrf ' '1^''^'^' ^"^ «"« for th^" 
 hrough an opening made b the ' „'' • '" ^'°^^'^^' ^"^ passed 
 lit afong t, ^p^^J'^ and sLu^eTh"''^""^^"^^^ «-P- It s 
 
 Lt?h °P^"-"^' ''° ^' te prevent suhln ?^"'"' ^« the margins 
 
 ortion of the urethra to Ztt-^'^'f'T ^^""^^ the provS 
 kle o the incision. Thr^^rt^" ° '^' '^'" ^^ ^^^ PosS 
 Nnections, and separated at d et ''"°'f ^^^ ^^^^^ frSm their 
 am. hy suitable raspatories An e,lS^TT -^'""^ '^' ischio-pute 
 
 69 
 
 M 
 
 I 
 
logo 
 
 A MANUAL OF SURGERY 
 
 knife completely removed. All bleeding points are ligatured, anc 
 the anterior wound closed by a continuous suture in the middh 
 line, a drainage-tube being placed in the perineal portion for i 
 few days. The results of this operation have, on the whole, beer 
 very satisfactory, although the patient has to assume the sitting 
 posture in order to micturate. 
 
 APPENDIX. 
 
 With regard to the surgical affections of the female genita 
 organs, it is not our intention to do more than briefly refer to i 
 few of those affecting the region of the vulva and labia. 
 
 Vulvitis, or inflammation of the lining membrane of the vesti 
 bule, is due to gonorrhoea or to irritating discharges coming fron 
 above. It is characterized by injection of the mucous mem 
 brane, by itching or smarting pain, especially on walking, and i 
 secretion of mucus or muco-pus, causing the labia to stick together 
 The mucous follicles may become affected, and a localized abscess 
 result, situated either immediately beneath the mucous membrane 
 or in the substance of the labium. The treatment consists in the 
 use of warm and mild antiseptic lotions to purify the part, sittin<. 
 in hot water being most beneficial. At the same time the patieni 
 is kept quiet, and the bowels opened by a saline purge. When ? 
 follicular abscess forms, it should be incised through the mucou! 
 membrane and its cavity stuffed with a small portion of dressing, 
 A labial abscess should be freely opened at any spot where it is 
 tending to point, and the cavity packed with gauze to ensure 
 healing from the bottom. 
 
 Cysts of the Labia are occasionally seen, being due to the blocking 
 of the duct of a mucous follicle, or of the more specialized vulvo 
 vaginal glands (glands of Bartholin) ; they may attain considerable 
 dimensions and must be freely dissected out. 
 
 Hematoma of the vulva is due to traumatism, e.g., a kick or 
 fall, or to rupture of a varicose vein, especially during parturition. 
 The labium is much swollen and firm to the touch, owing to 
 the coagulation of the blood ; suppuration often follows, especi 
 ally if the injury is associated with a superficial abrasion. 
 Treatment. — If the swelling persists, or if suppuration ensues, an 
 incision should be made and the blood removed ; the cavity is 
 then stuffed, but of course the most thorough antiseptic precaution? 
 must be adopted. 
 
 Another occasional result of traumatism is laceration of the 
 recto-vaginal septum, which may be caused by kicks, or by 
 faUing on a stick or paHng. The wound is usually contused, 
 and the margins irregular, so that immediate suture is unlikely 
 to succeed. The parts are, therefore, kept clean by frequent 
 douches and allowed to granulate, and the loss of substance is in 
 that way often repaired. Should a fistula persist, a plastic opera 
 tion will be subsequently necessary. 
 
are ligatured, and 
 are in the middle 
 neal portion for a 
 )n the whole, been 
 issume the sitting 
 
 the female genital 
 an briefly refer to a 
 md labia. 
 
 nbrane of the vesti- 
 tiarges commg from 
 
 the mucous mem- 
 iv on walking, and a 
 iia to stick together, 
 id a localized abscess 
 ^e mucous membrane 
 inient consists in the 
 urify the part, sitting 
 same time the patient 
 dine purge. When a 
 
 through the mucous 
 ill portion of dressing. 
 t any spot where it is 
 ' ith gauze to ensure 
 
 lingduetotheblockinfi 
 
 We speciaUzed vulvo. 
 
 lay attain considerable 
 
 rnatism, e.g.. a kick or 
 tlly during parturition. 
 f the touch, owmg to 
 
 often follows, especi 
 , superficial abrasion, 
 iuppuration ensues, an 
 lemoved; the cavity is 
 
 t antiseptic precautions 
 
 n is laceration of the 
 ksed by kicks, or tni 
 £ is usually contused 
 fate suture is unlike. 
 W clean by frequent 
 floss of substance IS IB 
 persist, a plastic opera- 
 
 CHAPTER XXXVIII. 
 
 AFFECTIONS OP THE TESTIS, CORD, SCROTUM, AND 
 SEMINAL VESICLES. 
 
 Congenital Affections of the Testis. 
 
 It is scarcely necessary to state that the testicles are not developed in the 
 scrotum, but from the posterior wall of the abdominal cavity, so that they lie 
 at first behind the peritoneum close to the kidneys. The body of the gland 
 arises from the so-called genital ridge, which is covered by columnar epithelial 
 cells, and lies to the mesial side of the Wolffian body. The vasa efferentia 
 are developed from the tubules of the latter structure, coming into relation at 
 a later date with the seminal tubules, wliilst the vas deferens is formed by the 
 Wolffian duct. 
 
 Occasionally the body of the testis is entirely absent, whilst a few cases are 
 on record of absence or deficiency of the vas. Very rarely two testicles have 
 been developed on one side, and have both found their way into the scrotum 
 {polyorchism). 
 
 The passage of the testis from the abdominal cavity to the scrotum takes 
 place at about the end of the eighth month of intra-uterine life. ' The guber- 
 naculum testis is the active agent in bringing about tlie descent of the testis. 
 This is a band of involuntary muscular fibres which traverses the inguinal 
 canal, and establishes important connections both within and without the 
 abdominal cavity. Below three main attachments of tlie gubernaculum may 
 be recognised, viz. : (a) to the abdominal wall ; (b) to the pubis ; {c) to the 
 bottom of the scrotum. Above, the gubernacular fibres are chiefly connected 
 with the testicle ; but many of them are also attached to the peritoneum on 
 the posterior wall of the abdomen. By the traction which the gubernaculum 
 exerts on the testicle the descent of that organ is brought about. By the portion 
 attached to the abdominal wall the testicle is pulled down to the internal 
 abdominal ring, the pubic portion drags it througli the inguinal canal, whilst 
 the scrotal part finally leads it into the scrotum. 
 
 ' The formation of the processus vaginalis is accounted for in the same way. 
 Some of those gubernacular fibres which are inserted into the peritoneum drag 
 down the peritoneal diverticulum which lines the inguinal canal and scrotum 
 and prepares the way for the testicle.' (Cunningham's ' Manual of Anatomy,' 
 vol. i, pp. 426, 427.) 
 
 Two chief forms of malposition of the testis are described, arising either 
 from its incomplete or abnormal descent. 
 
 I. Incomplete Descent or Retention of the Testis. — The testis may 
 remain in the abdominal cavity attached to the abdominal wall by a mesor- 
 cliium [rctcntio abdominal is) ; more frequently, it is found just within the 
 internal abdominal ring (rctentio iliaca ) ; but most commonly it occupies the 
 inguinal canal, or lies just outside of it {rctentio inguinalis). Tiie organ in the 
 latter position is freely mobile, being readily pressed up towards the abdo- 
 
 69 — 2 
 
I092 
 
 A MANUAL OF SURGERY 
 
 minal cavity. Tlie Causes of this condition must be looked for mainly i 
 some abnormal attachment of the gubernaculum, or possibly in the existenc 
 of intra-uterine peritonitis. Less commonly a contracted condition of tl 
 external abdominal ring, or an unduly large epididymis, may determine i 
 occurrence. 
 
 The condition is easily recognised by the absence of the testicle in tl 
 scrotum, whilst in the inguinal variety the organ can usually be detected ; 
 a small moveable swelling about the size of a horse-bean, giving the chara< 
 teristic testicular sensation on pressure. The scrotum on the affected side 
 imperfectly developed. 
 
 In any of these varieties a late descent of the testis may occur, usual 
 accompanied by a congenital hernia, possibly of an interstitial type. 
 
 2. Malposition of the Testis. — Two distinct forms are described : (a) Ectop 
 Perincalis. — In this variety the testis finds its way into the perineum, slippir 
 along the groove between the thigh and the scrotum. It may exist as a coi 
 genital condition, being tlien due to the contraction of an accessory band i 
 gubernacular fibres : or it may happen in consequence of a late descent of tl 
 testicle, owing to atrophy of the scrotum. It always causes considerable i 
 convenience to the patient, especially on sitting or riding, (b) Ectopia Cntrali 
 — The testicle here lies on the inner side of Scarpa's triangle, in the region 
 the saphenous opening. It is said to escape along the crural canal, b 
 more probably it passes down the inguinal canal as usual, and then finds i 
 way over Poupart's ligament to this situation, guided by a second accesso: 
 band of gubernacular tissue. When, as not uncommonly happens, a r 
 genital hernia also exists, it may travel outwards to the anterior supe; . 
 spine, being directed there by the arrangement of the fascia;, as in a femor 
 hernia (extraparietal interstitial hernia, p. 930). 
 
 In all cases of retained or misplaced testis the organ is atrophic, ar 
 probably functionally useless. At first it is normal in texture, but as a rest 
 of frequently repeated injury and inflammation it is likely to undergo c 
 generative changes. If only one organ is affected, but little harm follow 
 but if both are involved, the individual is probably sterile. 
 
 Complications of a Retained or Misplaced Testicle. — Any of the conditio 
 to be described hereafter in this chapter may involve a retained or mispla 
 testicle, just as if it were in the scrotum, and give rise to considerable trou 
 especially when the organ is lying in close proximity to the peritoneum, 
 testis misplaced or retained in the inguinal canal is much exposed to inju 
 and a subacute traumatic orchitis often occurs ; it is stated that such orga 
 are very prone to become the seat of malignant disease at a later period of 1 
 but the accuracy of this statement is a little doubtful. 
 
 Treatment. — Taking into consideration the discomfort occasioned by 
 condition, as well as the risk arising from the tendency to malignant disea 
 there can be little doubt that the best method of treatment is the remova 
 the testicle. Many operations have been devised with the idea of placing 
 organ in its normal position in the scrotum, but the majority of such metht 
 have proved useless, owing to the traction required and the defective lengtl 
 the spermatic vessels and cord. 
 
 Another condition met with congenitally is Inversion of the testis 
 epididymis lying in front, and the body of the organ behind. It is of 
 clinical significance, except that in careless hands it may be injured wh 
 tapping a hydrocele. 
 
 Torsion of the Spermatic Cord, resulting in acute strangulation of the tes 
 has attracted some attention of late years. The cause still remains unknov 
 but several of the cases recorded have been associated with late descent of 
 testicle, and others have been attributed to twists and strains. The sympt 
 are tolerably cliaracteristic : the patient complains of an acute sickening ] 
 in the testis which persists until gangrene has supervened, and may then 
 appear ; it is accompanied by a certain amount of pyrexia, and the appeara 
 of a tumour, eitiier in the inguinal region or in the scrotum. The testi( 
 
 tl 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 
 
 »093 
 
 ooked for mainly in 
 Sibly in the existence 
 :ted condition of the 
 •s, may determine its 
 
 of the testicle in the 
 
 TnSe^lecie<^ side is 
 
 tis may occur, usually 
 :erstitial type. 
 
 Umayexistasacon- 
 
 of an accessory band ^^ 
 
 \(\ late descent of the 
 
 •^ . \J \n the region ot 
 triangle, in the r I 
 
 ig the cru'ra ca'g^^^ .^^ 
 usual, and ^hen nnu 
 ed by a second accessoi v 
 mmonly happens, a f - 
 
 he fasciae, as m a lei 
 
 „ :„ atrophic, and 
 ,e organ is a uop 
 
 if "Any of the conditions 
 
 ien<-y ••'-' , removal on 
 
 treatment IS *?'?"„ * 
 „iththe.deaotpacmf 
 
 i\S°KeSe-e„g...l| 
 Lr.i.u 0. the tes^s « 
 
 Vrn,5 ^ ■.-i-'' «""*■ 
 
 l="?anc"utercke™gpf 
 s of an acuic ^^^ 
 
 «,„ene<l and m'^ ' ,„ 
 
 slightly enlarged, is felt below, and above it a larger mass, consisting of tlie 
 twisted cord and the congested and swollen epididymis. In some cases the 
 latter swelling has been crepitant, owing to the development of gases due to its 
 putrefaction. The condition is very likely to be mistaken for a strangulated 
 hernia, which it closely resembles ; but the presence of fever, and the absence 
 of abdominal distension and of faecal vomiting, are important distinctive signs ; 
 moreover, constipation, though often present, is never absolute. If the testis 
 is situated in the scrotum, the cord and inguinal canal are found to be clear ; 
 whilst if in the canal, the affected side of the scrotum is empty. The only 
 Treatment possible is exploration and removal of the inflamed or gangrenous 
 testis and cord, unless the case is seen very early, when it may be feasible to 
 untwist it. 
 
 Injuries of the Testis and Cord. 
 
 Contusion of the Testis is a very common form of injury. It 
 arises from blows, kicks, squeezes, and the like, and is always 
 associated with immediate pain of a most sickening and intense 
 character, which is not only experienced in the testicle, but also 
 radiates along the cord towards the loins and back, and down 
 the front of the thigh. Severe shock accompanies the pain, and 
 m>.y be so profound as to lead to a fatal issue. A well-marked 
 traumatic orchitis often follows, and this may in turn induce 
 atrophy of the organ, although the same condition sometimes 
 occurs without much evidence of inflammation, as a result of 
 thrombosis and occlusion of the spermatic vessels. A ha;matocele 
 is also induced by a subcutaneous lesion of this nature. Treatment 
 consists in keeping the patient in the recumbent posture with 
 the scrotum well raised, and in applying fomentations or an 
 icebag. 
 
 Penetrating Wounds or Punctures are uncommon except as a 
 result of surgical treatment (e.g., tapping a hydrocele). A certain 
 amount of haemorrhage usually follows, whilst the immediate 
 lesion is associated with severe testicular pain. If the wound 
 becomes septic, the tubules are likely to protrude, and a hernia 
 testis may result. All that is ordinarily required is to purify the 
 parts and allow them to heal ; sutures should not be inserted 
 into the tunica albuginea. If the gland is totahy disorganized, 
 as by a gunshot wound, castration must be undertaken. 
 
 Hsematocele, or a localized collection of blood in the tunica 
 vaginalis or cord, is a common result of injuries. 
 
 I. Hsematocele of the Tunica Vaginalis arises from traumatism, 
 such as a sudden blow or severe strain, and occasionally follows 
 the tapping of a hydrocele if a superficial vessel has been ruptured 
 or punctured, or if the body of the testis has been wounded ; it 
 may, however, be due to general oozing from dilated capillaries 
 in the serous membrane owing to the sudden relief of tension. 
 It also occurs more or less spontaneously in connection with 
 malignant disease. The History generally given is that the 
 patient was seized with a sudden sickening pain in the testicle, 
 which became quickly enlarged without any evidence of inflam- 
 
1094 
 
 A MANUAL OF SURGERY 
 
 U:' 
 
 ^ ji" 
 
 mation. If blood is extravasated at the same time into th 
 scrotum, the integument becomes discoloured in the course of 
 few days owing to a diffusion of the blood pigment. At first th 
 swelling is smooth and fluctuating, exactly resembling a hydrc 
 cele, except in the absence of translucency ; but owing to 
 deposit of fibrin on the walls from the coagulation of the blood, i 
 becomes hard and firm in a short time, closely simulating a soli 
 tumour. In slight cases the blood is entirely absorbed, but whe 
 the effusion is considerable the coagulum is likely to persist. O 
 laying open such a swelling, the testicle is usually found in 
 healthy state, whilst the enlarged tunica is occupied by som 
 blood-stained brownish-yellow fluid, and surrounded by a mas 
 of fibrinous coagulum, part of which is deposited in lamin; 
 upon the walls, and part remains as shreddy masses projectin 
 into its lumen. In very chronic cases the walls of the tunic 
 become thick and indurated, and may even undergo calcareou 
 changes. Suppuration is sometimes met with as a result c 
 auto-infection. The Diagnosis of a haematocele in the earlie 
 stages is easily made ; but when it has solidified it can onl 
 be suspected by the history, and by the exclusion of othe 
 sources of enlargement, whilst an exploratory incision or punctui 
 is often necessary to settle the diagnosis. Treatment. — Whe 
 the patient is seen soon after the injury, he must be kept at res 
 the parts elevated, and evaporating lotions applied ; whilst if th 
 effusion is large, removal of a portion by aseptic tapping wi 
 expedite the process of absorption. In more chronic cases it ma 
 be necessary to lay the cavity open and remove its contents, whil 
 in the later stages, if the tunica has become thick and indurate 
 and the testis atrophied, castration may be advisable. 
 
 2. Haematocele of the Cord is but rarely seen. It is due to tl 
 rupture of one of its vessels, as a result of injury or strain. . 
 swelling of considerable size rapidly forms, extending along tl 
 cord from the inguinal region to the scrotum, but the test 
 remains free and unimplicated. Such a condition may be mi 
 taken for an omental hernia, but on careful examination th 
 tumour is felt to be more uniform in consistency, more rounde 
 in outline, and even semi-fluctuating. It is irreducible and witl 
 out impulse, whilst the history of the case will assist the surgeo 
 in making a correct diagnosis. Treatment in the early stag* 
 consists in the application of evaporating lotions, and later on, 
 the blood-clot is not absorbed, the cavity may be laid open an 
 the coagulum removed. 
 
 Rupture of the Vas Deferens has resulted from excessive Ftrain 
 it is, however, very rare, not more than half a dozen cas( 
 being on record. It may affect the intra-abdominal portion ( 
 the vas, and then gives rise to haemorrhage from the urethn 
 together with some amount of fever and hypogastric pain, leadin 
 possibly to atrophy of the organ. Rupture of the scrotal portio 
 
AFFECTIONS OF THE TESTIS, CORD, ETC. 
 
 1095 
 
 ime time into the 
 [ in the course ot a 
 ment. M first the 
 BsembUng a hydro- 
 r- but owing to a 
 Ltion of the blood, it 
 V simulating a sohd 
 absorbed, but when 
 ikely to persist. On 
 usually found in a 
 5 occupied by some 
 rrounded by a mass 
 deposited in laminae 
 dv masses projecting 
 . walls of the tunica 
 1 undergo calcareous 
 with as a result ot 
 ttocele in the earlier 
 solidified it can only 
 . exclusion of other 
 ■V incision or puncture 
 Treatment.— When 
 
 must be kept at rest, 
 applied; whilst if the 
 r aseptic tapping will 
 re chronic cases it may 
 ove its contents, whilst 
 le thick and indurated 
 advisable, 
 seen. It is due to the 
 f injury or strain. A 
 extending along the 
 rotum, but the testis 
 ;ondition may be mis- 
 ireful examination the 
 iistency, more rounded 
 ; irreducible and with- 
 will assist the surgeon 
 It in the early stages 
 otions, and later on, 1 
 maybe laid open and 
 
 from excessive Ptrain; 
 n half a dozen cases 
 [-abdominal portion ot 
 tage from the urethra, 
 Ipogastric pain, leading 
 ' of the scrotal portion 
 
 is followed by enlargement of the testis, and perhaps scrotal 
 haemorrhage. This was associated in a case under our observa- 
 tion with haemorrhage from the urethra on attempting coitus 
 shortly after the accident, and subsequently with severe pain 
 and swelling of the testis produced by the same act, but atrophy 
 did not follow. If it occasions any inconvenience, it is best treated 
 by castration. 
 
 In flammatory Affections of the Te stis. 
 
 Inflammation of the Te sticle n iay be chiefly confined at its 
 on set "eTther to the body Of the'^rgan or to tBe epjd jjjyfntrp*!] 
 thelormer case the terrn l?rcEitl8 is apj^ied to latter 
 
 Epididymitis; either condition may be acute or cKronic. 
 
 JV. 
 
 ABC 
 
 Fig. 377. — Diagrammatic Sections of (A) Orchitis, (B) Epididymitis 
 AND (C) Hydrocele of Tunica Vaginalis. (Tillmanns.) 
 
 Ho, Testis ; N, epididymis ; Hy, hydrocele. 
 
 Acute Orchitis most frequently results from injury, but it is 
 also met with as a primary afifection in gouty and rheumatic 
 individuals, sometimes arising spontaneously; or it may follow 
 mumps or other eruptive fevers, as a result of metastasis, whilst 
 it is always to some extent associated with epididymitis. 
 
 The testicle becomes considerably enlarged, exceedingly pain- 
 ful, and tender to the touch. The shape of the organ is more or 
 less globular (Fig. 377, A), whilst the pain is of a peculiar 
 sickening character, extending upwards along the course of the 
 cord towards the back and loins. The scrotal integuments 
 become red and infiltrated, and, owing to the acuteness of the 
 process, more or less adherent to the coverings of the gland. 
 A plastic or serous effusion into the tunica vaginalis is some- 
 times present, giving rise to what is known as an ' acute hydro- 
 cele.' Some constitutional disturbance accompanies the process, 
 the temperature being elevated two or three degrees, whilst 
 vomiting and constipation are marked symptoms. It is unusual 
 

 1096 
 
 A MANUAL OF SURGERY 
 
 for suppuration to ensue, but an abscess occasionally forms, 
 then, after the pus has been let c.;S a hernia testis may fol 
 Atrophy is a more common sequela, especially in adults, b 
 caused by constriction of the vessels and tubules, owinfj 
 organization of the inflammatory exudation. 
 
 AcuteEnididyauturis almost__alwaysdue to the extension o 
 inflammatory process ftt)m~Ffie urefTira^"tBe~usual: cause b^ 
 gonorrhcea ; it occasionally follows the passage of instrument 
 the lodgment of a calculus ; o r it may be secondary to a suppj 
 tive^rostatitis.. unconnected-jviik. gonorrhoegu Ir is usherec 
 by pain m the inguinal region and perKap§~!h the hypogastr 
 along the course of the vas deferens, which soon extends to 
 scrotum. The testicle becomes enlarged, but its shape is tha 
 an elongated oval, somewhat flattened laterally. The epididy 
 is readily felt as a crescentic swelling, partially overlapp 
 the gland in all directions, and in its concavity the rounded < 
 line of the anterior wall of the testis can usually be distinguis 
 (F'ig. 377, B), or the tunica vaginaHs distended with fluid, 
 scrotum is red, oedematous, and adherent to the testis, whilst 
 cord is infiltrated, enlarged, and tender. The same constitutic 
 symptoms are met with as in orchitis. Suppuration is perh 
 more common than after the latter affection, since the conditio 
 usually due to a suppurating inflammation of the deeper parts of 
 urethra ; but it is a rare complication. Atrophy of the testis 
 not unfrequent result in cases which are not efficiently treai 
 the plastic material exuded into the epididymis being organi 
 into fibro-cicatricial tissue, and constricting the spermatic vessi 
 an acute attack of double epididymitis may in this way render 
 individual sterile. 
 
 The Treatment of both these conditions in the acute st 
 consists in keeping the patient in bed, with the scrotum suppor 
 on a small pillow. The part is assiduously fomented, exc 
 when the case is seen very early, an icebag or Leiter's > 
 being then employed. Leeching should not be utilized, as 
 triangular leech-bites are very liable to become irritated i 
 septic, and never heal well in the scrotum ; if local abstract 
 of blood appears desirable, one or more of the scrotal ve 
 may be punctured ; the haemorrhage is easily arrested by elevat 
 the part. Pain, if severe, may be mitigated by a hot sitz-k 
 or by morphia suppositories. As regards general treatmc 
 the patient, after a preliminary dose . : calomel, is kept 
 a fluid, unstimulating diet, whilst alkaline purgatives are 
 ministered, with the addition of tincture of henbane or opium 
 a sedative ; if the pulse is hard and the temperature high, vin 
 antimonialis in 10 minim doses is also beneficial. When 
 acute stage is passed, the organ usually remains enlarged, ; 
 for a time somewhat tender ; it is then best treated by strapp 
 with lead plaster, or with the emplastrum ammoniaci c 
 
Y 
 
 ccasionally forms, and 
 nia testis may follow, 
 •ially in adults, bemg 
 id tubules, owmg to 
 
 to the extension of an 
 TTTTIsuai^^^angS-tjemg 
 sage of instruments or 
 icondarytoasuBEaia- 
 
 loea. It rruiHirid in 
 ;r!h the hypogastnum 
 h soon extends to the 
 out its shape is that ot 
 rally. The epididymis 
 partially overlapping' 
 cavity the rounded out- 
 asually be distinguished 
 ended with fluid. The 
 
 AFFECTIONS OF THE TESTIS, CORD, ETC. 
 
 1097 
 
 hydrargyro. This must be continued until all signs of thickening 
 and induration have disappeared. 
 
 Subacute or chvouic forms of inflammation are also met with 
 afl"ecting the testis or epididymis, either as a consequence of the 
 above, or resulting primarily from blows or strains. The charac- 
 teristic enlargement is readily detected, associated with a certain 
 amount of tenderness. A useful d iagnostic point between the 
 chr onic epididymi tis following gonorftlCPTl-aTTd-thnrcmrto syphilis 
 1s TKaT'tfeMnTer" ugiially involves t he' globiTS-_mih or. and the 
 lat ter is almos tJUmTted tQ. tht^.^IoSus major. The'condiTtoh is 
 r best" treated by strapping, and perhaps tlie administration of 
 small doses of mercury and iodide of potassium may assist in the 
 absorption of the inflammatory products. Chronic orchitis is very 
 I similar to the enlargement produced by syphilis, from which, indeed, 
 I it can only be distinguished by the absence of a syphilitic history. 
 
 3n, since the condition is 
 of the deeper parts of the 
 Urophyof the testis is a 
 b not efficiently treated, 
 lidymis being organized 
 g the spermatic vessels; 
 ■ this way render the 
 
 11 
 
 y in 
 
 stage I 
 
 Tuberculous Disease of the Testis {Syn. : Tuberculous Sarcocele, 
 
 Chronic Tuberculous Orchitis).— This affection is most commonly 
 
 r^the testis, whilst thai seen in young adults with a distinct 
 
 Th same constitutional 1 tuberculous history, but it also occurs in 
 
 SuDDuration is perhaps i otherwise healthy individuals. It may 
 
 ^^vV ., — ju;,^Ti ic K commence as a primary affection of the 
 
 epididymis, or it may be secondary to 
 tuberculous disease elsewhere. 
 
 Pathological Anatomy. — The process 
 
 originates in the connective tissue of the 
 
 epididymis, and runs its usual course, 
 
 at first consisting merely of miliary 
 
 lelements deposited around the vessels, 
 
 ,vhich by their coalescence and casea- 
 
 ion lead to the formation of cheesy 
 
 nasses, and these at a later stage may 
 
 mulsify and give rise to abscesses. It 
 
 ay be limited to any one part of the 
 
 ipididymis (most often the globus 
 
 najor), or may widely infiltrate its 
 
 iubstance, causing a general enlarge- 
 
 ent (Fig. 378). In the latter case it early tends to spread, either 
 
 to the body of the testis or along the vas deferens. The corpus 
 
 ighmorianum becomes first involved by a similar deposit, and 
 
 jially the intertubular connective tissue of the gland ; this is 
 
 ways associated with overgrowth of the epithelium in the tubuli 
 
 miniferi, the cells after a time undergoing fatty degeneration, 
 
 d perhaps to such an extent that, on microscopic section, the 
 
 iormal appearance of the organ has entirely disappeared. An 
 
 scess may form within it, and find its way to the surface by 
 
 im: 
 re 
 
 -ons in the acute 
 y the scrotum supported 
 lously fomented, except 
 icebag or Leiter's co,l 
 not be utilized, as the 
 become irritated and 
 ■ if local abstraction 
 of the scrotal veins 
 ily arrested by elevatind 
 ted by a hot sitz-bathJ 
 rds general treatment, 
 - calomel, is kept oni 
 ine purgatives are ad- 
 f henbane or opium as I 
 niperature high, vmuni 
 beneficial. When the 
 remains enlarged, an(l| 
 
 Fig. 378. — Tuberculous 
 Disease of Testis, 
 mainly affecting the 
 Epididymis. (Treves' 
 ' Surgery.') 
 
 ^st treated by strapping; 
 Istrum ammoniaci cuin| 
 
 prrowing through the tunica albuginea, the visceral and parietal 
 [vers of the tunica vaginalis having previously become adherent. 
 
logS 
 
 A MANUAL OF SURGERY 
 
 
 After the pus lias escaped, a hernia testis is likely to d| 
 If the process extends upwards alonf? the cord, the vas is 
 implicated, becoming perceptibly thickened, the other str^ 
 of the cord being but little affected. The disease spread| 
 the vas on the outside of the bladder to the vesicular ser 
 and prostate, and may even involve the base of the bladdl 
 ureters, and kidneys. Lastly, acute miliary tuberculoj 
 phthisis, may result from general dissemination. 
 
 Clinical Signs. — The disease is generally unilateral, althoul 
 other testicle often becomes involved at a somewhat late/ 
 Its onset may be abrupt or gradual ; in the former case the! 
 simulates an acute orchitis, but at the end of a week, alt| 
 the pain subsides, the swelling persists, being followed 
 development of abscesses containing cheesy pus. In thel 
 chronic cases, one or more firm and indurated nodules, whi 
 free from tenderness, are felt in the epididymis, but more 
 the whole of this structure is found to be enlarged and thicl 
 forming a painless crescentic swelling, surrounding the po: 
 half of the body of the testis, from which it is usually sep; 
 by a deep groove or sulcus. The epididymis is nodula 
 craggy to the feel, and may be of unequal consistency, ar 
 softening being interposed betweeii portions which are dist 
 hard. The vas is early thickened, and the body of the testi; 
 be involved and enlarged, the line of demarcation between i 
 the epididymis becoming indistinct. Testicular sensation re 
 as long as any normal glandular tissue exists, but effusion 
 the tunica vaginalis is not usual. When suppuration o( 
 the pain increases, especially if the abscess is in the substai 
 the organ. As it finds its way to the surface, the skin bee 
 adherent to the testis, and is red and congested. Grac 
 fluctuation manifests itself, and escape of the pus may be fol! 
 by a hernia testis. An abscess forming in connection wit 
 epididymis is less painful, and may attain considerable dimei 
 before it bursts ; it never gives rise to a hernia testis. Exte 
 of the disease to the seminal vesicles causes no charact( 
 symptoms, and is only detected on rectal examination ; • 
 however, the base of the bladder and prostate are affected 
 siderable dysuria and irritability of the bladder are induced. 
 
 The differential diagnosis is discussed at p. iiii. 
 
 Treatment. — There can be little doubt that, when once i 
 culous disease has involved the testicle to such an extent 
 render its diagnosis certain, the sooner the organ is remove 
 better. This applies especially to the poor. Amongst the i 
 seen in the very earliest stage, when only a small nodule ex 
 the epididymis, it is possible that prolonged residence i 
 seaside, or a sea-trip, combined with suitable constitu 
 treatment, may lead to its disappearance. Moreover, if appa 
 limited to one portion of the epididymis, it may be dealt wi 
 
rERY 
 
 AFFECTIONS OF THE TESTIS, CORD, ETC. 
 
 1099 
 
 5tis is likely to develop. I :he conservative measure of cuttinj,^ down on the site of the disease, 
 e cord, the vas is mainly i .orapin{]f it away, and applyin<r pure carbolic acid; but such 
 lied, the other structures hneasures are seldom feasible, since the disease has usually pro- 
 rhe'disease spreads alon^^ ,'ressed too far, whilst it must be remembered that the function 
 3 the vesiculae seminales ;)f the organ is almost certain to be thereby seriously impaired, if 
 ! base of the bladder, the^iot destroyed. Castration (p. 11 12) is more generally required ; 
 miliary tuberculosis, or : n tuberculous disease it is always important to divide the cord 
 ination. i^ ^^S^. "P ^.^ possible. If the vas is thickened at the external 
 
 ly unilateral, although the; ibdominal ring, it need not deter the surgeon from operating, 
 t a somewhat later date. ;\ en if the vesicular are enlarged, since tuberculous disease is 
 
 lot like cancer ; if the great bulk of the mischief is removed, 
 
 Nature can frequently eliminate any small portion that remains. 
 
 n such cases the inguinal canal should be freely opened, and the 
 
 as traced backwards and divided. In one case thus dealt 
 
 ,vith, the bladder was distended with boracic lotion, the patient 
 
 )laced in the Trendelenburg position (p. 1056), and the vas 
 
 "oiiowed back along the side of the bladder nearly as far as 
 
 he seminal vesicles. For tuberculous disease of the seminal 
 
 esicles, see p. 11 13. 1/ 
 
 the former case the attack 
 end of a week, although 
 s, being followed by the 
 heesy pus. In the more;| 
 urated nodules, which are 
 5ididymis, but more often 
 •e enlarged and thickened 
 surrounding the posterior 
 ch it is usually separated 
 3ididymis is nodular and 
 qual consistency, areas o:f 
 rtions which are distincthf* 
 
 esticular sensation remainj 
 e exists, but effusion intJ 
 /hen suppuration occurs! 
 Icess is in the substance o| 
 surface, the skin become 
 [nd congested. GradualH 
 f the pus may be followed 
 
 Syphilitic Disease of the Testicle. — The testicle niay become 
 
 ffected by syphilis, either in the late secondary or in the ter- 
 
 the body of the testis ma\Bary stage ; most commonly it results 
 
 marcation between it ancgrom the acquired variety, but occa- 
 
 iionally is met with in the inherited. 
 Secondary Syphilitic Epididymitis is 
 ot very frequently seen. It occurs in 
 he form of a chronic enlargement of the 
 pididymis, associated perhaps with a 
 ydrocele, about six to twelve months 
 Iter infection. The case is very similar 
 g m connection with thtlo a simple chronic epididymitis, but 
 n considerable dimensionllie nodular thickening mainly involves 
 
 pe globus major, and is usually sym- 
 
 etrical. It readily disappears on the 
 
 dministration of mercury. 
 
 Tertiary Syphilitic Orchitis is ob- 
 
 lerved at a much later period of the 
 
 isease, even twenty or thirty years after 
 
 fection. It is not unfrequently bi- 
 
 teral. Pathologically, it resembles the 
 
 ajority of tertiary manifestations in 
 
 insisting of a diffuse infiltration accompanied by overgrowth of 
 
 e connective tissue. If the process affects equally the whole 
 
 irgan, the ordinary syphilitic sarcocele or sclerosis of the testis 
 
 suits ; if it is more localized in its distribution, the gummatous 
 
 -ariety is said to be present (Fig. 379). The former affection is 
 
 uch more common than the latter. 
 
 hernia testis. Extension 
 
 causes no characteristic 
 
 jctal examination; when! 
 
 irostate are affected, con] 
 
 tladder are induced. 
 
 I at p. Ill I. 
 
 )t that, when once tuberl 
 
 to such an extent as t| 
 
 |he organ is removed, tlij 
 
 oor. Amongst the rich, 
 
 a small nodule exists id 
 
 [longed residence at m 
 
 suitable constitutional 
 
 Moreover, if apparentljj 
 
 it may be dealt with bj 
 
 Fig. 379. — Tertiary Syphi- 
 litic Disease of Testis 
 WITH GuMMAOF THE Body. 
 (Treves' 'Surgery.') 
 
IIOO 
 
 A MANUAL OF SURGERY 
 
 -J 
 
 'i ! 
 
 
 
 In the tertiary sypliilitic sarcocele, the body of the te 
 primarily inxolved, and becomes evenly enlar^'ed and stony 
 It is globular in outline, frequently accom{)anied by a hydr 
 and the normal testicular sensation early disappears. The 
 process occasionally extends to the epididymis and cord, 
 puration is exceedingly rare. On section the charact( 
 appearance of a testicle has entirely vanished ; the 
 albuginea is much thickened, and extending from it throug 
 substance of the organ are bands of connective tissue, repr 
 ing the normal septa ; in bad cases the gland substance is a 
 completely destroyed. 
 
 In the gininiiatoiis variety a similar condition involves the gi 
 part of the organ, but in addition one or more gummatou 
 are present. (3n section they appear as yellowish-white m; 
 fairly well defined, and since the central portions are non-vas( 
 they undergo the usual degenerative changes, becoming sof 
 diffluent. If the gumma conies to the surface the skin 
 give way, and a deep syphilitic ulcer with a sloughy base 
 wet wash-leather results. Hernia testis very rarely follows 
 an occurrence. The clinical features of the gummatous vi 
 are at first similar to those of the former, but after a tim^ 
 portion of the organ becomes prominent and painful, and as 
 increases in size the central parts become soft and fluctus 
 and finally yield, giving exit to the characteristic gummy cont 
 Under suitable treatment the swelling in each of these vari 
 may disappear entirely, leaving the testicle either of norma 
 or atrophied ; but, as in tuberculous disease, its functional ut 
 if not entirely destroyed, is probably considerably impaired. 
 
 P'or the differential diagnosis see p. iiii. 
 
 Treatment consists in the administration of iodide of potas: 
 and mercury, whilst the hydrocele may be tapped, and the o 
 strapped or supported by a suspender. If a gummatous ulc 
 produced, it may be possible to excise the greater portion oi 
 characteristic slough at its base ; but in all cases it shoul 
 dressed with lint or gauze steeped in lotio nigra, or some ( 
 mercurial preparation. 
 
 Hernia Testis is the term applied to a protrusion of the 
 stance of the gland, mere or less infiltrated with granul; 
 tissue, through an opening n the tunica albuginea and sk 
 the scrotum. It arises from various causes, such as a si 
 penetrating wound of the t'.;stis, acute suppurative orchiti; 
 from a chronic abscess, whether simple or tuberculous in na 
 It is rarely produced by the breaking down of a gumma, o 
 to the extensive infiltration of the organ with fibro-cicati 
 tissue, and necessarily it never follows suppuration in the 
 didymis. It is always preceded by a condition of inert 
 pressure within the tunica albuginea, and consequent!; 
 
:hy 
 
 AFFECTIONS OF THP. TESTIS, COHD, FTC. 
 
 1 101 
 
 is| 
 
 ! body of the testis 
 nl;irj;ecl :incl stony hard 
 iipaiued by a hydroceU 
 disappears. The sani 
 idymis and cord. Su\ 
 tion the charactenstu 
 vanished; the tunica 
 inf,^ from it throuf,'h th. 
 lective tissue, represent 
 land substance is almost 
 
 ition involves the greater] 
 3r more gummatous foci 
 
 yellowish-white masses. 
 )ortions are non-vascular 
 mges, becoming soft ano 
 e surface the skin may 
 
 ith a sloughy base liktl 
 
 is formed in this membrane, its natural 
 its contraction, forces a portion of its 
 
 soon as an aperture 
 elasticity, allowing o 
 
 contents out of the opening; this may even proceed to such an 
 I'Ntent as to cause the wliole of the substance of the gland to 
 protrude, the tunica albuginea being practically turned inside 
 out. A mass resembling granulation tissue is then seen to pro- 
 ject through an opening in the scrotum ; it is often somewhat 
 pedunculated or mushroom-like in shape, possibly overhanging 
 J the margins of the skin, but in less advanced cases the integu- 
 inent may be distinctly urdermined. A considerable discliarge 
 of pus usually accompanies it. The condition must be distin- 
 j^uished from the fungating growth which occasionally results 
 from malignant disease of the organ ; in the latter case the protru- 
 sion consists of tumour substance, in which there is no trace of 
 testicular tissue. 
 
 The Treatment of hernia testis usually consists in extirpation 
 of the organ, especially when it is affected by tuberculous disease. 
 In simple cases it may be possible to obtain healing of the wound 
 by keeping the part aseptic, and applying pressure by means of a 
 
 VI. ., . , 
 
 very rarely follows sue r ., ■. , -, , 
 
 f the LrumiTiatous variet\|p''i'' of ga"^^«- I" ^ther cases it may be possible to separate the 
 1.. . ^t^^^r o t?mft omBniass, and after paring the edges of the wound, to bring them 
 
 Itogether by sutures, and thus co\er in the gland substance, 
 yhich, however, remains projecting from the opening in the 
 unica albuginea. Such proceedings are seldom very satisfactory. 
 
 ner, but after a time one 
 
 and painful, and as thiJ 
 
 3me soft and fluctuatin<;, 
 
 cteristic gummy content!^, 
 
 in each of these varieties 
 
 .icle either of normal smj 
 
 lease, its functional utility, 
 
 siderably impaired. 
 
 1 1 
 
 On of iodide of potassuinl 
 
 lin all cases it should k\ 
 t>tio nigra, or some otheil 
 
 Tumours of the Testis are generally malignant in character, only 
 ne non-malignant form being at all common, viz., fibro-cystic 
 isease, or adenoma testis. 
 
 Fibro-Cystic Disease {Syn. : Adenoma Testis, Cystic Sarcocele). — 
 his condition is characterized by the formation of a tumour of 
 d and the ort'atW''^''^'^^l^ ^^^^' scattered through the substance of which are 
 be tappe , ^^ ulcer Aunierous cystic cavities, lined with cuboidal or stratified epithe- 
 ^ ^^t r nortion of theBi^"^ (Fig. 380). These cysts are usually rounded, but occasionally 
 
 e grea p ^ ^^ iMubular in shape, and may communicate with one another; they 
 
 Dntain serous fluid and sometimes intracystic growths. They 
 
 re surrounded by connective tissue, the amount and character 
 
 f which vary greatly in different cases. It consists mainly of 
 
 hnple fibrous tissue, but it is very common to see cartilaginous 
 
 odules and myxomatous foci scattered through its substance. 
 
 t is thus very similar in its structure to the simple parotid 
 
 umour (p. 745), and like it is very prone after a time to undergo 
 
 malignant transformation. According to Bland Sutton and 
 
 ve, these tumours arise from the remains of the Wolffian body 
 
 ir mesonephros, which is almost always normally represented in 
 
 e neighbourhood of the globus major of the epididymis by the 
 
 ructure known as the organ of Giraldes (paradidymis). The 
 
 sticle can be found in most cases spread out in a thin layer over 
 
 e tumour substance. 
 
 la protrusion of the sub^l 
 lltrated with granulatM| 
 [a. albuginea and skin 
 pauses, such as a_ septitj 
 , suppurative orchitis, of 
 )r tuberculous in natutej 
 )wn of a gumma, owM 
 Ian with fibro-cicatriciaf 
 suppuration in the epij 
 condition of increase! 
 and consequently 
 
 il^^ 
 
II02 
 
 A MANUAL OF SURGERY 
 
 Clinical Signs. — This condition is met with in young ac 
 and may possibly be attributed to an injury. The organ stej 
 becomes enlarged, but this gives rise to no inconvenience ex 
 by its size and weight. It is round in outline and elastic in 
 sistency, the cord remaining unaffected unless malignant dis 
 supervenes. When of great size, the skin of the scrotum 
 ulcerate. The case runs a chronic course, and even should 
 growth become malignant, the change of type only appears 
 in the disease. 
 
 Treatment consists in removal after an exploratory incision 
 demonstrated the nature of the growth. 
 
