COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDAHD Dr»oH n HX64060802 RD31R72 1914 Rose and Carless's m RECAP l^s^Ki Columbia IHnibersiitpv^^ v intijeCitpof^etogorfe COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/rosecarlesssmanuOOrose A MANUAL OF SURGERY jfor StuDents auD practitioners ROSE AND CARLESS'S MANUAL OF SURGERY jTor Stubente ant) practitionere NINTH EDITION REVISED BY ALBERT CARLESS, M.B., M.S. Lond., F.R.C.S. Professor of Surgery in, and Surgeon to, King's College Hospital, London formerly examiner in surgery to the universities of london, glasgow, Manchester, Liverpool, and Leeds ; Consulting Surgeon to the King Edward's Memorial Hospital, Ealing ; to the St. John's Hospital, Twickenham, etc. NEW YORK WILLIAM WOOD & COMPANY MDCCCCXIV First Edition, May, iSg8. Second Edition, September, iSgg. Hungarian Translation. Tliird Edition, September, iqoo. Fourth Edition, September, igot. Fifth Edition, August, igo2. Reprinted, September, 1Q04. Sixth Edition, August, 1905. Reprinted, April, igoy. Ameri an Edition, August, igos. Reprinted, November, rgo6. Seventh Edition. September, ,goS. Reprinted, May, igw. American Edition, September, igoS. Reprinted. July, igic. Chinese Translation. Eighth Edition, September, igjj. Refrinted, April, igij. American Edition. August, igir. Reprinted. August. ig,2. Arabic Translation. Ninth Edition, October, igi^. American Edition, October igi^. LONDON BAILLlfeRE-, TINDALL AND COX 8, HENRIETTA STREET, COVENT GARDEN TO THE LATE LORD LISTER, ll.d., f.r.s., o.m., Late President of the Royal Society, THE FATHER OF ANTISEPTIC SURGERY, THIS WORK WAS, WITH PERMISSION, IN GRATEFUL ACKNOWLEDGMENT OF THE MANY ADVANTAGES THEY DERIVED WHILST ASSOCIATED WITH HIM IN HIS WORK AT king's COLLEGE HOSPITAL. PREFACE TO THE NINTH EDITION The triennium which has elasped since the issue of the eighth edition of this Manual has been characterized, not by the discovery of any revolutionary or wonder-working novelty, but by the steady elaboration of ideas and methods which had already been introduced, and required time for their investigation. Salvarsan and radium in particular maybe mentioned as subjects to the consideration of which a vast amount of work has been devoted. Salvarsan stands as the conqueror of the worst ill-effects of syphilis, if only it be employed in time; radium has proved itself a potent agent for good in many cases, but the magniloquent prophets who hailed it as the victor of cancer have not yet proved their claims. Steady progress is being made in all the varied realms of research which are touched on in this work, and an effort has been made to incorporate therein the mast important, keeping in view the double purpose of this manual — viz., to instruct students and to help practitioners. Room has been found for a new chapter on modern methods of treatment by heat, light, electricity, etc., and for other fresh subjects. Many new illustrations have been added, as well as a few more coloured plates, and this without adding a single page to the book. The paper on which it is printed is slightly thinner than previously, so as to keep its weight within the requirements of the postal authorities, who distribute it far and wide overseas. I trust that this edition may prove even more helpful than those which have preceded it, and pray that when the tenth edition is required the sounds of war and strife, which boom on the ear as these lines are penned, may long have ceased, and that a righteous peace leading to a happy competition of race with race in the effort to viii I'REFACE TO THi; NINTH IIDITION promote, not the destruction, but the welfare of mankind of all nationalities may have been established. 1 have to thank many vvho have kindly helped me in preparing this edition. Dr. Emery has again answered pathological queries; Dr. Knox has helped me with radiographic preparations; Dr. Silk has kindly revised the chapter on Anaesthetics. Mr. John Everidge, Dr. Thurston Holland, Dr. Knevitt, Dr. Salmond, Dr. Mack, and others have helped with photographs, which have been prepared for press by the artistic skill of Dr. Dupuy. To one and all I offer my hearty thanks, as also to Mr. Eric Gauntlett, who helped me until called out on active service. Again I have to acknowledge the kindly courtesy of my publishers, who have cheerfully assisted me in every way possible. ALBERT CARLESS. 6, Upper Wimpole Street, W., September, 191 4. PREFACE TO THE FIRST EDITION In preparing this Manual of Surgery 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 the needs of the student, even of those who are preparing for the higher examinations. At the same time, the requirements of the general practitioner have not been overlooked, for we have taken care to discuss in detail those con- ditions which are most likely to be met with in ordinary practice. The main difficulty has been to compress into a small space the ever-increasing amount of material available, so that we have only been able to sketch in outline 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 genital 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, 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 Thomson, who has kindly looked through the proofs of the sections devoted to X PREFACE TO THE FIRST EDITION the Nose and Ear; to Dr. Silk, who has fuhilled 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. 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, Harley Street, W. A. CARLESS, 10, Welbeck Street, W. London, May I, 1898. CONTENTS CHAPTER ^'^'^^ I. SURGICAL BACTERIOLOGY INFECTION IMMUNITY (BY DR. W. D'eSTE emery) - - - " " ^ II. INFLAMMATION - - " " " "29 III. THE USE OF HEAT, LIGHT, ELECTRICITY, AND RADIUM IN SURGERY - - - - - - -47 IV. EXAMINATION OF THE BLOOD IN HEALTH AND DISEASE (by dr. w. d'este emery) - - - - 58 v. non-specific pyogenic infections - - - 68 vi. ulceration ----"" ^^^ vii. gangrene -----"' ^0° viii. specific infective diseases - - " " 129 ix. tumours and cysts ----- ^94 X. WOUNDS ------- 239 XI. THE GENERAL TECHNIQUE OF OPERATIVE SURGERY - 27I XII. HEMORRHAGE ------ 282 XIII. INJURIES AND DISEASES OF ARTERIES ANEURISM LIGA- TURE OF ARTERIES - - " - " 299 XIV. SURGERY OF THE VEINS ----- 34^ XV. DISEASES OF THE LYMPHATICS - - - - 35^ XVI. AFFECTIONS OF NERVES - - - - " 37^ XVII. SURGICAL DISEASES OF THE SKIN AND OF THE CUTANEOUS APPENDAGES ------ 399 XVIII. AFFECTIONS OF MUSCLES, TENDONS, AND BURSiE - - 4I4 XIX. DEFORMITIES ---"■" 432 XX. INJURIES OF BONES — -FRACTURES - - - " 47^ XXI. DISEASES OF BONE ------ 555 XXII. INJURIES OF JOINTS DISLOCATIONS ■ " " 599 XXIII. DISEASES OF JOINTS - - " " 627 Xii COi\ri£NTS CHAPTER PAGE XXIV. IXJURIES OF THE SPINE - - . . 584 XXV. DISEASES OF THE SPINE - . _ . yoo XXVI. AFFECTIONS OF THE SCALP AND CRANIUM - - 722 XXVII. AFFECTIONS OF THE BRAIN AND ITS MEMBRANES - 744 XXVIII. AFFECTIONS OF THE LIPS AND JAWS - - - 783 XXIX. AFFECTIONS OF THE NOSE AND NASO-PHARYNX - 814 XXX. AFFECTIONS OF THE MOUTH, THROAT, AND CESOPHAGUS - 832 XXXI. AFFECTIONS OF THE EAR ... - 873 XXXII. SURGERY OF THE NECK . - . - - 884 XXXIII. SURGERY OF THE AIR- PASSAGES, LUNGS, AND CHEST - 9OO XXXIV. DISEASES OF THE BREAST - . . . g^j XXXV. ABDOMINAL SURGERY - . - - . g^g XXXVI. HERNIA --.-.-. 1084 XXXVII. INTESTINAL OBSTRUCTION . - . . 1124 XXXVIII. AFFECTIONS OF THE RECTUM AND ANUS - "1144 XXXIX. SURGICAL AFFECTIONS OF THE KIDNEYS - - 1 1 75 XL. SURGERY OF THE BLADDER AND PROSTATE - - I2I5 XLI. AFFECTIONS OF THE URETHRA AND PENIS - - I253 XLII. AFFECTIONS OF THE TESTIS, CORD, SCROTUM, AND SEMINAL VESICLES - - . . . 1275 XLIII. SURGERY OF THE FEMALE GENITAL ORGANS - - 1 299 XLIV. AMPUTATIONS -----. 1324 XLV. ANESTHESIA -.-_.. 13^2 INDEX .--... - 1357 ri.ATE I. fjo I —Staphylococci in pus. Slaininij— Gram and dilute carbol-fuchsm. Fi^ "2 —Streptococci in pus. Staining-methylene blue. Fis;. 3.-Gonococci in pus Gram and carhol-fuchsin, only the latter of which has stained. Fig. 4.— Pneu- mococciin sputum. Methylene blue. Fig. 5.— Sarcinae. from a culture. Grams stain. Fig. 6. — Spirilla (with a few bacilli) from \incent s angina. Carbol-fuchsin. [To face page I. A MANUAL OF SURGERY CHAPTER I. BACTERIOLOGY— INFECTION— IMMUNITY. The importance to the surgeon of a study of bacteriology is twofold. In the first place, many surgical diseases (especially those of an inflammatory nature) are due to the action of bacteria; secondly, these organisms are practically ubiquitous, and in the absence of suitable precautions will infallibly enter any external wound, whether accidental or intentional, and by their development and the in- flammatory troubles which result therefrom delay the process of healing, or even give rise to fatal results. Hence every surgeon must have a general knowledge of the habits and distribution of the more important species of bacteria, their mode of life, and the mechanism by which they give rise to morbid processes in the human body, as well as of the methods used in their investigation. It was only by means of such knowledge that the present methods of treating wounds were evolved, and without it these methods cannot be intelligently applied in actual practice. Moreover, the .diagnosis of disease is often much assisted by the bacteriological examination of morbid products, and information of the highest importance may be obtained thereby. Bacteria (schizomycetes, or fission fungi) form a very important group of the lower plants. Although several thousand species have been described, comparatively few are of importance in medicine or surgery. They may be defined as minute unicellular plants, which reproduce themselves bv simple fission, or in some forms by endo- genous spore-formation, not more than one spore being formed in each cell. They are devoid of organs except flagella, and contain no chlorophyll. Their structure is extremely simple, consisting of a delicate cell-wall (composed of cellulose or an allied substance) which encloses a mass of protoplasm, in which there may be one or more vacuoles and a few granules of unknown nature. External to the cell-wall there is sometimes a gelatinous capsule, which may serve to unite the bacterial cell looselv with its neighbours. When 2 A MANUAL OF SURGERY such capsules become very prominent, large numbers of bacteria may become embedded in a gelatinous mass, known as a zooglaa. Capsule-formation is of some importance in diagnosis; the pneumo- coccus, for example, possesses a well-marked capsule when it occurs in blood or morbid exudates, and may thereby be distinguished from many organisms otherwise resembling it. Flagella are delicate filamentous extensions of the protoplasm, which occur in those bacteria which are possessed of spontaneous mobility. They are sometimes of great length, but are always extremely thin, and are only visible after the use of complicated staining processes. Their number is of importance in diagnosis. The tvphoid bacillus, for example, has usually from twelve to twenty flagella (Plate III., Fig. 25), whilst the closely-allied Ij. coli has from three to six. It should be remembered that bacteria which are devoid of flagella often exhibit very marked Brownian movement, which the uninitiated might mistake for spontaneous motility. Reproduction among the bacteria is extremely simple, nothing akin to sexual processes having been observed. In simple fission the cell becomes divided by a thin membrane into two portions, which develop into mature organisms. The two bacteria thus produced may become entirely separated from one another, or may remain more or less connected by means of the capsules described above, thereby becoming united into groups, which are more or less characteristic of the species. This process of division may take place with great rapidity, so that a suitable m.aterial which has become infected with one or two bacteria mav contain vast numbers in the course of a few hours. Spore-formation is a more complicated process, and is found only in certain of the rod-shaped bacteria or bacilli. Bacterial spores are round or oval in shape, and are formed within the bacterial cell (endospores). They consist of a thick cell-wall filled with proto- plasm, which contains less water than the mature bacterium, and has, therefore, a highly refractile appearance when seen under the microscope. The shape and size of the spores have much diagnostic value; thus, the bacillus of tetanus has an almost spherical spore, which is distinctly larger than the diameter of the rod in which it is formed, whilst the spore of the anthrax bacillus is oval, and little or no broader than the rod itself. The position of the spore is also of importance. The spores of the tetanus "bacillus are at the extreme end of the bacillus, giving it the appearance of a drumstick, whilst those of anthrax are central. Spores are to be regarded as resting forms adapted to maintain the life of the species under adverse con- ditions, and in this respect are analogous to the seeds of the higher plants. They resist dr\'ing to a far greater extent than do the bacteria themselves. Anthrax spores have been preserved in the laboratory for twenty years without loss of viability or virulence, whilst asporogenous anthrax dies in a few weeks when dried. They are also very resistant to heat. Most bacteria (when moist) are killed when exposed to a temperature of 60'^ C. for half an hour. BACTERIOLOGY—INFECTION— IMMUNITY 3 whereas many spores are not killed by prolonged boiling. Lastly, they are very difficult to kill by means of antiseptics. Anthrax spores can be killed by immersion in i in 20 carbolic lotion, but only after several days. Of the bacilli of chief interest to the surgeon the B. tetani, B. anthracis, B. rvdemaiis maligni form spores, and of these only the B. tetani in the body, whilst those of glanders, tubercle, diphtheria, typhoid fever, leprosy, influenza, and soft sore are asporogenous. The Classification of the bacteria is based, in the first instance, on their morphology, but owing to the simplicity of the shape of the organisms, morphological characteristics have to be supplemented by physiological and cultural properties in the definition of the separate species. There are three great groups — the cocci, bacilli, and spirilla. I. Cocci are organisms which are spherical, or nearlj^ spherical. They constitute the simplest forms of bacteria, since but few species possess flagella, and spore-formation is unknown, (a) Micrococci are those forms in which there is no definite arrangement into groups. The term ' staphylococcus ' — more properly the name of a species, the Staphylococcus pyogenes — is applied to cocci in which the individual elements are arranged in clusters resembling bunches of grapes (Plate L, Fig. i). {h) Diplococci (Plate L, Fig. 4) are forms in which the two elements arising from the division of a single coccus remain in more or less close apposition, so that they are arranged in pairs, (c) Streptococci (Plate L, Fig. 2) are arranged in longer or shorter chains, like a necklace. This formation is due to the fact that the successive planes of division in which the cocci are divided lie parallel to one another, (d) In a few cases a coccus divides into two, which are again divided in a plane at right angles to the first, so that the four cocci which result lie at the corners of a square; these are called Tetracocci. Lastly, {e) Sarcince are formed by three consecutive divisions in the three planes of space, so that the eight cocci which are formed lie at the corners of a sphere (Plate L, Fig. 5), and the group resembles a bale of wool tightly tied in three directions. These cocci often divide again, and lead to the formation of composite masses. IL Bacilli (Plate IIL, p. 128) are bacteria which have the form of straight or curved rods, the long diameter of the cell being greatly larger than the short diameter. Spore-formation is common in this group, and many of its members possess flagella, and are there- fore motile. The group is not subdivided, but l^e terms strepto- hacillus for those which remain adherent in chains, and leptothrix for forms which produce long threads before breaking up into short rods, are convenient. IIL Spirilla are rods which are uniformly curved in the three planes of space, so that when sufficiently long they form corkscrew- like spirals. Short forms also occur, and these are sometimes designated vibrios, the term ' spirilla ' being then reserved for the long spiral forms. The spirilla are not of much surgical importance, the only well-known pathogenic varieties being the F. choleroi 4 A MANUAL OP SURGERY Asiaticcc and the sj)irilluin of rclapsiiif,' fever (I'kite I., Fig. b), wliicli latter, how e\i'r, is now thought to be a protozoan. Conditions of Life. — l^acteria resemble other jikints devoid of chloropliyll in being unalile to form proteid from simple materials in the presence of sunlight, and have to be supplied with ready- formed organic nitrogen from animal or vegetable sources. Re- garded from this standpoint, they may be divided into two classes — the parasites, which can obtain their pabulum only from the living animal (or plant), and the saprophytes, which are unable to do so, and flourish only in dead materials. The leprosy bacillus may be taken as an example of a strict parasite, since, as far as is known at present, it grows only in the living tissues, and cannot be cultiveited outside the body. The term facultative saprophyte is applied to those organisms which prefer a parasitic existence, but which will grow under suitable conditions in dead materials. The gonococcus is a good example; it multiplies readily enough in the living mucous membrane, but grows only feebly on dead culture media. Facultative parasites, on the other hand, are organisms which grow best in dead materials, but which have the power of adapting themselves to a parasitic existence. It must be understood that the terms ' parasitic ' and ' pathogenic ' are not quite synonymous. K pathogenic organism is one that has the power of producing disease, and it may do so without entering the living tissues at all, as when putrefactive organisms gain access to a blood-clot in the uterus and cause toxaemia. A parasitic organ- ism is not necessarily pathogenic, especially in the lower animals, since these frequently harbour blood-parasites without appearing to suffer therefrom in any way. In addition to combined nitrogen, all bacteria require water, certain salts, and a suitable temperature for their growth. The necessity for water must be borne in mind in surgical practice, and every attempt must be made (by accurate co-aptation of parts, drainage, etc.) to prevent the accumulation of putrescible material in wounds or body-cavities. This is well seen in dealing with the peritoneum, the absorptive power of which is one of the chief natiiral defences against peritonitis. In laboratory experiments we find that large amounts of fluid cultures of pathogenic bacteria can be injected into the peritoneal cavity of animals without injury; the fluid is rapidly absorbed and bacterial growth ceases. If, however, the peritoneum is injured so that absorption is checked, the bacteria continue to grow, and fatal peritonitis results. The requirements of different bacteria as to temperature vary greatly. The majority of those of importance in human pathology grow best at or about the body temperature (37° C), but man}' forms, especially those which are commonly met with as saprophytes outside the body (such as Staphylococcus pyogenes and B. coli), grow well at 18° C, or even lower. Other forms flourish best at lower or higher temperatures than these, but they are not of pathological importance. Lower temperatures inhibit growth, but do not kill BACTERIOLOC, Y— INFECTION— I MMUN IT Y 5 tlie bacteria unless applit'd for loni; periods. The destruction of bacteria and spores bv lieat has been already mentioned. I i'dit is injurious to almost all bacteria. This is especially the case with B. litberciilosis, which in vitro is killed after a very short exposure to sunlight and more slowlv bv diffused daylight. The action seems to depend on the formation of peroxide of hydrogen in the culture medium. r .t. • j 1 Manv pathogenic organisms require free oxygen for their develop- ment and are^ spoken of as aerobes. A few, such as the tetanus bacillus will grow onlv in the complete absence of oxygen, ceasing to develop though still remaining alive, when that gas is admitted; such organisms are called anaerobes. Bacteria which grow best m air but which will also grow in its absence, are called facultative anaerobes, and those which grow best under anaerobic conditions but are capable of some growth in presence of oxygen, are called facultative aerobes. It must be pointed out that the conditions in the living bodv are pecuhar, in that both strict aerobes and stnct anaerobes are capable of growth. Further, a strict anaerobe may grow in a fluid freely exposed to air in the presence of other organisms which have a great affinitv for oxvgen and rapidly absorb it. in this way tetanus baciUi may flourish in superficial wounds it other bacteria are present. In their <^rowth bacteria give off metabolic products which are often of great importance. The chief of these are (i) acids, such as lacric, acetic, but\Tic, etc.; (2) alkalies; (3) gases, such as sul- phuretted hvdrogen, marsh gas, etc. ; (4) pigments, such as the green colouring matter produced bv B. pyocyaneus and seen m the so-called blue pus; (5) aromatic substances, such as mdol, phenol, and tvrosin; (6) alcohol and other similar bodies; (7) ferments— e o diastase, invertase, and a ferment allied to rennm. A more ir^portant enz\Tne is one resembling trvpsin and having the power of peptonizing proteid material. It is produced by one of the commonest pvogenic organisms {Staphylococcus Pyogenes), and plavs some part in the destruction of the tissues m suppuration. Its "presence or absence is ascertained by cultivating the organism on gelatin or coagulated blood-serum, either of which is digested or '^liquefied ' if the enz\Tne is produced. (8) Certain crystalhzable organic substances of definite chemical composition, alhed to the ve-etable alkaloids, and spoken of as ptomains. They have some poisonous properties, and were once thought to be of great impor- tance in the production of disease. {9) The true Toxins have never been isolated in a state of puritv, but appear to be allied m chemical composition to the albumoses, and have some features m common mth the enz\Tnes. Thev are intenselv poisonous when injected into the blood or tissues, though innocuous (m most cases) \vhen taken bv the mouth. Thev are verv unstable substances, being readily destroyed bv heat, peptic digestion, etc., and when kept m a state of solution graduallv become inert. . ^ . Toxins are di\dded into two distinct classes : {a) Certain organisms. 6 A MANUAL OF SURGERY of whicli the most important arc the bacilH of tetanus and diph- tlicria, produce soluble exiraccUiilar toxins which accumulate in the fluid in which they are grown, {b) In the case of many other organisms, the specific poison appears to remain locked up in the bodies of the bacteria, and is only given off under conditions which we are unable to reproduce experimentally; they are known as intracellular toxins. For example, the soluble products secreted by the tubercle bacillus have but little toxic action, whereas the washed bodies of the bacilli themselves are extremely poisonous. The pathological effects of these toxins are highly diverse, but in nearly all cases they include the production of fever. Some are selective in their action, affecting onh' a certain class of cell — e.g., the cells of the central nervous svstem in the case of tetanus. Others, such as those of the pyogenic bacteria, affect any tissues they may happen to reach. Under natural conditions the results vary with the amount of toxin present in the body, and with the susceptibility of the animal and of the tissues in question. Thus a very powerful toxin may immediately destroy the vitality of a part en masse, whilst one that is somewhat less intense in its action may kill the tissues after causing an acute inflammation. A similar but still slower process leads to caseation; in this fatty degeneration has time to supervene in the affected tissues before their death. In another group of cases the inflammation may terminate in a slower but progressive molecular death of the tissues, leading to suppura- tion. Finally, if a very feeble toxin acts for prolonged periods it may serve as a stimulant to growth and determine proliferation of the fibrous tissues, etc., without the development of any external signs of inflammation. Distribution. — Bacteria are very mdely distributed in nature. Their presence in the air varies greatly with circumstances. They are absent from the air of mountain-tops or mid-ocean, and present in vast numbers in towns. They are not given off from the surface of liquids containing them, and only remain in suspension in the air when adherent to particles of dust or moisture. They are more plentiful in dry weather than in wet, and more abundant in occupied houses than in the open air. When the atmosphere of an enclosed space is kept at rest, the dust gradually sinks to the bottom and the air becomes absolutely sterile. It has been found that the air of schoolrooms contains far fewer bacteria when the scholars are sitting quietly than when they are allowed to move about — a fact which should be borne in mind by spectators at a surgical operation. Expired air is sterile, but in speaking and coughing minute particles of fluid are ejected, and are usually charged with an abundance of bacteria, wliich are frequently pathogenic, and may constitute a source of danger in operations. The bacterial contents of water also vary greatly. That suitable for a public water-supplv should contain but few bacteria, and pathogenic forms should be absent. Where this is known to be the case, the water mav be used in an emergency to cleanse wounds, though even then BACTERIOLOGY— INFECTION— IMMUNITY 7 it is desirable to sterilize it ; but as a rule water from natural sources contains so many injurious bacteria that a preliminary steriliza- tion is absolutely necessary before its use for surgical purposes. Earth contains vast numbers of bacteria, and pathogenic varieties are freciuently present. The human skin teems with bacteria, like anything else which is exposed to dust and dirt. The majority of these organisms are present simply by accident, and are readily removed by washing. A few, however, are normal inhabitants of the skin, and are very difficult to destroy, as they penetrate deeply. Bacteria are also present in the alimentary canal from the mouth to the anus, the external auditory meatus, the inferior meatus of the nose, the con- junctiva, the anterior portion of the male urethra, and the vulva. The superior meatus of the nose, the deeper portions of the urethra, and the upper part of the vagina in a virgin are in general sterile, as are also the healthy gall-bladder, together with the bihary and pancreatic ducts. The blood and deeper tissues of a healthy animal are usually free from germs, but careful observations have shown that the escape of small numbers of bacteria from the alimentary canal into the blood and lymph is a common, perhaps constant, occurrence. Under conditions of health these bacteria do not find suitable conditions for continued growth in the body, and are soon destroyed in the blood; but when the general vitality of the body is lowered they may persist, and, finding a suitable foothold in an area of low vitality, may develop and give rise to pathological effects. This is probably the explanation of the suppuration that sometimes occurs in deep lesions, such as the subcutaneous rupture of a muscle or ligament, and it is termed aitto-infection (p. 72). Methods of Observation — (i) Microscopical Exajnination. — This may be carried out on morbid material taken direct from the body, or on cultures of organisms derived therefrom. A high magnifying power (yV-inch oil immersion) and a suitable substage condenser are necessary. The material may be stained or unstained. Un- stained specimens are usually examined in a ' hanging-drop ' preparation, and this enables the observer to recognise the shape, size, and arrangement of the bacteria present, the presence or absence of spores, and also whether the organism is motile. This method of examination is of the highest importance in dealing with cultures, and should never be omitted. For morbid exudates, pus, etc., it is often unnecessary, and chief rehance is placed on stained specimens. To this end a thin film of the material is spread on a clean shde or cover-glass, allowed to dry, and fixed by being passed two or three times through the flame. This film is then submitted to the staining process, of which there are three chief varieties: {a) Simple stains, such as carbol-fuchsin, carbol-thionin, methy- lene blue, etc., affect all bacteria, as well as the cells, nuclei, etc., of the morbid material. They enable the presence of the bacteria to be recognised, and their shape, size, etc., to be determined. 8 A MANUAL OF SURGERY {})) Grani's Method. — Tlie film is imnuTsed for three to five minutes in a stain consistinj^' of lo parts of a saturated alcoholic solution of f^entian violet diluted with 90 parts of i in 20 carbolic acid in water. It is then treated for two or three minutes with a watery solution of iodine in iodide of potassium (iodine i, KI 2, water 300), and finally washed in alcohol until no more colour is dissolved out. Some bacteria remain stained when treated in this way, whilst others are completely decolorized. The following remain stained, and are termed Gram-positive : Staphylococci, Streptococcus pyogenes, the pneumococcus, the Micrococcus tefragenus, the bacilli of tetanus, anthrax, tubercle, lepros^^ diphtheria, and the streptothrices causing actinomycosis. The following lose their stain and are Gram-uegative : The gono- coccus, the meningococcus, the Micrococcus Melitensis, the B. coli, the bacilli of glanders, typhoid fever, influenza, and soft sore, the B. pyocyaneus, the vibrio of cholera, the spirillum of relapsing fever, and the spirochfete of svphilis. {c) The Ziehl-Nielsen Method. — The film is stained by means of a powerful stain, usually carbol-fuchsin, which is either heated or allowed to act for several hours. It is then immersed in 20 to 25 per cent, sulphuric acid for five or ten minutes. This removes the stain from all cells, etc., and from the majority of bacteria. A few, however, retain it, and these are called acid-fast. Films may also be stained in the same way and subsequently decolorized in alcohol, and organisms which retain the stain are called alcohol-fast. Of the organisms which are of importance in human pathologv, the bacilli of tubercle and leprosy and a bacillus frequently found in smegma are acid-fast, and the two former are also alcohol-fast. Certain streptothrices are also acid-fast. _ (2) It is usually necessary to supplement microscopical examina- tion by cultural methods in which a suitable culture medium is inoculated with the material to be examined and kept in an incu- bator at a proper temperature. These culture media are very numerous, but broth, gelatin, sohdified blood-serum, and agar- agar suffice for most purposes. Broth is chiefly used for making vaccines, and for observations on the chemical products of bacteria. Solid culture media are more generally useful, since many organisms form characteristic growths or colonies on the surface or in the depth of the medium. Nutrient gelatin is especially valuable, since it is liquefied by some bacteria, whilst others have no such action : un- fortunately, it melts at the temperature necessary for the growth of many pathogenic bacteria, and when this is the case observations on the formation of a peptonizing ferment have to be carried out by cul- tures on blood-serum coagulated by heat. Agar-agar is not rnelted at the temperature of the body, and is not liquefied by any organism. For full details of this method of examination a work on bacteri- ology must be consulted. (3) The inoculation of living animals is also frequently necessary, in order to prove that an organism which has been isolated in cases BACTERIOLOGY— INFECTION— IMMUNITY g of a given disease is actually the cause of that disease. In the early days of bacteriology, when the bacterial origin of disease was hotly contested, Koch formulated the following postulates, and when these are fulfilled, we may consider the cause of the disease as proved to demonstration: (a) The organism (which must be one that can be definitely recognised from all others) must be present in the body in every case of the disease. {b) It must be possible to cultivate it for many generations apart from the bodv, thereb\' getting rid of every trace of the original substance taken from the first case of the disease. [c) The inoculation of a suitable animal must be followed by the appearance of the specific disease. (d) The organism must be found in the animal thus infected. ^^'■e do not now demand so rigid a proof of the pathogenic effects of bacteria. Thus, although the B. leprce is universally admitted to be the cause of leprosy, it has never been cultivated, so that with it only the first of Koch's postulates holds. Other tests, such as the presence of specific agglutinins in the blood of cases of the disease, are now applicable. Inoculation experiments are frequently employed in the practical diagnosis of various clinical conditions. Thus, in examining the morbid products (urine, pus, etc.) of tuberculous affections, the B. tuberculosis is often present in such scanty numbers that staining and cultural methods prove ineffective. The subcutaneous or intraperitoneal inoculation of a guinea-pig is an extremely delicate test, and will infallibly lead to the development of tuberculosis if living bacilli are present. The chief drawback is the fact that it takes two or three weeks for the disease to develop. Inoculations of pure cultures are also often resorted to where the organism present has so close a resemblance to a non-pathogenic form that its recognition is a matter of uncertainty. Thus, several harmless organisms have a close resemblance to the anthrax bacillus, and the latter can only be distinguished by causing anthrax when injected into the lower animals. A refinement on this method, which is applicable in some cases, consists in injecting a normal animal and also an animal immunised against the organism suspected to be present in the culture. Ihus, the tetanus bacillus in pus is usually mixed with many other bacteria, so that it is excessively difficult to isolate. A broth culture is inoculated with the pus in question, and incubated in the absence of air, since the tetanus bacillus is an anaerobe. It is then di\'ided into two parts, of which one is injected into a normal animal and the other into one which has received a dose of antitetanic serum. If the former dies and the latter remains alive, the presence of the tetanus bacillus in the culture is certain. A few micro-organisms other than bacteria require brief mention, but most of them are of little surgical importance. lo A MANUAL OF SURGERY 1. The yeasts or hlastomycetes are devoid of chlorophyll, and multiply by budding, or endogenous spore-formation. They cause many forms of fermentation — e.g., the alcoholic fermentation in solutions of grape-sugar; they occasionally gain access to the urinary bladder in diabetes, and, by leading to the production of irritative products of fermentation, give rise to cystitis. The only important disease now attributed to the veast-fungi is blastomycetic dermatitis, which is characterized bv multiple chronic lesions, resembling verrucous tuberculides. 2. The hyphomycetes, or filamentous fungi, are characteiizcd by the presence of a mycelial network of long fibres, and have a method of sporulation which is more complicated than that seen in the bacteria or yeasts. The following are the more important of their pathological effects: Thrush, due to Oidiiim albicans, an organism sometimes included in the blastomycetes, and called Saccharomyces or Monilia albicans. Ringworm, which may be caused by Microsporon Audouini (the small-spored fungus), or the Trichophyton or large-spored fungus, of which there are several varieties. Of these the former is more common in London and Paris, but is rare in most parts of the Continent. Favus, caused b}^ the Achorion Schdnleinii. pityriasis rubra, due to the Microsporon furfur. Keratomycosis, or parasitic ulcer of the cornea, is due to fungi of the aspergillus type, and similar organisms may also affect the lungs (pneumomycosis) or the external auditory meatus (otomycosis). The group streptothrix rray be regarded as the lowest of the hyphomycetes, and its members possess many similarities to the bacteria. They are of importance, since their pathogenic members give rise to the group of diseases known as ' actinomycosis.' The streptothrices form long filamentous hypha, which are narrower than those of the higher fungi, and which differ from the leptothrical filaments sometimes exhibited by some bacilli in that they show true branching. Thev form chain-spores, the protoplasm of the mycelial threads collecting in small masses separated by spaces in which the sheath is empty. These appear to be true spores, since they resist a temperature higher than that which kills the mycelium itself. The streptothrices are widely distributed, and many forms are known, of which but a few are pathogenic. It is worthy of notice that the tubercle bacillus (as well as other organisms usually classified as bacteria) sometimes grows into long branching filaments. Hence some regard it as belonging to the streptothrices, and term it ' tuberculomyces.' 3. The protozoa, or unicellular animals, are a group of consider- able importance, since syphilis and not a few tropical affections are due to members of this family. The life-history of many of them is not known in its entirety, but it has been traced out in some. Malaria and the amcebic "form of dysentery, together with the tropical abscess of the liver associated therewith, are protozoal BACTERIOLOGY— INFECTION— IMMUNITY ii in origin. Trypanosomcs are also of animal nature, and by their development in the bod^^give rise to sleeping sickness and numerous other tropical diseases in man and lower animals. Infection. Infection may be defined as the access of living, virulent, patho- genic bacteria to a region whence their toxins may act on the tissues of the body. Certain points in this definition require ex- planation: (i) It is interesting to notice that dead bacteria, especi- ally dead tubercle bacilli, may cause pathogenic effects quite similar to those of the living ones. This, however, can scarcely be spoken of as infection, since one of the fundamental ideas of that process is that it can be transmitted from one sufferer to another indefinitely. (2) The question of vimlence is one of the greatest importance, since differing strains of the same organism may vary much in the degree of \arulence, as may also the same strain under varying conditions. Thus, rabbits are often but little affected by the injection of large amounts of a pure culture of the Streptococcus pyogenes, and yet it is possible so to exalt the virulence of the same culture that an extremely small dose (possibly a single coccus) may produce death. This exaltation of virulence is usually accomplished by ' passage ' through a series of animals, each in turn being inoculated from the last ; the disease appears more rapidly and runs its course more acutely in each instance up to a certain point of maximum intensity, which persists. Probably something of the sort occurs under natural conditions, for an organism taken directly from a patient is usually much more virulent than one that has been cultivated in the laboratory. Thus, a slight post-mortem wound infected from a case of streptococcic peritonitis is usually very severe, indicating a very high degree of virulence in the organism. In general, we know little or nothing of the causes which lead to increase of virulence under natural conditions, and especially so as regards epidemic outbreaks of disease. Cultures of an organism of diminished virulence are said to be attenuated. The artificial attenuation of pathogenic bacteria is a subject of great importance in connection with the production of immunity, and it may be laid down as a general rule that the cultiva- tion of an organism under shghtly disadvantageous conditions tends to diminish its virulence, and vice versa. For example, the anthrax bacillus grows best at 37° C, or thereabouts, and retairis its virulence for long periods at this temperature, but if it is culti- vated at 42° C. it becomes attenuated. Cultures thus treated con- stitute Pasteur's vaccine against anthrax; when injected into animals they cause transient ill-effects, but the animal becomes immune to the disease. (3) The organism must be pathogenic, if infection is to occur, arid by this we mean capable of producing disease in the animal in question. Thus, the inoculation of the gonococcus into the urethra 12 A MANUAL OF SUUGF.RY of animals leads to no results, and infection does not take place. Hence two factors must be present : the organism must be virulent, and the host susceptible. (4) Lastly, an essential feature of infection is that the toxins of the organism must act on the tissues of the host. Thus, it is quite possible, and not uncommon, for streptococci to be present in the outer layers of the skin, and the B. diphtherice in the mouth, etc., and yet for no harmful effects to arise, since either the organisms do not form toxins, or else these toxins do not reach the tissues. This is not infection, although in such cases any slight lesion or any condition leading to local or general lowering of resistance may bring it about. The terms specific and non-specific as applied to infectious diseases also require explanation. A specific disease is defined as one which is produced by a single cause — i.e., a particular species of micro- organism, and by no other. Thus, tetanus is a well-marked patho- logical entity, always due to the B. tetani, and may be taken as the type of a specific infection. Suppuration, on the other hand, is caused by many different species of bacteria, and is therefore termed ' non-specific' The boundaries of these divisions are constantly changing with the advancement of pathological research. The common process is for diseases which are apparently homo- geneous to be split up into specific groups, each due to its own organism. Thus, ringworm is now known to be due to several different forms of fungus, and combined clinical and pathological research have shown that the conditions due to one variety differ in minute points from those due to another. Again, actinomycosis was formerly thought to be a specific disease due to a single organism, but it has now been shown that many organisms may produce it. The reverse process is sometimes seen, several apparently different diseases being united together on the discovery of their cause. For example, malignant pustule and wool-sorter's disease are apparently quite distinct maladies; vet since it has been found that thev are both caused by the F>. anthracis they can now be included as manifestations of one specific disease. Local Infective Processes are those caused at the site of inoculation by the growth and development of the microbes. After a period of incubation — which varies with different organisms, and during which we may imagine that thev are struggling wdth the germicidal action of the tissues, and establishing their foothold in the body — the bacteria begin to grow and multiply, and bv the deleterious products of their activity cause irritation of the tissues and various degrees of inflammation. These inflammatory foci mav remain limited, or diffusion may occur by the bacteria spreading with more or less rapidity by con- tinuity of tissue or along lymph channels; or the organisms may be widely disseminated through the body by the bloodvessels in the shape of emboli. A certain amount of constitutional disturbance may accompany these manifestations, due to the absorption of the BACTERIOLOGY— INFECTION—IMMUNITY 13 toxins produced locally, whilst in some diseases the general toxic symptoms (or toxaemia) associated with some local mischief may be extremely severe, as in tetanus and diphtheria. Hence local in- fective processes ma}' be classed in two divisions: {a) those in which there is but little or no general toxaemia, such as a soft chancre, a tuberculous abscess, or a mild attack of gonorrhoea; and (b) those in which the toxsemic condition is well marked, as in erysipelas, tetanus, diphtheria, etc., the character of the symptoms varying necessarily with the different toxins. Many of the organisms which are the causes of local infection may also develop generally in the system, and produce grave con- stitutional affections. General Infective Processes are those in which the organisms develop and multiply in the blood-stream, so that inoculation of a sound person \\'ith the blood would almost certainly transmit the disease if a sufficient dose were introduced. Many of the bacteria producing local infection give rise to these general diseases, and, indeed, in surgery we rarely see the latter wdthout some local condition being present to explain its origin. Septicsemia, pya-mia, acute tuberculosis, the second stage of syphihs, anthracaemia, and probably the exanthemata, are illustrations of general infection (see Chapters V. and VIII.). Immunity. Under ordinary circumstances every living animal is constantly exposed to possible sources of infection. Bacteria are present in the air Vv'e breathe, in our food, drink, etc., as well as on our skins and in our alimentary canals. It is obvious, therefore, that there is some potent natural means of resisting the attack of these organisms, and that it is only when these means break down or are insufficient that infection occurs. This power of resisting the invasion of micro-organisms is termed immunity, and it is the exact opposite of susceptibility. Further, the process of natural cure of any infective disease is brought about by the production of such a degree of immunit}^ (whether local or general) as shall suffice to destroy the causative bacteria. It is therefore obvious that the study of immunity is of the greatest importance in connection \\dth the prevention and cure of disease, and the more so since the most potent artificial methods of accompHshing these ends are those which imitate, or stimulate, or give free play to, these natural processes. Natural Immunity is that which is inherent in the constitution of the animal when born, and not due to any event taking place in its hfe history. Thus the lower animals are all naturally immune to gonorrhoea and many other diseases which affect man, whereas man is naturally immune to many diseases of the lower animals. In most cases natural immunity is general throughout all the members of the species, but this is not alwa^/s the case; thus, some children are absolutely immune to vaccinia, though the vast majorit}- are M A MANUAL OF SURGERY susceptible. Hence racial and natural immunity are not quite identical. It must be clearly understood that there is no absolute standard of immunity, since the reaction of the tissues varies from time to time between the highest degree of susceptibility and the highest degree of immunity. Thus, if several animals are inoculated with equal doses of the same bacterial culture, one may show no ill- effects; another may exliibit a slight amount of inflammation at the site of inoculation; a third may acquire a spreading inflamma- tion, which may progress to suppuration or gangrene; whilst a fourth may develop a fatal general infection. Further, an animal may be highly immune to an organism of ordinary virulence, but at the same time highly susceptible to the same organism when its virulence is exalted. Again, the immunity or susceptibility of any animal to a given bacterium is greatly influenced by external and internal conditions. A study of these conditions is of fundamental importance in the prevention of disease. It may be regarded as certain that man possesses a verv considerable degree of immunity to nearly all bacteria (including even the tubercle bacillus), and it is only when this immunity becomes lowered by general or local causes which depreciate the vitalitv that infection occurs. Of the general causes which predispose to infection, cold and wet, especially if combined, are perhaps the most potent, but the method in which they act is still uncertain. Starvation and mal- nutrition are also important, and even in slight degrees have a very decided effect on immunity. Thus, it lias long been recognised that post-mortem wounds received when fasting are more dangerous than those received when digestion is in progress. In this case the immunity may perhaps be correlated with the increased number of leucocytes in the blood during digestion, but it does not appear to be a constant fact that a large number of leucocytes always implies a high grade of resistance, and vice-versa. Age is an impor- tant factor, children being, as a rule, much more susceptible than adults. Immunity is greatly reduced by hcemorrhage , and by certain poisons, particularly alcohol. Protracted exposure to a vitiated atmosphere is a very potent factor in the production of susceptibility to the tubercle bacillus. Prolonged ancesthesia lowers the general resistance of the body, as also certain diseases, notably Bright's disease and diabetes. The local causes include injury, especially bruises, contusions, burns, and the irritation due to chemical substances. This latter condition is often used in the laboratory to exalt the virulence of certain bacteria. Thus, pyogenic cocci are often without effect on rabbits, even in tolerably large doses; but if injected together with some dilute lactic acid, the toxins of other bacteria (such as B. prodigiosus), or other soluble irritant, they arc frequently enabled to develop and produce pathological results. Consider- able surgical importance is attached to this observation, since it BA C TERIOLOG Y~INFEC TION—IMM UNIT Y 1 5 must not be forgotten that nearly all antiseptics are irritant, and if applied in too concentrated a state or for too long may lower the local resistance, and render the wound more liable to be infected by any organism that may at the time or subsequently gain acci- dental entrance. The local application of cold or hot liquids has a similar action, and hence all fluids used to wash out wounds or body cavities should be used exactly at blood heat, unless the direct effect of the heat or cold is required. Lastly, a defective supply of fresh blood, due to disease in the bloodvessels, or stagnation of venous blood due to tight bandaging, pressure, etc., also renders a part less resistant to infection. Acquired Immunity is of two lands — active and passive. Active immunity results from a previous attack of the disease, either natural or due to artificial inoculation, so that the individual is freed from the risk of contracting it again. S\^philis and the exanthemata are good illustrations of diseases conferring an active immunity, which, however, is not always absolute, since well- confimied examples of second attacks, even of syphilis, have been recorded. On the other hand, it is doubtful whether tuberculosis and the pvogenic diseases are capable of producing immunity. The following are the most important artificial methods of bestow- ing active immunity: (i) Inoculation of the disease as it occurs in nature. This is of course a dangerous method, since the attack is almost as severe as one acquired in the normal way. It was for- merly practised as a preventive of small-pox before the introduc- tion of vaccination. (2) Inoculation with the virus of the disease or its causal micro-organism in an attenuated condition. Vaccina- tion is the best example of this process; the Ij^roph employed is a culture of the small-pox organism (the exact nature of which is at present not definitely known) in a state of diminished virulence. Pasteur also applied the same method in the prevention of hydro- phobia (p. 140) and of anthrax in cattle, the ' vaccine ' in the latter case being a living culture of anthrax bacilli attenuated by being cultivated at a temperature of 42° C. (3) Injection of dead cultures of bacteria is used in the preventive inoculation against plague (Haffkine) and against typhoid fever (Wright). The cul- tures are killed by heat, and small doses injected subcutaneously. The result is a local inflammatory reaction of varpng severity, together with general s\'mptoms, such as fever and malaise. When these have passed off, the patient has acquired some immunity to the disease, so that he is now able to withstand the injection of a larger dose or even of a li\ang culture, by which means the immunity is greatly increased. Koch's tuberculin (TR) is of a similar nature; it consists of an emulsion of finelv comminuted tubercle bacilli which have been killed by a process of grinding. This method has now been extended to the cure of man}^ other infective conditions. (4) Injection of the extracellular toxins of the causative organism is not used in man, but it is of the utmost value in immunizing the lower animals for the preparation of i6 A MANUAL OF SURGERY curative sera, especially antidiphtheritic and antitetanic. The horse is chosen for this purpose, since it is easy to liandle, and yields a large amount of serum at each bleeding. The principle of the method is simple. A small quantity of the toxin (which has been filtered to remove living bacteria) is injected subcutaneously. It causes local inflammation, fever, and malaise: but when these have quite subsided, another and slightly larger amount of toxin can be tolerated. In this way the dose is gradually increased, until the animal is so resistant that the injection of enormous doses of most powerful toxin will produce but slight and transient ill-effects. In actual practice this method is usually modified, the earlier stages being considerabh' shortened by the injection of a mixture of toxin and antitoxin, or by the use of peculiar forms of toxin of diminished activity. It will be noticed that in all these methods the animal which subsequently becomes immune combats with and overcomes the organism or its toxin, and is always rendered more or less ill (in some cases very slightly) by the process. For this reason it is teiTned an active immunity — i.e., it is acquired by the animal's own active combat with and victory over the disease. Passive immunity is that which is conferred on an animal without effort on its part by the injection of serum from an animal that has alreadv acquired an active immunity against the disease in question. For example, if some of the serum from a horse which has been actively immunized against tetanus is injected into a second horse (or other animal), the latter will also become immune to the tetanus bacillus or to its toxin. The second animal is not rendered ill by the injection, and is merely the passive recipient of protective sub- stances which have been elaborated by the first. The fact that the injection of these sera into man sometimes causes transient ill-effects, such as fever, joint-pains, rashes, etc., in no way modifies the truth of this statement : the phenomena in question do not always occur, and may be due to other causes (p. 28). Passive immunity cannot be bestowed by the injection of serum from an animal w^hich is naturally immune: most of the lower animals, for example, are naturally immune to syphilis, but their serum has no protective or curative action in man. The diseases in which the serum has the greatest practical value for protection or cure are those in which the specific micro-organisms produce extracellular toxins, especially diphtheria and tetanus. Active and passive immunity also differ in other respects. Passive immunity is produced immediately the serum is injected, whereas active immunity is only developed slowly after the in- jection of the toxin, or of the hving or dead culture; in general, a week at least must elapse before the full degree of immunity is produced. Again, passive immunity lasts a comparatively short time, unless, of course, the dose of the immunizing serum is repeated. In the case of a prophylactic injection of antidiphtheritic serum in man, the duration of the immunity is about a couple of months. BACTERIOLOG Y— INFECTION— IMM UNITY 1 7 Active immunity is usually much more lasting, though its duration varies greatly in different cases. In most cases of syphilis and small-pox it is permanent, second attacks being extremely rare, whereas in pneumt)nia and erysipelas it is of very short duration. When we turn to the theories which have been promulgated to explain the facts briefly outlined above, it must be borne in mind that there are two groups of phenomena which require elucidation: the immunity to the bacteria and the immunity to their toxins. Thus, if a culture of living diphtheria bacilli is injected together with their toxin into a susceptible animal, the bacilli will continue to grow in its tissues, and the toxin will exert its poisonous effects, both local and remote. If the same culture is injected into an immune animal (whether the immunity is natural, active, or passive), the bacteria will be killed and the toxin will have no action. This bacterial immunity must first be discussed. Omitting theories which are merely of historical interest, we come first to the humoral theory, which asserts that the destruction of the bacteria is due to certain substances which are present in the blood, lymph, etc., and which are designated alexins. The ex- perimental foundation for this theory consists in the fact that fresh blood, and more especially fresh blood-serum, has very consider- able bactericidal action. This action is destroyed if the serum is exposed to heat (about 60° C. for half an hour), and disappears spontaneously after a day or so; when the alexins have been destroyed by either process, the serum becomes an excellent culture medium for most bacteria. MetchJiikoff's theory of phagocytosis (the cellular theory) was at first in strong opposition to the humoral theory, but subsequent researches have brought the two closer together. Starting from the fact that unicellular protozoa (such as the amoeba) ingest, digest, and assimilate the bacteria found in water, Metchnikoff was led to examine the action of the leucocytes, or wandering cells of the higher animals, which in their morphology so strongly resemble the lower protozoa, and found in them a similar power of engulfing and digesting living micro-organisms. This process he termed -phagocytosis. A striking example occurs in Daphnia (the fresh-water flea), an animal which is so transparent that the whole phenomenon can be followed under the microscope during life. It is affected with a disease due to the growth in its tissues of a. fungus known as Monospora. The spores of this parasite are taken in with the food, and penetrate from the alimentar}- canal into the body cavity ; when unchecked, they continue to grow until the whole animal is filled with growth. If, however, but few spores gain access, the defensive mechanism comes into play, and the spores are surrounded and engulfed by the leucocytes, submitted to a process of digestion, and finally destroyed. It is ob\aous that Daphnia is partially immune to Monospora, and that the immunity depends on the phagocytic activity of its leucoc\i:es. Metchnikoff had no difficulty in finding many examples of the same process in 1 8 A MANUAL OF SURGERY man and tlie liiglier animals. If, for instance, a culture of a non- pathogenic organism is injected into the peritoneal cavity oi an animal, and ])ortions of the peritoneal fluid are examined from time to time, the bacteria will be seen first lying free; then engulfed in the protoplasm of the leucocytes, but retaining their normal appearance and staining reactions; then less distinct and refractile than before, indicating that they have undergone partial digestion, and in this state they stain badly. Similar appearances may also be seen in sections of tuberculous tissue, especially those that are healing, though here the phagocytic cells are not leucocytes, but endothelioid or giant cells. The leucocytes are attracted to the region of the bacteria owing to the fact that the latter give off soluble substances for which the leucocytes have an affinity, so that they move into the region in which these substances exist in a high state of concentration. This process is known as chemotaxis, and it is one which is widely dis- trilnited throughout the lower members of the animal and vegetable kingdoms. If, for instance, a capillary-tube filled with meat-extract is placed in a watery emulsion of typhoid bacilli, the latter will be attracted by chemotaxis and enter the tube. Similar phenomena are seen in the formation of an abscess: the pyogenic bacteria give off substances which attract the leucocytes, so that they soon become surrovmded by a zone of these cells, and at the same time some of these substances gain access to the blood and attract the leucocytes from the bone-marrow, giving rise to a general leuco- cytosis. Metchnikoff found that in cases where phagocytosis was active recover}^ usually took place, and that when it failed the bacteria continued to grow and death occurred; from this he argued that immunity depends entirely on the leucocytes. He further noted that in animals with acquired immunity the leucocytes had gained the power of ingesting the bacteria, although previously unable to do so; hence he explained acquired immunity as being due to the education which the leucocytes had gained during the previous attack. The opponents of the theory urged tliat only dead, or at least non-virulent, bacteria were taken up by the cells, but Metch- nikoff's great technical skill enabled him to isolate bacilli that had been actuall}^ ingested by leucocytes and prove them to be living and virulent. The theory of phagocytosis was never generally accepted in its original form, and it was soon found not to apply in certain cases. Thus, it is possible to enclose active bacteria in a collodion sac, which will allow the transudation of body fluids, but will prevent the passage of leucocytes ; if such a contrivance is placed in the peritoneal cavity of an immune animal, the bacteria are often killed. Further research also showed that even when bacteria are ultimately destroyed by phagocytic activity they may lose their definite out- line, |refractility, etc., and give other indications of being injured whilst still free and extracellular. The fact that this extracellular BACTERIOLOG Y— INFECTION— IMMUNITY ig injury or destruction usually occurs when the bacteria are sur- rounded by leucocytes led to the theory that the alexins are formed from or secreted bv the leucocj'tes. This is the celliilo-humoral theory, and it may be regarded as a compromise between the two views enunciated above. It agrees with the humoral theory in regarding the destruction of the invading bacteria as due wholly or partlv to soluble substances present in the bodv fluids; and with the cellular theory in attributing to the leucocytes the paramount role in the defences of the body, but differs from it in allotting to them a double action, partly chemical and partly phagocytic. Many facts go to prove that there is much truth in this com- promise, but it is not a complete explanation. Thus, Behring's investigations on the subject of passive immunity, especially in con- nection with diphtheria, introduced a new element and opened up a fresh field of research. It was found possible to cure the disease by a suitable serum or antitoxin which has no bactericidal effect whatever, so that its activity cannot be attributed to alexins or other bactericidal substances. Metchnikoff explained its practical value by attributing to it the power of stimulating the leucocyi:es to more vigorous phagocytic action; but this view can no longer be sustained, though, as we shall see, it has a substratum of truth. Further researches showed that the action of the antitoxin is an extremely simple one. It unites with its specific toxin, and forms a compound which is devoid of toxic properties. It is unnecessary to give the full evidence on which this statement is based, but one single proof mav be men- tioned. Several bacteria — amongst others the tetanus bacillus — - produce toxins which have the power of dissoKing red blood cor- puscles (haemolysis) ; hence these substances are called the bac- terial hemolysins. Experiments on haemolysis can be carried out in vitro, and it is thus possible to avoid all complications arising from phagocytosis or the action of the living tissues. Now it is found that tetanus antitoxin will prevent the hffimol}i:ic action of the haemolysin of the tetanus bacillus in the test-tube as well as in the body. Here, therefore, there must be merel\^ a simple process of chemical neutralization, which may be compared with the action of an alkali on an acid. The discovery of the antitoxins for diphtheria and tetanus led to numerous attempts to form similar substances for other poisons. It was found impossible to produce antitoxins for the alkaloids, mineral poisons, etc. iVntitoxins were, however, prepared for snake- venom, eel-serum, abrin, ricin, etc., and for some other bacterial toxins. These poisons have these factors in common: they are all formed in living organisms, whether animal or vege- table, and they are all proteids or closely- allied substances. The method of action of the antitoxins throws a certain amount of light on the mechanism of some forms of immunity. It has no bearing on natural immunity, for the blood of an animal which is naturally immune, say, to tetanus, does not contain tetanus anti- 20 A MANUAL OF SURGERY toxin; but in recovery from tetanus the antitoxin appears in the blood. When this happens, any fresh toxin that the bacilU form will be immediately neutralized, and the latter will thereby be deprived of their power to injure the cells of the animal, and can be dealt with by phagocytosis or other means. In the production of passive immunity similar phenomena take place; the antitoxin artificially mjccted in the blood combines with the toxin and shields the cells from its action. But this still leaves the method of formation of these antitoxins unexplained. Several theories have been advanced to account for this phenomenon, but the only one of importance is Ehrlich's side-chain theory. It is somewhat com- plicated, but the brUliant way in which it accounts for the chief facts, and its profound inlluence on modern ideas of pathology, justify a brief outline of its more important features. A toxin possesses two properties, that of poisoning a cell and that of com- bining with antitoxin, and Ehrlich proves that these two functions reside in different portions of the molecule. To the part that unites with antitoxin he gives the name ' haptophore," whilst the toxic portion is termed the ' toxophore.' Ehrlich next assumes that a molecule of living protoplasm may be con- sidered as consisting of two parts. One discharges the function of the cell of which it forms part, whilst the other subserves the nutrition of the former more highly differentiated portion, and has the power of uniting with mole- cules of proteid dissolved in the blood or lymph, and then building them up into living protoplasm. This function is suppo.sed to be accomplished by side-chains, or specialized portions of the cell, which unite with the molecules of food proteid. It is assumed that these latter contain a haptophore group similar to that of a molecule of toxin, but no toxophore group ; so that the first step in the nutrition of the cell consists in the union of a side-chain with the haptophore group of a molecule of proteid, a process which Ehrlich compares with the seizure of particles of food by the tentacles of a sea-anemone. Further, tliere are many varieties of proteids in the blood, and the molecules of each of these must have their own peculiar haptophore groups. Each haptophore group must ' fit ' a side-chain (like a key fitting a lock), or it will be useless for nutrition. In applying this view to the action of a toxin, it must be remembered that the toxins are proteids or similar substances. If we inject a solution, e.g., of tetanus toxin into an animal, it may happen that the side-chains carried by the animal's cells do not possess haptophore groups which ' fit ' those of the toxin; in this case no poisoning can occur, as the to.xin cannot unite with the cells. If the cells do po.ssess such side-chains, they will unite with the haptophore of the toxin, just as if these side-chains had seized a nutritious molecule. The toxophore radicle is thus brought into action, since it is united to the cell by means of the haptophore group and side-chain. Pre- sumably it exerts an injurious influence similar to that of an enzyme, and the integrity of the functionating part of the protoplasmic molecule is thereby destroyed. In other words, the first step in the into.xication of a cell by a true toxin is exactly the same as the first step in cell-nutrition. Suppose, now, that a certain number of the side-chains are fixed to molecules of toxin, and that the living molecule is injured, but not fatally. The side- chains are necessary for the nutrition of the cell, and those that are rendered useless must be regenerated, just as a hydra replaces a lost tentacle. If a second dose of toxin is given this process is repeated; and if we continue to administer toxin in suitable (non-lethal) doses, we may gradually ' train ' the cell to produce side-chains more and more rapidly. But it often happens that the reaction of a living tissue is much greater than the stimulus demands ; e.g., the formation of callus is disproportionate to the amount of bone to be replaced. Jhis may be presumed also to happen in the production of antitoxins. The cell produces more side-chains than it has any necessity for — more, indeed, than can JJA CTJiRJOLOG Y— INFECTION— 1 MM UNIT Y 21 remain united with it, and the super/luous ones detach themselves from the cell and float off in the blood. They still retain their power of uniting with the huptophore group of a toxin molecule, thereby rendering the toxin inert, and thus they constitute antitoxin. It is impossible to discuss here the evidence that has been brought forward in support of this theory, but one remarkable point may be noticed. For a cell to be poisoned by a given toxin, it is necessary that it should contain side-chains which ' ht ' the haptophore group of that toxin. But antitoxin consists of such side-chains, so that it follows that any cell which can be poisoned by a toxin may be made to produce an antitoxin to it. There is evidence that this is the case in tetanus, the toxin of which (tetano-spasmin) acts only on the cells of the central nervous system. It was found by Wasser- mann that an emulsion of the gray matter of the brain has the power of neutralizing tetanus toxin just as antitoxin has, but that this power is lacking from emulsions of other tissues. Thus the cells of the central nervous system are the only ones which have side-chains that can unite with the tetanus toxin. Again, it would not be surprising if some of these side-chains were to break off and pass into the blood under natural conditions. This actually happens, for traces of antitoxins (and other ' antibodies ') frequently occur in normal blood. Ordinary chemical poisons do not give rise to the formation of antitoxins, since they do not unite especially with the side-chains as if they were nourish- ing proteids, but form chemical combinations with all parts of the molecule indiscriminately. It was soon found that substances allied to antitoxin might be obtained by the injection of proteid substances other than toxins into living animals. These are known as antibodies, the term being used to include precipitins, agglutinins, cytolysins, bacteriolysins, etc. Precipitins are substances formed by the injection of proteid solutions, and have the property of forming a precipitate when mixed with a solution of the same proteid as was injected. Thus, if a solution of egg albumen is in- jected into a rabbit, the serum of this animal (after a week or so) will give a flocculent precipitate with egg albumen, but not with other proteids. The precipitins are not known to have any bearing on the question of immunity, except in that they form an example of the general law that if any foreign proteid is injected into a living animal it gives rise to the production of an antibody. Agglutinins are formed by the injection of bacteria, red blood corpuscles, cells, etc., and they have the power of causing the cells injected to collect into clumps. A special case of great importance is in typhoid fever, where the agglutinin is formed early in the disease and is of diagnostic value [Widal's reaction). In most infections this is not the case; thus in pneumonia the serum rarely shows any power to agglutinate the pneumococcus before con- valescence is established. They are, however, of value in that they often enable the bacteriologist to prove the causal relationship of an organism and the disease it is supposed to produce. Thus in the investigation of the path- ology of dysentery various organisms are isolated from the stools, and if one of these is found to-be clumped powerfully by the patient's own serum, it affords strong proof that it is really the infective agent. The agglutinins are also useful as proving the identity of an organism which has been isolated in culture. For example, if a culture of an organism resembling the tjnphoid bacillus had been isolated from the stools in a case of suspected typhoid fever (or from drinking-water, etc.), the first test applied to establish its nature would be to see if it clumped with the serum of an animal which had been injected with a known culture of typhoid bacilli. Agglutinins are not known to play any part in the production of immunity, and their presence in the blood does not necessarily indicate that the animal is immune, though this is usually the case. The next group of antibodies — cytolysins (including the bacterio- lysins, hcBmolysins, etc.) — are of great importance in the doctrine 2 2 A MANUAL OF SURGERY of immunity, and are much more complex in their structure and action than the preceding. The earliest indication of their existence was obtained by Pfeiffer, who immunized guinea-pigs to the cholera vibrio, and when the immunity was fully established injected a culture of that organism into the peritoneal cavity. Some of the peritoneal fluid was withdrawn from time to time, and the organisms therein examined microscopically. They were found to undergo remarkable changes, losing their shape, becoming spherical, and finally undergoing complete solution; the whole process often takes half an hour or so. This is called Pfeiffcr's reaction, and is specific — i.e., the peritoneal fiuid of an animal vaccinated against cholera has no effect on the typhoid bacillus or any organism other than the cholera vibrio or its congeners. Further research showed that the reaction can be obtained in vitro, provided that the peritoneal fluid is perfectly fresh; if, however, the fluid is kept a day or two, it loses this power, but regains it if mixed with perfectly fresh serum, whether tliis be taken from a normal or from an immunized animal. Thus: Fresh normal blood serum.