 Other non-malignant tumours have been described, sucl 
 
 Fig. 380. — FiBRo-cvsTic Disease of the Testis. (College of 
 Surgeons' Museum.) 
 
 chondroma, osteoma, fibroma, myxoma, etc., but they are 
 ceedingly uncommon, if they occur at all apart from sarcoma 
 fibro-cystic disease. 
 
 Sarcoma of the Testis commences in the body of the org 
 ei<-her within the first decade of life or between the ages of thi 
 and forty, and is sometimes a sequela of late or imperfect desce 
 It is usually a soft, round-celled growth, taking on the form 
 a lympho-sarcoma ; in other cases it is harder, and of the nati 
 of a fibro-sarcoma. Frequently cartilaginous nodules are inc 
 porated in its substance, and patches of myxomatous tissue 
 cystic degeneration from haemorrhage are also seen. As alrea 
 stated, it is sometimes secondary to fibro-cystic disease, 
 origins ces in the connective-tissue elements of the organ, t 
 
r^-i.o(' 
 
 iY 
 
 AFFECTIONS OF THE TESTIS, CORD, ETC. 
 
 1 103 
 
 A^Uh in young adults, 
 . The organ steadily 
 ) inconvenience except 
 ne and elastic in con- 
 less malignant disease 
 a of the scrotum may 
 B, and even should the 
 type only appears late 
 
 ixploratory incision has 
 
 ;en described, such as 
 
 glandular substance being early destroyed. It appears as a 
 rounded swelling, and at first its outline is irregularly smooth ; 
 as the disease progresses, however, it may become nodulated 
 from the development of cysts. The tumour may attain veiy 
 large dimensions, but the cord and scrotal tissues only become 
 affected in the later stages, and then ulceration and the forma- 
 tion of a fungus testis occasionally follow. Secondary growths 
 are always found in the lumbar glands and internal organs, 
 whilst, when it has spread beyond the tunica albuginea, involv- 
 ing the scrotal structures, the inguinal glands may be similr^rly 
 affected. There are but few subjective symptoms at iiist, a 
 feeling of weight and dragging being alone experienced, whilst 
 testicular sensation is soon lost ; but at a later date, when the 
 cord is involved, pain and cachexia become very marked. The 
 Course of these cases is slow up to a certain point, but the tumour 
 may then rapidly increase in size, spreading along the cord to the 
 interior of the abdomen even in the course of a few weeks, thereby 
 rendering removal utterly impossible, although it would have 
 been easily practicable at an earlier period. Treatment con lists 
 in the extirpation of the growth with the testis as early as possible, 
 the cord being divided high up. 
 
 Carcinoma of the Testis is usually of the encephaloid type, and 
 arises in the body of the organ as a soft rapidly-growing tumour, 
 which soon extends to the tissues of the cord, and contracts 
 adhesions to the scrotum ; ulceration and the formation of a 
 tungating mass follow, whilst secondary deposits are found in the 
 lumbar and inguinal glands, and sometimes in the viscera. It is 
 impossible to distinguish a carcinoma from a sarcoma of the testis 
 by clinical signs, since it occurs at the same period of adult life, 
 although never in children. Very rapid growth, and early enlarge- 
 ment of the cord and lymnhatic glands, point, however, to cancer 
 rather than sarcoma. The only treatment is castration. 
 
 
 I 
 
 / 
 
 'ESTis. (College of 
 
 etc., but they are ex- 1 
 apart from sarcoma or I 
 
 [the body of the organ. I 
 
 Iween the ages of thirty 
 
 Lte or imperfect descent.! 
 
 [taking on the form ol 
 
 [irder, and of the nature 
 
 fious nodules are incor 
 
 1 myxomatous tissue or 
 
 also seen. As alreadv] 
 
 Lro-cystic disease. 
 
 Ints of the organ, tlie| 
 
 Hydrocele. 
 
 Any collection of fluid, other tti' ous or blood, in the neigh- 
 bourhood of the testis or cord, 's t.irmed a Hydrocele. The fluid 
 usually consists or serum, br. in some forms spermatozoa iire 
 also present, and in rare cases it may consist of chyle or a -in-iV-r 
 milky fluid (chylous hydrocele) Two chief varieties are desciiued, 
 according to whether the testis or the cord is involved. 
 
 I. In Hydrocele of the Testis the fluid is contained in thc; tunica 
 vaginalis (vaginal hydrocele) ?t exists as a circumscribed swelling 
 in its neighbourhood (encysted hydrocele). 
 
 I. A Vaginal Hydrocele is one in vvbicb. there is an accumula- 
 tion of fluid in the tunica vaginalis, and the ru'-bwuif- ' aileties 
 may be differ- mtiated : 
 
 {a) Acute Hydrocele occurs in conjunct'on with acute inflanima- 
 
 / 
 
 A 
 
 I ' 
 
 \J 
 
 *: 
 
II04 
 
 A MANUAL OF SURGERY 
 
 tion of the testis or epididymis. The effusion of fluid is 
 abundant, and is often only made out on careful examina 
 at first it consists of plasma, as in all acute inflammations 
 serous membrane, and is therefore spontaneously coagulable 
 may merge into the chronic type, or may disappear enti 
 perhaps leaving a few adhesions. 
 
 (b) A Congenital Hydrocele occurs in cases in which the funi 
 process is still patent. The general signs of a vaginal hydrc 
 as described below, are present, but the fluid can be returne 
 pressure into the abdominal cavity. It is rarely seen in o1 
 than infants, and may be treated by the application of evapon 
 lotion to the scrotum, whilst a light truss or woollen suppo 
 placed over the inguinal canal, as for congenital hernia, 
 often associated with phimosis, which should of course be 
 with by circumcision. If it persists, it may be treated by open 
 as for congenital hernia, to which, indeed, it frequently leads. 
 
 (c) An Infantile Hydrocele is one due to non- obliteration o 
 funicular process of peritoneum, except at its upper extrei 
 It presents the signs of an ordinary acquired hydrocele, tl\. 
 however, extending along the cord, even into the inguival z: 
 Its treatment is the same as for an acquired hydrocele. 
 
 (d) Acquired Vaginal Hydrocele is the most common v.i' 
 Causes. — It may arise idiopathically in middle-aged pe'.sons, 
 has then been looked on as resulting from some functional disc 
 rather than from any organic change in the membrane, tbe no 
 balance between secretion and absorption being disturbed. Ii 
 majority of cases, however, the testicle is swollen and ^jei hai 
 a state of chronic inflammation, and the tunica vaginalis thicke 
 A hydrocele almost always accompanies a tertiary syphilitic 
 largement of the organ, but is uncommon in tuberculou 
 malignant disease. Hydrocele is very frequently seen in t 
 who dwell in hot climates, probably as a result of the lax 
 pendulous conditions of the scrotum and testicles. In I 
 natives always support the scrotum by passing the end of 
 'kummerbund' between their legs, in order to prevent su( 
 development. 
 
 Signs. — Vaginal hydrocele appears as a rounded pyrij 
 swelling in the scrotum, which extends for a variable dist; 
 along the cord. Its tension differs with the amount of 
 present, and with the t'lickness of its walls ; it is genei 
 elastic, and with ob\ious fluctuation. The cord is felt distir 
 above the rounded upper part of the tumour, and the testi 
 generally situated posteriorly (Fig. 377, C), although it proj 
 forwards into the cavity, and is thus not readily detected, 
 position may be ascertained by pressure over it, when the cha 
 teristic testicular sensation is evolved. On holding a light c 
 to the scrotum, the tumour is seen to be translucent, and 
 position of the testicle can be demonstrated. In old-Plani 
 
 t,V>^ \\:^^^■\■ 
 
 i 
 
 ' G' 
 
 V 
 
 V 
 
iGERY 
 
 effusion of fluid is nev.^i 
 
 on careful examination ; 
 
 acute inflammations of a 
 
 itaneously coagulable. It 
 
 may disappear entirely, 
 
 AFFECTIONS OF THE TE<^Tr<: . 
 _ ^ '■^^T^IS, CORD, ETC 
 
 -ses in which the funicular I tous^n^o^^ '"^^^ '^^ divided into'comp' t" T'u^ 
 
 ns of a vagmal hydrocele, I It is scarcely necessarv . • ^°"ipartments by 
 
 fluid can be returned by icoue-hinp- nr,^ *-u : , ^ ^° menhon thnt- th^ • 
 
 t is rarely seen in otherl Idis S I ""' '^^ '""^°"^ ^^ di 11 on 'err, •' "° ^"^P»^«« on 
 
 --plicatioiofevaporatinglvveilhtcrusesad'^ ^'''''' -^'^ ' °" P^^^ussion. When the 
 
 t is rarely seen in others idistension is ver. *""'°"'' 
 application of evaporating i weight causes a drJ ^^^^^' ^^^ 
 ass or woollen support isithe neni^j K^^ "^^g'&ing pain ; 
 congenital hernia':^ ,:■. Jthe sweZ. anTe? ^"'^'? ^" 
 should of course be dealt Iscrotum mLvHuT °^ ^^^ 
 lay be treated by operation iurine tricklinLveH tT J^-^ 
 H ^t frequently leads. lin the sir ,•<:,, ^r i ^he/«/rf 
 iuK^.i.: r ., I /"^ ^'?^ IS yellowish or Qfro,,, 
 
 lay ue ireaiea oy oper 
 
 d, it frequently leads. iin 'the';;T;"?. 7^' • V The/«/^ 
 to non-obliteration of thelcoloured • its '•i' °'" '^^^'^■ 
 
 5 upper extremity, Jaries from mf^,'' gravity 
 
 of 
 
 :o non-obliteration of thelcoloured- its «; •« ^traw- 
 : at its upper extremity, Jaries from ro^r^.^^. gravity 
 lired hydrocele, th. fl.^Hlontains a llZi ° '°'5 ; it 
 into the inguiral ::u.a.,Rl. umen, especfallv fiT""^ °^ 
 red hydrocele. fen old-st^ndm^ ^f I i^f/^^^^^"' 
 
 t 
 
 uired ^ , 
 
 1 into the ingui 
 
 ired hydrocele. w n old-standing cases cl 
 
 e most cornmon vav,ety,biay rlso be present 
 iddle-aged pe-.sons, anci The Treatment of 
 !ome functional disorderBivdrnrAlo ,• n- .. 
 
 ff't old-standing casp<; rKoi 5 • 
 niav -iQn K^ ^ ^^ses cholesterm 
 
 vaginal 
 
 j "-.r^'^v 'J so De present 
 
 middle-aged pe-.sons, aRci The Treatmen+'of 
 1 some functional disorderBiydrocel^ i^noir ^ vaginal 
 
 :he membrane, tbe norn..I>alliafive treatment^?' '^^^'"^• 
 ti being disturbed. In thefcapping the cavtvo, "'''*' ^" 
 is swollen and r.eihapc irSig the fl uid tl ^ "^ ^^'"o^" 
 :unica vaginalis thic^enedf absequentlv'direrSf'f"* ''""'"^ 
 .s a tertiary syphilitic ..luspender, Ld X -nflf " 
 nmon in tuberculous oftiation of thp V f ^""^m- 
 frequently seen in thosMpp] 7 cooling Inf. • r"^^?^^' ^° 
 
 a result of the lax a J can of en * ^" ^"^^^is 
 
 ^Wb'"..^„u""^^^. without 
 
 is 
 
 a result of the lax ancffcan^^fte? h"°"'- f" ^"^ants ^^'^-38i.- Method ok taphnc . 
 
 and testicles. In Indlpplng h!'"..^" , ""^^^, without "^^l^^^'^--- (TlI-LM^^"^; " 
 
 passing the end of theiKaporlff/..- ) ^^^ ^PP¥ng an '^"- ^^^^jit' ^^. epididymis; 
 
 order to prevent such*/ « hy,''oce'':' '^ \ order to "y. hydrocele. 
 
 for a variable distancf Se it.. , .^f?,^^ ^^e antero-inferior ^aT4^^^^^^ 
 ith the amount of flui.uula in sen .'^- '^^Po^sible, and a fine sT^"/' ^" '^^^^^ed, 
 . walls; it is generalll pass rS: J"..'^ ?'^ almost cWt^v^^'"^ 'T"''^^ ^"^ 
 
 rhe cord is felt distinctllpph' ".^st of ^' ^^°^>^ °f ^'^^ tes is ThJ T"""'?'' ^° ^^'^ 
 umour, and the testis .Ihich Should h '°"''' ^''^^^^^ ^^^^h the posilion ?.f ^'"^"^ f°^ 
 
 C), although it proieclen whhdra,„'^ tlTT'' /''^^'"^^'^^^^^^^^^^^ 
 .„* — j:i.. j„^„_._j '-nvered ^ArifK ' ^ cannula s remnx-^H j , "^" having 
 
 e Tlonf '°'"f ^^°°^ '^«^ collodion ^^u^"^ *i^« puncturl 
 
 atecl rT °' '^^^^^^^ Period, and t^iJ J^^.^^^'^^^io" recurs 
 died. If a „, instriimenf • . operation must hp r*. 
 
 ^n s;:pp...on, '.a;^i;^:^\ -- -P'-Vec^ inflamniaS^J^^;^ 
 '^^--- ^^'-^--ed,aha.maWeirma/re3^^^^^^^ °' '^^^ ^°^^ ^f 
 
 70 
 
 iinour, ana ine testis 1* 
 C), although it projectij 
 lot readily detected. IiJ 
 over it, when the charac] 
 On holding a light closr 
 be translucent, and tli'' 
 trated. In old-Flar'-" 
 
 i I 
 
V 
 
 iio6 
 
 A MANUAL OF SURGERY 
 
 Many different plans have been suggested for the Radical 
 ment of hydrocele. It is unnecessary, however, to do more 
 describe the two most frequently adopted, (i.) Injection o 
 cavity after tapping has long been a favourite method, 
 different reagents have been employed, such as port wine, tim 
 of iodine, solution of corrosive sublimate (i in 500), or glyc 
 of carbolic acid. Perhaps the best is the tincture of Iodine 
 that contained in the British Pharmacopoeia is not strong eno 
 and the old Edinburgh tincture, which is nearly the same stre 
 as the lin. iodi, B.P., should be employed. The amount 
 varies with the size of the hydrocele, but for one of mod( 
 dimensions it will suffice to inject, after tapping, 2 drachms o 
 tincture, and after manipulating it well within the cavity, a 
 say I drachm, is allowed to escape. Smart inflammatory reac 
 follows, and a cure will probably result, either from obliten 
 of the vaginal space by the formation of adhesions, or by impi 
 ing some change of function upon the serous membrane, 
 certain * centage of cases failure may be expected, and th 
 more likf. ^ '• ppen if too weak an irritant has been emplo 
 or if the hv ..... -Je is a chronic one with thick and indurated w 
 and has beei /ped on several previous occasions, (ii.) 
 open method of operation is now generally adopted, and is 
 ticularly recommended in large and chronic cases. The hy 
 cele is cut down on through an incision in the upper part of 
 scrotum, and the tunica vaginalis isolated from the superjai 
 structures. The cavity is opened, and the parietal portion of 
 tunica snipped away with scissors close to the testicle. A nun 
 of vessels will need to be ligatured ; a drainage-tube is inser 
 and the wound closed in the ordinary way. The results of 
 practice are most satisfactory. 
 
 2. Encysted Hydrocele of the testis occurs in two main for 
 according to whether it arises in connection with the epididy 
 or the body of the testis. 
 
 (a) Encysted Hydrocele of the Epididymis exists usually a 
 rounded globular swelling, tense and elastic in consistency, 
 translucent. It is situated above the body of the testis, . 
 close to the head of the epididymis (Fig. 382). As a rule, it d 
 not attain a size greater than that of the body of the testis its 
 so that it may appear as if a double testicle was present ; 
 hydrocele is, of course, devoid of testicular sensation. L 
 frequently it may attain considerable dimensions, even project 
 below and around the testicle, which, though enveloped by 
 is quite distinct from it. The fluid contained witliin these cv 
 is usually milky and opalescent in appearance, owing to an 
 mixture of semen ; under the microscope spermatozoa, eiti 
 living or dead, can be demonstrated ; on account of this it 
 sometimes termed a spermatocele. The specific gravity is lov 
 than that of ordinary hydrocele fluid, and there is less albunn 
 
 y 
 
iGERY 
 
 isted for the Radical treat- 
 lowever, to do more than 
 3ted. (i.) Injection of the 
 favourite method. Many 
 ;uch as port wine, tincture 
 e (i in 500), or glycerine 
 he tincture of iodine, but 
 )oeiais not strong enough. 
 > nearly the same strength 
 )yed. The amount used 
 but for one of moderate 
 rapping, 2 drachms of the 
 within the cavity, a part, 
 art inflammatory reaction 
 :, either from obliteration 
 adhesions, or by impress- 
 serous membrane. In ; 
 be expected, and this ii 
 itant has been employed, 
 hick and indurated walls. 
 3us occasions, (ii.) The 
 lly adopted, and is par 
 onic cases. The hydro 
 in the upper part of the, 
 ed from the superjacent 
 le parietal portion of the 
 3 the testicle. A number 
 rainage-tube is inserted, 
 ay. The results of thij 
 
 ;urs in two main forni:.! 
 tion with the epididynii>[ 
 
 ^^FECTIONS OF THE TESTr. . 
 
 — "^;J^TIS, CORD, ETC. 
 
 nis exists usually as 
 astic in consistency, aiicl 
 body of the testis, an(:| 
 382). As a rule, it doe,| 
 body of the testis itselil 
 jsticle was present ; thJ 
 icular sensation. Lesf 
 ensions, even projectinij 
 hough enveloped by i 
 ained within these cysti 
 arance, owing to an ad 
 )pe spermatozoa, eitlieij 
 on account of this it is 
 pecific gravity is Ioto 
 '. there is less albumer' 
 
 liydrocele, or even t^ different nature to the Tv '''''™ssion. 
 
 of one or more of the vnc 1-°" 
 entia testis, or more fr.n ''' ^^^'■ 
 distension 'of s^me oiT""')^ ^" 
 
 relics alwavs fonnrf ^^^ ^^^^^^ 
 c^^ +K 'V,^ round near the hpnri 
 of the epididymis, esDechM, ! 
 those known -m T^^i u^ '^^^^ ^^ 
 
 these, as aTso ?hevasa?ff'"'^^^ 
 testis, are deriverl f J ^u^^^'"^"*'^ 
 
 however, from them^^iothf' 
 ^ommg attached to the hoH ; 
 the testis (Fi^ .q/ Ti? ^^ °^ 
 
 t lis region, arising from ! "^1'^ '" 
 s'on of the liydatid of M "'"■ 
 wWch is devJioped lomT®"'' 
 "la.nsoftheMuLrianduct*''" 
 
 llydroceie, vi..!^,;'^4-„-|'-, __ _ 
 
 palliative measure ■^r.A -^ ^ 
 
 !a radical cur^ '' ""' ^"J^^^^^" or excision, in order . , 
 
 , ^^) J^ncysted Hydrocele of a. T ■ ''" °^^^^ ^^ establish 
 
 seen, consisting of ^sm/u u''"'-^ ^ 
 
 visceral portion of It ? collection of seroi f fl ?u ^'°" ^^rely 
 
 ciilatation^ STyntlZl ""^'" ^'^^'nalis. T s proh^f ^^^^^ '''' 
 
 Significance. ^ P'^'"''" ^P'^^^es, and has absoluteli ^^^ 1"" ^° 
 
 I H; Hydrocele of the Cord ^ "° '^'""'''^ 
 
 ^^-i^^llmi W^ ^" - 
 
 Surgeons' MusEui ) ^''^''^ "^ 
 
 ' 70—2 ""'"^ 
 
iio8 
 
 A MANUAL OF SURGERY 
 
 the testicle the cyst is no longer moveable. The fluid cont; 
 within it is identical in nature with that in a vaginal hydrc 
 In the female a similar condition arises from imperfect obliter 
 of the canal of Nuck, giving rise to what is known as a hya 
 of the round ligament. Treatment consists in removal of the 
 by tapping, or, if a more radical proceeding is necessary, inje 
 or excision. 
 
 2. Diffuse Hydrocele of the Cord is but rarely seen. It re 
 from a dififuse cedema of its cellular tissue, and presents on e> 
 nation a fusiform or sausage-shaped tumour, which extends 
 the cord for a variable distance. 
 
 The term Chylous Hydrocele is applied to a distension o 
 tunica vaginalis with a chylous fluid, recognised by being i 
 in appearance, and under the microscope seen to consist 
 fatty emulsion. Several modes of origin have been sugge 
 but none are very satisfactory. In a case recently under t 
 ment, a series of dilated lymphatics filled with a similar 
 extended upwards from the testicle to the inguinal canal. 
 
 Varicocele. 
 
 \ \ 
 
 A varicose condition of the pampiniform plexus is very ( 
 inonly -net "' 'll in young men, but seldom in those of adva 
 
 age, except when it has become chr 
 or is due to malignant disease oi 
 kidney (p. 1018). It usually occui 
 individuals with a lax and pendi] 
 scrotum, and is often associated 
 masturbation, which induces abno: 
 vascularity of the testis. It may 
 be caused by the pressure of a t 
 applied for the relief of a hernia, 
 almost invariably on the left side, 
 the reasons given for this are as folk 
 (a) The left testis usually hangs h 
 than the right, and hence the spern 
 veins are longer and exposed to gn 
 blood pressure, {h) The left spern 
 vein opens into the left renal vei 
 right angles, and no valve is pre 
 at the orifice, whilst that on the 1 
 side opens obliquely into the vena < 
 and is valved. {c) The presence ol 
 sigmoid flexure on the left side of 
 body, and its distension by accumul 
 faeces as a result of constipation, may lead to pressure on 
 abdominal portion of the left spermatic vein. 
 
 Fig. 383. — Varicocele. 
 (Treves' 'Surgery.') 
 
RY 
 
 The fluid contained ! 
 ti a vaginal hydrocele, t, 
 1 imperfect obliteration ^; 
 s known as a hydrocele 
 in removal of the fluid 
 cr is necessary, injection 
 
 rarely seen. It results | 
 and presents on exami- 
 ur, which extends along 
 
 to a distension of the 
 ^ognised by being milky 
 pe seen to consist ot a 
 in have been suggested, 
 Lse recently under treat- 
 led with a similar fluid 
 e inguinal canal. 
 
 AFFECTIONS OF THE TESTIS, CORD, ETC. 
 
 1 109 
 
 -V \ .\ 
 
 Al. 
 
 form plexus is very com- 
 
 om in those of advancec 
 
 len it has become chronic, 
 
 bialignant disease of the 
 
 [S) It usually occurs 111 
 
 th a lax and pendulouj 
 
 lis often associated with 
 
 which induces abnorma 
 
 the testis. It may alsc| 
 
 the pressure of a trus: 
 
 relief of a hernia. It i3 
 
 ply on the left side, an 
 
 en for this are as follows 
 
 stis usually hangs lowe; 
 and hence the spermatii 
 r and exposed to greate 
 Ih) The left spermatid 
 o the left renal vein a; 
 \nd no valve is presenl 
 whilst that on the ngk 
 quely into the vena cav; 
 (c) The presence ot th 
 . on the left side of tbi 
 tstension by accumulate 
 ilead to pressure on thi 
 ein. 
 
 A varicocele is characterized by the presence of a soft irregular 
 swelling in the scrotum, which is somewhat pyramidal in shape, 
 the main mass being below and slightly overlapping the testis, 
 and the apex above. It consists of dilated and tortuous veins 
 the outlines of which can often be seen through the skin ; they 
 impart a sensation to the finger which has been likened to a col- 
 lection of worms in a bag ; there is a distinct impulse down the 
 veins on coughing. On assuming the recumbent posture the 
 swelling almost disappears, owing to the vessels being emptied 
 of their contained blood ; if pressure is subsequently applied over 
 the external abdominal ring, and the patient allowed to standi 
 the tumour reappears, filling from below upwards. A sensation 
 of weight and pain usually accompanies a varicocele, whilst severe 
 neuralgia of the testis may be induced. It is a frequent source of 
 seminal emissions, and may result in testicular atrophy. Phlebitis 
 is liable to follow an injury, and may lead to a spontaneous cure ; 
 if one of the dilated veins is ruptured, severe haemorrhage ensues, 
 causing a diffuse haematocele of the cord. In favourable cases 
 the condition disappears spontaneously. 
 
 The Diagnosis of varicocele is easily made, the only condition 
 for which it is likely to be mistaken being an omental hernia ; 
 the difference between the two conditions has been discussed at 
 p. 932. 
 
 The Treatment of slight cases of varicocele consists of support- 
 ing the testicle and scrotum by means of a well-fitting suspender, 
 whilst the patient is also instructed to bathe the parts with cold 
 water night and morning, and to take such measures as shall 
 ensure a daily action of the bowels. 
 
 Radical Treatment by excision of the veins is ad\'isable in 
 neuralgic cases, where atrophy of the testis is threatening, or in 
 order to fit the patient for admission into any of the public services. 
 The operation is conducted as follows : The pubic region having 
 been shaved and purified, an incision 2 inches long is made in the 
 direction of the cord, with its centre a little below the external 
 abdominal ring. The structures of the cord are raised on the 
 lingers, and the coverings divided, so as to expose the spermatic 
 veins at their upper end. Two main branches are usually found in 
 this situation, but occasionally there is only one. These are cleaned 
 land carefully isolated from the other structures of the cord, and a 
 ligature is applied to them at the external abdominal ring. The 
 vessels are now clamped with a pair of Spencer Wells' forceps 
 below the ligature, and divided between it and the forceps. The 
 jlower end, grasped by the forceps, is stripped downwards, 
 [so as to free the pampiniform plexus from the other elements 
 [of the cord, and the dissection can be carried nearly as far as 
 Ithe epididymis by drawing the testicle up into the wound. 
 jThe lower end of the veins is ligatured in one or two portions, 
 land divided. F5y this means the whole varicocele is removed. 
 
mo 
 
 A MANUAL OF SURGERY 
 
 KiV 
 
 r/ 
 
 h- 
 
 h^ 
 
 \'\ 
 
 W 
 
 If the scrotum is pendulous, and the testicle hangs low, i 
 be advisable to raise it by tying the upper and lower lig.' 
 together, care being taken not to pull them off in so 
 perhaps it is wiser to introduce a suture through the divided 
 of the veins above and below, which are purposely left long, 
 wound is then closed without a drainage-tube, and dress 
 usual. The patient is kept in the recumbent posture for ten 
 or a fortnight, until a firm cicatrix has formed. This meth 
 treatment is infinitely superior to that usually practised o 
 posing the veins in the scrotum, since a wound in the 
 always heals much more readily than one in the scrotum ; \\ 
 it is easier to dissect the veins out from above, where onl} 
 or two trunks exist. The venous return after the operati( 
 maintained by the vein or veins running with the artery to th( 
 in the posterior portion of the cord. 
 
 Neuralgia of the Testis is characterized by the organ becoi 
 exquisitely tender and painful, although apparently healthy 
 usually occurs in young adults of nervous temperament, c 
 middle-aged gouty men. It is not uncommonly associated 
 a varicocele. The pain is usually paro..ysmal in character, 
 very intractable. 
 
 Treatment must be directed mainly to the general health, 
 sisting in the administration of nerve tonics, such as iron 
 quinine, whilst locally sedatives, such as belladonna and aco: 
 may be applied. It is also advisable for a suspender to be w 
 
 Atrophy of the Testis results from several causes : (i.) It : 
 be due to a congenital arrest of development, as met witl 
 displacement or late descent, (ii.) It is most frequently the < 
 sequence of inflammatory affections, either of the body or 
 didymis, owing to the cicatricial contraction caused thereby 1 
 ing to compression of the vessels. It occasionally follows 
 metastatic orchitis of mumps, especially in adults, whilst 
 also due to syphilitic disease, (iii.) It arises from impa 
 nutrition, as after the division of the spermatic arteries in op 
 tions for varicocele or hernia, or from compression of the cor( 
 closing the inguinal canal too firmly in the operation for 
 radical cure of hernia, (iv.) Chronic congestion of the orgai 
 by a varicocele, may induce atrophy ; whilst (v.) sexual exce 
 are also stated to lead to it. If unilateral, it is of comparati 
 little importance ; but where both organs are affected, sterilii 
 sure to result, and the patient, if previously young and heal 
 is likely to become depressed in spirits and melancholic, 
 may be due in part to mental causes, but also in measure to 
 absence of seminal secretion, the reabsorption of which into 
 system is, according to Brown-Sequard, an important facto 
 the maintenance of a vigorous state of mind and body. 
 
RY 
 
 iclc hangs low, it may 
 ,er and lower ligatures 
 them off in so domg ; ^ 
 irough the divided ends -^ 
 irposely left long. The f 
 e-tube, and dressed as | 
 ent posture for ten days 
 rmed. This method ot 
 isuallv practised of ex- 
 a wound in the grom 
 , in the scrotum ; whilst 
 above, where only one 
 n after the operation is 
 ;ith the artery to the vas 
 
 [ by the organ becominj,' 
 apparently healthy. It 
 ■ous temperament, or in 
 )mmonly associated with 
 .ysmal in character, and 
 
 the general health, con- 
 tonics, such as iron and 
 b belladonna and aconite, 
 a suspender to be worn.' 
 
 .eral causes : (i.) It may 
 Dpment, as met with in 
 most frequently the con- 
 her of the body or epi- 
 ion caused thereby lead- 
 occasionally follows the 
 f in adults, whilst it u 
 ,t arises from impaired 
 rmatic arteries in opera- 
 -npression of the cord b\ 
 In the operation for tli( 
 gestion of the organ, as 
 lilst (v.) sexual excesses 
 1 it is of comparatively 
 ■ kre affected, sterility is 
 asly young and healthv. 
 land melancholic. This 
 t also in measure to tht 
 •ption of which into the] 
 an important factor ::. 
 Ind and body. 
 
 \. 
 
 AFFECTIONS OF THE TESTIS, CORD, ETC. 
 
 Qeneral Diagnosis of Scrotal Tumours. 
 
 nil 
 
 The diagnosis of the different forms of enlargement of the testis 
 described in this chapter has been purposely omitted to prevent 
 needless repetition. Moreover, there are other scrotal conditions 
 with which they may be confused, and it is better to discuss the 
 whole subject at one time. 
 
 When a patient presents himself for examination with a swelling 
 in the scrotum, the surgeon has to decide whether it is a hernia, 
 a hydrocele, a ha^matocele, a varicocele, or a solid enlargement of 
 the testis, and, if the latter, of what nature. Tlie first point to 
 which attentio" is directed is the condition of the cord immediately 
 helow the exteinal ring. If this is of normal size and consistency, 
 hernia and diffuse hydrocele of the cord are thereby excluded, 
 whilst the existence of a rounded tense swelling, moveable within 
 the canal, but becoming fixed on holding the testis, indicates that 
 an encysted hydrocele of the cord is probably present. When, 
 however, the cord is more or less masked, further examination 
 speedily determines whether a hernia, or a diffuse hydrocele or 
 haMiiatocele of the cord exists, since the former is often reducible, 
 has an impulse on coughing, and is rounded or nodular in outline, 
 and the latter are sausage-shaped, always irreducible, and semi- 
 lluctuating. 
 
 When the swelling is purely scrotal, inspection and manipula- 
 tion will at once decide if it is a varicocele, by its characteristic 
 eel, by its disappearance on assuming the recumbent posture, 
 nd filling again from below on standing up. If the swelling is 
 ounded in outline, the next point to be determined is whether it 
 s solid or fluid. If fluid, it is probably a hydrocele, or the early 
 tage of a haematocele ; the translucency of the former, and the 
 udden appearance and non-translucency of the latter, should 
 uffice to demonstrate its nature. It is possible that the hydrocele 
 s merely a secondary complication, and hence no final opinion 
 hould be given until it has been tapped, and the condition of the 
 ody of the testis investigated. If, however, a solid mass exists 
 the scrotum, it is either a haematocele in its later stages, or 
 ome form of sarcocele, whether simple, syphilitic, tuberculous, or 
 eoplastic. A hamatocele is possibly recognised by its history, 
 id by there being a fluid centre to the swelling, surrounded by 
 lidified tissue. Chronic ^orchitis and syphilitic enlargement of 
 ;he testis are so much alike as to render diagnosis always uncer- 
 in in the absence of a distinct syphilitic history; but if the 
 telling is extremely hard, with a smooth and regular outline, 
 fithout testicular sensation, limited to the body of the testis, and 
 .ccompanied by a hydrocele, it is probably syphilitic. Tuberculous 
 sease, on the other hand, occurs more frequently in younger 
 dividuals than does the syphilitic variety, whilst the epididymis 
 
1 1 12 
 
 A MANUAL OF SURGERY 
 
 is usually first attacked, becoming nodulated, the cord is 
 implicated, hydrocele is rare, suppuration is fre(iuent, and 
 ticular sensation remains till the body of ihe testis is disorgan| 
 Tumoiiys always impart a distinct sense of weight to thv'i 
 quite different to that noticed in tuberculous or syphilitic du-.t 
 if a simple tumour is present, it is rounded, slow in growtlij 
 the cord is unaffected. Malignant disease is characterize^ 
 rapid growth, more severe pain, and early implication ol| 
 structures of the cord and of the lumbar lymphatic glands, 
 enlargement of both testes is in favour of tubercle or syp| 
 rather than of malignant disease. A certain small numbt 
 cases will remain where, in spite of every care, the nature 
 mass is still a matter of doubt ; in such the diagnosis canno] 
 established without puncture or an exploratory incision. 
 
 Whilst weighing carefully the local conditions, we must 
 omit to thoroughly investigate and appreciate the general his 
 and condition of the patient, his age, appearance, pre\'ious ha 
 and illnesses, etc. At the same time, an examination of 
 internal organs should be made to ascertain, as far as possi 
 the existence or not of concurrent disease, e.g., tuberculous dis( 
 of the lungs or kidneys, or secondary malignant deposits. 
 
 Castration is required for many different conditions, whicli h 
 been already described, e.g., for malposition, tuberculous dise 
 old-standing haematoceles, and simple or malignant tumours 
 has also been undertaken for chronic enkvrgement of the prost; 
 The operation is conducted as follows : The pubes and perine 
 having been previously shaved and purified, the surgeon, stand 
 on the same side of the patient as the organ to be remo\ 
 makes an incision down to the testis. If large and adherent 
 the scrotal tissues, the incision must necessarily involve 
 scrotum, but wherever practicable it is wise to avoid the sen 
 integuments, making the incision over the cord. It should alvv 
 extend upwards as far as the external abdominal ring, so as 
 enable the structures of the cord to be divided high up, a n 
 important matter in tuberculous and malignant disease ; 
 inguinal canal can then also be closed, if necessary. The te 
 or tumour is enucleated from its surroundings, and the c 
 isolated and divided as high as possible, after transfixing ; 
 securely ligaturing it with silk. Some surgeons prefer to sepai 
 the tissues of the cord, and to take them up individually, but \ 
 is a matter of little importance. The stump should not 
 allowed to slip back into the canal until all bleeding has complel 
 stopped, and it has been suggested that the cut end of the 
 should be touched with pure carbolic acid as a precaution 
 measure. Considerable attention was formerly directed to 
 condition of the pulse at the moment when the cord was divid 
 and it was a regular instruction to the anaesthetist, that if et 
 
GERY 
 
 lulated, the cord is early 
 ion is frecjuent, and tes- 
 the testis is disorganized. 
 i of weight to the hand, 
 lous or syphilitic di;>ease ; 
 ided, slow in growth, and 
 ease is characterized by 
 early implication ot the 
 - lymphatic glands. The 
 r of tubercle or syphilis 
 certain small number of 
 •y care, the nature of tlui 
 
 the diagnosis cannot be 
 iratory incision, 
 conditions, we must not 
 3ciate the general history 
 5earance, previous habits 
 
 an examination of the 
 rtain, as far as possible, 
 !, e.g., tuberculous disease 
 lignant deposits. 
 
 it conditions, which have 
 ion, tuberculous disease, 
 " malignant tumours; it 
 Tgement of the prostate, 
 "he pubes and perineum 
 2d, the surgeon, standing 
 
 organ to be remo\ed, 
 :f large and adherent to 
 necessarily involve the 
 ise to avoid the scrotal 
 ; cord. It should alway; 
 bdominal ring, so as to 
 divided high up, a most 
 nalignant disease; the 
 f necessary. The testis 
 •undings, and the cord 
 ;, after transfixing and 
 geons prefer to separate 
 jp individually, but tl 
 
 stump should not ut 
 bleeding has completelv 
 the cut end of the vas' 
 cid as a precautionan' 
 rmerly directed to tliei 
 1 the cord was di\idd, 
 laesthetist, that if ether 
 
 and these n/v^'r'' "^ ^^^ ^'^-^otun Ire nr'' °^ '^'' '-^"-^thetic 
 
 Affections of the Vesimia. a • 
 Acute Vesiculitis is nnt u vesiculffi Semmales. 
 
 with prostatitk ; ^ °^'«" met with h.,^ c 
 
 ;leep-4te?'^?„ S tL'^S'^^^'"" ^ ^r^S'^l^ T'^ '" ----ion 
 the bladder and increi.inf "'"' 'o^ether with irri/. • . "'^'""''^'^ferized by 
 Pa.nful, and on e amhS ^'fT"'y "^ micturition ^'r'^/ "^ -'^'^ "eck- 7{ 
 and tender, if s«ppu;;^H°" °^ '^'^ rectum the vesTculT. n ''f'''^"" ^^'^"mes 
 ■nto the rectum but .i.^ • ''"^"^s, an abscess form ?^" ''^ ^^It enlarged 
 ■•ule, the condhio ' i.° "'"'■"^^■^ ^"t" the bladder or ' -'^''^'^ "'^"aUv buS 
 puration has su ^e^veS',?/:/;'''.' ^IT ^^^ ZnZZTi'''''''y ' ^- 
 through the perineum m'.i ,^'^'"''^'''e ^o open the X/ u' ^"^ ^^''^n sup- 
 Subacute or Ci^onFc VeS,>^ '" ^"^^'^ '" ^''" rectum '^^ ^'' " ^'^^P '"^-''S. 
 often associated with prostS*" V'"' ""^"^mon ^elattPr r • 
 Semmal emissions and nH. ' '^"'' °"« "f the most frl ^"nci'tion being 
 
 can be felt through" ,? Sum '"'Y ^^ ^'-^"-^^l by t ," th' '"f^^ "^ ''^'-^' 
 I'ackis experienced The trl ^^ '^ ^'"°'I 'i^al of pain nf ^"^ '-"-fi^ed organ 
 ^ Tuberculous Disease \t\. '^^^"^^"t is the same as fo ' h " ^^^^^ved to the 
 rom the testis aCgth?"'^" tl'e.vesiculcr semU es is ''■°"'',P''"«'^'iti^ 
 disease of the prosit^ an 1 h ''"'".^ ^^"""'^ always a.^ochf]^ °^. ^'^'ension 
 enlarged, and if suppuration ""'^ °^ '''« bladder ^tS'^'^^ ^^'^h similar 
 adder, or possibl^S SMr'"'"' ^'"^ '-^^scess may burst inf"f, ''''' '^« ^^^t 
 it is possible to rLch;S'^-'^';'°-^'^-^ical fistula bei^^^^^ 
 penneum, displacing li ^'e^icula: throutrh a Lnf'.^ Hiereby developed 
 
 K-vards, or f?om Kh d T'"'" '^^^'^^-rclr ami ^ bh n^"^"'"" *" the 
 k in Kraske's opeSt "' \'^"'''''^^^ the coccvVand i 1 r^"^ P^-^state 
 possible, or an openin„"s mf/'"" "'^P"'^^^'' complete ex?fsi °^- '^'" ^^^'-"m. 
 C. n^ made .to them, and S^fclS^^^ £,-^2;^ 
 
 ,,^^«-esoftheScrotut''T"'*'''"°*""- 
 
 te^t -t— ^ ^ -= ^t^tlS--;ccWis. 
 
 incsed wounds may af^ct th. . • '''""'^ ''^« 
 
 eneral princioles rl''.!" '^^'^^'^r the wotmd ZZl.Jl^ .^^''}^^^ ■ All thai 
 
 — *SiSSH3ili|£g 
 
1II4 
 
 A MANUAL OF SURGERY 
 
 by transplantation of flaps from the in^'uinal region, or by Rrafting aero 
 to Tliifrscli's niftliod. 
 
 Cellulitis of the Scrotum most conitnonly rt'sults from extravasation of i 
 fcir wiiicli si'o p i(i>s.(. It may occasionally arise from otiier causes, but i 
 no special dcscriplion. 
 
 (Edema of thw Scrotum is usually due to dropsy, bein^; often associated 
 genera! anasarca and ascites. It may attain consitlerabk^ dimensions. 
 iiirhuiiiiiiilory (iiliiiht of the scrotum is a term sometimes applied to erysi 
 alfectiiif^ tliis region, on account of the absence of tiie vivid red colour us 
 associated with tliat aftection Considerable irdema is aluays present 
 Kanfirene of the skin may result. As soon as the >j;an>(rene becomes limit( 
 should be excised, and the mar>,'ins of the wound brought together by sut 
 or alloweil to heal by granulation. 
 
 
 Fifi. 384. -EriTHELio.MA Scroti following Paraffin Kcz 
 
 (TlLLMANNS.) 
 
 Scrotal Fistulse are usually due to the bursting of abscesses in connec 
 \\ith tlie urethra (see Perineal Abscess), 
 
 Sinuses of the Scrotum are often found in connection with tuberculous 
 syphilitic disease of tlie testicle. 
 
 Eczema of the Scrotum is a troublesome affection, giving rise to gi 
 pruritus and irritation. It results from the p'-esence of pediculi, but 
 more chronic forms occur amongst workers i'-. tar and parafHn, and als( 
 chimney-sweeps, being due to the constant irritation of the corrugated scr 
 integument by dirty clothes. It is characterized by the presence of w; 
 outgrowths, and not unfrequently runs on to epithelioma, originating the c 
 dition known as cliinuuy-Su'ccp's or pa laffin canccv (Fig. 384). The usual cha 
 teristics of such a new growth are present, and in some of the deeper c 
 particles of soot have been demonstrated. The inguinal glands are usu 
 involved, but not till late, and the progress of the case is slow. The t 
 treatment which can be adopted is complete removal, the wound cau 
 thereby being closed or allowed to granulat^. ; 
 
 For Elephantiasis Scroti, see p. 287. \\ 
 
lY 
 
 or by «raftinj{ arcoriliiiK 
 
 ■om extravasation of iiriiu-, 
 ,m other caust^s. but needs 
 
 H.inK often associated with 
 lerabU'iliminsions Aaite 
 ,mes applied to erysipe as 
 lie vivid red colour usually 
 ma is alvvays present, and 
 .n-rene becomes bmited, it 
 roGght together by sutures, 
 
 JG Paraffin Hcz 
 
 of abscesses in connection | 
 
 Inection with tuberculous orl 
 
 Iction. giving rise to great 
 esence of pedicuh but in* 
 txr and paraffin, and also it 
 Ion of the corrugated scrotal 
 \i by the presence of warty 
 telioma. originating the on. 
 Ig ^84). The usual charac- 
 lin some of the deeper ce hi 
 Inguinal glands are usua 
 Ihe case is slow. The onl 
 ^moval, the wound caused 
 
 CHAPTER XXXIX. 
 
 VENEREAL DISEASES. 
 
 TiiREK forms of veneieal disease must be specially clescribcd, 
 jvi/., gonorrhoea, soft chancre, and syphilis. 
 
 Gonorrhoea. 
 
 Gonorrhoea is an infective process due to the action of a specific 
 
 [micro - ort^anism, the Goiiococciis (Fi^. 3X5), and characterized 
 
 |by a discharge of pus from the urethra. The organism was 
 
 ftrst isolated by Neisser in 1879, and is found with or without 
 
 ither pyogenic cocci in the discharge, most commonly in the 
 
 pithelial cells or pus corpuscles, but sometimes apart from them. 
 
 Fhey are readily demonstrated by 
 
 taining a film of pus, dried on a 
 
 :over-slip, with triethylene blue 
 
 ir gentian violet, and are almost 
 
 hvays found in the diplococcus 
 
 :ondition, i.e., they occur in pairs, 
 
 lekl together possibly by some 
 
 ilight capsule ; but often a con- 
 
 liderable number, even up to 
 
 iventy, are massed in a clump. 
 
 he gonococcus is not easily 
 
 ;ultivated, except in acid media ; 
 
 le addition of an alkali checks 
 
 growth and renders the 
 
 less virulent. The 
 
 lisease has been transmitted both 
 
 animals and to the human 
 
 bject by inoculation 
 
 irganisms 
 
 FIG.385. — GONOCOCCI FROM UrETHRA 
 
 IN Cells and Dlscharge. 
 
 experi- 
 ents with a pure and active culture. The organisms find their 
 ay into the male urethra, and appear to invade the epithelial 
 lis of the mucous membrane, within which they may often be 
 en; they determine an acute catarrhal inflammation, which 
 ickly ruiiS on to suppuration. One great characteristic of 
 norrhoea consists in the readiness with which it extends from 
 
11 
 
 Iii6 
 
 A MANUAL OF SURGERY 
 
 one part to another, and the ease with which even a healt 
 urethral or vulval mucous membrane becomes affected by 
 simple contact sufficing to determine an attack. Hence, althouj 
 the symptoms are often very slight and insignificant, seve 
 complications may arise, which may permanently cripple t 
 individual, or even destroy life, especially if other pyoger 
 organisms are present. 
 
 The Symptoms of Acute Gonorrhoea usually commence with 
 a few days of the infection, varying from two to eight. Mc 
 commonly the discharge appears about the third or fourth da 
 being preceded by itching of the meatus and a scalding pain 
 passing urine. The lips of the meatus are congested and swolle 
 and the discharge, which is at first thin and mucoid, soon becom 
 thick, abundant, and yellow in colour. This stage lasts for 
 variable time, and is sometimes associated with a good deal 
 dragging pain in the back and loins, together with some constiti 
 tional disturbance and fever. The bowels are usually constipate 
 and the appetite impaired. Occasionally the swelling and conge 
 tion of the mucous membrane are so great as to lead to retentic 
 of urine or haemorrhage from the urethra. The first attack 
 always more serious than subsequent ones, although it is moi 
 amenable to proper treatment. Gouty and rheumatic people ai 
 especially difficult to treat, and often suffer from relapses after tli 
 discharge has apparently ceased, and it is said that fair peopl 
 suffer more than those who are dark. 
 
 if suitable treatment is adopted, the discharge entirely cease 
 at the end of two or three weeks ; but if neglected, or sometime 
 in spite of treatment, the inflammation spreads backwards, givini 
 lise to what is sometimes termed a Posterior Urethritis, since i 
 involves that portion of the canal which lies behind the deej 
 constrictor. It usually becomes evident about the end of tin 
 second week, and is characterized by frequent and painful mic 
 turition, a sense of pain and heaviness in the perineum, possibly ; 
 little blood in the urine, and a general feeling of depression. Thii 
 extension backwards is always serious, since it is likely to precedf 
 complications involving the prostate, testis, or seminal vesicles, 
 whilst it is an extremely common cause of Chronic Gonorrhoea or 
 Gleet. A more or less abundant discharge continues for some 
 time without any other troublesome symptom than occasional 
 scalding on passing urine. The discharge varies in consistency, 
 but is often thin and muco-purulent, whilst sometimes, if due to 
 chronic prostatitis, it may be so clear and transparent that it 
 resembles uncooked white of egg. The cau?oes of gleet vary in 
 different cases ; it is sometimes due to an ulcerated or granular con- 
 dition of the mucous membrane, the discharge then being yellow, 
 whilst in others it arises from chronic prostatitis, a condition not 
 uncommonly associated with chronic enlargement of the vesiculs 
 seminales. The latter condition may be recognised on rectal 
 
>«*n./_jC' '**^ 
 
 VENEREAL DISEASES 
 
 1117 
 
 ich even a healthy 
 mes affected by it, 
 c. Hence, although 
 insignificant, severe 
 anently cripple the 
 if other pyogenic 
 
 ly commence within 
 two to eight. Most 
 third or fourth day, 
 i a scalding pain on 
 ingested and swollen, 
 -nucoid, soon becomes 
 tiis stage lasts for a 
 
 with a good deal ot 
 •r with some constitu 
 -e usually constipated, 
 - swelling and conges- 
 as to lead to retention 
 The first attack is 
 3, although it is more 
 
 rheumatic people are 
 from relapses after the 
 
 said that fair people 
 
 icharge entirely ceases 
 jglected, or sometimes 
 ;ads backwards, giving 
 rtor Urethritis, since n 
 lies behind the deep 
 about the end of the 
 fuent and painful mic- 
 e perineum, possiWy a 
 g of depression. This 
 'it is likely to precede 
 , or seminal vesicles, 
 Chronic Gonorrhoea or 
 re continues for some 
 ptom than occasional 
 varies in consistency, 
 [t sometimes, if due to 
 id transparent that it 
 luses of' gleet vary in 
 >i ated or granular con- 
 [ac then being yellow, 
 tatitis, a condition not 
 lement of the vesiculs 
 recognised on rectal 
 
 examination, whilst, when the prostate is involved, flocculi of 
 mucus in the shape of worm-like threads may be detected in the 
 urine. A patch of granular urethritis should be suspected when 
 one portion of the urethra is especially tender on the passage of a 
 sound, but its presence can only be certainly recognised by the 
 use of the urethroscope. 
 
 E very ^p urulent discbarge is not necessarily gonorrhoeal, since 
 a JTmpIe urethritis "niay fdllow connection with a woman wH'o is 
 dimply suffering ^^f rom l euco'frhTe'a, or" has scairfcely'recbVered from 
 her menstrual peno^ TSarwith 'nO'^'UspiCiCrn' 'Df a' Venefeni-^taint. 
 In these cases infection may be aue to ordinary pyogenic cocci, 
 or possibly to the Bac. coli communis, which is known to be not 
 an unfrequent cause of vulvo-vaginitis. A diagnosis of simple 
 urethritis may be suggested by the history, but only a micro- 
 scopical examination of the pus, and a demonstration of the 
 absence of gonococci, can establish it with certainty. At the 
 same time, it must be remembered that gonococci are capable of 
 remaining in a latent or passive state for a very long time in the 
 folds or crypts of a mucous membrane, and hence there is a con- 
 siderable likelihood of a person who has once suffered from it 
 being capable of transmitting the disease, although there may be 
 no evidence of its presence at the time. 
 
 In the Treatment of the early stages of acute gonorrhoea it is 
 essential to keep the urine free from acidity by the use of alkalies, 
 to maintain a free action of the bowels, and to allay the irritability 
 of the parts by sedatives, such as tincture of henbane. The diet 
 should be light and unstimulating, and all alcoholic drinks pro- 
 hibited, as also strong tea and coffee, whilst the patient should be 
 recommended to take plenty of bland fluids, such as barley water, 
 or milk and soda-water. The scrotum should be supported in a 
 suspender, and the patient advised against taking severe or pro- 
 longed exercise. No local treatment is necessary, although the 
 use of hot hip-baths may relieve the pain and irritation ; indeed, at 
 this period injections are harmful. The same treatment must be 
 adopted as long as the discharge is copious, and the scalding con- 
 tinues. As soon as these symptoms moderate, oleo-balsams in the 
 shape of oil of sandal- wood (10 minims, in capsules, three to six 
 times a day), copaiba (10 minims, in capsules or mixture, thrice 
 daily), or cubebs (^ to i drachm doses, wrapped in wafer-paper), 
 may be advantageously employed. Both cubebs and copaiba, 
 especially the latter, are capable of producing a bright-red erythe- 
 matous rash which causes much irritation, and may be extensively 
 diffused over the body. 
 
 The value of injections in the treatment of the disease has 
 
 been much discussed, and is a point on which difference ot 
 
 opinion exists. On the whole, we are inclined to think that many 
 
 j of the less severe cases of acute gonorrhcea can be successfully 
 
 treated without them, and that they should never be employed when 
 
I 
 
 III8 
 
 A MANUAL OF SURGERY 
 
 any local irritation or scalding is present ; but where the discha 
 tends to persist, or the urethra has been thickened by previ 
 attacks, and especially in gleet, their use is imperative. To emp 
 them with advantage, the following plan should be adopt 
 The urethra is first washed out, so as to remove any discha 
 from it ; for this purpose the normal act of micturition answ 
 admirably, so that the injection should be used immediately a 
 passing water. The rounded nozzle of a small glass syrin 
 containing about half an ounce, is- inserted into the meatus, 
 lips of which are compressed over it. The fluid is thrown i 
 the urethra, and held there for about twenty seconds by co 
 presriing the orifice with the finger and thumb as the syringe 
 withdrawn ; then, on relaxing the pressure, the fluid escap 
 Other forms of syringe, on the principle of the indiarubber bot 
 etc., are recommended, but perhaps the glass is the cleanest, 
 the many different injectiqns^mployed, perhaps ' best consi 
 ^jLitfi^xIurejcf imcl^reQ^FcaUec^ 5unce of wai 
 
 and sulphate of zinc (2 grains to i ounce), or of pierniiangafiate 
 ■■*ii*€~(4^:gfain "to" r'ouncej, of riitrate of silverf^ grain fo*T"'(5tffi'c 
 THe"greaTSgeret consists In using the ittjecTion fotif'drTh'irttn 
 a day at first, and afterwards night and morning, even after 
 visible signs of the discharge have ceased. The fluid shoi 
 always be warmed prior to use, and care taken not to use 
 strong a solution. 
 
 One is bound to admit, however, that many genito-urinj 
 surgeons hold views very different to these, and, indeed, ma 
 tain that gonorrhoea can be aborted, or, at any rate, rapi( 
 V brought under control at any stage by large injections of 
 / weak solution of permanganate of potash, introduced with su 
 I cient force to distend the urethra in all its parts and enter t 
 \ bladder. All the crypts and lacunae are thus reached by t 
 \ antiseptic, and the records given of this plan of treatment i 
 very gratifying. 
 
 The Treatment of Q-leet is always a matter of difficulty. T 
 general habits of the patient must be attended to, as in the aci 
 stage, whilst the bowels must be opened, and absolute sexi 
 continence enjoined to prevent the spread of the infection. Lar 
 doses of the liq. ferri perchlor., combined with a sufficient amou 
 of Epsom salts to prevent constipation, may be given. Loc 
 treatment is generally necessary in the shape of injections 
 alreeidy described, and the passage of a cold solid metal bov^ 
 every three or four days has an excellent effect. Methodical dilat 
 tion of the urethra is also advised, with the object of compressir 
 all the crypts and lacunae, and removing pent-up secretion, 
 granular urethritis is present, the topical application of nitrate 1 
 silver may be undertaken tlirough a urethroscope, but requires tt 
 greatest care, for fear of the subsequent formation of a stricture 
 chronic prostatitis and vesiculitis are dealt with by counter-irri!.' 
 
 ( 
 
rERY 
 
 but where the discharge 
 n thickened by previous 
 5 imperative. To employ 
 an should be adopted : 
 
 remove any discharge 
 t of micturition answers 
 3 used immediately after 
 
 a small glass syringe, 
 :ed into the meatus, the 
 riie fluid is thrown in.o 
 wenty seconds by com- 
 :humb as the syringe is 
 iure, the fluid escapes, 
 f the indiarubber bottle, 
 lass is the cleanest. Of 
 jrhaps " best consists 
 imslo OTncFoTwSRr) 
 , or of permanganate*^ 
 ^er , (1 gi-ain 'toT''(5tffi'ce), 
 ecTion fmii-'ofltt 5iimes 
 morning, even after all 
 sed. The fluid should 
 e taken not to use too 
 
 it many gen i to- urinary 
 ese, and, indeed, main- 
 )r, at any rate, rapidly 
 Y large injections of a 
 I, introduced with suffi- 
 its parts and enter the 
 e thus reached by the! 
 
 1 plan of treatment are 
 
 itter of difficulty. The 
 mded to, as in the acute 
 ;d, and absolute sexualj 
 of the infection. Large! 
 tvith a sufficient amounif 
 may be given. Local 
 shape of injections i\ 
 :old solid metal bor^itf 
 "ect. Methodical dilataf 
 le object of compressinjj 
 f pent-up secretion. li' 
 ipplication of nitrate ol. 
 -oscope, but requires tliej 
 armation of a stricture! 
 : with by counter-irritaj 
 
 ■ff 
 
 __J^^^^EAL DISEASES 
 tion applied tn fv. - 
 
 These „,a, U """""""""^ <" ""-oah., 
 
 r ti^'nS- e/' r?"~r jpv^!S'.^ -"> (o„, .... 
 
 lymphatics of fh« • ^ secondary resnff ; 2 o^&anisms, and 
 iacunse with fi, '*^'t>es trom inferfinr. c ^ '*^^^ow. 
 
 which may proiecMnf i °""^ ^^onff the floor^ ? l°'"^'''"'sms. 
 
 urethra, or mS jv^ '^l^^^^^^^ ^"^1 fcharL .1^" ""'^'^'^^ 
 will result rf "^y^^' or both ; in the , ", ^'^^S^e either into the 
 
 from wZut^': ;tTo " ^'^"^^ betp ^nid^r::rr ^^"* >^^''« 
 
 often very difficuItTo Serif ^^ ^'^'^- oc"urrenL"Ji°"J'!^ 
 an inch or so of the miff ^^ ^ ^s^uJa forms xvhh- ' '^^'^^ is 
 ofitself, but may in ome"'"-'" ?"^"^°" siS Ln 1" ^^"'-^^^^^ -^ 
 eiectric cautery or" , ""^'^^ ^^^ closed bv an .7 • ^^''°"^ ^^als 
 
 ever, it remaZTnt^aSe^t'T °^ -^^'te ofX'?^"?f°I ^^^ 
 the meatus. When if. ' ^^'^ ^^^^^a should bf S ^^' ^°^^- 
 operation is usually ^L'"? '" ^^^^ body of the n^ °P"" '"^^ 
 dissectinfr un thT ?■ "^^quired; it consists in r. P^"'^' ^ Plastic 
 
 the medifnTe'^ ^'"" °" «"- -de s?'aV o^'bd;!! 1 t„'4 ^"^ 
 Ohordee results from infl, *^""""" '" 
 
 sponposum or one of th " '"''''°''y infiltration nf h 
 penis becomes erect if -1 ™''P°''"-' cavernosa ,n *?, Z'"', ''"'■Pus 
 to incoinnletfrficf '■ ' '" '"«"' downvvardsTV *^' "'^n the 
 
 patient becoTneswi-' ^""^ ""st marked!., ■ ^'"^ "Condition 
 "W to the part ^^" ''!<'•. It is best deal wi'tf h "'"^" ">e 
 
 r?*""™**'"" »f CowD6r'» n, . " -P0tassujm.or 
 
 f^^oF^^J" F^^^-™ 'S,'L:;- -- give rise 
 k latter corpfaiSr'^""^- " ^ "ealt lillZZsZl T''^' 
 ' Acute and Chron n b . ^^^3^ as 
 
 Acute and ChS ,^'°«**««s (p. 1058) 
 
 Epididymftis arises ^^^^^^ (P 1113). 
 ^^.^■^^dy descr bed at n ^ 'i'"'^°" ''^^^"i^ the vas .n M u 
 
 ii 
 
 I 
 
ill 
 
 
 il20 
 
 A MANUAL OF SURGERY 
 
 '^Hl 
 
 
 i? 
 
 51 
 
 Acute Cystitis (p. 1027). 
 
 In the female many complications arise by direct extension 
 the gonorrhceal inflammation along the urinary and genital trac 
 The primary affection is most commonly a vulvo-vaginitis, and tl 
 may spread to the lining membrane of the uterus, or even to tl 
 of the Fallopian tubes (salpingitis), whilst ovaritis and pel 
 peritonitis also occur. 
 
 II. Complications arising from Direct Transmission of the Vir 
 — Gonorrlioeal Proctitis sometimes results in the female from 
 fection by the discharge which escapes from the vulva, whilst 
 both sexes it may be due to unnatural practices. Considera 
 tenesmus is produced, accompanied by a thick muco-purule 
 discharge. It is treated by injecting lotions of acetate of le 
 and opium, or of boric acid. 
 
 Gonorrhoea! Rhinitis has also been seen in a few cases. It lej 
 to an abundant discharge of pus, and should be treated by war 
 soothing injections, followed after a time by dilute astringents. 
 
 Gonorrhoea! Conjunctivitis occurs either in adults, when it 
 unilateral to start with, or in infants, when it is bilateral, and 
 to infection during transit through the maternal passa^ 
 (ophthalmia neonatorum). It is a remarkable fact that, althou 
 gonorrhoea is so very prevalent, such a small proportion of 1 
 patients suffer from conjunctival infection ; it would appear, the 
 fore, that not only must there be direct contact with the gonorrho 
 poison, but in addition the mucous membrane must be in a rec( 
 tive condition. In the adult variety it is ushered in by redness a 
 irritability of the eye, followed quickly by a discharge which is 
 first mucous, but soon becomes purulent. The eyelids are r 
 and swollen, the conjunctiva is thickened and spongy (chemosi 
 and the discharge liable to accumulate within the conjuncti) 
 sac. If allowed to progress unchecked, the cornea may be injur 
 by the inflammatory process, ulceration, or even necrosis, ensuii 
 and possibly general panophthalmitis. The first detail in I 
 Treatment consists in protecting the opposite eye by means 
 what is known as Buller's shield ; a watch-glass is fixed in 
 piece of mackintosh over the eye, and kept in position by plasty 
 The affected conjunctiva must be imremittingly attended to nij; 
 and day, so as to prevent accumulation of discharge; it is fi 
 f}uently irrigated with warm boric acid lotion, and every fo 
 hours the membrane is carefully washed, dried, and swabbed ov 
 with a solution of nitrate of silver (5 grains to i ounce). Betwe 
 the applications lint wrung out of iced boric acid lotion is ke 
 over the eye. This plan of treatment is continued until the su 
 puration ceases, and then the silver salt is omitted, and simp 
 astringents, such as chloride or sulphate of zinc, substituted. 
 
 In infants the disease often runs a rapid and severe course, ai 
 is very likely to lead to ulceration or sloughing of the cornea, 
 complication not uncommonly followed by escape of the let 
 
ERY 
 
 by direct extension of 
 inary and genital tracts, 
 vulvo- vaginitis, and this 
 i uterus, or even to that 
 ilst ovaritis and pelvic 
 
 ansmission of the Virus. 
 
 ; in the female from in- 
 om the vulva, whilst in 
 )ractices. Considerable 
 a thick muco-purulent 
 ions of acetate of lead 
 
 in a few cases. It leads 
 aid be treated by warm. 
 )y dilute astringents. 
 r in adults, when it is 
 n it is bilateral, and due 
 :he maternal passages 
 ible fact that, although ' 
 small proportion of the 
 ; it would appear, there- 1 
 :act with the gonorrhoea! 
 ■ane must be in a recep- ' 
 jhered in by redness andi 
 
 a discharge which is at 
 The eyelids are red' 
 
 and spongy (chemosis)J 
 within the conjunctival 
 3 cornea may be injured 
 r even necrosis, ensuing. 
 The first detail in ihti 
 )osite eye by means o! 
 atch -glass is fixed in a 
 >t in position by plaster.j 
 tingly attended to nightl 
 
 of discharge ; it is in} 
 
 lotion, and every foii; 
 iried, and swabbed over, 
 s to I ounce). Between 
 oric acid lotion is kepi 
 ontinued until the supl 
 
 is omitted, and siiiipltf 
 if zinc, substituted. I 
 
 and severe course, anl 
 ighing of the cornea, 2I 
 by escape of the lee J 
 
 and blindness fvZr^ — — _"^' 
 
 mate soon ^ftt ?•"//''" °^ "^^^^te of siht Z ^°"J»nctival 
 
 , developed in case^ nf ^"^'^^^, *« those of pyc^mia ar^ . .• 
 dififbsion nf r. -^^ gonorrhoea, nrohiW, . u^^ ''^"^^tmies 
 
 S2 C^ncre. 
 
 ^ Soft Chancre resnif r ^""^ 
 
 i^r^^^EGWtfflrt^^S^^^^^ with some vir, 
 
 and a sharr. ^- ^- ^^' an ulcer form <; wifv. i ^.H^^sent, as 
 
 I . d. snarp, distmct outlinf» tk i ^^^" cleanly cut ed<r^o 
 
 71 
 
 
 13 
 
 i 
 
 i 
 
1 1 22 
 
 A MANUAL OF SURGERY 
 
 
 and that no constitutional immunity results from its presen 
 Frequently several sores are present at the same time, whilst t 
 discharge from one chancre is very likely to produce a simi 
 affection on any cutaneous or mucous surface brought into c( 
 tact with it ; e.g., it may spread from prepuce to glans, or v 
 versa, or from one lip of the vulva to the other. It is a curio 
 but well -authenticated fact that soft chancres are rarely seen 
 any part of the body other than the genital organs. 
 
 Various Modifications of the typical chancre are seen, usua 
 resulting from neglect or carelessness on the part of the patie 
 Thus, if a long foreskin is present, the discharge may be retain 
 behind it, and an extensive ulcerative balanitis occur, which m 
 even result in the glans sloughing through the upper part of t 
 prepuce, which drops beneath it. If the fraenum is involve 
 smart ha-morrhage takes place from ulceration into a branch 
 the artery found in that structure. When there is much inflar 
 niation, the base of the sore becomes indurated and infiltrate 
 somewhat resembling'the Hunterian chancre. Not unfrequent 
 syphilitic infection occurs at the same time as a soft chancre 
 contracted, or subsequently ; the sore is then likely to run a long 
 course, does not heal, even if kept clean, and after a time tl 
 patient presents the characteristic signs of syphilis. 
 
 In all cases the neighbouring Lymphatic Glands become "e 
 larged and tender, and the process may terminate in suppuratio 
 constituting a bubo. Two forms of this affection are describecj 
 (a) The simple or sympathetic bubo results from the absorptic 
 of ordinary pyogenic organisms from the abraded surface. • Tl 
 pus in this case, if inoculated elsewhere, may produce a pustul 
 but not a true chancre. The process is usually limited to tl 
 interior of the lymphatic glands, (b) The vivtilcnt bubo is one di 
 to the absorption into the lymph stream, not only of pyogen 
 organisms, but also of the specific virus, so that when suppun 
 tion ensues, the pus, if inoculated, always produces a typical so 
 sore. In these cases the suppuration occurs not only within, bi 
 even more abundantly around the lymphatic glands {periadenitis 
 so that the skin becomes considerably undermined, and the wouii 
 produced by opening the abscess may take on the form of a hu^ 
 soft chancre in the groin, in the centre of which may be seen th 
 lymphatic gland only slightly enlarged. 
 
 The Treatment of soft chancre consists in keeping it clear 
 dusting its surface with iodoform, and co\ering it with lint dippa 
 in lotio nigra or boric acid lotion, healing usually occurring ii 
 from ten to twenty days ; where much balanitis exists it ma; 
 be necessary to slit up the prepuce, but circumcision should no 
 be undertaken until the sores have healed. The surface of th( 
 chancre may be treated with caustics, such as pure carbolic oi 
 nitric acid, and may perhaps heal quicker for such applications: 
 but they need not be employed as a routine treatment, since sofi 
 
ERY 
 
 nits from its presence, 
 e same time, whilst the 
 !y to produce a similar 
 rface brought into con- 
 repuce to glans, or vice 
 
 other. It is a curious 
 icres are rarely seen on 
 1 organs. 
 
 lancre are seen, usually 
 he part of the patient, 
 charge may be retained 
 mitis occur, which may 
 I the upper part of the 
 le fraenum is involved, 
 ration into a branch of 
 
 there is much inflam- 
 lurated and infiltrated, , 
 ere. Not unfrequently 
 ne as a soft chancre is 
 tn likely to run a longer 
 , and after a time the 
 syphilis. 
 
 ic Glands become "en- 
 •minate in suppuration, 
 iffection are described : 
 ts from the absorption 
 abraded surface. ■ The 
 may produce a pustule, 
 usually limited to the 
 vivulent bubo is one due 
 
 not only of pyogenic 
 
 that when suppura 
 produces a typical soft 
 rs not only within, but 
 tic glands {periadenitis), 
 rmined, and the wound 
 ! on the form of a huge 
 which may be seen the 
 
 5 in keeping it clean, 
 ring it with lint dipped 
 
 1 usually occurring in 
 alanitis exists it may 
 ■cumcision should not 
 . The surface of the 
 h as pure carbolic oti 
 for such applications: 
 B treatment, since soft j 
 
 '^hancres, if Jient rl ~ ~ ~~~——-^ "^^ 
 
 Buboes are treated i„ „ '"">' ''" 
 
 "surptaS'"'^'™'™'^"-"",::^^^^^^^ the patient at 
 
 as toSZ '"'■''• ""= "l^cess should h" ■''°'"«''nes occurs 
 
 S IJ • • Syphilis. 
 
 initial les on vvh.V^ '^^^^'^^" demonstrated .n ''''^" '^^entified 
 •■" smegma The Jn km- "^ '"°^^ ^^an the bLS?' , ""^ •'^>'P^"'Jis, 
 
 dunne- whiVh o period, known at: fk^ • I^ secondary 
 
 f«tatL:tay ET ™'7 '« -«■ eW abse," Tf """^ ^'•■'"'=- 
 
 Mode of Infaotinn tu ^ '''<= 
 
 «l> in wS; heTseasTisf ™- 0--^™a % l^f.:!'''^''^ 
 chancre may be fo,S'^ (ef ragenifal chancres) th" °" f'-^ 
 
 <>- same „Lt'zi°„i Z 't,:v -'^' °f '"'^"w^m^:;^ 
 
 equentJy occurs inlh ".1^"^^^°" ^om 
 
 \B's^^ii^=%p=:~^;^a„. 
 
 *ey at onc-e'^cotne l:ST%r"'' '"'^^^^'tlJC 
 I Hrt=sages may 
 
 Is ■, 
 
124 
 
 A MANUAL OF SURGERY 
 
 ■to 
 
 If; 
 
 
 entirely escape, the ovum becomes diseased. It is usually he 
 that in the tertiary stage the patient is no longer capable of tran 
 mitting the affection. 
 
 The syphilitic virus is exceedingly resistant to the action 
 antiseptics, and hence the risk of infection is very great, evt 
 though prompt measures are taken to destroy it. Thus, mar 
 cases are on record in which an abraded surface was bro"'ght in 
 contact with a syphilitic poison, and, although cauterized wi 
 fuming nitric acid within a few hours, the disease ran its ordinal 
 course. In one case, however, under our observation, in which 
 student's finger was accidentally pricked with a bent broad needl 
 which a moment before had been inserted into the anterior chamb 
 of a syphilitic patient suffering from a secondary suppurative iriti 
 nitric acid was applied within a quarter of an hour, and althouj 
 a suspicious indurated spot formed six weeks later at the site 
 injury, no other evidences of syphilis have been observed, in spi 
 of the fact that the individual had not previously suffered fro 
 the disease, and took no mercury. 
 
 One attack of syphilis usually confers immunity on the patie 
 from further outbreaks of the disease, even if exposed to infectio 
 This protection is, however, not always permanent, since we 
 authenticated cases have been observed of second attacks 
 syphilis, in which the primary lesion was followed by distin 
 signs of general infection. 
 
 Course of the Case. — The stage of Incubation lasts for a vai 
 able period, extendin g from two t o six weeks : as a rule, howevi 
 evidences of induration or tne~50re"can oe detected about t 
 third week. It is probable that long ere this the virus h 
 entered the circulation, and hence removal or destruction 
 the local lesion has not the slightest influence upon the pre 
 nosis of the case, unless it can be undertaken immediately af 
 infection. During this period nothing unusual is noted at the s 
 of inoculation, if the infection is purely syphilitic, and the lo 
 sore merely a slight abrasion ; it may then heal completely in 
 course of a few days, and nothing further is noticed until 
 typical induration manifests itself. Not unfrequently, howev 
 a soft chancre is also present, and then the usual phenomena 
 this condition appear, but the lesion does not heal in a typi 
 manner, and the base of the ulcerated surface becomes indura 
 after a time. w 
 
 I. The Primary Stage of syphilis is characterized by the devel 
 ment of a typical primary sore, associated with enlargement of 
 neighbouring lymphatic glands. It is usually situated on the b 
 of the prepuce, close to the corona glandis, or on the frsenum 
 the female the inner aspects of the labia majora or nymphae 
 the most common sites. 
 
 The primary sore does not invariably present the sa 
 appearance, although it is always characterized by a cert 
 
lY 
 
 d. It is usually held 
 inger capable of trans- 
 
 ;tant to the action of 
 m is very great, even 
 stroy it. Thus, many 
 rface was brcght into 
 lough cauterized with 
 lisease ran its ordinary 
 (bservation, in which a 
 th a bent broad needle, 
 to the anterior chamber 
 dary suppurative iritis, 
 an hour, and although 
 2ks later at the site of 
 been observed, in spite 
 reviously suffered from 
 
 nmunity on the patient 
 if exposed to infection, 
 permanent, since well- 
 [ of second attacks of 
 s followed by distinct 
 
 bation lasts for a vari- 
 ks : as a rule, however, 
 %e detected about the 
 3re this the virus has 
 oval or destruction of 
 fluence upon the prog- 
 taken immediately after 
 isual is noted at the site 
 syphilitic, and the local 
 1 heal completely in the 
 ler is noticed until the 
 unfrequently, however 
 the usual phenomena of, 
 is not heal in a typical 
 rface becomes indurated] 
 
 acterized by the develop 
 with enlargement of the! 
 lally situated on the base| 
 is, or on the frsenum ; 
 L majora or nymphae arj 
 
 ibly present the sanii 
 racterized by a certaij 
 
 ^EliEAL DISEASES 
 
 amount of infiltraf ^ — ~~~~~— — — — !'^^ 
 
 reSS;"ul„„, ^ ""^^ ''ore has ifrst 7l^,' 'O;,™'! jnvading 
 
 surface covered tfth'''°";K }' '' "«"-% smklM^uM"'^/ ^"^^"'^ 
 to the irrifn J! c ^P^^heJial scales Tf « ' . ^^^^^^ ^nd its 
 
 take p ace'^^'^d ° '''^>^^ discharge ' u cer.'^'"^ '° ^"^^^o"' or 
 
 UnJes? this 'occurs" itt""'' ^""^'Sn SrT iTl '"^f^ ^° 
 
 patient becomes ^phim^^irt? ''l 1°"^^ unobserved lnd"th""- 
 
 source of infection /I Th-'^"* ^^^"^ able to trace fh. .• "' "" 
 
 IS that mncf / ^V ^"6 indurated hnr^ Vr *"^ time or 
 
 -veiy "dlffu's Th oS'' ,°h' '"^ '"""-''^ may' r'Tor"" ^'^ 
 possible thJt . ^^® infect on occurs; !f ^ • ^^^" on the 
 
 in 
 
 'i ,1 
 
1126 
 
 A MANUAL OF SURGERY 
 
 \'-l 
 
 the induration may completely encircle it. In all these case 
 stricture is apt to form subsequently. 
 
 Extragenital Chancres are often observed, perhaps most cc 
 inonly on the lips, finger, and nipple ; but, of course, any } 
 of the body may become affected. These conditions are usu; 
 characterized by a greater amount of infiltration and less disti 
 and definite induration than in the forms met with on the gen 
 organs ; hence the swelling is more prominent and vascular, ; 
 if ulceration occurs there is a greater amount of discharge, wl: 
 forms a thick scab over the surface. The neighbouring lymph; 
 glands are enlarged, and sometimes surrounded by infiltra 
 tissue. 
 
 This condition has often been mistaken for epithelioma, fr 
 which, however, it can be distinguished by the age of the patic 
 the character of the sore, its rapid development, and 
 simultaneous enlargement of the glands. Tlie course of the c 
 in an extragenital chancre is generally nio?e"severe thfttt'Wl 
 the prirhiifjjesion _is ^ ii^Udt ■situatjon. a fact explained 
 
 the diseaL>e often remaining unrecognised till secondary syniptc 
 appear. 
 
 --4n-surgeons or accoucheurs infection may occur on the fing< 
 usually starting by the side of the nail. It gives rise to 
 indolent sore, which becomes infiltrated and ulcerates, tending 
 spread under the matrix and along the semilunar fold. Ther 
 a good deal of discharge and pain, and the terminal phal< 
 becomes swollen and bulbous. The epicondyloid and axill; 
 glands are enlarged as the case progresses, and the condition n 
 even be mistaken for malignant disease. 
 
 Phagedena is a t'orm of spreading ulceration, rarely met witii at 
 present time, except in connection with venereal disease, and, accordinj 
 most authorities, seldom apart from syphilis. It always attacks unheal 
 and debilitated individuals, especially men with phimosis. The discharg 
 retained under tlie long foreskin, and, undergoing decomposition, gi\es ris 
 a spreading destructive inflammation of the prepuce and glans. 
 
 The Treatment consists in the relief of all tension by division of the fores 
 if that structure has not been already destroyed, followed by prolonged 
 mersion of the patient in a hot hip-bath, so that the toxins may be so dili 
 as to prevent any extension of the ulceration, and thus facilitate the nati 
 processes of repair. If the patient cannot be kept for twelve or twei 
 four hours in a warm bath, it will suffice to immerse him in warm w; 
 for two or three hours every day. In the intervals the wound should 
 dressed with iodoform, and covered with lint dipped in lotio nigra. Un 
 such circumstances, the surface of the r.ore cleans, and becomes cove 
 with healthy granulations. The later treatment is conducted as for prim 
 syphilis, although the depressed condition of the general health may necessii 
 the administration of tonics and even a visit to the seaside. Should treatm 
 by immersion in hot water be for any reason impracticable, the old-fasliioi 
 plan must be resorted to, viz. , scraping the sore, and freely cauterizing the I; 
 with fuming nitric acid. 
 
 The Lymphatic Qlands which receive lymph from the regi 
 in which the sore is situated become characteristically enlarg( 
 
VENEREA L DISEA SES 
 
 1127 
 
 In all these cases a 
 
 , perhaps most con)- 
 of course, any part 
 'onditions are usually 
 ation and less distinc 
 ,et with on the genita 
 ,ent md vascular and 
 nt of discharge, which 
 eighbouring lymphatic 
 •ounded by inhltrated 
 
 for epithelioma, from 
 
 the age of the patient, 
 
 development, and the 
 
 The course of the case 
 ao?e-'severe mtr^WhSti 
 
 on, a fact, explained by 
 ill secondary symptoms 
 
 ay occur on the fingers, 
 I It gives rise to an 
 ,nd ulcerates, teiiding to 
 emilunar fold. There is 
 I the terminal phalanx 
 ^condyloid and axillary 
 , and the condition may 
 
 n rarely met xvith at the 
 i'Sase. and according to 
 It aUvays attacks unheaUhv 
 nhimosis. The discharge is 
 Proposition, gives r>sc to 
 
 rt^:!i£ofthefores^ 
 , followed by prolonged >m, 
 the toxins may be so diluteu 
 . , thus facilitate the natural 
 kept for twelve or twen y 
 Srse him in -arm ^va er 
 :rvals the wound ^l^ould 
 bped in lotio nigra. Uncle 
 Peans and becomes covered 
 Tconducted as for pnmarv 
 bneral health may necessitat 
 P aside. Should treatn^n 
 racticable. the o^-fashu nej 
 Vd freely cautenzmg the Use| 
 
 1 lymph from the regionl 
 Iracteristically enlarged. 
 
 They fe ej^ hard^ and shotty, moving freely under, the sJdiv like 
 hpilei's . pellets of cartiTa^fe. or aliuoiuls (hence the . term ' amjg- 
 daloid wJiidT has often been applied to the.in} ; tlicy, arcoahually 
 "^ite, pt|inli^ss. If a pure syphilitic infection occurs at the site 
 ofmoculation, there is no tendency for them to suppurate; but 
 if the original sore is septic, or also inoculated vith the \irus of a 
 soft chancre, an aiiscess often follows, one or more of the inguinal 
 glands breaking down, and causing a red and brawny infiltraiion 
 of the superjacent integument. After a time the skin gives way, 
 and is often found extensively undermined. 
 
 Occasionally the lymphatic vessels extending from the sore to 
 the glands become the seat of a chronic lymphangitis, and may 
 be felt as hard cords beneath the skin. The dorsal lymphatic of 
 the penis is frequently blocked in this way, and gives rise to solid 
 or lymphatic (jedema of the prepuce and glans. Should the 
 ( hancre suppurate, an abscess may form in the course of the 
 lymphatics. "^ 
 
 The duration of the priinary sore \aries in different cascs^aJj:.d 
 dep'en3s in .^reat^ measure on, whether treatment. is Gomnienced 
 early pi iat^e. If the case comes under obser\ation during the first/ 
 sTx weeks, and a mercurial course is at once started, the chancre 
 heals, and the induration usually disappears in from six to eight 
 weeks. The glands in the groin, however, remain enlarged for 
 some time. The longer the case is left untreated, the more slowly 
 does the induration disappear. If no mercury is administered at 
 all, the induration may last for twelve months or more, and then 
 slo vly passes off. From an uncomplicated syphilitic sore but 
 littlv scar results, although a well-marked cicatrix may follow a 
 soft or septic chancre. 
 
 Re-induration of the cicatrix sometimes occurs from too early a 
 cessation of the mercurial couise, or from some localized irrita- 
 tion, or from a fresh exposure to infection. It is occasionally due 
 to a tertiary or gummatous development, and will then be free 
 from lymphatic complications. 
 
 II. Secondary Syphilis. — In the secondary stage, the virus is 
 [diffused generally throughout the body by means of the blood, 
 which is itself infective. A certain amount of constitutional 
 [disturbance may exist, the patient feeling ' seedy ' and out of 
 ;orts, whilst in some cases distinct febrile phenomena and head- 
 ache have been noted. Well-marked anaemia is often present, 
 ind on examination the red corpuscles are found to be deficient in 
 lumber, and defective in. the amount of haemoglobin contained 
 within them. The chief secondary manifestations consist in the 
 .ppearance of various forms of rash on the skin and mucous 
 iiembranes, associated with a general enlargement of the lym- 
 )hatic glands, sore throat, mucous tubercles and condylomata, 
 [o,ss of hair, and other less common phenomena, and these usually 
 )liow themselves in from seven to nine weeks from tnetime of 
 
 •'.*-'*»*W-rt««».^ 
 
 4 ,.*t***y*"*'*'*"''=t«iB» 
 
1128 
 
 A MANUAL OF SURGERY 
 
 
 inocula tion, altliough they may be delay ed to a nnich lAter d 
 'I'neir TiiT^hsity also' varies cohsiclerably, the phenoinenalie 
 sometimes scarcely evident, and at others very marked. They 
 also influenced jj^reatly by the period at which the administra 
 of mercury commences ; the earlier the drug is given, the 
 
 obvious are the secondary pTVertomfenc'ir" >«"-.h,. 
 
 "The Cutaneous Eruptions of secondary syphilis are chi 
 characterized by the fact that, although any form of rash may 
 simulated, no specially distinctive variety is originated. M 
 over, in the same individual the eruption is not always of 
 same character throughout, several distinct types developing 
 separate parts of the body {polymorphism). The rash is usu; 
 more or less symmetrical, the colour in the early stages bein 
 dusky red, rgfiejubiuig that of raw ham, whilst later on it beco 
 ^qf a rnore coppery hue; occasionally, however, it mayTJaabj, 
 rosy 'red. §j(;;^hiHtic rashes do not completely fade on pressi 
 but leave a browii stain, and give rise to but littTe IrritatTon 
 itcnmg ; tney always tend to progress from the smipler tyj 
 due to hyperemia, to the more serious, in which infiltration i 
 overgrowth are evident. 
 
 In the simplest form, merely a hyperapmia is present, sot 
 times appearing as a dusky mottling of the skin {voseoi 
 syphilide), which quickly fades, or may persist whilst ot 
 types are developing. If distinct papillae become infiltrated a 
 hyperaemic, a papular syphilide is said to be present ; such nj 
 become either vesicular or pustular, constituting the vesicular 
 pustular syphilides ; the latter cliange is uncommon, and oi 
 appears in bad cases or in debilitated patients. Another form 
 eruption is the squamous syphilide, characterized by patches 
 hyperaemia and infiltration, combined with superficial desquaii 
 tion. It is usually bilateral, and, unlike simple psoriasis, affe 
 the flexW mther than the extensor surfaces. In the later Stag 
 ttisfincVrioduIes ofluTiercles are produced in the skin, which rr 
 even run on to ulceration {tubercular syphilide). 
 /""As to the situation of the rash, the roseola is usually limited 
 I the abdomen, whilst the other forms are often widely scatte: 
 ^over the trunk and extremities, involving, however, the fie; 
 l more than the extensor surfaces of the limbs. A somewl 
 characteristic phenomenon is the appearance of a papular rash 
 the forehead, sometimes known as the corona Veneris. 
 
 \ 
 
 The Mucous Membranes may be affected in mu( 'i th. ^amc w 
 ^s'lhe skin. The fauces become red and coi' the hyp 
 
 semic area being abruptly limited, and semi( a" in outlir 
 
 symmetrical ulceration usually follows, orij, (ting near i 
 anterior pillars of the fauces, and spreading thenu to w ton; 
 and along the soft palate to the uvula. These ulcers aic shalk 
 have sharply-cut edges, and present a characteristic greyish i 
 pearance, constituting what is known as a ' snail-track ' ulc 
 
^NKIU-AL DISEASES 
 
 ERY 
 
 id to a imich liiter date. 
 
 , the plKMioinenabemg 
 
 very marked. They are 
 
 v'hich the administration 
 
 drug is given, the less 
 
 iry syphilis are chiefly 
 
 iny form of rash may be 
 
 ty is originated. More- 
 
 DH is not always of the 
 
 net types developing in I riTnni2ig5~i;n? ^ -"^^'^^^^^^^^ 
 
 ). The rash is usually I wWdT^S^^^./^ ^^l^'i-.membrancs^ t^^^^ in 
 
 :he early stages being i | r^u^^^T^^ ^tj^^^ MucotS T^f^^.?^^^ ^ tl. j^J,in 
 
 nilst later on it becomes 
 
 ^ever, it may }je." a. hriglit 
 
 >letely fade on pressure, 
 
 o but Iitt'Te IrritatTon" or 
 
 from Ihe simpTer'"t'ypes; 
 
 n which infiltration and 
 
 aemia is present, some- 
 of the skin (roseoloiis 
 ly persist whilst other 
 become infiltrated and 
 be present ; such may 
 jtituting the vesicular or 
 i uncommon, and only 
 ients. Another form of 
 Lcterized by patches of 
 ^ superficial desquama- 
 simple psoriasis, aflTects 
 55. In the later Stages, 
 in the skin, which mav 
 ide). 
 