+ cholera vibrios = no reaction. Fresh serum (or peritoneal fluid) from immunized animal+ cholera vibrios = solution. Stale serum from immunized animal+ cholera vibrios =no reaction. Stale serum from immunized animal+ fresh scrum from normal animal + cholera vibrios =solution. It is obvious from this that tivo substances are necessary for the solution of the organisms in the tissues of an immunized animal. One occurs only in the fluids of the immunized animal, not in a normal one, and is an antibody similar to the agglutinins, but more complex; it has received many names, and is usually known as amboceptor, or substance sensibilatrice. The other occurs in normal blood, as well as in the blood of the immune animal, and is very fragile, rapidly disappearing when the fluid is kept ; it is also readily destroyed by heat. It is probably the same as the alexin referred to above in connection with the humoral theory of immunity, but German writers usually term it the complement. Further research on the antibodies of this group has been greatly facili- tated by Bordet's discovery of the production of ha?molysins by the injection of blood from one animal into another of a different species. Thus, rabbit's serum is without effect on the red corpuscles of a horse; but if the rabbit is injected with a horse's red corpuscles, its serum acquires the power of dis- solving or haemolyzing them. These haemolysins apparently act in exactly the same way as do the bacteriolysins in Pfeiffer's reaction, and are much more convenient for experimental purposes. Further, it appears that the reaction is a general one, and that cytolysins can be prepared for sperma- tozoa, liver and kidney cells, cells of the central nervous system, etc., and that in each case the reaction depends on a stable antibody or amboceptor and a labile ingredient of normal blood, the complement or alexin. In applying these facts to the production of acquired immunity — e.g., to the immunization of an animal by injections of small doses of cholera vibrios — it must be noted that the organism at first continues to grow in the tissues; the only known force capable of opposing it at this stage is the action of the phagocytes, for the BACTERIOLOG Y~-INFECTION~IMMUNITY 23 alexins or complements are unable to act, since they cannot imite directly with the bacteria, and there is no amboceptor. After a time the cells of the host begin to form antibodies to the proteids of the bacterial protoplasm. Some of these may be antitoxins, which pre- vent the further intoxication of the animal; others are agglutinins, which are without known value to the host ; lastly, there are ambo- ceptors which link the alexin or complement of the blood to the bacteria, and bring about the solution of the latter. The animal is now immune, and when any further invasion with cholera vibrios takes place the apparatus of amboceptor and complement is ready for the defence of the animal. Further, the serum of the animal contains amboceptor, and when injected into a second animal this acquires passive immunity, provided that a suitable alexin is also present. This is one of the practical difficulties which prevent the successful application of the bacteriolytic sera in medicine. The alexin presen'. in the serum of the immunized animal soon disappears, and although an amboc ^ptor which is formed in the blood of one animal is alwa^-s capable of being ' activated ' by the complement of the same animal, it cannot necessarily be activated by the comple- ment of other animals. This question is one which is extremely complex, and is at present not thoroughly investigated, though we can hardlv hope for any further advance in serotherapy until it has been elucidated. The role of the leucocvtes now acquires fresh interest. We have alreadv seen reason to believe that alexin is derived from these cells, and some hold that they are also the main source of the production of amboceptor and the other antibodies. The study of these latter substances has afforded a further insight into the function of phago- cytosis. It was found (by Mennes) that leucocytes from a normal animal had no power of ingesting virulent pneumococci, but that they acquired this power when mixed with the serum of an animal which had been immunized to pneumococci. It is thus evident that immune sera have the power of- aiding the action of the leuco- cytes, presumably in virtue of containing an antibody which unites with the bacteria and renders them vulnerable. The antibodies which act in this wa}' might be antitoxins, amboceptors, etc., but it is possible that they may be fundamental^ different. Sir Almroth Wright, who has done much in elucidating this field of work, terms them opsonins (from opsono, I cook, or prepare for food), and holds that the amount which is present in the blood determines the degree of immunity to various infections. That they act directlv on the bacteria maj^ be proved thus: Bacteria are mixed with fresh serum, and the latter removed by centrifugalization, and the organisms freed from all traces of serum by repeated washings with normal sahne sohition. Bacteria thus treated are taken up by the leucocytes as readilv as if the serum were still present, from which we infer that they have retained some element of the serum which has sensitized or prepared them for phagocytosis. It is, of course, possible that the serum may also act directly on the leu- 24 A MANUAL 01- SURGERY cocytes, stimulating them to greater activity, but there is no proof of this. These substances have recently been the subject of much in- vestigation, both from the clinical and scientific aspects. There is, of course, no method by which the amount present in a given sample of serum can be estimated quantitatively, but Wright has devised a process by which the quantity in two specimens can be compared. Thus it is possible to count the number of individual bacteria of any particular type which can be ingested by washed healthy leucocytes when mixed with a patient's serum, and the number ingested bv similar leucocytes mixed with the serum of a known healthy individual, the two mixtures being kept at the body temperature for the same period of time. The ratio between these two numbers is termed the opsonic index. The test is carried out by preparing two mixtures in separate long capillary pipettes. The first contains equal parts of washed corpuscles, bacterial emulsion, and the patient's serum ; the second, equal parts of washed corpuscles, bacterial emulsion, and the healthy serum. The contents of each pipette must be well mixed. The two pipettes are then in- cubated for fifteen minutes at body temperature. Films are prepared from each mixture, suitably stained, and examined microscopically; the leucocytes will be found to have ingested a certain number of the bac- teria (Fig. 7). A careful count is now made of the number in 50 or 100 leucoyctes in each preparation, and the ratio between the totals determined. Thus, if in the preparation cor.t lin- ing the normal serum there were 240 organisms {e.g., tubercle bacilh) in 100 leucocytes, and in the other only 120, the opsonic index would be ^§= 0-5, showing that the patient's serum contained much less of the opsonin to the tubercle bacillus than did that of the healthy person. In practice the process is a difficult one, and many precautions are necessary if accurate results are to be obtained. Opsonins are delicate substances, which chsappear on keeping, and are readily destroyed at moderate temperatures (60" C. or less), closely resembhng the alexins in this and some other respects. They appear to be specific (though this is disputed). A patient may have a high opsonic index to one organism and a low one to another. Healthy persons approximate closely to one another in their Fig. 7. — Phagocytosis of Tubercle Bacilli in Opsonin Preparation. (Emery.) ILI CTERIOLOG Y— INFECTION— IMM UNIT Y 25 opsonic indices. In the case of the tuliercle bacillus it is rare to find a non-tuberculous patient with an index above i-2 or below o-8, and in a doubtful case a figure decidedly above or below these limits is very suggestive of tubercle. The diagnostic value of this test, however, is diminished by the fact that many tuberculous patients have normal indices. As a general rule, in cases of acute diseases, it is found that the index is below normal, and that as recovery occurs it rises to or above the healthy level. This rise may be sudden, as in most cases of pneumonia, or gradual, as is usually the case in furunculosis. It is not uncommon to see patients in whom the disease is progressing though the index is high, and this is especially the case in tubercle. Oct. 8 9 10 11 n 13 1A 15 16 17 1S 19 io x\ n 23 n 35 u 27 Xi %.- U* 1.9 i 1 f?' 1.8 D- (U 1.7 5- ^ ^ A \ 16 "^ ^ ^ ^ 1 i \ 1.5 ^ ^ / \ 1.4 ^ i f 1.3 t ^ A 0- / 1.2 J? i r V -^ 1 1.1 ^ / A 1.= ■ A r^ ^ \ .9 1 \ f ■^ =.8 / v f v =.7 / V %6 ,/ / .5 1 Fig. 8.- -Chart of Opsonic Index in a Case of Injection of a Staphylococcic Vaccine. It is too early to form a definite opinion of the importance of the opsonins in immunity. There can be no doubt that they play some part, but they are not the sole agents; and their importance has certainly been exaggerated by man}^ authorities. In some respects their discovery has rendered the phenomena of immunity still more difficult of comprehension. Wright has put the study of the opsonic index to practical use in the regulation of the dosage of his vaccines (Fig. 8). After each injection there is a rapid fall in the opsonic level (the negative phase), followed by a rise, the index usually going well above normal (the positive phase). The improvement is supposed to coincide with and be due to the increased amount of opsonin in the blood, and when this begins to diminish, a fresh injection is given. A second injection should not be given during the negative phase, since if this is done the index falls still further, and it is held that danger (of dissemination or rapid spread of the disease) might arise. 26 A MANUAL OF SURGERY Wright therefore controls his injections by ])erioclical examinations of tlie opsonic index, determining the dose which gives the maximum rise, and giving a fresh injection as soon as the effect begins to wear off. The experience of the past few years has, however, shown that the frequent and laborious estimations of the opsonic index are really unnecessary, and the majority of practitioners dispense with them in the more simple cases, relying for the recognition of the good or bad effects upon the clinical results — e.g., diminution of fever, dis- charge, or pain, commencing healing of the wound, etc. Where this fails, opsonic control should be resorted to, as also when dealing with internal infective processes, especially if acute and dangerous, and particularly in septicaemia and basic meningitis. The practical applications of these researches and theories of immunity are twofold — diagnostic and therapeutic. The chief examples of their diagnostic application are the agglutination reac- tion, as used in Widal's test (p. 21) in the diagnosis of typhoid fever and to a less extent in other diseases, Wassermann's reaction in syphilis (p. 153), and the employment of the opsonic index. The therapeutic applications are more important, though there is still much to be done before their practical use is fully understood. The substances employed in artificial immunization, and in the curative treatment of disease, fall under three main headings: I. Vaccines, using the temi more especially in reference to the emulsions of dead bacteria referred to on p. 15. As used curatively, they are prepared as follows: The organism is obtained in a pure condition from the patient to be treated, and a voung culture is emulsified with sterile normal saline solution, and sterilized by being heated in a sealed test-tube to a suitable temperature — e.g., 60° C. for half an hour. The number of bacteria per cubic centimetre is then ascertained (there are several methods by which this can be done), and the emulsion diluted with a sterile 0-25 per cent, solution of lysol or carbolic acid in normal saline solution. 1 he degree of dilution has, of course, to be determined by the strength of the original emulsion, and by the number of bacteria which it is desired to administer in each dose. This varies greatly with different organisms; thus staphylococci and gonococci are usually tolerated in large doses (500,000,000 or more), whereas B. coli in large doses causes severe local and general symptoms, and the number given should be much smaller. As a rule, too, the patient acquires some degree of tolerance, and the dose may often be slightly increased as the treatment progresses. It is always advisable, where practicable, to prepare the vaccine for each patient from the organism which is attacking him (auto- genous vaccine), since there are minute differences between the various strains of bacteria, and a ready-made vaccine may not prove efficacious against an infection with, apparently, the same species. This is less important in the case of the staphylococci, more so in dealing with the streptococci and B. coli. As, however, the vaccine takes a few days to prepare (having to be tested for sterilit}), it is BACTERIOLOG Y~INFECTION~IM MUNITY 27 often a good plan to commence the treatment with a small dose of a stock vaccine. At present the use of vaccines must not he looked upon as replacing surgical t-eotmenf, but as an adjunct thereto. Abscesses must be opened and drained, dead bone removed from the bottom of a sinus, etc., just as before, but the use of a suitable vaccine mav often greatly aid the process of healing and shorten the conval- escence. In cases which are not amenable to surgical treatment, or in which the surgeon desires to wait for a time before operating, this treatment should be tried whenever possible. Boils, however, may often be aborted in a most striking manner bv an injection of 250,000,000 to 500,000,000 staphylococci. 2. Antitoxic Sera are the antitoxins to tetanus, diphtheria, and possibly, to some extent, dvsenterv. These, as has already been explained, contain substances which neutralize the extracellular toxins of the organisms in question : the problem of preparing potent antitoxins for the intracellular toxins has not yet been solved. The main point to notice in the use of antitoxic sera is that they will render the toxins inert, pro\'ided that they are brought in contact therewith before the latter have combined with and injured the living cells; hence the importance of their early administration. Time may also be saved by intravenous injection, since it has been found that diphtheria antitoxin is not fully absorbed from the sub- cutaneous tissues for twenty-four hours or more. The process is simple. The serum is warmed to body-heat and sucked into an all- glass syringe (carefully sterilized). The skin over a large vein of the forearm is prepared as for an operation, and the vein itself rendered prominent bv obstructing the circulation bv gentle pressure with the finger. All air is removed from the syringe and needle, and the latter introduced obliquely at the side of, and about | inch from, the distended vein. It is pushed gently in until the vein is entered, when the blood will rise into the syringe. As soon as this happens, the finger which is obstructing the vein is removed, the piston pushed gently down, and the antitoxin forced slowly into the circulation. There is less object in administering the serum bv this method in tetanus than in other cases ; but even here the first dose may be given in this way with advantage. 3. Other Sera. — These act bactericidally (from containing ambo- ceptor), or perhaps facilitate phagoc\i:osis. They are not, as a rule, so potent curatively as are the antitoxic sera, but, wiiere these and the vaccines are not available, mmst be given a trial. The sera most important in surgical practice are : {a) Anti-stre ptococcic Serum. — This is prepared by immunizing horses with living cultures of Streptococcus pyogenes. This organism is found to present marked differences in cultures from various sources : and since it is held that a serum prepared against one variety is useless against another, polyvalent sera are prepared by treating horses with cultures from manv sources, and should always be used if possible. If no noticeable benefit follows shortly after the first 28 A MANUAL OF SURGERY dose, it is advisable that the second should be from a different laboratory, as one serum may be efficacious in one case and another in a different one. If there is marked improvement, especially a fall in the temperature, the serum should not be changed. A transient rise of temperaturi; (due, possil)ly, to solution of the streptococci and liberation of their toxins) is not necessarily a bad sign, and is often followed by marked improvement. The dose may be lo to 20 c.c, or even more. (b) Anti-anthrax Sera, of which the best known in this country is that prepared by Sclavo. This has given excellent results in the treatment of localized anthiax (malignant pustule), and the improve- ment is often manifested within twenty-four hours. (c) Anti-pneumococcic Serum (Pane's or Romer's) may be tried in severe pneumococcal infections, more especially in septicaemia and peritonitis, and in some cases seems to act well. Good results have also been obtained in pneumococcal ulceration of the cornea (ulcus serpens). There are numerous other sera, which do not call for notice. Serum Disease. — It sometimes happens, especially if the patient has received large doses of antitoxin, that a remarkable series of phenomena take place after an incubation period of eight to twelve days or more. The chief are fever; a skin rash (urticarial, scarlatiniform, or morbilliform), usually accompanied by severe itching; enlargement of the lymph-glands, corresponding to the site of infection ; pains in the joints, especially the metacarpo-phalangeal, wrist, and knee; and leucocytosis. Though unpleasant, the symp- toms are not dangerous, and recovery usually occurs in a few days. Calcium lactate, in 15-grain doses at the time of the injection and for a day or two subsequently, diminishes the frequency with which the disease develops, and constitutes the best treatment for it when developed. Anaphylaxis is a condition of supersensitiveness to certain proteid substances, such as serum, egg albumen, bacterial toxins, etc., set up in the body by their injection. It may follow one in- jection, or may require several in order to determine its occurrence. Thus, if a subtoxic dose of horse serum is injected into an animal, and a second subtoxic injection be made after a suitable interval, the second injection may be followed by marked toxic or even fatal symptoms. About eight to twelve days is usually the minimum necessary to establish anaphylaxis, and the condition may persist indefinitely. Thus, a patient with sarcoma of the ileum had been treated repeatedly and wth much benefit by injections of Coley's fluid. After a somewhat prolonged interval he was again submitted to an injection of half a minim of the fluid. The result was a febrile attack of great intensity lasting for over a week, with a temperature of 104° F., which only gradually siibsided to the normal. Nothing definite is known of the cause of this phenomenon, and the treatment is merely symptomatic. CHAPTER II. INFLAMMATION. ' Inflammation is the succession of changes which occur in a Hving tissue when it is injured, providing the injury is not of such a degree as at once to destroy its structure and vitaHty.' Such was the definition given in 1870 by Burdon Sanderson, and it is sufficiently accurate if we reahze that the exciting injury usually involves the admission of a soluble chemical irritant, and in most cases of a bacterial toxin ; we must also exclude from the process of inflamma- tion the later stages of repair. Formerly inflammation was looked on by pathologists as always of a destructive and harmful nature; but at the present time bacteriological research has demonstrated that, if it can be suitably controlled, it is rather of a protective or conservative character, being Nature's means of limiting the advance of noxious micro-organisms, and of finally eliminating them from the system. Occasionally, however, the tissue reaction called into existence by bacterial invasion is so severe as to increase, rather than diminish, the risks of the patient, who may, moreover, be destroyed by absorbing virulent toxic bodies produced by the bacteria. The causes of inflammation are varied and numerous. Most frequently it is due to the admission of bacteria, and we have already alluded (p. 14) to the conditions, local and general, which pre- dispose an individual to such invasion, and render him more liable to an inflammatory attack. Apart from bacteria, inflammation may be lighted up by (a) mechanical lesions, such as blows, sprains, tension, pressure, etc. ; (b) burns or scalds ; (c) toxic bodies, such as acids, alkalies, or vegetable and animal poisons; and (d) the electric current, either in the form of lightning, or as applied by the surgeon or through the agency of strong currents as employed for purposes of traction or illumination. It is but fair to state that not a few authorities look on the tissue reaction caused by these non-bacterial irritants as distinct from inflammation, limiting the latter term to conditions resulting from bacterial invasion. The phenomena, however, are identical up to a certain point, and we see no advan- tage in the suggested dissociation. 29 30 A MANUAL OF SURGERY The actual phenomena of inflammation are ju'iiiaps 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 physiological activity may be seen : {a) the flow of blood through the vessels (Fig. 9), as indicated b\' 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 rolhng lazily along in the inert corpuscle-free peri- pheral portion of the tube: {b) the constant rhythmical changes in calibre of the arterioles independent of the heart's action, and influencing in a marked degree the flow through the capillaries: and (f) the changes which occur in the pigment-cells, and are mainly due to the influence of light, the cells contracting or expanding as the light is increased or diminished. I. The Vascular Changes in acute inflammation. If a crystal of common salt, or some such irritant, is applied to the web, 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 b}' a rapid and lasting dilatation of the vessels, accompanied by an increase in the rapidity of the blood-flow {acceleration) ; it is probably brought about by some change in the local vasomotor mechanism present in the 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 the passage of the blood; next a period of oscillation will be noticed, the crowded corpuscles 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 coagula- tion. During this period the relations normall}- existing between the vessel walls and the varied constituents of the blood have obvi- ously become modified, as a result of invisible changes m the former, and not of 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 changes, Exudation, becomes evident at a very early stage. Every element of the blood partici- pates in this process. It has been already mentioned that the leucocytes collect in the peri-axial layer, a phenomenon due partly to an alteration in the vessel wall, whereby it is rendered more ' sticky,' and partly to chemotaxis (p. 18). The next change consists in the passage of the leucocytes through the vessel walls, especially those of the smaller veins and less often of the capillaries. The process is a strictly vital one, brought about by amoeboid movement ; a small INFLAMMATION 31 arm or outgrowth of the leucocyte {pseudopodium) is inserted between the endothehal cells lining the vessel, whose cohesion has been probably interfered 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 surrounding connective tissues (Fig. 10). The migration of 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 perivascular tissues, it may undergo various changes. In the first place, it may die and be at once disintegrated, setting free fibrin ferment, and thus assist in the production of the inflammatory coagulum to be shortly de- scribed; or, again, it may find its way back into the circulation Fig. 9. Fig. 10. Semi-diagrammatic Representation of the Vascular Phenomena of Inflammation (after Thoma). On the left is a normal vessel with its peripheral la5'^er free from corpuscles, and its axial stream so rapid that the individual corpuscles cannot be seen. On the right is a similar vessel in a state of inflammation; the blood-current has been retarded so that the individual corpuscles are visible; the leucocytes occupy the periphery of the vessel, and are in process of migration, whilst sundry red corpuscles can also be seen in the surrounding tissues. through, the lymphatics, or be transformed into a pus corpuscle ; moreover, prior either to disintegration or transformation into a pus corpuscle, it may attack and assist in removing any dead tissue which exists in the neighbourhood of the inflammatory focus, whilst a phagocytic or microbe- destroying function 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 destruc- tive process, they in turn give place to larger and more useful 32 A MANUAL OF SURGERY cells (fibroblastic) 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 acute attacks. When once external to the vessels, they are broken up and tlu-ir colouring matter diffused through the tissues, whence, as a rule, it is completely reabsorbed. The liquor sanguinis is also extravasated. This is merely an exaggeration of a normal process, but to such an extent that although for a time the lymphatics of an inflamed region do in- creased work, yet the transudation is soon greater than they can deal with. If the fluid escapes into the tissues, it undergoes coagu- lation by meeting the necessary coagulating media developed from the breaking-down leucocytes; inflammatory lymph forms locally, whilst the serum collects in the meshes of the tissues, constituting an inflnmmatorv form of oedema; 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.e., consists of plasma) ; if coagulation occurs, the clot or lymph eitlier forms an adherent plastic mass on the surface or floats free in the fluid. Looked at, therefore, simply from a vascular point of view. Inflammation^ Hypercemia + Exudation. Each of the elements in the inflammatory reaction is of benefit to the patient in combating a colony of bacteria, which together with their toxins have gained access to the tissues. The accelera- tion of the blood-flow serves in the first place to dilute and to remove the toxin; if the amount present is small, the rapid flow of blood may serve to remove it completely, and then the process begins and terminates in hyper?emia. Further, the increased supply of blood must serve to keep the nutrition of the tissues at its highest level, so that if possible they may be preserved alive in spite of the action of the toxin. Lastly, if the blood contains antitoxins, or other antibodies, or alexins (complements), which inhibit the action of the toxins or destroy the bacteria, these will be brought in large amounts to the region where they are required. The excessive transudation of the plasma may be regarded as an additional means of fulfilling these desiderata. The value of the retardation and stasis of the blood is less obvious, although it probably assists the emigration of the leucocytes, which might otherwise find difficulties in attaching themselves to the walls when floating freely in a rapid blood-stream. The role of the leucocytes has been already con- sidered. II. The Tissue Changes in inflammation cannot be so easily ob- served as the vascular, but are of great ini]-)()rtance. The reaction of the tissues in acute bacterial inflammations aj)- pears to depend entirely on the irritative power of the toxins, or INFLAMMATION 33 rather on the relation of this power to the resistance of the patient's tissues. It may be laid down as a general rule that any irritant, if weak enough {e.g., when very diluted), acts as a stimulant to the growth of cells; on the other hand, if sufftciently powerful, it will cause some variety of necrosis or death of the tissues. Uncom- plicated examples of tissue-overgrowth in acute inflammation are not often seen in man, since the slighter lesions are rarely examined microscopically. The process is best observed in the early stages of acute inflammation of serous membranes in animals, where the endothelium may be seen several cells thick, whilst its nuclei show active mitosis, pro\ang that cell-proliferation was in progress. An examination of the outer zone of a mass of granulation tissue (where the toxins are present only in small amount) will often show similar appearances. In most cases, however, the toxins are more active, and death of the tissue results. This is often brought about by what is termed coagitlation-iiecrosis. In this condition the tissues and cells become soaked in the coagulable plasma which exudes from the vessels, and the activity of the toxins causes coagulation and death of the whole mass. The result is that all structure disappears from the area involved : the nuclei cease to stain with hematoxylin or other basic d3'es, and all the tissues stain uniformly with acid stains, such as eosin. The further history of the lesion depends on the nature of the causative organisms. If these are of a pyogenic nature, the necrotic mass will become (or has already become) infiltrated with polynuclear leucoc\i:es, some of which are killed by the toxins, and suppuration follows (see p. 74). When the organism is not of this nature, the polynuclear leucocytes make their appearance in but moderate numbers, and the inflamed area becomes infiltrated with ' small round cells,' which appear to be identical with hmiphocytes. It is as yet uncertain whether these are formed locally or whether they are attracted from the blood. It seems, however, tolerabty clear that they undergo a local increase by direct division in the inflamed area. If the bacteria are killed and the process stops at this stage, the phenomena of repair supervene (Chapter X.), and the inflamed part is replaced by a mass of fibro-cicatricial or scar tissue. In non-bacterial inflanimations of superficial parts the amount of effusion between the individual cells may be so excessive as to separate and disintegrate them, and thus colliqtiative-necrosis ma}' be induced, as occurs in the formation of blisters after a burn. In chronic inflammations, on the other hand, active cell-prolifera- tion is a most important element in the process, resulting in sclerosis and induration of the parts. This,, however, mainly affects the interstitial tissues, and thereby the true structure of the organ may be impaired. III. The Terminations of inflammation will therefore vary con- siderably, and more especially with the cause of the trouble, whether bacterial or not, with the intensity and duration of its action, and finally with the powers of resistance possessed by the individual. 3 34 A MANUAL OF SURGERY In bacterial inflammations (i) it is unusual for the tissues so to assei t tliemselves as to permit of the occurrence of resolution, or the reappearance of tlie s/atiis quo ante ; it is, however, seen occasionally. (2) More frequently local destruction of tissue results, and, according to the nature of the bacteria and the tissues involved, this may be followed by {a) repair, the necrotic tissue disappearing and scar tissue taking its place; {h) suppiiralion, in which the affected tissues and the exudate are liquefied and transformed into pus; evacuation of the abscess thereby formed gives exit to the bacteria, the exudate, and the necrotic tissue, and repair is finally brought about by cica- trization ; (c) ulceration, when the necrotic or suppurative process affects the surface; or {d) extensive necrosis or gangrene, when the toxic effects of the bacteria are able to break down the tissue re- sistance to such an extent that the bacteria can diffuse them- selves widely through the part. In this connection it is interesting to note that the more highly organized and important organs 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. When the inflammatory attack is due to mechanical or other non- bacterial causes, there is frequently much effusion of fluid, and at first but little cellular exudation, whilst the process is distinctly limited and has no tendency to spread. The most common termina- tions are: (a) Resolution, complete and absolute, which is seen not uncommonly; {h) the formation of fibro-cicatricial tissue, as seen in the organization of lymph into adhesions; (c) sometimes the in- flamm.atory process becomes chronic, and is then characterized by sclerosis or fibroid thickening of the part, or by persistent effusion into a serous cavity. Resolution, or the restoration of the part to its natural condition and function, can only occur when the injury has not been so severe as to destroy the vitality of the affected tissues. 'Ihe phenomena 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 is some time before the peripheral inert layer can be seen. The (-xuded leucocytes find their way back into the circulation either through the vessel walls, or to a greater extent via the lymphatics, or else they are disinte- grated in the tissues and absorbed. The fluid exudate is removed by the lymphatics. For some time after an acute attack the vessels of the part, especially the veins, are dilated from simple loss of tone, but this also gradually disappears. IN FLA MM A TION 35 Clinical Signs of Inflammation. The Local Phenomena may be described under the four headings suggested by Celsus (about a.d. 50), viz., heat, redness, swelhng, and pain, with the addition of a fifth, viz., impairment of function. Heat. — An inflamed part feels hot to the touch, and the tempera- ture, if taken by a surface thermometer, is definitely raised above that of the surrounding skin. This is due to the increased amount of blood flowing through it, for 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. The cause of the increased temperature of the blood is noted elsewhere (p. 37). Redness is due to the h^-perjemic condition of the inflamed part. In the early active h37pergemia the colour is a bright rosy-red, fading quicklv on pressure, and returning with equal rapidity. During the period 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 3'ellowish tinge often remains from extravasated haemoglobin. When stasis is reached, and a fortiori when thrombosis, pressure does not remove the red colour, and, should such a state persist for long, permanent pigmentation may remain. When the tissue inflamed is non- vascular — e.g., the cornea or arti- cular cartilage — redness is of course absent until the part becomes penneated by newly-formed vessels. In the case of the cornea, however, a zone of deep pink injection is seen in the ciliary region. A similar absence of redness is observed in an inflamed iris, owing to the excess of pigment hiding the dilated vessels; if, however, the inflammation is very prolonged, the pigment may be absorbed, and the iris becomes obviously red. Swelling arises from the same two causes, viz., hyperaemia of, and exudation 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 the amount of pain. "Where the inflamed area is covered by a thick and firm fascia, not only is the tensive pain very considerable, but the chief swelling may occur away from the inflamed area, e.g., over the back of the hand in a palmar abscess; where the inflammatory products escape into lax tissues, the subjective phenomena are diminished, although the swelling ma}' be very great. Similar illustrations of the occurrence of oedema at a distance are to be seen in inflamma- tions of the sole of the foot, and in the swelling of the eyelids when the scalp is inflamed. Swelling due to inflammation, though diminishing after death, does not entirely disappear. Pain results from the mechanical irritation of the peripheral nerve terminals, both by the increased arterial tension and by the pressure of the exudate, 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 3G A MANUAL OF SriRGHRY exudate may have some direct chemical action on the nerve ter- minals, especially when destructive changes arc taking place, or if the\' are insufficiently nourished with healthy blood. A marked feature of inflammatory pain is that it is always aggra- vated by pressure, whether intrinsic — i.e., by increasing the blood- pressure, as by hanging down an inflamed hand — or extrinsic, from outside agencies, such as mechanical or digital pressure, the pain then being known as tenderness. The pain of suppuration is throbbing in character; of an inflamed jnucous membrane, scalding, burning, or gritty; of an inflamed serous membrane, stabbing; of inflamed hone, aching or boring, and often worse at night; of an inflamed testicle, sickening. When the organs of special sense are inflamed, there may be little real pain, but much exaggeration of the special sense, e.g., flashes of light in retinitis and noises in the ears in otitis interna. The pain is not limited only to the inflamed part, but is sometimes experienced in distant regions, either through a similarity of nerve- supply or from the fact that a sensory stimulus is always referred, by a patient to the end of the affected nerve. For example, in hip disease the chief pain is often felt in the knee, because both joints derive their nervous supply from similar sources. In renal calculus or colic, pain is referred along the course of the genito-crural nerve into the groin and front of the thigh, and is often accompanied in the male by retraction of the testicle on the side affected. In spinal caries pain is frequently experienced in the terminal branches of the nerves issuing from the part affected, e.g., the ' girdle ' pain in dorsal disease, and the so-called ' belly-ache ' when the dorsi-lumbar region is affected. Occasionally a s\'mpathetic pain is experienced on the opposite side of the body, especially when a bilateral organ such as the kidney is involved. Impairment or Loss of Function is due sometimes to the mechanical difftculty of using a swollen organ, sometimes to the pain elicited by such attempts, but often to the paralyzing effect of the inflammatory process, and this in infective lesions results from the direct influence of the toxins on the protoplasm of the cells affected. Thus, an inflamed eye is from various causes of little use for vision; a muscle, when inflamed, is naturally kept at rest; glandular organs, e.g., the liver and kidneys, have their functions, if not lost, at least much diminished; and many similar illustrations might be added. Constitutional Symptoms are constantlj^ present in inflammatory conditions, and vary greatly in their severity with the cause. In non-bacterial cases there is usualh^ some shght fever which does not last long; but when bacteria are present, the absorption of toxins may cause general symptoms varying in degree from a mild febrile reaction to a grave toxsemia which causes death. It is, however, astonishing to note how much disturbance a small bead of pus under tension may sometimes produce. It is only necessary at this place to deal very briefly with the subject of Fever or pyrexia. The general characteristics of the IN FLA MM A TION 37 lcl)iiU' state consist in a greater or less elevation of temperature, acconipanicd l)y a corresponding acceleration of the rate of the heart- beat and of the respirations. If it continues, the patient becomes thin and emaciated, and loses muscular power. The mouth is dry and the tongue furred; and in the later stages the lips and teeth are usually covered with sordes (or accumulations consisting of inspis- sated mucus and food debris). The appetite is impaired, digestion is imperfect, and the bowels constipated; the motions are often very offensive. The urine is scanty and high-coloured, and owing to the excessive tissue change contains an unusual amount of urea and urates. The excess of urea is demonstrated clinically by adding an equal part of cold nitric acid in a test-tube to some urine, when crystals of nitrate of urea will form on the top of the fluid, giving rise to a mass somewhat resembling sugar-candy in appearance. The skin of a febrile patient is often dry. Causes of Fever. — The temperature of the body, it is well known, is con- trolled by a principal heat-governing centre in the corpus striatum, assisted possibly by accessory centres in the cord, and is maintained by the establish- ment of equilibrium between the amount of heat lost from the skin, by the breath, and in other directions, and the amount of heat produced by the tissue metabolism occurring in the viscera generally, and especially in the volun- tary muscles. Pyrexia is necessarily due to one of two causes, viz., a de- creased loss of heat, or an increased production. The former is a scarcely tenable proposition when we look at the patient's condition, and hence we are driven to conclude that fever is due to increased activity in the heat-forming tissues, especially the muscles, a fact which explains the rapid emaciation and loss of strength under such circumstances, and the presence of a large amount of extractives in the urine. In all probability this increased activity is due to the excitation of the heat-producing centres by some pyrogenous body developed in connection with the local inflammatory process. Experi- ments have shown that fibrin ferment, various products of the breaking down of tissues, and many of the toxins produced by the action of micro-organisms possess such a power. In regard to the symptoms of fever, it may be stated briefly that they are in large part due to the effect produced by the increased temperature or the toxic products circulating in the blood upon the constituent cells of glandular and other organs. The phenomena in question are termed by different pathologists ' acute or cloudy swelling,' ' granular degeneration,' ' albuminous infiltration,' etc., and are characterized by the organs becoming soft, friable, and more or less swollen. The secreting cells of glands are increased in size, and the protoplasm becomes markedly granular, so that the nucleus can only be distinguished with difficulty. The granules are albuminous in character, clearing up completely on the addition of acetic acid. A similar change is also evident in the fibres of the cardiac muscle, which lose their striation and become granular, a condition which must considerably interfere with their contractility. The effect produced upon the glands of the digestive system explains many of the febrile manifestations. The salivary and buccal glands are unable to excrete the normal amount of saliva, and hence the mouth be- comes dry, whilst gastric digestion is interfered with in a similar way. The intensity and character of the fever vary with the preceding condition of the patient, and also with the nature and duration of the disease. In young healthy adults of sound constitution, the fever associated with an acute inflammation is usually of an active type, pyrexia and its accompanying phenomena, including a noisy delirium, being well marked {sthenic inflam- matory fever). In debilitated subjects, as also towards the close of a long period of pyrexia {e.g., in the third week of enteric fever), and in grave infec- tions such as erysipelas and septicaemia, exhaustion and collapse manifest 38 A MANUAL OF SURGERY themselves {asthenic fever, or the typlioitl slate). The pyrexia is not neces- sarily high, and the patient often passes into a condition of low muttering delirium, picking at the bedclothes, passing his excreta into the bed, and more or less unconscious. Varieties of Inflammation. — Many different tenns are used t<^ indi- cate the manifestations of the inflammatory process in the body, and to some of these we must now direct attention. A? Catarrhal inflammation is one affecting mucous membranes, whicli in tlie early stages become dry, vividly red, and the seat of a burning or scalding pain, whilst in the later stages there is free secretion of mucus, muco-pus, or pus. At first the mucigenous function of the hyper^emic membrane is abrogated, and any extra- vascular exudation passes into its substance, causing it to become swollen. Proliferation of the epithelium soon follows, resulting in an increased formation of mucus; as the membrane becomes more and more infiltrated with leucocytes, these are added to the dis- charge, which is thus transformed into muco-pus, or even pus. Small ulcers may develop from the loss of superficial epithelium, but tliis is an exception rather than the rule. Microscopic examina- tion of the discharge reveals pus cells, leucocytes, and epithelial elements in various conditions, some containing globules of mucin, and some of the normal type. This form of inflammation is caused by bacteria, or by the action of local irritants, or by what is known as ' taking cold.' A Croupous or plastic inflammatic^n is one characterized by the formation of a firm false-membrane, due to the coagulation of the plasma exuded from the vessels, the resulting fibrin being deposited on the surface. When involving a serous surface, such as the pleura, peritoneum, or synovial membrane, it gives rise to a layer of plastic Ivmph, which may (jrganize into adhesions; it is also seen in the alveoli of the lungs in lobar pneumonia. On mucous membranes, such as the conjunctiva or that of the pharynx, it occasionally forms white, flaky masses, which can be readily detached, leaving an injected surface below, with merely one or more oozing points, and no loss of substance. A Diphtheritic inflammation is, properly speaking, one that is due to the action of the diphtheria bacillus on a free surface (p. ijj). 'I he term is, however, often applied to inflammatory processes due to other causes, but resulting in a ' false-membrane ' of similar nature. This differs from the false-membrane of croupous inflammation in that it is formed, in part at least, by necrosed tissues, and not simply by fibrin deposited on the surface. Hence it is more difficult to ' peel off,' and when this is done a raw bleeding surface is left. The term Phlegmonous is now but rarely employed. It was formerly applied to any inflammation of the subcutaneous connective tissues where the local phenomena tend to spread, and there is a well-marked brawnv inflammatory swelling or phlegmon. Parenchymatous and Interstitial are terms which indicate that in an inflamed organ or gland the process is mainly limited, either to INFLAMMATION 39 the actual and active substance of the organ, or to the supporting fibrous tissue. The term Metastasis was formerly employed to indicate a sudden transference of an inflammatory attack from one place to another without apparent cause. Increased knowledge of pathology has explained awav nearly all the formerly-described illustrations of metastasis, and, indeed, the use of this term is now almost limited to the inflammation of testis, ovary, or breast which follows mumps. It is often incorrectly applied to the secondarv abscesses of pyaemia and to the secondary deposits of mahgnant disease, both of which are of embolic origin. Treatment of Acute Inflammation. It is only possible here to deal with the general principles which guide us in the treatment of inflammatory affections ; the application of these to different parts of the body will be considered later. 1. The Local Treatment of Non-bacterial Inflammation. — i. Remove the exciting cause, if exddent, and any contributory causes when feasible. This is not a difficult matter when the lesion is a gross one and the exciting cause tangible, e.g., a foreign body imbedded in the conjunctiva or cornea, or the use of a chemical irritant such as formalin in an occupation eczema. In the majority of cases, however, the exciting cause has ceased to act, as in the case of blows, sprains, burns, etc., and all one can do is to protect the part from further irritation or bacterial infection, to relieve tension, and then to assist the tissues towards healthy repair. 2. Keep the inflamed part at rest. Wherever inflammation exists, both physical and physiological rest should be secured as far as possible. Thus, an inflamed joint is immobihzed; an inflamed mamma needs both support and the fixation of the arm, whilst if in a condition of physiological acti\'ity this must be checked; an inflamed cornea needs the application of a pad and bandage to prevent the friction of the eyelid; an inflamed retina is put to rest by exclusion of the light. 3. Reduce the local blood-pressure and h\^er£emia, and thereby reUeve tension by diminishing both exudation and pain. It may be pointed out here that, although both hyperemia and exudation are beneficial, yet they are ahnost always present in excess, and it becomes needful to keep them under control. Elevation of an inflamed limb may secure this end, and is usually required in in- flammatorv conditions of the leg, for it is well known that emptpng the veins by gra\ity leads to reflex contraction of the arteries. This principle must not be carried to excess, or serious interference with the vitality of the limb may result. The rule adopted is to raise the affected part to such an extent as to assist the venous return without interfering with the arterial supply. Local blood- letting by punctures, scarification, and wet or dry cupping, is 4" A MANUAL Oh' SURGEUY useful in suitable cases, and sometimes gives iinuucliate relief to pain. Cold wisely utilized is of the greatest service in reducing hyper- aemia by causing contraction of the arterioles. It should only be used in the early stages, as it depresses the vitality of the part, and so, if much congestion is present, may do more harm than good. Again, it should be used with the greatest care in old people, from fear of causing necrosis of the skin. There are various methods of applying it, as by means of an ice-bag; or by irrigation from a vessel suspended over the part, containing iced water or lotion, from which strips of lint descend to envelop the inflamed area; or a piece of lint wrung out of evaporating lotion may be placed directly on the part ; or, better still, the iced water may be run through a coil of leaden pipes (known as Leiter's tubes), fitted carefullv to the inflamed region. Heat, especiall}' when combined with moisture, is very largely used in treating inflammatory affections, and acts in a diametrically opposite way to cold by relaxing 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 facilitating lymphatic absorption. For subcutaneous lesions, rubber hot-water bottles, fomentations, medicated or not with opium or belladonna, or spongiopiline wrung out of hot water, poultices, or simply dry heated cotton-wool, may be employed. Other methods of employ- ing dry heat are suggested in Chaptci- III., but are more applicable to the chronic varieties of inflammation. II. The Local Treatment of Inflammation of Bacterial Origin. — This is a somewhat different problem in that its object is to destroy bacteria, to eliminate their toxins, and to attain this end with as little destruction of tissue as possible. The chief difficulty lies in the stagnation present in the bloodvessels and Ivmphatics of the inflamed part, so that no fresh blood is circulating through it. At the same time the toxins formed by the bacteria have the opportunity of acting on the tissues, and are absorbed into the blood, thereby 1 eading to its deterioration. The means at our disposal of combating a bacterial inflammation are: [a) The antitoxic and bactericidal properties of the blood, which can be influenced beneficially by anti- sera, vaccines, drugs, and diet; and {b) external applications and procedures, directed towards the removal of stagnant blood and exudate, and to the provision of a sufficient supply of fresh blood which shall assist the tissues in the direction of repair. The actual methods are as follows: 1. Remove the cause if possible, as, for instance, an infected foreign body, or a buried stitch at the bottom of a sinus. In a few cases it may be possible totally to excise a local focus — e.g., a malignant pustule; whilst in others, such as a carbuncle, one can scrape away the inflltrated and sloughy tissue with a sharp spoon. 2. Keep the inflamed part at rest a.% far as possible, not only for physical and physiological reasons, but also to prevent mechanical IN FLA MM A TION 4 1 dissemination of the infective virns. This may be effected by con- lining the patient to bed, or by the use of sphnts or sUngs. 3. ^Unload the stagnant vessels, both veins and lymphatics, by elevation, hot applications, which soften and relax the tissues, or local blood-letting. Scarification is of great value in the slighter cases; but when stasis has occurred, free incisions are often indi- cated in order to relieve tension, and also to allow of the escape of bacteria and their toxins. 4. Promote the removal of the exudate by the insertion of rubber drainage-tubes into deep inflamed cavities, such. as abscesses or sinuses, or by packing an open wound wdth gauze and covering it with a fomentation or a hydrophile dressing, encouraging thereby capillarv drainage. In other cases immersion of the inflamed area in a bath at a temperature of 99^ to 105° F., either of sterihzed salt solution, or of some mild antiseptic, such as boric acid, may be of great value in diluting and washing away toxins and cleansing the part ; but it must not be used to excess, or repair may be hindered by the tissues becoming waterlogged. '5. Increase the supply of healthy blood to the part by the applica- tion of heat, as by poultices when the skin is unbroken, or boric acid fomentations if there is a wound, or by emplopng one of the methods of artificial hypersemia suggested by Professor Bier. Artificial or induced hypercemia as a means of treatment for inflammation is based on the assumption that the hypersemia and accompanving leucoc3'tosis present in all its forms are useful rather than harmful if they'^can be suitably controlled; but in acute cases the hyperemia is usually excessive, and therefore harmful by pre- venting the access of fresh healthy blood to the part. Bier's treat- ment requires the relief of this natural harmful congestion by elevation, etc., and subsequently replaces it by a controlled hyper- semia, the parts being flooded from time to time with fresh blood, which can by its contained antibodies assist in destroying bacteria and bringing about a cure. Induced hypersemia is of two tj-pes, active and passive. The active varietv consists in determining an increased flow of blood to the part bv vaso-dilation, and is arterial in origin. It is best accom- phshed bv heat, either by fomentations, or immersion in hot water, or by one of the diverse methods of applying hot air now available. This plan is not so generally beneficial in acute cases as passive h\^erffimia, but mav be useful in the later stages by hastening the absorption of inflammatory exudates, thereby completing the cure. Passive hypercEmia is venous in origin, and may be induced by the application of a constricting bandage on the proximal side of the inflamed area, or by the use of Klapp's suction balls. The constrict- ing bandage is of elastic material, and Martin's rubber bandage may be suitablv utilized. It is applied with sufficient firmness to obstruct the venous return without interfering Ndth the arterial supply, and if this is satisfactorily effected, the limb becomes reddish-blue, swollen, and oedematous, but without pain; if it becomes cold, or 42 A MANUAL OF SURGERY the patient comphiins of the pain beinj^' increased, the bandage has been apphed too tightly. When the correct degree of tension has been reached, the hmb is comfortalik", and the l)andage may be retained in position for twenty or more hours at a stretcli, being re- moved each day for two or three hours in order to reheve the oedema and empty the hmb of the accumukited and more or less stagnant blood. This method of treatment is maintained until the inflamma- tion diminishes, and then the length of the daily application of the bandage is gradually reduced. Klapp's suction halls (Fig. ii) are employed in cases where a rubber bandage cannot be applied — t.'.r,'., for an abscess or carbuncle on the trunk or back of the neck, for an inflamed breast, or for a septic finger. A suitably-shaped bell-glass (similar in type to the wet or dry cup of olden days), the edge of which is greased or moistened, is htteci over the inflamed part, and the air within rarefied by a rubber suction-pump. Blood is thereby drawn into Fig. II. — Klapp's Suction Ball. Suitable for small superficial infections, e.g., boils or carbuncles. the tissues, which swell up into the cup; and if there is an open wound, as in a boil or carbuncle, discharge and sloughs are sucked out therefrom. The application is maintained for hve or ten minutes two or three times a day. 6. Prevent the access of fresh or a mixed infection to an open wound b\' suitable dressings and antiseptics. III. General Treatment of Inflammation. — This varies considerably with the condition of the patient and the severity of the attack. In robust patients where the blood-pressure is high, the pulse large and full, and the local signs, pain, etc., well marked, it may be advisable to lower the arterial tension by means of such drugs as antimony, aconite, ipecacuanha, acetate of ammonia, colchicum, etc., whilst means are also taken to determine free activity of the skin, kidney, and bowels, whereby toxins and other irritating sub- stances may be eliminated from the body, and the blood thereby purified. In a few cases — viz., acute pneumonia or meningitis — it may even be desirable to resort in the early stages to venesection, but only in powerful, full-blooded adults, and never to such an IN FLA MM A TION 43 extent as uiululy to lower their resistance. Subsequently the administration of a suitable supply of simple, easily-digested food is required, the exact nature of which depends on the temperature and the condition of the digestive organs, as indicated by the tongue. When the patient is weakly and feeble, and especially when his strength has been gradually sapped by persistent fever and toxaemia, general treatment is mainly a matter of feeding, and depends as much on the care and devotion of the nurse as on the skill of the doctor. Stimulants may be required in these cases, and, of course, the functions of the bowels and kidneys must be suitably attended to, though without depressing the patient's strength. It is probable that moderate pyrexia is useful rather than harmful in infective diseases, in that it encourages the formation of anti- bodies. Hyperpyrexia, however, is harmful, in that it paralyzes the tissues and checks the production of these substances. It is un- necessary, therefore, to employ antipyretic measures except when the temperature runs high, and the chief reliance should then be placed on drugs such as quinine or aspirin, or on tepid sponging. Chronic Inflammation. The Causes are similar in character to those producing the acute mischief, but slighter and more prolonged in their action. The most striking point in the aetiology is the large part played by diathetic conditions or constitutional predispositions. Most of the manifesta- tions met with in surgical practice are due to syphilis, tubercle, gout, or rheumatism, and one should never treat chronic cases with- out carefully inquiring as to the possible existence of some such taint. The Phenomena are essentially the same as those of the acute process, though the manifestations are somewhat different. 1. The hyperemia is less in degree, but longer in duration, owing to the causative irritant being frequently of little activity. The local manifestations, therefore, are less obvious; pain is not so great and mainly of an aching character, whilst there is less heat, the redness is more dusky, and the tissues often become pigmented. Consider- able loss of tone in the vessels, especially the veins, results from their prolonged distension, and thus there is greater difficulty in restoring them to a normal state. 2. The corpuscles do not adhere together or run into rouleaux to the same extent as in acute inflammation, and migration, though it exists, is on a limited scale. The exudation is more fluid in character, containing comparatively little albumen or fibrin ; in fact, in some chronic inflammations of serous membranes the cavities are distended with fluid of a much lower specific gravity than that of blood serum. 3. The greatest difference between the acute and chronic pro- cesses lies in the reaction of the tissues. In acute inflammation, in- creased proliferation of the tissues is rarely a marked feature, since 44 A MANUAL OF SURGERY tlic toxin lias usually sulticirnt power to dcstnjy tla-ir \italit\'. In clu-onic inrtamniations tliis is not the case, at least not until tin- later stages of lesions like those of tuberculosis or syphilis. An area which in is a state of chronic inflammation is infiltrated with round cells which are derived from various sources, (a) In certain tissues cell-proliferation is well marked, especially in the endothelial cells of the vessels and lymph-clefts, or the secreting cells of the breast, whilst in other parts {e.g., the central nervous system) the cells never undergo proliferation. {/;) In most cases, however, these round cells are lymphocytes, and are often found grouped in large numbers round the smaller vessels; in the chronic granulomata this is very characteristic, large areas composed entirely of Ixniphocytes being met with, (c) Another cell which is often found in these lesions, and has recently attracted much attention, is the plasma-cell. It is much larger than a lymphocyte, and usually of an oval shape; the nucleus is about as large as that of a lymphoc\d:e, is usually divided into five or six segments, and is placed excentrically in the cell. The protoplasm has peculiar staining affinities. These cells sometimes occur in chronic inflam- mator}' lesions in great numbers, scarcely another type being seen in areas of considerable size; but usually they are mixed with lymphocytes. From whatever source they are derived, these newlv-formed cells usually develop into fibrous tissue, but sometimes produce struc- tures more or less resembling normal tissue. Organization is there- fore a marked feature of chronic inflammation. The actual Results vary according to the part of the body aftccted, and also with the predisposing diathetic state. In simple chronic inflammation, not due to tubercle or syphilis, the part becomes infiltrated and en- larged, and if this persists, fibrosis or sclerosis follows. Thus, a bone is thickened and condensed in chronic osteitis (osleo-sclerosis), whilst in chronic periostitis a new subperiosteal formation of bone occurs. Glands become enlarged and indurated, mainly bv hyperplasia of the connective tissue, whilst if the skin is involved it either becomes hypertrophied and thickened, or entirely loses its characteristic structure, being converted into granulation or fibro-cicatricial tissue, with or without an intervening ulcerative stage. True suppuration rarely occurs, although certain organisms of low virulence occa- sionally lead to its development. Constitutional symptoms are but little evident, beyond those dependent on the diathetic condition to which the local phenomena are due, or to septic changes dc\-eloped secondarily. The Treatment of chronic inflammation is usually more prolonged and difficult than that of acute cases, because of the constitutional dyscrasia which exists so frequently behind it. I. The cause must be removed whenever practicable. Dead or diseased bone must be removed, and tuberculous material got rid of by the knife or sharp spoon, whilst it is often desiraljle to supple- ment this by swabbing the parts over with hquelied carbolic acid. IN FLA MM A TION 45 A chronic abscess increases the action of the original irritant through tlic tension engendered by its presence, and hence it should be dealt with as early as possible. 