 >la is usually limited to 
 I often widely scattered 
 ig, however, the flexor 
 limbs. A somewhat 
 ice of a papular rash on 
 na Veneris. 
 
 I in mu( 'i tb ^amc u. 
 1 coi ;he hype' 
 
 iemi( a in outlin 
 
 ori^ iting near thej 
 Ig theijd to ' It' tonsilsl 
 hese ulcers aic shallow, 
 aracteristic greyish ap 
 a * snail-track ' ulcer, 
 
 The secondary sorp th.- ~T \ ' -^ "'^ 
 
 ^'^^^^^:^Sl>?entlv"":^'^^^ 
 
 'V number of bir^ ^ , ^ '^'^'' ^''^'^« nianifesMH" '^^ ''f'*'^ "^'^se 
 
 on the dors m of ??''^"^'^ ^^""' ^^ss Jcnhu^''' '" '^'^ ^^^"^es 
 
 very painful 1 ^^"^ ^°"^'"^'' or seN'er-iV 1 ,"'" '"''^>' ^'^ ^^^n 
 
 , y Pa.nful, ulcers n.ay develop onX „ ide 'of'r"'',"''^'; '^"^ 
 
 J^i'cous tuberri , ' ''^'''''^^ "'• 
 
 i'eaped „p;Jer"hem ''Vf'^^'''^'^ »Cd Z'T^'^^'f^' ^"^ 
 corners of the m,?, .T' ' ''">" »« most com nn? u ' •'P't'iehun, 
 
 ^^.d?H'---sri££^f^?e's!S: 
 
 affection. IW^v"'^''^^"^^ of the de^rree of ,^^ ? "^^' ^°'^- 
 
 ;:s--^^»^s^s^;!r^-3iShi:r:;i;^ 
 
1130 
 
 A MANUAL OF SURGERY 
 
 metrical chronic effusion develop within the synovial mem 
 of joints. 
 
 Syphilitic Iritis is characterized by pain in the eye, gen( 
 referred to the supra-orbital nerve, together with some interfe 
 with vision, and possibly a little lachrymation and photoph 
 On examination a bright-red circular zone immediately surrc 
 the cornea, resulting from hypera^mia of the ciliary vessels, 
 iris is lustreless, and its definition somewhat blurred. Its c 
 is changed, a blue iris becoming greenish-yellow from the pre 
 of lymph. The pupil is diminished in size, and perhaps irreg 
 its movements are always considerably hampered, and some 
 entirely prevented by the formation of adhesions either t( 
 back of the cornea (anterior synechia;) or to the lens ca 
 (posterior synechiae). Occasionally srriall yellowish nodule 
 seen on its surface, consisting of plastic lymph. 
 
 The Duration of the secondary stage varies considerab 
 different cases, and is largely influenced by the character o 
 treatment and the period at which it is commenced. The sc 
 the patient is brought judiciously under the influence of mere 
 the less severe the secondary phenomena, whilst cases in \\ 
 treatment has been delayed are likely to be much more tro 
 some. Hence the disease is often of an aggravated type a 
 following extragenital chancres, as also in women, by whon 
 primary lesion often passes unnoticed and untreated. V 
 treatment is commenced within four or five weeks of infec 
 the secondary stage is slight, and all traces of its existence 
 pass off in two months or less ; if mercury is not administered 
 the cutaneous eruption has appeared, this stage is likely to 
 much longer. The condition of the patient's health is an in 
 tant factor, as also the previous habits, particularly as to ten 
 ance, since syphilis always follows a more aggraxated cour: 
 the weakly and the dissipated. Even under the best cin 
 stances, the patient is liable to outbreaks of the affection w 
 the first twelve months. Relapses are by no means uncomi 
 being usually due to intermissions in the treatment. The 
 which appears under these circumstances is often of a i 
 characteristic type, the papules being grouped into rounde 
 corymbose figures. 
 
 III. The Intermediate or late Secondary Stage comprij 
 group of symptoms which form a link between those air 
 described and the tertiary phenomena ; and indeed no dis 
 limits to this period can be defined, nor need it appear at 
 the patient's general health is good, and the treatment has 
 carried out regularly. Some of the secondary manifestat 
 especially those of the bones and joints, may persist through 
 period, whilst even if they have disappeared, the patient is 1 
 to suffer from ' reminders ' in the shape of various cutan 
 affections, and perhaps epididymitis. Deep lesions of the 
 
RY 
 
 VENEREAL DISEASES 
 
 113' 
 
 tie synovial membrane 
 
 n in the eye, generally 
 r with some interference 
 vtion and photophobia, 
 immediately surrounds 
 he ciliary vessels. 1 ^^ 
 lat blurred. Its colour 
 yellow from the presence 
 
 or 
 
 (choroido-retinitis), and of the central nervous s^st^ilL.(&ypiuUti£; 
 monoplegia) are not uncommon, the latlei" usually aris.iug,, from 
 anaemiia "" of the " cerebral "centres" du§ tp ^"syphHilic^endariewtls 
 (f)r~222)l THe prTncipaT "cutaneous affection is the so-called 
 syphilitic psoriasis, most frequently seen on the palms and soles. 
 A squamous syphilide is often observed in the secondary stage, 
 but is then symmetrical and readily influenced by mercury. In 
 this intermediate period, the lesion may be bilateral or limited to 
 one side, according to whether it appears early or late. In the 
 ytiiw" "-- •rreffular; ■ ^°^'"^'- there is' a considerable tendency to proliferation of the 
 3, and perhaps o^^^^^l epithelium, together with deep cracks and fissures; in the latter 
 impered, anc so ^^ theltli^f^' is less epithelial overgrowth, but the edges are often dis- 
 adhesions ei ronsulel^^^^t^y serpiginous in outline, and there is an infiltrated border. 
 \^ ]^u\^^a,aX are! Rupiaand Ecthyma are lioth met with in this stage of the 
 
 diseaSe^ TlTey'are^iaractenzed by an inliltration of the skin, 
 
 \hich progresses to ulceration. In rupia the discharge forms a 
 
 - vrtiiv.-. "— - -- ^|^^B(listiiict scab on the surface, which increases in thickness by the 
 
 1 by the 1 '^'' T^ViP ^ooner^^P°^^t of successive layers one under the other, each being 
 
 oniewhat larger than the one which precedes it ; hence a scab 
 liaped like a limppt-shell is produced, resting on an inflamed and 
 yperaemic base ; any part of the body may be affected in this 
 
 ri t ne whenP'^y- ^" ecthyma no scab forms over the ulcerated surface, or, if 
 
 in aggravate-^ hom thel^'^'^^^^' ^^ readily comes away, leaving exposed a hollow punched- 
 
 women,^Dy^^ "Whenl'"^ sore, surrounded by an area of vivid congestion. Under 
 
 "^ "^"^ ppropriate treatment these conditions disappear, but leave de- 
 
 ressed, whitish cicatrices, often surrounded by pigmentation. 
 
 A somewhat unusual intermediate manifestation is a subacute 
 
 ynimetrical epididymitis, in which the cord also becomes 
 
 lickened, enlarged, and tender (p. 1099). 
 
 1\ . -Tertiary Syphilis. — The phenomena occurring in this stage . 
 
 ;iy appear within six months 01 infection, or not Tor twenty 
 
 ___^ T^^Lfs. They art 'mainly ■ characterized by infiltration 
 
 overgrowth of the connective tissues of the body. Such 
 
 ay occur in one or many places, and may be diffuse or localized. 
 
 the former case the organ or part affected becomes enlarged, 
 
 rd, and sclerosed, and unless the condition is treated promptly, 
 
 e normal tissue of the part may entirely disappear, being re- 
 
 aced by fibro-cicatricial tissue. If, however, the process is 
 
 :alized, a Qumma is formed. 
 
 ^ny^lisslie in Ufebbdy may be the seat of a gummatous 
 
 posit, which apparently arises without any definite cause, 
 
 xasionally its onset may be determined by an injury. 
 
 ed area becomes occupied by a round-celled infiltra- 
 
 U yellowish nodules 
 
 ^"Jaries considerably in 
 -acter of the 
 ommenced. The sooner] 
 the influence of mercury. 
 >a, whilst cases in which 
 o be much more trouble- 
 
 i' and" untreated. WJi 
 r f\ve weeks of infection.! 
 aces of its existence mav 
 vis not admimstered until! 
 
 Ihis stage is likely to lastf 
 ient's health is an impor 
 particularly as to temperi 
 lore aggraNated course u 
 ' under the best circunv' 
 ks of the affection withir 
 ,w no means uncommonj 
 he treatment. Ihe rast 
 ces is often of a niorj 
 [grouped into rounded ol 
 
 idary Stage comprises 
 
 W between those alrei 
 K i)t;iv\tv. distinclfP"^"^' ^^'' 
 
 ; and inaee ^^ jillftliough occasionally its onset may be determined by an injury, 
 
 r need it app beeB'^ involved area becomes occupied by a round-celled infiltra- 
 
 l the ^'^®^*'"^^"-fggt"j^tioii«'"' tlie cells being derived partly from proliferation of the 
 ^econdary ."^/^l]^ ^^ tl,fcnective tissue, and partly from leucocytes. This gradually 
 L may persist . j^ li,^«reases in amount, the normal tissue of the part disappear- 
 kred, the patie ^^^"^j^^qM before it. \'ery few vessels penetrate into the mass thus 
 Ipe of various ' e#"eJ. which otherwise somewhat resembles granulation tissue. 
 'Deep lesions ot tlie e-p s 
 
■li » 
 
 mn i 
 
 
 Hi 1 
 
 
 ii 
 
 ■ 
 
 "fi 
 
 I ;'. 
 
 1132 
 
 A MANUAL OF SURGERY 
 
 As the process extends peripherally, the older portion is 
 formed into cicatricial tissue, and, finally, owing mainly 1 
 compression of the v^essels by its contraction, and partly 
 concurrent syphilitic affection of the tunica intima of the nu 
 arteries (p. 222), the blood-supply of the centre of the gi 
 fails, and the tissue dies. In this stage a gupimau. consist 
 central, >yhitish-yellovy slough, devoid,,, of. vessels, formt 
 tfie oldest portions of the growth in a condition of fatt^ deg( 
 "tion'arid hecr-bsTs ;' SUtroiindfng' 1tti§"Ts*" a zone" of ro6se'"v^ 
 fabro-cicatfidal tissue, whilst the periphery of the tumour i: 
 stituted by a round-celled hyperaemic infiltration of the n 
 tissues of the part. Under appropriate treatment, the wh 
 this new formation may disappear, being replaced by a fi 
 cicatrix ; but not unfrequently the central portion breaks 
 into a gummy, semi-purulent fluid, which finds its way t 
 surface and is discharged. Where the necrotic mass is la 
 portion of it may remain adherent to the surrounding tissues 
 ulceration has taken place, looking somewhat like a piece ( 
 wash-leather. Under exceptional circumstances the o 
 slough may become encysted by the formation of a fibrous 
 sule, and calcification of the centre may even occur ; this is s 
 to be most frequently found in the brain, testis, and liver. 
 
 Clinically, the appearances vary according to whethe 
 gumma is cutaneous or subcutaneous. 
 
 Cutaneous gummata are very frequently observed in te 
 syphilis, especially in the earlier stages. They occur as d 
 red nodules of firm consistency, and but slightly painful, 
 such growths are often grouped together in one region, and 
 ulceration has occurred, they produce by their confluence 
 with a rounded or serpiginous outline. Considerable destri 
 of tissue follows, but they are readily cured, giving rise to depi 
 white cicatrices, surrounded by pigmentation. 
 
 Occasionally a diffuse infiltration of the skin is met with i 
 stage, appearing as a red hyperaemic area with a rounded c 
 piginous border, and not at all unlike lupus in appearance, 
 readily amenable to treatment, and runs a much more 
 course than lupus ; the edge is usually thickened to the 
 extent all round, and there is but little tendency to the forn 
 of outlying nodules. The apple-jelly-like granulations, so t; 
 of lupus, are of course not present. A cicatrix not uncomi 
 results, even if ulceration has not taken place. 
 
 Subcutaneous gummata are characterized by the formation 
 firm nodule, which gradually increases in size, and sooner ot 
 travels towards the surface ; the centre of the tumour be( 
 elastic and fluctuating ; a certain amount of pain and tendt 
 is noticed, and when the skin is affected, it becomes dusk 
 even oedematous. Ulceration follows, and the contents t 
 gumma thus escape. The sore produced is deep, the edges 
 
RGERY 
 
 the older portion is trans- 
 lally, owing mainly to the 
 itraction, and partly to a 
 nica intima of the nutrient 
 the centre of the gumma 
 ge a gumnisL consists, of a 
 d,, of., vessels, formecf '|> v| 
 ;onditwn of fatt^ degeiiera 
 s" a zone of fbose"" va^SCtlla 
 •hery of the tumour is con- 
 infiltration of the normal! 
 te treatment, the whole ol 
 ;ing replaced by a fibrous 
 itral portion breaks dowr 
 i^hich finds its way to thf^ 
 ! necrotic mass is large, ; 
 e surrounding tissues aftei 
 mewhat like a piece of wei 
 ircumstances the centra' 
 ormation of a fibrous capl 
 ' even occur ; this is stated 
 n, testis, and liver. 
 Lccording to whether th 
 
 ^^f^EAL DISEASES 
 
 II 
 
 oi 
 
 ntly observed in tertia 
 s. They occur as dusk\ 
 at shghtly painful. Maiii 
 er in one region, and whe 
 
 by their confluence soJ 
 Considerable destructic 
 ed, giving rise to depress! 
 tation. 
 
 :he skin is met with in tl; 
 irea with a rounded or sf 
 upus in appearance. It 
 runs a much more rap 
 ly thickened to the sai 
 
 tendency to the formati 
 ke granulations, so typic 
 I cicatrix not uncomniorj 
 
 place. 
 
 ed by the formation of 
 in size, and sooner or la; 
 e of the tumour becon 
 nt of pain and tendero 
 jd, it becomes dusky 
 
 and the contents of 
 ed is deep, the edges bei 
 
 sharply cut, and perhan^ „r,^ ^ ~ 
 
 sinceT, Wongs thr,™;;^ ^^f'^" '"'7 b ^^ ^.S?' ^^'^"°!l- 
 'Msy which me\enT<^ f^^;r -1 •^. ^^'^^^ 
 
 )f the LreneraJ rrUr^A \ , character ^f the n«;h ^ , i^^^y when 
 
 )Prlinr.e • f^^^nauJar en arijemen^ in A "' ^"^ t'^e extent 
 
 siilissliii 
 
 As to the Curabilitv nfl f -r ' ^^^ involved. ' "^'^ 
 
 » y seen amongst femaS '^'™°"'™'-' "^^ P^^en, ; such t e 
 ine Treatment of CT,r>K;r 
 "jury during .he pSrylnSL'" "f •'"'""•n-tration of 
 
IIJ4 
 
 A MANUAL OF SURGERY 
 
 l! 
 
 
 V 
 
 amount of benefit from the druf;; with the minimum of 
 venience. {a) It is usually given by the month, either in th 
 of pills composed of grey powder (grs. i.— iii., t.d.s.), or 
 green iodide (gr. ^ — i, t.d.s.), or as a mixture contaii 
 solution of corrosive sublimate. The last method is dis 
 objectionable, inasmuch as its prolonged use in sufficient 
 disturbs the digestion. £j^rey.j;aQ)>v(;lpr i^ PPrK''-r.^!. j"^'^ J?^^^ 
 of giving the drug ; the patient should cqmmeince wittf ^2 ^ 
 n"ve n thre e "tiities 'a day, or in some cases j J ^r^-iAS .lUuiUt 
 ctajs^dnil)ilied wl?lT"a"TrttTe ejj:tract of ppiyin Qr,pul\'. ipec, 
 if there is any tendency to diarrhoea; but thisaddition 
 always needed. This should be cautiously continued uh 
 prominent sighs of the disease have disappeared, and the 
 dose is gradually reduced, (b) Ijii}UJ:twioiXhe,miiZQ.uual.QUi 
 is also frequently ^ai.d.QpJted,. and with great, success,, inasmuc 
 's..]eig,J|^Qiy„t0^.cause digestive derangenieqt?,. If thejarj 
 officinal ointment is employed, a portion as large as. aJiazel- 
 'TinSlieH'intb tKegj-bln "of axilla nightly, the pai't being wash( 
 foTIowmg rhot-mhg, and' riot useil again for this purpose for 
 or four days ; if the ointment is made up with lanoline, a 
 what smaller amount is required. Possibly this is one of th( 
 ways of bringing a patient rapidly under the influence of the 
 (c) MeycHvial vapour baths may be advantageously employed a 
 the cutaneous eruption is very extensive. Tlie patient sits i 
 on a cane-seated chair, and covered with a blanket or spe 
 constructed cloak reaching from the neck to the ground, an 
 touching the body ; 20 or 30 grains of calomel are placed 
 metal plate surrounded by a trough containing about i our 
 water. The water is boiled, and the calomel sublimed, by n 
 of a spirit-lamp placed under the chair. In about twenty mi 
 all the calomel will be volatilized, and deposited in part upo 
 skin of the patient, who perspires freely during the process, 
 then gets into bed between varm blankets, without wipinj 
 skin. This treatment may be combined with medication b 
 mouth, (d) Mercury is sometimes administered by subcutai 
 injections, in the form of the perchloride, \ grain or less 1 
 injected once or twice a week into the substance of the gl 
 maximus. A little thickening of the site of injection results 
 (juickly passes away, and suppuration scarcely ever follows. 
 
 During the course of mercury, the patient's general healtl 
 habits must be carefully regulated, all excesses in drink and 
 being forbidden, and strict instructions given as to keeping 
 teeth and gums clean. To minimize the risk of throat and n" 
 trouble, it is wise to stop all smoking for at least six mo 
 The dose required varies in difterent individuals, being inert 
 in robust people, and diminished in those who are weak 01 
 healthy. It should always be pushed until mild physiolo 
 effects are produced in the shape of slight tenderness of the g 
 
JRGERY 
 
 d with medication ny t, 
 inistered by suhcutaneoi 
 ide, \ grain or less beinj 
 
 substance of the glute 
 te of injection results, I 
 :arcely ever follows, 
 .tient's general health 
 ixcesses in drink and d 
 
 given as to keeping ti 
 ! risk of throat and mou: 
 for at least six mont' 
 dividuals, being increa 
 )se who are weak or u 
 until mild physioloj,nc; 
 t tenderness of the gun 
 
 -— ^,^ .h 'nsertecl between oppo§. 
 
 I 
 
\'4'- 
 
 1 136 
 
 A MANUAL OF SURGERY 
 
 m: 
 
 m 
 
 f 
 
 I 
 
 ing surfaces to keep them from rubbing one against the ( 
 Secondary ulceration of the throat does not usually reciuire 
 treatment, as it soon disappears under the influence of mer 
 A mercurial gargle may, however, be employed, or in bad 
 ralUIllBl f fra;5r-iie-pfa'ced otl a itot; copper coin, and its vi 
 'Tnf[a\edl 'Superj^aargm^^ ulcers are treated by removin 
 
 "Scabs^ and applying some form of mercurial ointment. A ( 
 mined attempt should be made to keep deep gummatous i 
 in an aseptic condition, since the advent of sepsis to such < 
 especially if they are connected with bones, makes a m 
 difference in their progress. In neglected cases the wound 
 become exceedingly foul, and even give rise to septic absor 
 characterized by a hectic temperature, whilst amyloid dege 
 tion of the viscera has even been observed. When gun- 
 come to the surface and point, they should be opened wit 
 same precautions as are adopted in the case of an abscess 
 either dressed antiseptically, c^ their cavity stuffed with li 
 gauze soaked in lotio 
 
 f 
 
 ptically, or 
 nigra, sj 
 
 Inherited or Congenital Syphilis. 
 
 Syphilis may be conveyed to the ovum either by direct 1 
 mission from the father or mother alone, or both parents 
 be tainted with the disease. Occasionally the mother ace 
 syphilis during pregnancy, and in such cases the foetus 
 becomes affected. In those instances where the ovum is in; 
 from the father, whilst the mother has escaped, the latter bee 
 in measure protected, so that, if the child is put to her b 
 she does not contract the disease, even though there are ulcei 
 lesions on the child's gums and lips, whilst healthy wet-r 
 are invariably infected {Colles's Law). Whether the immur 
 permanent or not is still a matter of uncertainty, and eve 
 .inviolability of this law has recently been called in question. 
 
 The length of time during which the patients retain the ] 
 of transmitting the disease to the foetus is an exceedingly di 
 point to determine, and one which is constantly coming 1 
 the practitioner, who is asked to decide at what period it i 
 for a syphilitic patient to marry. The, ruie of .^practice g^en 
 followed is that no one suffering from syphilis ^iouli3^ BeaT 
 to marry until he or she lias Been free froiri all symptoms 
 least twelve months, and even then it is advisaole thaf a 
 ■course of mercury should^ber given for about three months si 
 \ tjefore marriage. 
 \ -A' syphilitic foetus often fails to arrive at maturity, the it 
 ■vmiscarrying at the end of six or seven months. This is pro 
 due to a specific affection of the endometrium, especially ir 
 ing that portion of the decidua which enters into the forn 
 of the placenta. The circulation and nutrition of the foetu 
 
RGERY 
 
 ng one against the other. 
 > not usually reciuire local 
 ■ the influence of mercury 
 
 ^_/^^£liEAL DISEASES 
 
 thereby impaired, so that it ' ^ --~ 
 
 u.. uu.u«u.. u. u....u.y. be "epeat'ed 'f "^^^^^^^«d, and pani^^ ^.^ "°^ only dead, but 
 
 >t is sometimes "snv?M^^" 'Wars lieaJthv and »-«n 
 
 finite symptoms of I i r"^ '"^Perfectly develoneH "^r'"'^^^' 
 
 nod, extendm?f?.!^^'i^'^^''^^^ "manifest then 'iff.!^- ^ ^'^ first 
 
 , treated by removing 
 :urial ointment. A deter- 
 ;p deep gummatous ulcers 
 nt of sepsis to such sores, 
 bones, makes a marked 
 cted cases the wound may 
 
 but 
 
 lefinite symptoms of hi r"^ '"^Perfectly develoned ""^^'"'^^^^ 
 fjeriod, extending fmmfhr'"'" "^^"'^est thef^e^^^^^^^^ ^ ^'" -^''^ 
 f'-e child becomes h^ T ^^^^^ ^o three moZt ,^ ^^rmUe 
 urinkles over h. I i """'^ emaciated- the JI '^-''^^^^ '"^th ; 
 
 .e feat .r.?',i^,^ ^^^X^ changes to' H. n .!^i^' ^^'^'.^fi han^^s in 
 
 to septic absorption J rink Js ,^^^^ '-^"^I emadatej Ih'' T"''^''^' ^^^r 
 
 t amyloid degeneraJ iLe feature fl ^i' ^°^>'' changes to f d.n' '^'u' ^^'^'^^ h. 
 1, When gu'mmatai Alarl^d /" J^l PJ^^ed and' wi^ned^fc^^^^ -^-r, 
 
 , whilst amyloid degenera-i ihe featnrp^'i 'T "°'^>'' changes toTH.wT """;'' ^^'^'^h hai 
 3served. When gummatai Marked^n "^' P'"^^^^^ and wi/ened ri ''Y^^>' ^°^°nr, . 
 .hould be opened'with the! Sl'"!;:!;'^ '^^^--ys presemrn^'Jl'l ^.'-- of an old ,nan 
 
 wliiJst 
 
 )servea. vvnen gummauif Uarl<-f.rl o^, • • ^'""-''t^n and w xpn^ri n , -^ ^"^our, whsf 
 should be openedVith thJXtwe'i-™« -alway, presemrand'i Lt' oT °^^'" °''' "'- 
 le case of an abscess, andisvohili^ J • •, ^P^aking generallv fh Persist for a con 
 
 cavity stuffed with hnt 'Mt^n,^,^::^ ^J^^ of^ k^:^^^ of inlferiS 
 , |ll«childdeveW, •''''"'• Thus, durimrtif'-t"'!' '^«'=P1 that 
 
 land superficla l*^""™"^ ^'"••'"'^ous er^Mion j „, " ^"■■'^ °f 'ife 
 
 un, either by direct transO' > /"''owed by tife aXeannce '?" "°' '^»' "™g. ThTs^{ 
 lone, or botj; parents n,aJ;':fti°s Z^':^'^}" ''« "- a^d /CdThVf '^ ''"-'^ « '"» 
 
 where the ovum is infecteljS'''' ^^faces, which, by the r '^^1 ^ """''""'' *?'"■>*: rise , „ 
 escaped, the latter becon,eC|,'"? -ars (or rhagadesVes7ec?Lt?r ' ^ir'^--"'""- ve" 
 
 ;onstaniiy commg oero 
 e at what period it is sa, 
 , rijle of ^ practice general] 
 syphilis ^oul3 be aTTovJ 
 froni all symptoms'ForJ 
 t Is advisaole thaf" a nil 
 ibout three months shorT] 
 
 sd^^^^X^i Sr- -- ap^ 
 
 /e at maturity, the '"notlij J^-nu^ jr^I ^^^5 ^^ar, any of the tertia 
 
 months. This is probalm,' ri^/^^. ^ypnih's maydeveJon Jmf' ;'« * j i- ' '" ^mizn aonea 
 
 .etrium, especially' invofc^nd^- may be'proSd "^pTe?',t^^ PeSar 
 
 enters into the formatif -p,. ' ^-"'' .^^^."ea. ' ^^^PeciaUy affecting the teeth 
 
 nutrition of the foetus *„ ., 't®®*'^ ^ inherited syphihs are r.r, 
 
 72 
 
 
1 138 
 
 A MANUAL OF SURGERY 
 
 crumble away. The permanent teeth may be sound and heal 
 but are not uncommonly deformed. The central incisors of 
 upper jaw are those most particularly affected, but the uj 
 laterals and the incisors of the lower jaw may also be invoJ[ 
 Instead of being broader at the crown than at the root, 
 diminish in size from root to crown, being often stunted, 
 separated from one another by interspaces. The angles ofl 
 crown are rounded off, and a distinct notch, forming a 1[ 
 segment of a small circle, occupies the centre. The enan (l 
 often imperfectly developed, and hence they decay early. OJ 
 sionally they may be shaped like a screw-driver, narrowing f| 
 root to crown, and with a straight free border. The note 
 and stunted teeth described above are sometimes knownl 
 ' Hutchinson's teeth.' 
 
 The Bone affections observed in inherited syphilis have I: 
 already described at p. 487. 
 
 Interstitial Keratitis, or diffuse inflammation of the corr 
 usually occurs about the age of puberty, or earlier. It is limi 
 at first to one eye, but the other is almost certain to be simih 
 affected at a later date. It commences as a diffuse haziness 
 the cornea, which looks something like ground glass, associa 
 with hyperaemia of the ciliary region. Red areas, or ' sain 
 patches,' may be produced in the midst of the opacity, due t( 
 new formation of minute vessels. There is no tendency to ulce 
 tion, but in protracted cases the anterior part of the eye may bu 
 forwards, constituting a condition known as * anterior staphylom 
 The inflammation may spread to the iris and ciliary body. W 
 suitable precautions the cases usually do well, although treatmi 
 for several years may be necessary. 
 
 The Treatment of inherited syphilis should commence as sc 
 as definite manifestations of the disease are present. The gene 
 health must be attended to, and if the mother is unable to nu: 
 the child, it must be brought up by hand ; on no account mi 
 it be given to a wet-nurse. Merc,uix.is best administerecj^ 
 anointing the uni^ejf^s^rface^fjthe flannel T)en"y-T)ancr\vini m 
 (!tirfal"birifment, or the sam^ preparation may be riitibfel! into t 
 seics-pfttr6;ife€l every 'nigfitT T sIToiiTd" be 'c6htlfi\ie'd iititir 
 Secondary phenomena Tiave disappeared, advisably until the ch 
 is a year old. Cod-liver oil may also be ordered with advantage 
 some cases. When tertiary symptoms appear, iodide of potassiii 
 and mercury may be given in a mixture, in suitable doses. 
 
 The local treatment of external lesions is conducted accordii 
 to the rules laid down for the acquired type of the disease. 
 
 
'GERY 
 
 lay be sound and healthy, 
 le central incisors of the 
 ' affected, but the upper 
 w may also be involved. 
 1 than at the root, they 
 being often stunted, and 
 ices. The angles of the 
 notch, forming a large 
 centre. The enan el is ' 
 they decay early. Occa- 
 w-driver, narrowing from 
 e border. The notched 
 e sometimes known as 
 
 rited syphilis have been 
 
 nmation of the cornea, 
 or earlier. It is limited 
 : certain to be similariyj 
 as a diffuse haziness of| 
 ground glass, associated 
 Red areas, or 'salmon 
 jf the opacity, due to al 
 is no tendency to ulcera , 
 art of the eye may h\x\<A 
 IS * anterior staphyloma, 
 md ciliary body. Witlii 
 veil, although treatment! 
 
 CHAPTER XL. 
 
 "" Jn this chapter v..r u ./^^'oration to a " '=""''l%er the 
 extremities. amlntliT 'H" "^^'^h deal w,>h .k™^'' °^ ^ve 
 
 ect somewl,at bW.fl'f ' Necessary hmitatinn '?f_^'-«a«t and 
 
 'sefuj, con- 
 as appJieti to 
 
 l,ff" "escribed elsewhere^ \r ' "■'*""=* «ucft as 
 
 "P"^ated nature, ha^•e 
 
 X 
 
 ,^' 
 
 y 
 
 / 
 
 )uld commence as soon 
 e present. The general 
 ther is unable to nurse 
 I ; on no account must] 
 \ best administered hi 
 :1 Beny-T)ana^itH"iner 
 may be f ubb'6d into tfii 
 be cdntifiued imtil aL 
 
 dvisably until the child^WN-G 'Fla7X ''^J'''^'^^'^'"' "'"R the j 
 lered with advantaf^e inl""^ applied for DmLr'*''^" ^^ck. 
 sar, iodide of potassiuJ ""^ °" ""^ Muse 
 
 1 suitable doses, 
 s conducted accordin? 
 
 2 of the disease. 
 
 jS6.— Circular AMprrT*^. 
 
 Fl.p .„^"' station- kor the Arm. 
 
 AND 
 
 LES. 
 
 Kn devised Ti 
 
 over; the vessels 
 72—2 
 
 ii I, 
 
1 140 
 
 A MANUAL OF SUKGEKY 
 
 moreover, are divided transversely. The stump is not very sliapj 
 after a time, owing to tiie shrinking of the soft parts, the cicatrix is 
 to become attached to the bone. The arm is almost the only sitiia 
 which a pure circular operation is ever und£r.taken_jat_Llic present 
 
 - ^ modified form is still occasionally utilize 
 
 where. Thus, one or two vertical incisior 
 be associated with the circular cut, in or| 
 facilitate the removal of the bone at a 
 level, as in disarticulation of the hip-joi| 
 Furneaux Jordan's method (p. 1155). 
 
 The Racquet-shaped Method (i-'ig 302) i 
 similar to the last-described modification 
 circular. In it an oval incision is made a 
 the limb with one end pointed, and if nee 
 prolonged upwards to form, as it wer 
 handle of the raccjuet. This method is 
 for removing fingers and toes, and is 
 employed at the hip and shoulder joints 
 
 A somewhat similar operation is kno\* 
 the Elliptical or Oval Method (I'ig. yji. A 
 it an oval incision is made around the limb 
 lower or distal portion is then dissected up 
 to enable the amputation or disarticulation 
 completed at a spot a little below the pro 
 end. The free convex border of the flap is 
 turned over, and fitted into the concavity < 
 wound. 
 
 The Flap Method is that chiefly made u 
 at the present day in amputating through 
 shafts of the long bones. It was formerly 
 formed by transfixion in order to save 
 but the bulk of muscles included in the flap^ 
 the fact that the vessels and nerves are c 
 sliced longitudinally, render this an undesii 
 proceeding. Hence it lias l)een discarded, 
 the flaps are now usually marked out si 
 ficially, and then raised hy dissection. As a 
 they consist merely of skin, subcutaneous ti 
 and deep fascia, a little muscle being perl 
 included towards the base. 
 
 The best method of amputating in muse 
 parts, such as the thigh, is that known as 
 Modified Flap and Circular (Fig. 388), which 
 originally suggested by Lord Lister. In tliis 
 rectangular flaps with the corners rounded 
 are raised on opposite sides of the limb, 
 length of the anterior being two-thirds of 
 diameter of the limb at the point at which 
 proposed to divide the bone, and the po.ste 
 flap half the length of the anterior. These, consisting merely of skin and 
 cutaneous tissues, are dissected up ; the muscles are then divided circula 
 being retracted for another half-diameter. The advantages of the flap 
 circular methods are thus combined. In cutting the flaps it is most esset 
 that they should not taper, but should remain the same breadth through 
 the corners being merely rounded off. 
 
 Oeneral Remarks on Amputations. 
 
 Certain important details must always be attended to by the operator w 
 selecting an amputation suitable for any particular case. 
 
 Fig. 388. — Lister's Modi- 
 fied Flap and Circular 
 Amputation. 
 
 The continuous dark line in- 
 dicates the outline of the 
 anterior flap ; the dotted 
 line, the lower end of the 
 posterior flap ; the line of 
 section and retraction of 
 the muscles is represented 
 as an interrupted line. 
 
RGERY 
 
 ump is not very shapely, anc] 
 iolt parts, the cicatrix is likeh ■ 
 IS almost the only situation in' 
 
 r.taken_iLt_LliC prP.Lt.nt 4ay~ bull 
 
 IS still occasionally utilized else 
 ne or two vertical incisions ma\ 
 th the circular cut. in order t( .. 
 noval of the bone at a higher! 
 rticulation of the hip-joint bvf 
 I's method (p. 1155). \ 
 
 haped Method (Fig 392) isveryj 
 t-described modification of the! 
 n oval incision is made around! 
 i end pointed, and if necessanf 
 ■ ds to form, as it were tlilf 
 cquet. This method is usefi: 
 ngers and toes, and is alsj 
 lip and shoulder joints, 
 milar operation is known a| 
 )val Method (Fig. jtjj, A). \-\ 
 I is made around the limb ; thl 
 rtion is then dissected up so J 
 utation or disarticulation to bJ 
 ot a little below the proximJ 
 nvex border of the flap is tluJ 
 fitted into the concavity of tl 
 
 3d is that chiefly made use < 
 y in amputating through tli 
 
 bones. It was formerly pt- 
 xwit in order to save time 
 iscles included in the flap.aa 
 vessels and nerves are ofie: 
 ly. render this an undesirabli 
 :e it has been discarded, ai;: 
 
 usually marked out superj 
 aised by dissection. As a nilfj 
 )^ of skin, subcutaneous tissLi 
 
 little muscle being perhai 
 he base. 
 J of amputating in muscula 
 
 thigh, is that known as tlii 
 Circular (Fig. 388), which w: 
 1 by Lord Lister. In this t« 
 'ith the corners rounded 
 'osite sides of the limb, t 
 nor being two-thirds of t 
 lb at the point at which it 
 
 the bone, and the postern 
 sting merely of skin and su 
 i are then di\-ided circular! 
 
 advantages of the flap 
 
 the flaps it is most esseiii; 
 e same breadth througlioi 
 
 IMPUTATIONS 
 
 1141 
 
 -ifinificance whence fh"'n'y '"^ "tatter f some 
 ^ ^ir'^lc flap,?' "f ft. '''''' ""'^ ^'^•'••■ved tluTs 
 '« "°n. be^;e;o^^if ';;nterior ""^ P^^'e ' 
 ^f maintaining 11^,'-^'"^ '«'''« difficult^ 
 
 Iff. in part,s' I'il'e X 'Sm ^f' ""^^'^'^ 
 ^} tlie stump will not L ' '^''^'"^ 'he end 
 f-enerally. howevPr^L ^ exptised to pressure 
 
 flapandcircuW.or "ometim'^ °^ "^« '""''ified 
 former, owing to th^ . m """^ ''"'' '''''««; in the 
 
 ;?"-'-, a co\.eWnte'n;^ 'to'/ "'T"°" " ^c? 
 tJ'e hmbi.s provided 7^"/ ■ ^'r ^''ameters of 
 consists in raisin. . ,.?!' ^ '""^"'"""MKiR. 389) 
 
 ^e.andi„c;;^^:^-I-intofsec;ionoft^ 
 bone. The posteriV.r fla ^ ^'"^' ^'°^vn to the 
 Uie anterTH?^rrS,^^i^i««'milar in nature to 
 
 The free e^n;, '"/ te\lS%.''' -''^ /^"^^ 
 dnrerior flap ,s doubled 
 
 ':\, I;, 
 
 The free end 
 
 "yer.and accuiter^smSf .^'''? ''' ^'°"Wed 
 The advantages claimed .o?H*° "'^ Posterior, 
 'hat the vessels are'St'Tong'^Zf'''''"" ^'^ 
 
 Operative Sdrgerv.') 
 
 (Treves' 
 
 are 
 - thus the 
 nutrition of the flaps 
 s<:cured, whilst a 
 
 covering nearlyequal 
 to two diameters of 
 tlie limb is provided 
 /he great objection 
 to the method con- 
 sists in the amount 
 of the hmb which 
 "as to be sacrificed 
 on account of the 
 
 length of the anterior 
 nap, and hence it 
 
 ('ccasionallv thf rr,,,^ • ■ • P' ^nd hence it 
 
 mt 0««„,„„ :„ .... ^ ^^' '" '^'' "P"n the 
 
 ..uemity. Where the weigh/ of thj^body ' hf 
 
 l,n..li"- '^^. anterior flap is oi^enZarioS'S^^ t ^^^'-^«- -d to 
 
 iportant matter sincSL fe'l.*^^ Posterior. Th 
 
 utations. 
 
 Jed to l)y the operator \m 
 
 "'°^;ever. is not such'an i^rf ? °"^" "^^^e longerThin I'h "'■^'"^?^' ^nd 
 
 IS, 
 
 ic 
 
 r case. 
 
 'epsis, since^r^Sar S'^ ^'"^^'^s^ cfre must h??t '" '^e patient. 
 
 '^«ibly the meSi'L^.?.^. ^^^^'^'al planes ha^e Len S" '" "'^'"'^■" 
 
 exposed thl 1 ^ °P^"«^' an 
 posed, the dangers of septic 
 
1 142 
 
 A MANUAL OF SURGERY 
 
 ftl)sorpti()n under such circumstances are obvious. Heemorrhage is prei 
 by previous exsanguination of the Hmb by elevating it for two i>r thrct; mi 
 and then applying an elastic tournicjuet In the leg a piece of rubber 
 may be employed, Sam way's tourniciuet being perhaps the best. In tin 
 however, the subcutaneous position of the principal nerves leaves them 
 exposed, and paralytic synintoms have followed the use of such appli 
 especially when made of solid rui)l)er ; a flat elastic bandage carried s 
 times around the limb, and secured by a knot or with a safety pin, is all 
 needed Should the tourniiiuet have to be applied close to the area of 
 tion, it must, of course, be soake<l in carbolic or sublimate lotion ; it i 
 advisable to protect tin skin over which it is placed by a few layers of 
 so as to prevent blistering. After the limb has been removeii. the main v 
 are at once ligatured, both artery and vein being sepjirately ti'-d. It isv 
 isolate and draw them down for a little distance, so as to maki- sure tha 
 have not been buttonholed. Any other vessels which can be seen ar 
 before the tournicjuet is removed. An assistant should for a time be re 
 c(mtrol the main trunk after releasing it from the tournicpiet. In some 
 it may be impracticable or undesirable to apply a tourniquet, and the 
 main vessels may be temporarily controlled by digital compression at 
 suitable spot whilst the amputation is completed. Any bleeding-point 
 naj^idly secured by pressure forceps, and subsecjuently tied, and the 
 trunks isolated, and clamped or ligatured before division. 
 
 For special methods of controlling the haemorrhage in amputation thi 
 the hip-joint, see p. 1154. 
 
 We have already drawn attention to the necessity of not tapering the 
 but of cutting them square, the corners alone being rounded. In disst 
 them up, the deep fascia should be included with the flap, and the bli- 
 the knife always turned towards the part which is to be removed, so tha 
 under surface of the flap, and with it the nutrient vessels, shall not be so 
 Whilst dividing the muscles the flaps must be carefully guarded by the 1 
 of assistants. I?efore sawing the bone, it is recommended that the period] 
 should be retracted for some distance, so as to more efficiently provide f( 
 nutrition ; this plan should certainly be adopted for the humerus and ft 
 Any irregular bony spicules left after sawing should be trimmed off 
 cutting pliers. Attention must next be directed to the main nerves ai 
 any tendons which lie exposed in the wound, all such structures beingcut £ 
 the nerves as high as possible. The wound is usually closed by a contii 
 suture, but one or two deep tension stitches should also be inserted, anc 
 vision made for drainage from one of the angles of the incision. The dre 
 is applied in such a way as to draw the flaps down over the end of the 
 and a splint is often necessary in order to control the upper ends of the di 
 muscles and to keep them at rest. 
 
 The chief ComplicatiouB likely to arise in the subsequent course of th( 
 are shock, reactionary haemorrhage, and those which result from sepsi; 
 these conditions, and the treatment suitable to them, have been desc 
 elsewhere. 
 
 In a Healthy Stump the end of the bone is rounded, and ""the medi 
 cavity closed by a layer of compact tissue. The divided muscles and tei 
 are either incorporated in the cicatrix, or gain fresh adhesions to the t 
 The vessels are obliterated as far as the next patent branches, whih 
 nerve-ends usually become bulbous, but, if suitably shortened, do not a 
 either to the end of the bone or to the cicatrix, and hence give rise 
 trouble. A sufficient covering of no;i-adherent skin and subcutaneous 
 should form a pad for the protection of the bones. 
 
 Affections of Stumpa.— (a) Narosis of the end of the bone is sometimi 
 result of carelessness on the part of assistants, who can readily denud< 
 its periosteum by rough sponging, etc. ; it rarely follows if the periosteui 
 been first retracted before the bone is divided, and practically never apart 
 sepsis. A small annular sequestrum is usually all that separates, but s 
 
RGERY 
 
 ^AIPIJTATIONS 
 
 )iis. Hwmorrhage is prevented 
 
 itinKit for two or three minutes, 
 he le^,' .1 piece of rubber tubing 
 perhaps the best. In the arm, 
 cipal nerves leaves them muci) 
 eel tile use of sucli apjihances, 
 elastic bandage carried several 
 r with a safety pin, is all that is 
 plied close to the area of opera- 
 or sublimate lotion ; it is then 
 laced by a few layers of j^auze, 
 been removed, the main vessels 
 IK separately ti<>d. It is well to 
 e, so as to makt: sure that they 
 s which can be seen are tied 
 t should for a time be ready t( 
 the tournitjuet. In some cases 
 ly a tourniquet, and then the 
 y digital Cf)mpression at some 
 !ted. Any bleeding-points are| 
 )sequently tied, and the main 
 e division, 
 rrhage in amputation througli 
 
 ssity of not tapering the flaps,! 
 being rounded. In dissecting] 
 nth the flap, and the blade oil 
 I is to be removed, so that the! 
 nt vessels, shall not be scoredf 
 ;arefully guarded by the hantl>L 
 jmmended that the periosteuirl 
 Tiore efficiently provide for iif 
 d for the humerus and femurl 
 should be trimmed off witll 
 id to the main nerves and t( 
 <uch structures being cut short] 
 isually closed by a continuouj 
 3uld also be inserted, and prcj 
 of the incision. The dressirJ 
 nvn over the end of the bon( 
 I the upper ends of the divide 
 
 subsequent course of the t-a.J 
 which result from sepsis , 
 o them, have been describ^ 
 
 "43 
 
 Amputation of th« n ^^^""^^^ Amputations. 
 
 a-ul similar injuries or i,f*'" "* ^'"'^'('"-'ntly required nf, , 
 
 • i"e naps being obtained frr 
 
 'ften 
 
 fled from 
 
 "' -^90.— Incisions kor AM..r.^ 
 ','- OK Th.m.n.. ,"^;,\Tr^- 
 ( I 'llmann.s.) 
 
 '"IVOER. 
 
 OF 
 
 Fig 
 
 rounded, and ''the medulla 
 2 divided muscles and tendoij 
 fresh adhesions to the bono 
 t patent branches, whilst ti 
 ably shortened, do not adliej 
 ix, and hence give rise to a 
 
 skin and subcutaneous tissj 
 es. 
 
 of the bone is sometimes tij 
 who can readily denude ill 
 ' follows if the periosteum L 
 d practically never apart ixd 
 all that separates, but shoa 
 
 PSSe:;^^''"-''-- present 
 
 Mi?Ac7,ln„' 'T°^^'^^'^''^- 
 ^AT,oN,sHoVlN"aD,v?oKn/"'ct;- 
 MANNS.) ^thSELb. (TlLL- 
 
 The following, however 
 
 Amputation of the Ter»,i« , r.u *"' "ov,ever. are the chief 
 
 No uspfi.l ^»„..i. r .. ^ "'"*"epulpofthefinc«, 
 
 ^0 useful result fnlln ""^ ""^'^ ^^^ Pulp of the finger 
 
 ..bbniis tendon, the flaps forsurs''' ''° ^' *° '^^ve 
 e finger, and the ^on^ J^^S)^^]^^^n, 
 
 inyrtionofthefllxorsu... 
 ■ " '^ ^'^°'n any part of the 
 
 k I 
 
1144 
 
 A MANUAL OF SURGERY 
 
 a- 
 
 ftemoval of a finger at the Metaoarpo-phalangeal Joint (Fig. 391) 
 operation frequently necessary'. It is best conducted by means of a rac 
 shaped incision (Fig. 392, A), which starts over the knucl<le, extends bet 
 it and the next finger, curves round to the palmar aspect so as to be plac 
 little below the crease in the skin at the root of the finger (Fig. 393, C), 
 returns in the same way to the back of the knuckle. This incision can be 
 with one sweep of the knife, but there is no real advantage in such a 
 cedure. The articulation is then opened from behind, and is found fui 
 forwards than one would at first expect ; the structures on either side are 
 successively divided, making them tense by rotation of the finger, anc 
 flexor itndons finally cut across. Bleeding-points (usually one on each 
 are secured, and the wound closed. 
 
 The question of removing the head of lie matacarpal bone is one w 
 
 must be decided by the occupatic 
 
 the patient ; if he is a working ma 
 
 needs strength of hand, it shoul( 
 
 left, as its removal always causes \\ 
 
 ness. In ladies and those where si 
 
 ness and elegance of the hand 
 
 required rather than strength, it 
 
 be taken away by slightly prolon 
 
 the incision upwards,|clearing tlie 
 
 on either side, and applying cu 
 
 pliers. The gap between the adjoi 
 
 fingers can in tiiis way be almost 
 
 literated. It is especially advisab 
 
 do tiiis in the case of the index-fii 
 
 since the head of the second metaca 
 
 bone forms an unsightly project 
 
 and is very exposed to injury. 
 
 this finger, Farabonuf's method ( 
 
 392, B) is often used (p. 1147). 
 
 Occi.sionally the four fingers 
 their attached metacarpal bones 1 
 t(j be removed en bloc. Short ei 
 flaps may then be cut from the f 
 and bav?k of the hand, and tlie 
 articulatif.n effected. The stump 
 remains, akii'iugli consisting merei 
 tlie carpus and thumb, is very ser^ 
 able. 
 
 Amputatior. of the Thumb sh 
 never be undertaken unless absoli 
 necessary, since its removal seriously impairs the functional utility of 
 hand ; as large a portion must be saved as practicable, so so to assist 
 patient in grasping. The phalanges may 1x3 removed by any method w 
 enables the bone to be covered with the least possii:>lo sacrifice. 
 
 When it is also necessary to take away the metacarpal bone, one of the 
 following plans should be adopted : 
 
 r. The raa/iict method (Fig. 392, C). In this an incisioi. commences in the ii 
 tendinous lioilow known as the tahutiiic, and extends along the dorsum ol 
 thumb to tlie head of the inetacarpal bone, the oval portion sweeping roiii 
 at the le\el if llie web when the tliumb is abducted, and on the palmar r^ 
 corresponding to the oblique crease at its root. Tlie remaintler of the operr 
 resembles tliat for removal of a finger. Care must be taken not fo wouni 
 trunk of the radial artery as it passes through the base of the inteross 
 space ; the blade of the knife is tlierefore kept closely applied to the bom- 
 2. By -A palmar flap . In ih)s the knife is first carried across the dorsal ;is 
 of the thumb, from the centre of the web between it and the index-hnger, 
 
 Fig. 302. A, incision for amputation 
 of finger by rac(iuet method ; B, 
 Farabonuf's metliod of amputation, 
 as applied for index-finger ; C, 
 rac(|uet-sliaped incision for disarti- 
 culation of thumb at carpo-meta- 
 carpal joint. 
 
GERY 
 
 mgeal Joint (Fig. 391) is an 
 ucted by means of a racquet- 
 the knuckle, extends between 
 ir aspect so as to be placed a 
 ■ the finger (Fig. 393, C), and 
 de. This incision can be made 
 eal advantage in such a pro- 
 behind, and is found further 
 ictures on either side are then 
 itation of the finger, and the 
 nts (usually one on each side) 
 
 latacarpal bone is one which 
 decided by the occupation of 
 nt ; if he is a working man, or 
 ength of hand, it should be 
 1 removal always causes weak- 
 iadies and those where small 
 
 elegance of the hand are 
 rather than strength, it can 
 
 away by slightly prolonging 
 on upwards,|clearing the bone 
 
 side, and applying cutting 
 
 he gap between the adjoining 
 
 m in this way be almost oi)- 
 
 It is especially advisable to 
 
 tlie case of the inde,\-finger, 
 liead of the second metacarpal 
 ms an unsightly projection, 
 ery exposed to injury. 1m ir 
 ;r, Farabonuf's method (Fij; 
 
 often used (p. 1147). 
 )nally the four fingers and 
 died metacarpal bones ha\e 
 moved en bloc. Short ecjua 
 ' then be cut from the fmn 
 
 of the hand, and the (li> 
 in effected. The stump tha; 
 alUi'High consisting merei', 1 
 s and thumb, is very service 
 
 ition of the Thumb shoul 
 
 undertaken unless absoliitfl' 
 tlie functional utility of thj 
 actical>le, so so to assist tl 
 loved by any metiiod wliir| 
 sihlc sacrificf . 
 :acarpal bone, one of the im 
 
 ;isioi. commences in the inir 
 mds along the dorsum ol \\\ 
 va.\ portion sweeping roum 
 ed, and on tiie palmar asiw] 
 he remainder of the operati 
 St be taken not »o woun<l 1 
 the base of the interossc 
 )sely applied to the bone 
 rried across the dorsal \\s\t\ 
 1 it and the index-hnger, ti 
 
 IMPUTATIONS 
 
 rf45 
 
 lUSCnlnr fl. ^^ '"^ "I tile 
 
 S"''^l5' ^^"h a well. 
 
 'ir eminence. The 
 
 ards, and inserted 
 
 t'^at at whici, ^eVL^r^'^'^^'R^ at the 
 
 '•■ ia)'ln H,. .;,V.l'^*^'''y tissues. Thr^^ 
 
 methods nrp i,„ 
 
 incision takes the forT^""' ^'««cribed 
 "'e highest poin hp?n "^ '?" «"''P«e, 
 .'• .inch belol The ?;;.':,""/'V« ^'"'"'"n; 
 
 J'^nt, and the lowest in tL '^"^ '''''''- 
 palm 2 inches bel/w tlw "''*^°f ^^e 
 
 "le ulnar side thi n ^"'■'"^'" "n 
 
 '^^•cen the pisiform h "°" '^''^^-^^'^ ^e- 
 
 "f the fifth' m.7'"^_h"'^ ^"'i tl'e base 
 
 t „ I t'"-'"-" irom 
 lation comnJet^T -n," ^''^ '^i^articu- 
 "'e palmar flap is fif/l^ '•""'■^'^ ''"'I "^ 
 ^^vity of the d rsum ' T? '^'^ ^"n- 
 "H's forms a c rved^i,'""^' ^''^'^'catri.x 
 /;,f . "^"" t''e hack 
 
 ^Mn „. ss'jiifi— ;-- 
 
 "fthe stump, (M ,^ 
 ::3,J93, H) is s!,4et 
 
 /on 
 
 'A' pii/iiuir tlap 
 
 process dcwn tn nk ? fit/ier styloid 
 
 "•<^ nietacarm bonrV''"-'""'''''^ - 
 (^ap being parallelt' ' "'f '''^''^^ "^ "'is 
 'I-rsal inc\!i™sses S '''^''' ''''' 
 ^'-ntally between thr;^''"'P"'* '>'"-''- 
 I'Hhe former worn r tT" "•\"-«'"i"es 
 "^ tl>en di.s.secteT n J''^P^''"ar flap 
 
 ""lyskinand sub' t^n '''' '" '"^'"''^ 
 P'-'-haps a lit eZ'^"7"■'^•.'■'^«»'-^ with 
 
 "•^' "i«narand Inn th •''■ ''''■''"^ ^'•"■" 
 ■riie wrist-join Vs"'"'''','""''"^'nces. 
 
 •>'*>« chvisi,,„,7Cflr'''-""'"f''''f«'' 
 "! '"■"! a few rnll! _.!: ^''"^"- tuidons. 
 
 method- Ji /j,in I }'^' ^"ip'ical 
 through'ui ''.;;:;;)• '-imputation 
 "^« slotted li les ^'^^ r'"^-'^'- flap 
 "'eciorsal i cis^ns' ?:''■' /'^f'.'-^^^^"' 
 palmar incisio "',1^ V. ■'^'/'';^""n "f 
 --•') in amputatiS, fi g^" '" "'^ 
 
 Amputation thr;;'i"Th!''^ -""nd. ^•^^'^^"•'^' "'^P - carried inwai 
 
 , iJisarticulaMnn .* *u "-^ ""'""<' he thorouL' 
 
 I Dtao .,'",'"= "ivision, ■' - ""II ine Do 
 
 flap 
 
 the 
 
 'roughly 
 
 p"ca..e,h„.„.-iS;r^rss.^s;;-"'''» 
 
1 146 
 
 A MANUAL OF SURGERY 
 
 Amputation through the Arm may be carried out by any of the mel 
 
 described, t^'., the flap, circular, or modified flap and circular, the chol 
 any particular instance being determined by the requirements of the casi 
 
 Dibarticulation at the Shoulder-Joint. Three chief methods are praq 
 for the performance of this operation, viz., Spence's and Larry's, or tha 
 means of an external or deltoid flap. In all, the third part of the subclJ 
 artery may be controlled by digital compression, the surgeon endeavouril 
 leave the vlivision of the main vessels until the last stage of the proceed| 
 or perhaps it is better to clamp all the smaller vessels as soon a.i they art 
 and to isolate and tie the main trunks before their division. 
 
 (a) Spiiuf s operation (Fig. J95). -A preliminary incision similar to thai 
 excision of the shoulder is first made, extending downwards and out\\[ 
 through the fibres of the deltoid, from a point midway between the corj 
 and acromion processes. This passes directly down the bone, and, if necesJ 
 the joint '^ at once opened an 1 examined prior to any further steps being U 
 The surgeon, standing on tht; outer side of the limb, then carries his 
 
 -^ 
 
 Fig 394.— Ami'CTation niRoudu 
 Wrist hv Dubkeuil's Method. 
 
 (TiLLMANNS.) 
 
 Fi'i. j')5 — Si'ence's Amputation at t 
 SiioLLDEK liv Anterior RAcyui 
 (Treves' 'Operative Surgery.') 
 
 !!': 
 
 from the lower part of the incision downwards and inwards across the axilli 
 folds around the limb to the point from wiiich it first started, thus making 1 
 incision raccjuet-shaped. The soft tructures on the outer side of the verti 
 ircision are separated from the bone, and tlien the outer half oi the capst 
 to;^ether with the muscles inserted into the greater tuberosity of the humer 
 and the long tendon of tiie biceps, are divided The parts on the inner side 
 the joint, including the subscapularis and front of the capsule, as well as 1 
 pectoralis major, biceps ai d coraco-brachialis, are dealt with in a similar \vi 
 exposing the main vessels and nerves The vessels may now be secured a 
 divided, and the neves isolated, pulled down and cut short, or they may 
 left intact for a time Hy retracting the external flap and protruding the ht 
 of the bone from its socket, tlie remainder of the capsule can be severed, n 
 then the knife, travelling downwards between the humerus and the axill; 
 vessels, is made to cut its way out, thus completing the disarticulation, I 
 vessels and nerves, if not already dealt with, being divided as the last step 
 the proceeding. If the knife is kept (lose to tlie bone, the trunk of the poster 
 circumflex artery is not interfered with. 
 
 (h) Larny's operation (Fig ^o6) is very similar to the above, except that 1 
 vertical incision is made on the outer aspect of the joint, reaching downwai 
 from the prominence of the acromion for a distance of about 6 inches, the o' 
 portion starting from its centre, and being directed obliquely downwards a 
 
iGERY 
 
 ed out by any of tlie methods 
 lap and circular, the choice in 
 e requirements of the case. 
 ie chief methods are practised 
 ence's and Larry's, or that by 
 li third part of tiie subclavian 
 , the surgeon endeavouring to 
 last stage of the proceedings ; 
 essels as soon as they are cut 
 iir division. ' 
 
 y incision similar to that for 
 ng downwards and outwards 
 midway between the coracoid 
 .vn the bone, and, if necessary 
 • any further steps being taken! 
 ; limb, then carries his knife 
 
 ^'yPUTATlONS 
 
 M^ 
 
 inwards Th« ♦■• 
 
 i"^ opened by a tj''""" ""''' '•^^ected o 
 
 tlie humernf. "'" '^ The kn>/ 
 
 uuncrus .so as to sever fl,„ T ""^' 
 
 I,.. ,,,^^'^'"e vessels la.st 
 -"> the external 
 
 1 147 
 
 W 
 
 '" either side of fh« i 
 
 •««r«at '"l^erosity vhicr-.7"'i'!'^' J"'"' 
 - ';nally carrie<I down ^n'.f '^'^ '''^''^'^s "'« 
 '^'-•V'fcon,siderecrSbr;""--^'eof 
 
 — - ...i-tuuns. 
 ^Jccasionallv it i 
 whole of the upper "h^^T^ '" '•^'"ove the 
 ■scapula and ou K? \l rTl \"T'^''' ^^"•■' e 
 '"-'^vgrowths, usuall f .' "^^ ^'■•^^•''■le for 
 - for_injury. ^ ^'^t^^l'^lf^'^'-'at ur^ 
 
 --;thisp^;-'7-^^'-;iofthecia;:;;:,;: 
 
 ;)^ ♦« enable the surgeon to 'r"?"^"^'^'' «' 
 'i«ai'ires the siihrN " 'I'vide betweei, 
 
 •\''^vei with Mo:'rt"'"'r>-^^"^' vein'o 
 '■'f^-. The antenor'C is^^H ''' "^ "'« fir.s 
 
 anmc..ionreachi,Vh-om n'"" ^'"-""^'J '^r 
 former and e.xtendt! ""' ^'en're of the 
 )vards over the X3 ''"^^"^^ards and o 
 "'^' "f t''« ■'•'ilt S^rf'-^'-eanteri 
 'i"«Ieof thescann n 'Vk' ^""^ »« t'>e lowe 
 
 'i"«Ie of the scapula 
 
 '-noraredindedalong^-^Hn 
 
 t- 
 
 or 
 
 Tiw. " "" '"^ lower 
 
 .file pectc.rales major 
 
 thereby 
 
 I'ENCE's Amputation at thk 
 HV Anteriok RACyUET 
 Operative Surgery.') 
 
 inwards across the a.\illar\ 
 rst started, thus making the 
 le outer side of the vertical 
 ■ outer half 01 the capsule 
 tuberosity of the humerus' 
 le parts on the inner side of 
 :he capsule, as well as tlit 
 leak with in a similar way, 
 s may now be secured and 
 cut short, or they may he 
 ip and protruding theheaii 
 ipsule can be severed, and 
 humerus and the axillan 
 ng the di.savticulation, tht- 
 divided as the last step in 
 i, the trunk of the posiericir 
 
 he above, except that (lie 
 oint, reaching downward* 
 of about 6 inches, the ovai, 
 obliquely downwards ami 
 
 ; ;;i'-'«ing the brach^ XSs '/r"""- ^'"^'"'^y 
 
 ! erves of which are sew?^/','' ''>'-' constituent 
 
 e section of the ^.^^S ""rl '^'^■^' -■''> 
 
 N Mce cati now be ooenlT. t .. ^''^ '-"^iUarv 
 
 I'^i'i. J96. - 
 
 T A T I c N 
 -Sll(/LL1>EK 
 
 Larrey's AmI'U- 
 
 THROUGH THF 
 
 Joint m- Ev. 
 
 V£S' 
 
 T'-:«N-AL Kac^UET ^/Tr, 
 ^^•■iiKATIVE SUROERY.')" 
 
 unil;,r ,?::r°"*^«Toe8attht 
 
1148 
 
 A MANUAL OF SURGERY 
 
 nearly as far as the interphalangeal articulation, and then crosses tlie p 
 surface of the toe so as to reach the centre of the web between it ai 
 second toe ; thence the knife is carried straight back to the commencem 
 the incision. These cuts are deepened, the tendons divided, the joint 
 and the toe removed. It will then be found that an internal flap rei 
 whicii can be brought across the iiead of t!ie metatarsal bone, and covet 
 9o that the cicatrix is not exposed to pressure. 
 
 Amputation of the great toe at the tarso-metatarsal articulation is cone 
 either by a racquet-shaped incision, or by dissecting up a flap from the 
 side. 
 
 Fig. 397. — FARABUiUF's Amih:- 
 
 TATION OK THE GkEAT ToK. 
 (TkKVKS' ' Ol'KKATIVE SfK- 
 GERV.') 
 
 Fig. 398. — Incisions kor I.isfranc s .' 
 TATioN. (Treves' ' Operative Surgi 
 
 perfc 
 
 Amputation of a foot at the Tarso -metatarsal Articulation is 
 either by Lisfranc's or Hcy's operation. 
 
 Lis/niin's amputiition (Fig. j()S) consists really of a disarticulation, no 
 being sawn acros.i. The patient lies on the hack with tiie foot elevated 
 extending beyond tiie end of the table On the riglit foot a sligiitly ci 
 dorsal incision extending down to the bones is made from the tip of the 
 metatarsal bone on the outer side to the base of the first on the inner, 
 plantar flap is then marked out, reaching from the terminations of the U 
 incision forwards as far as tlie roots of tlie toes, and being necessarily 1 
 on tiie inner than tin; outer side On tiie left foot tlie incisions are ms 
 tlie opposite direction. This latter flap is dis.sected up, the toes being 
 extended by an assistant ; only tlie skin and subcutaneous tissue.! are 1 
 for the first inch, but further b.ack all the structures in the sole of the fo< 
 included. The appearance of tiie peroneus longus tendon will indirat* 
 the dissection has been carried back far enough. Disarticulation is no\ 
 formed from the dorsal aspect, the line of the joints (I'Mg. jijo) being k( 
 mind. The I, nife is entered behind the spur of the fifth metatarsal bone, 
 at first directed forwards and inwards towards the head of the first met.i 
 
iGERY 
 
 n, and then crosses the plantar 
 :>{ the web between it and the 
 : back to the commencement of 
 dons divided, the joint opened, 
 that an internal flap remains, 
 etatarsal bone, and covers it in 
 
 itarsal articulation is conducted 
 ecting up a flap from the inner 
 
 
 ^^<^ond metatarsal i."'' ''^'^ '^^«« of 
 between the first L.;' ''"'^'^ ''"wnu. 
 
 betweenU;;S:^r;n;itr'"'^"-"-a:^ 
 bone-^ and cutt nfl ' c w?'/"''' "^'^'^'^••«a 
 ankle, elevatin.MLu^'^^,^'''''^ ">wanls the 
 r'^'- f" 'I" -so "^,5J^'^"<i'e."' the knife n 
 :^ ^"ft hand, nd orcihr'""^' ^'''^ '"«« " 
 'he remaining «aSr'''"'!'"« *'''^'"- 
 a-spect are div'ided a^K . ''r ""^ ''"'"■'^a 
 <-^an then be complered ''''^^'•'''-■"lation 
 
 "-I-sCS':y;;;r"'-^'"-fcnnedas 
 "merely been m „ ^^i "P^ation. han,/^ 
 
 '"«;ance. In sucl^'t,""' '" "'^' ^rst 
 ^■'•"^'/^" is first maiV the ""' "^"''^^ *"" 
 articulated, and e 'oh f, '"''''atarsus dis- 
 ^vuh.n outwards. ^ '^"'^•' '^ap cut from 
 
 .he abov:^';S";,,;;;^entially similar to 
 "f ^he second metati.in^^ V "''" "•^- ''ase 
 J-'jection of the "^ :;' ^"''' P^''-'>ap.s. the 
 ''awn across, leavim/a ";'' '^""'-''f'^rm are 
 
 "^ ^''"f It is certain vTo? '''"'^". '^"'•'■ace 
 '■' -^'mple clisarticul-u ",, ^'^ P^'^fcr.ed to 
 
 SVME. 
 
 i-CHOPAI»T. 
 
 ISIONS FOK r.lSFRANX S AmIU 
 
 eves' 'Operative SuKGEK^ 
 lal Articulation is perforn 
 
 of a disarticulation, no Ixn: 
 Lck with the foot elevated, ar 
 he right fool a slightly con\ 
 made from tlie tip of the (if 
 f the first on the inner 1! 
 the terminations of the form 
 
 and being necessarily lon; 
 oot the incisifMis are mach^ 
 ected up, the toes being t 
 ibcutaneous tissues are ra 
 ures in the sole of the fool 
 igus tendon will indicate t 
 Disarticulation is now [x 
 joints (Fig. yjq) being kept 
 e fifth metatarsal bone, an 
 he head of the first metata 
 
 A _,^ .■•'■'"' "tuiation — --w lo 
 
 Fig. 
 
 390 -Skelktov an-,. 
 
 LINK OK Foot '^^" "UT- 
 
1 150 
 
 A MANUAL OF SURGERY 
 
 i 
 
 hence unavoidable, it woulr perhaps be wiser to avoid the operation eij 
 substituting for it a subastragaloid amputation, or modifying it by rer 
 the astragahis after the foot has been taken away, Tripier's amputatiJ 
 also been utilized to prevent sucli displacement ; in it an oblique eJ 
 racquet is made, reaching backwards to the anterior border of the [ 
 Achillis ; disarticulation follows at the mid-tarsal joint, and then the osl 
 is sawn across horizontally on a level with the sustentaculum tali, stj 
 leave a broad base of support, which is not so likely to become tilted fori 
 It is but fair to say, however, that in not a few cases of C'hopart's ampii 
 an excellent stump remains without any of these inconveniences. 
 
 Subastragaloid Amputation of the foot is occasionally possible in cal 
 injury, where the astragalus remains uninjured. The best plan to adi 
 that known as Maurice Peyrin's oval operation. A racquet-shaped incisi 
 made, commencing at the insertion of the tendo Achillis, ard extending^ 
 the outer border of the foot to a point immediately behind the spur 
 fifth metatarsal, from which it sweeps over the dorsum, along the instej 
 after crossing the sole returns to the same spot. The dorsal part of thi 
 is then dissected up, the ar.tragalo-scaphoid joint opened, the tendo Acf 
 
 divided, and by twisting the for 
 wards the joints between the astra 
 and OS calcis can be entered, and ti 
 terosseous ligament severed. By 
 further inverting the foot until i 
 sumes a position of extreme varus 
 structures on the inner side of ti 
 calcis can be detached, and by 
 tinning the same torsion, the 
 surface of the bone is finally cle; 
 tiie dorsal aspect of the foot lo( 
 downwards. When the foot has 
 removed, bleeding-pt)ints are seci 
 tendons and nerves cut short, and 
 wounil, wiiich now lies horizon tall; 
 secured by sutures. A very firm l 
 of support is provided by tliis operation, and the stump is covered by the 
 of the heel, which is accustomed to pressure. 
 
 Amputation of the Foot Symc's amputation consists of a disarticulatic 
 the ankle-joint, together with removal of the two malleoli and the artic 
 surface of the tibia. The patient lies on the back with the leg well elev 
 and projecting over the end of the table, the surgeon standing either b( 
 or a little to the right of tiie patient. Having exsanguinateil the limit, 
 operation is, on the right foot, commenced by making an incision from 
 tip of the external malleolus down to the heel, and extending up I 
 point '1' inch below and behind the internal malleolus (Fig. 400). On 
 left side the incision is made in the opposite direction. For this purpo 
 short-handled strong-hladed knife should be employed (an ankle knife), 
 incision is directed slightly backw.irds, otherwise a bucket-shaped heel 
 is formed, in which discharges may collect. The knife is carried dowi 
 the bone at the first cut, and tiie surgtion then proceeds to dissect up the 
 flap thus marked out by inserting his tluimb into the wound, and pj 
 peeling, partly cutting, the soft tissues from the back of the os calcis (FMg. .] 
 This is sometimes a tedious and tiring proceeding, since .1 is most impor 
 to keep close to the bone for fear of dividing tlie nutrient vessels of the 
 (external and internal calcanean) The dorsal incision is then made, uni 
 the ends of the former wound, and carried slightly forwards so that a s! 
 convex flap is thereby made This is dissected up, and ^he ankle-j 
 opened, the line of the articulation being placed ^ inch above the tip of 
 internal malleolus. By division of the lateral and posterior ligaments, of 
 tendo Achillis, and of tlie few remaining fibrous connections along the to 
 
 F^IG. 
 
 400. — Incisions in Svme's 
 Amputation of Foot. 
 
RGERY 
 
 to a\oid the operation entirely 
 n. or modifyinK it by removinK 
 vay, Tripier's amputation has 
 ent; in it an oblique external 
 anterior border of the tendo 
 •sal joint, and then the os calcis 
 he sustentaculum tali, so as to 
 likely to become tilted forwards 
 
 cases of Choparfs amputation 
 se inconveniences. 
 :casionally possible in cases of 
 d. The best plan to adopt is 
 
 A racquet-shaped incision is 
 3 Achillis ard extending along 
 liately behind the spur of the 
 dorsum along the instep, and 
 \- 1 he dorsal part of the flap 
 int opened, the tendo Achillis 
 ind by twisting the foot in- 
 joints between the astragalus 
 CIS can be entered, and the in- 
 
 IiRament severed. By still 
 verting the foot until it as- 
 losition of extreme varus the 
 on the inner side of the os 
 
 be detached, and by con- 
 le same torsion, the inner 
 the bone is finally cleared 
 
 aspect of the foot looking 
 • When tlie foot has been 
 I) eeding.points are secured 
 d nerves cut short, and the 
 ich now lies horizontally is 
 
 sutures. A very firm basis 
 stump is covered by the skin 
 
 insists of a disarticulation at 
 o malleoli and the articulir 
 ck with the leg well elevated 
 rgeon standing either belou 
 exsanguinated the limb, tlif 
 laking an incision from' the 
 -M and extending up to a 
 ■lleolus(Fig. 400). On the 
 action. For this purpo.se a 
 oyed (an ankle knife I Tiie 
 2 a bucket-shaped heel (lar 
 le knife is carried down t. 
 )ceeds to dissect up the Iuy 
 to the wound, and paith 
 :kof the OS calcis (Fig, 4011 
 ,'. Since .t is most importaiii 
 nutrient vessels of the tlaj- 
 :ision is then made, uniting 
 ly forwards so that a short 
 i np, and the ankle-j-mi: 
 \ inch above the tip of the 
 posterior ligaments, of tlic 
 innections along t!ie top <>i 
 
 IMPUTATIONS 
 
 »iSi 
 
 the OS calcis ih^ r ■ 
 
 then cleared 'in,! ''' ""emoved Th*. i 
 
 ■';'' »re ,lr„„.„ ,,„ "^ » « »"/ "Iher 
 
 'irtinage through 
 
 ""ftit:.-*. ■ t""*i31 
 
 * '°" '« required for tars-^r i P''«««"re. 
 
 t'lrsal di.sease. inas- 
 
 ^la; hkom o.s Calcis 
 
 inch 
 fcervati 
 
 '^^ ""^ -^ AlWI-UTATlON. 
 
 .'IS it is then rarph- .-,<■ 
 l!'^' 'if-a'and ffi r^ -?; ^"^ """- fa'c'r;:f';7 ^'"■•""^ -^ >'- os calci • 
 
1 153 
 
 A MANUAL OF SURGERY 
 
 an 
 
 what longer stump is obtained than in Synie's, and the patient is able 
 on the posterior part of the os calcis instead of on the sawn ends of t 
 and fibuha. Tiie operation is mor^i useful in cases of injury than for d 
 Amputations of the Leg may be undertaken either immediately ab 
 malleoli (supramalleolar) or in the middle third, or a hand's-breadtl 
 
 the knee (site of election) 
 two former positions aim 
 operation may be practised 
 inn to 'l>t-' needs of the c 
 perhaps the most satisfac 
 that by means of e(pial 
 flaps, each of which is t 
 length to one diameter of tli 
 and consists of skin, fat 
 ftiscia, whilst the muse 
 divided circularl\', In di\ 
 bones, care must be takei 
 leave a sharp projecting 
 the front of the tibia, 
 best prevented by partially 
 through the bone in an 
 direction from above down 
 and when this has rettched 
 beyond its centre, the saw i 
 drawn, and a horizontal 
 made, cutting across the 
 incision in such a way as to 
 a wedge of bone from the fi 
 I'ltv. 403. Farabceuf's Amputation at the tibia, which thus becomt 
 THK Site ok Klixtion, a Hand's ably bevelled (Fig. 403). The 
 Hkeadtu helow the Knee. should always be divided 
 
 The continuous line. A, U. C, indicates ^^ompleting the section of th(J 
 the shape of the large external flap ; 
 the dotted line, B, C, the incision on 
 the inner side of the limb. The direc- 
 tion in which the bones are sawn is also 
 shown. 
 
 1 
 
 th 
 
 In the lower third of 
 Teale's amputation (Tig j 
 sometimes recommended, an( 
 good results. 
 
 Amputaticn of the Leg ) 
 Site of Election may be perf 
 either by the modified fla; 
 circular operation, or b\- a large external flap (Farabwu/'s opiiation 
 the latter, the external flap (Fig. 403, A C), which is U-shaped, i 
 marked out with the knife, extending i^ inches higher in front tiian b 
 and its length being e(iual to the diameter of the limb at the po 
 which the bones are to be di'. ided. The incision on the inner side ii 
 made, extending directly across the limb from a point ij inches belc 
 upper end of the anterior horn of the former incision to its posterior ext: 
 (iMg. 403, B C) The external flap is dissected up, commencing ante 
 the fingers and knife being inserted between the tibialis anticus and the 
 all the soft parts down to the bone and interosseous membrane are d 
 oblicjuely. The anterior tiliial artery is cut long, and care must be tak 
 to free the flap from the interosseous membrane too high, for fear of in 
 the trunk of this vessel as it passes between the bones, an accident 
 would s^'riously imperil the vitality of this large and fleshy mass. The 1 
 on the inner side of tlie limb are now divided, either by transfixion or ci 
 division. The interosseus membrane and bones are bared, and th 
 applied according to the method already described. 
 
 Disarticulation at the Knee-joint is a very useful and valuable proce 
 The methods chiefly employed are as follows: (i.) Stiphen Smith's opt 
 or amputation by equal lateral flaps. The incisions extend from a 
 
 m 
 
JRGERY 
 
 s, and tlie patient is able to walk 
 of on the sawn ends of tlie tibia 
 :<ises of injury than for disease, 
 en either immediately above the 
 lird, or a iiands-breadtli below 
 e knee (site of election) In the 
 ^o former positions almost any 
 •eration may be practiseil accord 
 I,' to the needs of the case, but 
 rhaps the most satisfactory is 
 at by means of e(jiial lateral 
 ps, each of which is e<jual in 
 igth to one diameter of the limb 
 d consists of skin, fat and deep 
 icia, whilst the muscles arc 
 •ided circularly. In (lis idinj; the 
 nes, care must be taken not t( 
 .ve a sharp projecting edge on 
 ■ front of the tibia. This i 
 
 'mmediaf<»lv u i 
 
 ('•'^' 404). Th,. • '" "'«-' midrll,. I 
 
 ^'^^ POTATIONS 
 
 ''■'"■''i backward.s 
 
 '" f'le median line ^^n 
 •ccurred. jl,.. .; J"*:- . ^^hen union 
 
 s are 
 er 
 
 as 
 
 -v-u. reel, the cicatrix •. I '" ""'"" ''as 
 ...'u^ ui u.e uoia. inis i^ie"!!'//'V?'^''-'-'"ndvloi,n,J^r'y" "P ''«'iind 
 U prevented by partially sawinKlfi , T*""^ '"""'e'l cove-r „' '" "'•'*' «" 
 
 •ough the bone in an obliqucl , ■ 7''^'" t'nti ,.f ,he' Sm^""-''''^ 
 
 ough the bone in an (jbliqut 
 ection from above downwards 
 1 when this has readied a litt 
 ,'ond its centre, the saw is with 
 iwn, and a horizontal incisid' 
 de, cutting across the obli(iii 
 ision in such a way as to remo\ 
 'edge of bone from tiie front 1 
 tibia, which thus becomes suit 
 y bevelled (Fig. 40J). The fibul 
 uld always be divided befoi 
 ipletingthe section of the tibi. 
 n the lower third of the Ici 
 de's amputation (Fig. jSy) 
 
 letimes recommended, and gi\ 
 d results. 
 
 mputaticn of the Leg at ti 
 > of Election may be perfo 
 er by the modified flap an 
 lap {Faniluvu/'s operation). 
 '), which is U-shaped, is li. 
 < higher in front tiian behin 
 
 of the limb at the point 
 sion on the inner side is tli 
 
 1 a point ij inches below t 
 ;ision to its posterior extrem 
 id up, commencing anteriori 
 
 2 tibialis anticus and the tlL. 
 osseous membrane are divid 
 g, and care must be taken .. 
 J too high, for fear of injurii 
 the bones, an accident wlii 
 
 and fleshy mass. The tissu 
 ither by transfixion or circiiii 
 nes are bared, and the 
 )ed. 
 
 lefiil and valuable proceedi 
 : (i.) Stephen Smith's opei, 
 cisions extend from a p 
 
 
 '"•jection to 
 
 par 
 
 • joi 
 
 r ;j-;- remains ini'-irVT' ."^''''"'""'int' "f 
 
 ."dertaken by - / ■^'"P"fation can . 
 M'-'"a being^i ;7 T'""- "^P til 
 
 ^"■'^'erior flan i.j ', ""'-^^ances 
 I), so ,-.r?'^'^''*?/"rmed 
 
 A 
 
 ved. 
 
 Supracondvloid A ''"^"'^^ersely, 
 
 -■■'h disease '^T''^ 
 
 " "f an anterior Sn''? ' >« '-rma- 
 
 J"i 
 
 (;. 
 
 •>04. 
 
 'S" «»p-«l.^ 
 
 
 73 
 
 \'»j»*^m:/:t,i- 
 

 "54 
 
 A MANUAL Of-' SrHGKRV 
 
 in>; the patella, and a shorter posterior flap is then fashioned. The soft pa 
 art; divided by a circular cut of the knife, and the femur sawn across about 
 level of the adductor tubercle. The cartilaginous surface of the patella is tl 
 removed with the saw, and the remainiuR portion of the bone secured b 
 silver wire to the divided end of the femur. Considerable difficulty may 
 experienced in kecpin>{ the patella in accurate apposition, and to obviate t 
 Stokes recommenaed division of the femur at a slif^htly higher level (abf 
 rather than through the condyles), (d) Amputation by a /cz/a,' h'stciu'r Jlnf 
 sometimes recjuired in cases where the tissues in front of the limi) have becoi 
 disorganized from disease of the joint, or when cicatrices produced by 
 pre\ ious excision are present The posterior flap is first marked out and d 
 sected up, including merely the skin and subcutaneous tissues A transvei 
 incision is made across the limb above the cicatrices or sinuses, the bone sai 
 just above the site of the preceding excision, and the posterior muscles a 
 vessels divideil circularly. A very gooil stump usually results. 
 
 Amputation of the Thigh may be conducted by any of the general metlui 
 already described, but the modified flap and circular (I.ister's operati 
 I'lK i'^^) is perhaps the best. 
 
 Amputation through tiuO Hip-Joint. -Disarticulation at the hip-joint 
 always an operation of the greatest gravity, and every precaution shouki 
 taken to minimize the immediate risks by preventing h.i-morrhage a 
 lessening shock. No part of the body should be unnecessarily exposed, whi 
 the head is kept low, and although the operation must not be hurried over, 
 time is wasted 
 
 Perhaps the best way of preventing h.imorrhage is to secure the mn 
 vessels before di\iding them, and then to take up each bleeding-point as 
 ap^iears ; the limb can thus be removed with the loss of merely a few ouni 
 of blood. Other plans which have been suggested are: (a) Lister's aori 
 tournitiuet, which, however, is not to be recommended, partly because it 
 difficult to apply to stout or muscular individuals, and in any case it is vc 
 liable to slip, (h) Davys rectal lever for compressicm of the common ili; 
 artery consists of a rod of ebony, vulcanite, or metal, which is inserted in 
 the rectum, and directed so as to compress the artery against the brim of tl 
 pelvis It is dangerous in application, and not always efficient, (c) An elast 
 tourniiiuet may be applied either around the upper part of the thigh to conti 
 the lower end of the external iliac, or around the body in such a way as i 
 compress the abdominal aorta. For the latter purpose a pin-cushion or p;i 
 is placed on the abdomen over the aorta, and behind the back a board pn 
 jecting a few inches on each side of the trunk, and with two notches cut : 
 either end. The elastic rod is passed over the cushion, and around the notcht 
 at the end of the board in a figure-oi-.S fashion, sufficient tension being en 
 ployed to force the cushion down on the aorta, and thus control the circulatio 
 through it. This method, which was also suggested by Lord Lister, is cei 
 tainly etiicient, though somewhat cumbersome (d) More recently Wyeth, i 
 New York, has introduced a method of preventing h.rmorrhage by applying ; 
 rubber tourni(|uet close to the pelvic brim, which is prevented from slippini 
 by inserting long needles immediately below it The limb is first exsan 
 guinated by elevation, or possibly bj- the use of an Lsmarch's bandage. Tw 
 long steel needles, lo inches in length and |',, inch in thickness, are then in 
 serted, one on the outer side of the thigh and one on the inner. The formei 
 ' is introduced | inch below the anterior superior spine of the ilium, w 
 slightly to the inner side of this prominence, and is made to traverse super 
 ficially for about j inches the muscles and fascia on the outer side of the hi 
 emerging on a level with the point of entrance. The point of the soo 
 needle is thrust through the skin and tendon of origin of the adductor lont' 
 muscle A inch below the crutch, the point emerging i inch lielow the ail 
 ischii. The points should Ije shielded at once with cork to prevent injiin 
 the hands of the operator. No vessels are endangered by these skewers 
 mat or compress of sterile gauze 2 inches thick and 4 inches square is laid 1 1 
 
 
fCRY 
 
 1 fashioned. The soft parts 
 Femur sawn across ahout tlie 
 surface of the patella is then 
 >n of the bone secured by a 
 nsiderable difficulty mav hi- 
 position, and to ob\ iate'this 
 slightly higher level (abovt- 
 on by a Ikii); /^osterinr Jlap is 
 jnt of the limi) have become 
 I cicatrices produced by a 
 is first marked out and dis 
 leous tissues A transverse 
 Bs or sinuses, the bone sawn 
 I the posterior muscles and 
 lally results. 
 
 any of the general method 
 ircular (IJster's operation 
 
 idation at the hip-joint is 
 every precaution should ln' 
 eventing h.imorrhage am: 
 nnecessarily exposed, whils' 
 lust not be hurried over, m 
 
 ige is to secure the mail 
 p each bleeding-point as i: 
 loss of merel\- a few ouni:t> 
 ed are: (a) Lister's aortic 
 ended, partly because it i 
 , and in any case it is ven 
 ission of the common iliat 
 etal, which is inserted int- 
 2ry against the brim of tin 
 ays efiicient. (c) An elasii 
 part of the thigh to conti 
 body in such a way as t 
 rpose a pin-cushion or jia; 
 ind the back a board pn 
 id with two notches cut a 
 ion. and around the notchft 
 ufficient tension being en. 
 thus control the circulation 
 !ted by I,ord Lister, is cer 
 
 More recently Wyeth, a 
 h.rmorrhage by applying 
 is prevented from slippin 
 
 The limb is first e.\saa 
 Lsmarch's bandage. Tu 
 
 in thickness, are then in 
 :)n tlie inner. The forma 
 ir spine of the ilium, an 
 s made to traverse super; 
 n the outer side of the hij 
 
 The point of the seon 
 gin of the adductor hiiiKui 
 ng I inch l)elow the ai 
 
 1 cork to prevent injiir\ 
 ered by these skew ers 
 4 inches square is laiii v\ 
 
 ^^r PUT AT JONS 
 
 
 ;• -v. cicular incision 
 
 "" "le anted 
 
 nilt'i" 
 
 ncision 
 below the 
 
 incision ;;. trT' '?°"^' -^'^ h^"" ''''^'''- ^^^ ^^^Z^cl 
 
 ;rte^'---rS 
 
 
 Febru 
 
 lary. 1897. 
 