2. Keep the part at rest. This is just as much an essential as in the treatment of acute inflammation. Joints should be immobilized; the spine must have the weight taken from it by suitable appliances, or, better still, by maintaining the recumbent position; secretory glands are not actively exercised, and the organs of sense are protected from irritation. 3. Counter-irritation is one of the most useful forms of treatment for chronic inflammatory conditions. It is applied in many different ways, according to the character of the disease and the part involved. T\v\xs, friction with the hand, or with stimulating embrocations, pro- duces a hyperaemic condition of the skin, and promotes local activity in the superficial parts which may react beneficially on deeper structures. Scott's dressing may be similarly employed; it consists in wrapping up the part {e.g., a joint) in strips of lint covered with ung. hydrarg. co. (containing over 10 per cent, of camphor), and then encircling it fimily with soap plaster, spread preferably on chamois leather. Iodine paint is another useful application, whilst blisters are most valuable in suitable cases; they are produced by apphdng a cantharides plaster, or by painting the affected area with liquor epispasticus or a collodion blistering fluid. The moxa, a wound produced by burning a spirituous solution of saltpetre on the skin; the issue, the maintenance of a raw surface, however pro- duced, by the constant presence of some irritant, such as the inser- tion of a bead, or the use of savin ointment as a dressing; and the seton, a double thread knotted at each end, passed for some distance under the skin, and drawn from end to end daily — all these are but little used now, although they might be occasionally employed with advantage. The actual cautery is the most severe form of counter- irritant, and is especially useful in some varieties of chronic inflam- mation of bones and joints. The exact modus operandi of counter- irritation is a little difficult to understand, but it seems likely that in some cases they act by determining hypersemia of the part, and in others through some influence on tlie nervous supply. 4. Pressure is an important element in the treatment of chronic inflammatory disorders, and probably acts by bracing up vessels which have become relaxed and atonic from the prolonged distension to which they have been subjected. It also favours the absorption of inflammatory exudations. Firm bandaging, and especially the use of an elastic support, are the usual methods of application. 5. Artificial Jiypercemia (Bier's treatment) is also of value in chronic inflammation, and perhaps finds most useful expression in the form of hot-air baths, or various electrical methods noted else- where (Chapter III.), or in the direction of massage and remedial exercises. Massage is also a valuable means of treatment of manj- chronic inflammatory affections and other lesions. In its simplest variety 46 A MANUAL OF SURGERY it consists in rubbing with some embrocation or liniment, and the stimulating effect of the latter may be of some value in determining hyperaemia of the part. In its more elaborate forms it constitutes an art which is of the greatest value, and concerning which lengthy text-books have been written. It must suffice here to point out that the chief varieties of movement are known as effleurage, petrissage, and tapotement. Effleurage consists in plain up and down rubbing of the limb with the flat of the hand, the up stroke being always firmer than the down, so as to assist in the return of the blood and lymph from the part. In this way the circulation is quickened, and the vital activities of the tissues are increased. The skin should be lubricated with oil, vasehne, or some stimulating embrocation, and the rubbing, at first light, so as only to affect the skin and sub- cutaneous tissues, should gradually become firmer, so as to influence the deep structures. Petrissage consists in kneading the muscles or other tissues between the finger-tips and the palm of the hand; this necessarily should be done across the muscle fibres, working from below upwards, and is especially valuable in hastening the absorp- tion of exudations. In Tapotement a series of blows perpendicular to the surface is rapidly delivered by the ulnar side of the open or clenched hand; the circulation in the parts thus struck is much quickened, and when skilfully done no pain should be caused. As a modification of the last proceeding, Vihro-massage has been recently introduced, in which rapidly repeated blows of the affected region give rise to a vibratory effect, which is often of the greatest value. Hand vibrateurs are sold, and may be used witli advantage ; but the best results follow from the employment of vibrateurs worked by electricity. Rheumatic inflammation of joints and fasciae, such as occurs in lumbago, some forms of sciatica, and other neuralgic conditions, are often much benefited by this procedure. 6. General or constitutional treatment must be adopted to meet the specific diatheses which are commonly associated with chronic inflammation, e.g., mercury or iodide of potash in syphilis. 7. Finally, if the condition is bacterial in origin, and the organism can be isolated, a vaccine may be prepared and treatment carried out on the lines laid down on p. 26. Ordinary surgical methods should, however, not be neglected. CHAPTER III. THE USE OF HEAT, LIGHT, ELECTRICITY, AND RADIUM, IN SURGERY. Within recent years there has been so large a development in the application of various physical agencies in the realm of medicine that it seems desirable to discuss their powers and applications in one chapter, and we propose in this to discuss the use of heat, light, electricity, and radio-activity. Heat (Therrao-Therapy). Apart from its value as a sterihzing agent, heat is of use in treatment on account of the active arterial hyperemia it pro- duces, whereby the part to which it is applied is bathed with fresh blood containing defensive agents, such as leucocytes, opsonins, antitoxins, and other antibodies, by means of which the activities of harmful bacteria and their toxins are neutralized. Moreover, when applied to a part which is infiltrated and brawny, it assists in the restoration of a healthy circulation, as already mentioned (p. 40), by softening and relaxing the tissues. Heat is employed in two chief forms — viz., as moist or dry heat — and either may be utilized as a general or a local apphcation. I. Moist Heat is utilized locally in the form of the fomentation or poultice (p. 40), in order to assist an inflamed part to healthy repair. It matters little as to the material employed when the skin is unbroken, so long as it retains the heat, and, with this object in view, a linseed poultice is often preferable to a fomentation. When, however, there is an open wound, the fomentation or poultice must be aseptic at least, if not antiseptic, in character. The horacic fomen- tation is useful in these cases, consisting of boracic acid lint wrung out of boiling water, or a carholized poultice may be employed. This latter consists of linseed-meal mixed with boiling lotion (i in 40), and applied, not directly to the wound, but over a few layers of cyanide gauze. A hint is given elsewhere (p. 84) as to the dangers [of using carbolic acid in chronic infective cases with amyloid changes in the kidneys. Occasionally it is desirable to add a counter-irritating effect 47 48 A MANUAL OF SURGERY to the poultice, so as to inflncnce unckTlyinf^^ inllaininatory con- ditions— e.g., l)ronchitis, etc. — and then a suitalde projjortion of mustard may be added to the hnseed. Generally, moist heat is employed in the form of a hot hath, and, apart from its cleansing purposes, this is most valuable in many- conditions and for varying purposes — e.g., to act as a sedative in cases of slight shock and general bruising of the body after accidents; to assist in the painless removal of extensive dressings which might stick to raw surfaces, such as burns, especially in children; to dilute toxins and help in their removal from the body, as in extensive infected wounds. The hot bath is also used in various schemes of hydro-therapy in order to act upon many foci of chronic inflam- matory trouble ; e.g., in general muscular rheumatism and libro- sitis, the heat of the bath helps to relax and loosen the parts, and therebv to restore them to a healthy function. Plain water may be utilized for this purpose, or hot mud or peat baths. Active chemical substances, such as alkaline carbonates, sulphur, etc., naturally present in the water, or artificially added to it, are readily absorbed through the skin, and influence the patient considerably; natural mineral waters are probably more active than those arti- ficially prepared. 2. Dry Heat may also be made to serve as a therapeutic agent, generally or locally, but in most instances introduces a new element — viz., diaphoresis as well as superficial hyperaemia. It is especially valuable in chronic cases, and, of course, higher tempera- tures can be borne without discomfort than in the preceding variety. Generally, various methods of hot air or vapour baths are avail- able. Turkish baths consist in the exposure of the unclothed body to dry heat at varying temperatures (up to 250° F. or more) for twenty or thirty minutes; by this means an abundant perspiration is induced, and thereby toxins are eliminated. It is followed by massage, douching, and rest for an hour or so, to allow the surface of the body to cool. A Russian bath is very similar, but the air is full of the vapour of steam, and therefore cannot range so high ; perspiration is induced more rapidly, and the bath is of shorter duration. In both of these agents the object is to induce the rapid elimination of toxins and other poisons, and at the same time to assist in maintaining the free mobility and function of the various parts of the body by massage. Either may be employed advan- tageously as a routine preventive of gout or rheumatism, especially by those who are unable to secure suitable exercise; or they may be utilized as a means of cure. In patients who are incapable of leaving their beds or homes — e.g., in cases of uraemia, or of very bad chronic rheumatism — hot-air baths may be given by covering the patient with a large cradle over which is placed a blanket or two, and under it, in such a way as not to endanger him, a lighted spirit-lamp or a suital^le number of electric lights of sufficient power. Occasionally, however, wet packs have to be relied on in such cases. THE USE OF HEAT. LIGHT, ELECTRICITY. AND RADIUM 49 Locally, there are many metliuds of applying dry heat to a part, of which the following are the chief: 1. Hot-air baths, such as the Shefheld-Tallerman apparatus, etc., consist essentially of a box or chamber with walls composed of felt or asbestos, and arranged so that the contained air can be heated to a required temperature by an oil or gas burner. The affected limb is introduced into the chamber through a window with a closely- htting curtain, and carefully suspended to prevent the skin touching the hot walls, thereby avoiding burns. Recently air baths heated by electric currents passing through metallic resistances have also been used. 2. Radiant-heat baths have electric incandescent lamps as their heating agents. The therapeutic value of these baths depends not only on the hot air evolved, but also, and probably mainly, on certain light rays which have no heating power. A bath con- sists of a cabinet containing a number of lamps, which may have various- coloured globes, so that, by absorbing rays corresponding to certain portions of the spectrum, the quality of the hght may be varied. They may be used for the whole body or for individual limbs. 3. Diathermy, or thermo-penetration, is somewhat akin to the high-frequency current, but has a sustained instead of an inter- rupted oscillation. A current of high potential is passed through the affected part, which offers some resistance to its passage, and thereby its temperature is raised several degrees. The action of this agent, therefore, differs from hot-air baths, etc., in that the internal temperature of the body is raised rather than that of the external air, and hence the therapeutic results are increased. Applications. — Hot-air and radiant-heat baths are chiefly em- ployed to promote the absorption of chronic inflammatory exudates, and for such conditions as chronic arthritis, adhesions, neuralgia, lumbago, and sciatica. They are also used to aid elimination by determining diaphoresis in general toxic conditions, such as gout, Bright's disease, and obesity. Diathermy is useful for chronic inflammation, osteo-arthritis, rheumatic and gouty librositis, etc. Heat is also of great value in preventing or counteracting shock. The importance of keeping a patient warm during a lengthy opera- tion is emphasized again and again, and to this end operating-rooms are now maintained at a high temperature (70° to 80° F.), and the patient is carefully clothed. This is a much better method to employ than to heat the table on which he Hes, a procedure which has before now resulted in serious burns to the back or buttocks. To combat the shock which follows operations or serious injuries, such as bad burns, especially in children, when the patient's tem- perature often falls as low as 95° or 96° F., it is important to surround the body with air at a higher temperature; and this can be effected by covering him with a cradle over which a blanket is placed, merely leaving the head uncovered, and within which is placed an electric lamp of 50 or 100 candle-power, so that it cannot touch 4 50 A MANUAL 01- SURGERY or be touched by the i);itieiit's hiiibs. The result of this liut-air bath is often most valuable. Cauteries are employed in three forms: 1. The actual cautery, which consists of solid irons of various shapes, and these are lieated in a suitable tlame to a temperature depending on the use for which the}^ are required. 3. The galvano - cautery consists in a loop of platinum wire mounted on an insulated liandle, and connected with the ter- minals of a battery of sufficient strength. The handle is fitted with a key, so that the current may be opened or closed at will. During the passage of a sufficiently strong current (5 to 6 amperes for small loops) the platinum becomes red or white hot. 3. Paquelin's thermo-cautcry depends on the principle that, when the vapour of benzoline is driven over heated platinum, its com- bustion generates sufficient heat to maintain or increase the tem- perature of the platinum. By means of a rubber bellows, air is driven over the surface of benzoline contained in a bottle, and then, saturated with its vapour, through a hollow handle into a platinum point. The platinum point is previously heated to a dull redness in a spirit ffame, and on pumping the mixture through the apparatus it can be kept at a red or white heat. Applications. — i. .4s a counter-irritant, when the skin over an affected part, usually a joint or the spine, is seared lightly. 2. As a hcemosfatic or bloodless knife. By this means vascular tissues can be divided without loss of blood, and at the same time the tissues involved are kept or rendered aseptic. Thus, polypi or piles can be removed in a bloodless fashion, and the stimip is left sterile. It is also employed to divide the intestine between clamps without soiling the peritoneum. It is well to remember that a dull red heat is the most efficacious, since thereby the vessels are seared and effectively closed: a cautery at white heat cuts almost as cleanly as a knife. The possibility of secondary haemor- rhage when the slough separates must not, however, be forgotten. Light. Light as a curative agent, apart from its thermal effects, is chiefly employed in the form of (i) the arc light, (2) Finsen and mercury vapour lamps, and (3) sun-baths. I. The projection of the light from an arc lamp by means of a suitable concave mirror may be employed as a general bath, or locally to diseased areas. The heat evolved by the lamp can be projected to some depth beneath the surface, and care must be taken not to burn the patient by focussing the rays on the skin. This method differs from radiant heat in that its light contains abundantly the chemical rays of the violet end of the spectrum, whilst that of incandescent lamps contains mainly the heat rays of the red end. This method is utilized for conditions similar to those for which radiant heat is employed, but more especially in THE USE OF HEAT, LICHl'. ELECTRICITY, AND RADIUM 51 cases where a localized application is required — e.g., in lumbago, rheumatic torticollis, etc. 2. The Finsen and mercury vapour lamps arc methods of ex- posing small areas of disease to large doses of light containing an abundance of chemically active rays. A Finsen lamp consists of a powerful arc, the rays of which are collected and focussed by quartz lenses on a small area of skin, which is cooled and rendered auccmic by a quartz compressor, through which a stream of cold water flows. Compression aids the penetration of the rays by rendering the part bloodless, the blood having the power of absorb- ing the violet rays. The mercury vapour (Cooper Hewitt) lamp consists of a glass tube exhausted of air, and containing mercury and mercury vapour. The passage of a suitable current through this produces a light rich in ultra-violet rays. These lamps are chiefly used in the treatment of lupus, although better results are often obtained bj^ the X rays. 3. Sun-baths need no special comment, but there is no question as to their value in cases of anaemia and malnutrition, especially since they involve exposure of the body to an abundance of fresh air. Electricity. Electricity, apart from its thermogenic power, has many im- portant applications in the domains both of diagnosis and treatment. I. As a Diagnostic Agent. (i) By means of the faradic and galvanic currents the electrical response of muscles and nerves can be investigated, and valuable information obtained as to the condition of the nervous and mus- cular sj^stems. A muscle with a normal nerve-supply contracts under stimula- tion from both the faradic and galvanic currents in sufficient strength, the contraction being most readily obtained when the electrode is applied over a definite skin area, varying for every muscle, and called the ' motor point.' With the galvanic current the contraction obtained, when the current is closed, is greater than that produced when the current is opened. Again, the contraction elicited when the electrode applied to the muscle is attached to the kathode of the battery is greater than that resulting when the anodal electrode is used. This fact is expressed in the formula — K.C.C.>A.C.C. In the muscular degeneration which follows nerve injuries, neuritis, anterior polio-myelitis, etc., these reactions are modified, and constitute the reaction of degeneration (R.D.). The response of the muscle and nerve to the faradic current quickly disappears, and with the galvanic current the anodal closure contraction be- comes greater than the kathodal (A.C.C. >K.C.C.). A greater strength of current will be required than in the sound side of the body, and the response will be sluggish, and not brisk. As long as 52 A MANUAL 01' SURGERY the R.D. persists, however, the j)()ssil)ility of repair in tlii' muscle remains, should the centres and conducting apparatus be restored. This persistence of the R.U. may exist h)r years. When once the K.D. is lost, all hope of repair is gone. In spastic conditions the electrical irritability of muscles and nerves is often increased. (2) Radiography. — When a current from the secondary circuit of an induction coil is passed between two suitable metal elec- trodes'Jn a vacuum tube of a high degree of exhaustion (Crookes tube), a stream of rays, called ' kathodal 'or ' /3 rays,' which consist of negatively charged electrons, is generated from the kathode. If the kathode is concave, and the rays are thereby made to converge to a focus on a third electrode called the ' target,' or ' antikathode,' from their impact thereon results a production of rays of a very special character, known as the ' X rays of Rontgen.' X rays have the power of penetrating most opaque bodies in varying degrees, and in general terms substances are opaque to X rays in proportion to the atomic weights of their con- stituent elements. X rays also have the power of acting upon sensitive silver salts in the same way as light, so that if a structure, such as a limb, be interposed between the source of the rays and a sensitive photographic plate, the rays will readily penetrate the softer parts; but their passage will be hindered by the more resistant structures, such as bones, which will thereby throw a shadow on the plate. Radiographs or skiagraphs are the shadow-pictures produced in this manner. The greater the vacuum in the tube, the greater will be the strength of current needed to traverse it, and the greater the penetrating power of the X rays produced. These are known as ' hard tubes.' Soft tubes are those in which less strength of current is required to produce the rays, which have a less penetrating effect, and therefore are more useful in per- mitting a greater differentiation of shadow. Barium platino-cyanide and certain uranium salts are rendered fluorescent by the passage of X rays, so that, if a screen covered with one of these substances is held distal to the limb or part to be examined, a shadow similar to a radiograph is produced, and can be seen. The radiographic screen is of great value in many con- ditions as a means of rapid diagnosis, and sometimes gives better results than the radiograph, especially when absolute immobility cannot be obtained. Thus the movements of the heart, of the diaphragm, the pulsations of an aortic aneurism, etc., can be better examined by the screen than by taking a radiograph. As an illustration of this may be mentioned a case where a silver probe had slipped down through a tracheotomy wound into a bronchus. An attempt to photograph it failed completely, but on examina- tion with the screen the probe was seen lying transversely in the left bronchus, moving up and down at each beat of the heart. Great care is necesseiry in the interpretation of radiographic pictures, as, the rays being divergent, some distortion of the re- sulting shadows occurs, according to the distance of the object from THE USE OE HEAT, LIGHT. ELECTRTCTTY. AND RADIUM 53 the source, and tlie exact an,e;le at which the rays impinge upon it. To avoid this deception, stereoscopic photographs, or views in two directions at right angles to one another, are necessary. Moreover, the results vary much, according to whether the radio- graph is taken from before or behind. Thus, if a shoulder be radiographed from behind, with the plate in front, the details of the coracoid process and of the head of the humerus will be most clearly defined; whereas if the plate is posterior, and the picture is taken from the front, the acromion and spine of the scapula are most sharply represented. In practice the outlines of bones are clearly seen; cartilage and callus are more transparent; muscles and tendons are sometimes visible if a very soft tube is employed. Calculi vary according to their composition, oxalates being most- opaque and uric acid stones most transparent. Gallstones are very seldom impervious. By the use of soft tubes the outlines of viscera, such as the liver and kidneys, may often be obtained. 3. As a Therapeutic Agent electricity is employed in many ways : (i) The galvanic and faradic currents are employed, both generally and locally, for their stimulating action. Under the former head- ing one would include the use of the electric hath, in which a patient lies in water to which a small addition of salt is made, and through which a galvanic current is passed. The effect of this is to increase the superficial circulation and produce cutaneous hyperasmia. It is often useful in diffuse rheumatic and gouty fibrositis, as also in conditions in which the general muscular and nervous tone of the bodj^ has been lowered. It is of considerable value in the treatment of conditions depending on arterial spasm, such as Raynaud's disease. Care must be taken only to increase or decrease the strength of the current gradually, otherwise the patient may experience an unpleasant shock. Locally the galvanic and faradic currents find their chief em- plo3niient in cases of muscular paralysis, in order to prevent de- generation of muscles where the nervous control has been lost, as by division of motor nerves, and also to maintain the conductivity of the nerves where this has been impaired. The faradic current is probably more useful in this direction than the galvanic. (2) Electrolysis is used chiefly for the destruction of superfluous hairs, moles, etc., the removal of naevi, and the coagulation of blood in aneurisms. The passage of a current of sufficient strength between metallic poles actually inserted into the tissues sets up an electrolytic action, and coagulation of the blood or local destruc- tion of hair folHcles, etc., results. The clot formation is most marked at the positive pole ; hence it is often unnecessary actually to insert the negative needle into the tissues, but to use an ordinary flat pad, moistened with salt solution and apphed to the skin away from the part to be treated. The use of the negative pole is more likely to produce scarring, since a caustic alkaline com- pound is formed around it, and this may lead to sloughing of the tissues; the quality of the clot produced, moreover, is loose and .54 A MANUAL 01- .S f ^ AY; /;/.' V spongy. In larf^c n.x-vi, etc., sevcriil needles attached to tiie ])ositivc pole are used with advantat^e, and should be made of ])latinum or steel, insulated by shellac or sealinf^-wax up to the point of entry through the skin, in order to protect it from the electric current; ineffective insulation results in destruction of the skin. The strength of the current employed varies according to whether both poles are introduced, or only the positive. Under the latter cir- cumstances a current equal to about 25 to 75 milliamperes should be applied for ten to fifteen minutes, care being taken to increase its strength gradually to the maximum, and similarly to decrease it. An anesthetic is needed, and the immediate effect should be to make the mass feel hard and firm by the coagulation of the blood. Organization of the thrombus leads to obliteration of the vascular spaces and the disappearance of the tumour. Two or more sittings are usually necessary before the growth is effectively treated. Oif course, some scarring is almost always left, and hence it is wise not to do too much at one sitting, and to make the intervals sufficiently long to allow of effective cicatrization. (3) Static electricity generated by a machine such as Wimshurst's or Holtz's is used as a bath or brush discharge in the treatment of neurasthenia, general or nervous debihty, neuralgia, and in certain chronic skin diseases, such as psoriasis, lupus, etc. It is of use rather as a general tonic than as having any specific effect. The high-frequency current is an induced current set up in a secondary circuit by a modified induction coil, in which Leyden jars take the place of a voltaic cell. It is said to increase metabolism and heat production, and is recommended for constitutional diseases, such as gout, diabetes, and rheumatism, etc. (4) Ionic medication, or cataphoresis, consists in the introduction of drugs directly into the tissues of the bodv by means of an electric current. It is based on the principle that the passage of a current through a solution of a salt is accompanied by movement of the constituent ions — i.e., of the atoms or molecules which are elec- trically charged. The positively charged ions (kations), which include those of all metals, alkalies, and alkaloids, are attracted to the negative pole, while the negatively charged ions (anions), such as those of chlorine, iodine, the acids, and hydroxyl, are attracted to the positive pole. If the human body is interposed in the current, instead of a solution of salt in a vessel, and lint pads, soaked in a solution of the salt or drug, are placed between the skin and the electrodes, kations at the positive pole and anions at the negative pole will enter the tissues and be disseminated in them for a variable distance, probably from i to 10 millimetres. The pads should be thick and of large area, and the strength of current 2 to 3 milli- amperes per square centimetre of area of the pads. This method is chiefly used in the treatment of chronic inflamma- tion of joints and other tissues, but good results have also been obtained in chronic ulcers, rodent ulcers, lupus, warts, etc. Zinc, copper, magnesium, iodides, and salicylates, are the drugs ////■; //,S7: OF Iffi.l r, I.IGHT, ELECTRICITY, AND RADIUM 55 tiiicfly used; but qniniuc, cocaine, and adrenalin, have also been employed. (5) X rays are used therapeutically in the treatment of cancer, rodent ulcer, and certain skin conditions, such as ringworm, to produce epilation; keloid scars; and also in general conchtions, such as exophthalmic goitre, lymphadenoma, the leukaemias, etc. The effects will be noted under the ensuing section, deahng with radium. Radium and Radio-Therapy. Radium, discovered by Madame Curie in i8g8, is a constituent of pitch-blende. It is mainly sold in the form of radium bromide, a hard, yellowish, crystalhne substance, and is the chief of a group of elements which have a radio-active property — that is to say, they can influence a photographic plate through an opaque layer of black paper. Radium emits three types of rays, named «, 13, and 7, of which the 7 rays are the most penetrative and of the greatest therapeutic value. For application, the salts of radium are contained in hermetically sealed tubes of glass, aluminium, silver, lead, or platinum, each tube containing from 5 to 100 milligrammes, or are spread on flat metal plates in definite amounts per square centimetre of surface. These are covered by lead, aluminium, or silver filters of variable thick- ness, in order to exclude the a and (3 rays, so that the y rays may be alone utilized. It is also possible to charge water and other fluids with emanations (probably gas given off from the radium) which render them radio-active, and enable them to exercise to a limited degree similar powers. It is possible that the therapeutic value of certain mineral waters — e.g., Bath — is in part dependent on the possession of radio-active properties. Radium may be applied directly to lesions of the skin or mucous membranes, or it may be possible to influence deeper growths through healthy integument or mucous membrane ; but in the latter instance it is better, if possible, to implant the radium for a time into the midst of the growth. In particular, it is of value to expose to the influences of the radium any cavity from which a surgeon is doubtful as to the complete removal of a malignant growth. It is impossible at present to write dogmatically on the power of radium or to discuss its method of action; but certain facts are agreed on: (i) That it has a power of influencing the cells of living tissues is undoubted. If a series of suitable growing plants be exposed to radium at various distances, it will be found that it is possible to kill some that are close to it by exposures which stimu- late others to richer and fuller development, whilst at intermediate distances growth is hindered. (2) This influence lies particularly in the direction of checking the growth of actively multiplying cells, and perhaps of aiding the development of the m.ore stable elements. Hence the actual growing cells of a cancer or sarcoma are likely to be affected destructively by exposure to radium. 56 A MANUAL OF SIJ RCIIRY whereas the connective tissues of tlie part may by suitable dosage ho. stimulated to reparative activity. {^) The (luestion of dosage and length of exposure is therefore of tiie gravest importance, jind it is also one on which opinions differ considerably. Probably it will be wise at present to work with moderate doses, and not to employ them for too long a time. (4) What has been written con- cerning radium is similarly true as regards X rays; but, of course, the great distinction between the two procedures is the ready applicability of radium to the surface and into the substance of tumours, whereas X rays can only be applied from a distance. The results of radium and X-ray treatment vary considerably, and at present, out of the mass of evidence accumulating on every hand, it is only possible to draw certain broad conclusions : 1. Superficial growths of various kinds are effectively and satisfactorily influenced by this means. Warts, ncevi, keloidal growths, and similar non-malignant developments, are often cured by one exposure or application; laryngeal warts are similarly affected. Rodent ulcer is readily cured by either radium or X rays, and there is really nothing to choose between the two. It is un- usual for operative measures to be required except when the disease has spread deeply and affected bone or cartilage. In these cases it is probable that repeated exposures to radium or X rays have depressed the vitality of the parts to such an extent as to influence the result even of operative treatment. Cutaneous epithelioma may be affected beneficially, but the results are not so good as in rodent ulcer, and it is quite probable that excision should be undertaken in the first place where possible, and radium treatment be employed subsequently. Cancer of mucous membranes is, on the whole, less favourable to treat than that of the skin. 2. Cancer of deeper organs is variously influenced by radio- therapy. There is as yet no justification for replacing operative treatment of cancer of the breast by this means. It is, of course, desirable to follow operation by radio-therapy, in the hope of de- stroying any living cells that may remain. Inoperable recurrences may also be cured by this means; and even large, hopeless growths involving the whole breast may be improved by burying radium in its substance for twenty-four to forty-eight hours, introducing it at intervals into different parts of the organ. Pain is usually reheved thereby, ulceration may be healed, and discharge diminished. Cancer of the mouth, tongue, and jaws, may be improved locally to some extent, but recurrence in the glands and death are only too hkely to end the chapter. If the glands have been effectively removed, local recurrences may be hopefully attacked. In the (Esophagus, a cancerous stricture may be o[)ened up by introducing into it a tube of radium; but, although the power of deglutition may be thereby restored or retained for a longer time than other- wise, a cure is not in the least likely. Cancer of the stomach or intestine can rarely be treated by radium, as destruction of the THE USE OF HEAT, LIGHT, ELECTRICITY, AND RADIUM 57 growth may involve serious consequences, such as perforation of the bowel, thrombosis of important vessels, or grave haemorrhage. Some cases of rectal carcinoma may be treated thereby ; but perma- nent improvement can scarcely be expected, although some relief of pain may be experienced. Similar remarks apply to cancer of the bladder. Uterine carcinoma is undoubtedly influenced most beneficially by radium; haemorrhage is arrested; the discharge is diminished and rendered inoffensive ; ulceration is healed and pain relieved. Often the peri-uterine thickening and infiltration are absorbed to such an extent as to render operable a case previously considered hopeless. Naturally, the ultimate prognosis depends on the extent of glandular involvement, and hence, where prac- ticable, operation is still desirable. 3. Sarcomata are amenable to radio-therapy to an even greater extent than cancers. It is desirable to implant the radium into their substance, and cessation of growth often follows. Periosteal or round-celled sarcomata of the long bones may be thus treated, and thereby amputation avoided ; but, of. course, the ultimate prog- nosis depends on whether or not secondary deposits have occurred in the viscera. Myeloma of bones can also be treated by this means, with or without erasion of the growth, and thereby in early cases amputation or excision of an important bone may be avoided. 4. Many other growths are capable of being influenced by radio- therapy — e.g., lymphadenoma, tuberculous lymphadenitis, etc. These will be alluded to elsewhere. It is important to remember that prolonged exposure to X rays produces erythematous burns which frequently lead to dermatitis, with chronic ulceration of the skin. In some cases this progresses and takes on a malignant type (X-ray cancer) ; this has been seen most frequently on the fingers and hands of the early workers in X rays, before the necessity of strict protection of the operator was realized. CHAPTER IV. EXAMINATION OF THE BLOOD IN HEALTH AND DISEASE. Although an examination of the condition of the blood is frequently of great importance to the surgeon, a mere outline of the chief facts is all that can here be attempted. The red blood corpuscles average about 5,000,000 to the cubic millimetre in men and about 4,500,000 in women, and are readily counted by means of the Thoma-Zeiss h?emocytometer or other similar instrument. The chief surgical value of such investigations arises in connection with haemorrhage, for they enable us to deter- mine the amount of blood lost at a surgical operation or as the result of a wound, and to trace the process of recovery. It is usually advisable to supplement the counting of the corpuscles by estimating the amount of haemoglobin present by means of Haldane's or some other h?emoglobinometer, the resvilt being expressed as a percentage of the normal amount. Thus, blood containing half the amount that should exist in a given bulk in a normal man is said to contain 50 per cent, of haemoglobin. It is also convenient to calculate the ' corpuscular richness ' or ' colour-index,' which is done by di\iding the percentage of haemoglobin by the number of corpuscles expressed as a percentage of the normal. For example, under normal con- ditions the haemoglobin is 100 per cent., and there are 5,000,000 corpuscles per cubic millimetre, so that the colour - index is i^^=i. If the corpuscles have fallen to 3,000,000 (60 per cent, of the normal), whilst the haemoglobin has fallen to 30 per cent., the colour-index is f^=o-5; that is to say, each red corpuscle contains only half as much haemoglobin as it should do. In general a high colour-index is indicative of pernicious anaemia, and one which is greatly reduced of chlorosis, though in cases of severe secondary anaemia of long standing a similar reduction may be present. If the blood is examined immediately after a patient has suffered from a severe hcemorrhage, it w\\\ naturally be found to be normal in composition; part has been lost, but the quality of the remainder has not altered. After a short time the volume of blood is restored to normal by means of fluid derived from the tissues. In this stage 58 liXAMINATION OF THE BLOOD IN HF.ALTH AND DISEASE 59 the blood is more diluted than normal, the red corpuscles and hjemof^dobin being alike reduced, so that the colour-index remains i. There is also in most cases a temporary increase in the number of leucocytes. The process of absorption of fluid from the tissues is imitated artificially in the infusion of saline solutions in collapse or after severe hemorrhage, and it is found that this process has a beneficial effect in accelerating the subsequent regeneration of the blood as well as in raising the blood-pressure and removing the urgent symptoms. In the subsequent process of recovery the red corpuscles increase more rapidly than the haemoglobin, so that the colour-index falls somewhat. The length of time necessary for full regeneration of the blood varies greatly, the process being more rapid in men than women, and in young adults than in the old or young. Approxi- mately I per cent, of haemoglobin is regenerated per diem; thus the blood becomes normal in about twenty days after the loss of 20 per cent, of haemoglobin if the patient is kept under favourable conditions. It is not possible to lay down any definite rule as to the amount of haemorrhage which is necessarily fatal. Other things being equal, a patient will survive a much greater loss of blood if it takes place gradually than if it takes place quickly. In the latter case a reduction of the haemoglobin to 50 per cent, will probably be fatal, whereas in the former it may fall to 20 per cent., or lower, and recovery still take place. Women tolerate loss of blood better than men, and men tolerate it better than children. Anaemic patients are usually bad subjects for operations, but it is not possible to formulate any rule for the guidance of the surgeon as to the degree of anaemia which should make him unwilling to operate. It is important to notice that a high degree of anaemia occurs in acute spreading inflammation, septic fever, septicaemia, etc., and. this fact is occasionally of diagnostic value. The diminution of the corpuscles and haemoglobin usually occurs rapidly, sometimes with a rapidity only second to that which occurs after severe haemorrhage, and gives rise to a severe form of secondary anaemia. The colour- index is usually low, the haemoglobin being destroyed more rapidly than the corpuscles. The examination of the leucocytes is often of the greatest im- portance. It comprises an enumeration of the total number per cubic millimetre, and a differential count of the relative number of the various kinds. The former examination is carried out by a method similar to that used in counting the red corpuscles, and, as it takes but a few minutes and requires but little practice, should be learnt by all surgeons. The differential count is made on thin films of blood, which are dried and stained by a double or triple stain, Jenner's stain being the simplest and most useful. Jenner's stain consists of a solution of eosinate of methylene blue in methyl alcohol. To use it the blood film is allowed to dry spon- 6o A M ANIMAL Ol- SnUGRRY taneously and is tlifn flooded witli the stain, \\Iii( li is allowed to act for about two minutes. It is then poured off, and the liim is rinsed in distilled water for a few seconds, drained, allowed to dry spontaneously, and mounted in Canada balsam. This is then examined under a ,1 inch lens, each leucocyte seen being noted down, until 400 or more have been counted. The results are reduced to percentages. In health the blood contains from 4,000 to 10,000 leucocytes per cubic millimetre, five different forms of cell being present — the polynuclear leucocyte, the eosinophile leucocyte, the mast-cell, the lymphoc\i;e, and the hyaline cell. Of these, the first three contain definite granules in their protoplasm, the others do not. Tn the following description we assume that the film has been stained by Jenner's method. If other staining processes are used, the colours of the various structures will naturally be somew^hat different. 1. The polynuclear or polymorphonuclear leucocyte (Fig. 12, c) is rather larger than a red corpuscle. It is characterized by having a twisted or indented nucleus, which in badly prepared specimens may appear to be multiple, although with proper preparation and the use of high powers of the microscope the connecting filaments between the various parts can always be made out. It contains in its proto- plasm numerous very minute granules which have an affinity for acid stains, and hence are coloured pink by the eosin in Jenner's stain. In specimens which have not been well stained these granules may not be visible, but the cell can always be identified by its nucleus. ^ The polynuclear leucocytes are the chief phagocytic cells of the blood, being actively amoeboid and endowed wnth the power of ingesting bacteria or other small objects. Thev are formed, mainly or entirely, in the bone-marrow, and constitute in health from 65 to 75 per cent, of all the leucocytes. 2. The eosinophile leucocytes (Fig. 12, d) are about as large as the foregoing, and have a bilobed or polymorphous nucleus. They have also granules which stain with eosin, but these are much larger and more defined than those of the polynuclears. The eosinophils form 2 to 4 per cent, of the leucocytes of normal blood. They are probably formed partly in the bone-marrow and partly in other connective tissues. They are feebly mobile, and their functions are not definitely known. 3. The mast-cells (Fig. 12, e) have lobed nuclei and granules which stain with methylene blue, though usually metachromatically, taking a purplish colour. They are present in very small proportions (about I per cent.) in normal blocid, and their functions are unknown. They are connective-tissue cells, and are often present in considerable numbers in inflamed tissues. 4. The lymphocvtes (Fig. 12, a) are devoid of granules, and their nuclei are not polymorphous. They vary in size, but the majority are rather smaller than the red corpuscles. Fach lymphocyte has a single circular nucleus which is situated centrally; this is sur- liX.lMlNAriON OF THE BLOOD IN HEALTH AND DISEASE 6i rounck'tl l)y ;i narrow /.one ol j)n)t()i)lasin, whirli in suitably stained specimens takes the nietlulene blue more deeply than does the nucleus itself. Lymphocytes constitute 20 to 25 per cent, of the leucocytes of health. In children the proportion may be much higher, the poly- nuclears being correspondingly reduced. They arc formed in the lymphatic glands, spleen, Peyer's patches, and lymph-adenoid tissue generally. They are probably identical with the ' small round cell ' wliich is so characteristic of non-suppurative inflammatory foci, and in these lesions we have reason to believe that they can be pro- duced locally in any part of the body, probably by a process of budding from the endothelial cells. 5. The large hyaline or large mononuclear cells (Fig. 12, h) vary in size, but as a rule are decidedly larger than the red corpuscles. They have a single circular, oval, or kidney-shaped nucleus, which is smaller relatively to the cell than the nucleus of the lymphocyte. Fig. 12. — Corpuscular Elements of Normal Blood. (Emery.) a, Lymphocyte; b, hyaline or large mononuclear cell; c, polynuclear leucocyte; d, eosinophile cell; e, mast-cell ; j/", red corpuscle, to show the relative sizes of the other cells. The protoplasm stains faintly with methylene blue. It is devoid of granules, but often shows bluish points, which are really nodal thickenings of the reticulum. These cells form 2 to 4 per cent, of the leucocytes of normal blood, and have considerable powers of phagocytosis. Their origin and relation to the lymphocytes is not definitely known, but there is some reason for regarding them as endothelial cells which have been detached from the walls of the vessels. An increase of the total leucocytes present in the blood is termed leucocytosis. Under most circumstances this increase is mainly due to an increase in the number of polynuclears present; special terms are used for an increase of other forms of leucocytes. An increase in the eosinophiles is called eosinophilia, and an increase in the lymphoc3^tes is called lymphocytosis. A diminution of the leucocytes is termed leucopenia. 62 A MANUAL OF SURGERY Leucocytosis occurs under physiological conditions during diges- tion, during pregnancy, and in tlie new-l»orn infant. This has to be remembered in interpreting leucocyte counts in disease. The former factor is of especial importance, and if possible the blood should be collected whilst the patient is fasting. Pathological leucocytosis occurs in many conditions, the most important being the infective diseases, and in these the highest counts are met with in pneumonia and in suppuration. The latter is of special importance to the surgeon, as the presence of a high leucocytosis may be regarded as the most definite single sign of the presence of pus. It is especially valuable in appendicitis, where the other evidences of suppuration are often equivocal. When no pus is present, the blood shows slight leucocytosis, the number not usuallv exceeding 15,000 per cubic millimetre. When pus is present the number is much greater, being usually not less than 18,000, and it mav rise as high as 50,000, or even higher. For practical purposes a count of 20,000 leucocytes per cubic millimetre may be taken as an almost certain proof of suppuration, presuming, of course, that the other causes of lecocytosis can be excluded. Figures between 15,000 and 20,000 are not sufficiently definite to be of much value, and where they are obtained it is advisable to repeat the examina- tion in twenty-four hours. If suppuration is taking place, the count will almost certainly rise, wliilst if it remains at the same level, or shows a decline, the presence of pus is unlikely. The height of the leucocytosis gives no indication of the size of the abscess or of the rapidity of its spread. The opening of the abscess is usually followed by a fall in the number of leucocvtes, and this is so rapid as to be quite definite in the course of twelve hours. When it does not take place, the probabihty is that a second abscess is present, which was overlooked at the time of the operation. The absence of leucocytosis is presumptive evidence that sup- puration has not occurred, but several facts have to be considered in applying this rule in actual practice: I. The cause of the leucocytosis is the passage of the bacterial products from the inflammatory focus to the blood-stream, where they exert a positively chemotactic action, attracting the leucocytes from the bone-marrow, whilst at the same time they stimulate the latter to an increased production of leucocytes. As long as the abscess remains unopened and is spreading, these substances gain access to the blood-stream with ease, for it is the only path available to them. But when the abscess is opened so that the pus laden with bacterial toxins can drain away, the leucocytosis falls, even although the abscess may burrow for a time. An example of this was seen in a patient suffering from appendicitis, in whom there were very doubt- ful chnical indications of pus, and who showed a leucocytosis of 38,000; this was regarded as definite proof of the existence of an abscess. A few hours after the count was made the patient suffered from diarrhoea, and pus was found in the stools. A second EXAMIXATJUX OF THE BLOOD IN HEALTH AXD DISEASE 63 CDUut was made forty-eight hours after the llrst, and the leucocytes were found to ha\'e fallen to 13,500, 3'et at the operation a large abscess cavity with extensive ramihcations was found. If the patient had been admitted to the hospital after the rupture of the abscess into the intestine, the leucocyte count would have led to an erroneous conclusion. For a similar reason — viz., the non- absorption of toxins into the blood — there is but slight leucocytosis in suppurative inflammation of the mucous membranes. 2. When the pyogenic bacteria have been killed, the toxins are soon carried away in the blood-stream and eliminated from the body, and when this has happened the leucocj^tosis falls, although there is still a collection of pus in the tissues. In other words, a high leucocytosis is to be regarded as a proof of the process of sup- puration rather than as a proof of the presence of pus. For example, such sterile collections of unabsorbed pus often occur in cases of pyo- salpinx of some standing, and are unaccompanied by leucocytosis, although acute suppuration in the Fallopian tubes causes the usual reaction. 3. When the organisms are ver}' virulent and the patient of feeble constitution, so that the infection rapidly spreads, there is occasion- ally a failure of leucoc3.tosis or even a leucopenia. This is notably the case in severe cases of diffuse septic peritonitis. The general (as well as the local) leucocytosis must be regarded as a conservative and defensive reaction, whatever views are held as to the nature of immunity. Its presence indicates that the patient has sufficient resisting powers to combat the infection, or at least to localize it for a time ; its absence in a case where there is suppuration renders the prognosis unusually bad. 4. Leucocytosis does not occur in cases of chronic or cold abscess. The products formed by the bacteria which produce these lesions have no positive chemotactic action on the polynuclear leucocytes. The cells found in the local lesions are mostly lymphocytes. Hence, even when the toxins of these organisms enter the blood, they fail to attract the polynuclear leucoc3'tes from the marrow. We might reasonably expect that an increase in the lymphocytes would occur; but these cells are not actively motile like the polynuclears, and are not so readily subser\dent to chemotactic influences. Another method sometimes used in the diagnosis of suppuration is based on the appearance of granules of glycogen (or an allied substance) in the protoplasm of the leucocytes in septic diseases. Dry blood-films are mounted in a recently prepared solution of iodine i, iodide of potassium 3, water 100, which has been saturated with powdered gum acacia. This stains the granules deep brown. This test is not as useful as the foregoing. The relations of some of the other infective diseases to the leucocytes may be briefly epitomized. In pneumonia, erysipelas, diphtheria, scarlet fever, plague, and whooping-cough there is a high leucocytosis, the number rarely falhng below 20,000. In rheumatic fever (uncomplicated), syphilis, and gonorrhoea there is usually a 64 A MANUAL OF SURGERY slight rise, and in tuberculosis, typhoid fever, influenza, measles, and malaria there is usually no excess, and often a diminution, in the number of leucocytes (ieucopenia). Pathological leucocytosis also occurs after severe luemorrliage, and in all cachectic conditions, especially in that due to malignant disease. In these cases it is almost always due to a local inflamma- tion excited by the new growth, and is rarely of diagnostic value. In carcinoma of the stomach there is usually an absence of digestion- leucocytosis, and this fact may assist in the diagnosis. The leuco- cytes are counted whilst the patient is fasting, and two or three times (at intervals of an hour) after a meal, which should include some meat. If the count does not rise considerably (2,000 per cubic millimetre or more), it affords strong presumptive evidence of the presence of mahgnant disease of the stomach, but, like all laboratory tests, must be considered in conjunction with the clinical phenomena. Lymphocytosis, or an increase of the lymphocytes, may be absolute or relative. A relative increase {i.e., such that the per- centage of these cells rises above 25, although the total number of leucocytes of all sorts does not exceed the normal) occurs in typhoid fever, tuberculosis, and malaria. A great excess of leucocytes (150,000 or more per cubic millimetre), the great majority being lymphocytes, occurs only in lymphatic leucocythsemia, and con- stitutes an important means of diagnosis between this condition and Hodgkin's disease, in which the leucocytes are normal or but slightly increased. Children's blood contains an excess of lympho- cytes, reaching 60 per cent., and in inflammatory diseases of children the increase in the total leucocytes may be due partly to an excess of lymphocytes, and not only of the polynuclears, as in the adult. This is especially the case if the lymph-glands are involved in the inflammatorv process. Eosinophilia, i.e., a relative increase of the eosinophiles, occurs in several conditions: (i) In infection with animal parasites, especially in trichinosis, where the proportion may be 60 per cent, or more. They are sometimes increased in hydatid disease; in doubtful cases this fact has some diagnostic value, but a count in which there is no increase is of little importance. (2) In some skin diseases, especially when a large area of skin is involved. (3) In asthma. (4) In gonorrhoea, and a few other diseases. A brief account of the blood conditions in those diseases which are especially connected with the blood-forming organs may be of some value: I, In pernicious ancemia the corpuscles are greatly reduced in numbers, whilst the haimoglobin is reduced, but to a lesser extent, the colour-index being greater than i. The red corpuscles are often distorted in shape (poikilocytosis), and large (megalocytes) or small (microcytes) forms occur. Large nucleated red corpuscles (megalo- blasts) are usually present, and are almost diagnostic of the disease. The leucocytes are usually normal or subnormal in number, and there is a relative increase of lymphocytes. EXAMINATION OF THE BLOOD IN HEALTH AND DISEASE 65 2. In chlorosis the haemoglobin is reduced to a greater extent than the corpuscles, the colour-index being less than i. There may be some microcytes, but the red corpuscles are usually normal in shape and size, though of pale colour. The leucocytes are usually normal. 3. In spleno-medullary leiicocyihcemia there is an enormous increase in the leucocytes; the number is usually not less than 100,000 per cubic milhmelre, and may rise to 1,000,000 or even more. Of these a large proportion are myelocytes, cells which do not occur in normal blood. They var}' in size, but are usually large, and may be very large; they have a single nucleus, which stains badly and is circular, oval, or indented, and often excentrically placed; they contain granules similar to those of the polynuclear leucocj^tes. The eosinopliile cells are greatly increased in absolute numbers, though their proportion relativelv to the other cells may be normal. Eosino- phile myeloc\-tes also occur; they are similar in all respects to the myelocvtes, except that their granules are large, resembhng those of" the eosinophiles of normal blood. The polynuclears are present in vast numbers, but their relative proportion is less o\\ing to the number of the mvelocytes. The lymphocytes are scanty, but the mast-cells are often abnormally plentiful. Nucleated red corpuscles occur. 4. Lymphatic lencocythcBmia can be distinguished from Hodgkin's disease (lymphadenoma) only by an examination of the blood. In the former disease there is a vast number of leucocj'tes, the great majority (90 per cent, or more) of which are Ijmiphocj^es. In the early stages of Hodgkin's disease the blood is absolutely normal, whilst later there is marked anaemia. The leucoc3i;es are not usually increased in numbers, and there may be leucopenia; there is often a slight relative increase in the l^-mphocjtes. In some cases there is leucoc\i;osis. Hodgkin's disease cannot be differentiated from tuberculosis of the Ij-mphatic glands by a blood count alone. The examination of the blood for parasites (including bacteria) is often necessary. It may be carried out by microscopic examinations of fresh blood or blood- films, or by cultures; the method to be selected must depend upon the organism sought. The diagnosis of malaria may be made by an examination of a wet fihn of fresh blood made by taking a small drop of the blood on a perfectly clean cover-glass, and placing the latter, drop downwards, on a perfectly clean shde; or films may be prepared in the ordinary way and stained bv carbol-thionin, haematoxylin and eosin, Jenner's stain, or bv other methods. For a description of the organisms and their Hfe-history the reader is referred to special treatises. Relapsing fever is due to a corkscrew-like organism (the Spirillum Ohermeyeri),\v]Ac]x is about two or three times as long as the diameter of a red corpuscle. They may be demonstrated by the method used for the malaria parasite, and in fresh specimens are as a rule actively motile. The diagnosis oi filariasis is best made by examining \\ith a low- power lens thick layers of fresh blood taken at night, if F. noctiirna 5 66 A MANUAL OF SURGERY is suspected; in the daytime, in the case of F. diiirna ; and at any time if F. perstans is sought. Where bacteria are sought for in the blood, cultural methods are almost always necessary, for their numbers are usually so small that the chance of finding even a single specimen in a stained blood-film is remote. The blood must be drawn directly from a vein with a sterilized hypodermic needle and syringe (or better with a hypo- dermic needle mounted on a short length of glass tul^ing and the whole sterihzed by heat), and full precautions must be taken in sterilizing the skin. At least 3 or 4 c.c. should be taken and inoculated directly into broth or melted agar, which is incubated and examined at the end of twenty-four and forty-eight hours. It is worse than useless to attempt to make a bacteriological examina- tion of blood obtained from a skin puncture, however carefully the skin may have been sterilized. In septicaemia, pyaemia, ulcerative endocarditis, and other diseases due to the pyogenic bacteria, the organisms may or may not be found in the blood. A positive result is most hkely to be obtained in severe cases, especially when the blood is collected during a rigor; it is of evil omen, although such cases are by no means necessarily fatal. Cultures in wliich staphylococci are the only organisms to develop must be interpreted with caution, as being possibl}^ due to accidental contamination. A negative result is usually of httle value in diagnosis, as organisms may be absent from the blood for long periods in cases of chronic septicaemia. It is sometimes necessary to examine the blood for bacteria in the diagnosis of typhoid fever, especially when the infection is not due to the ordinary typhoid bacillus, but to one of its congeners (the para- typhoid bacillus, etc.). In general, the diagnosis is made by means of VVidal's reaction. Typical Blood-Counts. It must be understood that the series of blood-counts here appended are to be looked on merely as typical illustrations; in any particular instance considerable differences from the figures given may be manifested. Normal Blood — Red corpuscles Haemoglobin Colour-index Morphology of red corpuscles ^ 5,120,000 per c.mm. 100 per cent. I (nearly). ^No abnormal forms seen . Corpuscles uniform in size, and stain only with the acid stain (eosin). Normal Blood — continued : Leucocytes - 7,000 per c.mm. Polynuclears - 72*0 per cent. Lymphocytes - 22-8 Eosinophiles - 2*4 Large hyalines 2*4 Mast-cells - 0-4 No other forms of leucocytes seen. Secondary Aneemia from repeated slight hcemorrhages — Red corpuscles - 4,200,000 per c.mm. Haemoglobin - 72^00 per cent. Colour-index - '85 EXAMINATION OF THE BLOOD IN HEALTH AND DISEASE 67 Secondary kasdvai^— continued : f Corpuscles Lymphatic Leucocythsemia- Morphology of red corpuscles stain a little faintly ; no nucleated forms seen. (N.ll. — In severer cases of secondary ana;mia, and especially in cases of profound anremia after a single large haemorrhage in a previously healthy person, normohlasts may be seen, and are a good sign.) Malignant Disease with cachexia — Red corpuscles Haemoglobin Colour-index Morphology of red corpuscles Leucocytes Polynuclears - Lymphocytes - Large hyalines Eosinophiles - Mast-cells Morphology of leucocytes 3,200,000 per c.mm. 48*00 per cent. •75 ' The corpuscles stain some- what faintly ; normoblasts are present, but in scanty numbers. 12,000 per c.mm. 82-4 per cent. 14-8 •4 Nothing ab- normal seen. Suppuration (acute appendix abscess) — Red corpuscles per 4,500,000 c.mm. 85-00 per cent •95 Haemoglobin Colour-index Morphology of red corpuscles Normal. Leucocytes - 23,oooperc.mm. Polynuclears - 86'2 per cent. Lymphocytes - ii'6 ,, Eosinophiles - i*o ,, Large hyalines i'2 No abnormal forms seen. Some of the poly- nuclears show ' glycogenic ' degeneration. Tubercle (not complicated with sec- ondary infections) — Red corpuscles - Haemoglobin Colour-index Morphology of red corpuscles Leucocytes Polynuclears - Lymphocytes - Large hyalines Eosinophiles - Morphology of leucocytes - 4,112,000 per c.mm. 76'0 per cent. •9 Normal. 4,200 perc.mm. 64'2 per cent. 32-8 „ 2-8 •2 Normal. Red corpuscles Haemoglobin Colour-index Morphology Leucocytes Poljmuclears - Lymphocytes (nearly all small) Eosinophiles - Myelocytes per 2,000,000 c.mm. 36*0 per cent. •7 ' The corpuscles stain some- what faintly; normoblasts are present, but in scanty numbers. I 12,000 per c.mm. 8-2 per cent. gi-2 (N.B. — In lymphatic leucocythamia there is not necessarily a great total increase in the num- ber of the leucocytes, but the relative increase in the lymphocytes is usually very marked.) Leucocythaemia (spleno-medullary) — Red corpuscles - Haemoglobin Colour-index Morphology of red corpuscles Leucocytes 3,200,000 per c.mm. 52-0 per cent. •8 Normoblasts present in rather large numbers (about one in every two fields of a -^-inch lens) . 456,000 per c.mm. Myelocytes and cells inter- mediate be- tween them and polynu- clears Polynuclears - Eosinophiles and eosino- phile myelo- cytes - Mast-cells and mast- cell myelocytes - Lymphocytes and large hyalines Many of the polyiuiclear leucocj'tes show signs of degeneration, having faintly stained nuclei and few granules ; some are difficult to distinguish from myelocytes. Some of the myelocytes are also deficient in granules, and almost indis- tinguishable from large hyaline leucocytes. 42'0 per cent. 39-0 7-6 3-0 CHAPTER V. NON-SPECIFIC* PYOGENIC INFECTIONS. In this chapter \vc propose to deal with a series of affections asso- ciated with or aUied to suppuration, and due to non-specific bacteria. These organisms, usually termed pyogenic, cause an inflammatory reaction in the tissues, which sooner or later is associated with liquefaction of both tissue and exudate, the liquefied material being known as pus, and the process which leads to its formation as sup- puration. Any localized collection of pus in the tissues is known as an abscess, and this, according to its course, may be acute or chronic, the latter being uncommon. Sometimes the infection involves the cellular tissue of a part in a more or less diffuse manner, the pus burrowing widely ; this condition is termed cellulitis. Constitutional phenomena are associated with these local manifestations, and may be of two types: (a) When toxic products alone are absorbed, re- sulting in toxceniia or some modification of the same; and {h) when the bacteria invade the blood-stream and become disseminated to distant parts, thereby giving rise to either septicamia or pycemia. Each of these various conditions must be dealt with separately, but one must first describe in some httle detail the organisms com- mon to the whole group. Bacteriology.^ — The following are the more important pyogenic bacteria : I. The Staphylococcus pyogenes (Plate T, Fig. i) is perhaps the most common organism of acute localized suppuration, especially in connection with the skin and subcutaneous tissues. It is a coccus of medium size which occurs in the pus in characteristic clusters, which have been compared to bunches of grapes. It stains by Gram's method, and liquefies gelatin or solidified blood-serum, as it produces a powerful peptonizing enzyme, and is readily cultivated on almost all media; it grows best when an abundant supply of oxygen is present. Cultures on sohd media develop rapidly, and the colonies spread, the surface being soon covered by a imiform thickish film of growth. This may be orange-yellow, lemon-yellow, or white in colour, and three organisms — Staphylococcus pyogenes aureus, ciireus, and albus, *■ For the significance of the term non-specific, see p. 12. 