 73- 
 

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 IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
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 Sciences 
 
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 WEBSTER, N.Y. 14580 
 
 (716) 872 4503 
 
 i 
 
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 S^ 
 
 
 (/x 
 
 I . 
 
iiS6 
 
 A MANUAL OF SURGERY 
 
 
 the acetabulum, and the head (jf tlie bone is thus set free. One gre 
 tage of this operation is that the incisions are placed as far as pos; 
 the risk of septic contamination from the genital organs and perineu 
 To our minds, the best method of amputating at the hip-joint is 
 of an aitttrioy racquet incision (Fig. 405). This commences over ti)e 
 Poupart's ligament, and is carried down along the course of the ma 
 for about 3 inches. The common femoral sheath is e.xposed, and be 
 and vein are secured by double ligature and divided. The incisio 
 completed ; it sweeps over the inner side of the thigh 4 or 5 inclies 
 perineum to the back, and is brought up again to the front 3 or 4 incl 
 the great trochanter. The muscular structures in the outer flap art 
 through, and the external circumflex artery and otiier bleeding vessel 
 by pressure forceps en route. By rotating the limb inwards, the in: 
 the gluteus maximus can be divided, as also the muscles attached to 
 trochanter. The muscles in the inner flap are then similarly dealt ' 
 rotating the limb outwards, the internal circumflex artery, etc., beinj. 
 The capsular ligament is next divided transversely, and the head of 
 disarticulated. Finally, the limb is rotated forcibly outwards, and a' 
 parts at the back of the limb, including the sciatic vessels and ni 
 divided from within outwards with one sweep of the knife. Tlie woi 
 sutured lies antero-posteriorly. 
 
iURGEHY 
 
 s thus set free. One great advan-l 
 are placed as far as possible frornl 
 inital organs and perineum. f 
 
 ating at the hip-joint is by ineand 
 'his commences over tlie centre ol 
 ang the course of the main vessel! 
 sheath is exposed, and both arteni 
 nd divided. The incision is theii 
 f the thigh 4 or 5 inches below thf 
 im to the front j or 4 inches belov 
 ures in the outer flap are then r™ 
 and other bleeding vessels secui 
 u^ lir^K iriT.ai-ric tliB insertioH 
 
 ain to the front j or 4 inches belov 
 ures in the outer flap are then cm 
 
 ^,-,A ^tUov Kiooriinrr v-gssels securei' 
 
 iertion 
 J luc iiiu3»-ic3 ciiiai-ucu lu the gre; 
 are then similarly dealt with afte 
 cumflex artery, etc., being securer 
 verselv, and the head of the borj 
 
 forcibly outwards, and all the S( 
 he sciatic vessels and nerves, a 
 sp of the knife. Tlie wound aIk; 
 
 CHAPTER XLI. 
 ANiESTHESlA. 
 
 K practice of sur^prv h 1 
 
 ^-;n^846 by Mort^^r^TSilSln,^^^ dem'o'^sSio'n'ofTi'r" ^-d 
 i'"- James (then Profes.or\ c P'"""' ^"d of chlorofor?! • , P^'operties of 
 
 ;erat,on„ which before ^ sc.T:°"' ^^^'ded in a°™.;"e/;""''^"' ''^7, 
 n at the present rla,. , -.u scanty m number u^ "cw eia of surwrv 
 
 ^>^tant dependenc^^on ;S ""'■^^^'^"^ J^no\vSd.^e?n'5' '''''^'y "^"'tip'S' 
 'cfce could have bee i^'\^-«"t- it is difficult to nn, "Pe"ence, and our 
 .^^eon confidently to a M°f ^"f ^^^ ^^itl'out it AntX f '''r^' ^o^^' ^^rgicaf 
 rations being hurried ol^^'"^^^ «very region orieh"'.'"''" ""^^^«d the 
 
 It requisite at the nresenV? '""^'^ '""'•« deliberation P^^'^"* '^ sufTerings 
 -n^f hetics may be^dhSd '^^■; ^"^ ""'- as fo^erK rV r^^'^' ^^>"^ ^^e 
 ;'^^Tt '' ^^^^'^'i^:;^^^'^^^^^^^ genera, 
 
 ht^ietic, ^^"°"s cases, where the patient cannn. ''f'K'^^^n, or, 
 
 Cocaine is an alkaloid obt.in. , . ^^ ^"^ ^ ^""^''^j 
 
 Mer. Its propertS at? r^^''^" "^ ^ "x'ta ine poS'l°^'^'°^-/e. -hich 
 hna, and it was nt f?,l A r 1°'^*^ anesthetic weri^-^ "^^"^ readily soluble 
 '■ fhat its afue i ^P'l.*halmic Congress at H-IT^"^^ ''y Koller of 
 lonstrated. ^'"" ^" ophthalmic and Seal ^"'t'^"'"''^ '? September 
 I"cous membranes are r. r, ''^' ^'■~'** P^hliclj^ 
 
 hSrr°^,t^St-^Tt^^S.^^Sg^^"^ a , or .0 per 
 
 "le Heart -.^^ 1 '^" '''at cocame hnc a ,1: i- ^ °' '"is reaeent it 
 
 "ne of mcision, and the 
 
 -^ 
 
 I ' 
 
II58 
 
 .1 MANUAL OF SURGERY 
 
 L ' :iM 
 
 injection equally diffused along it. Should any toxic effects be m; 
 by pallor of the face, a cold clammy sweat, gi(ldiness, weak and r 
 the patient should be laid with the head low, and stimulants a( 
 Some recommend that a little nitro-glycerine (i drop of a i per ce 
 should always be injected at the same time as tiie cocaine, so as 
 contraction of the peripheral arterioles. In some parts of the bo( 
 possible to control the circulation so as to hinder the general abso 
 drug. Thus, for circumcision the base of the penis may be const 
 elastic band, whilst a similar arrangement may be applied to the 
 toes for small operations, such as avulsion of a toe-nail. 
 
 2. A substitute for cocaine has recently been proposed in the sy 
 pound known as Eucaine Hydrochloride. Its to.xic properties ar 
 marked than those of cocaine, and doses of even 5 or 10 grj 
 employed either hypodermically or bj' painting over a mucous me 
 action is somewliat slower than that of cocaine, and it causes a littl 
 of the part, whilst cocaine leads to ana?mia ; it also gives ris( 
 tingling pain on injection, and may leave a certain amount of 
 thickening for a time. The reports hitherto given have been very 
 although, on account of the irritation produced, it does not seem t 
 suitable for ophthalmic work. 
 
 3. Local anaesthesia is also produced by freezing the part, e 
 application of ice and salt, or by the ether spray, or with etl 
 The latter reagent is now put up conveniently in small glass o 
 flasks with a fine capillary outlet ; on holding the flask in the hai 
 produced, which is allowed to play upon the part to be operat 
 rapid evaporation from the surface leads to the freezing of the 
 becomes of a dead white colour. The anaesthesia produced i 
 fugitive nature, and a certain amount of pain may be associal 
 thawing process, but less than that caused by the ether spray. 
 
 General Ansesthesia. — i . Nitrous Oxide Gas (N,_,0) is most comn 
 dental work, or for short operations, such as bending a stiff' joint i 
 down adhesions, the avulsion of a toe-nail, or the opening of an 
 is practically safe and not unpleasant, either in its use or in it 
 effects. It is also employed in conjunction with ether, the patie 
 anaesthetized with gas, and the condition maintained by ether, 
 been recommended for the removal of adenoids ; but the gei 
 now obtaining is that, to perform this operation satisfactorily, a 
 anaesthetic is required. The gas is stored in a condensed and li 
 in special steel cylinders, closed by a screw which can be readilj 
 as to allow the gas to escape through a tube into an indiarubber 
 attached to a closely-fitting face-piece, with a suitable arrangem 
 and stop-cocks, by means of which the gas is allowed to read 
 A valvular exit for the expired air is also present (Fig. 406, A, 
 p. 1 160). In its usual method of administration the bag is first fi 
 and then air is completely excluded by carefully adjusting the 
 piece to the irregularities of the face. Some anaesthetists, howe\ 
 of a special apparatus devised by Dr. Hewitt, allow tlie admin 
 minute proportion of pure oxygen at the same time, in order tc 
 lividity of the face and the twitching of the limbs often presen 
 thesia is induced in the ordinary way. These symptoms of incip 
 may also be avoided by allowing the last few inspirations of 1 
 mixed with air. This may be done by raising the face-piece, b^ 
 air-valve, or, as suggested by Dr. Flux, by using an open inhal 
 the gas is poured. Of course, in removing teeth the mouth is 
 open prior to the commencement of the administration. 
 
 2. Chloroform is perhaps the anaesthetic most generally employe 
 of the ease with which it can be administered, although there ca 
 doubt that its use is attended with somewhat more risk than 
 Much controversy has arisen as to whether the heart is ever dii 
 
^ SURGERY 
 
 lid any toxic effects be manifested (aJ 
 at, giddiness, weak and rapid pulse .' 
 id low, and stimulants administereci 
 jrine (i drop of a i per cent, solutioij 
 time as the cocaine, so as to pre\c!i 
 In some parts of the body it may 1 
 D hinder the general absorption of tl 
 )f the penis may be constricted by r. 
 ;nt may be applied to tlie fingt-rs aq 
 3n of a toe-nail. 
 
 y been proposed in the synthetic ci>;j 
 Its to.xic properties are mucii Id 
 ises of even ^ or •" -—:-.• 
 
 ^N.ESTHESL-] 
 
 ises of even 5 or 10 grains may 
 linting over a mucous membrane, j 
 ocaine, and it causes a little congeslii 
 
 nfrimin • if nlwM ari\'P>c; ri«p trt n liti 
 
 ria?mia ; it also gives rise to a lit 
 ave a certain amount of crdemati 
 ;rto given have been very satisfacti 
 xluced, it does not seem to be quite 
 
 1 by freezing the part, either b\ 
 ether spray, or with ethyl chlorij 
 eniently in small glass or thin mt 
 elding the flask in the hand a spra 
 3n the part to be operated on, 
 ds to the freezing of the skin, 
 anaesthesia produced is of i 
 of pain may be associated with 
 ed by the ether spray. , 
 
 e Gas (N,_,0) is most commonly use! 
 h as bending a stiff joint and brea'| 
 lail, or the opening of an abscess, j 
 either in its use or in its subseqj 
 ion with ether, the patient being! 
 m maintained by ether. Gas has! 
 f adenoids ; but the general opij 
 peration satisfactorily, a more la* 
 •ed in a condensed and liquefied 
 
 hy the drug or uh«,i "^ "^'^ 
 
 ■icimmistration of cMnl/J ^^'^ '''■•^■'it'iing alone .S. -' ^>'"^e and Lister 
 ^'fe-naJ ; the .seconri .[?'''"• '^a-'ure of the re^ni , '','' ^^'itched durincr th ' 
 
 ''"J^J'ng that, althoS 1 ""'""-^ons and ana^stheHsK """^^'^^ '" "^"fi^'" 
 
 probably a majorUrif ?! '"espirations mavS Ifi! m "Pf'^ "^'^ statemen 
 ''^art failure is akn ^^'''' ^''i«e«. yet tjiere pL '" ^'^rge percentage 1 i 
 
 "Pon its muscular snh? ^' "" '■««"'' of he chrect^o'"'''!^'" """^^er i^v',,-" 
 "'« administra on of hT"^ ^^^'"'''linly. in ^'t Vf^^"^ ^^^^^^ "f the cIdoroV 
 
 t'^at occur ^////-/Jthe aT ■''''''^'■^' ^^''i^'' >-esuIt £,,' 1) """^ '"^ ^'^"^^ clistinctio,7 
 
 -thout doubt, felt ^'i^^^}-? -f ^^^-'^-^ An mSi:;:::: r\ ^''^ '-'^^- 
 
 ' ^^'^i^'v. a fatal result mav 
 
 Wl' 
 
 a \i 
 
 '^■-^^es. if suitable precanlf^'^ °^ ^'^^ respirations' 
 
 'e averted. Cases in wli?f,r,^'^"P''^'' ^ufficientlv";;;!;.'"' T^'^'^'y "^ ^"^1' 
 and are not entirelv L ^ *'^^ ''*^art stops firs^ nri' . -\' ^ ^^^^^ ''esult mav 
 Chloroform mav^hP^P'"'^^"^ "" ^he nal Jre of tt .^^ f ^'-'' ''""^ ^" ^vnc^rj 
 '" be attended to L. ^"'^f '" '^^^ral different wif '^"^^^^etic administered ' 
 ^ot more than /np/'^"'^''''>' "^ ^'ose, "0^/,^/^ ^"' '" ''^'' '''^^^ief S^ 
 '7P%ed of poutin^g'^an^unk"' '''' ^-P^^^nS^'^'^r'^ ->•, sHha 
 olded in two or three L, ""^^nown quantity of chlS' '^ P'''^" «" "^en 
 
 nost unscientific and In^T ^"'' ''^^^ close to the mH?' "" "" P''«^« "f Hn 
 ecommended Ey Lo d Ltr'''"?^'^ condemned ^T hTo^r M^'iL^ '"""'''•- 
 
 J a stage ofLlVlSL''''^ "^'""tes th 
 
 :rew which can be readily loosenej 
 tube into an indiarubber bag. T' 
 ■vith a suitable arrangement of v, 
 i gas is allowed to reach the pa 
 .Iso present (Fig. 406, A, B, C a 
 LStration the bag is first filled witi 
 y carefully adjusting the padded, 
 Some anaesthetists, however, by ij 
 Hewitt, allow the administratin 
 He same time, in order to preve 
 f the limbs often present when 
 These symptoms of incipient as, 
 last few inspirations of the gas 
 raising the face-piece, by openi- 
 , by using an open inhaler into 
 ving teeth the mouth is firmly : 
 : administration. 
 : most generally employed, on a 
 itered, although there can be b' 
 
 noxirKof tnr\r*i »-iclr tlian tViaf n\ 
 
 ---. "ui lue J 
 
 commencement. " "•" ™er stases k n,„„. , -V" ■■"" 
 
 l>»*o-'s ,•„/,„/„ i^ , ^ee.'i IS mucl, less tl,a„ „, 
 
 h" 'he nose and face" Yu. l7 «"'"« ^Hloroforn, especialK- ■ 
 
 !™J!''^.-.orC'.-r-la',i-S^^^^^ 
 
 !?■ •? a ce„a£ ITS. ^.S'/r-.';'""°-'eft:c?,' 
 
 10 
 
 istereu, aiiuuugu iiicic i_a,ii uc 1 
 mewhat more risk than that n 
 ther the heart is ever directh 
 
 inspired being regulated. 
 
ii6o 
 
 A MANUAL OF SURGERY 
 
 so that at first a considerable admixture of air is permitted, whilst latJ 
 vapriir in the propcrtion of a third, a half, or even two-thirds, il 
 The great value of this apparatus is the ease with which tlie amouni 
 administered is regulated ; but a distinct disadvantage exists in th( 
 
 Fig. 406. — Apparatus 
 
 for the auministkation of nltrous 
 Ether in Combination. 
 
 Uj:i 
 
 A, steel cylinders containing compressed nitrous oxide ; B, indiarubb 
 C, three way stop-cock with valves ; D, Clover's ether chamber ; 
 piece. If nitrous oxide alone is administered, D is omitted. Whi 
 alone is used, .\ and C are omitted, and a smaller bag substituted 
 
 the patient breathes his own expired air again and again, and so, un 
 is taken, he is likely to become cyanosed. This can, however, be pi 
 by removing the mask occasionally, and giving the patient a few br 
 unmixed air. Another objection lies in the amount of mucus whi( 
 
SURGERY 
 
 Jr is permitted, whilst later on etiier 
 
 se u th winch the amount of ether 
 disadvantage exists in the fact that 
 
 »C 
 
 n6i 
 
 collects about the ni, ^ — — ^ 
 
 the ba- uhir^f, 1 Pharynx, whUsf ,u ~~~~ 
 
 l>uln,.'vhfi™' ,'"■'>'"'■« ?,?„""?""■ iwlcSerJ " '"""'.lined i„ , 
 
 i^first aIlo^ve so' '''!'""^-^^'^V tube of . nt/"''^"" ^^'"& imerpo^Tf ' '^°^^'" '" 
 f er-chamber is"T^ned ^ '^^^^^ ^"" "'piraTion "-^'/'^ '-^PpSu s T7.r'" -'^^ 
 As soon as svmntom ° ^'^'■"I'tof ?rad> nU "^ "^ "'trons oxide /'f Patient 
 
 ''■•?«"Iar sterto^"Jr„^°^"'f'•ous oxidf nl"!"^'"^'-easin.do^^^^^^^^ 
 
 TION OF NiTKOL'.S OxiDE aM 
 TION. 
 
 US oxide ; B. indiarubber ba I 
 overs ether chaml^er; E fac'J 
 ■^''•.P's "fitted. When'etli, 
 -mailer bag substituted for R 
 
 and again, and so, unless al 
 lis can, however, be prevenj 
 ? the patient a few breaths J 
 mount of mucus which of lej 
 
 ! '-comi rather livS^^^"^ '"^ ^^re'^cialh-'^'^P^'^''^"^ ''an wl en ei^'P"'-^^"^ 
 
 •"inute or two "'"^ ""^' '"'Sid. burtheje^eon r?-*^" ^'"'""b 's m^ ^'' '-^'""^ '« 
 
 , 4. To obviate the i conditions pass off in S^ ''" "«^d. to 
 
 I 'i^'-^ A.C.E. BifvLl. •'^^^''^ssing effects nf m '^°"''^'« °f a 
 
 '•<^quire but little V " ^/ ^PP'icab le to rV i^ °P^" Method 'sfi" ' u} "'''^>" be 
 
 ,,™--«ca,p,acH,i ""'"'*'^«°'' «f A„»,tietio. 
 
 JrlementofrisA-isnl""^^ "lust never I. 
 
 '''=■<» oni,e,„,iWc,„a,XK^PSM''« VV'„e„ 
 
 'arelully regulated 
 
Il62 
 
 A MANUAL OF SURGERY 
 
 for a few days prior to tlie operation, and on tlie preceding niglit a si 
 purgative is administered, castor-oil being perhaps the most etticacioiis. 
 food given on tlie morning of the operation should be light and 
 assimilable, whilst nothing should be taken for at least three hour 
 viously, so as to make sure that the stomach is empty. In casualty cj 
 may be advisable to relieve gastric distension with an emetic, or by w 
 out the organ before commencing the administration. The an.Tsthetis 
 ascertain that no loose artificial teeth are present in the mouth, and t! 
 tight clothes or bands encircle the neck or thorax. In very nervous ca 
 where much shock is anticipated, a preliminary hypodermic inject 
 strychnine or a nutrient enema may be administered. 
 
 The anjESthetic should never be pushed in the early stages, but is 
 slowly and gradually, especially in nervous individuals. When there 
 struggling, the movements of the limbs should be restrained with aslitth 
 as possible, and care must be taken during the deep respirations which 
 such struggling not to administer an overdose. The ccjndition whi( 
 administrator should aim at maintaining is one characterized by total mu 
 relaxation, insensitiveness of the cornea, and a contracted state of the 
 whilst the pulse and breathing continue regular. If the pupil commer 
 dilate, and the corneal reflex is present, the patient is apt to move wh( 
 knife is used, indicating that more anaesthetic is required. Dilatation 
 pupil with an insensitive cornea is always an indication for suspendii 
 administration for a time. If the anaesthesia is not sufficiently deep, vo 
 is likely to occur, being ushered in by weakness and rapidity of the puis 
 pallor of the face ; this may often be averted by pushing the anaesthetic, 
 anaesthetist's chief attention must be directed to observing the state 
 respiration and pupil ; but he should also note the colour of the lips, c 
 and ears, as thereby \ aluable information is gained as to the condition 
 circulation. The pulse should be felt occasionally, but it is less import 
 attend to this than to tlie other points noted above. After the deep ana;; 
 required in division of tlie skin, most operative proceedings on the 
 taneous tissues are comparatively painless, and hence the anaesthetic ne 
 be pushed quite so far. Whilst the wound is being closed, the patieni 
 be again somewhat more completely under control. In operations upi 
 mouth associated with h:rmorrhage, the head must be occasionally tun 
 one side to allow the blood to gravitate out of the mouth, and the pi' 
 well sponged, so as to prevent the admission of clot and other matters ir 
 air-passages. It is also a \aluable routine plan to insist upon the head i 
 being turned on one side, especially when ether is being given, since 
 tends to collect about the pharynx. 
 
 The After-Treatment of the patient is always a matter of considerab 
 portance. He is carried from the table and placed on his back, or prefe 
 when possible, on his right side, in bed with the head low. Where tl 
 any tendency to shock, hot- water bottles, well wrapped up, should be a 
 to the feet and sides, and hot blankets over all. Absolute quiet mi 
 enjoined for some hours, and the room darkened, so that, if possibl 
 patient may fall asleep. No food is administered for at least three c 
 hours, and then only very cautiously, a little weak tea, soda-water, or b« 
 being given. The patient is likely to vomit on returning from unconscioi; 
 perhaps bringing up a little bile-stained mucus, but if the anx'sthetic ha 
 judiciously given, it soon ceases. Occasionally, however, the vomiting p 
 for some time, becoming very troublesome. It may generally be check 
 a hypodermic injection of morphia, and by washing out the mouth with 
 water ; but in more severe cases, lasting for some days, the patient's nu 
 may have to be maintained by enemata, and the stomach kept absolul 
 rest. Benefit may sometimes be derived by giving a little bismuth and 1 
 cyanic acid in an effervescing mixture, or perhaps champagne ; but, as : 
 all administration of food by the mouth should be stopped until the voi 
 has ceased. 
 
RGERY 
 
 the preceding niglit a suitable 
 haps the most etticacious. Any 
 m should be light and easily 
 
 for at least three hours pre- 
 is empty, in casualty cases, it 
 1 with an emetic, or by washing 
 itration. The anfrsthetist must 
 ;sent in the mouth, and that no 
 )rax. In very ner\ous cases, or 
 inary hypodermic injection of 
 stered. 
 
 I the early stages, but is given 
 dividuals. When there is any 
 
 be restrained with as little force 
 
 deep respirations which follow 
 ose. The condition which the 
 characterized by total muscular 
 a contracted state of the pupil, 
 ar. If the pupil commences to 
 .tient is apt to move when the 
 
 is required. Dilatation of the 
 1 indication for suspending the 
 i not sufficiently deep, vomiting 
 s and rapidity of the pulse, and 
 y pushing the anatsthetic. The 
 d to observing the state of the 
 ! the colour of the lips, cheeks, 
 lined as to the condition of the 
 lally, but it is less important to 
 love. After the deep anaesthesia 
 tive proceedings on the subcu 
 i hence the anaesthetic need not 
 
 being closed, the patient must 
 ntrol. In operations upon the 
 must be occasicnally turned to 
 )f the mouth, and the pharyn.x 
 [ clot and other matters into the 
 I to insist upon the head always 
 er is being given, since mucus I 
 
 ys a matter of considerable im-j 
 iced on his back, or preferably,! 
 he head low. Where there isl 
 wrapped up, should be applied [ 
 ■ all. Absolute quiet must bel 
 ened, so that, if possible, the! 
 itered for at least three or foiirj 
 ^eak tea, soda-water, or beef-teal 
 returning from unconsciousnessT 
 , but if the anaesthetic has beeDJ 
 , however, the vomiting persist;] 
 L may generally be checked byl 
 ihing out the mouth with warral 
 lie days, the patient's nutritiocl 
 the stomach kept absolutely al 
 zing a little bismuth and hydrof 
 ips champagne ; but, as a rulej 
 1 be stopped until the vomitiiiif 
 
 1163 
 
 ■': Obstructed Resoiraf ' """ ■'^<'-'"'«t'-ation of ,n^'. 
 
 ''"■'^'<y. and if nf''""^^ more and more ^L '? '"" '^'^ 'arynx TI,« •""' 
 
 immmsmi 
 
 wsmmem 
 
 occurrence. «""•»"=■' '° .he g,„„i, %*™ J^^^'l^l. or i," .h^ !;;;<- 
 
 
 mmmmm 
 
 '"easures must be undertaken^'^^vf '"'f ^ ^^ an hour'L /^^"'^^'^^-^tionlS 
 -irii ? w'^ occasionally resnh« f "''' "^^'i^viselv 
 
 immimmm 
 
 ;as are especially affeS'f."^^^ Pf'"''^?^ '"fi'tra'ed ^Jth 'f^?' ^^^'' '""-^^'^ i' 
 
 hthJ^ t'-eatment to be adonl r^P^"'^'^^. ^o not Lnir.i,^^''°"^' ^^'^ere 
 "' -- - "" -PPa.e1?r - Sol-"- SS™ S,^- 
 
1 164 
 
 A MANUAL OF SURGERY 
 
 The Choice of an Aasasthetic in any particular case depends mainls 
 condition ol the circulatory and respiratory apparatus of the patient. K 
 perhaps, on the whole, the safest drug to employ, especially in adults, altl 
 it is less pleasant to take ; it may cause a good deal of bronchial irritatio 
 congestion, and is more likely to give rise to troublesome after-von 
 although such does not usually last long. It is sometimes followed h 
 pleasant delirium. Chloroform is easier to administer, more pleasant to 
 and less likely to lead to objectionable after-effects. It is the best ana 
 for young children and old people, though its action upon the heart c 
 indicates its use in patients whose circulation is weak. The A.C.IC. m 
 may also be safely employed, if the precautions already indicated on an 
 page are attended to. 
 
 Ether is certainly contra-indicated in patients suffering from any bron 
 or pulmonary trouble, and its administration for operations about the f; 
 mouth is, of course, impracticable. Chloroform should not be gi\en in 
 of cardiac weakness or advanced renal disease ; for abdominal work 
 always to be preferred to an}' other agent, as also in operations on the b 
 
iGERY 
 
 Icar case depends mainly on the 
 laratus of the patient. Ether is 
 y, especially in adults, althougii 
 deal of bronchial irritation and 
 3 troublesome after-vomitinf;, 
 is sometimes followed by un- 
 ninister, more pleasant to take, 
 ects. It is the best antPsthetit 
 action upon the heart contra- 
 is weak. The A.C.E. mixture 
 already indicated on an earlier 
 
 s suffering from any bronchitic 
 or operations about the face or 
 m should not be gi\ en in cases 
 ise ; for abdominal work it is 
 so in operations on the brain. 
 
 INDEX 
 
 AnnoMiNAr. aorta, l,w„.. r 
 
 operations, general e^'n'"^' ^-^9, 262 
 surgery (ChapteTvy T.''^''' °"' 9' 7 
 
 A..^f^---:;^^^'). 8,8-930^ 
 
 wails, injuries of SiS 
 -\hsce.ss, acute, 26.,; "* 
 alveolar, 69. "^ 
 anal, 980 
 a.xillary, ^^^ ^ 
 cerebellar. 778 
 
 Chr?''"' ^55. 680, 7y8 
 
 <^^-nic^.ubercu,ouf 35. .08, e,6. 
 
 .^sati;V°tf^^°■^-.93x,94X 
 iliac, 621 -^ 
 
 !" f^one, 482, 476 
 m hip-jomt disease c,^ 
 '" kidney, ,009 ' ^^^ 
 ntra-mammarv o, So< o 
 
 'schio-rectal, Z' lis p^'^ 
 acunar,iii9''-^''^^«-97S 
 
 lumbar, 617, 623 
 of abium, loQc-" 
 of liver, 906 
 of spleen, 916 
 of tongue, 733 
 palmar, 34. ^^^ 
 perinea!, 1083 
 
 Perinephritic, rooo 620 
 prostatic, locg ^' ^° 
 psoas, 617, 62:1 
 Pyasmic, 93, gi 
 residual, 3^. If^ 
 
 sublingual'. 83;'74f ' '' ^^^ 
 submammary. 826 8qo So 
 subphrenic, ^60. 872 9;o 
 
 Acne, 7n ^^ 
 
 too„,,„„, dislocation of, „, 
 fraciure of, 4,8 ' ''3 
 
 ■'™'"'"i';a'-"°' -="""■■* =40,,,, 
 
 Adder's bite, i68 ' -^'° 
 
 Adenoma. 136 '' 
 
 ofadrenal bodies. 1017 
 ot breast, 85^ '^ 
 
 of kidney. 1017 
 ofPalatal glands, 75. 
 ofpost.analgut,6io^ 
 of prostate, 1062 
 o' rectum, 986 
 
 Of thyroid, 788, 702 
 
 Adeno-sarcoma of breast 8.- 
 
 ■^dhesions in hernial s^c'S" 
 
 !njoint.S392 -'g ■923. 930, 945 
 
 . . 'ntraperitoneallr' ^t?. «^ 
 Adrenal tumours, 10/7^' ^-^^' ^^'- 898, 961 
 Adventitious burs.x 'L 
 Aerial fistula, 786 ^ ^"*"^ 
 Aerobic bacteria, r . 
 
 VVTv , s"i surgery 
 4iK^^^'^' 796-823 ^ ^ 
 ^ buminuria, 1042-^ 
 A ibert;s keloid, 177 
 
 ^ sarcoma xS'' ''''''''°''' of, 694 
 
 ASa"c^^;-'-;-^^-ctures,4oo 
 Amputation of penis r^« 
 Amputations iSi^,'"^^ , , 
 
 [Junngshock,i63 ,87' ^^-^'56 
 
 for acute arthritis: 546^ 
 
 for aneurism, a^islr 
 
 for compound fractures rr 
 
 for gangrene, 60 62 6,' fi '^f-* 
 254. 403 ' ^' ^3. 65, 68, 162, 
 
 •'^ee Veins 
 of (Chapter 
 
ii66 
 
 INDEX 
 
 Aiuptitations for sarcoma of hunr, 499 
 for secondary li;iniorrhage, a'jg 
 for >prea(liiiK traumatic K-^nKriMU", ')8 
 fur tuberculous ilist-ases of joints, 554, 
 
 555. 556. 557. 570 
 Amussat's opor.ition, 892 
 Amyloid dt'Kcncratioii, 37, 104J 
 Aiiai'njbic bacteria, 14 
 Anxsthosia (Chapter XI. I), 1157-1163 
 
 dolorosa, dtti 
 An;v'Sthetic, choice of, 1163 
 
 li'prosy, 112 
 Anatomical wart, 169, 327 
 Aiiels ligature for aneurism, 234 
 Aneurism (('hai)ter I X.I, 2J5-251 
 
 by anastomosis, 134, 500, itcS 
 
 cirsoid, 134, 668 
 
 ditluse traumatic, 203, 215 
 
 of bone (osteo-aneurism), 500 
 
 varicose, 219, 667 
 Aneurismal varix, 218, 245, 276,283,644, 
 
 Aneurisms, special, 239-251 
 
 Angina of I.udwig, 82, 744 
 
 Angioma, 133 
 
 Angular curvature of spine. See Pott's 
 
 disease, on 
 Ankle, acute arthritis uf, 548 
 
 amputation at, 481, 1150 
 
 ankylosis of, 571 
 
 etfusion into, 537 
 
 excision of, 587 
 
 fiacture-dislocalions of, 457, 532 
 
 tuberculous disease of, 556 
 Ankyloglossia, 731 
 Ankylosis, 569, 63, X12, 303, 577, 626, 
 
 709 
 Anthrax, 103 
 
 Antiseptic treatment of wounds, 178 
 Antiseptics, 178 
 Antistreptococcic serum, use of: 
 
 before abdominal section, 917 
 
 operations on tongue or pharynx, 
 
 741, 759, 762 
 operations on joints, 532 
 
 in cellulitis, 81 
 
 in erysipelas, 89 
 
 in pya;mia, 96 
 
 in sepiica'Uiia, 92 
 Antrum, affections of, 698 
 Antyllus' ligature for aneurism, 234 
 Anus, affections of, 977, 980, 983, 985, 
 987, 998 
 
 artificial, 873, 876, 877, 878, 880, 890, 
 950, 954, 957, 967, 973, 989 
 Aorta, abdominal, aneurism of. 247 
 
 compression of, 205, 248, ri54 
 
 ligature of, 249, 262 
 
 thoracic, aneurism of, 239 
 Aphasia, 661, 778 
 Apnoja, 821 
 Appendicitis, 896 
 Arachnoid cyst, 150, 155, 629, 644 
 .Arm, amputation through, 1x46 
 
 deformities of, 358 
 
 Arterial lurmorrhagf, loc, 203 
 .Arterial suture, 317 
 
 thrombosis, 61, t4, 214, 22.} 
 .Arteries, affections of (Chapter l.\. 
 
 ligature of, 251-268 
 Arteno-venous wounds, 217 
 Arthrectomy for tuberculous diseasi 
 
 joints, 553, 555, 556 
 Arthritis, acute, 543, 503, 708 
 
 deformans. Sec C>steo-arthritis 
 Arthrodesis, 627 
 Artificial respiration, 3-3 
 Ascarides, 078, ic^j 
 Asepsis, 182 
 Asphyxia, 821 
 Aspiration for hydronephrosis, 1006 
 
 of bladder, io8_' 
 
 of chronic abscess, 39 
 
 of empyema, 817 
 
 of heijatic abscess and cyst, 908, 9 
 
 of pericardium, 820 
 Asthenic fever, 1 1 , i38 
 Astragalus, dislocation of, 533 
 
 excision of, 376, 588 
 
 fracture of, 461 
 
 tuberculous disease of, 480 
 Atheroma, 220, 225 
 Atlas, dislocation of, 596, 619 
 Atony of bladder, 1037, 1051, 1063 
 Atrophic scirrhus, 144, 841 
 Atrophy of bone, 492, 387, 438, (171 
 
 of muscles, 299, (127 
 
 of skull, 671 
 
 of testis, 1 1 10 
 Axillary abscess, 33, 290 
 
 artery, aneurism of, 247 
 ligature of, 259 
 
 cellulitis, 82 
 
 470, 621, 84 
 898, 907, 91 
 1071 
 
 Bacilli, 12 
 
 Bacillus anihracis, 103 
 
 coli conmiunis, 29, 75 
 852, 856, 873, 879, 
 948, 969, 978, 1027. 
 
 lepne, in 
 
 of malignant a-dema, 67, 80, 90 
 
 mallei, no 
 
 tetani, 14, 97 
 
 tuberculosis, 106 
 
 typhosus, 29, 470 
 Bacteria, .2-18 
 Baker's cysts, , 542 340 
 Balanitis, 1088, 11 19 
 Ballooning of rectum, 985 
 Banks' (Mitchell) operation for hern 
 
 938 
 Barker's operation for fractured patel 
 
 452 
 operation for hernia, 938 
 Basal meningitis, 653 
 Base of skull, fracture of, 630 
 Basilar artery, aneurism of, 244 
 Bassini's operation for hernia, 935 
 Bedsores, 65, 605 
 
i.i'morrliaKc, 190, ^03 
 
 uture, 217 
 
 iibosis, 61, 64, 314, 224 
 
 ittections of (C'lmptiT IX.), 214- 
 
 ire of, '.'51-268 
 
 irious wounds, 217 
 
 my for tuberculous cliseasu of 
 
 i.S3. 555. 55'' 
 
 'i''"e, 543. 50.^ 708 
 
 nans. .See Ctsteo-iirthritis 
 
 is, 627 
 
 espiration, 8-^ 
 
 82 
 821 
 
 for hydronephrosis. 1006 
 Jder, io8_' 
 onic abscess, 39 
 lyema, 817 
 
 atic abscess nnd cyst, 908, 910 
 cardium, 820 
 :ver, u, i88 
 , dislocation of, 533 
 '" of". 376, 588 
 e of, 461 
 
 ulous disease of, 480 
 220, 225 
 
 ication of, 5(16, 610 
 ladder, 1037, 1051, lof.? 
 :irrhus, 144, 841 
 bone, 492, 387, 438, 1,71 
 cles, 299, 627 
 I, '571 
 s, IIIO 
 scess, 33, 290 
 aneurism of, 247 
 iture of, 2c;9 
 s, 82 " 
 
 hracis, 103 
 
 iimunis, 29, 75, 470, 621, 848, 
 
 856, 873, 879, 898, 907, 91J, 
 
 >'^9. 978, 1027, 107 1 
 
 :ii 
 
 inant a'dema, 67, 80, 90 
 no 
 
 4. 97 
 osis, 106 
 s, 29, 470 
 18 
 
 '- . 542 340 
 
 88, 1119 
 
 if rectum, 985 
 
 chell) operation for hernia, 
 
 ration for fractured patella, 
 
 n for hernia, 938 
 fit's. 653 
 , fracture of, 630 
 ', aneurism of, 244 
 ration for hernia, 935 
 605 
 
 e.\tremity. 
 
 1041 
 
 462. 
 
 •Wlocc, s sound, 728 
 "'eeps cruris, fenofon.u ^r 
 
 'bladder in licrnii 
 
 "oil, 322, 77, ' ■^ 
 
 Hone, diseases of /< u 
 50. '^'-^ °M< hapter .Wn 
 
 fjoricacid, ,79 
 
 ouffies, urethral, 107- 
 
 "-'^'''■^' artery, con Jir;33i„„„,^^. 
 
 Pie.\u.s, affections of q, , 
 ,, . stretchinir of ^t- 
 
 V ^, *■ under ( erchrai ( • 
 ,, ^ind Compression ' ' ""^ussion, 
 
 n'sdoS' "'"^' "^'''ions of 780 
 
 243 °^' operation for anetSm, 236 
 
 '--.diseases Of (Chapter XXX.), 824- 
 
 'ironchocele. See r^-. 
 bronchus. See A^r """^ 
 B^yant•s testtlin.^';, ' ''^^'^ 
 Hubo, 1,19. ,,^^ Wi 
 
 Hubono I. 926 
 
 Bullet ';ss"^^rT'^°^-s5 
 
 Bunion, 382 ^'^ ^^unshot wounds 
 
 Burns, 71 
 
 Burste, diseases of, o , , 
 
 ""■•sal cysts in neck^-^7-^83 
 
 lNl)E\ 
 
 Cancer of intestine, 870 
 
 nf[^^ '"''"• 70., 707 
 o kidney, ,oiH ' ' 
 
 of lip, 09a 
 
 of "•SOp(,,,pus, 766 
 
 of Paroti.i, 7 ,- 
 
 oj P'-'nis, ,089^ 
 
 of ph.irynv, 76, 
 
 of prostat., 1067 
 
 of pylorus, 868 
 
 of n-ct„n,_ 987 
 
 of testis, , ,03 
 of thyroid, 794 
 of tongue. 736 
 . of tonsil, 75,; 
 
 ancru.u oris, 09, 7C9 
 ^;arjolic acid, 178^^-^' 
 
 1167 
 
 I II 
 
 Carboluria, 178' 
 
 7JI 
 
 »043 
 
 Ciecal hernia, 904 
 t-,.'«cum, cancer of. 880 
 ^alaum chloride in blood, 269 
 forha>mophiIia, 21:! ^ 
 ta cu ous anuria, ,01 .^ 
 t-alculus. biliary. 9x,,-*96, 
 
 •"pacted in urethra .r 
 '"testinal. 964 ^' '^^o 
 
 Piostatic, 1061 
 renal, 1012 
 salivary, 7. , 
 vesical, 104^ 
 Ca osity, 32s ^"^ 
 Callus. 394 
 
 (anahzation of veins am 
 Cancellous osteoma 'r'; 
 Cancer, general facts of T,« 
 of bladder, ,03, ' '^^-'^^ 
 of bone, 499 
 of branchial deft, 78^ 
 of breast, 838 ^ 
 
 <-arbuncIe, ^(20 
 Carcinoma.^ .Se,. < •..„ 
 
 a^-'« anipu;;^^; -:^ 
 
 Caries, 461^ "' "53 
 
 of spine, 61 1 
 of temporal bone 77 ■ 
 syphilitic, 485 ^^^ 
 tuberculous, jyo r, , 
 Carciid artery, ant'^' ^.'-'or''.^' ^V4 
 
 ;:ompression o' . jr ° ' ■^' 
 ,. ligature 01,, zcj 0.0' o 
 ^^arr'.s splint. .,„^-* ^■*=*' =4^. ^44. 245 
 I J;..^;;.'f''"yan^de,424 
 Camlage, affections ot ;„ >,• . ,. 
 
 54'. 54?, C.O .„ •*°"" disease. 
 ! se. .ilunar st^i ^57-559. -^eo 
 
 *-astration, ma 
 
 I Catheterism asepsis in cnr r 
 
 i ^064. 1075 "^^' ^^'' '°29, 
 
 dangers fro,,,. 1076 
 
 difficulties in, ,076 
 
 N-theTers"'i^g-^P^-'-''^.-64 
 
 ''997.Toor°^"^^«'3^9.552.6oo,6a,. 
 Cellulitis, 79.83 
 of scalp, 82 
 
 CephaIotetanus,g9'' 
 
 t^erebellar abscess, 7,8 
 
 Cerebral abscess, 65^5. 680 7-3 
 b^-emorrhaire, 645 S ^' ' 
 "■ntatioii. 647 ^^' ^ 
 
Wr'h 
 
 mii 
 
 1168 
 
 INDEX 
 
 Cerebral tumours, 676 
 Cerumen in ear, 770 
 Cervical plexus, injury to, 314 
 
 rib, 351, 246 
 Chancre, hard, 1125 
 
 of anus, 9'' '5 
 
 of lip, 690 
 
 of nipple, 825 
 
 of tongue, 735 
 
 of tonsil, 758 
 
 of urethra, 1125, 1072 
 Charcot's disease, 564 
 Chemiotaxis, 17, 4 
 Chest. See Tiiorax 
 Chinosol, 197 
 
 Chloroform, administration of, 11 58 
 Cholangitis, suppurative, 906, 912 
 Cholecystectomy, 915 
 (Jholecyst-enterostomy, 911, 914 
 Cholecystitis, 912 
 Cliolecystotomy, 906, 913 
 (Jliolelithiasis, 911 
 Cliolesterine, 37, 911 
 Chondroma, 127 
 Chopart's amputation, 1149 
 Chordee, 11 19 
 
 Chronic inflammation, 22-25 
 Chylous hydrocele, 286, 1108 
 Chyluria, 1042 
 Cicatrices. See Scar 
 Circular amputation, 1139 
 Circumcision, 934, 1086 
 Circumflex nerve, affections of, 315 
 Cirsoid aneurism, 134, 668 
 Clavicle, dislocations of, 512 
 
 fractures of, 415 
 Claw foot, 381 
 
 hands in leprosy, 112 
 
 of ulnar paralysis, 318 
 Cleft palate, 748 
 Club foot, 369 
 
 hand, 177, 358 
 Coagulation necrosis, 5, 29, 30 
 Cocaine, 1157 
 Cocci. See Micrococci 
 Coccydynia, 438 
 
 Coccy.x, excision of, 438, 977, 990, 991, 
 1113 
 
 fracture of, 437 
 Cock's operation of perineal section, 1082 
 Cold in treatment of inflammation, 20 
 Coley's fluid, 125, 145 
 Colic, appendicular, 901 • 
 
 biliary, 912 
 
 renal, 1014 
 Collapse, 183, 853, 949, 974 
 Colles' fracture, 431 
 
 law, 1136 
 Colliquative necrosis, 5 
 Colloid cancer, 144, 862 
 Colotomy, 892. 969, 977, 985, 986, 989, 
 992, 1000 
 
 methods of, compared, 896 
 
 uses of, 892 
 Columnar carcinoma, 142 
 
 Columnar carcinoma of bladder. 1033 
 of breast, 841 
 of intestine, 879 
 of rectum, 987 
 of upper jaw, 701 
 Coma, diabetic, 63 
 
 diagnosis of, 650 
 
 m cerebral abscess, 681 
 
 in cerebral tumour, 677 
 
 in head injuries, 643, 644, 643, 'o. 
 652, 653, 658, 665 
 
 uraeniic, 1014 
 Compound fractures, 403, 162 
 Compression, cerebral, 048 
 Concussion, cerebral, 61.5 
 
 of the spine, 598, 601 
 Condylomata, 136, 1129 
 
 of anus, 985 
 Congenital cysts, 146 
 
 dislocation, 503 
 
 fracture, 388 
 
 hernia, 921, 927, 938, 942 
 
 hydrocele, 1104 
 
 malformations of rectum, 976 
 
 syphilis, 1136 
 Congestive stricture, 1071 
 Conical stump, 1143 
 Conjunctivitis, gonorrhaeal, 1120 
 Contagion, 78 
 Contusions, 154 
 
 of abdoiriinal walls, 848 
 
 of intestines, 873 
 
 of lung, 812 
 
 of kidney, 1002 
 
 of nerves, 297 
 
 of skull, 629 
 Corns, 325 
 
 Corrosive sublimate, 179 
 Costal cartilage, separation of, 414 
 Counter-irritation, 24 
 Cowper's glands, inflammation of, 1119 
 Co.xa vara, 362 
 Coxalgia and coxitis. See Hip diseas 
 
 572 
 Craniectomy, linear, 673 
 Craniotabes, 487, 488, 671 
 Cranium, injuries of, 629-641 
 
 diseases of, 669-676 
 Croupous inflammation, i8 
 C'rus cerebri, injuries to, 662 
 Crutch palsy, 315, 402 
 Cryptoscope, 164 
 Cubitus valgus, 424 
 
 varus, 424, 428 
 Curvature of spine, angular, 611 
 
 lateral, 351 
 Cut throat, 783 
 Cylindroma, 124 
 Cystine, 1046 
 Cystitis, 1027 » : 
 
 in spinal affections, 595, 601, 6c 
 619, 1027 
 Cysto-adenoma, 136, 789, 836 
 Cystoscope, 1026 
 Cystotomy, perineal, 1030 
 
 y 
 
carcinoma of bladder, 1033 
 " breast, 841 
 
 ■ intestine, 879 
 rectum, 987 
 
 ■ upper jaw, 701 
 betic, 63 
 
 )sis of, 650 
 ibral abscess, 681 1 
 ibral tumour, 677 
 d injuries, 643, 644, 645, 649, 
 653. 658, 665 
 c, 1014 
 
 fractures, 403, 162 
 jn, cerebral, 048 
 I, cerebral, 6j5 
 spine, 598, 601 
 Lta, 136, 1 129 
 s, 985 
 cysts, 146 
 tion, 503 
 e, 388 
 
 92 r, 927, 938, 942 
 ale, 1 104 
 
 mations of rectum, 976 
 3, 1 136 
 
 stricture, 1071 
 mp, 1143 
 
 tis, gonorrhcEal, 1120 
 78 
 
 154 
 )minal walls, 848 
 itines, 873 
 , 812 
 ey, 1002 
 es, 297 
 , 629 
 
 iblimate, 179 
 
 iage, separation of, 4x4 
 
 tation, 24 
 
 ands, inflammation of, 1119 
 
 362 
 
 id coxitis. See Hip disease, 
 
 y, linear, 673 
 , 487, 488, 671 
 juries of, 629-641 
 > of, 669-676 
 flammation, 18 
 , injuries to, 662 
 /, 315, 402 
 :, 164 
 [US, 424 
 24, 428 
 
 f spine, angular, 611 
 351 
 783 
 124 
 6 
 
 7 ■-■'■■• ^ 
 
 d affections, 595, 601, 604, 
 027 
 
 ma, 136, 789. 836 
 1026 
 perineal, 1030 
 
 blood, 150, y83 
 branchial, 780 
 aental, 695 
 dentigerous, i:,r -o<c 
 
 ^ 832, 1018^ '°' ^^9. 742, 781. 
 
 /95;''oxf5°°'^77.783.8x9,832. 
 implantation. 150 
 
 "floor of „,outh 742 
 
 'Evolution. 828, 831^^' 
 Morrant Baker's Co 
 mucous, 691 ■ ^-f^' ^49 
 of breast. 830 
 
 o; labia, 1090 
 of neck, 781 
 
 of pancreas, 9rr 
 of round limmpnt , 
 
 ofspermatfcc^rd'r,?'"°^ 
 of%roid,789 ^''■*y'"°7 
 
 ,. s^'-ous, i4o^||:^°9. 783 
 
 Czerny-Lemhpr; c, ^' ^'' ^^^iS 
 J- A-emoert suture, 88i 
 
 SSK br'^'"S--«"reof.268 
 
 Drowning 8?, ' °^^^°"nds, 159. ,s\ ^ 
 Dry gangreners4 
 I^uct cancer, 837, 841 
 ,^ papilloma. 837^ 
 
 r, splint, 460 
 
 Dura mater, injuries of. 638 6,r 
 sarcoma of, 67c ^ ' ^^' 
 
 ^ysZtT^I,^^-^^^^^'"^ epilepsy, ess 
 Dyspnoea. Se'e Asphyxia 
 
 Dactyl, ,s. tuberculous 4,8 
 Delormities (Chapter Xin o 
 ^ m rickets, 488 ^^^•^■348-385 
 
 Degeneration, cysts of, I „ 
 m arteries, 223 ^^ 
 m nerves, 299 
 nehrmm tremens! i8g ,0, 
 ent.gerous cysts IOC ' ^^i 
 epressedfractur;s^|;7°^ 
 ermatitis maligna '82^," 
 
 J'iabeteri044 ^^^ ^>'^'^ 
 
 S^Sg-ss - ,, 
 
 Dilatation o^c^re^orffir^e'/^^.'/^^ 
 of oesophagus 767 ' 7^5,768, 864 
 of pylorus, 867 
 of rectum, 981; 
 o[ urethra, 1078 
 
 [ ofspme, 59r*^ ''-''502-535 
 
 pissecting aneurism, oo. 
 
 [,=43, 4 ' °' ^"''""'"^' ^36, 242, 
 "'istension of War?^ 
 1036. 1038 ^'^^^'' ^"h overflow. 
 
 Jsiinited fracture, 407 
 
 Ear.^afrections of (Chapter XXVII.), ,,0- 
 Kcchondroses, 123 
 
 i^ChmocoCCUS t-Y^n,., 
 
 Kcthyma, 1x31 "^' '51. 272, 909 
 
 |caa;?i--3 
 
 ,, varicose, 47, I7- '' ''''5 
 Kczematous ulcVr, 48 
 J-'ggshell crackling .n, 
 706 ""^' 497, 500, 675, 699. 
 
 E-lbow.joint. acute arthriti, nf 
 
 amputation through x^^' ^"'^ 
 ankylosis of. r7i ^ ' "45 
 
 dislocations at. cjs 
 effusion into, ^^7 
 excision of, 580 
 
 i'-mboli, 272 od o^ 
 
 EmbolicgL'g?^^^,^3^^-23o.23r.393 
 Embryonic tissue, c ,0 
 l^-mphysema, surgi^j^° « ^ 
 
 875 ^"^''408.675,785,813, 
 
 ^-mpyema, 816, 813, 617 o. 
 
 of antrum, 698 '^' ^^°' 907 
 
 Pn. °V'"?n'al sinuses, 676 
 Encephalitis. 6?^) 6;. ^ 
 Kncephalocele.^l^o •'■^ 
 ^;ncephaloid cancer, 144 o,, 
 t^ncysted hernia. 928 ^^' ^-^^ 
 hydrocele of cord i-q „, 
 
 olrrn'^r^' '^« "06"°^ 
 
 Kn.i-to-en1;rstoSS' '^^' "°8 
 ^-ndarteritis. 23 62 "'^^"'^ 884 
 
 X132 ^' ^2- ^07. 220, xi3r. 
 
 Endocarditis, infective o^ 
 
 74 
 
II70 
 
 INDEX 
 
 m 
 
 Enterectomy, 883, 850, 876, 878, 879, 
 
 954. 958. 967 
 F".nteritis, acute, 873, 955 1 
 
 Knterocele, 924 . • •.' i 
 
 Enteroliths, 964 
 Enteroplasty, 883, 878 
 Eriteroptosis, 1002, 934 
 Enterorrliaphy, 884 
 Enterostomy, 883, 966 
 Enterotome, Dupuytren's, 958 
 Enterotomy, 882 
 
 Epididymitis, 1096, 1077, 1097, 11 19 
 Epilepsy, traumatic, 665 
 Epiphysis, separation ot, 389 
 Epiphysitis, 474, 481, 487 
 Epiplocele, 924 
 Epispadias, io68 
 Epistaxis, 727, 408 
 Epithelioma, 139 
 
 after lupus, 328 
 
 branchial, 781 • . 
 
 of anus, 987 ■ ' 
 
 of bladder, 1033 ' 
 
 of glands in neck, 783 
 
 of gum, 697 
 
 of jaw, lower, 707 
 upper, 701 
 
 of larynx, 801 
 
 of lip, 692 
 
 of nipple, 825 
 
 of nose, 723 
 
 of oesophagus, 766 
 
 of palate, 756 
 
 of penis, 1089 
 
 of pharynx, 761 
 
 of scalp, 669 
 
 of scar, 177 
 
 of tongue, 736 
 
 of tonsil, 759 
 Epulis, 696, 127 ■ . •. . 
 
 Erethitic shock, 185 
 Ergot, gangrene from, 64 
 Erysipelas, 83, 757, 11 14 
 
 curative action of, 87, 125 
 Erythema nodosum, 86 
 F'.stlander's operation, 818 
 P'ther, administration ot, 1159 
 Ethmoid, diseases of the, 719 
 Eucaine, 1158 
 Excision of joints, 581-588 
 
 for acute arthritis, 546 
 
 for ankylosis, 571 
 
 for dislocations, 510 
 
 for fractures, 392, 428 
 
 for tuberculous disease, 553 
 
 of breast, 845 
 
 ofcondyleof jaw, 710 
 
 of Gasserian ganglion, 310 
 
 of larynx, 803 
 
 of mandible, 707 
 
 of maxilla, 702, 723. 724, 
 
 of parotid gland, 746 :v 
 
 of pylorus, 868 
 
 of rectum, 989 
 
 of rib for empyema, 818 
 
 Excision of rib for sub-phrenii 
 861, 908 
 of stomach, 866 
 of thyroid, 791, 794 
 of varicocele, 1108 
 Exclusion of intestine, 880 
 Exomphalos, 942 
 Exophthalmic goitre, 792 
 Exophthalmos (proptosis), 244, 
 
 643. 698,792 
 Exostoses, 129, 674 
 Exostosis bursata, 129 
 of ear, 771 
 of first rib, 246 
 subungual, 130 
 Expansion of bone, 479, 496, 5c 
 Extension of leg, 444 
 
 in hip-joint disease, 57 
 External carotid, ligature of, 
 
 759. 762, 785 
 External popliteal nerve, affei 
 
 321 
 Extirpation of aneurism, 237 
 Extracapsular fracture of femur 
 
 of humerus, 420 
 I'^.xtradural abscess. See i 
 
 abscess 
 Extragenital chancres, 1126 
 Extra-medullary haemorrhage 
 
 599 
 Extravasation of urine, 1084, ic 
 
 1038, 1056, 1069 
 Extroversion of bladder. See 
 
 vesicae, 1023 
 Exudation cysts, 149 
 
 Facial artery, compression of, 
 
 ligature of, 257 
 Facial cleft, oblique, 689 
 nerve, affections of, 311 
 
 operation on, 313 
 paralysis, 311, 634, 745, 77 
 tic, 313 
 
 Facies Hippocratica, 853, 949, 
 Foecal fistula. See Fistula 
 Faeces, impaction of, 967 
 False joints, 405, 508 , 
 
 passages, 1075 
 Faraboeuf's amputations, 1144, 
 Farcy. See Glanders 
 Fat embolism, 392 
 Fatty hernia, 126, 944 
 
 tumour. See Lipoma 
 t'emoral artery, aneurism of, 
 cotupression of, 205 
 ligature of, 265, 250 
 hernia, 939 
 
 strangulated, 957 
 Femur, fractures of, 438 
 
 separation of lower epiphy 
 upper epiphysis o 
 P'ever, 9, 187 
 Fibrin ferment, 10, 187, 198, 2 
 Fibroblasts, 5, 172, 195 
 Fibro-cystic disease of jaw, 706 
 
5ion of rib for sub-phrenic abscess 
 
 86i, 908 
 of stomach, 866 
 of thyroid, 791, 794 
 of varicocele, 1108 
 usion of intestine, 880 
 Tiphalos, 942 
 ohthalmic goitre, 792 
 ahthalmos (proptosis), 244, 305. 633, 
 3, 698, 792 
 ■toses, 129, 674 
 
 itosis bursata, 129 ' 
 
 of ear, 771 
 of first rib, 246 
 subungual, 130 
 ansion of bone, 479, 496, 500 
 insion of leg, 444 
 
 in hip-joint disease, 578 
 :rnal carotid, ligature of, 255. 211 : 
 19, 762, 785 ^ • f 
 
 ;rnal popliteal nerve, affections of, 
 '.I 
 
 rpation of aneurism, 237 
 acapsular fracture of femur, 440 
 
 of humerus, 420 
 radural abscess. See Subcrani 
 jscess i 
 
 ragenital chancres, 1126 I 
 
 ra-medullary haemorrhage, spina!) 
 10 
 
 669. 
 
 .0 
 
 '9 . . o 
 
 ravasation of urme, 1084, 1025, 1031 
 
 J38, 1056, 1069 
 
 reversion of bladder. See Ectopj 
 
 jsicae, 1023 
 
 idation cysts, 149 
 
 ial artery, compression of, 205 
 
 ligature of, 257 
 ial cleft, oblique, 689 
 nerve, affections of, 311 
 
 operation on, 313 
 paralysis, 311, 634, 745, 772 
 
 tic, 313 
 
 lies Hippocratica, 853, 949, 961 
 cal fistula. See Fistula 
 ces, impaction of, 967 
 se joints, 405. 508 , 
 passages, 1075 
 
 aboeuf's amputations, 1144, 1148, 
 cy. See Glanders 
 embolism, 392 
 ty hernia, 126, 944 
 tumour. See Lipoma 
 noral artery, aneurism of, 250 
 compression of, 205 
 ligature of, 265, 250 
 hernia, 939 
 
 strangulated, 957 
 nur, fractures of, 438 1 
 
 iparation of lower epiphysis of, I 
 upper epiphysis of, 446 1 
 187 ' 
 
 set 
 
 ,rer, 9, 107 
 
 »rin ferment, 10, 187, 198, 213 
 
 troblasts, 5. 172, 195 
 
 »ro-cystic disease of jaw, 706, 135 
 
 Fibrous union Ar r ' ^^ 
 
 chancreof. „26 ""''3 
 deformities of, org 
 fissure of anus, 983^-^ 
 
 aerial, 786 
 
 Miliary. 851. 9„. 
 
 b'mucosa, 856 877^ 
 
 branchial. 780' ^^ • 
 
 fecal, 851. 856, 87, «,, 
 
 . 956, 959 ^ • ^3' ^77, 900, 904, 
 
 -in-ano, 980 
 
 median cervical, 782 
 
 oesophageal, 786 
 
 penile, 1119 ' 
 
 perineal, iqcq ^oa 
 
 10S5 ^' ^°73. 1083 
 
 recto-vesical. 103.. io„ 
 salivary, 747 ■^^' ^°5S 
 
 umbilical, 851 
 
 'oating kidnev, looi 
 
 spleen, 916 
 ''uctuation, oj o, 
 oetal residues, 116 
 oot, amputation of, urn 
 ' contusions of, 162 ^ 
 
 deformities of, 060 
 "•cipressure, 199 "^ ^ 
 
 S?hn!I^P"^^^'°" through 11^. 
 •reign bodies in air-passage^' l'^^ 
 
 .m appendix, 897^^ ''7^5, 796 
 
 in bladder, 1026 
 in ear, ^^i 
 in hernial sac, qar 
 .m intestine, 96, ^ 
 in nose, 715 
 m oesophagus, 76, 
 m stomach, 8<:o 
 in urethra, 1070 
 i"n nerve, paralvsis of --/: 
 
 "al lobes, njuries of «? ^ 
 
 --3.Wti;-5:^4^^^^^ 
 
 '"c'e. SeeIioiI,322, 
 aneurism, 226 ^ 
 
 1171 
 
 1083, 
 
 Galactocele, 830 
 
 Ganglion, 34^"' ^^^ 
 
 Gangrene (Chapter IV ) „,, 
 after aneurism, 23o^'/i-7^ 
 
 [-•on. nfptSof aTter?""'"^' ^'' '53 
 fro.'" splint press^ire ■«> '5 
 of intestine, 947 'qcV^^'^°3 
 of Jung, 819 ■*^' ^•5'»' 967. 970 
 
 gastric ulcer, Sw 
 »-»astrocnemiiic - 
 
 Gastro-ereSonlP'S'^S^^^ 
 
 Sstnf '"'"y- 768^864''' '° 
 ^astrotomy, 765, 860 
 
 Genu recurvatum 361 ' 
 valgum, 363 f^^ 
 varum, 367 ^^ 
 
 ^S-dS";r "'■ '«. 3.8. 465 
 
 «f«, ...6. ,„8'' "' 
 
 Glossitis, 732 
 
 ^^'-o-P'^aryngea, nerve, affections 
 Gluteal artery, aneurism of, ,,, 
 haemorrhage from 212 
 P .^ 'igature of 26^ 
 Goitre, 786 ' ^^3 
 
 (jonococcus in r. 
 Go„orrhM%°',' «■• S«, 852, ,,,5 
 
 Graves' disease, 7™ 
 Growth ofbone, 463 '^3 
 
 of abdomen, 166 
 
 °^'"ng, 814 
 
 of skull, 637, 660 . 
 
 of, 
 
 of abdominal walls. 848 
 01 ear, •^yo '* 
 
 Hematuria, 1041, X047 
 
 74—2 
 
 tltM^Jm 
 
1172 
 
 INDEX 
 
 Haemoglobinuria, 63, 1041 
 Haemophilia, 213 
 
 joints in, 566 
 Haemoptysis, 191, 812 
 Hremorrliage (Chapter VIH.), 190-213 
 
 during amputations, 1142 
 at hip-joint, 1154 
 
 from catheterism, 1076 
 
 reactionary, 206 
 
 secondary, 207 
 
 special sources of, 211 
 Haemorrhoids, 992 
 Hnemothorax, 812 
 Hahn's tracheotomy-tube, 739, 808 
 Hallux valgus, 381 
 Halsted's operation for hernia, 939 
 
 suture, 882 
 Hammer-toe, 382 
 
 Hammond's splint for fracture of man- 
 dible, 412 
 Hand, amputations of, 1145 
 
 deformities of, 358 
 Hare-lip, 682 
 
 Head injuries (Chapter XXH.), 628-666 
 Healing of wounds, 171 
 
 by granulation, 174 
 
 by organization of blood-clot, 176 
 
 under a scab, 176 
 Heart, wounds of, 820 
 Heat in treatment of inflammation, 21 
 Heat-stroke, 650 
 
 Hectic fever, 37, 77, 544, 551, 577, 619 
 Hernia (Chapter XXXH.), 921-959 
 
 cerebri, 639, 664 
 
 en-bissac, 930, 952 
 
 fatty, 126, 931, 944 
 
 femoral, 939 
 
 inguinal, 925 
 
 interstitial, 930, 952 
 
 of lung, 815 
 
 strangulated, 946 
 
 testis, 1 100 
 
 umbilical, 942 . "• 
 
 ventral, 904, 943 
 Herpes labialis, 691 ■ ' '■; 
 
 in neuralgia, 303 •' '■''■' 
 
 preputialis, 1088 
 
 zoster, 319 
 Hey's amputation, 1149 
 
 saw, 639 
 Hilton's method of opening abscess, 33 
 Hip-joint, acute arthritis of, 474, 547 
 
 amputation through, 1154, 579 
 
 ankylosis, 571, 572 . . .- 
 
 congenital dislocation of, 503 
 
 di'-'ications of, 523 
 
 effusion into, 537 ■ J 
 
 excision of, 585, 579 
 
 osteo-arthritis of, 563 '•,•:!;.•'. 
 
 tuberculous disease of, 572 
 Hodgen's splint, 444 ' 
 Hodgkin's disease, 295 
 Horn, sebaceous, 332, 1088 
 Hospital gangrene, 68 >. . . 
 Housemaid's knee, 346 , , - 
 
 Howship's lacunae, 465 
 Humerus, fractures of, 419 
 
 separation of lower epiphysis, 
 upper epiphysis, 421 
 Hunterian chancre, 1125 
 
 ligature for aneurism, 235 
 Hunter's canal, ligature of lemoral| 
 
 in, 266 
 Hydatid cysts, 151 
 
 of bone, 500 
 
 of brain, 677 
 
 of breast, 832 
 
 of kidney, 1018 
 
 of liver, 909 
 
 of limg, 819 
 
 of Morgagni, 148, 1107 
 
 of spleen, 916 
 Hydrarthrosis, 542 
 Hydrocele, chylous, 286, iio8 
 
 of breast, 831 
 
 of cord, 149, 1 107 
 
 of hernial sac, 923 
 
 of neck, 783 
 
 of round ligament, 149, 1108 
 
 of tunica vaginalis, 149, 1103 
 Hydrocephalus, 672 
 Hydrogen, peroxide of, 179 
 Hydronephrosis, 1004, 83, 1013, 
 
 1073 
 Hydrophobia, loi 
 Hydrops antri, 700 
 
 articuli, 542 
 
 of frontal sinuses, 676 
 Hygroma, 286, 782, 610 
 Hyoid, fracture of, 413 
 Hyperostoses, 130 
 Hypertrophy of bone, 493 
 
 of breast, 834 
 
 of gums, 69s 
 
 of prostate, io6r 
 Hypoglossal, injury to, 314 
 Hypospadias, 1068 
 Hypostatic pneumonia, 402, 439 
 Hysteria in spinal injuries, 601 
 Hysterical joints, 368, 569 
 
 Ileo-colostomy, 878, 880 
 Iliac abscess, 621 
 
 aneurism, 248 
 
 colotomy, 894 
 
 vessels, ligature of, 262, 249 
 Immunity, 15 
 Impacted calculus in urethra, 1070 
 
 faeces, 967 
 
 fracture, 389 
 
 gall-stones, 913, 914 
 Impassable stricture, treatment of, k 
 Imperforate anus, 976 
 Impermeable stricture of urethra, 10; 
 Implantation cysts, 150 
 Incised wounds, 156 
 Incontinence of urine, 1035, 604, 61; 
 Infantile hernia, 928 
 
 hydrocele, 1104 . ' 
 
 paralysis, 626 . •- ... 
 
lip's lacunas, 465 • • .'. 
 
 rus, fractures of, 419 
 
 paration of lower epiphysis, 427 
 
 upper epiphysis, 421 
 nan chancre, 1125 
 ature for aneurism, 235 
 r's canal, ligature of lemoral artery 
 00 
 
 d cysts, 151 . . 
 
 bone, 500 
 
 brain, 677 . 
 
 breast, 832 
 
 kidney, 1018 
 
 liver, 909 
 
 lung, 819 . 
 
 Morgagni, 148, 1107 
 
 spleen, 916 
 
 throsis, 542 
 
 ele, chylous, 286, iio8 
 
 Jreast, 831 
 
 :ord, 149, 1 107 
 
 lernial sac, 923 
 
 lack, 783 
 
 ound ligannent, 149, noS 
 
 unica vaginalis, 149, noa 
 
 jphalus, 672 
 
 en, peroxide of, 179 
 
 -Porosis, roo4, 83, 1013, 1063 
 
 lobia, loi 
 
 > antri, 700 
 
 :uli, 342 
 
 ontal sinuses, 676 
 
 a, 286, 782, 610 
 
 racture of, 413 
 
 toses, 130 
 
 )phy of bone, 493 
 
 ■east, 834 
 
 ims, 695 
 
 ostate, 1061 
 
 ssal, injury to, 314 
 
 dias, 1068 
 
 ;jc pneumonia, 402, 439 
 
 in spinal injuries, 6oi 
 
 il joints, 368, 569 
 
 itomy, 878, 880 
 
 :ess, 621 
 
 rism, 248 
 
 omy, 894 
 
 Is, ligature of, 262, 249 
 
 . IS 
 
 calculus in urethra, 1070 
 
 .967 
 
 ire, 389 
 
 tones, 913, 914 
 
 e stricture, treatment of, 1081 
 
 te anus, 976 
 
 ble stricture of urethra, 1072 
 
 ion cysts, 150 
 
 )unds, 156 
 
 ice of urine, 1035, 604. 610 
 
 lernia, 928 
 
 cele, 1104 
 
 sis, 626 . „ ,:, 
 
 infection 78 
 Inferior rjf>n»'>i 
 
 Infra-orbitTne?v^P'''"^)'i-25 
 
 INDEX 
 
 ''75 
 
 See Osteoma 
 
 1 159, 1 160 
 
 ,„ ^^. a- ' 
 
 ^ngrowing toenail „, 
 
 Ingu-nal aneurism! gg 
 colotomy, 894 '*^ 
 nernia, 925 ^ 
 
 Inhalers. 'iSi'"'^' 9S6 
 /"JectionsTg^nS "58. "^9 
 
 Innominate aKterv 'n '"'^ 
 
 , ligature of 2^; ""f^r^sm of. 240 
 
 "operable maii^Smtf 
 
 n'eSs^!""'"^"^ "66'"^^^' "^' ''' 
 
 /"I-SSl^f-rrhagefrom 
 
 ^-ernalcat;5,--SSor2 
 
 ^-rna,fcL°;'i1^" '' 
 
 mammary aSvf'"''" °f' ^63, 
 «gature"f72'S''^'"°"hase. 
 
 , popliteal nervp tw ■ 
 interstitial hernia •o^''"°"« «f. 32: 
 
 keratitis. 1138 -" 
 , njastitis, 828 
 
 Intestinal anastomosis 88, s 
 
 Intracapsular frac „r« r u 
 r, offemfr "S '^"'"^^"^•419 
 
 ^"^■•^'■ranial aneuris'n'' 244 
 inflammation. 6c t m 
 ntraniammaryabscL' ?°' ^75 
 ^ntr^niedullar/ hSrt^e of 
 
 fcSSSJ:;-orrhag, 644 
 Intubation ofTarw'r's.^^-^ 
 ntussusception. So' " 
 
 spine. 
 
 U38 
 
 Inversion o"S",' '^ 
 "volucrum. 468 ' '°5" 
 
 iodoS"xrr^^«3x 
 
 Irreducible hernia^o° • 
 
 '-Satio„ofabdom^^„f8,8,3 
 
 ofchronic abscess 40 
 '-I'abili,yfe'/-i,y. 8xr 
 IrrUableuVer.'i6'''^^'-'^°36 
 
 Ischio-rectal abscess, 978 
 
 ' of. 547 
 1152 
 
 211 
 
 T067 
 
 211 
 
 /""ker;s iSlef J';;;"^. ^'L 778 ' ' ''■ 
 
 Keloid, 177. I 
 
 1001-1022 '^''apterXXXV.l 
 
 amyloid disea.:^ ^i 
 Spley-s 3ptr4%°'' 39 
 
 ^<-e-joi„?^' --;,-^5 
 
 aniputation tl.rou gh 
 ankylosis of, c,/^ ' 
 
 contractions of 068 
 
 5'sIocationsof,'c^,o 
 effusion into, J^ 
 
 I K Obeli's tubes, cvsts m 
 
 148, 149. I, '/^^'S'n connection with. 
 
 Labia, aflections of r^ 
 
 Lacerated wounds, ',6°'° 
 
 Laceration of brain 6^fi 
 
 Lacunar abscess i;,T 
 
 Laminectomy 6' ^ 
 
 . 'n Pott's diseasf. ^o 
 
 Laparotomy for abri'nf^ 
 for^.n^'-JP'^ominM 
 
 intestinal obstruc 
 
 intussusception, c 
 
 perforation of apL 
 
 of stomach, 860 "' ^°''' 903 
 
 , - -iumacn, 860 " ' 
 
 SrSS;;£^^ions.836.86. 
 
 °i:intestine.87^''^,^J;'9ii 
 ofliver,9o5^-5'^^-'^^- 
 ,of stomach, 858 
 
 860, 862 
 
 767, 
 
 . /oruTcerofSacf 8 
 Lardaceous disease S V?''' 
 Larrey's operation!'ii^6 « 
 Laryngeal paralysis ^1 
 
 788. 801 ^ • ^39. 241, 242, 
 stenosis. 800, 810 
 Laryngectomy, 80V 
 Laryngitis, (Edematous fio »< 
 
 p"ngS^c-f^-79l^-«-""""^^^' 
 Laryngotomy, 80^4! 796. 79, 
 
 ,LJJ 
 
1174 
 
 INDEX 
 
 
 •! 
 
 Larynx, diseases of, 799 
 
 foreign bodies in , 796 
 
 injuries of, 784, 798 
 Lateral anastomosis, 890. 880, 915, 959 
 
 curvature of spine. See Scoliosis, 351 
 
 implantation, 880 
 
 sinus, thrombosis of, 777, 93, 96 
 Leg, amputation of, 1152 
 Leiomyoma, 130 
 Lembert's suture, 880 
 Leontiasis ossea, 700 
 Leprosy, in 
 Leucocytes, migration of, 3, 195 
 
 phagocytic action of, 16 
 Leucocytosis, 32 
 Leucoplakia, 733 
 Leukaemia, 294 
 Ligature of vessels, 251-268 
 causing gangrene, 64 
 for haemorrhage, 203 
 Lingual artery, ligature of, 256, 738 
 
 nerve, operations on, 309 
 Lip, affections of, 682-694 
 Lipoma, 125, 609, 626, 932, 941 
 
 arborescens, 126 
 
 diffuse, 126 
 
 nasi, 712 
 
 of femoral canal, 941 
 
 parosteal, 126 
 
 subserous, 126 
 Lisfranc's amputation, 1148 
 Listers amputation, modified flap and 
 circular, 1140 
 supracondyloid, 1153 
 
 antiseptic treatment of wounds, 180 
 dressings, 182 
 
 strong mixture, 179 
 Liston's long splint, 443 
 Lithiasis, 1012, 1039 
 Litholapaxy, 1049 
 Lithotomy, lateral, 1051 
 
 suprapubic, 1056 
 Lithotrity, 1049 
 Littr^'s hernia, 946, 961 
 
 operation, 894 
 Liver, affections of, 904-910 
 
 amyloid disease of, 38 
 Local anaesthesia, 1157 
 Localization of cerebral injuries, 661 
 Loose bodies in joints, 567 
 Lordosis, 357 
 Loreta's operation, 867 
 Lower jaw. See Mandible 
 Ludwig's angina, 82, 741 
 Lumbar abscess, 617, 623 
 
 colotomy, 893 
 
 hernia, 944 
 
 operations on kidneys, 1019, 1022 
 Lungs, affections of, 812-820 
 Lupus, action of erysipelas on, 87 
 
 erythematosus, 329 
 
 vulgaris, 327, 735, 755 
 Lymphadenitis, acute, 288 , . 
 
 chronic, 290 
 Lymphadenoma, 294 
 
 Lymphangiectasis, 285, 690 
 
 Lymphangitis, 284 
 
 Lymphatic glands, affections of, 2fc 
 
 vessels, affections of, 284-288 
 Lymphorrhoea, 287 
 Lympho-sarcoma, 121, 296 
 
 of testis, 1 102 
 
 of tonsil, 759 
 Lymph varix, 285 
 
 McBurney's spot, 899 
 
 Macliwen's operation for hernia, 93I 
 
 osteotomy, 367 
 MacEvven's treatment of aneurismj 
 
 240, 246, 248 
 Macrocheilia, 285, 689 
 Macrodactyly, 359 
 Macroglossia, 285, 732 
 Macrostoma, 689 
 Malar, fracture of, 409 
 Malarial spleen, 916 
 Malignancy, characteristics of, 116 
 Malignant endocarditis, 93 
 
 oedema, 67, 80 
 
 pustule, 103 
 
 ulcers, 51 
 Mallet finger, 360 
 Malpositions ol testis, 1092 
 Mamma. See Rreast 
 Mandible, diseases of, 694, 705 
 
 excision of, 707 
 
 injuries of, 409 
 
 tumours of, 705 
 Mandibular cleft, 689 
 Massage, 24 
 Massage in treatment of fractures, 4 
 
 420, 428, 429, 434, 452, 457, 460 
 Mastitis, acute, 825 
 
 chronic, 827 
 Mastoid disease, 772 
 Maunsell's operation, 884, 973 
 Maxilla, affections of, 694-705 
 
 excision of, 702 
 
 injuries of, 409 
 Meckel's diverticulum, 873, 962 
 Median hare-lip, 689 
 
 nerve, affections of, 317 
 Medulla oblongata, injuries 16, 662 
 
 of bone, inflammation of. Sei 
 Osteomyelitis 
 Medullary cancer, 144 
 Melaena, 191, 996 
 Melanotic sarcoma, 123 
 Melon-seed bodies, 339, 345, 567 
 Meningeal haemorrhage, cerebral, 642 
 
 spinal, 599 
 Meningitis, 652, 68 r, 777 • ' 
 
 spinal, 599, 620 
 Meningocele, 608, 669 \ 
 
 Meningo-myelocele, 607 
 Mercurialism, 697, 732, 1135 
 Metacarpals, dislocation of, 522 
 
 fracture of, 435 
 Metastasis, 19, 743, 1093 
 Metatarsalgia, 384 
 
 k. 
 
angiectasis. 285, 690 
 
 angitis, 284 
 
 atic glands, affections of, 288-206 
 
 ;sels, affections of, 284-288 . 
 
 orrhcea, 287 
 
 o-sarcoma, 121, 296 
 
 estis, II02 
 
 ;onsiI, 759 
 
 varix, 285 
 
 ley's spot, 899 
 
 2n's operation for hernia, qqB 
 osteotomy, 367 
 
 2n's treatment of aneurism. 2^8, 
 
 46, 248 "^ 
 
 leilia, 285, 689 
 
 'Ctyly. 359 
 
 ossia, 285, 732 
 
 3nia, 689 
 
 acture of, 409 
 
 spleen, 916 
 
 icy, characteristics of, 116 
 
 It endocarditis, 93 
 
 Tia, 67, 80 
 
 lie, 103 
 
 s, 51 
 
 iger, 360 
 
 ons ot testis, 1092 
 
 See Breast 
 , diseases of, 694, 705 
 on of, 707 
 es of, 409 
 
 ns of, 705 ; 
 
 ir cleft, 689 
 24 
 
 n treatment of fractures, 400 
 ' 429. 434. 452, 457. 460 
 cute, 825 
 c, 827 
 sease, 772 
 operation, 884, 973 
 fections of, 694-705 
 n of, 702 
 s of, 409 
 
 verticulum, 873, 962 
 re-lip, 689 
 affections of, 317 
 longata, injuries to, 662 
 le, inflammation of. See 
 >myeliiis 
 cancer, 144 
 I, 996 
 
 ircoma, 123 
 bodies, 339, 345, 567 
 
 laemorrhage, cerebral, 642 
 lal, 599 
 
 552. 68 r, 777 
 i99, 620 
 
 , 608, 669 \ 
 
 elocele, 607 
 I. 697, 732, 1 135 
 dislocation ot, 522 
 of. 435 
 9. 743. 1095 
 >. 384 
 
 Microcephaly, 67, 
 Micrococci, 12 ^^ 
 
 VJ?5';°s'0"ia. 689 
 Middle turbinar^H k 
 
 Moveable kS'ey 1^^° 
 
 Mucous CVSte ^ /. 
 
 niemiaJes 7fjH^9x, 1^^ 
 
 330 ' '"^^"-^"'ous disease of, 
 
 polypus, 720 
 
 MulJ^rrrcSuluTxS "^^^ "34. x.^y 
 >J"'nps, 742, 1095 
 Murphy's button, 887 
 
 Ma"sSlsS'Se°'r33« 
 Mye'itis. sS,To • '"'^'^"""^ °^' 3x5 
 Myelocele, 607 
 
 Myeloid sarcoma, 122 ^n, « 
 
 Myoma, 130 ' "''' -^97. 675, 697. 706 
 
 Myo-sarcoma, 122 rnr^ 
 
 Myositis ossificans\°8^. 
 Myxoedema, 702 ^nr' "^^^ 
 Myxo-lipo„,'aff,'6'»95 
 
 Myxoma, ns 
 
 INDEX 
 
 Nerve grafting, 30, 
 stretching, 304 
 suture, 300"'^ 
 
 PiS;^^^'^^305-32r 
 injuries of, 297 ^^' '^7. 298 
 tumours of, i^r 
 Neuralgia. 231.' 30^3 
 
 of joints, 569 
 
 o* testis, 1 1 10 
 
 trigeminal, 306 
 
 Neuritis. 30^ ^ ^ 
 Neuroma, 131 
 Neurotomy, 304 
 
 Nose, affections ofTh°? 
 729 ^ °' (Chapter XXV. ), 7„. 
 
 o"fW 
 of scalp, 668 
 of tongue, y^e 
 
 Nails" "'I' '^J^""' ^80 
 i^aiis. See Onychia 
 
 Neck =.ff V ' °'seases of, 722 
 
 <'f^o«e.403.^64,46,„6,,4„,,„. 
 
 of jaw, 697 
 
 of ossicles, 772 
 
 of palate, 755 
 
 of temporal bone, 770 
 
 Xilsan's line, 44, 
 
 Obstructed hernia, 946 
 
 "T:^s£^-of,205 ^ 
 
 g^^wyers tub^fir ^°' 
 O-^dema, malignant, 67, 80 
 
 ^ot"" ^- ^-y^g'tis. cdema- 
 of scrotum, m. 
 Ui;,ophagus. affections of ^a 
 
 Ogston's operation ?o7fl°a';.o'o't ,8z ' 
 0;-anon:°fS^-3^^4 ' ^^^ 
 
 &^SS^>-'^305 
 
 hernia, 924, 935^ 
 
 tumour, 855, 856 
 Onychia. 33r '^ 
 
 Oophorect ->rv,v. for r.c.»^ 
 
 ^ in canc..^of breast fi?'""'^"'^' 493 
 Operations, genSrTI'J'^^ ■ 
 
 for, isf ^' antiseptic methods 
 
 Opiic nerve, „fe,i„„5„. 
 
 Orchitis, 1095 
 
 Os calcis, fracture of, 461 ' 
 
 incisrr6t3?^68r6?°M8o 
 
 Ossic7ern"™'^'^'°'^^^'°"5522 
 ^ssjcjes, necrosis of. 772 ^ 
 Osteitis, 464, 466 ' ^^'^ 
 
 deformans. 490 
 
 tuberculous, 478 
 
 St 
 
1 176 
 
 INDEX 
 
 Osteo-aneurism, 500 
 Osteo-artliriti;, 558, 543 
 
 of hip, 563 
 
 of spine, 626 
 
 of temporo-maxillary joint, 564, 709 
 Osteo - arthropathy, hypertrophic pul- 
 monary, 496 
 Osteoblasts, 404, 463 
 Osteo-chondritis, syphilitic, 487 
 Osteoclasia, 408 
 
 Osteoclasts, 465 ■ . 
 
 Osteoma, 129 
 
 of antrum, 700 <■ • 
 
 of lower jaw, 705 ; . 
 
 of skull, 674 
 
 of upper jaw, 700 
 Osteomalacia, 493 ' ' ' 
 
 Osteomyelitis, 469, 474 .1 
 
 gummatous, 486 
 
 of cranium, 673 .' . 
 
 of spine, 611 
 Osteo-periostitis, chronic, 475 
 Osteoplastic section of upper jaw, 724 
 Osteophytes, 545, s.so, 560, 565, 570, 574, 
 
 626 
 Osteo-sarcoma. See Sarcoma of bone, 
 
 496 
 Osteotomy, 363, 366, 369 
 
 for ankylosis, 369, 571 
 
 for genu valgum, 366 
 Otorrhcca, chronic, surgical complications 
 
 of, 772 
 Ovarian cysts, 148, 149 
 
 dermoids, 147 
 Oxalates, 1039, 1045 
 Ozcena, 717 
 
 Pachydermatocele, 133, 669 
 Pachymeningitis, 600, 651 
 Paget's eczema of nipple, 825 
 Pain in burns, 71 
 
 in gangrene, 53, S7. 61 
 
 in mflammation, 8 
 
 in Pott's disease, 613 
 Painful scar, 133, 177 
 
 stump, 1 143 
 
 subcutaneous nodule, 132 
 Palate, cleft, 748 
 
 diseases of, 754 
 Palmar abscess, i;i 
 
 arch, haemorrhage from, 212 
 
 ganglion, compound, 340 
 Pancreas, affections of, 915 
 Panophthalmitis, following cellulitis of 
 
 orbit, 82 
 Panostitis, 469 
 Papilloma, 135 
 
 of bladder, 1032 
 
 of breast, 837 
 
 of kidney, 1017 
 
 of larynx, 801 
 
 of nipple, 825 1 
 
 of rectum, 987 ■ 1 
 
 of scalp, 663 
 Paracentesis abdominis, 857 "• 
 
 Paralysis, infantile, 626, 349, 
 
 374 
 
 of gut, 854, 912, 952, 955, 9I 
 
 of larynx. See l^aryngeal [I 
 Paraphimosis, 1087 
 Paraplegia, 602 ,' 
 
 bedsores in, 66 .' 
 
 gravitation, 599 
 
 in Pott's disease, 618, 625 
 Parasitic cysts, 150 
 Parenchymatous goitre, 788 
 
 inflammation, 19 
 I'aronychia, 170 
 
 Parotid gland, affections of, 742] 
 Parovarian cysts, 149 
 Parrot's nodes, 487 
 Pasteur's treatment of hydrophol] 
 Patella, dislocation of, 529 
 
 fractures of, 450 
 Pathogenic bacteria, 14, 78 
 Pelvic cellulitis, 83, 1025, 1034, i 
 Pelvis, fractures of, 435 
 Penis, affections of, 1086 
 Perforating ulcer of duodenum, 7 
 
 of foot, 326 
 Perforation of appendix, 899, 90( 
 
 of gastric ulcer, 859 
 
 of intestine, 876 
 Perforations of palate, 755 
 Pericardial effusion, 820 
 Pericranial lipoma, 126 
 Perineal abscess, 1083 
 
 cystotomy, 1026, 1030, 1035, 
 
 fistula, 1059. 1067, 1073, 108; 
 
 section, 1082 
 Perinephritic abscess, 1009, 
 
 loio, 1013 
 Perinephritis, 1009 ■ 
 
 Periosteal sarcoma, 498 ■. 
 