68 NON-SPECIFIC PYOGENIC INFECTIONS 69 respectively — have been recognised. Under certain circumstances, however, the one may change into the other, and there is httle doubt that the three really constitute one species. Staphylococci are very widely distributed, being common in air, dust, etc. They are frequently found in or on the human skin, though apparently not normal inhabitants of that structure. Sup- purative inflammations of the skin and subcutaneous tissue are due to staphylococci in the vast majority of cases; and when the inflammation is caused by other organisms in the first instance, a secondary infection with staphylococci almost always takes place later. Impetigo contagiosa, a disease due primarily'' to streptococci, may be taken as an example of this, and the vesicles of small-pox or vaccinia another, for in each case a secondary staphylococcic in- vasion takes place. The chief skin lesions due to staphylococci are abscesses, boils, carbuncles, pustular acne, etc. In some cases diffuse spreading cellulitis depends on the same cause, but this is unusual. Deep-seated suppuration, such as osteomyelitis, peri- tonitis, empyema, etc., may also be due to staphylococci; in fact, they may cause suppuration in any part of the body. Lastly, staphylococcic septicaemia, pyaemia, and ulcerative endocarditis occur, but are less common than the forms due to streptococci, and the prognosis appears to be slightly less grave. Most cases of suppuration occurring after operations in which the antiseptic or aseptic precautions have been inadequate are due to staphylococci, either alone or in admixture with other organisms. 2. The Streptococcus pyogenes is an organism in which the individual cocci are arranged in longer or shorter chains (Plate I., Fig. 2). It stains with Gram, and does not grow very easily on artificial culture media. A temperature approximating to that of the body is desir- able, and hence it does not grow well on gelatin. The colonies are small and translucent, and do not tend to spread or become con- fluent. It forms no peptonizing enzyme, and hence does not liquefy solidified blood-serum. The cultures readily die out. On comparing cultures of Streptococcus pyogenes from different sources, slight differences may be noted, e.g., in the length of the chains, the size of the cocci, the appearance of the colonies, etc. It is as yet uncertain whether these are sufficient to differentiate several species, or whether they merely indicate unimportant (and perhaps not permanent) varieties of a single species. The Streptococcus pyogenes is, on the whole, a more virulent organism than the staphylococcus, and tends to produce an acute spreading inflammation rather than a localized abscess, although the latter lesion is quite commonly due to it. Erysipelas is (in most cases) caused by a streptococcus which has been held to be a distinct species, although the differences are so unimportant that the two are generally considered identical. Cellulitis, too, is usually due to the Streptococcus pyogenes. The organism plays its most important role, however, in connection with septicaemia and pyaemia, whether puerperal or not, and is the usual cause of ulcerative endocarditis, 70 A MANUAL OF SURGERY 3. Tlie Pneiiinococciis (Plate I., ¥\^. 4), geiurully })r('S(.'nt in lobar pneiinionia, is a diplococciis, the individual cocci liaving usually a triangular or lancet shape, with the bases facing one another. When it occurs in pus or other animal fluids, it is surrounded by a clear capsule. In cultures it closely resembles the Streptococcus pyogenes. It is chiefly of importance in suppuration connected with the lungs, especially empyema. It occurs almost constantly in all inflam- matory lesions of the lung, whatever their origin, as a secondary infection; thus, in the walls of a tuberculous cavity suppuration is nearly always due to pneumococci alone or in conjunction with other organisms. It is a common cause of middle-ear disease, and of its cranial or intracranial compUcations. Pneumococci also cause arthritis, which may or may not result in suppuration ; the arthritis usually follows an attack of pneumonia, but this is not necessarily the case. Peritonitis is also due to this organism in 3'oung children, and may be primary or secondary to some pulmonary lesion. The pneumococcus frequently enters the blood and causes septicemia, with or without ulcerative endocarditis. 4. The B. coli communis (Plate III., Fig. 30) occurs in great numbers in the contents of the healthy intestine. It is a short motile bacillus which does not form spores, and is not stained by Gram's method. It grows best in presence of oxygen, but is a facultative anaerobe; no peptonizing enzyme is produced, so that gelatin is not liquefied, but an abundance of foul gas is developed. The B. coli is one of the most important putrefactive organisms, and it breaks down proteids, forming indol and allied bodies, and gases with faecal odour. It is closely allied to the tvphoid bacillus, and is distinguished therefrom by its action on various sugars; thus, the typhoid bacillus produces acid, but no gas, when grown in broth containing glucose, whereas the B. coli produces both acid and gas. These two bacteria are members of a large and important group of micro-organisms which have a close morphological resemblance to one another, bvit differ in their chemical activities. Under normal conditions the bacilli of this species, which occur in the intestinal contents, are not very virulent, but when any patho- logical condition arises in the gut — e.g., strangulation, ulceration, perforation, etc. — their virulence appears to be increased, and an active invasion of the tissues may follow. It is thus a common cause of appendicitis, acute peritonitis, etc., and pus due to its action has usually a fascal odour. It can also ascend the bile-ducts, and give rise to cholecystitis and cholangitis. Lastly, the B. coli is one of the commonest causes of cystitis. It has, however, no power to render the urine alkaline; this is due to the presence of a micrococcus, formerly known as M. itrece, but now believed to be identical with M. epidermidis albits, an organism of constant occurrence in the skin. 5. The typhoid bacillus (Plate III., Fig. 25) sometimes causes abscesses, especially in connection with the bones or joints, after an attack of typhoid fever. In some cases the organism may lie latent for years before suppuration occurs. It has also been proved that NON-SPECIFIC PYOGENIC INFECTIONS 71 some persons continue to give off these bacilli in the urine or faeces for many years after an attack of typhoid fever; in the latter instance the gall-bladder has sometimes been the infected focus. These ' typhoid carriers,' as they are termed, may at any time initiate an epidemic of the disease, which may thus appear to arise without reason. 6. The B. pyocyaneus is a comparatively rare cause of suppura- tion. The pus produced by it turns bluish-green when exposed to the atmosphere. It sometimes gives rise to a general infection. 7. The Gonococciis (see p. 142). 8. The M. tetragenus, an organism in which the individual cocci occur in tetrads, is rarely met with. Many cases of suppuration are due to a mixed infection with two or more of the species of bacteria enumerated above. In other instances an abscess formed by the action of one of the pyogenic bacteria may be subsequently inoculated with simple saprophytes that have the power of growing in dead pus, but cannot invade the living tissues. This accident is very likely to occur in a large abscess when the drainage is insufhcient and the dressings are not performed with sufficient care. It should be studiously avoided, for lesions due to a mixed infection heal with difficulty; the tissues appear more easily to acquire immunity to a single organism than to two or more at the same time. The fact that a wound is already infected is no reason for neglecting to treat it with the fullest anti- septic precautions. I. Acute Abscess. etiology. — (a) It may be taken as established that suppuration as met with in surgical practice is always due to the action of bacteria. It is true that in the laboratory it is possible to obtain aseptic sup- puration in animals by the use of chemical irritants, such as croton oil, etc., but this does not occur in man. It is also true that in certain abscesses, notably in the liver and in pyosalpinx, no organ- isms can be found in the pus on microscopical or cultural examina- tion; this is usually due to the fact that the bacteria have been destroyed and the abscess has ceased to spread. In other cases the organisms may be present in very small numbers, or may not grow on the ordinary culture media; and in this connection it may be well to point out that new varieties of pathogenic bacteria are frequentfy being discovered. {h) Bacteria can reach the area which becomes inflamed either from ivithout the body or from within. The former method is the more usual, and is illustrated by the observations of Garre and Bockhardt, who rubbed cultures of Staphylococcus pyogenes aureus into the skin of their arms, and produced acute suppuration, commencing in superficial pustules, and finishing as boils or carbuncles. The Staphylococcus pyogenes is commonly present in the skin, and fre- quently deposited on instruments, dressings, etc., from the air, and it is to infection from without, due to bacteria gaining access from 72 A MANUAL OF SURGERY one or other of these sources, that the majority of cases of suppura- tion are due. In some cases, however, bacteria may gain access to the tissues from tlie blood ; thus it sometimes happens that a deep lesion (such as a ruptured nuiscle or hgamcnt) results in suppuration, although the skin over it is unbroken, and the intervening tissues are ap- parently healthy. Here we must assume the possibility of auto- infection (p. 7), the bacteria reaching the blood from some focus of chronic suppuration, such as a neglected pyorrhoea, or ulceration of the mouth or intestine. In other cases abscesses may be due to organisms which have lain latent in the tissues, it may be, for long periods. This is never very easy to prove, but the possibility of such latency is shown by the fact that a patient may develop leprosy many years after ex- posure to infection. A more common example may be seen in the bone abscesses which sometimes develop months or years after an attack of typhoid fever, and which are due to the typhoid bacillus, though in this case we cannot exclude the possibility of a subsequent infection with the same certainty as in the case of leprosy. In what state the bacteria lie latent in the tissues and the nature of the con- ditions which excite them into activity are unsolved problems; we should expect the latter phenomenon to be due to general ill-health or to local injury, but cases occur in which no such factors can be traced. It is probable that they would regain their activity if an operation took place in the region in which they were deposited; suppuration would then follow in spite of perfect asepsis. Abscesses of a ver}^ different nature occur when pyogenic bacteria are carried from a suppurative lesion in one part of the body to another ; these are termed secondary embolic abscesses and develop in pyaemia, gonorrhoea, etc. (c) Sterilized foreign bodies {e.g., silver wire or glass splinters) do not produce suppuration, except in the rarest of cases, by auto-infection. Thus, a ragged splinter of glass, ij inches long and li inches wide, the result of the bursting of a soda-water bottle, was cut out of the neck of an hotel porter ten months after it had entered; it was en- capsuled and had caused no trouble. This fact is constantly made use of at the present day in surgical practice; deep layers of the tissues are brought together by carefully sterilized buried sutures, and divided structures such as bones, ligaments, etc., are approxi- mated and held in position by wire, screws, pegs, or other buried appliances, which would cause endless trouble but for their complete sterihzation. In conclusion, therefore, although we have to admit that suppura- tion may be experimentally induced in animals in the absence of micro-organisms, in man for all ordinary conditions suppuration does not occur apart frojn the presence and vital activity of pathogenic bacteria. The causes of an acute abscess may be grouped for practical purposes under the three following headings: (i) The individual affected is possibly in a depressed and unhealthy state, and the NON-SPECIFIC PYOGENIC INFECTIONS 73 germicidal power of his tissues may be defective. When abscesses have occurred more than once in the same individual, one may rightly suspect the existence of some intrinsic source of infection, such as oral sepsis, or some external contamination, as from defec- tive drains, leading to escape of sewer gas. (2) A local nidus must exist, which is in a condition of lowered vitality from injury, cold, or otherwise; and (3) this spot becomes infected with pyogenic organisms brought to it either from within or without the body. Formation and Structure of an Acute Abscess. — The bacteria which have gained access to the tissues grow and produce toxins that are Fig. 13. — Formation of Abscess in the Kidney. (Thoma.) In the centre is a zoogloea mass of organisms; around it, a zone of devitalized tissue; and, still farther out, an infiltration of the living tissues with polynuclear leucocytes. diffused into the surrounding structures, giving rise to acute inflam- mation; the vessels dilate, acceleration of the blood-stream occurs, and is followed by retardation and thrombosis, and the leucocytes emigrate. More vigorous action of the toxins on the injured tissues destroys their vitality, usually by a process of coagulation- necrosis. A section through the lesion at this stage will show two well-differentiated zones (Fig. 13): a central area in which the tissues are dead, have lost their staining properties, and contain the p3'ogenic bacteria; and a peripheral zone of ordinary acute in- flammation, which fades gradually into the surrounding healthy tissues. This inflamed zone is thickly infiltrated \vith leucocjrtes, 74 A MANUAL OF SURGERY and on examination these will be found to be inainly of the poly- nuclear variety, since the products of pyogenic bacteria have special attractive (chemotactic) powers over this form of leuco- cytes. The central necrotic mass which contains the bacteria is at this stage still attached to the surrounding living tissues, and if the lesion is incised it will appear as a small slough, which can only be removed with difficulty. Hut this condition soon changes; as a result of increasing exudation, especially of plasma, the tension in the inflammatory focus becomes so great that the cohesion of the tissues around the central slough is destroyed, and a third zone — of polynuclear leucocytes swimming in fluid — is formed between it and the inflamed outer zone. Where the toxins have a peptonizing enzyme action, it is possible that this plays some small part in liquefying the tissues. The fate of the small slough varies according to circumstances. It may occasionally be recognized when a small abscess is opened —e.g., the core of a boil — but in most cases it is absorbed by the leucocytes or digested by the peptonizing enzymes which many pyogenic bacteria form. It may even happen that no definite slough is ever formed (Fig. 14), the earliest effect of the bacteria being to attract the leucocytes in vast numbers into inflamed but still living tissues, which are then killed and digested cell by cell. This collection of leucocytes suspended in fluid and surrounded by a zone of inflamed tissue constitutes an abscess. The leucocytes and fluid are collectively termed pus, and it is important to recognise that the characteristic cells of the pus from an acute abscess are the polynuclear leucocytes. These, however, differ somewhat from those seen in blood-films. Many of them are killed by the toxin (as can be seen from their loss of motion when the fresh pus is examined on a warm stage), and undergo various degenerative changes. Some of them may contain bacteria. At first the abscess often extends rapidly, but after a day or two (in most cases) a certain amount of local immunity is produced, and the abscess spreads more slowly. This is an indication of the fact that the tissues, which were at first overwhelmed by the action of the bacteria and their toxins, are now carrying on the contest on more even terms. At this period the cavity becomes lined by granulation tissue (Fig. 15), which forms a "thick, soft layer of velvety appearance and bright-pink colour. It is composed of large numbers of loops of newly-formed bloodvessels embedded in a mass of leucocytes and tissue-cells in a state of active proliferation. Its appearance does not necessarily indicate that the abscess has entirely ceased to spread, for the toxins may still be powerful enough to kill the delicate newly-formed tissue cell by cell; but in most cases it is the first indication of repair and of "the ultimate victory of the tissues. Leucocytes continue to pass from the thin-walled vessels of new formation into the abscess cavity, being attracted chemo- tactically by the substances present in the pus; hence the layer of Fig. 14. — Abscess Formation in the Subcutaneous Tissues in the Early Stage (Four Days). To the right of the illustration are seen masses of round cells (polymorphonuclear leucocytes), which are ready to break down into pus. To the left is seen fatty tissue, permeated by strands of fibrous connective tissue in a state of cell proliferation. Fig. 15. — Section of Abscess in Subcutaneous Tissues (Seven Days). The structureless pus is seen below and to the right, and above it the intensely cellular linin? of the abscess cavity, which is in reality infiltrated with bacteria. The tissues beyond are in a stage of proliferation similar to that seen in Fig 14. (For the loan of these illustrations we are indebted to Mr. G. Lenthal Cheatle.) 76 A MANUAL OF SURGERY granulation tissue appears to secrete pus, and was formerly called a ' pyogenic membrane.' Its appearance was anxiously looked for by surgeons in the days when suppuration was considered essential for the healing of wounds, since it opposes a strong barrier to the bacteria and their toxins, and in large measure prevents their enter- ing the blood-stream. Thus the formation of thick, creamy pus of a 3'ellowash colour, such as is produced by such a pyogenic mem- brane, was looked upon as a sign that the patient was practically out of danger of ' blood-poisoning,' and the pus itself was termed ' laudable.' Abscesses do not as a rule spread equally in all directions, since certain structures, especially bone and fascia, are more resistant than cellular tissue or fat. The process of extension continues along the line of least resistance until the abscess points at some surface, and finally bursts through the skin or into the ahmentary canal or other cavity. When this happens, the bacteria and their toxins alike are able to escape, and in consequence their action on the pyogenic membrane is less profound, so that the contest between the defensive powers of the tissues and the destructive powers of the bacteria, in which the latter were victorious at first, turns in favour of the tissues. The bacteria which remain are attacked with greater effect by the leucocytes, and are gradually removed; the supply of toxin diminishes; the inflammatory process in the abscess wall becomes less severe, and finally organization of the granulation tissue commences. This begins at the bottom of the abscess cavity, the walls of the upper portions being kept apart from one another by the pus which is still secreted, though in gradually diminishing quantity. The result is that the abscess cavity fills up from the bottom, and finally heals altogether. This process is facilitated if efficient drainage is provided, so that the bacteria and toxins find a ready exit. Occasionally the defensive powers of the body are sufficient to kill off the bacteria after pus has been formed, and before it has escaped. When this happens, the pus may become absorbed and the ca\'ity obliterated, or the fluid part only may be removed, and the leucocytes (which undergo fatty degeneration) remain as a cheesy, structureless mass. In either case the abscess wall organizes into fibrous tissue, constituting a deep scar, in the centre of which ma}' be the inspissated pus. It is rare, however, for this to happen, except in the abdomen, and then usually in connection with the appendix, Fallopian tube, or liver. The Clinical Signs and Symptoms of an acute abscess may be arranged under three headings: I. The local signs consist of a patch of inflamed tissue, indicated by heat, pain, redness, and swelling, which latter is at first hard and brawny, but when pus forms, the centre becomes soft and elastic, whilst superficial oedema is more marked, and the pain throbbing in character. Naturally, the amount of this pain depends entirely upon the density of the tissue affected and the supply of sensory nerves to NON-SPECIFIC PYOGENIC INFECTIONS 77 the part, suppuration beneath a resisting membrane, such as the palmar fascia, being always intensely painful. Fluctuation is the most characteristic sign of the presence of fluid; it is obtained by making firm pressure with the finger or fingers of one hand on one part of the swelhng, whilst the fingers of the other hand placed on another part receive the impulse transmitted across the intervening space in the form of a fluid wave. Some soft sohds give a sensation of fluctuation — e.g., hpomata and soft, rapidly-growing sarcomata; whilst, on the contrary, it may be absent when the fluid is under great tension, or surrounded by a thick wall, or widety diffused in such a structure as the glandular tissue of the breast. Sometimes, when the pus is small in quantity, all that can be detected is a feehng of elastic resistance in the centre of the brawny hyperamic mass; but this, to the practised finger, is quite as con- clusive of the presence of fluid as fluctuation. When the pus is placed deeply under muscular and fascial planes, very careful examination may be needed in order to determine its presence ; the surgeon must not be misled bj' the sense of fluctuation obtained across the fibres of a muscle; none is noticed, however, by palpating along the course of its fibres. j\Iarked and increasing oedema is frequently conclusive of the presence of deeply-seated pus — e.g., in acute osteomyeHtis, and suppurating mastitis. If left to itself, an abscess sooner or later points and bursts. x\s it increases in size, it travels in the line of least resistance, and so may either find its way direct to the surface, or may burrow along mus- cular and fascial planes, or into adjacent cavities. The actual burst- ing of an abscess is often due to some injury — it may be a shght one — but is usually preceded by ulceration or necrosis of the integu- ment. 2. Pressure effects are mainly due to the mechanical influence of the swelhng upon surrounding structures. The most e\ident are those due to the irritation of nerves, as a result of which neuralgic pain may be present, or the patient may refer the pain to some distant unaffected region. In some cases, where large bloodvessels traverse the suppurating focus, the surrounding tissues may be destroyed, lea^dng them exposed in the abscess cavity as bands. Thrombosis and subsequent obfiteration may result, especially in the veins; or occasionally haemorrhage follows, due to sloughing of the arterial wall (suppurative periarteritis), preceded perhaps by an aneurismal dilatation of the vessel, owing to its loss of ex- ternal support. Such effects occur both in acute and chronic abscesses. 3. The general effects of the formation of an acute abscess are those of increased fever, sometimes amounting to a rigor, and leucocytosis. A rigor consists of a definite series of phenomena, the result of the stimulation of the thermogenic centres by an accumulation of toxin in the blood. It is very similar in nature to an attack of ague, being ushered in by a feeling of intense cold and discomfort ; the features are pinched, and the teeth chatter. The skin, however, feels dry 78 A MANUAL OF SURGERY and hot, and the temperature of the body rapidly rises. The sensa- tion of cold is partly due to the contact of air at a maintained normal temperature with the hot, dry, unperspiring skin, and also possibly to the condition of superficial anaemia which is present. After this stage has lasted a variable period, the patient gradually begins to feel warmer, the face becoming flushed, the thermometer ceasing to rise, and the skin commencing to act. Finally there is a rapid fall of temperature accompanied by profuse perspiration, which probably eliminates the toxin, but leaves the patient more or less exhausted. For leucocytosis and its value in the diagnosis of suppuration, see p. 62. Pus and its Constituents. — Normal or, as it v/as formerly called, healthy or laudable pus is a thick, creamy fluid, having a specific gravity of about 1030, an alkahne reaction, no smell (unless putre- fying or due to the activity of the B. coli), and containing 85 to 90 per cent, of water. If allowed to settle, it separates into two layers, an upper or fluid part, the liquor puris, which is usually clear or shghtly opalescent, and a deposit of a yellowish-gray colour, which is usually more bulky than the fluid portion. The liquor puris is derived from the plasma exuded from the vessels. It may undergo coagulation after removal from the body, a very loose clot being formed. Frequently, however, this does not happen, perhaps because it has already coagulated within the abscess, and the re- sulting fibrinous network has been dissolved by the peptonizing ferment of the toxins, or destroyed by the leucocytes. It consists chemically of an albuminous fluid very similar to serum, but more dilute, and contains bacterial toxins, enz3^mes, proteoses formed by the digestion of proteids, etc. Sometimes (when the abscess in- volves a region containing fat) a few globules of oil fl.oat on the surface or occur in an emulsified form in the fluid. The sohd portion consists in the main of pol^muclear leucocytes, most of which, as has been already pointed out, are dead and de- generated, whilst a few are still alive and capable of spontaneous movements. In addition, there are fragments of cells and nuclei from the tissues, shreds of fibrous tissue, granular debris, and bacteria. A few red blood corpuscles are often present. When pus is mixed with blood, it is termed sanious (short for sanguineous) ; when thin and acrid, it is ichorous; curdy, when mixed with curdy shreds, as is more usuall}- seen in chronic suppuration of a tuberculous nature. Blue or green pus is due to the activity of the B. pyocyaneus ; the colour is often seen best on the outer layers of the dressing which are exposed to the air. Its occurrence is uncommon. Muco-pus is of a sticky, glairy character, and arises from inflammator}- conditions of mucous membranes; sero-pus is thiin and more liquid from admixture of serum, and is derived from serous membranes. Occasionally an abscess contains not only pus, but also gas. This may be due to the existence of a direct communication with some hollow viscus — e.g., the stomach or intestine — and hence is met with NON-SPECIFIC PYOGENIC INFECTIONS 79 in many cases of subphrenic abscess. In some of the many types of abscess associated with appendicitis the gas is due to the activity of the B. coli either alone or mixed with other germs. In the limbs it is usually the result of infection with a gas-producing organism — e.g., the B. acrogenes capstilatiis or B. (vdematis maligni, and is associated with an acute spreading cellulitis or gangrene. Treatment of Acute Abscess. — When an inflamed area is threaten- ing to suppurate, the formation of pus can be but rarely prevented. In the early stages, elevation and rest of the part, together with the application of evaporating lotions and the administration of quinine with iron, may sometimes succeed in accomphsliing this, or Bier's treatment by induced hyperaemia may be useful. In a few regions of the body, pus may be absorbed after its forma- tion, but only when situated in a cavity of highly absorbing powers, such as the anterior chamber of the eye (hypopj'on) or the peri- toneal ca\'ity. In the former the process of absorption may cer- tainly be observed under the influence of local and general treat- ment. As a rule, however, one relieves pain and encourages suppuration by applying fomentations (medicated with opium or belladonna) or poultices to the part, and then, as soon as pus is present, an incision is made to evacuate the abscess cavit}'. The opening must be large enough to prevent re- accumulation : it should be placed at a spot suitable for drainage, but as far as possible from sources of secondary contamination, and in such a direction that movements of the part do not close it. Where the opening is not dependent, it may be desirable to make a counter-opening by pushing the finger or a probe through the abscess wall amongst the tissues, making it pro- trude beneath the skin at some dependent spot, and cutting down upon it in this direction. In dealing mth deep abscesses in dan- gerous regions, Hilton's method ma}' be advantageously employed. This consists in di\iding merely the skin and superficial structures, and then thrusting a pair of sinus or dressing forceps into the abscess ca\ity. On forcibly separating the blades a sufficient opening is made to insert the finger, and subsequently a drainage-tube. Rigid antiseptic precautions must be taken in opening abscesses, for, although bacteria are present, it is most essential that no fresh germs be admitted, thereby gi\'ing rise to a mixed infection, the presence of wliich is most unfavourable to rapid repair. It is ad\isable to remove any sloughs that are present, and when the abscess has burrowed, or if the canity is large, it should be gently explored with the finger, but adhesions or bands crossing it should not be indiscriminately broken down, as they may contain large bloodvessels. All that is subsequently needed, if there is no comphcation, such as the presence of dead or diseased bone, is to arrange for drainage, as by inserting a rubber or glass drainage-tube or a shp of protective, and to prevent a mixed infection by a care- fully-applied antiseptic or aseptic dressing, or by packing the cavity with gauze soaked in an iodoform emulsion (10 per cent.). There So A MANUAL OF SURGERY is often a considerable loss of blood during the first twenty-four hours from the yielding of the capillaries in the abscess wall, owing to the sudden reUef of tension; but this usually ceases of itself, or yields to moderate pressure. When once the abscess has been evacu- ated, no more pus is formed if external contamination {mixed infection) has been avoided, the discharge being merely serous, and the wound rapidly closing and healing, and this in spite of the fact that bacteria are for a while present ; they are evidently unable to develop or do any harm as the result -of a local immunity. An abscess cavity which has contained foul or stinking pus usually runs a healthy course if aseptic conditions are maintained, and if no communication with the bowel exists, the discharge becoming free from smell in a few days. The persistent discharge of pus from an abscess which has been opened means either that the opening is too small, or that matter is pent up in an undrained loculus, or that a mixed infection has occurred, or occasionally that the vital powers of the patient are so deteriorated that it is difficult to establish healthy repair, or that the part is not kept at rest. Free drainage, the improvement of the general health, and keeping the affected part at rest are essential elements in the successful treatment of an abscess. A small open- ing must be enlarged; loculi must be drained, and, if need be, a counter-opening made. DebiUtated patients may sometimes need to be sent to the seaside before healing will occur. Chronic Abscess of Pyogenic Origin. A chronic abscess may be defined as a collection of pus which forms slowly and without any signs of active inflammation, so that it is sometimes termed a cold or congestive abscess. The vast majority are tuberculous in origin, but a few may be due to the liquefaction of other granulomatous masses, to an infection with pyogenic bac- teria of low vitahty, or to chronic pyaemia. The chnical phenomena are alike in the two types, and will be dealt with later (p. 182), but there is one important distinction between them, in that the fining membrane of the pyogenic variety is merely granulation tissue more or less active, wlulst in the tuberculous fomi it contains living tuber- culous material. Hence, whilst a simple incision under aseptic precautions is all that is required in the former, the latter also needs removal of the tuberculous tissue by scraping or some such agency. Sinus and Fistula. When an abscess, acute or chronic, has been opened, and does not heal completely, a communication often persists between the original seat of the disease and the exterior, which is known as a sinus or fistula. A Sinus is a narrow track fined wdth granulations, penetrating into the tissues, open at one end and closed at the other; the discharge may be purulent or merely serous. A Fistula is an NON-SPECIFIC PYOGENIC INFECTIONS 8i abnormal communication, congenital or acquired, between two cavities, or between a cavity and the external surface. When such conditions result from the non-closure of an abscess of pyogenic origin, the walls consist of an external libro-cicatricial layer and an internal hning of more or less healthy granulation tissue. Should the abscess have been of tuberculous origin, the lining membrane will also contain tubercles. If the fistulous track is short, the granulating wall may become covered with epithelium, and under such circumstances the fistula cannot be expected to close naturally. It is often a matter of difficulty to secure the heahng of a sinus or fistula, and the following are the main causes of their non-closure : (i) The presence of some chronic irritant in the depths of the wound, such as a piece of the clothing, a catgut ligature, a piece of silk or silver-wire used in an operation, or of some diseased tissue, such as a fragment of dead or carious bone; (2) the irritation of discharges finding an exit through the abnormal opening, such as urine, faeces, or foetid pus ; (3) insufficient drainage of a deep cavity, so that there is always a certain amount of tension in the wound ; (4) want of rest to the part, due either to voluntary movements, as in the limbs, or to involuntary muscular action in the immediate neighbourhood, as in fistula-in-ano ; (5) tuberculous infection of the wall, or a tuber- culous deposit at the bottom of the sinus; (6) the growth of epithe- lium down the sinus or round the margin of the fistula; or (7) con- stitutional debility. The orifice of a sinus often looks depressed from the amount of infiltration around, but when the surrounding tissues are healthy, puckering in of the orifice is a good sign; in cases where foreign bodies are lodged within, or where diseased bone exists, it is usually surrounded by prominent f ungating granulations. Treatment. — The removal of the cause is the first thing to accom- plish in dealing with a sinus or fistula. The passage must be dilated or slit up to allow of access to the deeper parts of the wound, to remove any foreign body which may be present, or to allow of the satisfactory drainage of a deep cavity. The making of a dependent counter-opening often suffices to cure a sinus. A thorough disin- fection of the part by pure carbohc acid or chloride of zinc (40 grains to I ounce) must also be undertaken, and the wound dressed by packing with suitable material and kept at rest, whilst the general health of the patient is improved by tonics. Occasionally, the pressure of a roller bandage to immobihze the part is all that is required, or the application of a suitable splint. The most complete and certain method is to lay the sinus open and destroy the hning granulation tissue by scraping or cauterizing, and then to pack the wound, allowing it to heal from the bottom by granulation. Should a fistula have become lined with epithehum, the edges wll require paring, and some form of plastic operation -must be under- taken to close the opening. Sinuses often react well to vaccine treatment, and this is especially the case with those left after empyemata, when a single injection of 82 A MANUAL OF SURGERY 50,000,000 to 100,000,000 dead pneumococci will often prove effica- cious. Tuberculous sinuses, such as may be left after an operation for glands in the neck, etc., are sometimes curable by the use of tuberculin (TR), but there is not much chance of success if the non-hcahng is clue to dead bone, movement, etc. Results of Long-continued Suppuration. When an abscess, acute or chronic, pyogenic or tuberculous, is treated antiseptically, the formation of pus quickly ceases; the wound may not heal for months, but the discharge is merely serous, and no constitutional results will be manifested. The temperature remains normal, and the general health unimpaired, if no other disease is present. Should a tuberculous abscess become infected with pyococci, or a mixed infection occur in a pyococcal abscess, Fig. 16. — Temperature Chart of Hectic Fever. the discharge of pus continues or reappears, and fever to a varying degree follows. When an extensive or deep abscess is thus involved, the discharge may become very profuse, high fever may supervene, grave visceral changes may follow, and the patient may lose his hfe through toxaemia and cxliaustion. Long-continued suppuration is always an evidence of persistent infection, and prominent amongst the conditions which arise therefrom may be mentioned hectic fever and lardaceous disease of the viscera. Hectic Fever may be defined as a chronic toxrcmia due to the continued absorption of small doses of toxins, and is met with in any condition of chronic infection — e.g., after acute or chronic suppurative affections of bones or joints, in tuberculous disease of the lungs, and in chronic syphilitic or cancerous ulceration. It is characterized by a diurnal elevation of temperature .{Fig. 16) NON-SPECIFIC PYOGENIC INFECTIONS 83 during the afternoon or evening, when the face becomes flushed {firtiic flush oi the cheeks), the eyes are bright and sparkhng, the pupils dilated, and the patient feels better and stronger. The pulse, however, is small, compressible, and ten or twenty beats quicker than it should be. This condition continues till late in the night, by which time the temperature may have risen four or five degrees. In the early morning it falls as rapidly as it had formerly risen, and usually drops to the normal, or even below it, and this is accom- panied by a profuse perspiration, which leaves the patient in a much- exhausted condition. Day by daj^ this continues, the fever and sweating together causing rapid and marked emaciation. Fig. 17. — Amyloid Kidney in Early Stage. (Ziegler.) (Treated with Muller's fluid and perosmic acid, x 300.) «, Normal capillary- loop; b, amyloid capillary loop; c, fatty epithelium of glomerulus; Cj, fatt}^ epithelium of capsule; d, oil-drops on the capillary wall; e, fatty epithelial cells hi situ; f, loosened fatty epithelial cells; g, hyaline coagula (forming ' casts ') ; h, fatt}^ cast in section; i, amyloid artery; k, amyloid capillar}^; I, infiltration of connective tissue wdth leucocytes; m, round cells (leuco- cytes) within a uriniferous tubule. Amyloid, Albuminoid, or Lardaceous Disease of various organs is a condition due to the deleterious effects of toxic compounds circula- ting in the blood, whereby the walls of the smaller arteries (Fig. 17, h and i), and subsequently the protoplasm of certain viscera, are converted into or infiltrated with a waxy substance, from which lardacein, an extremely insoluble proteid body, may be obtained. The name ' amyloid ' is an entire misnomer, as this material is in no way akin to starch. It occurs as a waxy homogeneous material, 84 A MANUAL OF SURGERY becoming a dirty brown on the application of tincture of iodine, and an inky blue when sulphuric acid is subsequently added. With methyl-violet the amyloid substance is coloured ruby-red, whilst normal tissues are stained blue or indigo. The organs mainly affected are the liver, spleen, kidneys, and villi of the intestines. The liver becomes evenly enlarged to a considerable degree, often reaching from the fifth rib to the umbilicus, or lower; it is firm in consistency, like indiarubber, painless, and waxy-looking on section. The arterioles and capillaries in the intermediate zone of the lobules are those first affected, but the gland cells soon participate in the change. The glycogenic and bile-producing functions are naturally interfered with, so "that the digestive process, and especially the power of absorbing fats, is impeded, although the appetite may remain good. The kidneys become similarly enlarged, the change commencing in the arterioles leading to the glomeruli (Fig. 17), but the capillaries and the tubal epithelium are also early affected. In this stage the urine is very abundant (from the increased filtra- tion through the degenerated walls), pale, limpid, and containing a few hyahne casts and fatty cells; later on, when the tubules are more largely involved, there is less urine, with a higher specific gravity, and a considerable amount of albumen. The spleen increases in size, but not always to so great an extent as the other viscera; the Malpighian bodies are the chief seat of the mischief. The capillaries in the villi of the intestines become lardaceous, and allow of an in- creased transudation of the fiuid parts of the blood, resulting in diarrhoea; the absorption of nutriment is thereby much lessened, and thus both by increased excretion and diminished absorption of food the strength of the patient is steadily undermined. Amyloid changes in the viscera, far from being a contra-indication to operation, are rather to be considered as a sign that radical treat- ment is urgently necessary, unless the general condition of a patient is such that he cannot stand the strain of it. If by an operation — e.g., excision or amputation — the local disease can be eradicated, the amyloid changes in the viscera may totally disappear. At the same time one must not forget that the kidneys are seriously damaged, and that antiseptics, such as carboHc acid, which are absorbed into the blood and eliminated in the urine, may Hght up an acute nephritis with possibly fatal results. Persistent suppuration is present in a large series of other condi- tions than those following the opening of an abscess, prominent amongst them being that known as oral sepsis. The lesion usually present is pyorrhoea alveolaris {q.v.), in which suppurating pouches form in the gums around the roots of teeth, which are generally dirty, decayed, and covered with tartar; the tongue is coated, and the breath offensive. Grave results may follow, partly from the constant swallowing of bacteria and their toxins, partly by their direct absorption through the granulation tissue which surrounds the teeth, (i) The ingestion of pyogenic bacteria and their toxins acts injuriously upon the gastric and intestinal mucous membranes, NON-SPECIFIC PYOGENIC INFECTIONS 85 SO that the natural antiseptic powers of the gastric juice are lost or diminished; and thus a chronic gastritis may ensue, as also gastric or duodenal ulcers, whilst it is a noticeable fact that a septic state of the mouth due to bad teeth is constantly found in the subjects of appendicitis. In this connection it is advisable to note that careful disinfection of the buccal cavity should always follow, as well as precede, such operations as gastro-enterostomy, excision of the tongue, removal of the jaw, etc., so as to minimize the risks of infection which might follow. (2) The air-passages may become infected as an outcome of oral sepsis, in the form of a tracheitis with an abundant muco-purulent expectoration. Aspiration pneumonia may follow the administration of an anaesthetic in such cases. (3) A mild aucemia of a secondary type may develop, characterized by a blood count showing 3,000,000 or so red corpuscles, 60 to 70 per cent, of haemoglobin, and a moderate leucocytosis. Occasionally the anaemia may be of a graver type, corresponding to the pernicious variety (Hunter). It is also interesting to note that in lymphatic leukaemia ulceration of the mouth is often present. (4) Many other general conditions may ensue — e.g., a constant feeling of malaise, headache, mild furunculosis, and various phenomena due to neuritis. Occasionally severe pyrexia of a typhoid type has supervened, the temperature falling rapidly, and the patient recovering as soon as the mouth and teeth had received attention. Chronic osteitis and arthritis also occur, and the condition described hereafter as chronic osteo-arthropathy is due to the chronic absorption of toxic material. II. CelluUtis. Cellulitis (or, as it used to be termed, diffuse phlegmon) is a disease characterized by the existence of a spreading inflammation of the subcutaneous or cellular tissues, due to the activity of pyogenic organisms, and running on to suppuration, sloughing, or even to extensive gangrene. Causation. — The one essential is the infection of the cellular tissues with organisms which have gained an entrance through an operation wound, or through an accidental breach of surface, or even through some slight graze, prick, or scratch. Deep infected wounds which are not properly drained are amongst the most favourable for the development of this condition, especially if the general health of the individual is bad, if he is suffering from albuminuria or diabetes, or if his surroundings are of an insanitary nature. Wherever much loose cellular tissue is present, inflammatory phenomena readily supervene, owing to the absorption of bacteria from neighbouring contaminated structures — e.g., pelvic cellulitis arising from an in- fected uterus, or cellulitis of the neck from an ulcerated throat. Bacteriology. — The Streptococcus pyogenes is the organism most frequently found in cases of cellulitis, particularly when there is much tendency to spread. In some of the more localized forms the Staphylococcus pyogenes is present, whilst in the gravest and most 86 A MANUAL OF SURGERY acute manifestation the B. nedematis maligni is responsible for the trouble (p. 122), and the disease is then identical with what is usually known as acute emphysematous or infective gangrene. Clinical History. — The symptoms necessarily differ somewhat according to the site of inoculation and the virulence of the causa- tive microbes, and hence anything from a localized suppuration to the acutest form of spreading gangrene may result. In a case of moderate severity, due to a prick or abrasion which has become infected, there is often a period of quiescence for a day or two, and the site of inoculation shows but slight signs of inflammation, beyond being a little tender. The patient, though feeling somewhat seedy, is able to continue his work, but is finally obliged to give up, owing partly to the increased pain, partly to his general con- dition. Fever is almost always present to a greater or less degree, and in the more severe types one or more rigors occur, or the tem- perature may be subnormal, owing to the intensity of the toxarniia. The affected part is found to be hot, tender, and infiltrated; if superficial, it looks red and angry, and feels brawny. In some cases local haemorrhages or petechial spots are found in addition to the other inflammatory phenomena. The course of the case de- pends to a very large extent upon the treatment adopted; if freely incised, the process may become limited, and although suppuration and sloughing occur, repair is readily effected; if, however, the vims is very active, or the patient's power of resistance low, or if the inflamed area is left to itself or merely poulticed, the process may spread rapidly, and extensive destruction follow. Intense pain and sleeplessness, accompanied perhaps with delirium, form the most prominent symptoms, and these, together \\ith the toxic fever, rapidly exhaust the patient's strength. Suppuration at length occurs, but is often of slow development, and the swelhng may remain hard and brawny for some time in such a region as the neck with no evidence of softening, so that it may be difficult to determine whether pus is present or not. The infiltrated cellular tissues are likely to slough, and in a hmb extensive subcutaneous necrosis may occur, although the skin only gives way in places ; hence it is often possible to pass a probe between the skin and the deep fascia over a con- siderable area. Sometimes the inflammation skips a part of the limb, the chief focus of mischief being found at a distance from the original site of inoculation, whilst the intervening portion is but little affected, or shows the characteristic features of acute lymph- angitis {q.v.). This is due to the organisms or their toxins being transmitted along the lymphatics, and then arrested at a higher level. Occasionally the trouble spreads along the deeper areolar planes, or even along muscular belUes, which may be infiltrated with pus or may actually slough. In all these more severe forms the patient runs a considerable risk of developing general septicaemia or pyaemia. Treatment. — Careful attention to the dicta of antiseptic surgery can pre^^ent the occurrence of cellulitis to a very large extent in NON-SPECIFIC PYOGENIC INFECTIONS 87 casualty and operative work. Abrasions and small punctured wounds should always be protected, and all penetrating injuries disinfected, especially if the patient runs exceptional risk of infection owing to his occupation or surroundings, or to the nature of the injury. Should inflammatory phenomena supervene, the application of antiseptic fomentations, such as the boracic poultice, may prevent their extension, whilst the bowels should be freely acted upon and the general health attended to. If suppuration is present or is threatening, free incisions in the long axis of the limb should be made into the brawny tissues, so as to give exit to the serous and irritating discharges, and to allow sloughs to be cut or scraped away; the wounds thus made are hghtly packed with aseptic or iodoform gauze, over which the usual dressings are appHed. The object of this is to drain the fluids from the parts by capillary action, and hence an effective junction must be maintained between the gauze drain and the surrounding dressing. It is often wise to incor- porate a piece of sterilized gutta-percha tissue or mackintosh in the outer folds of the dressing, so as to keep the parts moist and encour- age a free discharge. Extension of the mischief requires further incisions, and the surgeon must follow up the disease with the knife. At the same time the patient's health and strength must be main- tained by the administration of suitable food, drugs, such as quinine, and stimulants. After the bleeding caused by the incisions has ceased, the limb should be daily immersed in a warm bath for some hours so as to dilute the toxins and render them innocuous. The bath should not continue for more than three or four hours at a time, for fear of the tissues becoming sodden. Sterilized salt solution at a tem- perature of 105° to 110° F. does perfectly well; antiseptics are practically useless in checking the disease when once started; the surgeon has to depend mainly on relief of tension, the removal of toxic discharges, and the antiseptic power of the tissues. At the same time the utmost care must be taken to prevent any fresh or mixed infection of wounds from decomposition of discharges. Polyvalent antistreptococcic serum (p. 27) has also been employed as a curative agent, with a view to destroy the streptococci (prob- ably by a bacteriolytic action) and immunize the system to their further development. A dose of 20 c.c. (i c.c. = ili^xvii.) may be given to start with, followed by 10 c.c. twice a day beneath the skin of the back or abdominal wall. The results have been very variable; sometimes it is apparently effective, but not unfrequently the results have been most disappointing. In the less acute cases vaccine treatment may be beneficial. Special Varieties of Cellulitis. Cellulitis of the Axilla not unfrequently follows an infected wound of the hand, such as occurs in the post-mortem room, and hence is not uncommon in medical practitioners, students or nurses. It may also be caused by extension from an axillary lymphadenitis. The tissues of the armpit become hai'd and brawny, the pain is severe, especially on movement of the shoulder, and the 88 A MANUAL OF SURGERY disease is liable to spread towards the chest walls under or between the pectoral muscles; it may also travel upwards, and lay open the shoulder-joint from sloughing of the capsule, and so give rise to an acute arthritis. Early and extensive incisions are required in order to })rcvcnt such comjilications, but respect must be paid to important vessels and nerves contained in the cavity. Cellulitis of the Scalp^usually results from a wound which has traversed the occipito-frontalis aponeurosis, and opened up the subjacent layer of loose areolar tissue; it may, however, follow a simple laceration of the scalp and remain superficial. In the latter case the scalp becomes red, oedematous, and tender, but the inflammation remains more or less localized ; in the former, pus forms beneath the aponeurosis, and extends to its limits of attachment, so that abscesses are likely to point in the forehead just above the eyebrows, over the zygoma, or along the superior curved line of the occipital bone. The whole scalp may be lifted up, and the patient runs a risk of necrosis of the cranial bones and of various intracranial complications. The scalp itself, however, rarely sloughs owing to its abundant vascular supply. In both con- ditions the temperature is often high and the patient severely ill. The treatment consists in making early and free incisions parallel to the lines of the vessels, and the insertion of drainage-tubes when the pus is beneath the aponeurosis. Cellulitis of the Orbit is not an uncommon sequela of penetrating wounds in this region, owing to the difficulty of rendering them aseptic and of draining them. It may also result from inflammation of the bony walls, secondary to suppuration within the cranial sinuses. The orbital tissues become infiltrated and swollen, the lids are oedematous, and the e^'eball is thrust forwards (proptosis). The inflammation may spread to the meninges, owing to the dura mater being continuous with the orbital periosteum through the fora- mina by which the nerves and vessels enter. Necrosis of the orbital walls may also occur, whilst the eye itself may suffer either from an infective panoph- thalmitis due to lymphatic infection, or from optic neuritis secondary to retro-ocular inflammation and pressure, or at a later date from optic nerve atrophy secondary to cicatricial contraction around the nerve. If the cellular tissue of the orbit sloughs, the subsequent movements of the globe may be much hampered, or indeed lost, whilst the lids may be drawn back to such an extent as to prevent their complete closure. Treatment. — No penetrating wound of the orbit ought to be closed if there is any question of its infection; indeed, it is often wise to increase its size slightly, so as to enable the deeper parts to be explored and drained. If cellulitis follows, the original wound must be opened up, and possibly fresh incisions made either through the lids or through the fornix conjunctivae. Antiseptic fomentations are then applied. If panophthalmitis supervenes, the eyeball must be incised crucially; this is a safer proceeding than enuclea- tion, which is more liable to be followed by meningitis. Cellulitis of the Neck is usually secondary to lesions in the throat, and there- fore associated with follicular tonsillitis, diphtheria, or scarlatina, the process probably starting in a deep lymphatic gland ; it occasionally follows operations on the neck. The tissues beneath the deep cervical fascia become infected, usually with streptococci, and sooner or later suppuration occurs. The affected side of the neck is swollen, red, and brawny; severe pain of a deep tensive character is experienced, and this is increased by movements of the head or jaw. The swelling is often peculiarly hard and resistant (the woody angina of French writers), and although redema may be present, it may be several days before the surgeon can detect any focus of softening suggestive of suppuration. During this period the constitutional symptoms are severe; fever may be high, and the pain and subsequent sleeplessness may exhaust the patient, whilst the difficulty of swallowing hinders his nutrition . Dangerous symptoms arise from pressure on important vessels and nerves, from extension of the inflammation to the mediastinum or to the glottis, causing oedema and consequent dyspnoea, or from the supervention of pyaemia owing to venous thrombosis. The process usually ends in sloughing of the cellular tissue and suppuration, the pus burrowing widely if a free exit by incisions through the deep fascia is not provided. NON-SPECIFIC PYOGENIC INFECTIONS 89 Treatment. — The causative lesion in the throat must be attended to, any operation wound freely opened up and drained, and the general condition improved by the administration oi' nourishing lluid food, stimulants, and quinine. Antistreptococcic serum may also be injected, but sometimes anti- diphtheritic serum (given hypodermically or by mouth) has been found more useful. Locally, fomentations are applied in the first place; but on the onset of suppuration, or before, if the pressure symptoms are severe, or if the affec- tion is obviously extending, free incisions must be made along lines of safety beneath the deep fascia, so as to relieve tension and give exit to discharges. It must be remembered that the tissues are matted together in such a way as renders their recognition difficult; and inasmuch as the pus often lies deeply, the greatest caution has to be taken to avoid injury of important structures. Special interest has been directed to a form of this affection which occurs in the submaxillary region, and is known as Ludwig's angina. It is usually secondary to some buccal focus, or may occasionally result from the extension of inflammation beyond the capsule of lymphatic glands, or may originate in disease of the middle ear, the mischief spreading down along the posterior belly of the digastric. The swelling in these cases extends forwards beneath the chin, and may involve the floor of the mouth and base of the tongue, pushing that organ forwards, and even making it protrude from the mouth. (Edema of the glottis may supervene, or a sublingual abscess form. Treatment is similar to that indicated above, and one or more incisions may be required. (Edenaa of the glottis will probably require tracheotomy. Pelvic Cellulitis is an infective inflammation of the loose cellular tissue which ensheaths the pelvic viscera. It may result from any penetrating wound, accidental or operative, which encroaches on this region — e.g., extra- peritoneal rupture or perforation of the bladder, suprapubic or lateral lith- otomy, injudicious catheterism, curetting the uterus, and sometimes attempts to induce abortion. It may also be due to the absorption of bacteria from any of the pelvic viscera — e.g., the bladder, prostate, rectum, uterus, or Fallopian tube. It is associated with all the local and general signs of deep inflammation, and often, indeed, with peritonitis, giving rise to a tense, flrm, painful swelling, to be felt per rectum or per vaginam, and sometimes to an indurated mass of inflammatory effusion, dull on percussion, above the pubic arch. Abscesses may form, bursting either externally above Poupart's ligament or into some of the viscera, or possibly in both directions, pro- ducing intractable forms of urinary or faecal flstulae, whilst venous obstruction and pyaemia are likely to develop. The surgeon may be called on to deal with such cases either in the early pre- suppurative stage, when rest, limitation of diet, small doses of opium, and fomentations to the hypogastrium, conjoined perhaps with hot antiseptic rectal or vaginal douches, should be adopted; or at a later date, when pus has formed and the abscesses need to be opened. An incision is generally made just above Poupart's ligament and close to the pubic spine; the abdominal muscles are divided to a sufficient extent to enable the surgeon to work down- wards between the transversalis fascia and the peritoneum, which must be pushed aside in order to reach the broad ligament, where pus is frequently found. As soon as the subperitoneal tissue is opened, the knife should be discarded, and only blunt instruments or the flngers employed. The cavity of the abscess should be well washed out and efficiently drained, and possibly a counter-opening through the vagina may be required. Intestinal obstruction may develop as a remote sequela from the contraction of cicatrices, and hydronephrosis may arise in the same way from pressure on the ureter. III. Wound Infection. When a wound, whether accidental or operative, has become infected with micro-organisms, healthy reparative action ceases, and is replaced by an inflammatory process of a suppurative type go A MANUAL OF SURGERY with the object of coping with the bacteria. To this condition the term sepsis was formerly applied, but with our modern know- ledge the terms ' sepsis ' and ' septic ' are rarely needed, and, indeed, are better avoided where possible. The organisms usually present are staphylococci, but in the worst cases streptococci may be found, and in others the presence of saproph^iiic germs may constitute a mixed infection. In casualty work wound infection is often unavoidable, and due to the dirty state of the skin or the nature of the accident; and, however thorough the subsequent disinfection, it may be impos- sible to render the parts sterile. After an operation, wound infec- tion is usually due to some gross avoidable mistake or oversight, rarely to auto-infection. Ineffective sterilization of silk or catgut is perhaps the most frequent cause of infection, since the intro- duction of rubber gloves has safeguarded the hands of the surgeon and his assistants. The local trouble may manifest itself merely as an acute or sub- acute suppurative process within the wound, or as an active cellulitis spreading into the adjacent tissues. It may commence deeply around a buried stitch, or more superficially. In the latter case the lips of the wound look red and puffy, the tissues often swell up between the stitches, which look as if they were too tight, and on introducing a probe pus may escape; the patient complains of pain, usually of a throbbing nature, and there is some rise of temperature, and in bad cases even a rigor. In the milder forms the trouble is limited to the immediate neighbourhood of the wound; but if neglected, or in an unhealthy subject, or if due to virulent germs, the phenomena of an acute cellulitis may superv^ene. When the process starts in the deeper parts of the wound, nothing may be obvious on the surface for a few days, except perhaps some fulness and tenderness on pressure. It will usuall}' be found, however, that the temperature is shghtly raised, and that some tensive pain is present. Sooner or later an abscess develops and comes to the surface, and a sinus is likely to be left until the hgature or buried stitch has been absorbed or removed. The same holds good as regards silver wire, screws, plates, etc., which must be removed before heahng can take place. The Local Treatment of an infected wound consists essentially in the rehef of all tension, and the apphcation of warmth and moisture to the part, to encourage the local reparative acti\'ity of the tissues. Stitches must be immediately removed, and the wound widely opened up, so as to give a free exit to the pus. Undue interference with the wound, as by squeezing, scraping, etc., is to be deprecated, as thereby germs may be disseminated. Sloughs are left to separate by natural processes, and even syringing or washing out the wound must be limited in the early stages. Peroxide of hydrogen (lo- volume solution) is useful, but not at first, since the sudden liberation of oxygen may drive germs into the tissues, and therebv increase the trouble. The application of NON-SPECIFIC PYOGENIC INFECTIONS 91 stronger antiseptics is equally futile, since the germs are in the tissues, and cannot be destroyed without also involving these structures; moreover, the phagocytic power of the leucocytes is checked by such applications. The wound, thus opened up, is lightly but thoroughly packed with gauze, and if there is a deep cavity it may be desirable to introduce a drainage-tube, since pus does not easily escape along a gauze drainage-wick. Warm moist dressings, such as an antiseptic fomentation, are then apphed, or the limb is immersed in a bath at a temperature of 105° to no F. for some hours daily. At the same time the bowels must be freely opened, and the general health of the patient carefully watched. In a few days, when granulations have formed, the wound may be irrigated with salt solution or swabbed out with peroxide of hydrogen. Healing is finally brought about by granulation, but can sometimes be hastened by strapping the edges of the wound together, or by grafting. j • r , • The general phenomena connected with wound infection vary chiefly in respect of the dose of toxins absorbed. I. Acute Toxsemia (formerly known as septic traumatic fever) results from the absorption of a large dose of toxic material from some focus of infective inflammation of sufficient extent and viru- lence. A small collection of pus under pressure is capable of giving rise to marked toxic symptoms, whilst in spreading inflamma- tions, such as erysipelas and celluhtis, the manifestations are often of a grave type. The same is true of infective inflammation of the peritoneal cavity, especially when the upper half is involved, since the communication with the lymphatics of the diaphragm is very free. Toxaemia is not unfrequently associated with a true septiccemia, and cHnically it may be almost impossible to distinguish between the two. . The Symptoms are characterized by fever, except m some of the gravest cases, when the temperature may be subnormal, although the pulse may still remain high. This is accompanied by loss of appetite, a dry tongue, a quick pulse, rapidly becoming w^k, severe headache, and nocturnal dehrium of some intensity. Ihe patient is at first constipated, but vomiting and diarrhoea niay ensue from gastro-intestinal irritation, followed by fatal exhaustion and collapse; or he may become comatose and unconscious for some time before death, according to whether the toxins act principally upon the alimentary or nervous systems. Dyspnoea from puhnonary congestion, and albuminuria, also occur. Effective treatment of the cause, as by opening an abscess, or drainage, may lead to a speedy disappearance of the symptoms, but in spreading inflammation the toxaemia may not subside for some time. _ Post-mortem Appearances.— Decomposition is early, rigor mortis feeble, and cadaveric hvidity well marked, especially along the hnes of the superficial veins and posteriorly. The blood coagulates imperfectly, and is dark and tarry in colour; if allowed to stand, the serum which separates from the corpuscles is much stained trom 92 A MANUAL OF SURGERY the breaking up of the red blood cells which occurs in all acute infective cases. This condition explains the amount of cadaveric lividity, and also the post-mortem staining of the endocardium and tunica intima of the larger vessels, which is such a marked feature in these cases, and which was formerly supposed to result from a diffuse arteritis. Most of the serous cavities contain a certain amount of blood-stained fluid, and under almost all the serous mem- branes are well-marked petechise, especially under the pericardium and pleura. The lungs are deeply congested, particularly at the back, and very oedematous ; the liver, spleen, and kidneys are enlarged, pulpy, soft, and congested, notably the spleen. The epithehum of most of the secreting glands, if examined micro- scopically, gives evidence of cloudy swelling. The Treatment of acute toxaemia must be chiefly directed to the local cause, which is dealt with by suitable surgical means. General treatment is merely symptomatic. Possibly a good purge may be advisable in the early stages, but in the later a supporting and stimulating plan of treatment must be adopted. Recently the acute toxaemia of peritonitis and similar conditions has been treated by the continuous injection into the rectum of large quantities of sahne solution (3i. ad Oi.), and excellent results have been obtained; the injections are followed by diuresis and diaphoresis, which presumably assist in the elimination of the poison. In some cases intravenous injections may appear desirable, and then it is wise to insert the needle of the infusion apparatus directly into a vein without dissection, as the wound might otherwise become infected. 2. When the dose of toxins is smaller, but absorbed regularly and for a long time, a definite diurnal range of temperature follows, known as hectic fever (p. 82). 3. Acute Saprsemia is a term that is now rarely employed in surgical practice, but is rather retained for a condition which occurs during the puerperium, due to the decomposition of a portion of retained placenta, as the result of a mixed infection. The symp- toms are moderately severe, and entirely due to chemical poisoning. Removal of the putrid mass results in almost immediate cessation of the fever and all the other manifestations. IV. Septicaemia. Septicaemia is an acute general infective disorder, arising from the development of some variety of pyogenic organism in the blood. It differs from pj-aemia in the absence of secondary abscesses (although, as explained later, it may be associated with it), and from toxaemia or saprsemia, by the fact that the latter are merely due to the absorption into the blood of toxins generated in a diseased focus in which the bacteria themselves remain localized. In septicjemia the organisms circulate in the blood, though in many cases in but scanty numbers, so that it is necessary to take rather large quantities NON-SPECIFIC PYOGENIC INFECTIONS 93 of blood (5 c.c. or more) for a bacteriological examination. Further, even in severe cases of septicemia periods occur m which no bacteria can be detected in the blood, so that too much weight should not be attached to a single negative result. ■, u^ n +1, Bacteriology. — The commonest orgamsm is undoubtedly the Strebfococciis pyogenes, which is found in about 50 per cent ot all cases- it is almost always present in the septicemia dependent on puerperal diseases and in ulcerative endocarditis, where the lesion m the heart acts as the source of the bacteria m the circulating blood. Next in frequency is t\iePneiimococciis,\\'hich often causes septicsemia, even when no puhnonarv or other local lesion can be traced. The Stabhvlococcus pyogenes' is also a fairly common organism m this disease, and the prognosis is then decidedly better than m cases due to the streptococcus or pneumococcus. Rare causes are the B. coli and alUed organisms, B. pyocyaneiis, B. (Tdematis maligni, and the Gonococcns. Clinical History.— Septicemia occurs most commonly from direct inoculation with suitable organisms through small lesions, such as post-mortem wounds, or from scratches or punctures wath infected pins or instruments; it also in rarer cases follo^^^ operation wounds and severe lacerated injuries. It is the usual accompamment of acute spreading gangrene (p. 122), and may be met with m celluhtis and cancrum oris (p. 123). As a rule the individual attacked is m a depressed and debihtated condition, perhaps deteriorated by alco- holic or other excesses, so that the inherent germicidal activity o± the tissues is markedly insufficient to cope mth the inroads of the ^The point of inoculation mav be the seat of any of the forms of local trouble which we have akeady described under the^title of celluhtis, and this may vary from a shght inflammatory blush to the acutest form of spreading gangrene. ■,.••. The General Symptoms are those of fever, often ushered m by a distinct and severe rigor; the temperature reaches 104 or 105 !<., and usuallv remains liigh, vvith but shght remissions and no inter- missions (Fig. 18). Malaise is present, ^^ith loss of appetite, and the tongue is brown and parched. The pulse is quick and feeble, the heart-sounds are weak, and the heart itself dilated. The slan has often a shght icteric ringe, and petechias are present Diarrnoea usuallv ensues, and may be blood-stained, whilst the urme is albuminous and contains blood. The patient, after a period of dehrium, becomes comatose, and dies. Dyspnoea sometimes precedes the fatal issue, whilst the temperature may be exceedingly high or occasionally subnormal ; the association, of a low tempera- ture vvith a verv rapid pulse is always of grave import. Leucocytosis is usuaUv present and well marked in the earher stages, but is absent in the worst cases and towards the fatal issue ; even under these circumstances there is a relative increase m the number ot ^^Oc'SLsionally a case takes a more favourable course when the 94 A MANUAL OF SURGERY local focus of trouble has been effectively dealt with, and perhaps suitable vaccine treatment adopted. The temperature falls gradu- ally, and the patient slowly though surely regains his health. The accompanying temperature chart represents such a case, where the true septicaemia, as demonstrated by a blood examina- tion, gradually disappeared after the uterus had been effectively curetted and disinfected (Fig. i8). The Post-mortem Signs are those found in all cases of acute toxa:mia, described above (p. 91), with the addition that on micro- scopical examination bacteria can sometimes be demonstrated in the blood and internal organs, especially the spleen. The Diagnosis has to be made from the more virulent forms of the acute exanthemata, in which the patient is destroyed before the char- FiG. 18. — Temperature Chart of a Case of Puerperal SEPTiCiEMiA. acteristic appearances are manifested; in such cases a definite opinion as to the nature of the affection is often impossible, if there is no clue as to the origin of the infection. Acute foxcemia is always associated with some very obvious focus of wound infection, but may be so severe as to cause grave anxiety for a time as to whether or not septicsemia is present. If, however, the wound is freely opened up and drained, the rapid disappearance of the fever proves that the mischief was merely a local, and not the more serious general, affection. A blood examination by cultural methods may assist in clearing up the diagnosis. From pycemia it is known by the absence of repeated rigors and secondary abscesses. The Prognosis of acute septicaemia is always very grave, but it NON-SPECIFIC PYOGENIC INFECTIONS 95 is to be hoped that the modern plans of treatment mentioned below may pro\'e beneficial in diminishing the mortality. the Treatment consists in dealing actively with anv local focus of inflammation, either by free incisions, purification, and drainage, or by amputation ; but, unfortunately, this is seldom likely to be successful, as blood infection has probably already occurred. In addition to such means, tonics and stimulants, \\ith plenty of suit- able nourishment, must be administered. Antistreptococcic serum (p. 27) may be utihzed when the streptococcus is responsible for the trouble, and cases have been reported as cured by its agency. Another plan which has been adopted is the intravenous injection of considerable quantities of normal sahne solution, repeated two or three times a day; by this means diuresis and diarrhoea are in- duced, and it is hoped that thereby the organisms and their products may be ehminated. This treatment will probably be of greater value in cases of toxaemia than in those of true infective septicaemia. A few cases have been successfulty treated bv means of auto- genous vaccines, and if time permit (the preparation of the vaccine takes three or four da\-s) this method should be tried. In the inter^-al a stock vaccine prepared from similar, but exogenous, organisms may be employed. It is, however, not hkely to be of much value in the acute and rapidly fatal cases, for which the serum treatment is still the best method at our disposal. A more chronic variety of septicaemia is also recognised, which may- last for weeks or months. The history usually commences with some locahzed inflammatory trouble from which the patient has never properly recovered. The temperature becomes of the hectic type, running up 3 or 4 degrees every night, and the fever is associated with profuse nocturnal sweats. Bacteria may be demonstrated in the blood at times. The probable cause of the trouble is the persistent absorption of germs into the blood-stream from some locahzed source of suppuration — e.g., a hepatic abscess or a sup- purating gall-bladder or appendix, or even a neglected pyorrhoea alveolaris; in other cases infective endocarditis is the cause of the trouble. The patient's health and strength are gradually lost, and, unless the local focus can be reached and dealt with, death is hkely to result. Surgical interference, though dangerous in these debihtated patients, may be essential in order to attack the cause of the mischief. Apart from this, vaccine treatment must be relied on, together with such general measures as shall build up the general health and improve the resistance of the blood and tissues. V. Pyaemia. Pyaemia (Greek ttvov, pus, and a.ip.a, blood) is a disease character- ized by fever of an intermittent type, associated with the formation of multiple abscesses in different parts of the bodv, arising from the diffusion of pyogenic materials from some spot of local infection. 96 A MANUAL OF SURGERY Bacteriology. — Any pyogenic organism may cause pyaemia, and, theoretically, pyremia may arise as a complication following any acute abscess. As a rule, however, there is a sufficiently rapid develop- ment of granulation tissue to limit the spread of infection. The organism most commonly found is the Streptococcus pyogenes, but in a few cases the Staphylococcus pyogenes aureus has been observed, and less commonly the Pneumococcus, Gonococcus, or B. typhosus. The mere injection of cocci into the circulation is not sufficient to give rise to pyaemia; if they are few in number, a transient pyrexia may supervene, and then the germicidal powers latent in the blood destroy them; but if the dose is large, or the individual is not in a very resistant condition, septicaemia, and not pyaemia, results, unless special conditions are present which determine the formation of embolic abscesses. If the cocci to be injected are mixed with such a material or aggregated into such masses that the organisms are carried on particles too large to pass through the terminal arterioles and capillaries, abscesses develop wherever they lodge. In human path- ology the infective emboli consist of zooglcea masses of organisms, or of infected particles of disintegrating blood-clot (Fig. 19). The Cause of pyaemia may be stated to be any condition which leads to the formation and detachment of infective emboli in the circulation, such conditions occurring mainly in the veins from disintegration of a throm- bus {infective phlebitis), but occasionally in the heart {infective endocarditis). Acute in- fective inflammation of the cancellous tissue of bones is very commonly associated with pyaemia, owing to the veins being abundant and thin-walled, and considerable tension present from the unyielding condition of the surrounding bony structures. Inflammation of the cranial bones coming on in the course of middle-ear mischief, and causing thrombosis of the lateral sinus, also leads to its development. The presence of large open- mouthed veins in the puerperal uterus favours the onset of the disease after parturition if infective material is present in their vicinity. When an infective embolus lodges in any region of the body, a thrombus forms upon it, and in this the micro-organisms rapidly develop, and thence pass through the vessel wall into the sur- rounding tissues, causing inflammation, which is likely to end in suppuration. In the lung many such foci occur, distributed mainly along the posterior border and near the surface; each is sharply limited to a wedge-shaped area of tissue, with the base directed towards the periphery. It is at first reddish in colour from effusion Fig. 19. — Disintegra- ting Clot lying in A Vein in a Case OF Pyemia. (After TiLLMANNS.) The apex of the clot projects into a larger trunk, in which circu- lating blood is pres- ent, and from it in- fected emboli would be detached. NON-SPECIFIC PYOGENIC INFECTIONS 97 of blood (a hcemorrhagic infarct), but soon becomes grayish-yellow from the formation of pus. These abscesses are small, and rarely give rise to any physical signs. Similar collections of pus, preceded or not by an infarct, may be found in any organ of the body. The lungs, acting as a filter to emboli derived from the systemic veins, are naturally the first organs to be affected, and from the abscesses formed therein infection of the arterial system may take place, resulting in fresh suppurative foci in the liver, spleen, kidneys, brain, and in or around joints, etc. If, however, the causative phlebitis is situated in the portal area, the emboli are lodged pri- marily in the liver, giving rise to what is known as pylephlebitis. When the emboli are many in number, the symptoms are severe, constituting acute pyaemia; this is sometimes associated with a de- velopment of micro-organisms in the blood, producing pyosepti- ccBmia, the patient perhaps dying before the secondary abscesses have fully developed. In other cases the general symptoms are due rather to the absorption of toxins from the local foci than to the development of organisms in the blood. If the emboli are few in number, and there is little or no development of microbes in the blood, the disease is termed chronic pyaemia. Clinical History, — The most marked symptom indicating the onset of a case of Acute Pysemia is the occurrence during a period of febrile disturbance of a severe rigor, which is repeated with a sort of irregular periodicity, most frequently at intervals of about twenty-four to forty-eight hours, somewhat simulating an attack of ague (Fig. 20). The rigors do not differ from those occurring in other diseases, but they are very severe, and usually followed by profuse sweating. Between the rigors the temperature may fall to the normal, but more commonly remains above it. The skin is hot and soon develops an earth}- or dull yellow tint, together with erythematous or petechial patches. A sweet, mawkish, hay-like smell of the breath is very characteristic. S^^mptoms of grave de- pression supervene, and the patient rapidly wastes. The pulse becomes soft and weak, the excretions are diminished, and a certain amount of nocturnal delirium is noticed, but no loss of conscious- ness. The presence of a bruit in the precordial region may suggest the existence of an infective endocarditis, which is not very un- common. The tongue varies, but is often red with very prominent papillae, and becomes dry and brownish. Towards the end of the first week secondary abscesses appear ; they are sometimes unaccom- panied by local pain or tenderness, and form very rapidly. Joints are not infrequently involved, and may fill with pus, with little or no pain. Unless treated early, rapid disorganization and disloca- tion may follow. The effusion may be puriform, or thin and oily; it is always, however, swarming with organisms. In the viscera the abscesses are as a rule small and numerous; if they occur in vital organs, such as the heart or brain, death may result from their local development. Thej^ are characterized, at first, by the almost total absence of a barrier of granulation tissue, and hence, even when opened earty and aseptically, are likely to extend and continue 7 9S A MANUAL OF SURGERY secreting pus, instead of following the usual course of rapid repair which succeeds the aseptic opening of an ordinary acute abscess. Not uncommonly in these cases painful patches occur here and there in the subcutaneous tissues, accompanied by hypera;mia, which fades away after a few days. These are probably due to the presence of small infective emboli, which the patient has suffi- cient \'italitv to get rid of without suppuration. In Chronic Pyaemia the febrile symptoms are much less marked; the abscesses are few in number, and not dangerous unless forming in important structures. Thus, a fatal result ensued from a single abscess which developed in the lateral ventricle of the brain of a patient who had no other symptom of pyaemia except an oscillating temperature: it followed an operation on an infected sinus leading to a kidney already disorganized. Fig. 20. — Portion of Temperature Chart of a Case of Py^IiMia. If the disease results from an external wound, the condition of the latter is always most unsatisfactory. It gapes open and presents an inactive, dry, glazed surface, any newly-formed scar tissue breaking down. A layer of healthy granulations is an almost certain barrier against the occurrence of pyaemia, on account of the germicidal power of its constituent cells. If the disease arises in connection with hone, the latter structure is usually seen lying bare at the bottom of the wound, denuded of its periosteum, and the cancelli filled with sloughy fcetid medulla or pus. Post-mortem Appearances. — The veins leading from the infected area are usually in a state of phlebitis; the coats are thickened, and the lumen is filled with soft, pale, disintegrating clot, which extends for a considerable distance: the tissues surrounding the NON-SPECIFIC PYOGENIC INFECTIONS 99 vein are also involved in the suppurative process (periphlebitis). Secondary abscesses are found in various parts of the body, most frequently in the lungs, and their different stages can be clearly demonstrated from the embolic colonies of micrococci, through the stage of haemorrhagic infarction to the complete abscess. The general signs common to all cases of death from toxaemia (p. gi) will also be manifest. The Diagnosis of pyaemia should not be difficult in the majority of cases; but when it originates without any obvious external wound from a deep-seated focus, or if the importance of some local lesion has not been appreciated, the initial symptoms may be mistaken for those of acute rheumalism or ague. The Prognosis depends upon the inherent vitality of the patient and the virulence of the disease. In acute cases it is extremely grave, probably terminating in a week or ten days, whilst in the chronic type recovery is not only possible, but probable, if the local abscesses are favourably situated. The ideal local Treatment consists in preventing, if possible, the further contamination of the general blood-stream by the dis- semination of infected emboli. This can sometimes be accomplished. in the case of a limb, by amputation well above the local lesion; or if the medullary cavity of a bone is the source of trouble, it may be possible to scrape out the gangrenous and offensive medullary tissue, and disinfect the cavity; or if it is due to a wound in the soft parts, it may be feasible to dissect out the implicated vein and sur- rounding tissues, or at any rate to remove the disintegrating clot after placing a ligature upon the vessel between the thrombus and the heart. A typical illustration of such treatment is that adopted for infective phlebitis of the lateral sinus complicating disease of the middle ear, where, after tying the internal jugular in the neck, the sinus is exposed by the trephine or gouge, opened, and all the infected clot removed, partly from above, partly from below; ad- mirable results have been thereby obtained. Where, however, such ideal treatment is impracticable, all that the surgeon can undertake is to render the primary focus as healthy as possible by free relief of tension and close care in asepsis. The abscesses must be dealt with, when possible, by early opening and draining them, or by aspiration; such wounds often heal well, and joints which have been distended with pus may recover with free mobility. Occasionally, however, although rigid asepsis has been maintained, the suppuration continues, and even sloughing of the abscess wall may follow. If the general condition can be improved, a barrier of granulation tissue will fonii in time, and repair be established. Constitutional treatment consists in supporting the patient's strength by nourishing diet and stimulants, and in taking pre- cautions to avoid bedsores or any local injury. Salicylate of quinine may be administered, though its value is doubtful. The anti- streptococcic serum (p. 27) may also be utihzed, and it may do good in cases which, have not progressed too far. Vaccine treatment may also be tried. , , CHAPTER \l. ULCERATION. Ulceration has been defined as the ' molecular or particulate death of a part,' by which is meant the disintegration of the superficial tissues, which hquefy and disappear, and 'usually \\athout any obvious slough. It differs from gangrene in that the latter term is used to denote the simultaneous loss of vitaUty of a considerable portion of tissue. The two processes are, however, often closely associated — in fact, both signify tissue necrosis; in the former the dead particles are not always \asible to the naked e^-e, whereas in the latter the necrotic portions, if superficial, can always be seen. An Ulcer is an open wound or sore which tends to persist, prob- ably as a result of pyogenic infection, but may under favourable circumstances heal. Any part of the surface of the body may be affected, but especially the lower extremities, whilst all the mucous membranes suffer similarly. Many small ulcers may be present, and then not unfrequently are caused by infection one from another; or the ulcer may be solitary and of large dimensions. It is almost impossible to classify ulcers, so multifarious are they in type and so wedded are we to an old-standing, inexact termin- ology. It must suffice to suggest that in surgical practice three chief classes are met with — viz.: I. Ulcers due to traumatism or to non-specific pyogenic bacteria, e.g., the spreading, healing, chronic, etc. II. Ulcers due to specific bacteria, e.g., soft chancre, lupoid, tuber- culous, syphihtic, etc. III. Malignant ulcers, e.g., rodent, epithehomatous, scirrhous, and fungating. Any form of surface irritant, whether chemical, thermal, me- chanical, or infective, may cause ulceration, and all the factors predisposing to inflammation will hasten its occurrence. Faulty nutrition, whether from anaemia or from long-standing congestion, is particularly hable to further the ulcerative process; thus, in the lower extremity it is predisposed to, on the one hand, by arterial disease wliich leads to anaemia, or, on the other, by the passive con- gestion dependent on varicose veins. General debility, such as results from Bright's disease, diabetes, etc., will also favour the ULCERATION loi occurrence of ulceration. Moreover, when any part becomes aUc-Esthetic, or is cut off from its trophic centres, the continued presence of an irritant may not be appreciated, and hence destruc- tive intfammation occurs, e.g., corneal ulcer following section of the hfth nerve, or perforating ulcer of the foot in tabes. In ma- lignant disease the projection of the mass of the growth ma}^ expose it unduly to irritation; but the chief cause of ulceration is the re- placement 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 Non-Specific Pyogenic Bacteria. 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 transition, or preparation for healing, which may be short or long, 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, merely a superficial loss of substance, the result of the preceding ulceration, remains, and to this sore the term ' ulcer ' would scarcely be applied, unless it tended to persist. If every simple ulcer passes through these three stages, then every variety of simple ulcer must necessarily be in one of the three 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 ulcer ma}'" from intrinsic or extrinsic causes relapse again to the stage of tissue destruction. Stage I.: Ulceration Proper, or Extension. — The special charac- teristic of this stage is that destructive changes are progressing with greater or less rapidity, and hence the ulcers may be described as inflamed, spreading, or sloughing. Naked-eye Appearances. — Surface, covered with ashy gray or dirty yellow material, partly slough, partly lymph, partly breaking- down tissue; no granulations are present; the tendency to slough is most marked when the organisms are particularly virulent, or if the resistance of the tissues is much diminished; discharge, con- siderable in amount, thin, sanious, and often irritating and offensive, rarely purulent; margins, thickened and inflamed, and the sur- rounding tissues often oedematous and infiltrated; edge, sharply cut and well defined; the base of the ulcer is thickened and fixed to the underlying structures. In fact, the phenomena are those of an acute spreading superficial inflammation, which terminates in tissue destruction. Treatment resolves itself into removing the cause, and protecting the surface from mechanical or other irritation. The inflamed part must be kept at rest, and if necessarj^ raised from a dependent I02 A MANUAL OF SURGERY position {i.e., the leg must not be allowed to hang down), whilst the sore IS dressed with moist and warm antiseptic applications, such as a boracic fomentation. When the parts are very offensive, a charcoal and linseed-meal poultice may be first employed. Stage II. : The Transition Period comprises all the changes which occur from the termination of the ulcerative process proper to the time when healing is fully established by the wound becoming covered with granulations. In short, it may be described as the stage of preparation for healing. Naked-eye Appearances. — When the destructive process has ceased, the surface of the ulcer begins to clean, and becomes, as it were, glazed over; sloughs are either removed in the dressing or absorbed. The discharge becomes less abundant and more serous in character, and the angry red blush is replaced by a rosy hyper- aemia. The infiltration of the base also diminishes, so that the tissues around are less fixed and more supple. The film on the surface becomes more and more defined, and in the course of time, shorter or longer, according to circumstances, little red spots make their appearance here and there ; these gradually increase in number and size, and coalesce, until the whole surface is covered by what has now become granulation tissue. The processes occurring in this stage are: (a) the removal of the sloughs; {b) the covering of the surface with a cellulo-plastic exudation; and (c) the vascular- ization of this newly-formed material, and its conversion into granulation tissue. All these changes do not necessarily go on equally all over the surface of the ulcer at the same time, and hence much variety in its appearance may be manifested; whilst at times the reparative changes may come entirely to a standstill. Hence all the forms of chronic ulcer which are neither spreading nor actively healing may he included in this transitional stage, viz., the indolent or callous ulcer, the irritable, the varicose, etc. The Indolent or Callous Ulcer occurs most frequently on the legs of women about the middle period of hfe. The size varies greatly, but it is sometimes so extensive as to involve the whole circum- ference of the limb. The surface is usually smooth and glistening, and of a dirty yellow colour, with perhaps a few badly-formed granulations; the edges are hard and sharply cut, and elevated con- siderably above the surface, whilst the skin around may be heaped up over the edge, and either covered with sodden cuticle or con- gested. The skin of the hmb is often deeply pigmented from chronic congestion, the pigmentation starting in the separate papillae as maculae, which gradually coalesce. The discharge is purulent or serous, and may be so abundant and irritating as to cause eczema of the parts around, and thus give rise to one form of eczematous ulcer. The base is adherent to the underlying tissues. fascicC, etc. ; and this constitutes one of the main difficulties in healing, as contraction is thus prevented. If the ulcer is situated over a bone, such as the tibia, chronic periostitis results, and a subperiosteal node is formed, corresponding exactly to the size and situation of the ulcer, forming a mushroom-shaped projection, and ULCERATION 103 possibly going on to necrosis or to diffuse osteo-periostitis of the whole bone. These ulcers are sometimes very painful from pres- sure on cutaneous nerves, or from a localized cellulitis, associated, perhaps, with inflammation of veins and lymphatics. Thrombosis not infrequently occurs in both sets of vessels, leading to chronic oedema of the foot, often of a very solid, brawny type, and the limb may even pass into a condition of pseud- elephantiasis. A somewhat similar condition may also follow large burns on any part of the body; heahng proceeds to a certain extent, and then stops from the fact that the contraction of the cicatricial tissue already formed interferes with the vitality of the part still unhealed by compressing the vessels, and so cutting off the granu- lations from their source of nutriment. The so-called Irritable Ulcer is usually met with in this stage. Its chief pecuharities are the position, generally in the neighbour- hood of the ankle, and the pain which accompanies it. The surface of a healing or chronic ulcer can usually be touched without the patient complaining; but in this variety the pain is excessive, especially at night. It was pointed out by the late Mr. Hilton that, if a probe is run lightly over the surface of such a sore, one or more spots win be indicated as the chief seats of the pain, the rest being insensitive. In all probabihty, nerve filaments 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 the subject of aggravated varicose veins, especially when the smaller venules are involved. The skin becomes passively congested, and its nutrition impaired; any injury or abrasion, which would readily heal in a sound hmb, is likely under such circumstances to give rise to a chronic sore. Again, it may be preceded by eczema resulting from the irritation of dirt or the friction of hard trousers, whilst occasionally it is due to the jdelding of the thinned skin which forms the only covering of a much dilated vein, an accident often leading to severe haemorrhage. The characters of a varicose ulcer in the main correspond to those of the indolent variety; it is usually situated on the inner and lower portion of the leg, whilst syphihtic sores are more often placed nearer the knee and on the outer side. Treatment in this stage differs according to the conditions present. If it is merely a passing phase in the progress of an ulcer tending rapidly to repair, the same course of treatment should be adopted as in the earlier period, viz., rest and protection from irritation. It may be advisable to shield the surface from contact with dressings by the intervention of a small portion of purified ' protective '—i.e., oiled silk coated with dextrin — so that the reparative material may not be damaged during their removal. The Chronic Ulcer needs much care in its treatment, and some cases require operative interference. Rest in a more or less elevated position is absolutely essential in order to reheve the congested condition of the hnib; whilst if the surface is foul, a charcoal poultice may be beneficial, or the sore may be dusted over with iodoform, and boracic fomentations apphed. This may be pre- I04 A MAXUAL OF SURGERY ceded in some cases by touching the surface with solid nitrate of silver, or with a solution of chloride of zinc (40 grains to i ounce). Pressure has been hjund of considerable service in the treatment of these ulcers; an ordinary bandage, reaching from the toes to the knee, will sufTice in some cases, a suitable dressing of boric acid ointment, with perhaps some resin ointment added to make it more stimulating, being applied beneath it. Marlins indiarubber 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 consists in the use of an adhesive plaster, made up as follows : Gelatin, 5 parts; oxide of zinc, 5 parts; boric acid, 1 part; glycerine, 8 parts; water, 6 parts; to this ichthyol (5 per cent.) may be added with advantage. The limb is first washed thoroughly with soap and water, and purified with carbolic or sublimate lotion. It is then wrapped round with a single layer of sterile gauze, and the paste, liquefied by placing it in a gallipot in a saucepan of boiling water, is applied over it with a paint or paste brush. Another layer of gauze is placed over the paste and a thin bandage over all, and the whole allowed to dry. Where there is extensive varix, the paste should extend from the ankle to the knee, and may sometimes include the foot. If there is much discharge, the ulcer should not be covered, and the dressing should be reapplied daily; but after it has di- minished in amount, the paste may be carried right over the sore, and the wiiole application left in position for a week, or even longer. When the edges are very indurated and thickened, and all action is at a standstill, Syme's suggestion may be followed, viz., to blister the whole surface, as well as the surrounding skin. A more satis- factory method, but requiring an anesthetic, is to scrape the surface with a sharp spoon, and then to rub in a strong solution of chloride of zinc. When healthy action has been obtained, assistance in healing may be secured by the use of such stimulating applica- tions as scarlet-red (a coal-tar derivative) used for twenty-four hours in the form of a 4 to 8 per cent, ointment, after effective purification, followed for two days by boric acid ointment, and then repeated; or the liquid extract of the common comfrey {Symphytum officinale), the active agent in wliich is allantoin, will stimulate the growth of granulations; or allantoin itself may be employed in a 5 per cent, solution. Any of these agents will hasten a cure. If, however, the surface to be healed is very extensive, skin-grafting may be employed, if necessary; it is useless to undertake this, however, unless the patient can promise to rest for a prolonged period, and even then elastic support will be subsequently required. In bad cases where a considerable portion of the circumference of the hmb is involved, when the ulcer is very callous and its base attached to the tibia, causing severe pain at night from chronic periostitis, and especially when the patient cannot obtain prolonged rest, amputation may be the best treatment. Farabceuf's amputa- tion at the site of election can often be undertaken with advantage. Where varicose veins exist, treatment is of little avail unless ULCERATION 103 these are efficiently dealt with either by operation or by some suitable support, such as Unna's paste. It is often undesirable to attack the veins locally owing to the dirty condition of the ulcer, which must be dealt with by rest and fomentations. Operation consists either in removal of the dilated veins at a higher level, or in Trendelcn]-)urg's operation {q.v.) in suitable cases. The Irritable Ulcer may be treated by discovering the painful spots, and incising the tissues just above them with a knife, so as to divide the exposed nerves; but thorough scraping under an anaesthetic is preferable. The Eczematous Ulcer must be dealt with differently from the others, or the eczema will be aggravated. Soothing apphcations are needed, such as lead lotion, and when once the acute stage has passed, tarry preparations (liq. carbonis detergens, i ounce to i pint of lotio plumbi), or an ichthyol ointment (5-10 per cent.), may be beneficially employed. A mixture of benzoate of zinc and boric acid ointments is a very useful application, or Unna's paste v\ith ichthvol may be utihzed. Stage III. : Repair having now been fully estabUshed, we have to deal with, not a healthy ulcer, for such a condition cannot exist, but a healthy granulating wound, the result of ulceration, or, as we call it, to avoid confusion, a ' healing ulcer.' A Healing Ulcer is characterized by the following conditions: Surface, smooth and even, shelving gradually from the skin, and covered vnth healthy granulations ; these present a florid red appear- ance, are piinless, and bleed, but not readily, on being touched. The discharge varies according to the plan of treatment adopted : if the surface is kept at rest and free from all irritants, the discharge is merely serous; but should the wound become infected, or be dressed with irritating antiseptics, ordinar\- pus is formed. The surrounding skin is soft, flexible, and free from inflammatory con- gestion, and the base is similarly free from fixity. The margins present a healing edge, which has been described as manifesting three coloured zones: within is a red area consisting of granulation tissue, covered by a single laver of epithehal cells, which cannot be seen except in a good light; next comes a thin duskv purple or blue Hne, w^here the granulations are covered bv a few lavers of epithe- lium, and the circulation is becoming retarded owing to cicatricial development; whilst outside is a white zone due to the heaping up of sodden cuticle upon the healthy or healed part. The method of repair in such a wound consists in a change of the deeper layer of granulations into fibro-cicatricial tissue, which gradually contracts and is finallv covered with epithelium. For full description see Chapter X. If emolhent applications are used too long, the granulations become pale, protuberant, and oedematous, and the heahng process is temporarily checked. A depressed general condition of the patient, or a varicose condition of the veins, mav also account for this, and the term a weak ulcer is applied to it, whilst the prominent flabby granulations are popularly known as proud flesh. io6 A MANUAL OF SURGERY Treatment.-- The part must be kept at rest, and if the leg is the seat of the trouble, it slunikl not be allowed to hang down. The wound must be protected from injury by a dressing which can be removed without damaging the surface. A piece of sterile protective, the exact size of the lesion, may be placed over it, and covered with sterile gauze, or the wound may be dressed with a simple ointment {e.g., ung. acidi borici, diluted with an equal part of vaseline) spread on sterile butter-cloth or lint. If the granulations become too prominent, they may be lightly touched with nitrate of silver, or a stimulating lotion applied, such as that known as lotio rubra (R Zinci sulphatis, gr. ii.; tinct. lavanduhe co., spir. rosmarini, aa ni^xx.; acidi borici, gr. x. ; aquam destill. ad 5i.). Large ulcers require assistance in order to obtain expeditious healing, otherwise a time comes when the contraction of the cica- tricial tissue interferes with the nutrition of the granulations, and retards the healing process. To ob\nate this difficulty, skin-grafting is frequently utilized. Skin-grafting, or the transplantation of more or less of the thick- ness of the skin from a healthy to a healing part, was introduced by Reverdin in 1869, and has since been much elaborated. The follow- ing are the chief methods employed: 1. Transplantation of small pieces of the cuticle and cutis, Reverdin's original plan. A small portion of the cutaneous tissue is pinched up with or without forceps, and removed by a pair of sharp curved scissors. It should include the cuticle and a portion of the cutis vera, so that a drop or two of blood will slowly ooze from the denuded surface. The graft is gently placed cutis down- wards on the surface of the granulations and covered with purified protective. Many of these may be applied at the same time, and the whole wound carefully dressed and protected. If there is much discharge, the grafts will not ' take ' ; but if the surface is healthy, there should be no difficulty in getting them to grow. Usually they disappear for a day or two, from the cuticle becoming softened or disintegrated; but soon the epitheUum of the cutis spreads, and makes itself visible as a distinct centre of repair. 2. Transplantation of large portions of cuticle as suggested by Thiersch. This method consists in removing large strips of cuticle with a razor, and implanting them on a fresh wound or on a raw surface denuded of granulations by scraping ; all haemorrhage must be previously stayed by pressure. In cutting the strips of cuticle care must be taken to make them as thin as possible; the papillae are always encroached on, however, and hence some amount of blood escapes, in which the grafts are allowed to remain soaking until required for use. The grafts are applied in such a way that they overlap each other and also the margins of the defect. There is always some tendencv for the edges to turn in, and this must be prevented by gentle manipulation. They are then dressed with dry sterile gauze, though some surgeons still prefer tf) keep the grafts covered with protective, or with perforated tin ULCERATION 107 or thin silver-foil. There is usually no need to look at the wound for some days. The outer sides of the thigh and arm are the best places from which to take grafts; the wounds caused by their re- moval are dressed by sterile gauze over protective or by gauze soaked in picric acid, and usually heal quickly, if the razor has not encroached on the subcutaneous tissues. The scar which results from the healing of the grafts is generall}- soft and supple, and free from the tendency to excessive contraction which marks the ordinary cicatrix. 3. The whole thickness of the skin is used in some instances {Wolfe graft). The graft is cut rather larger than is necessary, to allow for shrinkage, and all subcutaneous tissue and fat removed therefrom. It is applied to the raw surface of the wound after scraping away all granulations, and stitched into position. It may also be apphed to the raw surface of an operation wound. II. Ulcers due to Specific Bacteria. The different forms of infective ulcers met with in surgical practice will be described under the appropriate headings in different parts of the book. It will suffice here to mention them: Soft Chancre (p. 149). — This may be taken as a type of all in- fective ulcers, clearly showing the stages of infection, incubation, ulceration, and repair. Ulcers due to Syphilis : (a) The primary sore (p. 155). (&) Secondary ulcers, mainly of mucous membranes, but sometimes involving the skin (p. 159). (c) Intermediate, rupial, or ecthymatous sores (p. 161). [d) Tertiary ulcers from the disintegration of gummata (p. 163). Phagedenic ulceration (p. 157) is usually associated vnth syphilis. Ulcers due to Tubercle : {a) The lupoid ulcer, due to a cutaneous tuberculosis (Chapter XVII.), or [h) The tuberculous ulcer, arising as a rule from the bursting of a subcutaneous or submucous tuberculous abscess (p. 182). .... (f) Various other tuberculous ulcerative lesions of the skin are described by dermatologists under the title ' scrof- ulodermia,' whilst Bazin's disease (or erythema in- duratum) is possibly tuberculous in origin. III. Malignant Ulcers. These are due, as has already been pointed out, not to any in- flammatory process, but to the actual replacement of the skin by the growth, so that loss of substance necessarity ensues. They will be described in Chapter IX. CHAPTER VII. GANGRENE. By gangrene, or necrosis, is meant the simultaneous loss of vitality of a considerable area of tissue. If the process is limited to the soft parts of the body, it is often termed sloughing or sphacelation, and the dead mass a slough or sphacelus ; if a tangible portion of bone dies, the necrosed mass is called a sequestrum ; while the term gangrene is more especially applied to a necrotic process affecting simultaneously the hard and soft tissues of a limb. General History of a Case of Gangrene. Signs of Death. — Death of a limited portion of the body can be recognised prior to the supervention of evident post-mortem changes within it by five characteristic signs: 1. Loss of pulsation in the vessels. 2. Loss of heat, since no warm blood is brought to it. 3. Loss of sensation in the dead part, although much pain of a referred type may be experienced whilst death is occurring. 4. Loss of function of the gangrenous mass, which, if it is a limb, lies flaccid and motionless. 5. Change of colour, the character of whicli depends on the amount of blood present at the time of death; if the part is full of blood, it becomes purple and mottled; if anaemic, a waxy or cream colour results. These five signs may be in measure present when the vitality of a limb is seriously depressed, as by hgature of the main vessel or by its embolic obstruction; but if they continue for any length of time, death is certain to ensue. Sometimes it is a little difficult to deter- mine whether a part is dead, especially when it is engorged with venous blood and the arterial pulsation has ceased; if living, it will usually be found that pressure causes some modification of the colour, and that the discoloration returns when the pressure is removed. Changes occurring in the Dead Tissues. — The character of these depends mainly on the condition of affairs at the time of death, and whether or not putrefaction supervenes. 108 PLATE II. Fig. I. — Senile Gangrene of Foot. In this case amputation was performed above the knee, and the popliteal artery was found to be very atheromatous and in a condition of thrombosis. Fig. 2. — Keloid of Thoracic Wall. \_To face page 1 08. GANGRENE 109 1. Dry Gangrene {=^ death + mummification) can only occur when the tissue involved is, previous to its death, more or less drained of its fluids. The usual cause is chronic arterial obstruction, as brought about by arterio-sclerosis or calcification of the terminal arteries, to which a sudden or gradual complete occlusion of the main trunk is often superadded. The dead part becomes hard, dry, and wrinkled, and is of a dark brown or black colour from the diffusion of the disintegrated haemoglobin (Plate IL, Fig. i). The more fleshy parts {e.g., above the ankle) rarely undergo perfect mummification, and are often considerably inflamed, and, if bacteria be admitted, horribly offensive. 2. Moist Gangrene arises when a part of the body full of fluid dies, and is especially associated with conditions which involve venous obstruction as well as a sudden arterial block— e.g., in traumatic gangrene due to pressure upon, or rupture of, the main artery. Obviously, such a condition is well suited for the development of the organisms, which always exist in numbers on the skin, and unless the most vigorous efforts are made to render it aseptic before or immediately after death, moist gangrene is certain to be associated with putrefaction ; but it must be clearly understood that the latter is no essential part of the gangrenous process. Aseptic Moist Gangrene is characterized by the dead tissues be- coming more or less discoloured, either purple or any shade from black to yellow, green or white. It remains of much the same size and consistency as at the time of death so long as it is kept from contamination, and is then simply and quietly cast off from the surrounding tissues without any obvious inflammatory disturbance, although a certain amount of toxsemia may result from the absorp- tion of various products from the dead tissues. Septic or Putrid Moist Gangrene (Fig. 21) is necessarily associated with a rapid breaking-up and disintegration of the mass, which becomes black, green, or yellow. The cuticle is raised from the cutis vera by blebs containing stinking serum, or even bubbles of gas, and these can be readily pressed along under the epidermis for some distance. The tissues" of the hmb are soft and lacerable, and on grasping it emphysematous crackling is usually noted. The Later History of a gangrenous mass depends entirely on its asepticity or not, and on its bulk. [a) If the necrotic area is small in size and aseptic, it may, under favourable circumstances, be entirely absorbed in the same way as is a catgut ligature. This is often observed after sloughing of small portions of amputation flaps; if the part is kept dry and aseptic, it is gradually removed, and when the process is completed a small dark scab will fall or be picked off, and a cicatrix be found beneath it. In a similar way dead bone may be absorbed, if the sequestrum is not too large or too dense, and if it is in close proximity to healthy vascular tissue. The dead portion is first invaded by small round cefls, presumably leucocytes, which infiltrate and gradually remove the part ; granulation tissue replaces it, and this in turn is converted no A MANUAL OF SURGERY into a cicatrix, and covered with cuticle in the usual way (see Repair, Cliapter X.). {b) If the mass, though aseptic, is of such a size, or consists of such tissues, as to prevent its total absorption, or if tlie vital activity of the patient is lowered, a modification of the same process results in partial absorption of the dead material, whilst the remainder is cast off and separated by a simple process of ancemic ulceration. The dead part immediately contiguous to the living is removed and replaced by granulation tissue, and this change continues advancing into the mass until the layer of granulations which has penetrated furthest is at such a distance from its nutritive basis as to be unable to derive from it sufficient pabuhmi, owing to the contraction of the cicatricial tissue which is forming behind; and then a simple ulcerative process from defective nutrition causes a line of cleavage to form between the living and dead, and by this means the latter is separated from the body. The size of tlie portion thus cast off is distinctly less than / / / ^2). tiG. 21.- -Septic Moist Gangrene of Leg fkom Penetrating Wound of Femoral Artery. that of the original necrotic mass. This process is associated with no local inflammatory reaction, and but little resulting constitutional disturbance; it is slow in progress, but there are none of the risks attaching to the more rapid septic proceeding. Of course, the denser and harder the tissues, the longer they take in separating, and hence when a whole limb is involved it is possible for the soft parts to have separated, and the wound caused thereby to have cicatrized before much impression has been made on the bones. Considerable retraction ensues, giving rise to a ' conical stump ' from the apex of which the bone protrudes. (c) If the gangrenous portion is septic, its separation is accom- plished by an inflammatory act taking place in, and at the expense of, the surrounding living tissues. The extent of the gangrene is primarily indicated by a line of demarcation, due to the change in colour occurring in the dead part, the hving tissues retaining their GANGRENE in normal hue. The irritation of the chemical products formed in the necrosed mass causes inflammation in the surrounding structures, which ends in suppuration, whilst a layer of granulation tissue forms at the limit of the li\ang portion, and thus the final line of separation is produced. Clinically, one notices in this latter stage a bright red line of hypercemia at the extremity of the living tissues, which gradually spreads and deepens until about the eighth or tenth day, when, if the cuticle is intact, the h\dng and dead parts are separated bv a narrow white or yellow line, which is proved, on pricking the epidermis, to be due to the presence of a layer of pus; as the pus escapes, a shallow groove is seen running between a granulating surface on the side of the h\dng tissues and the gan- grenous mass. This process, gradually extending through the whole thickness of the Hmb, is accompanied by the local signs of inflam- mation and by fever, the degree of the latter depending on the amount of toxic material absorbed. The inflammation, moreover, is not alwavs hmited to the line of separation, but may spread upwards along the lymphatics or veins, or in the fascial and muscular planes, until, perhaps, the whole limb is involved in an extensive suppura- tive process. The Constitutional Symptoms of gangrene may be described under two distinct headings : {a) Those general conditions which predispose to the occurrence of gangrene, and which are mainly of a debilitating character, affecting either the composition of the blood or the \atahty of the hmbs. General diseases, such as diabetes and albuminuria, may be present, as also the constitutional results of a xdcious hfe, whilst local e\ddences of malnutrition often manifest themselves before the onset of gangrene. (b) Those conditions depending on the presence and connection with the body of the dead tissue. Various forms of toxsemia result, usuallv causing fever, asthenic in type and variable in amount. Pain, moreover, is frequently a prominent feature in some forms of gangrene, and the patient is hable to become exhausted from this cause. But little need be said as to the General Treatment of gangrene, beyond that the strength of the patient must be maintained by plentv of easily assimilable food, sufficient stimulant, and tonics. Pain and sleeplessness must be combated by the administration of a suitable amount of opium or morphia, if the kidneys are healthy. Diabetes and albuminuria need dietetic and therapeutic measures in order to limit, if possible, the excretion of sugar and albumen. The Local Treatment is discussed below. Varieties of Gangrene. The following classification is one which, though admittedly im- perfect, does in a measure group together allied t^-pes of the affection, and will serve as a useful one for practical purposes : 112 A MANUAL OF SURGERY I. Symptomatic Gangrene, or that predisposed to by preceding vascular or general conditions, and where a trauma, if present at all, is of very slight signiiicance. (a) Gangrene from embolus. (b) Senile gangrene. (c) Gangrene from arterial thrombosis (non-senile). {(i) Diabetic gangrene. (e) Raynaud's disease. (/") Gangrt'ne due to ergot. II. Traumatic Gangrene, which may be due to chrect or indirect injury, and where the damage done to the vessels or tissues by the trauma is the immediate cause of the loss of vitahty. Two varieties may be described, viz. : (a) The indirect, where the lesion involves the vessels of the limb at some distance above the spot where the gangrene occurs. (h) The direct, where the gangrenous process is limited to the part injured. III. Infective Gangrene, which arises from the activity and in- fluence of micro-organisms. (a) Acute inflammatory or spreading traumatic gangrene. (b) Wound phagedena and hospital gangrene. (c) Noma and cancrum oris. (d) Carbuncle and boil. IV. Gangrene from Thermal Causes — frost-bite and burns. Each of these varieties must now claim separate and indi\idual attention. I. Symptomatic Gangrene. ((0 Embolic Gangrene. (For general details as to emboli, see Chapter XIV.). When the main artery of a limb becomes blocked by a simple embolus, the condition is exactly similar to that which obtains after ligature, and imder ordinary circumstances should not lead to gangrene; but if either the general or local vitality is much reduced, the occlusion of the main trunk may be sufficient to deter- mine the death of more or less of the limb. Thus it may occur: (i.) Where the embolus consists of a fibrinous vegetation detached from one of the cardiac valves in a case of endocarditis following rheumatic or other fevers. The general nutrition has been depressed by the preceding fever, the heart's action is weak, and the circulation possibly impeded by the valvular lesion, so that the occlusion of a main trunk, even in a young person, is often sufficient to determine gangrene, (ii.) It also follows when a detached atheromatous plate blocks the main vessel of a limb previously rendered anaemic by arterial degeneration, an occurrence not unusual in elderly people. Emboli are most commonly arrested at the sites of division of the main trunks (Fig. 22, A), or where the calibre is suddenly diminished by the origin of a large branch, the embolus often saddling over the bifurcation, and thus, as it increases in size by the subsequent de- GANGRENE "3 posit thereon of fibrin, effectually closing both branches (Fig. 22, B) In the lower limb it occurs at the division of the femoral or popUt'eal; in the upper, at the origin of the superior profunda, or where the brachial divides. The chief early Symptom is sudden severe pain experienced both at the point of impaction and also down the limb along the course of the vessel. Pulsation below the block ceases, the limb becomes useless and devoid of sensation, and its temperature rapidly falls. If the vessels are healthy, stagnation of blood in the veins is an early result, the terminal portion of the hmb becoming congested and oedematous, and finally passing into a condition of moist gan- grene. If, however, the terminal arteries are calcified or atheroma- tous, so that the hmb is in a state of chronic anaemia, dry gangrene is likely to follow. The process starts peripherally, and spreads gradually upwards until it reaches a level where there is sufficient Fig. 22.- -DlAGRAMS OF EMBOLUS SADDLING THE BIFURCATION OF AN Artery. In A the embolus is seen, and the commencement of a thrombus on it but not yet obstructmg the vessel: in B both branches of the trunk are' blocked by the growth of the clot. circulation to maintain the life of the part. This usually obtains m the neighbourhood of a joint, since there is always a more free anastomosis here than in the interarticular portions of the hmb; thus, m the leg the gangrene is arrested either immediately above the ankle or below the knee. Treatment.— The first requisite is to prevent the advent of in- fection, even before any absolute signs of death are manifest. The nails should be cut, and the whole limb thoroughly purified (Chapter XL), special atteation being directed to "the intervals between the toes and the semilunar folds of the nails. It should then be wrapped in a dry sterilized dressing, with plenty of wool, and bandaged. The limb is kept slightly raised so as to assist the venous return without interfering with the arterial supply, and by this means gangrene may be prevented. Vigorous massage so as to break up the clot and drive it on into the peripheral vessels has been advocated. A few instances are also on record of the artery being ri4 A MANUAL OF SURGERY opened, and attempts made to extract or tunnel the clot; the results haA e not been very favourable. If, however, ^^angrene ensues, the same measures as to the maintenance of asepsis must be con- tinued until a natural line of separation forms. In old people with dry gangrene the question of amputation is decided by rules similar to those for the senile type: but in young people amputation through the living tissues a little above the line of se})arati()n is all that is required, and the period for this must be determined by the local and general conditions. If the parts are aseptic, the amputation may be delayed; but if spreading inflammation exists, one may have to remove the limb higher up than would be otherwise necessary, and this even bc^fore any line of separation has formed. {h) Senile Gangrene occurs in elderly people, and is the result of imperfect nutrition of the tissues (Fig. 23). The toes are most frequently affected, but it is also seen in the hand, and may attack the nose, ears, or even the tongue. i iG. 23. — Senile Gangrene. Causes. — These are to be found mainly in the condition of the circulatory organs, {a) Calcareous degeneration of the smaller arteries of the limb or part is always present, as also possibly ather- oma of the larger trunks. The vessels become pipe-like and in- elastic in consequence, and incapable of accommodating themselves to the requisite variations in the blood -supply. Hence a fixed minimal amount of blood enters the limb, which passes into a chronic state of anaemia and malnutrition, whilst the tunica intima is often so rough as to predispose to thrombosis with or without injury, {h) A weak heart is generally present, leading to low pulse tension, and increased difficultv in propelling the blood through the rigid and narrowed vessels; and (c) the condition of the blood may be impover- ished by albuminuria or glycosuria. When such predisposing factors are present, anything that results in (d) thrombosis either in the main GANGRENE "5 trunks or in the peripheral arterioles or capillaries is likely to deter- mine the onset of gangrene. Thrombosis of the main vessels may be due to a blow or strain which often passes unnoticed, or more frequently arises from a gradual deposit of fibrin on the already roughened walls. If the obstruction originates in the smaller trunks or capillaries, it is generally brought about by inflammation follow- ing some slight injury, such as striking the ball of the great -toe against the table, or even cutting a corn. Exposure to cold may also act as an exciting agent. In either case the clotting extends for some distance, and the he'ght to which the gangrene spreads will vary accordingly. Symptoms. — Evidences of malnutrition of the limb have probably been present for some time in the form of cramp and pain in the muscles, which become fatigued rapidly, or of sensations of pins and needles or numbness. The pulsation in the tibials may be so slight as to be scarcely perceptible, and the whole limb is shrivelled and feels cold and heavy. The skin is often passively congested, and hence prone to low forms of ulceration or eczema. When the gangrene commences as a result of some peripheral lesion, an area of painful redness is first noticed, perhaps running on to ulceration, and in the centre of this patch a slough forms, which becomes dry and black; the process gradually spreads from this focus with more or less inflammation, so that it is sometimes known as in- flammatory senile gangrene. If, however, it results from thrombosis of the main vessels, death occurs without the supervention of local inflammatory phenomena, the toes merely shrivelling up and dying {non-inflammatory senile gangrene). The inner side of the great- toe (Plate II., Fig. i) is perhaps the commonest situation for the mischief to start, and thence it spreads from one toe to another, and also along the instep and up the ankle to the leg. Pain is always a marked feature, whilst the extent of the gangrene is dependent partly on the amount of general and local vitality, and partly on the asepticity or not of the surrounding tissues. As the disease spreads, the patient becomes exhausted by the long-continued pain and want of sleep; and septic fever, bedsores, or the intervention of some cardiac, pulmonary, or renal complication, may also hasten a fatal termination. Treatment. — In the earlier stages of malnutrition of a limb from a defective arterial supply, marked by coldness and a sense of weight and fatigue, much may be done to improve the vitality of the part by the cautious use of hot-air baths, massage, etc., and attention to the general health. The patient must be warned of the danger of small injuries, and the possible harm that may follow the in- judicious use of hot-water bottles, or of incautiously cutting corns. If the condition progresses and actual gangrene is threatening, arterio -venous anastomosis may be justifiable. In this procedure the circulation is deflected from the obstructed arteries to the patent veins, and thereby the vitality of the limb may be preserved. Hunter's canal is the usual site of this operation. The vein and ii6 A MANUAL OF SURGERY artery are exposed and divided transversely; the distal end of the artery and the proximal end of the vein are ]ifj;atured, and a careful end-to-end anastomosis is effected between the ])ro\imal end of the artery and the distal end of the vein. When gangrene is actually present, treatmt-nt is governed l)y the observation that after an}^ attempt to amputate through neighbour- ing living parts the gangrenous process is certain to commence again in the flaps; if merely cutting a corn suffices to originate the malady, nmch more will so severe an injury as an amputation. It is there- fore necessary to amputate well away from the dead mass at a point where the blood-supply is sufficient to nourish the flaps, and yet not so near the trunk as to threaten life seriously through shock. This must be undertaken early, especially when pain is severe, or if a spreading cellulitis is present. In order to determine the most favourable site, the main artery should be carefully examined, and if feasible no operation is performed at a level where it appears to be occluded. It should also be remembered that the nmscles are better supplied with blood than the overlying skin. The condition of the limb will therefore influence the surgeon's decision; if thin, attenuated, and shrivelled, it will be wise to amputate high. The operation should inflict as little damage as possible on the parts, the flaps being nearly equal in length and sufficiently thick to in- clude plenty of muscle. Where the mischief is limited to the foot, it is usually advisable to amputate through the lower third of the thigh, or at any rate in the neighbourhood of the knee-joint, though not through the joint itself, as the flaps in that operation are always rather flimsy. If for any reason amputation is contra-indicated, the limb is kept aseptic (if possible), wrapped up warmly, and elevated. The general health is maintained by suitable nourish- ment, tonics, and stimulants, and pain alleviated by opium. (c) Gdngrene from Arterial Thrombosis (non-senile) is not a com- mon occurrence. It arises as a result of the aft'ection known as endarteritis obliterans, and also develops in the later stages of typhoid fever and other conditions of severe toxsemia as an outcome of arterial thrombosis, caused partly by the increased coagulability of the blood, partly by a localized endarteritis, lighted up by the circulating toxins. The femoral artery is most usually blocked, but occasionally the trouble will spread up to the aorta and involve both legs in the gangrenous process. Unless the vein is also involved, the gangrene is usually of the dry type. It is wise to wait until a line of demarcation has formed, and then amputate well above. A similar condition is met with chiefly in Russian and Polish Jews who are heavy cigarette smokers, resulting from an affection which has been designated thrombo-angiitis obliterans (Leo Buerger), in which extensive thrombosis occurs first in the arteries and later in the veins of the leg. In the earlier stages various sensory and trophic changes are noticed, and in the later gangrene, usually of the dry type, occurs. It has been suggested that in early cases arteriovenous anastomosis between the femoral artery and vein might be useful. GANGRENE 117 A limited gangrene of tlie tips of one or more fingers of a dry type may occur as a consequence of the pressure of a cervical rib on the subclavian vessels. A curious form of gangrene occasionally follows the application of a carbolic acid compress, even when weak solutions — e.g., i in 60 — are employed. The fingers are the parts usually affected, and the gangrene does not seem to be due to tight bandaging, or to the presence of a waterproof covering. Possibly the carbolic acid determined prolonged arterial spasm, and the anaemia was followed by local necrosis. {d) Diabetic Gangrene is mainly due to the abnormal condition of the blood in diabetes, thereby reducing the power of the tissues to resist bacterial invasion; but it is also in measure the result of a sclerosing endarteritis and peripheral neuritis. It is not generally met with in the subjects of acute diabetes, nor in people under forty years of age. It results usually from some slight traumatic or infective injury, and often commences on the under side or at Ihe ■^''-cftaaj Fig. 24. — Diabetic Cellulitis and Gangrene of Foot and Leg. extremity of one of the toes as a bleb, surrounded by a dusky purple areola. When the bleb is opened or bursts, the central portion of the underlying tissue is found to be necrotic, and from this focus the gangrene spreads. If the part is kept aseptic, and in limbs with some degree of endarteritis, the dead part may shrivel and dry up, especially when suitable dietetic restrictions are enforced; but if such local and general precautions are not observed, extensive suppura- tive infiltration of the soft parts may follow (Fig. 24), even though the necrotic process itself be of slight extent, and from this the patient may succumb, the fatal issue being due partly to diabetes, partly to toxaemia, and being often preceded by coma. Not un- commonly several foci of mischief develop, and the extent of subcu- taneous involvement is sometimes much more extensive than the limited affection of the skin. Treatment. — In the less severe cases, involving one or more toes, it will often suffice to keep the part warm and aseptic, until it is separated by natural processes, or at any rate the surgeon merely completes the work by dividing or dissecting out bones. Naturally, ii8 A MANUAL OF SURGERY the elimination of sugar must be checked, if possil)le, by suital)le diet and the administration of codeia. In more extensive trouble the character of the treatment turns largely on the amount of vascular disease and the degree of the accompanying inflammati(jn. If the vessels are tolerably healthy, amputation not very much above the upper limit of the gangrene is justifiable; but if the main trunks are probably affected, a high amputation will be recjuired, if the patient's general condition permits, although there is some risk that diabetic coma mav supervene. \Mien extensive suppuration is present, it is sometimes wise to lav the parts open for awhile and drain away the inflammatory exudations before considering the question of radical treatment. The choice of the anaesthetic will also require careful consideration; and spinal analgesia should be employed when the lower extremitv is involved. (e) Raynaud's Disease, <>r Spontaneous Symmetrical Gangrene, is a condition usually met with in ansemic or neurotic voung women between the ages of fifteen and thirty. It is due to vaso-motor spasm, dependent on some deep unrecognised lesion of the spinal cord, or in some cases to a peripheral neuritis. Three stages are usually described: (i.) local syncope or anaemia, due to arterial spasm, and characterized bv pallor and painfulness of the part; (ii.) local asphyxia or congestion, the affected tissues being blue and cyanosed from venous regurgitation; and (iii.) necrosis, the part becoming dry and black. The onset is often sudden, and the disease may last for a variable time, from days to months. If gangrene supervenes, the latter is the limit more often reached; but it by no means necessarily follows that tissue necrosis occurs in every case. The disease is usually symmetrical, and affects the fingers rather than the toes, but superficial patches may occur on any part of the body ; the process is non-febrile and often very painful. Paroxysmal haemoglobinuria has been observed, and is supposed to be due to vaso-motor disturbance of the kidneys. Ankylosis of the smaller interphalangeal joints and localized patches of anaesthesia, associated with neuralgic pain, are sometimes present, resulting from peripheral neuritis. The condition often resembles the later stages of a chil- blain, but is distinguished by its more dusky colour, the greater pain, the absence of itching, and the fact that the process is not limited to exposed or terminal parts, or to cold weather. The Treatment in the early stages is directed to the prevention of gangrene. Iron, quinine, and other suitable tonics are administered, and menstrual irregularities are attended to. Friction with stimu- lating embrocations, warm douches, and protection from cold and injury, may be employed locally, but probably the best results will follow the use of electricity. The constant current is employed, and ])referably in the shape of the electric bath, local or general as required, and repeated either once or several times a day. \A' hen actual gangrene is present, the dead tissue should be kept aseptic, when sooner or later it will be absorl)ed or separated. ( /) Gangrene from Ergot is a rare phenomenon, but it has been GANGRENE iig known to occur when diseased rye has been used in the manufacture of bread. The resulting gangrene may vary in extent from the loss of one or two fingers or toes to the sacrifice of the greater portion of one or more limbs. II. Traumatic Gangrene. B}' traumatic gangrene is meant the loss of vitality of some part of the body as the consequence of an injury, whether applied to the main bloodvessels {indirect traumatic gangrene), or directly to the tissues {direct traumatic gangrene). {a) Indirect Traumatic Gangrene arises from a considerable variety of lesions, and the course and clinical history are similarly variable. (i.) Ligature of the main artery does not produce gangrene in a healthy limb; but should it be in a state of chronic malnutrition and anaemia from preceding arterial disease, death of a certain portion may ensue, the case running a similar course to one of gangrene due to embolus. It is usually of the dry type, and limited to one or two toes, or to a patch of the superficial tissues; but if it reaches the more fleshy portions, the moist variety supervenes. Treatment consists in keeping the parts warm and aseptic until a definite line of separation forms, and then in assisting the natural processes at this spot by di^ading tendons and bones. If, however, a considerable area of the limb loses its vitality, and especially if the dead tissue is moist and putrid, an early high amputation is required. (ii.) Arterial thrombosis from injury only causes gangrene under special circumstances, the course and treatment being similar to that resulting from an embolus. (iii.) Obstruction to both main artery and vein is an almost certain precursor of gangrene, if it occurs suddenly. Cases are on record in which both vessels have been ligatured, or even portions of them removed without such a result, as in dealing with cancerous deposits in the axilla or in the extirpation of aneurisms; but in both these instances obstruction to the circulation must have previously existed, necessitating the opening up of collateral anastomotic branches. In a normal limb the simultaneous occlusion of both afferent and efferent trunks, as by inclusion in a ligature, is almost certain to determine tissue necrosis. It is also caused by the strangulation of organs, either within the body, as in a strangulated hernia, or outside of it, as when a ligature is tied round the base of the penis, or a bandage apphed too tightly round a fractured limb. It may even result from the swelling of a limb under a bandage which has been originally applied with no undue tension. Gangrene may also follow the rupture of a main artery and compression of the accompanying vein by the extravasated blood, an occurrence perhaps most frequently seen after fractures and dis- locations ; it is then alwa^^s of the moist type. (See Chapter XX.) Treatment varies considerably in these cases. If the parts are hopelessly injured, amputation should be performed at once, so as to prevent the risk of infection. In some fractures and dislocations I20 A MANUAL OF SURGERY with vascular lesions, it may be possible to save the limb by cutting,' down, turning out clots, and securing the injured vessels, whilst the bony lesion is dealt with in a suitable manner. The limb should afterwards be elevated slightly, and the peripheral segment kept wami and aseptic. Should gangrene supervene, amputation will be required, its situation depending on the character of the local lesion; if it is not of a serious nature — e.g., a clean fracture or simple dis- location — it is wise to wait for a line of demarcation; but if com- minution of bone or other grave local trouble is present, one should am])utate above the injury. {b) Direct Traumatic Gangrene, or that resulting from the im- mediate effect of injury to the parts, is similarly due to a variety of lesions. (i.) Severe crushes or blows are a common cause of this type of gangrene; thus a limb may become mangled between the wheels of machinery, or by heavy weights falling on it, or by the passage of vehicles over it. " Not only are the parts crushed, severely cont~used, or even ' pulped,' but the bloodvessels may be torn, and the pressure of extravasated blood contributes to the result. The gangrene is of the moist type, and is more likely to supervene in patients whose vitality is diminished. Thus, a crush of the foot in an elderly person is often followed by it, when in a young and healthy adult it could be prevented. Treatment.