 Periostitis, acute, 467, 469 
 
 albuminosa, 469 
 
 chronic, 475, 484 
 
 tuberculous, 477 
 Periproctitis, 978 
 Peritonism, 854, 920 
 Peritonitis, 853, 899, 955, 965 
 
 tuberculous, 856 
 Perityphlitis, 896 
 Peroneal artery, ligature bf, 268 
 Peronei, tenotomy of, 342 
 Peroneus longus, dislocation of 
 
 of, 335 
 Pes cavus, 381 
 PetechioB, 91. 190 
 Phagedena, 68, iia6 
 Phagocytosis, 16 
 Phalanges, amputation of, 1143 
 
 dislocation of, 522 
 
 excision of head of, 384 
 
 fractures of, 435 
 Phantom tumour, 851 
 Pharyngotomy, subhyoid, 802 
 Pharynx, afiections of, 760 
 Phelps's box, 622 
 
 operation (talipes), 378 
 
 1003 
 
 4 
 
ilysis, infantile, 626, 349, 368, 370, 
 
 374 
 of pt. 854. 912. 952. 955, 961. 964 
 oJ larynx. See Laryngeal paralysis 
 iphimosis, 1087 
 iplegia. 602 
 bedsores in, 66 .■ 
 gravitation, 599 
 in Pott's disease, 618, 625 
 sitic cysts, 150 
 nchymatous goitre, 788 
 inflamniation, 19 
 
 nychia, 170 v 
 
 tid gland, affections of, 742 
 varian cysts, 149 
 3t's nodes, 487 
 
 :ur's treatment of hydrophobia, 102 
 la, dislocation of, 529 
 ractures of, 450 
 Jgenic bacteria, 14, 78 
 : cellulitis, 83, 1025, 1034, 1055 
 >, fractures of, 435 
 , affections of, 1086 
 rating ulcer of duodenum, 72, 872 
 
 of foot, 326 
 ration of appendix, 899, 900 
 f gastric ulcer, 859 
 f intestine, 876 
 ations of palate, 755 
 rdial effusion, 820 
 anial lipoma, 126 
 !al abscess, 1083 
 'stotomy, 1026, 1030, 1035, 1065 
 itula, 1039, 1067, 1073, 1083, 1085 
 ction, 1082 
 
 phritic abscess, 1009, 1003, 1006 
 ), 1013 
 :phritis, 1009 
 teal sarcoma, 498 
 litis, acute, 467, 469 
 auminosa, 469 
 ronic, 475, 484 
 berculous, 477 
 jctitis, 978 
 lism, 854, 920 
 litis, 853, 899. 955, 965 
 aerculous, 856 
 ihlitis, 896 
 
 al artery, ligature bf, 268 
 i, tenotomy of, 342 
 us longus, dislocation of tendon] 
 35 
 
 'US, 381 
 
 oe, 91, 190 ' 
 lena, 68, iia6 
 
 ytosis, 16 •• 
 
 ?es, amputation of, 1143 
 location of, 522 
 ision of head of, 384 
 ;;tures of, 435 
 Ti tumour, 851 
 jotomy, subhyoid, 802 
 c, afiectiona of, 760 
 i box, 622 
 ration (talipes), 378 
 
 INDEX 
 
 I'lcric acid in r^.r^^ ' 3^4 
 
 Pponbreast,'489 "'°''"^"^'73 
 lies, 992 ^ y 
 
 ' neumectomy, slo - 
 neumocele, 815 
 
 ^ neumotomy. 810 ' • 
 
 oisoned wounds, 168 
 o ydactylism, 358 
 
 '•olypusofantru'm.7oo 
 of ear, 772 ' 
 
 of nose, 720 
 
 artery. ligature of 266 
 
 I ost-mortem wounds. '169 
 
 I I otts disease, 842 ^ 
 fracture, 457 
 
 I . puffy tumour, 6t;2 
 
 roctitis, 977. X120 
 
 irolapseofanus, 998 
 
 o';ntestine.85o. 896 
 °[ Jung. 816 ^ 
 
 , of rectum, 998 
 
 'rostate affections of, rocs T^« 
 , senile enlargement nf^ i^^^ 
 
 J^;ectivealbum'e?sy°'^ 
 rotozoa, 12 
 
 'seud-arthrosis, 401- roo 
 
 S^SSS^^- - V 
 
 SaK^^»487 • •; 
 
 fsoriasislinguJf73f"^^3.94i 
 
 , syphilitic, n,i 
 
 fsorosperms, 12, ros ' 
 
 itomaines, 15 
 
 ''°^.'S' 305 . . , ' 
 
 "bic dislocation of hip ^28 
 
 ■^' -Vi/--^'^ fro™, ,... 
 
 , ligature of, 264 
 
 Py disease of synovial membrlne. 548 
 
 1 177 
 
 ''"'sating exophthalmos. 24c 
 tumours of bone. 5^0 **^ 
 n of scalp, 667 
 
 'Punctured fractu;e of skull 6,= 
 wounds, 163 "• ^35 
 
 of chest, 813 
 
 of heart, 820 
 
 i'.,c • intestine, 871: 
 
 ' "Sin acute abscess i 
 
 m chronic abscess. 36 ' 
 
 '•"stSe'^PCfcr- 9°7 
 ''y^^mia, 9206 8^"f' P-stule 
 
 •^74- Sxo'74'; 1% X' 76. 403. 471. 
 
 995. 1009 ^^' ^'^^ 777, 906, 
 
 y'orus, affectfo'ns S'sr- ^°'' ^^^ 
 ' yogemc membrane, .6 
 ,, organisms, 28 
 
 yonephrosis, 1008 
 
 ^ yuria, 1042 
 
 Quilled suture, 158 
 
 Quincke's lumbar puncture fi- 
 Quinsy, 756 HU'iccure, 654 
 
 Rabies, loi 
 
 fracture of, 430 
 
 R«"*.?'s''p!:°=';S''--pip^y3,-,,,3, 
 
 Kanula, 742 , 
 
 Rarefaction of bone 463 ,«. 
 
 Rashesofsyphi,i3^V2?'^^5 
 ^ay fungus, 113 
 
 Raynaud's disease. 6, 
 
 Reaction, 184, 646 ^ . 
 
 ,'ibroid, 122, 8,7 ■ 3*=' S°7> 5I> 
 
 Repair of bone after caries Afir « . 
 
 after fractures. 39^2; '^''^5 
 
 ofmSS;"S--.4S''4Sf473 
 
 L 
 
II78 
 
 INDEX 
 
 Repair of tendon, 335 
 
 of wounds, 171 
 Resection. See Kxcision 
 Residual abscess, 37, 619 
 Respiration, artificial, 823 
 Retained testis, 1091 
 Retention cysts, 150, 830, 
 
 of urine, 1037, 1063, io8r 
 Retro-peritoneal abscess, 860, 900 
 
 pharyngeal abscess, 616, 762 
 Rhabdomyoma, 131 
 Rhagades, 1137 
 Rheumatic arthritis, 540, 543 
 Rheumatic gout. See Osteo-arthritis, 558 
 
 spondylitis, 625 
 
 synovitis, 540 
 Rheumatoid arthritis. See Osteoarthritis, 
 
 558 
 Rhinitis, 715, 1120, 1137 
 Rhinophyma, 712 
 Rhinoplasty, 712 
 Rhinoscopy, 714 
 Ribs, fracture of, 413 
 Richter's hernia, 946. 950 
 Rickets, 488, 351, 356, 362, 363, 369 
 Riggs's disease, 695 
 Rigor, 31 
 
 Robson's (Mayo) bobbin, 889 
 Rodent ulcer, 141 
 
 Rontgen X rays, 164, 391, 425, 476, 1014 
 Rouge's operation, 724 
 Round-celled sarcoma, 120 
 Rupia, 1 131 
 Rupture. See Hernia 
 Rupture of aneurism, 231 ' 
 
 of bladder, 1024 
 
 of gall-bladder, 910 
 
 of intestine, 874 
 
 of liver, 904 
 
 of main artery, 214 
 
 of muscles, 335 
 
 of nerves, 297 
 
 of rectus abdominis, 851 
 
 of spleen, 926 
 
 of stomach, 857 
 
 of urethra, 1069, 1084 
 
 Sacculated aneurism, 228 
 Sacral tumour, congenital, 610 
 Sacro-iliac disease, 580 
 Sacrum, fractures of, 437 
 Salivary calculus, 744 
 
 fistula, 748 
 
 glands, affections of, 742-748 
 Salivation in mercurialism, 1135 
 Saphena, varix of, 276, 941 
 Saproemia, 77 
 Sarcoma, 1 19-125 
 
 after fractures, 307 
 
 curative action of erysipelas on, 88, 
 
 125 
 
 of bladder, 1033 ' 
 
 of bone, 496 
 
 of brain, 677 - 
 
 of breast, 837 • 
 
 Sarcoma of cranium, 674 
 
 of jaws, 697, 700, 701, 707 
 
 of kidney, 1017 
 
 of lymphatic glands, lai, 396 
 
 of muscle, 338 
 
 of naso-pharynx, 722 
 
 of nose, 723 . • ' 
 
 of palate, 755 
 
 of parotid, 745 
 
 of rectum, 987 
 
 of scalp, 669 
 
 of skull, 674 
 
 of spine, 626 
 
 of testis, 1 102 
 
 of thyroid, 794 ■ 
 
 of tonsil, 759 
 Sayre's treatment of fractured clavic 
 Scalds, 71 
 Scalp, affections of, 666 
 
 injuries of, 628 
 Scapula, fractures of, 418 , . 
 
 winged, 314, 513 
 Scar, affections of, 177 
 Schede's operation, 818 
 Schwartze's operation, 773 
 Sciatica, 319, 580 
 Sciatic artery, htemorrhage from, 21 
 ligature of, 264 
 
 dislocation of hip, 526 
 
 nerve, stretching of, 320 
 Scirrhous ulcer, 840 
 Scirrhus, 144 
 
 of breast, 829, 838 
 
 of pancreas, 916 
 
 of prostate, 1067 
 
 of pylorus, 868 
 Sclerosis of bone, 465, 476, 485 - 
 Sclerotitis, gonorrhoual, 1121 " 
 
 Scoliosis, 351 
 Scrotal tumours, iiii 
 Scrotum, affections of, 1 113 
 Scurvy rickets, 491 
 Sebaceous cysts, 332 
 
 of neck, 783 , 
 
 of nipple, 825 
 of scalp. 669 
 Sebaceous glands, cancer of. See R( 
 ulcer 
 
 horn, 332, 1088 
 Secondary haemorrhage, 207 
 Semilunar cartilage, dislocation 
 
 568 
 Semimembranosus, tenotomy of, 34^ 
 Senile atrophy of bone, 438, 492, 67 
 
 gangrene, 60 
 
 hypertrophy of prostate, io6i.' 
 
 tuberculosis, 105 
 Sepsis, 75 
 
 in treatment of chronic abscess, 
 
 secondary htemorrhage with, 2c 
 Septic arthritis, 543 
 
 intoxication, 77 
 
 meningitis. Sefe Meningitis 
 
 osteomyelitis. See Osteomyelit: 
 
 peritonitis. See Peritonitis 
 
 ;( I 
 
 of, 
 
iia of cranium, 674 
 jaws, 697, 700, 701, 707 
 kidney, 1017 
 
 lymphatic glands, t2i, 256 
 muscle, 338 
 naso-pharynx, 722 
 nose, 723 
 palate, 755 
 parotid, 745 . 
 
 rectum, 987 
 scalp, 669 
 skull, 674 
 spine, 626 
 testis, 1102 
 thyroid, 794 
 tonsil, 759 
 
 treatment of fractured clavicle, 4 
 71 
 
 iffections of, 666 
 iries of, 628 
 ., fractures of, 418 
 iged, 314, 513 
 fections of, 177 ■ , 
 
 5 operation, 818 
 ze's operation, 773 
 . 3^9. 5«o . . 
 
 irtery, haemorrhage from, 21 2 
 ligature of, 264 
 ocation of hip, 526 
 'e, stretching of, 320 
 s ulcer, 840 
 
 . 144 
 
 reast, 829, 838 
 
 ancreas, 916 
 
 rostate, 1067 
 
 ylorus, 868 ; 
 
 of bone, 465, 476, 485 
 is, gonorrhoual, 1121 ;: 
 
 . 351 
 umours, 11 ri 
 
 affections of, 11 13 
 ckets, 491 
 is cysts, 332 
 of neck. 783 , 
 
 of nipple, 825 
 af scalp. 669 
 
 s glands, cancer of. See Rodent 
 
 :er 
 
 , 332, 1088 
 
 y haemorrhage, 207 
 
 r cartilage, dislocation of, 530 
 
 branosus, tenotomy of, 343 
 Qphy of bone, 438, 492, 671 
 rene, 60 
 
 •trophy of prostate, 106 r 
 culosis, 105 
 
 atment of chronic abscess, 37 
 
 dary haemorrhage with, 207 
 
 iritis, 543 
 
 cation, yj 
 
 igitis. See Meningitis 
 
 nyelitis. See Osteomyelitis 
 
 nitis. See Peritonitis 
 
 Septic pneumonia, 69 am ,., ^ 
 
 810,813 ■*' 741. 767. 798, 
 
 traimiatic fever 7, 
 'Septic.x>mia, 89 ' ^^ 
 'Septum nasi, fracture of ^o« 
 
 ^erotherapy,^;^^^ 
 aerous cysts, 140 78, d 
 
 ^S^:i "^: 5 9, s« 
 «hock, 183 "^ ' ''''^'"1 "erve 
 
 an£esthesia during, ,87 
 , 11 .^'omamputaiions '?, 
 
 7 n ^'^'n ca">eterism. I076 
 
 >n abdominal sugerjfl.n n 
 
 860, 873.877 o °, ^ ' '^5' ^50, 858, 
 
 in burns, 72^74 ^'''^'^'9^7 
 
 ■" i-estinai obstruction. 949, 96. 
 
 ankylosis of, 571 "• 
 
 dislocation of, 4„ 
 effusion into, r,^'^ 
 excision of, 582 
 
 Sinusr5r"'°"^^''^^-« 0^555 
 
 Sk'[n^"T.^' ''•'Sections of ,„ 
 ^kin grafting, 49, 559, 712^ «,. 
 purification of, is/ ' ""^^ 
 surgical diseases nf m- 
 Skull ^r^33 ^^^^°^(CnapterXlII.), 
 ^Jvui], affections of, 660 
 
 'njuries to, 629 
 Sloufihmg ulcer, 44 
 
 ps^^si^ojl-... ... 
 
 [g torsion of, IOQ2 °'^ 
 
 Spermatocele, I ro6^ 
 Spina bifida, 370, 607 
 occulta, 609 
 ventosa. See Tuberculous dactylitis. 
 iSpinal accessory nerve, affections r 
 t^; . , stretching of ox? , ' "^ °'^' ^^2, 
 pP">al cord, diseases of^ 6^26^^' 
 ' injuries of, 598 
 
 ""S^a""' ^" ^°"'^ ^-ease. 
 
 'P-e. deff^Sr^^ lesion °^' ^3 
 
 diseases of (Chapter xvr; ^ 
 . , '"juries to (ChaoiPr vv f-^' ^7-627 
 ^play-foot. SelFfatlfoof'''^' 5^9-606 
 
 INDEX 
 
 1152 
 
 107 1 
 
 SpJeen. afTections of -,0 a,f 
 
 ^tacke's operation 77.- 
 i»aphylococci. ,3 '2^^ «„ 
 „ 469. 474 ''■ "'75. 80,92.322.333. 
 
 ( ^'aphylorraphy, 7-. 
 
 ' ^'«rch bandage 5SJ 
 Stercoral ulcers ,^o „ 
 
 Sterno-mas,o7d • ^Sof !v^'^ 
 
 3^8 • '"-"on of. in torticollis. 
 
 congenital induration of ^s 
 tenotomy of. 3ro°'^' 78' - 
 Jernum.fracturk^^f ,,. 
 
 sfS'ir— ^-urisms.238 
 
 mercurial, 1135 
 
 Stral-n ^^'^^ Calculi 
 •strain, 2rj ooa 
 
 ^fangulattd hennf • ^i-*' ^°'' ^98 
 
 Streptococci, i, 20 L 
 
 c/.^5. 470, 543 8?' ^' ^^' ^°' ^•^' 9°' 9=. 
 
 Stricture of appendiv Sn« 
 
 ofbiledua,^x3'!¥'^°^ 
 
 ofintestine 877 n^^ 
 
 ofa.soph!!:/u?^76f7-^7^ 
 
 of pylorus, 867 
 
 of rectum, 984 
 of urethra, 1071 
 
 S«.or,co,d .iataUon of .he 3h„„„„' 
 
 5>»bcranial abscess, 65, 6,s ft,« „ 
 775 ^ ' °5o. 681, 
 
 Sublingual abscess, 741 
 Subluxation of head nf «^- 
 
 ofknee,53o °^'^'^'"S'5ai 
 
 m 
 
ii8o 
 
 INDEX 
 
 Submammary abscess, 82, 826, 830 
 Submaxillary ct^llulitis, 83 
 Subphrenic abscess, 860, 872, 900 
 Subserous lipoma, 126, 943 
 Subspinous dislocatiou ul tiie sliouldur, 
 
 Subungual exostosi;;, 130 . ,j , 
 
 Sulphur in chronic abscess, 41 
 Superior maxilla, affections of, 698-705 
 
 excision of, 702 
 
 fracture ol, 409 
 Suppression of urine, 1008, 1077 
 Suppuration (('hapt'- II.), 26-42 
 Supraconclyloid amputation of thi^h, 1 153 
 
 fracture of femur, .|.;9 
 of humerii.., 424 
 Supracoracoiddislocatior of the shoulder, 
 
 517 
 Supra-orbital nerve, operations on, 307 
 Suprapubic aspiration, 1082 
 
 cystotomy, 1031, 1035, 1056 
 puncture for enlarged prostate, 1067 
 Supratrochlear nerve, operations on, 308 
 Sutures, 157 
 
 intestinal, 880 
 Sylvester's method of artificial respiration, 
 
 823 
 Synie's amputation, 481, 1150 
 horseshoe splint, 460 
 operation for restoration of lip, 693 
 
 of urethrotomy, 1080 
 treatment of chronic ulcers, 48 
 Symonds' tube, 768 
 
 Sympathetic nerves, affections of, 321, 
 132, 241, 793 
 in shock, action of, 185, 848, 974 
 Syncope, 184 
 Syndactylism, 360 
 
 Synovial membrane, pulpy disease of, 548 
 Synovitis, acute, 536 
 chronic, 539 
 gonorrhaeal, 541, H2i 
 syphilitic, 557 
 Syphilis, 11 23 
 Syphilitic affections of anus, 985 
 
 of arteries, 222, 223, 225, 1131, 
 
 113^ 
 of bone, 483 
 of breast, 82f;, 830 
 of bursa;, 345 
 of cranium, 485 
 of epididymis, 1099 
 of intestine, 878, 985 
 of joints, 557 
 of larynx, 800 
 of lip, 690 
 
 of lymphatic glands, 291 
 of meninges, 655, 665, 677 
 of muscles, 337 
 of nerves, 297, 302 
 of nose, 711, 719 
 of palate, 755 
 of pharynx, 761 
 of rectum, 985 
 of spine, 600, 625, 626 1 
 
 Syphilitic affections of testis, lot; 
 
 of tongue, 733, 735 
 
 of tonsil, 75B 
 ulcers, 51, 1132 
 Syringo-myelocele, 607 
 
 Tagliacozzian operation, 713 
 
 Talipes, 369, 627, 608 
 
 Tarsectomy. 377 
 
 Tarsus, amputation through, 1 1. 
 
 Taxis, 951 
 
 Tealc's amputation, 1141, 1152 
 
 Teeth in congenital syphilis, 1 13; 
 
 in rickets, 488 
 
 tumours in connection wit 
 
 Odontomata 
 
 Temporal artery, compression of, 
 
 ligature of, 257 
 Temporo-maxillary joint, diseases 
 
 injuries of, 511 
 Tendo Achillis, rupture of, 336 
 
 tenotomy 01, 341 
 Tendon sheaths in hand, 202 
 Tendons, injury to, 334 
 
 operations on, 341 
 Teno-synovitis, 338 
 Tenotomy, 341 
 
 of sterno- mastoid, 350 
 Testicle, affections of (Cliapter X \ 
 
 1091-1113 
 Tetanus, 96 
 
 neonatorum, 851 
 Thecal whitlow, 130 
 Thiersch's method of skin-graftinj 
 
 of nerve extraction, 304 
 Thigh, amputation of, 1154 
 Third nerve, affections of, 305 
 Thomas's hip-splint, 443, 578, 622 
 
 knee-splint, 556 
 
 wrench, 380 
 Thoracic duct, wound of, 286 
 Thorax, deformities of, in adenoid 
 
 in rickets, 489 
 
 punctured wounds of, 813 
 Thrombosis, arterial, 61, 62, 64, 2 
 
 of cerebral sinuses, 641, 655, ; 
 
 of lateral sinus, 656, 777 
 
 venous, 269, 995 
 Thrush, 730 
 Thumb, amputation of, 1144 
 
 dislocation of, 522 
 Thyroid body, diseases of, 786 
 Thyroid dislocation of hip, 527 
 Thyroid vessels, ligature of, 259, [ 
 Thyro-glossal duct. See Cyst of, 
 Thyrotomy, 802 
 Tibia, fracture of, 455 
 
 rachitic, 369 
 
 syphilitic, 369, 487 ' 
 
 Tibial arteries, compression of, 2c 
 ligature of, 267, 268 
 
 nerves, affections of, 321 
 Tic douloureux, or epileptiform ti 
 Tic, facial, 313 
 Toenail, ingrowing, 331 , , 
 
tic affections of testis, 1099 
 
 of tongue, 733, 735 
 
 of tonsil, 758 
 :ers, 51. 1132 
 3-niyeloccle, 607 
 
 cozzian operation, 713 
 
 5i 3^9. 627, 608 
 
 tomy. 377 
 
 , amputation through, 1 149 
 
 951 
 
 > amputation, 'i.|i, 1 152 
 
 in congeniial syplulis, 1 137 
 
 riclccts, 488 
 
 mours in connection with. See 
 Odontomata 
 
 )ral artery, compression of, 205 
 ;ature of, 257 
 
 )ro-niaxiliary joint, diseases of, 708 
 injuries of, 511 
 
 Achilhs, rupture of, 336 
 
 tenotomy ol, 341 
 n sheaths in liand, 202 
 ns, injury to, 334 
 5erations on, 341 
 synovitis, 338 
 amy, 341 
 
 sterno-niastoid, 350 
 le, affections of (CluipterXXXVIll. 
 
 lis, 96 
 
 ;onatorum, 851 
 
 1 whitlow, 130 
 
 ich's method of skin-grafting, 50 
 
 of nerve extraction, 304 
 , amputation of, 1154 
 nerve, affections of, 305 
 
 s's hip-splint, 443, 578, 622 
 
 ee-splint, 556 
 
 ench, 380 
 
 ic duct, wound of, 286 
 
 , deformities of, in adenoids, 726 
 
 rickets, 489 
 
 nctured wounds of, 813 
 
 bosis, arterial, 6t, 62, 64, 214, 224 
 
 cerebral sinuses, 641, 655, 719, 77 
 
 lateral sinus, 656, 777 
 ous, 269, 995 
 
 730 
 
 , amputation of, 1144 
 location of, 522 
 
 body, diseases of, 786 
 
 dislocation of hip, 527 
 
 vessels, ligature of, 259, 794 
 lossal duct. See Cyst of, 781 
 my, 802 
 racture of, 455 
 hitic, 369 
 hilitic, 369, 487 
 rteries, compression of, 205 
 
 ligature of, 267, 268 
 
 es, affections of, 321 
 loureux, or epileptiform tic, 306 
 
 ial, 313 
 ingrowing, 331 
 
 INDEX 
 
 I 
 
 
 Toej, amputation of, 1147 
 ... 'leformities of. jSi-jS? 
 longuej, atr.xtions of, 7,, .7., 
 lonsil, affections of. 7/6 
 Topography, cerebral, 66j 
 Torsion, 199 •* 
 
 Torticollis, 348 
 
 Tourniquets, ao6. 1143 
 loxins. r^ 
 
 Trachea, foreign bodies In, 707 
 
 wounds o(, 784 
 Tracheal fug, 240, 243 
 rracheotomy, 80? 
 
 Tracheotomy, preliminary, 70^ 7,,, ,62 
 Traumatic aneurism, 215-^17 ^^^' ^ 
 
 delirium, 188, 391 
 
 epilepsy. 665 
 
 fever. 77, 187, 391 
 
 Rangrene, 64. 67. See Gangrene 
 insanity, 666 ""srcne 
 
 neuroma. r33, 298 
 transfusion, 192 
 
 ■rransillumination of antrum, 6qq 
 I rendclenburg's position, 10:6 
 
 tr.-icliea tampon, -^q, 808 
 
 1 rigeminal neuralsj.a.'ooe 
 
 Irismus, 98. 114, 709 
 
 I rochanter, fracture of, 446 
 
 ropical abscess of liver, qo6 
 Iriisses. 932. 941 
 
 I uberculous ab-cess, 35, 109 
 
 disease of bladder, 1031 
 
 of bone, 477 
 
 of breast, 830 
 
 of bursa), 345 
 
 of cranium, 674 
 
 of epididymis, 1097 
 
 of hip-joint, 572 
 
 of intestine, 876, 878 
 
 of joints, 548 
 
 of kidney," loio 
 
 of larynx, 800 j 
 
 of lymphatic glands, 291 { 
 
 of mastoid, 773 
 
 of mucous membrane, a^o 
 
 of peritoneum, 856 
 
 of prostate, 1060 
 
 of sacro-iliac joint, 580 ' 
 
 of skin. 327 
 of spine. 611 
 
 of temporo-maxiUary joint, 700 
 of testis, 1097 
 of tongue. 735 
 of vesicuKx seminales. 1 1 1 o 
 empyema. 817 ^ 
 
 endarteritis. 107, 2''3 
 ischio-rectal abscess, 970 
 lupus. 327 ^'^ • • . 
 
 teno-synovitis. 339 
 , ulcers. SI, 330 
 ^uberculated leprosy, in 
 uberculosis. 105 
 ubulo-dermoids, 147 
 
 II81 
 
 Tumour congenital sacral. 610 
 
 J'f'tt.sp„n>. 653 
 1 amours. 115-145 
 
 ofailrenils, 1017 
 of antrum, 700 
 of bladder, 1032 
 of bone, 496 
 of brain, h-;t-> 
 of bre.ist, 833 
 of cranium, 674 
 of gum, 09t> 
 of intestine. 879 
 of kidney, 1016 
 of larynx, 801 
 of lip, 691 
 of liver, 910 
 
 of lymphatic glands, 204 
 of mandible. 705 
 of maxilla, 703 
 of muscle, 338 
 of nose, 712, 720 
 of crsophagus, 766 
 of palate, 755 
 of pancreas, 916 
 of parotid, 745 
 of penis. 1088 
 of pharynx, 76r 
 of prostate. 1061. ,067 
 of pylorus, 868 
 of rectum. 9S6 
 of scalp. 667 
 of spine, 626 
 of spleen, 916 
 of stomach, 862 
 of sub-maxillary gland, 747 
 of testis, uoi '^' 
 
 of thyroid gland, 786 
 of tongue, 736 
 of tonsil, 759 
 of urethra, 1071 
 Typhlitis. See Appendicitis 
 iyphoid necrosis, 470 
 sta'e, II 
 
 ulcer, perforation of, 877 
 
 43-52 
 
 Ulceration (Chapter III 
 
 Ulcer of anus, 983. 987 
 
 of bladder, 1031 
 
 of intestine, 72, 
 
 952 
 of palate, 754 
 of scars, 177 
 of stomach, 859 
 of tongue. 734 
 Ulcers, perforating. 
 872 
 of foot, 320 
 phagedenic, 1126 •" 
 scirrhous. 840 
 
 nini"S^'i''"'°V^' 330. 735. 800 
 Ulna, dislocation of, 520 52" 
 
 fracture of, 428 
 
 Ulnar artery, compression of, 20<: 
 
 ligature of, 261 
 
 nerve, affections of, 318 
 
 872, 877. 879, 948, 
 
 of duodenum, 72, 
 
IlS2 
 
 INDEX 
 
 Umbilical hernia, 942 
 Umbilicus, affections of, 851 
 Unna's treatment of ulcers, 47 
 Un-united fracture, 405 
 Uranoplasty, 751 
 Ureter, rupture of, 1003 
 Urethra, affections of, 1068 
 Urethral fever, 1065, 1077 
 Urethrotomy, 1079, ^oBo 
 Uric acid and urates, 1038, 1045 
 Urine, abnormalities of, 1038 
 Uvula, elongation of, 756 
 
 Varicocele, 932. 1018, 1108 
 Varicose aneurism, 218 
 
 eczema, 47, 277 
 
 ulcers, 47, 277 
 
 veins, 276, 271, 765, 992, 1073, 
 1108 
 Varix, 276 
 Vasectomy, 1067 
 Veins, affections of (Chapter X. ), 269-283 
 
 entrance of air into, 210, 642, 784, 
 808 
 Venesection, 282 
 Venous haemorrhaefe, 190, 2oq 
 
 sinuses, thrombosis of. See Throm- 
 bosis of 
 wounds of, 642 
 Ventral hernia, 943, 904 
 Vermiform appendix. See Appendicitis 
 Verruca necrogenica, 169 
 Vertebral artery, haemorrhage from, 211 
 
 ligature of, 258 
 Vesical calculus. See Calculus 
 
 fistula. See Fistula 
 Vesiculse seminales, affections of, T113 
 Vicious union of fractures, 407 
 Villous tumour of bladder, 1032 
 
 of intestine, 987 
 
 of pelvis of kidney, 1017 
 Vocal cords, paralysis of. See Laryngeal 
 
 paralysis 
 Volvulus, 962 
 Vomiting after concussion, 646 
 
 after shock, 184 
 
 anaesthetic, 1161 
 
 cerebral, 677, 680 
 
 ffecal, 949, 961, 974 
 
 in intestinal obstruction, 961, 974 
 
 in peritonitis, 853 
 
 in strangulated hernia, 949, 961, 974 
 
 persistent, after taxis, 952 
 
 with moveable kidney, 1002 
 Vulva, affections of, 1090 
 
 Wagstaffe's fracture, 455 
 Wardrop's operation for aneurism, 
 242 
 
 236. 
 
 Warts. See Papilloma, 136, 3J 
 
 anatomical, or butchers', iq 
 
 malignant, 140 
 
 on lip, 691 
 
 venereal, 1088 
 Wax in ear, 770 
 Weak ulcer, 49 
 Webbed fingers, 360 
 Whitehead's operation on ha2m| 
 998 
 on tongue, 738 
 White swelling, 548 
 Whitlow, 170 
 Wolffian body, cysts of, 148, iic 
 Woifler suture, 882 
 Wool-sorter's disease, 104 
 Wounds (Chapter VII.), 154-185 
 
 of abdominal walls, 848 
 
 of air passages, 784 
 
 of arteries, 214 
 
 of bladder, 1024 
 
 of brain, 656 
 
 of gall bladder, 910 
 
 of heart, 820 
 
 of intestine, 873 et seq. 
 
 of joints, 502 
 
 of kidney, 1002 
 
 of larynx, 784, 798 
 
 of liver, 904 
 
 of lung, 812 
 
 of muscles, 334 
 
 of nerves, 297 
 
 of pancreas, 915 
 
 of scalp, 628 
 
 of scrotum, 11 13 
 
 of spine, 591 
 
 of spleen, 916 
 
 of stomach, 858 
 
 of testis, 1093 
 
 of throat, 784 
 
 of tongue, 732 . 
 
 of trachea, 784 
 
 of ureter, 1003 
 
 of urethra, 1069 
 
 of veins, 209, 642 
 
 of vulva, 1090 
 Wrist-drop, 316 
 Wrist-joint, acute arthritis^of, 547 
 
 amputation at, TT45 
 
 ankylosis of, 571 
 
 dislocation at, 522 
 
 effusion into, 537 
 
 excision of, 584 
 
 tuberculous disease of, 555 
 Wry-neck. See Torticollis 
 
 Xanthine, 1046 
 
 Zygoma, fracture of, 409 
 
 THE END. 
 
 Bailliire, Tindall and Cox, King William Street, Strand. 
 
rts. See Papilloma, 136, 326 
 
 anatomical, or butchers', 160 
 
 malignant, 140 
 
 on lip, 691 
 
 venereal, 1088 , ' 
 
 X in ear, 770 ' . 
 
 ik ulcer, 49 • 
 
 Jbed fingers, 360 
 
 teheads operation on haemorrhoids 
 998 
 on tongue, 738 
 te swelling, 548 
 tlow, 170 
 
 flTian body, cysts of, 148, 1107 
 
 3er suture, 882 
 
 I-sorter's disease, 104 
 
 nds (Chapter VI r.). 154-189 
 
 >f abdominal walls, 848 
 
 )f air passages, 784 
 
 )f arteries, 214 
 
 if bladder, 1024 , . 
 
 if brain, 656 '■ 
 
 f gall bladder, 910 
 
 f heart, 820 
 
 f intestine, 873 et seq. 
 
 f joints, 502 
 
 f kidney, 1002 
 
 F larynx, 784, 798 
 
 f liver, 904 
 
 'lung, 812 
 
 ■ muscles, 334 
 
 nerves, 297 
 
 pancreas, 915 
 
 scalp, 628 
 
 scrotum, 11 13 
 
 spine, 591 
 
 spleen, 916 
 
 stomach, 858 
 
 testis, 1093 
 
 throat, 784 
 
 tongue, 732 
 
 trachea, 784 ' 
 
 ureter, 1003 
 
 urethra, 1069 
 
 /eins, 209, 642 
 
 'ulva, 1090 
 
 rop, 316 
 
 iint, acute arthritis of, 547 
 
 putation at, T145 
 
 ylosis of, 571 
 
 ocation at, 522 
 
 sion into, 537 
 
 sion of, 584 
 
 ;rculous disease of, 555 
 
 :k. See Torticollis 
 
 5, 1046 
 fracture of, 409 
 
 m Street, Strand. 
 
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 :>., D.P.H., Camb., .^1.25 ' 
 
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 al practitioners, by EnglishJ 
 rranged, and combining thi 
 those of a Medical Encyclo 
 new matter. In or ictav 
 ustrated with colu la 
 
 iir V. Meigs, M.D. Bounj 
 
 D. Mendel^eff. Translate 
 o. Kamensky, A.R.S.M.,^ 
 d edited by T. A. Lawso; 
 f Chemistry. With 96 dij 
 Jig- 
 By James E. Moore, M.jj 
 rofessor of Clinical Surge] 
 licine and Surgery. Octal 
 ui illustrations from phoi 
 Cloth, $2.50. - ' 
 
 ijamin Moore, M.A,, ij 
 nt Professor of Physiolcl 
 octavo volume of 295 paJ 
 
 CataloKue^, Med/c.i Book.. 
 
 Diseases of the Skin . 
 
 nORRls. ^ ^^""•' "^''75. ' ^''•*'^^'' ''"^' ^ n-imber of n' 
 
 Essentials of Hnf^e; ^ 
 
 Essentials of P ' '*^' 
 
 Injuries anil rii 
 Ringrworm. [„ thp r 1 r 
 
 Sur^ica, Disease. ., the K„„ey u „ 
 
 te;:^-^ if^-"-^- sirt - ^t"; cr^ 
 
 By HonoV Mor en 1';;,'"'?"^^^^^^ i" the Wr "'",'"• ^P^^^^ions 
 "f Hospital Ue • 'el"''^°?^ " ^^w to Become a mT "^'. ''^*^'^' ^°°'"' 
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 Atlas of Syphr ' ''' 
 
 P'ates from or,Vi„a| '" S'^''?"' and Hospiiai w ,1' '^^" ^'"fk i' 
 
 I 
 
26 
 
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 ■SI 
 
 NANCREDE. 
 
 Essentials of Anatomy and Manual of Practical Diss 
 
 Containing " Hints on Dissection." By Charles B. Nancrede, 
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 On the Diseases of the Kidney Amenable to Surgical 
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 Syllabus of Obstetrical Lectures in the fledical Departi 
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 Clinical Examination of the Urine. By j. Bergen Ogden, I 
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 A rianual of Anatomy for Senior Students. By Edmund C 
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 Surgical Diseases of Children. By Edrnund Owen, ] 
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28 
 
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 Treatment of Pelvic Inflammations Through the Vagini 
 
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 Elementary Bandaging and Surgical Dressing. With 
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 Vol. 
 
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 Essentials of Practice of Pharmacy. 
 
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 Elements of Bacteriol 
 
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 SCUDDER ^ '=°'°''« 
 
 SEMPLE. harvard Universit) 
 
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32 
 
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34 
 
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 er Kmhryology . . '°^/ '« VViliiams, Medk ^ n- ' ^"^ ^'^"''''^n • • 
 
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 2f 
 26 
 
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 .«,,„ o„^ t7V ^aborato.y Ciuide. . ^^ 
 
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 CHEMISTRY AND PHYSICS 
 
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 f) 
 12 
 
 21 
 
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 Yeo, Food 
 
 '" Health and bVs^a^e 
 <'anot. EIflm«„ ^,>„ • •;. n n__.^ • ^'^^ ^^ose and Thr.,..i ^ '°^ 
 
 4 
 8 
 
 i; 
 
 2: 
 33 
 
 34 
 3« 
 
 
 .lological Physics" 
 ■*" The Blood.. 
 
 Medical ChemVstry 
 
 CHEST, HEART AND LUNQS. 
 
 ^arter, Ophthalmi 
 Corwm. Physical" 
 1 norax 
 
 Diagn 
 
 osis of the 
 
 Jjalfe Clinical ChemisVr; ^4 
 
 ^V olff, Essentials of MedS r'.;:- V " " " 33 oToIot' ''''"°'°^^- Laryngologf 
 
 Otology 
 
 37 jGIeason, Essentials of bisea; 
 
 ogy and 
 seases of the 
 
 Eye 7. ^^ Diseases of the 
 
 God I 
 
 ee, 
 
 1st. 
 Diseases 
 
 of the 
 
 8 
 
 owler and 
 
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 "'!^on. Diseases of theHMr/o^'.' ; " " * ' 
 artnett. Pulmonarv Pnn ^"'' '^°'^^ 
 , "lier. TuberTulS ''°"^"'"P»'"n .... . ^^ 
 
 aget, Surgery of the Chest '^ ! » n ^^^^^"^ throat ." ^9 
 
 ^^''^^•"^'^^^^°d'-' Examination- of- Jh; "' 
 
 4 
 8 
 
 II 
 12 
 
 14 
 
 15 
 16 
 
 CHF DREN, DISEASES OF 
 
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 15 
 
 i« 
 
 ^9 
 27 
 
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 ^7 
 19 
 
 Eye 
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 Pll^ff,*"^ Wright-, "Dis-ea; 
 frilfith,' 
 
 •le 
 
 P^B°SSi^is„ 
 
 Optical 
 
 21 
 
 22' 
 
 Care Of the Babv " '^ I'rard. Diphtheri, .,,^ :_. M^ ^2' 
 
 37 
 
40 
 
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 MASTERS OF MEDICINE. 
 
 Bernard, Claude, Life of 
 
 Brodie, Sir Benjamin, Life of 
 
 Gross, Samuel D , Autobiography of . 
 
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 Harvey, William, Life of 
 
 Helmholtz, Hermann Von, Life of . . . 
 
 Hunter, John, Life of 
 
 Richardson, Vita Medica 
 
 Simpson, Sir James Young, Life of. . . 
 
 Stokes, William, Life of 
 
 Wakley, Life and Times of 
 
 Page 
 
 • 23 
 
 • 23 
 . 16 
 
 • 17 
 
 • 23 
 
 • 23 
 
 • 23 
 
 • 29 
 
 ■ 23 
 
 • 23 
 
 ■ 36 
 
 MATERIA MEDICA AND 
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 8 
 
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 15 
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 30 
 30 
 32 
 
 33 
 
 35 
 
 3« 
 
 10 
 
 12 I 
 
 13' 
 13; 
 
 '^\ 
 13! 
 
 14 
 
 15 
 
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 Practice 
 
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 Uric Acid Diathesis 
 
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 '^accination Vindicated 
 
 annual 
 
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 Life Insurance 
 
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 RVOUS AND MENTAL 
 
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 inity 
 
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 21 
 21 
 
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 24 
 
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 37 
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 8 
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 31 
 
 20 i 
 
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 Clarke.^Surgical Pathology and 
 Clark 
 
 Prin- 
 
 Pac 
 
 SKIN DISEASES. 
 
 'ns, Elements of H,;". ^ j ^'^fj"§^' Hand-Book 
 
 
 tology 
 
 McFarland 
 
 10 
 
 nai 
 
 ^^nory and 
 
 Liveing 
 
 Skin 
 
 Pathology ■ 21 ; Mo 
 
 on Diseases of th 
 
 T^Sin^^^ ^^'"^^^ Paihologicai '\ 
 
 Pepper, 
 ^chafer 
 Semple 
 
 niq 
 
 ' ^I'^'nentsof Surgical Po;.;:i " ' "^^ 
 Essentials of fS4^;^°^^^^^ 27 
 
 Mo^^S^l^^r^^^Skin: 
 
 and Syph 
 
 semple Esspn*;,! r i.^'=''"'ogy . . .. ^A ^ c. T ^■''P"'""c Affectii 
 
 peutics . . 
 Weichselbaum 
 logical HSiogr"'"'^ "^ ^"^^° 
 
 1. Surgical P^^h f ^''^o'oiv .... 
 cs ^ athology and Thera- 
 
 Eleme 
 
 33 
 361 
 
 las of Skin Disease, 
 nine Attections 
 
 r>isease.s of tht 
 
 37 
 
 SURGERY. 
 
 ,Jogy .. 
 
 for Stu- 
 
 sepsis 
 
 6 
 
 8 
 14 
 '4 
 
 reat- 
 
 PHYSIOLOGY. 
 
 AsTb^y^NcJiron^S,"^?^-' 
 dents °° Physiology fc 
 
 Furneaiiv pi * Physiology. . 
 
 Halliburton Chr'^'r ^'hysiio^gy ; i ; ' 
 
 te.9""/^°' ^"juries: 
 
 American Year-JW of T «^''> 
 
 Clarke, Orthopedic Surge;v 
 
 Da Costa, Modern Surgfrv 
 
 Enchsen. Science and i7t^ofSurge;y 
 
 ^f«, ' Physiology 27 
 
 logy 
 
 Waller, 
 
 Waller, 
 
 logy 
 
 'trorinction to Hu 
 
 man Physio- 
 
 LecturesonPhysi;io"; 
 
 txercKses in PracticarPhys'io: 
 
 33 
 
 36 
 36 
 
 &l5^^l:Si^--:: 
 
 Marsh 
 
 Spine 
 Martin. Essentials 
 
 Joints and 
 
 of 
 
 36 
 
 PRACTICE OF MEDICINE 
 
 'vte^^^^'-°^ Medicine in « 
 
 Amei.can Text-Book of* bi 
 American Text Book of 
 and Practice of Medicine"" ' "^"'^ 
 
 AS:T^-rBo?^°f^d^ne-:::: 
 
 licine . . 
 of Medicine..."" 
 
 Martin, Ess^nUals of q '"°' Surgery.' 
 Moore, Orthonln V °i.l"i^^'->' 
 
 diagnosis. , 
 the Theor 
 
 iders, Practice of Med c 
 Kichhorst, Practice 
 Hutchison an.1 i? • 
 
 Methods ^^'"y- <^'hnical 
 
 3 
 4 
 
 5 
 
 () 
 
 6 
 
 r ^ ! 
 
 ;^i^i'Si:j„i:^:-'Me^ 
 
 .Wrs°Es''^"-''^°^ Medic 
 Moms, Essentials of Practice 
 
 Jcine and 
 
 cine *""'"' ^'■actice of Medi- 
 
 19 
 
 20 
 
 21 
 
 25 
 32 
 
 *^age, Clinica Panprs or. ^ ■■>^ 
 
 jects * *P«" <^n Surgical Sub 
 
 Pick, Surgery"".' 
 
 Pye. Elementary Bandaging ' " 
 
 ;P>e.Surg,ca Handicraf?.^ 
 
 ' '&foS?el''^^^''"^"'°fCh^^^^^^^^^^^^ 
 Operations various 
 
 2t 
 
 27 
 28 
 28 
 
 28 
 
 War 
 
 evens, ivianii=.i „c .i "6""ais . , ^a c,.* y* ~"'^^ery for Nurses ^^ 
 
 Medicin^ '' °' '^^ '^'-actice of ' ?rel°."' 1"'"°^'' ^' 
 
 Van Valzah and NishpV n/ 
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