— If the part is hopelessly damaged, operation should not be delayed, on account of the dangers of infection; and therefore immediate amputation is recommended. The question of shock and its influence in determining operation is discussed elsewhere. When there seems a reasonable chance of saving the limb, it is cleansed and purified under the strictest antiseptic precautions; should gangrene supervene, it may be removed later. (ii.) Prolonged pressure is also capable of producing gangrene. Gangrene from splint pressure is either almost unavoidable, or the result of carelessness. When the fragm^ents are much displaced after a fracture, considerable pressure may be required to retain tliem in good position, and then in spite of every precaution necrosis may ensue. Pain of a neuralgic type is usually complained of for a few" days, but even that is not necessarily severe enough to attract much attention; when the limb is freed later on, the dead portion of the skin is white, anaemic, and insensitive. The necrotic process may extend to some depth, and hence the greatest care must be taken to keep the dead tissues aseptic, thereby avoiding grave local and constitutional disturbance. Bedsores are likely to occur in patients who are kept for a long time in the recumbent posture, or in any one particular position. The parts most exposed to pressure becorne red and congested, and finally ulceration or actual gangrene supervenes. Bedsores arc not usually extensive or deep; but if the patient is debilitated or para- lyzed, \he process may extend rapidly, destroying fascia?, laying open muscular sheaths, and even leading to necrosis or caries of bene GANGRENE 121 {acute bedsore). The spinal canal itself has been opened in this way, and death from infective meningitis has resulted. To prevent the occurrence of such sores, the nurse must see that the draw-sheet and bed-linen are placed smoothly and without creases, and that no contamination by urine or fasces is allowed. The skin of the back is daily washed with some unirritating soap, and rubbed with a soothing, strengtiiening, and hardening application, such as methy- lated spirit, or a mixture of brandy and white of egg. It is then dusted over with a powder, consisting of equal parts of oxide of zinc, boric acid, and starch, in order to harden and dry it. If the skin becomes red, it should be painted with a mixture of equal parts of tincture of catechu and liquor plumbi subacetatis, which when dr}' leaves a powdery film on the surface, and protected from pressure by a circular hollow water-pillow. Paraplegic patients or old people should be placed on a water-bed, which must be sufficiently, but not excessively, distended. If there is too httle water, the weight of the bod}' displaces it to one side, and no good results; whilst if there is too much, the bed becomes hard and resistant, and fails in the object for which it is employed. When an open sore forms, fomentations are required in the more acute stages, whilst later it m.ay be dressed either with diluted boric acid ointm.ent, or in the more sluggish cases with resin and boric acid ointments mixed. Friar's balsam, mixed with castor-oil (i part of the balsam to 7 of the oil), is useful in this condition. • (iii.) The action of corrosive or caustic chemicals is followed by a localized traumatic necrosis, the degree of which varies with the amount and character of the irritant present, and the duration of its action. All that is needed is to keep the parts aseptic, and allow them to be absorbed or separated by natural processes. III. Specific or Infective Gangrene. {a) Acute Spreading, Acute Emphysematous, or Spreading Trau- matic Gangrene. — This disease is one of the most rapidly fatal and serious met with in surgerv. Causes. — (i.) The individual attacked is often debilitated as a result of vicious or careless living, heavy drinking, or simple mal- nutrition; but even healthy individuals may be attacked if the virus is active. It is sometimes seen in diabetics, but a form of glycosuria occasionally develops in the course of the disease. (ii.) The causative lesion is usually severe, such as a compound fracture or dislocation, especially if the soft parts are much contused or ver}' dirt}-. Defective purification of such tissues, and injudicious attempts to save them by accurate and close stitching, perhaps without drainage, are amongst the most frequent causes of an outbreak of this disease. Less frequently it follows a small and insignificant prick, scratch, or abrasion, through which a virulent organism gains access to the tissues. In this way post-mortem porters, nurses, or pathological demonstrators may become infected. 122 A MANUAL OF SURGERY (iii.) An organism frequently present is the Bacillus (cdcmalis nialigni, which is identical with the Vibrion septique of Pasteur and the French writers. It is a rod-shaped organism, which closely resembles that of anthrax, but is Gram-negative, and has a greater tendency to grow into long threads. It is actively motile, and forms oval spores, which may be placed at the centre <)r at the end of the rod. Cultures only develop under anaerobic conditions; and if the culture medium contains glucose, a large amount of foul-smelling gas is produced. Mice and guinea-pigs clie within twenty-four hours of inoculation; locally a spreading oedema is produced, the con- nective-tissue spaces being distended with fluid containing bacilli, and perhaps gas; bacilli are also found in the exudations which occur in the serous cavities, in the connective tissues of important organs, and in the blood for some time after death. The B. aerogenes capsiilaiiis may also cause acute spreading gangrene. It is an anaerobe with a similar power of fermenting sugar, but is non- motile, rarely forms spores, and is Gram-positive. It usually possesses a well-defined capsule, but this is not invariable. Careful investigation of fifty-eight cases* of spreading gangrene demon- strated that in only fourteen cases was there a pure infection, with an anaerobic organism, which was more frequently the B. aerogenes capsidatiis than the B. (vdematis maligni. A special feature of infection with the former is the large amount of gas produced, not only in the tissues, but also post-mortem in the vessels, and notably in the liver, from which it can easily be squeezed, constituting the foaming liver ' of some writers. Symptoms. — The outbreak of this disease may be delayed for two or three days, during which the wound is perhaps a little painful, but shows no special signs of activity ; none the less, mischief is going on out of sight, and the absence of discharge is a bad sign. In some cases the period of incubation is shorter. Suddenly and perhaps with little warning the case develops as a hyperacute cellulitis, accompanied by general septicaemia. The wound, when opened up, is found to be unhealthy, the surface covered with sloughs, and a thin serous or sero-purulent discharge escaping. The inflammatory process rapidly spreads along the connective-tissue planes of the limb, which becomes swollen, painful, and brawnv; in one case the gangrene spread from the foot to the groin within twelve hours. At first the parts are occupied by a bright red blush, but they soon become purple, gangrenous, and crepitant. The emphysema spreads widely and rapidly, with at first no other local evidence of mischief; sloughing will, however, follow if the patient live long enough. Evidences of profound toxic disturbance, such as hyper- pyrexia and delirium, soon manifest themselves; but not uncom- monly fever may be entirely absent, the temperature being sub- normal and coma present. The outlook is exceedingly grave, death usually ensuing in two or three days. * See Corner and Singer on ' Emphysematous Gangrene,' Trans. Path. Soc. Lond., vol. Hi., 1901, p. 42; Welch's ' Shattuck Lecture,' Philadelphia Med. Journ., August 4, 1900. GANGRENE 123 Treatment. — It is impossible to emphasize too strongly the danger of closing up completely and without drainage lacerated and con- tused wounds which have been caused by accidents on the railways or in the street, whereby the damaged tissues have been brought into contact with the ground, and perhaps infected thereby. Dangerous anaerobic organisms are so constantly present in the soil, that to close up such a wound is to favour their development. Scrupulous antiseptic cleansing of the wound, and especially by the use of oxidizing agents, such as peroxide of hydrogen, sanitas, etc., loose suturing of the parts, and free drainage, are essential if dan- gerous consequences are to be avoided. The appearance of inflam- matory phenomena will necessitate free opening of the wound, followed by incisions through infected tissues and immersion of the hmb in a wami bath containing Condy's fluid or sanitas. If, in spite of this, the disease spreads, a high amputation, well above its upper limits, even through the shoulder or hip-joint, is the only hope of saving life. (b) Wound Phagedena and Hospital Gangrene were seen often enough in the pre- antiseptic era, but are now practically unknown. They consisted in a rapidly spreading ulceration or gangrene, which attacked operation wounds a few days after their infliction, and as a rule led to rapid death. (c) Cancrum Oris and Noma. — Cancrum oris is an infective gan- grenous stomatitis, affecting young children living in squalid sur- roundings in over-populated districts of large cities. The patients are always in a low state of health, and frequently convalescing from one of the exanthemata, particularly measles. The process starts in an abrasion of the mucous membrane, which, being infected from a diseased or dirty tooth, becomes inflamed and gangrenous. A foul ashy-gray pultaceous slough forms on the inside of one of the cheeks, and from this a most offensive discharge is poured into the mouth and swallowed, the breath in consequence becoming intensely foetid. The gangrene gradually spreads both superficially and deeply; the cheek becomes swollen, shiny, and tense, and, should the process extend through its whole substance, a black slough appears on its outer aspect. In bad cases, the adjacent bones of the face may be affected and die, and the tongue, palate, and even the fauces, may also be involved. The general'phenomena are those of a severe toxsemia, since not only are the toxic products swallowed, but they are also absorbed by the" lymphatics, and may be inhaled, in the latter case giving rise to septic pneumonia. Moreover, the patient runs a considerable risk of developing pyaemia, from implication of the facial or other veins in the necrotic process, whilst infective septicaemia may also super- vene. Rigors and high fever may occur early in the case, but death is usually preceded by symptoms of collapse and coma, wth a subnormal temperature. . . The bacteriology of this affection is a little doubtful, but it is probably due to the Streptococcus pyogenes in conjunction with one 124 A MANUAL OF SURGERY or more of the bacteria always present in a dirty mouth, and notal^ly the spirillum of Vincent's angina. The Treatment must be prompt and energetic if the child's life is to be saved. The j^atient should be an;esthetizcd, and all the pulta- ceous slough removed by cutting or scraping, until healthy bleeding tissue is reached. The denuded surface ife then freely rubbed over with pure carbolic or strong nitric acid. In using such agents, the throat must be carefully protected, and the excess of acid in the case of the former dissolved by spirit, and in the latter neutralized by bicarbonate of soda. If the bones of the face are involved, they must be removed, as also any offending teeth. Afterwards the mouth is to be washed out frequently with antiseptic lotions, such as a solution of peroxide of hydrogen (i in lo), sanitas (i in lo), boroglyceride (i in 20), or permanganate of potash. The child must be given plenty of suitable fluid nourishment, and, if need be, stimulants. In the most severe cases, the whole thickness of the cheek may be encroached on ; loss of substance must be made good by subsequent plastic work. Necessarily, the cicatrization fol- lowing this destructive process results in a good deal of permanent impairment to the movements of the jaw. Noma is the name given to a similar process occurring about the genital organs of children, especially the vulva. The Treatment is practically the same, except that here it is possible to immerse the patient in a warm bath, after having removed the infected tissues. {(i) For Carbuncle and Boil, see Chapter XVI T. IV. Gangrene from Thermal Causes. I. Frost-bite. — This condition is not often seen in this country, but is by no means uncommon in regions where the winter is colder, and is induced more readily if a high wind is blowing, the heat of the body being therebvmore quickly dispersed. Children and old people are more likely to be attacked, as their vital powers are less marked than in adults. It originates in one of two ways: (a) From the direct effect of cold on the tissues, which become shrunken, hard, and of a dull waxy appearance. No pain is ex- perienced in the freezing process, so that onlookers are more likely to recognise the condition than the individual himself. The ex- tremities of the body, where the circulation is a little sluggish, and exposed parts, such as the nose and ears, are chiefl}^ liable to be attacked. Gradually the part shrivels, turns black, and is either absorbed or separated by a process of ulceration, with or without suppuration. A feature of gangrene from frost-bite is the more extensive implication of the superficial tissues on accoimt of their greater exposure. (b) From the subsequent injiauunatiou in ])arts which, though frozen, are not immediately killed. The thawing of these structures is accompanied by severe pain, and the prolonged anaemia so depresses GANGRENE 125 the vitality of the vessel walls that the rc-adniission of the circulating blood is likely to be followed by an acute inflammation, which ter- minates in necrosis from compression of the vessels by the rapidly- formed exudation. If it escapes actual death, the part remains red, congested, and painful for some time, and superficial ulcers may even develop; eventually, however, it recovers. Treatment. — Tlie frozen parts must be thawed very gradually, and the blood admitted into the tissues slowly, if inflammatory gangrene is to be avoided. They should be gently rubbed with snow or cold water, and warmed by being held in the hands of the manipulator, whilst the patient should be placed in a cool room, the temperature of which is slowly raised. As reaction comes on, a small amount of warm drink may be cautiously given. Excessive pain or congestive oedema may be limited by elevation of the part. If actual gangrene- occurs, the dead tissue must be rendered and kept aseptic, and the case carefully watched until a definite line of separation has formed. Indians, lumbermen, prospectors, etc., in North- West Canada, where frost-bites are common, have found that oil of turpentine is the best apphcation in all stages. The parts are kept soaked with the fluid, and the results are reported as phenomenal. 2. Burns and Scalds. — These may be considered as a special variety of wound, not necessarily ending in gangrene, brought about by the action of heat; burns, either by the close proximity to, or direct contact with, flame or heated soHd bodies ; scalds, by the action of boiling water, superheated steam, or other hot fluids or gases, the difference in the effects being comparable to the distinction between roasting and boiling. Naturally, fluids such as oil, which boil at a higher temperature than water, produce increasingly severe results. Six different degrees of burn were described by Dupuytren, and his classification may still be retained with advantage. The first degree consists merely in a scorch or superficial congestion of the skin, without destruction of tissue; the part may, however, remain red, painful, and prone to ulceration for a time. Should the scorch be often repeated, as bv people constantly warming their legs before the fire, the skin becomes chronically "pigmented and indurated {erythema ah igne). In the second degree the cuticle is raised from the cutis, and a bleb or bhster results. When this bursts, and the cuticle is removed, the cutis vera, red and painful, is exposed below. Permanent discoloration may follow this lesion. In the third degree the cuticle is destroyed," as is also part of the cutis vera, but the tips of the interpapillary processes, including the exquisitely sensitive nerve terminals, are laid bare and left intact; consequently this is a most painful form of burn. The deeper structures of the skin— viz., the sweat and sebaceous glands, and the hair follicles — remain untouched, so that, although the surface during the healing process becomes covered with granulations, the integument is very rapidly replaced, since there are so many epithelial elements from which it can grow. The cuticle is able to form not from the edge only, as must occur wherever the whole of the cutaneous envelope 126 A MANUAL OF SURGERY is destroyed, but also from innumerable foci scattered over the wound surface. The resulting scar, though often white and visible, undergoes no contraction: it is supple and elastic from containing all the elements of the true skin. In the fourth degree the whole thickness of the integument is destroyed, as well as part of the subcutaneous tissues. In the fif/h the muscles are also encroached upon, whilst in the si.xih the whole limb is charred and disorganized. In the last three forms healing can only occur by removal of sloughs and the formation of a cicatrix, which by its contraction may lead to deformity. The Local History of a burn may be described in three stages, corresponding to the three stages through which an ulcer or a lacerated wound passes: (i) The stage of destruction or burning, the various degrees of which have been just alluded to; (2) the stage of inflammation and sloughing, whereby the dead tissue is removed, and the wound converted into a healthy granulating sore; (3) the stage of repair. There are no special characteristics of these processes which call for particular note, except that they are usually associated with infection, unless the burn is a small one. The skin is generally dirty (from a surgical standpoint) at the time of the accident; it may be infected from the clothes which are being worn, and immediate attention may be impossible. Moreover, the extent of the lesion and the terrible pain caused by it often render complete sterilization impracticable. The General or Constitutional Conditions which correspond to these three stages require a little fuller notice. 1. In the early stages shock is usually present, and its intensity depends as much on the extent of the burn as on its depth, so that total charring of a limb may cause less depression of the system than an extensive superficial scorch, especially if the latter involves the abdomen or the head and neck. It frequently passes into a con- dition of collapse, due in measure to the absorption of toxic products from the burnt tissues. 2. Subsequently a period of inflammatory fever, usually of infective origin, follows, and may last four to fourteen days. The viscera become congested, particularly the gastro-intestinal canal, liver, lungs, and brain, and various complications may result therefrom. One of the most interesting sequelae, though at the present day it is admittedly uncommon, is Ulceration of the Duodenum. The ulcer is of the usual duodenal type, and occurs close to the orifice of the bile-duct. It probably results from the elimination by the liver of some irritating substance derived from septic changes in the burnt tissues which is capable of inducing thrombosis, or of producing ulceration. In one case under observation, a post-mortem examina- tion revealed a patch of well-marked ecchymosis in the duodenal mucosa exactly opposite the orifice of the bile-duct. Obviously it was the early stage of this condition, and would have gone on to ulceration had the patient lived. For clinical phenomena, see Chapter XXXV. GANGRENE ^^7 3. When healthy repair is occurring locally, and the parts are kept aseptic, no abnormal constitutional condition should be present, although there may be a certain amount of asthenia or ana;mia! Where, however, the wounds are septic and suppurating freely, this tendency will be much more marked, and the patient may even develop hectic fever and amyloid changes in the viscera, and finally die of exhaustion. Causes of Death from Burns. — If an individual is burnt to death, the fatal event is usually occasioned by asphyxia from the smoke and noxious fumes of the fire; shock and syncope from fright may perhaps be adjuvants, especially if the heart is weak or diseased. Within the first few days death 'results from shock or collapse from toxaemia; in the second stage, from infection, internal complications, ulceration of the duodenum, etc. ; in the third stage, from exhaustion or intercurrent maladies. The prognosis in children is always more unfavourable than in adults. Treatment. — In superficial scorches without vesication, all that is needed is to protect the affected parts, e.g., by dusting them over with boric acid powder mixed with starch, or by painting them with collodion. Blisters, when present, should be washed antiseptically and then punctured, so as to allow the contained serum, which always contains bacteria, to escape; the separated epidermis should then be cut away, and a picric acid dressing applied, when the burnt area is not too extensive; a piece of steriHzed gauze or lint is soaked in a sterilized solution of picric acid (2 grains to i ounce), and apphed to the burnt surface, and over this a pad of sterilized wool. Thus a dry dressing is produced, which may be left in situ for some days, when it is reapphed. The results are usually most satisfactory. Where the burn includes deeper structures, the clothes must be removed with as httle dragging as possible, being cut away if necessary; the damaged tissues are then bathed with some anti- septic, such as sublimate lotion (i in 2,000), and covered up as rapidly as possible with sterilized lint or gauze soaked in eucal5^ptus- oil or weak carbohzed oil (i in 40). In some cases, where the skin and surface are exceedingly dirty, it is well to anaesthetize the patient, cut away parts which must obviously slough, and purify thoroughly the wound, which is covered with protective and dressed with cyanide gauze or some such material. In very extensive burns caution must be exercised in the use of poisonous antiseptics, such as carbolic acid or corrosive sublimate, or serious toxic effects may be produced. If the patient is in a state of shock, he should be put to bed and covered with warm blankets or rugs, whilst perhaps a little warm stimulating fluid is administered, and a dose of morphia given hypo- dermically; in bad cases an intravenous injection of hot sahne solution is advisable, and it may often be repeated with advantage. In the case of children with very extensive burns, it is sometimes useful to put them into a hot bath, to which some eucalyptus-oil, if obtainable, or Condy's fluid, has been added; the clothes are then 128 A MANUAL Ol- SURGERY removed or cut away, and the patient allowed to remain for some time, or until the shock has subsided, in the warm water, which should be replenished, if necessary. It may be desirable to repeat the inmiersion at every dressing. The wounds are then dressed, and the little patient removed to bed, where special attcnti(jn must be directed towards maintaining tlie bodily heat, as, e.g., by placing electric lights under the l^lankets which cover a cradle placed over the patient. When a limb has been hopelessly charred or burnt to the bone, it is useless to retain it, and early amputation through the nearest healthv tissues should be undertaken. During the stage of inflammation and siougliing the only requisite is to keep the parts as free from infection as possible, assisting the natural processes of repair by warm moist applications, and snipping away sloughs as they loosen. Subsequently the wounds are treated on general principles. The granulations often become prominent, and stimulating applications, such as touching them with nitrate of silver, may be necessary. In large wounds, healing should be assisted by skin-grafting, according to Thiersch's method, in order to pre\'ent the wound becoming chronic. A similar proceeding should be undertaken in burns which involve the flexures of joints, so as to avoid subsequent contractions. PLATE III. Fig. 21.— Typhoid bacilli, showing flagella. Van Ermengen's stain. Fig. 22. — Tubercle bacilli in sputum. Carbol-fuchsin and methylene blue. Fig. 23. — Tetanus bacilli, some showing spores : from a culture. Stained by carbol-fuchsin and methylene blue. Fig. 24. — Anthrax bacilli in blood. Gram and eosin. Fig. 25. — Leprosy bacilli, in cells from the spleen. Carbol-fuchsin and methylene blue. Fig. 26. — Bacillus coli in urine, with a few pus cells. Methylene blue. [To face page 128. CHAPTER VIII. SPECIFIC INFECTIVE DISEASES. Erysipelas.* Erysipelas is a contagious infective disease due to the development of the Streptococcus pyogenes in the smaller l}-mphatics of the skin and occasionaUv of mucous membranes, with a decided tendency to spread and to recovery without loss of tissue, the constitutional svmptoms being due to the absorption of toxins developed locally. OccasionaUv the subcutaneous connective tissue is also involved, constituting the varietv known as cellnlo-cutaneoiis erysipelas. There has been considerable discussion as to whether there is any difference between the erj-sipelas microbe and the ordinary Strepto- coccus pyogenes found in spreading suppuration, but it is now gener- allv admitted that thev are identical. The explanation of the dillerences in the clinical history and infectiousness between erysipe- las and other conditions due to the development of 5. pyogenes is probably to be found in the method of invasion and in the differing virulence of various strains of the organism, but the subject is not yet fully understood. The Causes of ervsipelas may be briefly stated as follows: (i.) The existence of an abrasion or wound in most cases, and particularly of an unprotected dirtv wound. Thus, it is not uncommon to find it associated with neglected scalp wormds or with those communi- cating \\A\h the mouth. In the so-called idiopathic erysipelas the wound may be verv minute, such as a prick or scratch, or there may be no ob^-ious wound at aU, infection occurring through a hair foUicle in healthy skin, (ii.) A weak, depressed state of the constitu- tion, as from alcoholism, deficient or bad food, vicious li\ang, diabetes, albuminuria, etc. Some people, moreover, seem naturally predisposed to the disease, particularly plethoric and gouty indi- viduals, and one attack renders the subject more liable to recurrence after a short period of immunity, (iii.) Bad hygienic surroundings * It is becoming more ttian ever doubtful wliether erysipelas is to be looked on as a specific infection. Careful bacteriological examination is indicating that other pyogenic organisms than the streptococcus may be responsible for its appearance, and it is probable that hereafter we may have to relegate it to the chapter dealing with non-specific infections 129 9 I30 A MANUAL OF SURGERY are a most important additional factor in its production, especially overcrowding in hospitals and defective ventilation. But these are all merely predisposing conditions; the only exciting and absolute cause is — (iv.) infection with the particular micro-organism. The Symptoms of the disease are usually ushered in by a period of headache and malaise for about twenty-four hours. These symp- toms are followed by a slight rigor, well-marked pyrexia, and the development of the rash, spreading either from the margin of the wound, or showing itself in apparently unbroken skin in the so- called idiopathic variety. If there is a wound, it usually presents a yellowish, unhealthy-looking surface, with very little evidence of repair. In an unmixed infection the healing process may continue until the rash appears on the third or fourth day, when the young cicatrix will break open again, exposing a dry and sluggish surface with a thickened margin. The rash is generally of a characteristic vivid rosy-red colour, disappearing on pressure, and accompanied by a sensation of stiffness or burning, scarcely amounting to pain, except when dense structures, such as the scalp, are involved, and then the pain may be severe. Swelling is not marked, except in lax areolar tissues, such as in the scrotum or eyelids; the oedema may then attain considerable proportions. The rash continues to ad- vance more or less rapidly, with a continuous slightly raised margin, and as it spreads to new regions it fades away from those already involved, leaving a slight brownish stain and a fine brann\' des- quamation. In some cases it does not spread regularly, buL appears to leap over an interval, and then the intervening lymphatics are found to be thickened. Vesicles and bullae foiTn superficially, con- taining serum, which speedil}^ becomes turbid, but suppuration is uncommon, except in lax oedematous tissue, such as the e^'elids. Occasionally, from the severity of the inflammation or the low state of vitality of the tissues, the skin may become gangrenous and slough, especially about the umbilicus and genitals of young chil- dren. Neighbouring lymphatic glands are always enlarged and painful, and this may even be noted at a period when the rash has not appeared. Periphlebitis may also be caused, leading to pyaemic complications. Fever is present as long as the rash persists, and merely shows slight diurnal variations. It is not uncommon for the temperature to rise to 104° F., but anything above that is of grave significance. At first the fever is of a sthenic type, the pulse full, and the delirium noisy and active; but later on the pulse becomes quick and weak, accompanied by low, muttering delirium and great prostration of the vital powers. Delirium is usually a well-marked feature in erysipelas of the scalp, but this is due to the general rather than to any local condition, unless meningitis supervenes. Leucocytosis is moderate in degree (15,000 to 20,000 leucocytes per cubic millimetre). The duration of the attack is most variable, lasting, as a rule, from one to three weeks, but relapses are not uncommon. The swelling of the part does not always clear up entirely, owing to persistent blocking of lymphatics; when repeated SPECIFIC INFECTIVE DISEASES 131 attacks occur, this swelling may become so great as to constitute a fonn of elephantiasis. The so-called Idiopathic Erysipelas mainl\' affects the head, and occurs in predisposed individuals, often recurring about the same time of the year; pain and delirium are prominent symptoms, and the subcutaneous tissue of the face becomes so swollen that the features are almost unrecognisable. Large blebs form, and ab- scesses are not uncommon about the eyehds. Cellulo-cutaneous Erysipelas is due to infection of the subcu- taneous tissues as well as of the skin with the specific virus, and results in suppuration and sloughing both of the skin and subjacent cellular tissue. To the ordinary phenomena of erysipelas are added a diffuse infiltration of the subcutaneous tissues, brawny at first in t\-pe, but subsequently softening and becoming boggy, the skin finally giving wa}-, and allowing exit to the pus and sloughs. The general s\Tiiptoms are correspondingly severe, and pyaemia may supervene. As distinguishing features from ordinary erysipelas, it it stated that the margin of the redness is less defined, and that the lymphatic glands are less enlarged. Erysipelas of the Scrotum, or, as it is sometimes termed, ' acute inflammatory oedema, ' is characterized by the part becoming greatly distended by serum, but wdthout an\' marked redness. Suppuration and sloughing are not unlikety to follow^ It thus somew'hat simulates the appearance produced by extravasation of urine, but is distinguished from it by the facts that micturition is usually not interfered wnth, and that the swelling is not limited in the same way as in the latter aft'ection. Pathological Anatomy. — On microscopic section of the affected skin, colonies of cocci arranged in chains will be found invading the lymphatics just beyond the spreading margin, w^hilst in the inflamed area there is a considerable excess of leucoc}i;es, blocking the l^-mph- atics, and e\ddently engaged in the destruction and removal of the cocci, since phagoc\i;ic inclusion of the organisms is frequently observable. The lymph glands will also be found enlarged and congested. Fatal cases merely show the ordinar}^ post-mortem signs of death from a general toxsemia (p. 91). Diagnosis. — There is not much difficulty in recognising a case of erv'sipelas, if the distinguishing features of the rash are remembered, viz., its method of extension by a broad, sharply-defined, slightly raised and infiltrated red margin, and its almost invariable associa- tion \Ndth superficial vesicles, perhaps visible only on examination with a lens, or wdth obvious pustules or bullae. Aninfected wound with pent-up discharge closeh' simulates erysipelas; but the redness has not such an accurately defined margin and does not spread beyond the immediate neighbourhood of the wound; cutaneous vesicles are not usual in ordinary sepsis, whilst hTuphatic enlargement is uncommon. A patch of cellulitis will also be distinguished by the same features. Prognosis. — Erysipelas is not peculiarly dangerous in itself (Osier gives the death-rate as 7 per cent, in hospital patients), but may 132 A MANUAL OF SURGERY become so from the complications. The most important of these are inflammatory conditions of tlic brain, kmj/s, and otlier viscera, especially of tlie kidneys. Erysipelas is usually attended with danger to life in old people, drunkards, and infants, whose vital powers become rapidly exhausted. It is interesting and important to note that, after an attack has passed, wounds, even if previously chronic and sluggish, often manifest marvellous reparative power, provided no other complication is present. Chronic lupoid and syphilitic ulcers may also rapidly cicatrize, and even malignant sores, especially sarcomata, have been known to be cured. Treatment. — Erysipelas is a notifiable disease under the Infectious Diseases Acts, 1889 and 1899, and the patient must be isolated or removed if possible from a surgical ward. If unfortunately this is impracticable, the patient must be placed as far away from others as possible, and especially from those with open wounds, which from their position {e.g., the mouth) cannot be properly protected from in- fection. It is wise under these circumstances to put off all operations that can be safely postponed; the bed should be surrounded with sheets kept moist with carbolic lotion, and the floor around sprinkled with the same. Special nurses and dressers must be told off to attend to the case, which should never be dressed with ungloved hands. Local Treatment is concerned with two chief objects, viz., to check the spread of the disease, and to cure the locahzed outbreak, (i) Anything that will determine a local accumulation of leucocytes in the skin beyond the spreading edge should be beneficial in checking its advance, and perhaps the best and simplest method of effecting this is by painting over the health}' skin w-ith two or three coats of liniment of iodine (the tincture is not strong enough), and repeating this daily until the disease has disappeared. Kraske's plan of scarifying the skin all round at a distance of an inch or two from the spreading margin, the knife just going deep enough to draw blood, acts in a similar manner and is effective; but it is painful and requires an anaesthetic. (2) Where tension and pain are severe, fomentations containing opium or belladonna {e.g., i ounce of laudanum to i pint of lotio plumbi) may be applied; but the best local applications are ichthyol or thiol, the latter being an artificial sulphur compound much resembling ichthyol, but without the objectionable smell. A 20 to 40 per cent, aqueous solution is painted over the affected area several times a dav until the fever disappears; a subsidiary advantage of this treatment is that the stickiness of the preparation hinders the diffusion of the virus. In cellulo-cutajieons erysipelas early and free incisions must be made to relieve tension, and, if possible, anticipate suppuration. The tissues, when incised, look gelatinous from the oedema present, and much fluid of a sero-purulent type will escape. Antiseptic fomentations should be employed after the incisions have been made, until granulations have developed. Constitutional Treatment must be of a tonic and supporting character. Good food, easy of assimilation, and quinine, should be SPECIFIC INFECTIVE DISEASES 133 freely administered, whilst the tincture of the perchloride of iron in J-drachm doses, repeated three or four times a day, is still looked on b}^ many as a specific. The latter drug must be combined with salines or purgatives, so as to avoid constipation. Antistrepto- coccic serum (p. 27) should be employed as early as possible, 10 or 15 c.c. of the polyvalent serum being given subcutaneously as a dose, and repeated once or twice a day. The results, however, have not been as satisfactory as was originally expected. Diphtheria. Diphtheria is an infectious disease, characterized by a fibrinous exudation which is closely incorporated with the superficial layers of the tissues affected, and results in a peculiar form of toxaemia. It usually involves the mucous membranes, particularly those of the pharynx, larynx, and nasal cavities; occasionally it attacks open wounds, the skin, conjunctiva, and the genitals. It is due to the Bacillus diphtheric^ (or Klebs-Loffier bacillus), which is a non-motile organism about 3 /x in length. It grows on all ordinary culture media, but most readily in the presence of blood-serum. It is Gram-positive, and often stains unevenly. The laboratory diagnosis of diphtheria depends chiefly on the recognition of the organism in the exudate and its cultivation. The process usually adopted is as follows: The outfit necessary consists of a culture- tube of blood-serum and a sterilized cotton- wool swab in a test-tube. If the throat is to be examined, the patient should be placed in a good light, and, if a child, securely held. The tongue being depressed, the cotton-wool swab is with- drawn from the test-tube, and gently rubbed over any visible mem- brane. The plug is then withdrawn from the culture-tube, and the swab lightly wiped over the surface of the blood-serum. The swab is then replaced in its tube, and both tubes plugged. The culture- tube is incubated at 37° C. for twelve hours, and then examined; if the Klebs-Loffler bacillus is present, a growth of small, opaque, white colonies, slightly raised above the surface, will appear. Direct films may also be made from the swab and stained. The operator must always be on his guard lest the patient cough pieces of membrane, etc., into his face during the operation. The serious feature of an attack of diphtheria is the absorption of the diphtheria toxin, for the bacilli are almost always localized. The toxin is an exotoxin, and not only produces fever, but also has a marked action on motor nerves, "thereby producing paralysis. This is most often shown in the palatal, orbital, and ocular muscles, but may affect the muscles of the trunk and limbs. Cardiac weak- ness is common, and is partly due to degeneration of muscle, and partly to action on the vagus. The toxin has considerable poisonous effect on the kidneys, and albuminuria is common. The character of pharyngeal and laryngeal diphtheria is treated of under their respective headings. ' 134 A MANUAL OF SURGERY Treatment. — The most important point is the administration of antitoxin, in doses of from 4,000 to 50,000 units. The unit is the amount of antitoxin which, injected into a guinea-pig of 250 grammes weight, neutrahzes 100 times the minimum lethal dose of toxin of standard strength. In addition, local antiseptics are useful, and in laryngeal cases, where dyspnoea occurs from obstruction of the larynx bv membrane, tracheotomy or intubation may be necessary. Tetanus. Tetanus is a local infective disease, due to the BacilUts tetani, associated with a characteristic toxaemia. The bacilli or their spores are found to be very widely disseminated, and, indeed, are present in almost every sample of garden or field soil ; they have been found in the grime on a working man's hand and on dirty surgical instru- ments. Great difficulty was experienced in isolating the bacillus, but at last Xicolaier and Kitasato succeeded, by heating the pus from an infected wound to a temperature of 80° C. for an hour, thereby destroying all the pyogenic organisms. It occurs in the form of dehcate straight rods, which sometimes grow into long threads. It is a strict anaerobe, ceasing to grow if the smallest trace of oxygen is present, and is usually cultivated in an atmo- sphere of hydrogen or nitrogen; no gas is produced by its growth. It forms characteristic spores which are nearly spherical in shape and situated at the extreme end of the bacillus, giving it the appear- ance of a drumstick (Plate III., Fig. 27); these appear both in the pus of the wound and in cultures. It stains by Gram's method and possesses numerous flagella. The bacilli themselves are not powerful parasites, and when separated completely from their toxins often fail to cause infection, even when injected into susceptible animals; should, however, a minute trace of toxin be present, it so depresses the vitality of the surrounding tissues that the bacilH continue to grow and produce more toxin. .ajtiology. — The causative organism is a facultative saprophyte — i.e., is capable of continuing its development apart from the body — and is almost constantly found in garden soil, stable refuse, and dust or dirt of any kind, those, therefore, who are likely to be much brought in contact with the ground — e.g., negroes and agricultural labourers — are specially liable to the disease, owing to their more constant exposure to infection. Horses, also, are peculiarly sus- ceptible to tetanus, and the bacilli are usually present in their faeces; hence stablemen and others brought into contact with horses are attacked with comparative frequency. The disease is more frequently seen in the tropics than in other climates, probably owing to the heat favouring the development and virulence of the organisms in the soil. The existence of a wound can almost always be demonstrated, and it is usually of a dirty, lacerated or punctured character, and suppuration is generally present. Any part of the body may be SPECIFIC INFECTIVE DISEASES 135 tluis affected, but perhaps those regions, such as the sole of the foot or the pahn of the hand, which are likely to be brought into contact with the soil, are most often involved. Serious street accidents, especially those due to tramcars and motor vehicles, are only too likely to" be followed by tetanus. The depressed vitality of the tissues ownng to the bruising and tearing, the irritation caused by the growth of pyogenic organisms, and the absorption by the latter of any oxygen" present, thereby determining a condition of an- aerobiosis, co-operate in favouring the development of the tetanus baciUi. Hence it is rare for the disease to affect wounds where asepsis has been maintained and rapid repair has been effected, and it is very uncommon, though possible, for it to develop after blows or bruises with no breach of surface. Gunshot wounds due to blank cartridges are often followed by it, since the injun,- is largely due to the wad, which is made of coarse horsehair felt, and is there- fore hkely to contain spores of the bacillus. Commercial gelatin, derived from the hoofs, etc., of horses, often contains the bacilh, and the injection of this substance in the treatment of aneurisms has been followed bv this disease. Pathology.— Tetanus forms the best example in pathology of a local infection with general toxsemia. The bacilli remain locahzed in the neighbourhood of the wound, and do not enter the blood or reach distant parts of the body. The toxins produced locally act on the cells of the central ner^-bus system in a manner very similar to strychnine. There is, however, "a very^ unusual feature in the mode of passage of the toxin from the local lesion to the brain and cord, in that it appears to travel in the ner\'es themselves, and not in the blood, as in other infections. One or two of the proofs that have been advanced in support of this theory may be quoted. Tetanus mav be caused by the injection of a very small dose of toxin directlv into a nerve, whereas the animal may resist the injection of four or five times this am.ount into a muscle; and if the ner\'e is cut between the site of inoculation and the central nervous system, the spasms may be delayed, or even prevented altogether. This may explain the beneficial effects which sometim.es followed the now abandoned operation of ner\-e stretching or section in tetanus. Further, the toxin can be demonstrated in the ner^-es themselves, since they give rise to tetanus when introduced into a susceptible animal. The post-mortem anatomical changes are not characteristic. The muscles are often pale, or show e\adences of rupture or extravasa- tion of blood. The peripheral ner^^es extending from the wound may be red and congested for some distance: this may not be due to the action of the toxin (which appears to produce no demonstrable lesions of the nerves themselves), but to p3^ogenic inflammation. The nerve-centres frequentlv present areas of softening and pen- vascular cellular exudation, \\-ith some hyperemia, especially m the pons and medulla. Degenerative changes may also be evident m the ganglion cells of the cord. 136 A MANUAL OF SURGERY Clinical History. — Acute Tetanus usually manifests itself in this country two or three weeks after infection, but sometimes abroad as early as a few^ hours or days. The causative wound is usually suppurating and looks unhealthy, but when infection is delayed it may be healed. The patient generally complains first of a diffi- culty in opening the mouth, associated with a cramp-like pain in the muscles of mastication and of the neck. This soon becomes so marked that it may be difficult even to insert a paper-knife between the teeth {trismus, or lock-jaw), causing great difficulty in the ad- ministration of food; to it is added a fixed and rigid condition of the muscles of the back of the neck and of the face, the latter producing a curious grin-like appearance (risus sardonicits), whilst dysphagia is sometimes caused by spasm of the pharyngeal muscles. A con- siderable degree of fever is often manifested, but in some cases an apyrexial course is maintained until nearly the end. The spasms soon extend to the trunk and extremities, accompanied by cramp- like pains, and when fully established they may be excessively pain- ful and violent, and the remissions between them but partial. For- tunately, the disease usually involves the respiratory' muscles late in the attack. The more severe spasms can be excited bv any form of stimulus, such as the slamming of a door, a draught of cold air, or some voluntar}^ movement, and are ahvays of a tonic {i.e., con- tinuous) character. The body is contorted in various directions, and respiration may be much impeded by the fixation of the thorax. Occasionally the body is arched backwards {opisthotonos) bv the con- traction of the muscles of the back, the recti abdominis being firm and tense- — ' as hard as boards ' ; sometimes it is doubled forwards (emprosthotonos), and in rare cases laterally {pleurosthoionos). The muscles may contract so violently as to be ruptured, whilst teeth have been broken and the tongue has been almost bitten off. The intellectual faculties usually remain clear to the end, which is gener- alh' due to exhaustion from a repetition of the convulsions, or more rarely to asphyxia induced by a prolonged fixation of the respiratory muscles. Before death the temperature sometimes runs up to io8°, or even, in one case, to 112""' F., and it often continues to rise for a degree or two after death ; such hyperpyrexia is mainh^ due to the continuous muscular contractions. The surface of the body is bathed in sweat, and the urine is scanty, and occasionally albu- minous. Death may occur in twent^'-four hours from the onset of the disease, or not for four or five days. Chronic Tetanus usually begins later after infection, is less severe in its symptoms, and more likely to be recovered from. The course is usually afebrile, and the spasmodic contractions mav be limited to the wounded part of the body whence the infection has arisen, or may be general. Sometimes the patient lies in bed with his jaw partially fixed, and the muscles of his neck, back, and abdomen rigidly contracted, but with none of the characteristic convulsions. A special and uncommon variety known as cephalo-teianits, or T. paralyticus (German, kopf -tetanus), follows injuries within the area SPECIFIC INFECTIVE DISEASES 137 of distribution of tlic cranial nerves, and especially those about the supra-orbital margin. It is characterized by the association of trismus with facial paralysis on the affected side, and for a time this may constitute the whole picture, so that the patient may walk to see the doctor; but later on the usual tonic spasms occur in other parts of the body, and other cranial nerves may become paralyzed, especiall}^ the third, leading to strabismus. Spasm of the muscles of deglutition and attacks of maniacal frenzy are sometimes present, and hence the name T. hydrophobiciis which has been applied to it. Diagnosis. — In the early stages tetanus must be distinguished from simple trismus arising from dental irritation, or from inflamma- tory ankylosis of the temporo-maxillary joint. This may be readily accomplished by noting that rigidity of the neck muscles is also present in tetanus. Strychnine-poisoning leads to a very similar group of symptoms, but is recognised from tetanus by the contrac- tions being more sudden and violent, the relaxation of the muscles between the spasms complete so that the mouth can readily be opened, whilst the hands are involved in the contractions, a rare sign in tetanus, and the muscles of mastication often escape. No difficulty should be experienced in distinguishing tetanus from hydrophobia, owing to the very different nature of the convulsions in the latter case — i.e., clonic and not tonic; moreover, they affect the muscles of respiration and deglutition, whilst the history of the case, the early hallucinations, and the absence of tonic muscular contractions, are also characteristic features. Laboratory methods are usually unnecessary for the diagnosis of the disease when developed, but in case of doubt the best method is to collect some of the discharge from the deeper portions of the wound, dilute it with broth, and divide it into two parts: one of these is to be injected into a mouse or guinea-pig, whilst the other portion is mixed with i c.c. of tetanus antitoxin and then injected into another animal. If the former animal develops tetanic symptoms, whilst the latter escapes, the diagnosis is assured. The Prognosis is unfavourable in any case, but the longer it lasts, and the lower the temperature, the more likely is the patient to recover, whilst an acute onset, hyperpyrexia, sleeplessness, de- lirium, and strabismus are bad signs. The length of the incubation period is also a most important factor; for even when antitoxin is administered, the mortality in cases with an incubation period of less than ten days is at least 20 per cent, higher than when the appearance of the disease is delayed to a later period. Treatment. — In places where tetanus is known to be rife, it is a wise precaution to administer antitetanic serum as a preventive or immunizing agent in cases of wounds or abrasions that might pos- sibly be infected, especially if due to street accidents, or if suspicious bacilli are found on microscopic examination of a scraping from the deeper parts of the wound. The dose need not be large (1-5 c.c). After the disease has appeared, the originating sore, if accessible, should be freely excised and the wound cauterized, or the hmb may 138 A MANUAL OF SURGERY be amputated; ]>ut even tlion convulsions may persist for a time, or prove fatal, from the amount of toxin already in the system. In addition to these local measures, the specific antitetanic serum, prepared from the blood-serum of an immunized animal, should be injected (p. 27). The serum is purely antitoxic, and has no effect upon the development of the bacilli, for the destruction of which local phagocytosis or other immunizing action has to be relied on. Any toxin circulating in the blood is readily destroyed or neutralized ; but inasmuch as the toxin travels by the nerves and rapidly unites with the protoplasm of the nerve-centres, and then cannot be influenced by the antitoxin, the results of its use are often disap- pointing. The treatment should always commence with a large dose, and smaller amounts should then be administered once or twice a day, varying with the severity of the symptoms; 20 to 30 CO. may be given as the initial subcutaneous injection, followed by doses of to to 15 c.c. twice a day. It is better, however, to intro- duce somewhat smaller doses into the veins, or into the subdural space after lumbar puncture. Intracerebral injections have been discontinued owing to the risks associated therewith, but there is no objection to ' blocking ' the passage of toxins up the main nerves in early cases by injecting them with antitoxin. Another plan of treatment, suggested by Baccelli, consists in the hypodermic injection of carbolic acid; 10 or 15 minims of a 2 per cent, solution are injected two or three times a day, and although its action cannot be explained, yet the percentage mortality of cases treated in this way hitherto re- ported is certainly less than that accompanying the serum treatment. The patient should be kept absolutely quiet in a darkened room, and free from all sources of irritation. The spasms may be dimin- ished or almost abolished by the injection, either subcutaneously or by lumbar puncture, of a sterihzed solution of magnesium sulphate, which acts solely by reducing the excitability of the motor cells, and has no action on the tetano-toxin, fixed or free. The dose subcutaneously is 10 to 20 c.c. of a 10 per cent, solution every four hours; whilst intraspinally 2 to 4 c.c. of a 25 per cent, solution can be injected daily without ill-effect. Chloroform may be adminis- tered with the same object. Opium, chloral hydrate, bromide of potash, physostigma, and curare, have been vaunted as beneficial drugs, but probably cases which have recovered after their exhibition would have done so ^^^thout. Food should be nutritious, fluid, and unstimulating; it has been suggested to feed the patient twice a day by a stomach-pump under chloroform, or by a soft rubber catheter through the nose, but rectal feeding can be tolerated just as well, and, indeed, the patient must be given an abundance of normal saline solution by this route in order to help in the elimination of toxins and relieve his thirst. Hydrophobia. Hydrophobia is an acute general infective disease, transmitted from animals to men, especially from rabid dogs, cats, wolves, etc. It consists in an affection of the central nervous system, and one of its most marked features is the SPECIFIC INFECTIVE DISEASES 139 long and variable incubation period. It never originates idiopathically either in animals or man, infection usually following a bite; but if the teeth pass first through a garment, the virus may be wiped off, and the individual may escape. It has also been proved that if an infected animal merely licks an abraded surface the disease may be transmitted, even when the animal has not at the time shown any of the more typical signs of rabies. In the Dog, rabies manifests itself three to five weeks after infection, but the period varies considerably; the original wound usually heals perfectly, or there may be some inflammatory thickening about it. The disease commences with a stage of depression, which is manifested by snappishness and irrita- bility, especially towards other animals, by restlessness, and by the dog moping in dark corners, with a depraved appetite, eating any kind of rubbish or dirt, and even its own excreta. This period lasts for two or three days, and is perhaps the most dangerous, since there is nothing very suggestive about the symptoms. It is usually followed by a stage of paralysis, going on to death. During the whole attack the mouth is filled with ropy saliva, which the animal vainly tries to scratch away; the bark loses its ring and becomes hoarse, and as the disease progresses the lower jaw becomes para- lyzed ; finally, after partial or general convulsions, the animal dies five or six days from the onset. In a few cases a stage of maniacal frenzy occurs, when the animal runs ' amok ' and bites anything and everything that comes in its way. In Man the incubation period is most variable, lasting from days to months or years, but as a rale it does not exceed six weeks. During this interval the wound heals, although the scar may remain tender and neuralgic. The disease is ushered in by a vague sense of terror, with illusions of the senses and disturbance of the mind, lasting for about twenty-four hours. Restless- ness, sleeplessness, loss of appetite, and a repugnance to fluids follow, with perhaps some slight febrile disturbance. The more characteristic symptoms are inaugurated by a convulsive stiffness of the tongue, neck, and especially of the muscles of deglutition and respiration, which becomes more marked if any attempt is made to swallow. The typical convulsions are clonic in character, and thus differ from those of tetanus; they become more and more generalized, being brought on after a time by almost any afferent impulse, however slight — such as a blast of cold air, a flash of light, a sudden noise, especially such as is caused by the movements of fluids; swallowing is quite impracticable. The mouth is usually filled with ropy mucus, which is very difficult to remove. The respirations become catchy, and a loud hiccoughing noise may be pro- duced by spasm of the diaphragm, which is sometimes thought to resemble the barking of a dog. Finally, the convulsions may entirely cease, and the patient dies, retaining his consciousness to the end, the fatal issue being due to the destructive changes taking place in the medulla, or to exhaustion ; it may, however, occur earlier, from spasm of the glottis. The disease lasts about a week, but may be more rapid, killing even in two days. The Post-mortem Changes are mainly negative. Evidences of acute inflam- mation of the lower part of the medulla, including the centres for the gth, loth, and nth nerves, are observed on microscopic examination, the vessels being thrombosed, and the connective tissue infiltrated with leucocytes. The nerve fibres and ganglion cells may also be found degenerated. The salivary glands are always somewhat enlarged. The disease may be diagnosed in the lower animals by the recognition of the Negri bodies in the hippocampus major and cerebral cortex. They are minute cell-like bodies, consisting of a large or small central mass, or of a cluster of minute corpuscles, surrounded by a homo- geneous hyaline zone, around which there is a delicate membrane. These are found in nearly all cases of the disease, and are thought to represent a stage in the life-history of a protozoal parasite. They can be demonstrated in a few hours, and afford a means of detecting the presence of rabies in a dog without waiting for the results of inoculation experiments. They have also been found in man, and have been cultivated by Noguchi. Preventive Measures should be adopted immediately in all cases of bites from dogs which are either rabid or may possibly become so. The circulation in the t40 A MANUAL OF SURGERY limb should be arrested by a string or bandage, bleeding encouraged, and some powerful caustic, e.^'., j)ure carbolic acid, applied as soon as possible. A free excision of the part is, ho\ve\er, preferable. Pasteur's Preventive Inoculation is based on the discovery that the injection of an attenuated virus in increasing iloses, and in gradually increasing strength, protects an animal or individual from the disease, and will even catch up the poison already inoculated, and save the patient from its subsequent develop- ment, if too long a start has not been given. The method employed is as follows: A virus of constant and maximum intensity is first obtained by passing the poison from a dog through a series of rabbits, until the animal dies with regularity on the seventh day, all parts of the cord being then equally virulent. The material inoculated is olataincd by mashing up a por- tion of the spinal cord or medulla of the diseased dog in sterilized broth, and injecting it with a hypodermic syringe beneath the arachnoid after tre- phining. All that is now needed is to take a series of these virulent cords, and dry them by hanging in a glass bell-jar with some caustic potash at the bottom for variable periods, the virus being thus weakened in its intensity, until at the end of fourteen days it is completely destroyed. Indi\iduals are inoculated with portions of such cords, pounded up in sterilized broth, be- ginning with the weakest, and gradually increasing the strength of the injec- tion, until a preparation of a cord which has merely hung one day is used. This method of treatment was introduced in 1S85, and the results hitherto obtained have been such as to indicate that we have here a most potent pre- ventive agent a.gainst hydrophobia, granted that the disease has not been allowed too long a start. When the disease has attacked an indivitlual, only palliative treatment can l;e adopted. Every source of irritation and dis- turbance must be removed, and the patient kept absolutely quiet. With a view to diminish the spasms, chloral may be administered internally, or chloroform inhaled, or cocaine sprayed on the fauces. All the nourishment that the patient can possibly take should be administered, and preferably by rectum. Anthrax. This disease results from infection with the Bacillus anihracis, which pro- duces in sheep, cattle, and other animals the so-called ' splenic fever,' charac- terized by well-marked fever and enlargement of the spleen. In man, if the microbe is inoculated through the skin, it produces a local inflammatory swelling, known as a ' malignant pustule,' or a more diffuse condition termed 'anthrax oedema'; sometiines the latter follows the former. If the virus is absorbed by the lungs or intestinal canal, it originates a general inflammatory disorder, known as ' woolsorter's disease,' or anthracaemia. The B. anthracis (Plate III., Fig. 28) is one of the largest of the pathogenic organisms, measuring 5 to 20 ix in length, and i to i'50 yit in breadth. It is found in the blood of diseased animals in the form of rods or threads, com- posed of a variable number of individual elements (from two to ten). It is aerobic, immobile, grows best at about blood-heat, and liquefies gelatin. Well- marked spores are formed within the bacillus when cultivated artificially and in the presence of oxygen ; but spore-formation has not been observed in the living tissues. The bacilli are readily killed by boiling for a few seconds, whilst the decomposition of the carcass in which they are present causes their death in about a week. The spores, however, are very resistant ; for whilst a I per cent, solution of carbolic acid kills the bacilli in two minutes, the spores remain alive after a week's immersion. Moreover, alcohol and even a 5 per cent, solution of carbolic acid have no effect on them, unless acting for a long time. If a mouse is inoculated, say, at the root of the tail with a needle, the point of which has been dipped in the blood of an animal which died of splenic fever, it succumbs in less than twenty-four hours, and bacilli are found in nearly every organ of the body. Some animals are immune against the attacks of anthrax, especially the do^^, and rat; and one of Pasteur's most useful discoveries was that of ]irov din- artificial immunity for cattle and sheep by inoculating them with an SPECIFIC INFECTIVE DISEASES 141 atknuatfd virus, obtained by exposing a cultivation for some time to a high lfni[)cTaturc. Symptoms. — Infection with this organism usually occurs amongst graziers who tend the living animal, or butchers who deal with the carcass; it is also met with amongst workers in hides or wool. Malignant Pustule is usually seen on the face or forearm, and commences as an angry red pimple at the site of inoculation, which rapidly spreads, with much infiltration of the base, whilst the centre becomes covered with vesicles, the serum within which becomes blood-stained or dark brown in colour, and contains the typical bacilli. This stage is associated with no pain, but' only with great itching and irritation. As the pustule extends, the centre becomes gray, and finally black, constituting an eschar or slough, whilst around it upon an area of deep brawny congestion and oedema is a narrow ring of vesicles. The process gradually becomes more marked locally, whilst the lymphatic glands and vessels are also enlarged and involved in the disease. Generally, there is a certain amount of fever and malaise, which does not become pro- nounced until about the fourth or fifth day. The temperature then rises to 102° or 103° F., the pulse becomes rapid and irregular, and gastric irritability, vomiting, and flatulence more marked. Should the disease progress un- checked, the surrounding parts are involved in a rapidly spreading cedema; thus from the face it may extend to the neck, chest, and back. The respira- tions become shallow and embarrassed, whilst signs of grave constitutional mischief, such as delirium or coma, manifest themselves, and the unfortunate individual rapidly succumbs, generally in less than a week from the onset, but sometimes in thirty to forty hours. More commonly the case runs a more favourable course, limiting itself to the local manifestations, which gradually clear up, the slough separating and the oedema disappearing. Of course, should there be more than one focus of mischief, the prognosis is much worse. Anthrax csdema 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 a time covered with vesicles, whilst finally gangrenous patches appear. The lymphatic trunks and glands are also involved. The condition may be mistaken in the localized form for accidental vaccina- tion or a staphylococcic infection, but is recognised by the presence of the bacilli in the serum of the vesicles; in cases of doubt cultures should be made. Woolsorter's Disease (or anthracsemia) is the term applied to the general condition resulting from the development of these bacilli in the body without any external lesion. The virus gains access to the system by either sv/allowing 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 of bacilli. This runs a rapid course, with high fever, great dyspnoea, impairment of the circulation, and finally collapse in a great majority of the cases. 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 breeding-ground, and the walls of the gut are soon attacked and the disease becomes general. Colic, cramps, vomiting, and blood-stained diarrhoea are the most marked features in such a case. The intestinal type appears to be not quite so virulent or fatal as the pulmonary, but is decidedly worse than the cutaneous. Treatment. — In the cutaneous 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, used to be recommended, though those who have had much experience of the affection think such treatment of little value, and trust in fomentations for the localized variety. Several sera (p. 28) have been introduced for the treatment of anthrax, and good results have been obtained, especially in the localized forms of the disease. Sclayo's is most used; it is obtained by immunizing asses or goats with Pas- teur's vaccine (p. 15), followed by injection of large doses of virulent cultures. The dose is 20-40 c.c. (340-680 minims), repeated in twenty-four hours, if 142 A IVANUAL OF SURGERY necessaiy; in severe cases tlic lirst dose may be injected intravenously. Sobcnhciin's serum is prepared in a ditierent way, and also Rives good results; the dose is the same. The use oi either serum may be followed by fever and sweating, and improvement is often very rapid. They appear to stimulate phagocytosis. Gonorrhoea. Gonorrhoea is an infective process due to the action of a specific micro-oig inism, the Gonococcus or Diplococcus gonorrhnece (Plate I., Fig. 3), and characterized (in its commonest form) by a discharge of pus from the urethra. The organism is a diplococcus, and each coccus of the pair is usually kidney- or bean-shaped, and the two lie with their concave borders facing one another. Single cocci and tetrads sometimes occur. It is not easily cultivated, and hccmo- globin is necessary for its growth ; the simplest method of preparing a suitable culture medium is to spread some sterile blood on the surface of ordinary agar. The colonies are small and translucent, appearing like droplets of dew. Such cultures set up gonorrhoea when injected into the human urethra, thus proving the causal rela- tion of the organism to the disease, as all of Koch's postulates are fulfilled. The lower animals are all immune. The gonococcus does not stain by Gram's method; this fact is of great importance in diagnosis, since most of the diplococci with which it might be con- founded retain the stain. It occurs in large quantities in the pus from a gonorrhoeal lesion, and in most cases it is found within the polynuclear leucocytes. This is very characteristic, as also the fact that, whilst most of the cells are usually free from organisms, those that are invaded by cocci contain them in abundance (see Plate I., Fig. 3, in which some of the cells are free from gemis, but in others the diplococci can be seen clustered round the poly- morphous nuclei). The pus also contained desquamated epithelial cells, in or on which many cocci may often be seen. The laboratory diagnosis of gonorrhoea does not usually in\"olve cultural methods, but can be made by an examination of stained pus-films. The best way is to stain by Gram's method, and to counterstain by dilute carbol-fuchsin. In this way the gonococci will be coloured red, whilst most of the other cocci with which they could be confounded are deep violet. The intracellular distribution of the cocci and the freedom of most of the pus-cells, whilst others are packed full of organisms, are points of great diagnostic value. Sometimes, however, most of the gonococci are extracellular. In the male the primary lesion is an acute catarrhal inflammation of the anterior portion of the urethra, which quickly runs on to suppuration, and is likely to spread back towards the deeper portions of the urethra, or even to the prostate, bladder, or epididymis. These lesions usually constitute the whole of the disease, but in some cases the gonococci enter the blood-stream and affect distant organs. The joints are most frequently affected, but occasionally typical pysemic phenomena supervene (gonococcaemia), with secondary abscesses and even ulcerative endocarditis. SPECIFIC INFECTIVE DISEASES 143 The Symptoms of Acute Gonorrhoeal Urethritis (male) usually com- mence within a few days of the infection, varying from two to eight. Most commonly the discharge appears about the third or fourth day, being preceded by itching of the meatus and a scalding pain on passing urine. The lips of the meatus are congested and swollen, and the discharge, which is at first thin and mucoid, soon becomes thick, abundant, and yellow in colour. This stage lasts for a variable time, and is sometimes associated with a good deal of dragging pain in the back and loins, together with some constitutional disturbance and fever. The bowels are usually constipated, and the appetite impaired. Occasionally the swelhng and congestion of the mucous membrane are so great as to lead to retention of urine or haemorrhage from the urethra. The first attack is always more serious than subse- quent ones, although it is often more amenable to treatment. Gouty and rheumatic people are especially difficult to treat, and relapses frequently occur after the discharge has apparently ceased ; it is said that fair people suffer more than those who are dark. If suitable treatment is adopted, the discharge entirely ceases at the end of two or three weeks; but if neglected, or sometimes in spite of treatment, the inflammation spreads backwards, giving rise to what is usually termed a Posterior Urethritis, since it involves that portion of the canal which Hes behind the deep constrictor. It generally becomes evident about the end of the second week, and is characterized by frequent and painful micturition, a sense of pain and hea\dness in the perineum, possibly a httle blood in the urine, and a general feehng of depression. This extension backwards is always serious, since it is hkely to be followed by comphcations in- volving the prostate, testis, or seminal vesicles, whilst it is an ex- tremely common cause of Chronic Gonorrhcea or Gleet, in which a more or less abundant discharge continues for some time without any other troublesome symptom than occasional scalding on passing urine. The discharge is often thin and muco-purulent, and may be so shght as merely to cause the lips of the meatus to stick together, or may only be evident on squeezing the urethra after a night's rest. This may last for a long time, even years, and it must be re- membered that even in this stage the disease can be transmitted to women. Gleet is sometimes due to an ulcerated or granular con- dition of some portion of the mucous membrane; the discharge is then yellow, and the urethra is tender on the passage of a sound; the presence of the ulcer or granular patch can be recognised by the urethroscope. In other cases gleet arises from chronic prostatitis, a condition not uncommonly associated with chronic enlargement of the vesiculce seminales. The latter condition may be recognised on rectal examination, whilst, when the prostate is involved, floccuh of mucus in the shape of worm-Hke threads may be detected in the urine, especially after massage of the gland by the finger introduced into the rectum. When the disease has lasted for a considerable time, or after repeated attacks, a certain amount of peri-urethral infiltration is 144 ^ MANUAL OF SURGERY certain to follow, and a stricture of the urethra may result : this may also be due to the cicatrization of the ulcerated and granular patches in the urethral wall, alluded to above. A routine examination of the urine in cases of gonorrhoea will often throw much light on the course and extent of the disease. In the acute stage 4 or 5 ounces are passed into one glass, and the remainder into a second ; if the anterior urethra is alone involved, the discharge will be swept out in the first few ounces, and the urine in the first glass is alone turbid, containing threads or small fiakes of pus. Involvement of the posterior urethra causes the urine in the second glass to be nearly as turbid as that in the first, and the co-existence of cystitis would make it even more turbid. In the chronic state, when merely a gleet is present, it is essential to wash out the anterior urethi-a with 5 or 6 ounces of boric acid solution, which are retained for examination, and then the urine is passed into two glasses, as suggested above. Unless this preliminary irrigation is undertaken, the stream of urine may wash out the discharge from the posterior urethra and invalidate the test. Examination by the urethroscope or endoscope is also necessary in cases of gleet. The instrument consists of a metal tube fitted with electric illumina- tion in such a way as to render visible the walls of the urethra, which are advisably distended with air by a bellows. A commencing stricture can be easily recognised, as also ulcerated areas, patches of granulations more or less poh'poid, etc., whilst suitable local treatment can also be undertaken. Every purulent discharge is not necessarily gonorrhoeal, since a simple urethritis may follow connection with a woman who is simply suffering from leucorrhoea, or has scarcely recovered from her menstrual period, but with no suspicion of a venereal taint. In these cases infection may be due to ordinary pyogenic cocci, or possibly to the B. colt communis, which is known to be not an un- I'requent cause of vulvo-vaginitis. A diagnosis of simple urethritis may be suggested by the history, but only a microscopical examina- tion of the pus, and a demonstration of the absence of gonococci, can establish it with certainty. It must be remembered, however, 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 a person who has once suffered from it may be capable of transmitting the disease, although no obvious evidence of its exist- ence is present. Moreover, a highly acid condition of the urine in a gouty patient, especially if loaded with uric acid crystals, may hght up into activity a urethritis which has been quiescent for some time. The practitioner is not unfrequently consulted as to the ad\asability of marriage after an attack of gonorrhoea; the cessation of the dis- charge is not sufficient to warrant such a step. The only safe test is to light up a fresh attack of urethritis by the injection of some chemical irritant — e.g., a solution of nitrate of silver (i in 100) — and to examine the discharge bacteriologically for the presence or not of gonococci. In the Treatment of the early stages of acute gonorrhoea it is essential to keep the urine free from acidity by the use of alkahes, to maintain a free action of the bowels, and to allay the irritabihty of the parts by sedatives, such as tincture of henbane. The diet should be hght and unstimulating, and all alcoholic drinks pro- hibited, as also strong tea and coffee, whilst the patient should be- SPECIFIC INFECTIVE DISEASES 145 recommended to drink 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 reheve 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 continues. As soon as these symptoms moderate, oleo-balsams in the form of oil of sandal-wood (10 minims, in capsules, three to six times a day), copa.iba (lo minims, in capsules or mixture, thrice daily), or cubebs (|- to I drachm doses, wrapped in wafer-paper), may be advan- tageously employed. Both, cubebs and copaiba, especially the latter, are capable of producing a bright red erythematous rash which causes much irritation, and may be extensively diffused over the body. The value of injecfloiis in the treatment of the disease has been much discussed, and is a point on which difference of opinion exists. On the whole, we are inclined to think that many of the less severe cases of acute gonorrhoea can be successfully treated without them, and that they should not generally be em.plo\'ed when marked local irritation or scalding is present; but when the discharge persists, or the urethra has become thickened by previous attacks, and especially in gleet, their use is imperative. To employ them with advantage, the following plan should be adopted: The urethra is first washed out, so as to remove any discharge from it; for this purpose the nornial act of micturition answers admirably, so that the injection should be used immediately after passing water. The rounded nozzle of a small glass syringe, containing about half an ounce, is inserted into the meatus, the lips of which are compressed over it. The fluid is thrown into the urethra, and held there for about twenty seconds by compressing the orifice with the linger and thumb, as the syringe is withdrawn ; then, on relaxing the pressure, the fluid escapes. Other forms of syringe, on the principle of the indiarubber bottle, etc., are recommended, but the glass is un- questionably the cleanest. Of the many injections employed, one of the best consists of a mixture of tincture of catechu (10 minims to I ounce of water) and sulphate of zinc (2 grains to i ounce) ; but solutions of permanganate of zinc (J grain to i ounce), or nitrate of silver (J grain to i ounce), or protargol (i per cent.), are also very effective. The great secret consists in using the injection four or five times a day at first, and afterwards night and morning, even after all visible signs of the discharge have ceased. The fluid should always be at a temperature of 100° F., and care taken not to use too strong a solution. One is bound to admit, however, that many genito-urinary surgeons hold views verj^ different to these, and, indeed, maintain that gonorrhoea can be aborted, or, at any rate, rapidly brought under control at any stage by large injections of a weak solution of permanganate of potash, introduced with sufficient force to distend 10 146 A MANUAL OF SURGERY the urethra in all its parts and enter the bladder; all the crypts and lacun;e are thus reached l^y the antiseptic. The Treatment of Gleet is always a matter of difficulty. The general habits of the patient must be attended to, as in the acute stage, whilst the bowels must be opened, and absolute sexual continence enjoined to prevent the spread of the infection. Large doses of the liq. ferri perchlor., combined with a sufficient amount of Epsom salts to guard against constipation, may be given. Local treatment is generally necessary in the shape of injections as already described, and the passage of a cold solid metal bougie every three or four days has sometimes an excellent effect. Methodical dilata- tion of the urethra is also advised so as to compress all the crypts and lacunae, and remove pent-up secretion. Massage of the prostate and vesicula; per recftini, once or twice a week, is also advisable when these parts are affected. Patches of granular urethritis must be treated topically by applications of nitrate of silver (beginning with a solution of i in i,ooo) through the endoscope. Should these measures fail, direct treatment of the posterior urethra by such reagents as solutions of nitrate of silver (i in i,ooo), or permanganate of potash (i in i,ooo), must be undertaken; perhaps the simplest method of effecting this is to pass a measured length of a rubber catheter into the urethra (about 7J inches), and then inject the fluid; this must be undertaken two or three times a week. Vaccine Treatment in Gonorrhoea and its complications has been proved to be of considerable value, though not so much for the treatment of the urethral discharge as for that of the complications. However, in some cases of a chronic gleet, or in the subacute stage when the discharge is slackening off, it may sometimes be used with advantage. In the gonorrhceal affections of joints, of the eye, or of internal organs, vaccines are most useful. The vaccine is prepared as described on p. 26, and the usual dose is from 100,000,000 to 500,000,000 dead gonococci. Complications of Gonorrhoea.^These may be conveniently ar- ranged under the following headings : I. Complications due to Direct Extension. — //; the male, the follow- ing may be described: Balanitis is of frequent occurrence in patients with long foreskins, and is ordinarily due to pyogenic organisms, and not to gonococci. As a secondary result, inflammation of the lymphatics of the penis and inguinal bubo may follow. Sometimes this inflammation results in the development of red papillomatous outgrowths, known as gonorrJural ivarfs, which are found mainly on the glans penis, but occasionally on the preputial margin (Chapter XLI.). Lacunar Abscess arises from infection of one or more of the lacunae with the gonococcus or accompanying pyogenic organisms. A tense painful swelling forms along the floor of the urethra, which may project into the passage and discharge either into the urethra, or externally, or both; in the latter case a penile fistula will result. The abscess should be opened as early as possible from without, so as to prevent the latter occurrence, which is often very difficult SPECIFIC INFECTIVE DISEASES 147 to treat. If a fistula forms within a short distance of the meatus— a common situation— it seldom heals of itself, but may in some cases be closed by an application of the electric cautery or a weak solution of nitrate of silver. If, however, it remains intractable, the fistula should be laid open into the meatus. When it occurs in the body of the penis, a plastic operation is usually required; it consists in paring the edges and dissecting up the skin on either side so as to bring it together in the median line. Chordee results from inflammatory infiltration of the corpus spongiosum or one of the corpora cavernosa, so that the penis, when erect, is bent downwards or to one side. It is exceedingly painful, and most marked at night when the patient becomes warm in bed. 'it is best prevented by the use of bromide of potassium or other sedative at bedtime, and when present may be treated by cold applications. Inflammation of Cowper's Glands may in some cases give rise to deep suppuration in the perineum, and unless treated eariy by incision may lead to a urinary fistula. Inflammatory conditions involving the prostate, seminal vesicles, epididymis, and bladder, and caused by gonorrhoea, are discussed elsewhere. 11. Complications arising from Direct Transmission of the Virus.— Gonorrhoeal Proctitis sometimes results in the female from infection by the discharge which escapes from the vulva, whilst in both sexes it may be due to unnatural practices. It is characterized by tenesmus and a thick muco-purulent discharge, and is treated by injecting lotions of acetate of lead and opium, or of boric acid. Gonorrhoeal Rhinitis has also been seen in a few cases. It leads to an abundant discharge of pus, and should be treated by warm soothing injections, followed after a time by dilute astringents. Gonorrhoeal Conjunctivitis occurs either in adults, when it is uni- lateral to start with, or in infants, when it is bilateral, and due to infection during transit through the maternal passages [ophthalmia neonatorum). It is a remarkable fact that, although gonorrhoea is so very prevalent, such a small proportion of the patients suffer from conjunctival infection; it would appear, therefore, that not only must there be direct contact with the gonorrhoeal poison, but in addition the mucous membrane must be in a receptive state. In the adult variety it is ushered in by redness and irritability of the eye, followed quickly by a discharge which is at first mucous, but soon becomes purulent. The eyehds are red and swollen, the con- junctiva is thickened and oedematous (chemosis), and the discharge hable to accumulate within the conjuncrival sac. If allowed to progress unchecked, ulceration or even necrosis of the cornea may ensue, and possibly general panophthalmitis. This is pre-eminently the commonest cause of bhndness in children. The first detail in the Treatment consists in protecting the opposite eye by means of what IS known as Buller's shield; a watch-glass is fixed in a piece of mackintosh over the eye, and kept in position by plaster. The affected conjunctiva must be unremittingly attended to night and day, so as to prevent accumulation of discharge; it is frequently 148 A MANUAL OF SURGERY irrigated with warm boric acid lotion, and every four liours after washing out with this, the membrane is dried and gently irrigated with a solution of nitrate of silver (5 grains to i ounce), followed by sterilized salt solution. Between the applications lint wrung out of iced boric acid lotion is kept over the eye. This plan of treatment is continued until the suppuration ceases, and then the silver salt is omitted, and simple astringents, such as chloride or sulphate of zinc, are substituted. In infants the disease often runs a rapid and severe course, and is very likely to lead to ulceration or sloughing of the cornea, a com- plication not uncommonly followed by escape of the lens and blind- ness. Crede's preventive treatment should always be adopted for new-born childern, viz., washing out the conjunctival sac with a weak solution of nitrate of silver {2 per cent.) or corrosive sublimate soon after birth. When suppuration occurs, the treatment to be adopted is practically identical with that detailed above, except that it is useless to attempt to limit the trouble to one eye. III. Complications resulting from General Absorption. — Gonor- rhoea! Affections of Joints are not uncommon sequelae, arising usually in the subacute stage of the disease. For clinical features and treatment, see Chapter XXIII. Gonorrhoea! Fibrositis. — Any muscular, tendinous, ligamentous, or aponeurotic tissues may become inflamed and painful during the course of an attack of gonorrhoea. Involvement of the ligaments supporting the arch of the foot is important, since, if the patient is still allowed to walk, the arch may be lost, and a permanent flat- foot result. Gonorrhoea! Sclerotitis, or inflammation of the deep subconjunc- tival fibrous tissue, is a rare affection, arising quite independently of gonorrhoeal conjunctivitis. It is characterized by marked sub- conjunctival redness, the globe of the eye becoming distinctly tender. Local applications of atropine are required, and, if need be. leeches to the temples. The pathology of the comphcations described in the last two paragraphs is uncertain. They are probably due to the presence in the tissues of a small number of gonococci of enfeebled virulence, or may be caused by toxins absorbed from the local lesion. A true Gonorrhoea! Pyaemia (gonococcaemia) occasionally develops, characterized by a formation of secondar}^ abscesses in various parts of the body, containing only the gonococcus. Tliey usually com- mence deeply, and at first are somewhat chronic, but subsequently the ordinary phenomena of suppuration supervene. They must be laid freely open, and as a rule heal satisfactorily, if slowly. Occasionally the cardiac valves become infected and inflamed, and an ulcerative endocarditis due to gonococci has been observed. More rarely a true septicaemic invasion has destroyed the patient by a generalized development of gonococci in|the blood. Gonorrhoea in Women is by no means uncommon, even apart from prostitutes, in whom it is more or less constant ; it is often overlooked SPECIFIC INFECTIVE DISEASES 149 or unrecopjnised, and is a frequent source of uterine and pelvic trouble. This is probably due to the fact that an uncured gleet in a man is not looked on as a bar to marriage. Occasionally the disease is contracted from the infected seat of a public water-closet, or from the use of infected towels, garments, etc. The primary lesion is usually either in the urethra or in the cervical endometrium, or in both. Vulvitis is by no means uncommon, but in the adult a gonorrhoeal vaginitis is unusual. Sometimes dis- charges from the cervix accumulate in the vagina and undergo septic changes, producing a simple vaginitis by the direct action of the bacterial toxins, but the gonococci do not attack the vaginal mucosa. In children a true vulvo-vaginitis occurs. The symptoms in acute cases are those of heat and burning about the genitalia, combined with a purulent discharge and painful mic- turition. The urethra can be seen and felt to be swollen, and its orihce is red and congested; on pressing it, pus escapes. If the cer- \ax is involved, the uterus becomes congested and painful; severe backache is noticed, and perhaps some tenderness on hypogastric pressure, with a blood-stained discharge. In the more chronic cases nothing may be noted except that the periods are painful, and that there is a certain amount of leucorrhoea, with occasional attacks of discomfort and frequency in micturition. In all cases the inflammation is likely to spread, either to the bladder, or up the uterus to the Fallopian tubes (salpingitis), ovaries, or peritoneum. In the latter case the inflammation may be local- ized, producing adhesions around the fimbriated extremities of the tubes, and these are often an important cause of sterilit3^ Occasion- ally a more generalized peritonitis results {q.v.). Treatment consists in the use of frequent mild antiseptic douches {e.g., lysol, I in 2,000), and in measures directed towards the urethra or cervax. When there is much urethral swelling and discharge, the diet is regulated and alkalies ordered, as for men ; balsams may be useful, and even injections. In the later stages the shortness of the urethra pennits topical applications of nitrate of silver to be made readily, and it is unusual for the inflammation to persist for long. In gonorrhoeal endocer\Tcitis the parts should be thoroughly cleansed by douching, and then a 10 per cent, solution of nitrate of silver applied through a speculum. Soft Chancre {Ulcus Molle). A Soft Chancre is a local infective disorder, which is rarely seen elsewhere than on the genital organs, and is almost invariably the result of impure connection. It is due to a specific bacillus, which was first described by Ducrey, and occurs in the form of short chains consisting of extremely slender rods, which do not form spores or stain by Gram's method. The organism has been cultivated, though With, difficulty, and there appears to be no doubt as to its causal relation to the disease, though ordinary pyogenic organisms are often present as well. If artificially inoculated, a typical series of I50 A MANUAL OF SURGERY events ii)lknvs. A red papule appears in twenty-four hours, whilst in two or three days a vesicle, surrounded by a zone of angry hypenemia, is seen. The serum witliin the vesicle soon becomes turbid, and by the fourth or fifth day a fully-developed pustule is present; as soon as the cuticle is lost, an ulcer forms with cleanly-cut edges and a sharp, distinct outline. The chancre gradually increases in size up to a certain limit, and then if kept clean heals in about three weeks. Such sores may be met with on any part of the penis, but more especially on the prepuce and glans, or on the corona glandis, and are very painful and tender. The secretion is highly infective, and if inoculated elsewhere on the patient produces a typical sore, showing that the condition is purely local, and that no constitutional immunity results from its presence. The discharge from a true syphilitic chancre may produce a localized pustule on auto-incjcula- tion, but no typical sore. Frequently several soft sores are present at the same time, and the discharge from one chancre is very likely to produce a similar affection (' satellite ' chancre) on any cutaneous or mucous surface brought into contact with it; e.g., it may spread from prepuce to glans, or vice versa, or from one lip of the vulva to the other. It is a curious but well-authenticated fact that soft chancres are rarely seen on any part of the body other than the genital organs. Various Modifications of the typical chancre are seen, usually re- sulting from neglect or carelessness on the part of the patient. Thus, if a long foreskin is present, the discharge may be retained behind it, and extensive ulceration occur, which may even result in the glans protruding through the upper part of the prepuce, which drops beneath it. If the fra^num is involved, haemorrhage may supervene from ulceration into a branch of the artery found in that structure. When there is much inflammation, the base of the sore becomes indurated and infiltrated, somewhat resembling the Hunterian chancre. Not unfrequently syphilitic infection occurs at the same time as a soft chancre is contracted, or subsequently; the sore then runs a longer course, does not heal, even if kept clean, and after a time the patient presents the characteristic signs of syphilis. In all cases the neighbouring Lymphatic Glands become enlarged and tender, and the process is very liable to terminate in suppura- tion, constituting a bubo. Two forms of this affection are described : (a) The simple or sympathetic buho results from the absorption of ordinary pyogenic organisms from the abraded surface. The pus in this case, if inoculated elsewhere, may produce a pustule, but not a true chancre. The process is usually limited to the interior of the lymphatic glands, {b) The virulent bubo is due to the absorption, not only of pyogenic organisms, but also of the specific virus, so that the pus, if inoculated, always produces a typical soft sore. In these cases suppuration occurs not only within, but even more abundantly around the Ivniphatic glands {periadenitis), so that the skin becomes considerably undermined, and the wound produced by SPECIFIC INFECTIVE DISEASES 151 opening the abscess may take on the form of a large soft chancre in the groin, in the centre of which is seen the lymphatic gland only slightly enlarged. The process is often slow, and a good deal of cutaneous redness is present with but little pus. Treatment consists in keeping the sore clean, dusting its surface with iodoform, and covering it with lint dipped in lotio nigra or boric acid lotion, healing usually occurring in from ten to twenty days ; where much balanitis exists, it may be necessary to slit up the prepuce, but circumcision should not be undertaken until the sores have healed. The application of pure carbolic or nitric acid may destroy the organisms and hasten a cure, but they need not be employed unless the routine treatment fails to check the spread of the sore. If the smell of iodoform is objected to, iodol or aristol may be substituted. Buboes are treated in the early stages by keeping the patient at rest and applying fomentations or Klapp's suction balls, when resolution sometimes occurs. If suppuration ensues, the abscess should be incised vertically, so as to allow free exit to the pus, even when the patient is sitting, the cavity being subsequently dressed by packing it with gauze impregnated with iodoform. Some sur- geons make small incisions, and trust to the suction effect of Klapp's apparatus; other's recommend that the enlarged glands should be freely removed by dissection, but such is not often required. The tissues surrounding them are so extensively infiltrated that it is sometimes impossible to define their limits, and surrounding tissues of importance may be encroached on. Moreover, complete removal of the lymphatic glands in the groin is sometimes followed by serious evidences of lymphatic obstruction in the limb or external genital organs (Fig. 120). Prolonged rest, free incisions, and scraping of abscess cavities and sinuses, followed by packing with iodoform gauze, usually result in a cure; when repair is slow, a visit to the seaside will often be beneficial. Syphilis. It is now fairly certain that the cause of syphilis is a protozoal parasite discovered by Siegel and Schaudinn in 1905, and termed the SpirochcBta pallida or Treponema pallidum (Fig. 31). Spiro- chetes and spirilla are common in the mouth and in dirty wounds ; but this organism can readily be distinguished from unimportant forms by its morphology and staining reactions. It has recently been cultivated by Noguchi on a mixture of agar and ascitic fluid under strict anaerobic conditions. It stains with difficulty, a fact which accounts for its having eluded observation for so long. Mor- phologically, it is a very delicate spiral filament, having eight to twelve fairly regular whorls; its ends are sharply pointed, and each terminates in an exceedingly delicate flagellum. It varies in length, but on an average is about equal in length to the diameter of a red blood-corpuscle, and each whorl occupies about i /a. The 152 A MANUAL OF SURGERY common 5. refringens, which is frequently met with in the mouth, ulcers, etc., is larger, broader, has blunter ends, and a smaller number of less regular whorls. Little is known of the life-history of the syphilitic form. The proof of its specificity lies mainly in the fact that it can be found in the great majority" of all cases of syphilis— the proportion depending on the care taken and the skill of the observer— and that it is found in regions in which accidental contaminations could hardly occur, e.g., in the lungs, liver, spleen, and other viscera of still-born syphilitic foetuses (Fig. 32). In acquired syphilis it may be demon- strated in the earliest stages of the sore that precedes the typical primary chancre, or in scrapings thereof; in the secondary stage it occurs in the corresponding glands, the skin lesions, or in the fluid of blisters raised near them, in the spleen, and has been demon- V K) oi -^ Fig. 31. — Spiroch^ta Pallida. Fig. 32. — Sechun uf Llng in Dead (x 1,500.) AND Macerated Syphilitic FcETus, SHOWING THE TISSUES CROWDED WITH SPIROCHi^TES. (X I,000.) (For the preparation and loan of these two specimens we are indebted to Dr. Eardley Holland.) strated in the blood, though rarely; in the tertiary stage it has been found in small numbers in gummata and other specific lesions, but in the majority of cases it can only be demonstrated vAih great diffi- culty and after prolonged search; especially is this the case in the so-called parasyphilitic affections of the nervous system. Syphilis only occurs naturally in man, but it may be inoculated into the higher apes, which develop a disease comparable in most of its features to human syphilis. Frequently repeated experiments on these animals have yielded results of much clinical interest. The disease has been transmitted by material obtained from the human subject in all stages — e.g., by the blood, the semen, discharges from the primary sores, from secondary lesions, and even from gummata. The incubation period is from three to four weeks, and then an SPECIFIC INFECTIVE DISEASES 153 indurated nodule appears which undergoes ulceration, and is accom- panied by enlarged lymphatic glands. Mild secondary symptoms usually follow, but tertiary manifestations have not been observed. It has been proved that the inunction of calomel ointment locally can prevent infection, even up to twenty hours after inoculation; but removal of the inoculated region has proved useless except when undertaken within eight hours after infection. The methods employed in the Laboratory Diagnosis of s^^philis consist in the demonstration of the spirochaste or in the Wassermann reaction. The Treponema pallidum can usually be found without difficulty in the serum which oozes from the margin of the supposed chancre after scraping it lightly with a scarifier, or which can be expressed after puncture of an enlarged lymphatic gland. Long before the sore has taken on a typical appearance the spirochetes can be seen and a diagnosis made, and it is important to realize that the induration of the sore is Nature's attempt to shut in the organ- isms, and therefore it is the more difficult to reach them by drugs. No antiseptic should be applied to the sore before examination, as thereby the spirochsetes are driven into the deeper tissues. Three methods of demonstration may be emploj-ed: (i) The material may be examined fresh under dark background illumination (ultra- microscope). This is the best method, the organisms being easily seen and their characteristic movements recognised. (2) Appear- ances somewhat similar can be secured by mixing the secretion with fluid Indian ink, spreading it out into a film, and allowing it to dry on a slide. Here also the organisms appear colourless on a dark ground, but, of course,' there is no movement. This is a simple and quick method. (3) There are numerous staining methods, most being modifications of Romanowski's; photographic processes depending on the reduction of silver salts are also used, especially when the organisms have to be sought for in the tissues. The Wassermann reaction depends on the fact that in the late primary, secondary, and tertiary stages of the disease the blood- serum usually contains a substance which, when incubated with an alcoholic extract of heart or liver (diluted with saline solution), removes complement (p. 22) from the mixture. This is demon- strated by adding sensitized red corpuscles, which are dissolved if complement is present, but which remain unaltered if it is absent. A positive Wassermann reaction is obtained in a few diseases other than syphilis — viz., in yaws, leprosy, and scarlet fever, but in the last it is inconstant and only present for a few days. In syphilis the positive reaction usually appears about the time of induration of the sore. It is present in all late primary and secondary cases. At the onset of the tertiary period a few patients are found in whom it is absent, and these gradually increase in number, until in very old-standing cases the positive results fall from 95 to somewhere about 80 per cent.* * These figures I'efer to patients who have been treated in the old-fashioned way by mercury only. 154 A MANUAL OF SURGERY The Clinical History of syphilis varies widely in dift'erent cases according to the virulence of the infection and the degree of resist- ance of the tissues, but as a rule the three stages suggested by Kicord are observable. The primary stage includes a varying period of incubation, and the appearance of a sore, usually known as a ' hard chancre.' This is followed in the course of a few weeks by evidences of general infection, referred mainly to the skin, mucous membranes, and lymphatic glands, comprising the secondary stage. After a variable time, perhaps extending to many years, during which symptoms may be absent, tertiary manifestations (gummata, etc.) may show themselves in any and every part of the body. Mode of Infection. — Acquired syphilis is almost always due to infection of the genital organs arising from impure connection. Occasionally cases are met with in which the disease is acquired innocently by direct or indirect contact with syphilitic lesions {syphilis insontinm), and then the primary lesion is often located on some other part of the body {extragenital chancres). Thus, the lip may be infected as a result of drinking out of the same glass or smoking the same pipe as a syphilitic patient, or even by kissing. Metchnikoff has proved that the spirochsete is a delicate organism, and quickly loses its virulence outside of the body. This probably explains the rarity of infection by indirect contact. An additional protection is the fact that the organisms cannot enter the system through unbroken skin or mucous membrane. The disease is not equally infectious in all its stages; in the primary, the discharge derived from the chancre will alone convey the contagion; in the secondary period the virus is present in the blood, and consequently in all pathological exudations, as also in the semen. Pure secretions — e.g., tears, milk, or urine — are free from infection, although, if mixed with a serous exudate from abraded surfaces, as so frequently occurs in the case of the saliva, they at once become infective. It is uncommon, but by no means impossible, for infection to be con- veyed by patients in the tertiary stage. One attack of syphilis usually confers immunity on the patient from further outbreaks of the disease, even if exposed to infection. This protection is not always permanent, since well-authenticated cases have been observed of second attacks of syphihs. The stage of Incubation lasts for a variable period, extending from two to six weeks; as a rule, evidences of induration of the sore can be detected about the third week. Removal or destruction of the local lesion has not the slightest influence upon the progress of the case, unless it is undertaken immediately after infection, or unless the patient is being treated by salvarsan. Many spirochaetes are shut up udthin the chancre, and as these are inaccessible to the drug, it is advisable to remove them by operation. During the in- cubation period the local sore may heal completely, if it is purely syphilitic, and nothing further is noticed until the typical induration manifests itself. Not unfrequently, however, pyogenic infection occurs, or a soft chancre is also present; in the latter case the lesion SPECIFIC INFECTIVE DISEASES 155 does not heal satisfactorily, and the base of the ulcer becomes indurated after a time. I. The Primary Stage of syphihs is characterized by the develop- ment of a sore, associated with enlargement of the neighbouring lymphatic glands. It is usually situated on the base of the prepuce, close to the corona glandis (Fig. 33), or on the frcenum; in the female the inner aspects of the labia majora or nymphs are the most common sites, but it often causes so little inconvenience as to be overlooked. The primary sore does not invariably present the same appearance, although it is typicahy characterized by a certain amount of infiltra- tion and induration. The following are the chief forms in which the chancre manifests itself: {a) The desquamating papule is a shghtly elevated spot, which is irritable, of a dusky colour, and free from ulceration. It is usually small, but hard, and its surface covered with epithehal scales. If exposed to friction or to the irritation of retained discharges, ulceration is very likely to take place, and an ordinary Hunterian chancre will then " form. Unless this occurs, it may run its course unobserved, and thus a patient becomes syphilitic without being able to trace the time or source of infection. (6) The indurated, hard, or Hvmterian chancre is that most commonly seen; it results from the irritation of a papule, or is developed in association with a soft sore. Should the initial superficial abrasion have p^^ 33IIHARD Chancre, displayed healed, a localized growth ot gy Eversion of Prepuce. almost cartilaginous hardness forms in the cicatrix, closely adherent to and invading the cutis; but if a soft sore has first developed, the surface remains ulcerated more or less deeply, with a well-defined margin, though the base be- comes indurated (Fig. 34). In some cases there may be but little elevation of the growth, and the surface is free from ulceration, con- stituting the variety known as the ' parchment induration ' of Ricord- and most frequently seen on the glans penis. Where, however, the prepuce or body of the penis is involved, the induration is more diffuse, owing to the laxity of the connective tissue. When affecting the base of the prepuce, the induration usually spreads transversely, producing a collar-hke mass, which on retraction of the part rolls back en bloc in a very characteristic manner (Fig. 33). When the orifice of the prepuce is involved, the part becomes generally infil- trated and hard, so that retraction is impossible, and a form of phimosis is thus acquired. Examined microscopically, the new formation consists merely of a mass of round and spindle cells 156 A MANUAL OF SURGERY packed closely together, witli a certain amount of intercellular fibrous tissue; giant cells are sometimes seen. The blood-supply of the i)art is scanty, a fact which explains the readiness with which ulceration occurs. It is all-important, however, to remember that a diagnosis of syphilis can be made by the microscope long before this typical induration appears, and unless this early diagnosis is made, and elective treatment commenced, the possibility of a complete cure is much lessened. Several chancres may be seen on the same individual if the infec- tion occurs at one time, and it is possible that a patient may be infected at two different periods if only a short interval elapsed between the inoculations; but the disease is not generally auto- inoculable, and when once a hard chancre has developed on the under surface of the prepuce, the glans does not become infected from contact. Multiple chancres are always of small size, and the induration is less marked than usual. A Uje'thral Chancre is usually situated just with- in the lips of the meatus, constitu- ting a sore with an indurated base. It may be felt as a hard nodule on grasping the ure- thra between the fingers, and gives rise to a thin serous discharge, often blood-stained. The orifice itself is sometimes the site of a hard chancre, which may encircle it, and be followed by a stricture. Extragenital Chancres are most commonly observed on the lips, finger, and nipple. They are often characterized by much infiltra- tion, due to pyogenic inflammation, and less distinct and definite induration than in the forms met with on the genital organs; hence the swelling is more prominent and vascular, and if ulceration occurs there is a greater amount of discharge, which forms a thick scab over the surface. Neighbouring lymphatic glands arc often much enlarged, and surrounded by infiltrated tissue. This condition has been mistaken for epithelioma, from which, however, it can be dis- tinguished by the induration and sharp limitation of the sore, its rapid development, and the earlier enlargement of the glands. The course of the case is sometimes more severe than when the primary lesion is in the usual situation, a fact possibly explained by the disease remaining unrecognised till secondary symptoms develop. Digital Chancres are usually seen in nurses, surgeons, and accou- cheurs, and start by the side of the nail. An indolent sore appears. Fig. 34.- -Hard Chancre of Abdominal Wall IN Suprapubic Region. SPECIFIC INFECTIVE DISEASES 157 which becomes infiltrated and ulcerates, spreading under the matrix and along the semilunar fold. There is a good deal of discharge and pain, and the terminal phalanx becomes swollen and bulbous. The epicondyloid and axillary glands are enlarged as the case progresses, and the condition has more than once been mistaken for mahgnant disease. Occasionally, however, the sore has been so small and so little obvious as to be overlooked. Phagedena is a form of spreading ulceration, rarely met with at the present time, except in connection with venereal disease, and seldom apart from syphilis. It always attacks unhealthy and debilitated individuals, and is largely due to the retention of discharges resulting from phimosis. The pre- puce and end of the organ become red, swollen, and infiltrated. On dividing or retracting the foreskin, the affected surface is found to be sloughy, and the ulceration, unless checked by treatment, rapidly spreads, and may destroy glans and prepuce, and even attack the body of the penis. Treatment con- sists in division of the foreskin if that structure has not been already destroyed, followed by repeated immersion of the patient in a hot hip-bath. In the intervals the wound should be dusted with iodoform, and dressed with lint dipped in lotio nigra. The later treatment is conducted as for primary syphilis, although the depressed condition of the general health may necessitate the administration of tonics, and even a visit to the seaside. Should treatment by immersion in hot water be for any reason impracticable, the old-fashioned plan must be resorted to — viz., scraping the sore, and freely cauterizing the base with pure carbolic or fuming nitric acid. Possibly, where there is much slough, this latter method may advantageously precede immersion in a bath. The Lymphatic Glands which receive lymph from the region in which the sore is situated become characteristically enlarged. Thej' move freely under the skin and feel hard, like bullets, pellets of cartilage, or almonds (hence the term ' amygdaloid ' which has often been apphed to them) ; they are usually quite painless, and do not suppurate unless the original sore is inoculated with the virus of a soft chancre or with pyococci. 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 l\Tnphatic of the penis is frequently blocked in this way, and gives rise to solid or lymphatic oedema of the prepuce and glans. Should the chancre suppurate, an abscess may also form in the course of the lymphatics. The Diagnosis of a syphilitic from a soft sore is not always easy. Of course, where there is no ulceration, and the typical induration of the base can be felt, no doubt need arise. But when the primar}/ sore suppurates, and an excavated ulcer is present, surrounded by infiltrated and hyper^emic tissues, it is difficult to be certain as to the nature of the case. The inguinal glands are enlarged in both varieties, and the fact that suppuration occurs proves nothing. Even the existence of a ' satellite ' chancre from auto-inoculation only demonstrates the presence of a soft chancre; it does not prove the absence of sj^phihs. The presence of the typical spirochaete in scrapings from a chancre, or in juice removed by a hypodermic needle from an enlarged inguinal gland after massage, is conclusive e\ndence. Rarely is it necessary to wait for the development of secondary symptoms before a decided opinion can be given. 158 A MANUAL OF SURGERY The Duration of the primary sore varies in different cases, and depends in a great measure on whether treatment is commenced early or late. If the patient comes under observation during tlie first six weeks, and a mercurial course is at once started, the chancre heals, and tlie 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 hardness disappear. If no mercury is given, the induration may last for twelve months or more, and then slowly passes off, although it may run a much shorter course. From an uncomplicated syphilitic sore but httle scar results, although a well-marked cicatrix may follow a soft or suppurating chancre. Re-induration of the cicatrix (relapsing chancre) sometimes occurs from too early a cessation of the mercurial course, or from some localized irritation, or from a fresh exposure to infection. It is occasionally due to a tertiary or gummatous development, and will then be free fromi 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 feehng ' seed}^ ' and out of sorts, whilst in some cases distinct pyrexia, wasting, and headache have been noted. Well-marked anaemia is often present, and on examination the red corpuscles are found to be deficient in number, and defective in the amount of haemoglobin contained within them. A moderate leuco- cytosis is present, chiefly involving the lymphocytes and plasma cells. The chief secondary manifestations consist in a general enlargement of the lymphatic glands, together with the appearance of various forms of rash on the skin and mucous membranes, loss of hair, and other less common phenomena, involving the eyes, brain, etc. ; these usually show themselves in from six to nine weeks from the time of inoculation, although they may be delayed to a much later date. Their intensity varies considerably, the phenom- ena being sometimes scarcely evident, and at others very marked. They are also influenced greatly by the period at which treatment commences; the earlier it begins, the less obvious are the secondary phenomena. The Cutaneous Eruptions of secondary syphilis are chiefly char- acterized by the fact that, although any form of rash may be simulated, no specially distinctive variety is originated. Moreover, in the same individual the eruption is not always of the same character throughout, several distinct types developing in different parts of the body {polymorphism). The rashes are usually more or less symmetrical, the colour in the early stages being a dusky red, resembling that of raw ham ; occasionally, however, they may be a bright rosy red. Syphilitic rashes disappear after a time, but often leave a coppery-brown discoloration of the skin for a while; more- over, they do not completely fade on pressure, but leave a similar brown stain, and give rise to but httle irritation or itching; they SPECIFIC INFECTIVE DISEASES 159 always tend to progress from the simpler types, due to hyperrcmia, to the more serious, in which infiltration and overgrowth are evident. Tlie simplest form consists of a mere hyperemia, sometimes appearing as a dusky mottling of the skin [roseoloits syphilide), which quickly fades or may persist whilst other types are developing. Sometimes distinct papillae become infiltrated and hyperaemic {papular syphilide) ; at others, vesicles or pustules appear {vesicular or pustular syphilides); the latter change is uncommon, and only appears in bad cases or in debiHtated patients. Another form of eruption is the squamous syphilide, characterized by patches of hyper?emia and infiltration, combined with superficial desquamation. It is usually bilateral, and, unlike simple psoriasis, affects the flexor rather than the extensor surfaces. In the later stages, distinct nodules or tubercles are produced in the skin, which may even run on to ulceration {tuhercnlar syphilide). As to the situation of the rash, the roseola is usually limited to the trunk, whilst the other forms are often scattered widely over the trunk and extremities, involving, however, the flexor more than the extensor surfaces of the limbs. A somewhat characteristic phenom- enon is the appearance of a papular rash on the forehead, sometimes known as the corona Veneris. The Mucous Membranes may be affected in much the same way as the skin. The fauces become red and congested, the hyperaemic area being abruptly hmited, and semicircular in outline; symmetrical ulceration usuahy follows, starting near the anterior pillars of the fauces, and spreading to the tonsils and along the soft palate to the uvula. These ulcers are shallow, have sharply- cut edges, and often present a characteristic grayish appearance, constituting what is known as a ' snail-track ' ulcer. The secondary sore throat rarely results in extensive loss of substance, and hence pharyngeal stenosis is not produced. Smoking undoubtedly aggravates these conditions. Concurrently with these manifestations in the fauces bare patches from loss of epithehum may be seen on the dorsum of the tongue, or several small superficial, but very painful, ulcers may develop on the inside of the cheeks or lips, or along the borders of the tongue, from the irritation of the teeth. Mucous tubercles and condylomata are somewhat similar affec- tions, though more pronounced, arising in the secondary stage in connection with mucous membranes and those parts of the skin which are soft and moist. Mucons Tubercles consist of slightly- raised patches of enlarged and infiltrated papillae, white in appear- ance from the superficial epithehum becoming sodden, and often progressing to actual ulceration. Examined microscopically, the papiflae are found to be definitely enlarged, and the epithehum heaped up over them. They are most commonly observed at the corners of the mouth, on the inner aspect of the cheeks, the side of the tongue, or the margin of the anus; in the last-named situation they are usually s\Tnmetrical, one side being infected from the other. They are also not at all uncommon between the toes, and the ulcers i6o A MANUAL OF SURGERY caused thereby become exceedingly offensive. Condylomata are similarly the result of overgrowth of the papilla-, differing from mucous tubercles merely in the extent to which this has been carried. They consist of definite wart-like masses, which may attain a great size, constituting a caulifiower-like growth. They are most com- monly seen about the anus or vulva, in the former situation being often mistaken by the patient for piles; they give rise to an abun- dant, highly infective discharge. A similar condition is sometimes met with on the dorsum of the tongue, and is then known as ' Hutchinson's wart.' The Lymphatic Glands are usually enlarged throughout the body during this period of the disease, being felt as round, hard swellings beneath the skin. Tlie extent of the glandular complication is possibly a measure of the degree of virulence of the affection. Chronic enlargement of tlie nuchal and epicondyloid glands, in the absence of any ob\nous local cause, is always suggestive of the existence of syphilis. Syphililie Alopecia. — The hair becomes dull and lustreless, and either comes out in patches from the scalp, eyebrows, beard, etc., or there is a general ' thinning.' The follicles, however, are not destroyed, and after a time the hair will grow again as before. Later secondary manifestations consist of flying pains in the bones (osteocopic), iritis, and various nervous lesions, whilst periosteal nodes may form on the tibiae and other bones, or a symmetrical chronic effusion develop within the synovial membrane of joints. Syphilitic Iritis is characterized by pain in the eye, generally referred to the supra-orbital nerve, together with some interference with vision, and possibly a little lachrymation and photophobia. On examination a bright-red circular zone immediately surrounds the cornea, resulting from hypera^mia of the ciliary vessels. The iris is lustreless, and its definition somewhat blurred. Its colour is changed, a blue iris becoming greenish-yellow from the presence of lymph. The pupil is diminished in size, and perhaps irregular; its movements are always considerably hampered, and sometim.es entirely prevented, by the foniiation of adhesions either to the back of the cornea (anterior synechia) or to the lens capsule (posterior synechia.*). Occasionally small yellowish nodules are seen on its surface, consisting of plastic lymph. The Duration and character of the secondary stage vary consider- ably. The sooner effective treatment is commenced, the less severe the secondarv phenomena, whilst cases in which treatment has been delayed are likely to be more troublesome. Hence the disease is often of an aggravated type when following extragenital chancres, as also in women, by whom the primary lesion often passes unnoticed. When treatment is commenced within four or five weeks of infection, the secondary stage may be slight, and all traces of its existence may pass off in two months or less; if treatment is delayed until the cutaneous eruption has appeared, this stage is likely to last longer. The condition of the patient's health is an important factor. SPECIFIC INPECTIVE DISEASES i6i as also the previous habits, particularly' as to temperance, since syphilis alwa^'s follows a more aggravated course in the weakly and the dissipated. Patients suffering from the debility caused by malaria or other tropical affections are particularly bad subjects, and the disease may then run a virulent course. Even under the best circumstances, the patient is liable to relapses during the first twelve months, which are usually due to intermissions in the treat- ment. The rash which appears under these circumstances is often of a more characteristic type, the papules being grouped into rounded or confluent figures. III. The Intermediate or Late Secondary Stage constitutes a hnk between the symptoms already described and the tertiary phe- nomena; no distinct limits to this period can be defined, nor need it appear at all if the patient's general health is good, and the treat- ment has been carried out regularly. Some of the secondary mani- festations, especially those of the bones and joints, may persist through this period, whilst even if they have disappeared the patient is liable to suffer from ' reminders ' in the shape of various cutaneous affections, and perhaps epididymitis. The bloodvessels are not unfrequently affected in this and later stages of the disease, the endothelium of the tunica intima undergoing prohferation (Figs. 97 and 98) ; the lumen is thereby diminished, and the nutrition of the part supplied may be lowered. Arterio-sclerosis of the larger trunks may be induced by an affection of this type involving the vasa vasorum, and various forms of nerve trouble may be lighted up if the cerebral vessels are involved. Paralysis of a single limb (monoplegia) may result, or of one side of the body (hemiplegia) ; but the affection may be limited to a single cranial nerve, or merely result in a severe headache. Unfortunately, treatment may be incapable of remedy- ing the mischief caused in this manner. Deep ocular lesions {e.g., choroido-retinitis) are also not unusual. The principal 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 in- fluenced 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 former there is a considerable tendency to proliferation of the epithelium, together with deep cracks and fissures; in the latter there is less epithelial overgrowth, but the edges are often distinctly serpiginous in outline, and there is an infiltrated border. Rupia and Ecthyma are both met with in this stage of the disease, but chiefly in patients whose nutrition is defective. They are characterized by an infiltration of the skin (in reality gummatous), which progresses to ulceration. In rupia the discharge forms a distinct scab on the surface, which increases in thickness by the deposit of successive layers one under the other, each being some- what larger than the one which precedes it; hence a scab shaped like a limpet-shell is produced, resting on an inflamed and liypenLmic l62 A MANUAL OF SURGERY surrounded by an area of vivid congestion. base (Fig. 35); any part of the body may be affected in this way. In ecthyma^no scab forms over the ulcerated surface, or, if formed, it readily comes away, leaving exposed a hollow punched-out sore. Under appropriate treatment these conditions dis- appear, but leave depressed, whitish cicatrices, often sur- rounded by pigmen- tation. A somewhat un- usual intermediate manifestation is a subacute symmetri- cal epididymitis, in which the cord also becomes thickened, enlarged, and tender. IV. Tertiary Sy- philis. — The phe- nomena occurring in this stage may appear within six months of infection, or not for twenty or thirty 3'ears. They are mainly charac- terized by infiltra- tion and overgrowth of the connective tissues of the body. Such may occur in one or many places, and may be diffuse or localized. When diffuse, the organ or part affected becomes enlarged and hard, and unless the condition is treated promptly, remains permanently sclerosed from the development of fibro-cicatricial tissue. If, how- ever, the process is localized, a Gumma is formed. Any tissue in the body may be the seat of a gummatous deposit, which apparently' arises without any definite cause, although occasionally its onset may be determined by an injury. The in- volved area becomes infiltrated with large oval endothelial cells and small round cells (lymphocytes) ; plasma-cells are usualh- present in considerable numbers. The constituents of this mass are quite similar to those which are found in a tubercle, but without the grouping into small nodules and the more or less orderly arrange- ment in zones ; giant cells are usually absent, though their presence is by no means rare, and they may closely simulate the tuberculous type. Very few vessels penetrate into the mass thus formed, which otherwise resembles granulation tissue; it gradually increases in size, infiltrating and replacing the normal tissues of the part. The Fig. 35. — RupiA OF Face. (From Wax Model in Museum of Royal College of Surgeons.) A diagrammatic section of the rupial patch is shown at the side. A, Scab formed of successive layers of dried discharge; resting on B, ulcerated granu- lomatous surface of gumma. SPECIFIC INFECTIVE DISEASES 163 fate of the fully-formed gumma varies according to circumstances. If the infection is a mild one, and especially if appropriate treat- ment is adopted, the bulk of the cells become absorbed, and the remainder are organized into fibrous tissue; even a large gumma may almost entirely disappear, leaving but a small fibrous scar. In the absence of proper treatment most gummata undergo a necrotic change, which commences at the centre of the nodule and spreads towards the periphery. This may be a comparatively slow process, accompanied by fatty degeneration and caseation somewhat similar to that seen in tubercle ; or it may be more rapid, the tissues undergoing a kind of mucoid degeneration, forming a gummy mass from which the lesion acquires its name. Sections through such a gumma will show a large white structureless centre of necrotic or caseous material, surrounded by a shell of cellular tissue, which gradually merges into the normal structure of the part. Two factors are concerned in the production of this necrosis: the toxins pro- duced by the causative organisms, and the deficient blood-supply of the central portions of the cellular mass. The vessels of the gumma are deficient from the first, and after a time the amount of blood which reaches them is diminished as the result of syphiHtic endar- teritis. Moreover, some gummata do not commence to undergo central necrosis until a certain amount of transformation into cica- tricial tissue has taken pi ace, in which case a still further interference with the blood-supply may be caused by the compression of the vessels traversing the newly-formed fibrous tissue. Under appropriate treatment the whole of the gummatous mass may be absorbed, even when caseation or necrosis has taken place; but not unfrequently the gummy, semi-purulent fluid which is formed at the centre of the mass finds its way to the surface and is discharged. Where the necrotic mass is large, a portion of it may remain adherent to the surrounding tissues after ulceration has taken place, looking somewhat like a piece of wet wash-leather. Occasionally the central slough may become encysted by the forma- tion of a fibrous capsule, and calcification may occur; this is most frequently found in the brain, testis, and liver. Clinically, the appearances vary according to whether the gumma is cutaneous or subcutaneous. Cutaneous gummata are very frequently observed in tertiary syphilis, especially in the earlier stages. They occur as rounded dusky red nodules of firm consistencj', but slightly painful, and if they break down give rise to typical circular ulcers (Fig. 36). Many such growths are often grouped together in one region, and when ulceration has occurred they produce by their confluence sores with a rounded or serpiginous outline. Considerable destruction of tissue follows, but they are readily cured, giving rise to depressed white cicatrices, surrounded by pigmentation. Any part of the body may be involved, but a very common site is about or just below the knee on the outer, rather than the inner, aspect of the leg. Occasionallv a diffuse infiltration of the skin is met with in this i64 A MANUAL OF SURGERY stage, appearing as a red hvpcnemic area with a rounded or ser- piginous border, and not at all unlike lupus in appearance (Fig. 37). It spreads rapidly at the margin, which is distinctly thickened, and may contain scattered nodules undergoing ulceration. W'liether ulceration occurs or not, a cicatrix is produced. It is readily amenable to treatment, and runs a much more rapid course than lupus; the apple-jelly-like granulations so typical of the latter disease are of course not present. KA subcutaneous gumma develops as a firm nodule or an indeimite thickening, which gradually increases in size b\- the infiltration of urrounding tissues, and sooner or later " ■ -'i^ "^ approaches the surface; the centre of ^: the tumour in time becomes elastic and fluctuant; a certain amount of pain and tenderness is noticed, and when the skin is affected it becomes dusky, and even redematous. If ulceration follows, the \ • contents of the gumma escape, and the '• sore produced is circular and deep, the ►.w*' edges being sharply cut and perhaps ^iit ;. ^ undermined; the base of the ulcer con- l sists of granulation tissue, although it ( is sometmies covered by the character- istic slough. The tertiary syphilitic affections of ^ special organs will be described under the appropriate headings; but the general relation of syphilis to the \ nervous system (the so-called hara- syphilis) has been purposely omitted, since it belongs rather to the physician than to the surgeon. The Prognosis of syphilis has been transformed of re- cent years by two factors, (fl) The possibility of dem- i onstrating the presence of Fig. 36.-CUTANEOUS GuMMATA of Leg the spiiocha^te in the primary AND Pigmented Scars. sore, before any typical in- duration has occurred, has placed in our hands a means of early diagnosis which is certain, and of which every advantage should be taken by the practitioner. [h) The discovery of salvarsan enables us to destroy the spirocha'tes. which are accessible to its inliuence. Organisms which are shut up in the fibrous-tissue meshes of a chancre, or in the deeper recesses of the cerebro-spinal axis, are to a large extent inaccessible. Hence the prognosis of syphilis may be stated to be entirely a matter of early diagnosis. It is, of course, at present a little too soon to dogmatize on the SPECIFIC INFECTIVE DISEASES 165 ultimate results of modern treatment, but the statistics published by both naval and military surgeons, who have a unique oppor- tunity of studying the disease, are most encouraging, and hold out hopes that this scourge of mankind has at length been brought under control. Thus Gibbard and Harrison* state that, of 378 patients treated exclusively by regular courses of mercury, 83 per cent, relapsed clinically at least once during the first year; whereas, of 152 patients treated by salvarsan and mercury, only 3-9 per cent!^ relapsed clinicallv ^^■ithin a year of the suspension of treat- ment. Similarlv, Bodley Scottf expresses his conviction that 99 per cent, of cases could be cured effectively if a diagnosis were reached and treatment commenced \\athin a few days of infection; whereas if treatment is delayed until the Wassermann reaction becomes positive or the sore indurated, only 60 per cent, of cures will result. Fig. 37. — Diffuse Gummatous Sore of Forearm. and doubts as to the permanence of , he cure may well exist for the next fifteen years. Prolonged treatment by mercury alone gives moderately good results if the disease is recognised early. Some strains of the spirochsete appear to be more virulent than others, especiallv those acquired in the tropics, and some systems are apparentlv 'more receptive than others. Idiosyncrasies pre- venting the administration of salvarsan, mercury, or iodide of potassium, are particularly unfortunate. The state of health of the patient at the time of inoculation may influence the evolution of the case, whilst the co-existence of tuberculous disease may render the outlook verv unfavourable, especially when the syphilis is inherited. The character of the secondary rash and the extent of the general * Colonel Gibbard and Major Harrison, Brit. Med. Joiirn., November 22. 1913, p. 1341. , t Surgeon Bodley Scott, R.N., Brit. Med. Jonrn., November 22, 1913 P- 1344- 1 66 A MANUAL OF SURGERY glandular enlargement may give some indication of the gra\ity of the case; a pustular eruption is almost always of grave import. Death is rarely ^^roduced by any of the secondar\' manifestations, except in the virulent forms developed in the tropics; but it is not uncommon in the tertiary stage, when important viscera, such as the brain, spinal cord, liver, etc., are involved. Affections of the nervous system, such as tabes and general paralysis, are likely to be developed in patients, such as doctors and lawyers, whose life-work entails considerable nervous and m.ental strain. Certain cases are to be looked on as practically incurable {maligiuint syphilis), owing probably to the xnrulence of the infection, and to the late period at which treatment was commenced. This condition is most often seen in women, and in them the rash quickly becomes of a rupial or gummatous type, the secondary manifestations running over into those of the tertiary period at an early date. It is probable that syphilis can be prevented by w'ashing the part exposed to infection with a solution of corrosive sublimate, and rub- bing in a calomel ointment (30 per cent.), if such treatment is under- taken within an hour or two of infection. This has been proved experimentally in apes, and certainly in one carefully observed case in the human subject. The Treatment of syphilis has been transformed of recent years by the recognition of its protozoal origin, and its kinship to sleeping sickness and other similar diseases. Attempts to treat it with organic preparations of arsenic w-ere not very successful at first; substances of the arylarsonate type, such as atoxyl, soamin, ars- acetin, etc., were tried, but, although a few good results were obtained, the majority were disappointing, and some disastrous, inasmuch as the prolonged use of such drugs was found to be followed by toxic phenomena, amongst which optic nerve atrophy was one of the most serious. Experiments in this direction w'ere still maintained by Ehrlich and Hata, and finally they introduced a substance now known as salvarsan, or ' 606 ' (diox3^-diamido-arseno-benzol), which seems to hold out a brilliant future in the treatment of this dread disease. It is a bright yellow powder, slowly soluble in water, and strongly acid in reaction. It may be administered by intravenous or intramuscular injection, preferably the former. The dose for an adult varies from 0*3 to o"6 gramme, which is dissolved in sterile normal saline solution, made with distilled water. It is then converted into a sodium salt of the base by adding a sufficient quantity of 15 per cent, solution of sodium hydrate to redissolve the precipitate formed when it is first added. This solution is then made up to 250 or 300 c.c. \vith saline solution, and introduced into one of the veins of the ami at the body temperature. The patient must be carefully prepared as for an operation, a purgative being given overnight, and no food being permitted for three or four hours before or after the administration. He must stay in bed for twenty-four hours, or longer if he manifests any evidence of pyrexia, muscular pains, headache, or other^type of reaction, and should take things quietly on the day after the dose. SPECIFIC INFECTIVE DISEASES 167 The effect of salvarsan is, apparently, to destroy all the spirochaetes that are accessible to its influence — i.e., in the circulating blood or in the looser tissues; where, however, the infection is of longer duration, and a certain niunber of spirochaetes have become locked up in sclerosed tissues, such as the indurated chancre, or disseminated through a fluid medium, such as the cerebro-spinal fluid, it is im- possible for the salvarsan to act on these organisms, and conse- quently a complete sterilization of the system cannot occur. Under the influence of treatment these cellular infiltrations are absorbed in a few weeks, and a certain number of spirochaetes buried therein are again set free, and to rid the system from these a further dose or tw^o of salvarsan will be needed. It must be clearly remembered that sah'arsan has not pushed mercury aside in the treatment of svphilis; it has added an element of safety and security, and thereby has diminished the amount of mercury required and short- ened the length of treatment. The course of treatment recommended by arm}^ surgeons lor cases seen in the earliest stages consists in — (i) An intravenous injection of 0'6 gramme salvarsan; (2) five weekly injections of mercurial cream; (3) a second intravenous injection of o'6 gramme salvarsan; (4) five more weekl}' mercurial injections; and (5) a final intravenous injection of o-6 gramme salvarsan. All cases are kept carefully under observation for at least a year, and this should include the testing of the blood for the Wassermann reaction, at first every month, and subsequently every three months. The shghtest sign of relapse, either clinically or by the Wassermann test, indicates the prescription of a second course of treatment similar to the above. If the patient was brought under treatment in the early primary stage, and his blood has shown no sign of relapse during twelve months subsequent to the cessation of treatment, it is un- hkely that he wnll have any later manifestations. If he first came under observation at a later date, and the blood is already positive to Wassermann's test, or secondary s^miptoms are already present, it is probably wise to make the mercurial course longer, and in severe cases to give mercury for twelve months. Relapses are more common, and the patient must be watched for two years. In tertiary sj^philis salvarsan is useful in helping in the cure of active manifestations of the ulcerative type, but mercury and iodide of potassium still maintain their position, and must be chiefly relied on. Over the deep lesions, especially of the parasyphilitic type, salvarsan has but little influence. Various modifications of administration are utilized by different surgeons, but they are comparatively unimportant. Neo-salvarsan (o'75 gramme for a dose) is sometimes substituted, and other methods of giving mercury are employed — e.g., by inunction. The intervals between the doses of salvarsan are also different, but the essential universally recognised is the combination of salvarsan and mercury. Occasional bad results, such as localized paralysis or deafness, have been reported after a dose of salvarsan, and even »68 A MANUAL OF SURGHRY death; but such a mishap is exceedingly rare. The reaction is sometimes unduly severe, possibly due to the rapid destruction of large numbers of spirochaetcs in the blood and the setting free of a large amount of endotoxin, but the percentage of such bad results is surprisingly low. The value of this treatment cannot be over-estimated, not only from the personal, but also from the public, point of view. The former has been already alluded to, and the future can alone dis- close the ultimate percentage of freedom from relapse. From the public standpoint, the chief advantage lies in quickly rendering the patient non-infectious, and thereby diminishing enormously the chances of spreading the disease to others. The chief limitation to its utiUty is the expense and the amount of special work required in order effectively to carry out the treatment. It is possible that the Government will have to step in and render such assistance available to all members of the community. Failing the employment of salvarsan, the practitioner can alone depend on the administration of mercury, and this must be thorough and prolonged, and even then good results cannot be ensured. Many different methods have been suggested in order that the patient miay derive the greatest amount of benefit from the drug with the minimum of inconvenience, [a] It is often given by the mouth, and preferably in the form of pills, composed of gray powder (grs. i. — iii., t.d.s.), or of the green iodide (gr. | — i., t.d.s.). Gray powder is perhaps the best means of administering the drug ; the patient should commence with 2 grains, three times a day, or in some cases i^ grains four times a day, combined with a little extract of opium or pulv. ipecac, co. if it causes diarrhoea; but this addition is not always needed, (b) Inunction of the mercurial ointment is also frequently adopted, and with great success, inasmuch as it is less likely to cause digestive derangemicnts. If the ordinary officinal ointment is employed, a portion as large as a hazel-nut is rubbed into the groin or axilla nightly, the part being washed the following morning, and not used again for this purpose for three or four days; if the ointment is made up with lanoline, a somewhat smaller amount is required. This is one of the best ways of bringing a patient rapidly under the influence of the drug. At Aix-la-Chapelle and Harrogate this treatment is a speciality, and is combined with the daily use of sulphur water and baths. The mercurial ointment is rubbed in daily by glass rubbers or the hand, and the course lasts six weeks, being repeated within the year, (c) Mercurial vapour baths may be advantageoush' emploved where the cutaneous eruption is very extensive. The patient sits naked on a cane-seated chair, and covered with a blanket or specially-constructed cloak reaching from the neck to the ground, and not touching the body; 20 or 30 grains of calomel are placed on a metal plate surrounded by a trough con- taining about an ounce of water. The water is boiled, and the calomel sublimed, by means of a spirit-lamp placed under the chair. In about twentv minutes all the calomel will be volatilized, and SFi-:ciFic infective: diseases 169 deposited in part upon tlic skin of the patient, who perspires freely during the process. Fie then gets into bed between warm blankets, without wiping the skin. This treatment may be combined with medication by the mouth, [d] The intramusculay miQcWon of mer- curial preparations has much to recommend it, and although alarmists have emphasized the dangers of suppuration, salivation, and emboli associated with it, yet increasing experience has proved it to be safe and efficacious in careful hands, and with due regard to asepsis. The satisfactory results following its extensive adoption by military surgeons are strong arguments in its favour. Insoluble preparations of mercury are mainly relied on, and especially in the form of metalhc mercury suspended in a cream.* The dose is injected deeply into the gluteus maximus, and the absorption, if slow, is regular, so that it is httle hkely to cause toxic symptoms. During the course of mercury, the patient's general health and habits must be carefully regulated; alcohol is forbidden, exercise limited, and strict instructions are given as to keeping the teeth and _ gums clean. An astringent mouth-wash containing alum and chlorate of potash should be ordered, and it may be necessary to remove or stop diseased teeth, but the dentist must, of course, be informed of the nature of the case. To minimize the risk of throat and mouth trouble, it is wise to stop all smoking for at least six months. The dose of m.ercury required varies in different indi- viduals, being increased in robust people, and diminished in those who are weak or unhealthy. It should always be pushed until mild physiological effects are produced in the shape of shght tenderness of the gums, but salivation of the patient is undesirable. Full doses are usually required for four or five months, followed by a milder course, which should extend till the end of the first year. It is advisable, however, to insist on a three months' course of mercury tv\dce a year for two and a half or three years. Symptoms of mercMrialism are induced in some people by very small quantities of the drug, and hence treatment should always commence with small doses. The gums become soft and spongy, and bleed readily on pressure ; sahvation follows, or even acute glossitis, whilst the breath becomes offensive. The teeth are loosened and may be shed, and the alveoU may undergo necrosis. Digestive derangements, such as cohc and diarrhoea, are also observed. Treatment consists in suspending the drug for a time, and giving a sharp saline purge, whilst the spongy state of the gums is remedied by the use of an alum or chlorate of potash mouth-wash. Iodide of potassium is essential in the treatment of the tertiary and intermediate stages. It appears probable that its chief action * A useful preparation is as follows: 1^ Hydrargyri . . . . . . • • • ■ 5ss. Adipis lanae anhyd. .. .. .. •• §ii- Paraffini liq. (carbolized 2 per cent.) ad 5V. (by volume). Finished product = gr. i. in min. x. Min. X. as a maximum dose once a week. Lambkin {Bril Med. Journ.. November 11, 1905)- lyo A MANUAL OF SUh'GI'h'Y is the removal of gummatous tissue, and that it has httle infkience upon the causative disease; in order to prevent recurrence, salvarsan or mercury is still required. The dose of iodide should not exceed 5 grains to start with, and is graduall3Mncreased, until in some cases I drachm four times a day has been reached. Plenty of water should always be taken immediately afterwards to assist in its dilution and facilitate its absorption. A feeling of depression and sinking at the epigastrium is sometimes produced, but may be alleviated by the addition to the mixture of sal volatile (m^xv.) or carbonate of am- monia, as suggested by the late Sir James Paget. S\aTiptoms of coryza often follow, and an acnciform eruption over the shoulders and face, which may disappear on increasing the dose. Occasionally a vesicular, or even bullous, rash is caused by this drug. When large doses are given, bicarbonate of soda or potash must be combined with it, in order to prevent its decomposition by the gastric juice. If mercury is required, it is better to give it in the form of gray powder than to add liquor hyd. perchlor. to the iodide in a mixture, as the latter usually disturbs the digestion. Other drugs, such as sarsaparilla, arsenic, and iron, are often combined with iodide of potassium in the later stages of the disease, and may be useful. The Local Treatment of syphilitic sores consists mainly in the application of various preparations of mercury. The primary chancre should be treated by excision, cauterization, or the use of calomel ointment (30 per cent.), with the object of removing or destroying the spirochaetes which may be locked up in the fibrous interspaces and are inaccessible to salvarsan. Mucous tubercles in the neigh- bourhood of the anus or vulva, or between the toes, are best dealt with by keeping them scrupulously dry and clean and dusting them over with powdered calomel and starch, or by the application of calomel ointment, a piece of lint being inserted between opposing surfaces to keep them from rubbing one against the other. Secondary ulceration of the throat does not usually require local treatment, as it soon disappears under the influence of mercury. A mercurial gargle may, however, be employed, or in bad cases the affected parts should be painted with glyc hyd. perchlor. (i in 2,000). Superficial gummatous ulcers are treated by removing the scabs, and applying some form of mercurial ointment. A determined attempt should be made to keep deep gummatous ulcers in an aseptic condi- tion, since the advent of sepsis to such sores, especially if they are connected with bones, makes a marked difference in their progress. In neglected cases the wound may become exceedingly foul, and in chronic cases a hectic temperature and amyloid degeneration of the viscera have been observed. When gummata come to the surface and point, they should be opened with the same precautions as are adopted in the case of an abscess, and either dressed antiseptically or their cavity packed with sterilized lint or gauze soaked in sterilized lotio nigra. SPECIFIC INFECTIVE DISEASES 171 Inherited Syphilis. The offspring of syphilitic parents often fails to arrive at maturity, the mother miscarrying at the end of six or seven months. The child may be well formed, and may even hve independently for a short while, but not unfrequently it is dead, and in many cases macerated; under these circumstances the tissues of the body are often swarming with spirochsetes (Fig. 32). The miscarriage may be repeated for several pregnancies, and then a living child is pro- duced. In other instances, however, a hving child is born at full term at the end of the first pregnancy in spite of the syphiUtic infection of the parents. This child may show evidences of the disease at birth, but more frequently appears to be healthy, specific manifestations not showing themselves for some weeks. Much discussion has arisen in the attempt to explain these phenomena, and also as to the relative frequency of infection by the father or mother. Theoretically, infection may occur at one of three periods: (a) At impregnation the disease may be conveyed by one or both parents, either the ovum or spermatozoon, or both, carrying the spirochaetes. The organism has been demonstrated in the semen of human beings as well as of apes. Infection ab initio is likely to be followed by a general development in the tissues, and possibly the cases where the mother aborts early and produces a dead foetus infiltrated with spirochsetes belong to this type. (b) During the pregnancy infection of the foetus may occur through a specific infection of the endometrium, especially involving that portion of the decidua which enters into the formation of the placenta. As a general rule the foetal and maternal circulations do not commingle, but when the placenta is diseased it is easy to understand that the spirochaetes might pass from mother to foetus. (c) It is possible that infection may be delayed until parturition, the organisms then finding their way from the separating placenta through the umbihcal vein. Such an occurrence may explain the delay of symptoms in the infant for some weeks after birth, although possibly this is due to a removal of toxins into the maternal circula- tion during pregnancy, so that, although the foetus is infected, symptoms are kept in abeyance. In this connection it is interesting to note that, although infective lesions may be present in the maternal passages, primary chancres are not seen in infants; they are presumably protected either by a previous infection or by the presence of the vernix caseosa. In some cases the mother has shown no obvious evidence of syphiHs, and yet is able to suckle her child without harm, even though there are ulcerating lesions on the child's gums and lips, whereas a healthy wet-nurse develops a chancre of the nipple. This is known as Colles's Laiv, and was first stated by him in 1837. The immunity of the mother under these circumstances was formerly attributed to the production of antibodies in the foetus and trans- mission to the maternal blood; but the researches of Neisser on the 172 A MANUAL OF SURGERY higher apes have shown that the serum of a syphiHtic subject contains neither protective nor curative substances, and it is therefore probable that the maternal immimity is due to a mild and un- recognised infection with the disease itself. Profeta's Law is the reverse of Colles's, and asserts that the child of a syphililic m.other or father is immune to syphilis, although it has never presented evidences of infection with the disease. In the light of modern research it seems extremelN- probable that this is not true. The length of time during which a syphilitic patient retains the power of transmitting the disease to the foetus is an exceedingly difficult point to determine, and one which is constantly coming before the practitioner, who is asked to decide at what period marriage is safe. The rule of prac- tice generally followed is that no one suffering from syphilis should be allowed to marry until the Wassermann re- action has re- mained negative and he or she has been free from all symptoms for two years, and even then it is advis- able that a mild course of mercury shoiild be given for about three months shortly before_marriage. The question of transmission to the third genera- tion is one of much interest, concerning which a good deal of conflict- ing evidence has been forthcoming. The dependence of this disease upon a recognised organism, which it has been possible to demon- strate in late tertiary stages, is presumptive evidence in favour of its transmissibility ; but, naturally, one of the chief difficulties is the de- monstration of the sexual purity of the second generation. Further evidence of an assured character on this point is much needed. At birth the child often appears healthy and well nourished, but is sometimes small and imperfectly developed. The first definite symptoms of the disease manifest themselves at a variable period, extending from three weeks to three months, after birth; the child becomes thin and emaciated; the skin, which hangs in wrinkles Fig. 38. — Child with Inhekited Syphilis, showing Radiating Scars round the Mouth. (From a Photograph kindly lent by Dr. G. F. Still.) SPECIFIC INFECTIVE DISEASES 173 over the body, changes to a dull earthy colour, whilst the features looked pinched and wizened, like those of an old man. Marked anaemia is always present, and may persist for a considerable time. Speaking generally, the s\-mptoms of inherited syphilis are similar to those of the acquired disease, except that the primary lesion is absent. Thus, during the ftrst year of hfe the child develops various cutaneous eruptions," mucous tubercles, and superficial ulceration of the mucous membranes. A dusky red roseola, especially about the nates (napkin area), may first be noticed, but does not last long. This is usually followed by the appearance of mucous tubercles at the angles of the mouth, in the nose, and around the anus, as also in the moist folds of the groin, and between the scrotum and thigh. The sores on the lips are sometimes very marked, giving rise to ulcerated sur- faces, which, by their sub- sequent cicatrization, leave radiating scars (or rha- gades), especially about the angles of the mouth (Fig. 38). Other cutaneous affec- tions, such as squamous syphilides of the soles of the feet, together with papular s\^hilides of the body, and a bullous erup- tion becoming pustular (pemphigus), are also ob- ser^'ed, the last-mentioned, however, only occurring in debilitated infants. A ca- tarrhal rhinitis is a very early and constant manifes- tation, gi\dng rise to ob- structed nasal respiration, or snuffles. This affection is often protracted, going on to ulceration and de- struction of the nasal bones and cartilages ; their subsequent development is thus prevented or impaired, and hence the bridge of the nose remains depressed and sunken, even when adult life is reached (Fig. 39). Enlargement of the spleen and liver is also common. Many infants during the first year of life die from malnutrition or marasmus; but if properly treated a considerable proportion regain their health within six or eight months, all the m.anifestations described above disappearing, although their scars may remain. The child's subsequent development is frequently impaired, and it often retains an almost pathognomonic facies. Fig. 39 — Head and Face of a Patient WITH Inherited Syphilis, showing De- pressed Bridge of Nose and Frontal Bosses. (From a Photograph.) 174 A MANUAL OF SURGERY After the first year, any of the tertiary phenomena which appear in acquired sypliilis may develop, but, in addition to these, pecuhar manifestations may be produced, especially affecting the teeth, bones, and cornea; deafness from disease of the internal ear is also not uncommon. The Teeth in inherited syphilis are sometimes very characteristic. The temporary teeth usuall\' appear early, are discoloured, and crumble away. The permanent teeth are often sovmd and healthy, but are sometimes deformed. The central incisors of the upper jaw are those most particularly affected, but the upper laterals and the incisors of the lower jaw may also be involved. Instead of being broader at the crown than at the root, they diminish in size from root to crown, being stunted, and separated from one another by interspaces. The angles of the crown are rounded off, and a distinct notch, forming a large segment of a small circle, occupies the centre (Fig. 40). The enamel is often imperfecth^ developed, and hence they decay early. Occasionally they may be shaped like a screw- driver, narrowing from root to crown, and with a straight free border. The notched and stunted teeth ^described above are sometimes known as ' Hutchinson's teeth,' but they are not very commonly seen at the present day. The Bone affections observed in inherited s\-philis will be described in Chapter XXI. Interstitial Keratitis, or diffuse inflammation of the cornea, usually occurs about the age of pubert3^ or earher. It is limited at first to one eye, but the other is almost certain to be similarly affected at a later date. It commences as a diffuse haziness of the cornea, which looks somewhat like ground glass, associated with hyperaemia of the ciliary region. Red areas, or ' salmon patches,' may be produced in the midst of the opacity, due to a new formation of minute vessels. There is no tendency to ulceration, but in pro- tracted cases the anterior part of the eye may bulge forwards, constituting a condition known as ' anterior staphyloma.' The in- flammation may spread to the iris and ciliar}' body. With suitable precautions the cases usually do well, although treatment for several years may be necessary, and some corneal opacity may persist. The Wassermann reaction in congenital syphilis is usually positive in the earlier more active stages, but in ihe later it may be absent, as in the late tertiary stage of the acquired variety. The Treatment of inherited syphilis should commence as soon as definite manifestations of the disease are present. The general health must be attended to, and if the mother is unable to nurse the child it must be brought up by hand; on no account mnsi it be given to a wet-nurse. Mercury is best administered by anointing the under •Fig. 40. — Hutchinson's Teeth in Inherited Syphilis. SPECIFIC INFECTIVE DISEASES 175 surface of the flannel belly-band with mercurial ointment, or the same preparation ma}^ be rubbed into the soles of the feet every night. This should be continued until all secondary phenomena have disappeared, and advisably until the child is a year old. It is sometimes advisable to replace this by the internal administra- tion of gray powder, gr. | or i. t.d.s., with a little sugar. Cod- liver oil may also be ordered with advantage in some cases, and everj" possible means adopted to improve the general nutrition. When tertiary symptoms appear, iodide of potassium and mercury should be given in suitable doses. The local treatment of external lesions is conducted according to the rules laid down for the acquired type of the disease. Yaws [Framboesia tropica) is a disease, rarely seen, in Europeans, endemic in various parts of the tropics, and due to a spirochaste, 5. pertenuis, which is transmitted from the discharge of the sores by direct contact, or indirectly by clothes, flies, or other agents. It is characterized by the development of granulomata, which break down and ulcerate. The primary lesion, often found on the face, is generally single, and its appearance is associated with pain and fever. Secondary nodules appear either in the neighbourhood of the original lesion or elsewhere, and the process goes on spreading, some of the sores healing, and others invading deeper tissues, which may be destroj^ed and give rise to serious deformities. The condition is closely akin to s^^shilis, but it is not so certainly influenced by mercury or iodide of potassium. In salvarsan, however, we have an almost certain and very rapid cure. Tuberculosis. By tuberculosis is meant a condition resulting from the develop- men.t within the tissues of the body of certain definite anatomical structures, known as tubercles, and caused by the grovkdih and activity of the Bacillus Uiherculosis. MiicAo^y. — i. It is more than doubtful whether heredity plays such an important part as was formerly attributed to it in the production of this disease, which is much more commonly due to direct infection. That there are famihes in which tuberculosis is specially prone to occur cannot be doubted, but the children are rarely born tuberculous, and only become infected under suitable conditions. Unfortunately, tuberculous indi\dduals often have a considerable degree of philo-progenitiveness, and may be remark- ably prohfic. Although tuberculous disease is most frequently seen in children or young people, no age is extempt from its attacks, even elderly people being affected. These senile manifestations differ in no wa3^ from those met with in the young. 2. A depressed condition of the general health, by lowering the general resistance of the body, is a much more common and impor- tant cause of tuberculosis. Thus not unfrequently the trouble starts in children after attacks of the exanthematous fevers, or as a sequela of rickets, whooping-cough, or other childish ailments. Many of them leave an inflamed condition of the mucous lining of the pharynx or intestine, and thus pro\dde a suitable entrance for the germs. Even in adults the debihtating effects of influenza, a 176 A MANUAL OF SURGERY neglected cold, or persistent overwork may be followed by an out- break of the disease. 3. Still more is this likely to happen if the patient lives in un- healthv or had hygienic surroundings. Hot and ill-ventilated work- rooms, dirty dwelling-houses, overcrowded schoolrooms, etc., are themselves "harmful by lowering vitality, but they often become hotbeds of infection if once consumptive patients are admitted and contaminate the air by expectorating. This probably explains the terrible frequency with which tuberculous trouble occurs in many parts of the country where one would expect the inhabitants to be particularly healthy — e.g., some of the holiday resorts of Scotland, Wales, and Ireland] unfortunately, the houses are small, dark, often dirty, and so hopelessly devoid of ventilation that, if tubercle bacilh once gain an entrance, they become virulently effective in producing disease. Naturally, tuberculosis is most common am.ongst the poor, but it is onlv too frequent in the well-to-do, arising usually from improper feeding and unwise coddling of the children, or from faulty hygiene or carelessness, especially as to jud^'cious clothing, in adults. 4. A local nidus suitable for the development C'f tl:e micro-organ- ism usually exists, although tuberculous infection occasionally follows wounds and punctuies in previously healthy parts. Thus, chronically iniiamed lymphatic glands form a suitable breeding- ground for the bacillus, as also bones and joints in a state of con- gestion resulting from slight and often overlooked injuries. 5. The ultim.ate exciting cause of tuberculosis is the development within the tissues of the B. htberculosis of Koch (Plate IIL, Fig. 26). They usually occur in the form of slender rods, which are straight or slightly curved; they are about 4 or 5 /x in length and 0-2 or 0-3 /a wide, but sometimes form long branched filaments, especially in cultures. These characters differentiate them strongly from m.ost bacilli, and suggest that the organism is in reality allied to the streptothrices, and probably several members of this group may produce the disease. This is interesting in view of the close clinical resemblance between tuberculosis and the other diseases due to streptothricial infections (the .so-called actinomycosis). The tubercle bacillus is a typical acid-fast organism, and when stained by the Ziehl-Nielsen method appears in the form of slender pink rods, which are often stained only in part, so that they seem to consist of short red lengths alternating with unstained areas, the whole looking not unhke a chain of very minute streptococci. In vitro they de- velop very slowly, two or three weeks elapsing before growth is visible, and require a temperature approaching that of the body and an abundant supply of oxygen. Many culture media are available, and all are im.proved by the addition of 3 or 4 per cent, of glycerine. The colonies consist of yellowish, white, or gray scales, which have a dryish look. The tubercle bacillus does not liquefy blood-serum ; it isnon-motile, has no flagella, and is not known to possess spores. The question of the identity of human and bovine tuberculosi'-. raised h\ Koch is still under discussion. Both can apparently cause SPECIFIC INFECTIVE DISEASES 177 tuberculosis in human beings, but it seems probable that the bovine variety is mainly responsible for intestinal and surgical forms of the disease — e.g., those including glands, bones, and joints^ — whilst the human variety leads to pulmonary phthisis and to acute general tuberculosis. Cultural distinctions are readily estabhshed by the use of egg media, the bovine variety growing scantily, and the human form abundantly, especially in the presence of glycerine. Inoculation experiments in rabbits also differ, in that human tubercle produces but little effect and rarely kills, whereas the bovine virus is actively fatal. The organism gains access to the body in one or other of the following ways : {a) Most commonly by inhalation. The sputum of consumptives contains vast numbers of tubercle bacilli, and, as drying does not immediately kill them, they frequently occur in the dust and in the air. But little advance will be made towards stamping out this disease until consumptive patients can be prevented from expectora- ting in public places. Even more important is the fact that in coughing and talking the tuberculous sputum is expelled in a state of very fine division, and the infective particles remain suspended in the air for long periods. It is therefore obvious that the strict enforcement of suitable regulations is necessary for the protection of the public from this disease. Tuberculosis acquired by inhalation usually manifests itself in the form of pulmonary disease, but may appear as a primary affection of the bronchial glands, from which tfie infection may be disseminated to other organs. {b) By ingestion — e.g., of infected milk from cows with tuberculous disease of the udders. This is by no means rare in children, the bacilli entering through the tonsils or other lymphadenoid tissues of the pharynx and invading the cervical glands, or passing through the stomach imharmed and infecting the intestine and mesenteric lymph glands. Examinations of tuberculous material from the cervical glands in 72 cases in Edinburgh resulted in the discovery that in 65 {i.e., 90 per cent.) the bovine bacillus was present.* Facts such as these indicate the crying need for some effective control of the milk-supply of our great towns. (c) By inoculation. This is very unusual, and occurs chiefly in pathologists, post-mortem room porters, etc., in the form of a verruca necrogenica (p. 252). A few cases of tuberculous infection from an accidental cut inflicted by a broken sputum cup have been recorded. The laboratory diagnosis of tuberculosis is conducted on one or other of the following lines : I. By the microscopic identification of the tubercle bacillus after staining by the Ziehl-Nielsen method. This is sufficient when bacilli are present in large numbers, as in the sputum ; but when this is not the case (as frequently happens in the urine, pus, pleuritic fluids, etc.) it is necessary to have recourse to other methods. * Mitchell, Brit. Med. Journ., January 17, 1914- 178 A MANUAL OF SURGERY 2. Inoculation of susceptible animals, especially guinea-pigs, is a most delicate test. The material is usually inserted beneath the skin of the groin, and the animal killed in three weeks, when the lymph glands and probabh- the internal organs will be found tuberculous. 3. Tuberculous exudates differ from many others in that the cell which occurs most abundantly is the lymphocyte, and this fact is made use of in the examination of pleuritic and peritoneal exudates, the fluid obtained by lumbar puncture of the spinal meninges, etc. It is useful, but must not be regarded as an absolute test. 4. In some cases a portion of the lesion may be excised and submitted to microscopic examination, which should include a search for bacilli, since other infections may give rise to lesions indistinguishable microscopicall}' from tuberculosis. 5. Tuberculin (as originally prepared by Koch) is obtained by filtering off the bacilli from a glycerine-broth culture of the organism and suitably diluting the filtrate, which obviously contains merely the exotoxins. It has been, and still is, used as a diagnostic agent. When injected into a healthy person, it produces no effect, but in tuberculous persons a sharp rise of temperature occurs in a few hours. The test is not altogether devoid of danger, and should never be used unless one is certain of the absence of a secondary infection, e.g., with streptococci. Two modifications of the test are, however, useful. In Calmette's reaction a drop or two of diluted tubercuhn (i in 100 or 1 in 200) is dropped into the conjunctival sac. In tuberculous patients this is followed by mild conjunctivitis, which commences in a few hours, and has usually passed off in twent^^-four. The test is somewhat dangerous, cases of severe conjunctivitis, corneal ulceration, and even loss of the eye, having followed its use. A safer procedure is that known as Von Pirquet's skin reaction, which is apparently free from danger. It consists in inoculating a small superficial scratch with a drop of 20 or 25 per cent, tuberculin. The reaction consists in the development in from twenty-four to forty-eight hours of a small papule surrounded by a ring of hyperaemia. This test is certainly of great value in children up to twelve j-ears of age, but of course the tuberculous deposit may be of a quiescent character. As a therapeutic agent the original tuberculin failed signally, and has been replaced by many other types which are more liopeful (p. 184). 6. The opsonic index is sometimes of value in diagnosis (see p. 24). In a healthy individual it ranges between o-8 and i-2, and figures above or below that limit are highly suggestive ; whilst considerable variations, even from day to day, are very characteristic of pro- gressive tuberculosis. Pathological Anatomy.^ — The characteristic lesion is the miliary tubercle, a cellular mass 2 or 3 millimetres in diameter, and when isolated readily visible to the naked eye. \\'hen young and in course of active evolution, tubercles are soft, translucent, and of a gra}^ colour; after a time they undergo fatty degeneration and be- SPECIFIC INFECTIVE DISEASES 179 come yellowish and opaque. It is often impossible to recognise them macroscopically, since when closely set they fuse together. A typical fully-formed tubercle without retrogressive changes can be best studied in sections from the meninges in tuberculous meningitis, or from the liver or kidney in a case of general tuber- culosis. In the centre of the mass there is a giant cell* (Fig. 41), the diameter of which may be many times that of a red blood- corpuscle. It has usually an oval or circular shape, and its outline is regular; it has many oval nuclei, and these are arranged round the periphery of the cell, their long axes lying in a radial direction. Around the giant cell there is a zone of endothehoid cells, usually oval in shape, and rather larger than a leucocyte; each has a single nucleus, which closely resembles one of the nuclei of the giant cell. Beyond this comes a third or outer zone of small round inflamma- tory cells, which appear to be identical with lymphocytes. It must be understood that tubercles do not con form exactly to this typical descriptit The giant cell, example, is frequently missing, especially acute cases, or there may be several cells this type, though this is unusual. Moreover, the width of the zones varies greatly; in some cases the endothehoid cells may appear to be absent, but can be detected mixed up with the lymphocytes, which extend to the centre of the tubercle. It must be clearly understood that a ' tubercle ' in the histological sense is not peculiar to tuberculosis, in the sense of a disease due to the tubercle bacillus. It is simply the reaction of the tissues to an irritant of comparatively feeble activity. Thus it occurs in actinomycosis (see Fig. 45, where a typical histological tubercle is shown surrounding a colony of actinomyces) , and may Fig. 41.- MILIARV'TUBERCLE WITH GlANT CeLLS. (X 120.) * It may be well to notice here that three forms of giant cell occur patho- logically, and are of very different significance: (i) Those described above (the tuberculous type), having their nuclei arranged around the periphery of the cell; (2) Myeloplaxes, which occur in myelomata, and have many nuclei grouped irregularly round the centre of the cell; (3) Parenchymatous giant cells occurring in the substance of tumours, especially sarcomata and carcinomata. These have usually a single nucleus, or at most a few, which may be of large size and have no definite arrangement. i8o A MANUAL OF SURGERY be produced by an unabsorhed ligature, irritants, such as grains of pepper, etc. Hence it is not always safe to make a diagnosis of tuberculosis from an examination of sections, unless the characteristic bacilli are demonstrated. The (kvelopmeiit of a tubercle is not yet fully understood. The bacilli appear to gain access to a lymph space or to a small vessel, where they set up an overgrowth oi the endothelial cells which constitute the middle zone. The giant cell appears to be composed of a mass of these cells, in which the nuclei have undergone re- peated divisions, but the protoplasm has remained unsegmented. The source of the lymphocytes, and whether the^^ are produced locally or attracted from the blood-stream, has been hotly debated. Probably they are formed locally, perhaps by a process of budding from pre-existing endothelial cells. Miliary tubercles may be embedded in practically normal tissues, but in most cases an inflammatory process can be traced beyond the nodules. It may be of a chronic type, with an increased forma- tion of fibrous tissue; but in the more active forms the intervening structures disappear, being replaced by granulation tissue, which is often oedematous and of a gelatinous appearance. This latter is especially frequent in tuberculosis of the bones and joints. The inflammation also involves the smaller vessels, and particularly the arterioles, the lumiina of which may become greatly narrowed, or even entirely obliterated, by a process of endarteritis. True tuber- cles may also be produced in the vessel walls, but this is much rarer. In either case the vascular affection diminishes the blood-supply of the tuberculous mass (already defective owing to the non-vascularity of the tubercles), and increases the likelihood of degenerative changes, such as caseation. A fully-formed tubercle may undergo evolution along one of the following lines, according to the virulence of the bacilli and the resisting powers of the patient. 1. When the bacilh are but slightly virulent and the patient's susceptibility moderate, the tubercle undergoes fibrosis ; this is the natural method of cure. The endothelioid cells become spindle- shaped, their nuclei elongated, and the cells are converted into fibro- blasts. The periphery of the giant cell becomes drawn out into delicate ramifying processes which penetrate amongst the endothe- lioid cells, and join with them in forming fibrous tissue. The lymphocytes become less numerous, and ultimately the tubercle is represented by an ill-defined nodule of new fibrous tissue. 2. When the bacilli are virulent and the patient in a non-resistant condition, caseation occurs. This is a process of fatty degeneration and necrosis of the nodule, which is transformed into a uniform structureless mass staining only with acid dyes, such as eosin (Fig. 42). It is not often possible to demonstrate bacilli in this cheesy mass; they are there, however, as inoculation experiments show. Caseation occurs in lesions other than tuberculosis, and is due to the action of toxins on the tissues; it is especially common in this disease, since no vessels penetrate the tubercles, which are m consequence badly nourished. SPECIFIC INFECTIVE DISEASES i8i Ciire may take place at this stage by a process of fibrosis of the surrounding parts, so that the caseous mass becomes walled in by a zone of fibrous tissue; the cheesy material gradually dries up, and may become calcified. It is possible, however, that living bacilh are present even in dried-up caseous substance, and under suitable conditions recrudescence may ensue, even after an interval of years. 3. In most cases in which caseation is present, the process con- tinues to spread, and involves not only the tubercles, but also the intervening tissues; in this way a cheesy mass of considerable size may be produced. Not unfrequently an exudation of fluid takes place into this mass, and the result is a chronic tuberculous abscess. .■y-i.'-.i«f ■ •:»:^ ■-.Cry Fig. 42. — Early Stage of Tuberculous Abscess in Lymphatic Gland. (x 3°-) In the centre is a caseating focus on the point of suppuration; outside it, granulation tissue, in which several giant cells can be seen; and external to this a zone of fibro-cicatricial tissue. Wherever tubercle is deposited, a chronic abscess may form; but it occurs most frequently in bones, joints, and lymphatic glands. The pus from such an abscess consists of disintegrated fatt}' material mixed \vith a variable quantity of fluid, so that it is some- times thin and milk}^ sometimes so thick that it will scarcely flow through a cannula. It often contains masses or flakes of curdy debris, and on microscopic examination a few lymphocytes may be found, together with large quantities of fatty granular m.aterial which will not stain. Tubercle bacilli may be found without much diffi- culty in the more active cases, but in chronic forms they are often few and far between, or possiblj^ cannot be demonstrated without i82 A MANUAL OF SURGERY inoculation experiments. In old-standing cases the presence of cholesterine crystals may be recognised by the ghstening sheen or greasy appearance imparted to the pus; microscopically, they appear as flat rhomboidal plates with one corner notched out. Secondary infection with pyogenic bacteria may also lead to the formation of an abscess in a tuberculous nodule. This is an entirely different process, and one that is usually much more serious for the patient. The pus in such a case may not differ appreciably from the ordinary pus of acute abscesses, and the fact that it contains tubercle bacilli may only be demonstrable by inoculation. The microscopic appearance of a tuberculous abscess ivall is quite characteristic. The cavity is lined by a layer of gray, yellowish- gray, or pinkish, pulpy granulation tissue, containing miliary tubercles, perhaps undergoing caseation. Its colour and vitality are dependent upon the chronicity or not of the process ; the longer the abscess is in forming, the less vascular the membrane, owing to the associated sclerosis of the surrounding structures leading to compression of the bloodvessels, whilst it has been already men- tioned that endarteritis always accompanies a chronic inflammation, and helps to render the parts non- vascular. This lining membrane, when necrotic, is but loosely connected with a layer of fibro-cica- tricial material, which forms the outer part of the wall, and from which it can be readily detached by the finger or a sharp spoon. A chronic abscess forms a soft fluctuating swelling which gradually increases in size, and may become painful by exerting pressure on nerves or other sensitive structures. Should it be superficial, it will probably come directly to the surface and burst ; the pus and caseous detritus will be discharged, and possibly, if the general health is good, the wound may slowh^ granulate and heal; but not unfre- quently the tuberculous tissue left behind prevents heahng, and a tuberculous ulcer develops. A similar condition is found in connec- tion with mucous membranes, the tuberculous foci starting in the submucosa, and subsequently bursting through the mucous mem- brane (Fig. 43). Whatever their location, the ulcers are characterized by an irregular and ragged margin with undermined and congested edges; the base is formed by pulpy granulation tissue containing caseous foci (z\), which must be removed before heahng can occur. On the other hand, a deep abscess is hkely to burrow along fascial planes, and may become superficial at a distance from its original source, e.g., in a psoas abscess due to tuberculous disease of the spine. The far-reaching extent of these abscesses, the impossi- bility of dealing adequately with the lining membrane or with the original focus of the mischief, render them most difficult to treat, and fully account for the dread of opening them experienced by surgeons in pre-antiseptic days; for under the best of circumstances a sinus is hable to develop and persist, and without the most minute precautions pyogenic infection is likely to ensue, and then the result is an increased discharge of pus, absorption of the chemical products of putrefaction, aggravation of the original disease, and SPECIFIC INFECTIVE DISEASES 1^3 only too frequently death from chronic toxaemia, associated with hectic fever and amyloid disease (p. 83). Natural Cure.— A tuberculous abscess, if left to itself, does not necessarily come to the surface. Occasionally one meets with a mass of putty-like consistency lying in front of the spme m the body of a patient who has been cured of spinal disease. This is evidently the desiccated remains of a chronic abscess, the fluid portion having been absorbed, and the sohd elements left behind, encapsuled and perhaps infiltrated with lime salts. Such debris can become the seat of recurrent inflammatory mischief years later, when suppuration may suddenly occur, giving rise to what is known as a residual abscess. Fig. a. 43 .—Tuberculous Ulceration of Large Intestine. (x30-) (ZlEGLER.) Mucosa; b, submucosa; c, inner transverse muscular coat; ^ outer longi- tudinal muscular coat; e. serosa; /, tuberculous focus m solitary giana , 9 mucosa infiltrated with cells; h. tuberculous ulcer; hy. focus of softening or tuberculous abscess; i, early tubercle, with giant cell m centre; ij, caseous tubercle. Probably a large amount of cholesterine will be found among its contents. The prognosis of such an abscess is good, and a cure may often be obtained by one tapping and free lavage. One of the chief dangers of tuberculous disease is its great ten- dency to diffusion, which is sometimes Hghted up by injudiciously vigorous operative interference. It mav occur (a) locally, by direct continuity of tissue, e.g., from the testis by way of the vas deferens to the prostate and seminal vesicles, or by extension along neighbour- ing lymphatics or bloodvessels ; or (b) distant viscera or organs may become infected, probably by embohc dissemination m the blood- stream. Thus, phthisis is a not uncom.mon sequence of a similar i84 A MANUAL OF SURGERY affection of bones, joints, or lymphatic glands, whilst meningeal tuberculosis is more frec^uently associated with tuberculous affec- tions of the genital organs, (c) Moreover, any tuberculous lesion may lead to acute general tuberculosis, in which the disease is scat- tered widely throughout the body, giving rise to rapid emaciation, high fever of an intermittent type, and usually severe diarrhoea, dyspnoea, and delirium or coma, death ensuing in a lew weeks. Treatment. — When Koch first discovered the tubercle bacillus, a great impetus was given to operative treatment, and some authori- ties went so far as to maintain that every particle of the diseased tissue must be extirpated with as much care as in the case of cancer. The pendulum has now swung slowly back, and we are relying more and more on the natural powers of repair inherent in the patient, and are endeavouring to maintain and increase these in every way by suitable general and local treatment, reserving operative measures for the comparatively small class of cases which resist such treat- ment, or to the larger class where such conservative treatment, for various reasons, most often financial, cannot be carried out. I. General Treatment consists chiefly in giving the patient an abundance of fresh air, as free from germs as possible. For surgical cases residence by the seaside, especially in bracing places, is usually recommended. Equally good results will often follow residence in hilly districts, provided that they are not too heavily wooded, that there is plenty of sunshine, and that the soil dries quickly after rain. Faihng seaside or country, it is wonderful what exposure to the air in suburban gardens or even on town roofs will do. The patient must be kept warm and well wrapped up, and given an abundance of nutritious food, such as milk, cream, and eggs, in addition to fresh butcher's meat (not too much cooked), fat bacon, and other commodities which tend to increase the patient's weight. The weighing-machine must be consulted weekly, and a steady increase in weight is the best possible prognostic sign. The amount of exercise must be strictly limited so as to conserve the patient's energies towards the cure of his disease, and in this connection it is well to point out that prolonged rest in a spinal carriage is suitable for many conditions other than disease of the spine or of the lower extremities. The internal administration of cod-liver oil, the phos- phates and iodides of iron, organic preparations of iodine, guaiacol, arsenical preparations, and other tonics is also indicated. As already mentioned, many forms of tuberculin have been intro- duced since the failure of Koch's original variety as a therapeutic agent, most of them involving the trituration of the bacilli so as to include the endotoxins. Thus, Tuberculin O was prepared by grinding up the dried bacilli from young cultures, adding water, and centrifugalizing; the clear fluid thus obtained was the tuber- culin. Tuberculin R (TR) was prepared by repeating this process until no solid residuum was obtainable, and mixing all the fluids (except the Tuberculin O). A ' New Tuberculin ' has also been pre- pared, consisting of a suspension in glycerine and water of the SPECIFIC INFECTIVE DISEASES 185 ground-up substance of dried bacilli. The human and bovine forms arc both prepared in this manner, and a combined variety is also obtainable (^Tuberculin PTO). Opinions vary much as to the exact dosage of patients in difterent forms of tuberculous disease, but as a rule in surgical cases small doses should be utihzed. In a child o-ooooi milligramme given hypodermically might be employed to start with, increased gradually up to o-ooi milhgramme, whilst an adult may start with a dose of o-oooi or 0-0002 milligramme. It may also be administered by mouth, and seems to act quite well. The result may be controlled by observations of the opsonic index, but usually the temperature, pulse, and weight wih be sufficient guides as to the good or bad results. The injection'; should not be repeated under ten or fourteen days, and should never be attempted when a mixed infection is present. In some cases good results follow, but in many the effect is disappointing, and in all its use must never supersede the hj^gienic and surgical measures required in the treatment of the disease. 2. Local Treatment (Non-operative). — In the first place all tuber- culous foci must be kept free from irritation, whether extrinsic or intrinsic. Thus, wherever possible the affected part must be main- tained at rest, both from movement and pressure. Joints should be immobihzed by plaster of Paris or suitable sphnts ; the effect of the weight of the body minimized by recumbency or other means when the disease affects the spine or lower extremities; a tuberculous testis should be supported by a suspensory bandage, etc. The advent of a mixed infection must be carefuUy guarded against, if possible, and especially in connection with lymphatic glands. A patient with glandular trouble in the neck should be carefully treated for any peripheral septic lesions, such as sore hps, dirty teeth, im- petigo capitis, or otorrhoea; enlarged tonsils and adenoids should also be removed, inasmuch as bacteria are often lodged in the crypts of the former or between the lamellae of the latter. These measures may be supplemented by counter-irritation — e.g., blisters, iodine paint, or Scott's dressing, and Bier's method of pas- sive congestion (p. 41). Parenchymatous injections of iodoform, or of some sclerogenic agent such as chloride of zinc, have also been em- ployed, acting probably by determining an increased flow of blood to the part, and thus strengthening the protective mechanism of Nature. 3. Operative Treatment is required when the measures indicated above have failed to check the disease, or when accidental comphca- tions — e.g., abscesses — develop in the course of the case, or when the disease is so extensive or progressive as to make it inadvisable to trust alone to the natural processes of repair. Obviously, extirpa- tion of the tubercular focus, if practicable, is the ideal treatment in all cases, and for some conditions no other treatment need be considered. Thus, in superficial lymphatic glands in the neck excision is the best tieatment whenever progress to recovery is delayed or absent. In many other conditions, as in bone and joint disease, total extirpation is practicable by excision or amputa- i86 A MANUAL OF SURGERY tion ; but such a proposal involves the consideration of many other questions, such as the operative risk, the possibility of diffusing tuberculous material into the system generally by the necessary manipulations, the possible infection of the wound or surrounding healthy tissues by tubercle, and the degree of post-operative dis- ability that may result. The cure by a local excision is not always certain, and the after-treatment is often very prolonged. On the other hand. Nature's cure may be equally uncertain, possibly less satisfactory, and the chances of dissemination and diffusion are not absent. The final decision as to the advisability of undertaking a radical operation of this type must be made bv a careful considera- tion of (i) the stage of the disease, whether early or late; (2) its position and extent; (3) its character, v/hether active and progres- sive, or chronic; (4) the probable resisting power of the patient to the spread of the disease; and (5) the hygienic conditions, etc., under which treatment has to be undertaken. Partial operations are sometimes required, consisting in cutting or scraping away as nmch of the diseased tissues as is practicable, swabbing out the cavity thus produced with some powerful germi- cide, such as liquefied carbolic acid, and dressing the part with gauze soaked in some modifying or antiseptic substance, such as an emulsion of iodoform, the wound being left to heal by granulation. Diseased bones, glands, and sinuses have often to be dealt with in this way, and satisfactory cures ma}' be established after a while. Open-air treatment must be instituted at the same time, or com- menced as soon after as possible. Theoretically, it is better to do the operation in the country rather than in town, but, of course, this is not always practicable. When the patient has more than one focus of disease — e.g., pulmonary phthisis at the same time as disease of some joint, or of the testis — it is often found that no progress is being made towards recovery, in spite of suitable treatment. It then may be advisable to remove entirely one of the foci, if such be possible, when steady, and perhaps rapid, repair will show itself in the other. The manifestations of tubercle as it affects special organs are dealt with elsewhere under the appropriate headings (see diseases of skin, bones, joints, lymphatic glands, kidney, testis, etc.). The Treatment of Chronic Tuberculous Abscess must necessarily vary considerably according to the position and condition of the part. A superficial chronic abscess is comparatively easy to treat, but one placed deeply, and connected with such an affection as tuberculous disease of the spine, must be approached with the utmost caution, in order to avoid pyogenic contamination. 1. In certain cases of external chronic abscess, especially when connected with lymphatic glands, it may be possible to dissect out the whole cavity en masse, and if such be feasible, it is the most satisfactory plan to adopt. 2. WTien the skin is thin and undermined, and the abscess nearly pointing, it is hopeless to avoid leaving an open wound ; and hence the condition must be treated by the open method. The cavity is freely incised, diseased tissue scraped away, unhealthy skin removed, and the cavity, if not too large or SPECIFIC INFECTIVE DISEASES 187 deep, treated with pure carbolic acid or chloride of zinc (gr. xl. ad 51.), packed with gauze infiltrated with iodoform, and allowed to heal from the bottom. Healing is often slow, if sure; but a tuberculous abscess ought never to be allowed to reach a condition in which it is necessary to leave an open wound of this type. 3. When a chronic abscess is situated deeply and covered with healthy tissues, treatment consists in emptying the cavity of its contents, removing as far as possible the tuberculous lining membrane, and closing up the wound after introducing into the cavity some modifying or antiseptic injection. In many cases tapping with trocar and cannula suffices for this purpose. The modus operandi is as follows: The skin over the abscess is incised, and a large trocar and cannula introduced obliquely so as tc allow the contents to escape. The cavity is then washed out with sterilized salt solution (3i. ad Oi.) at a temperature of 105° to 110° F., and the abscess wall gently kneaded from the outside so as to detach cuidy material and necrotic pyogenic mem- brane. This is continued until the escaping fluid is nearly clear or only slightly opalescent, and then a suitable quantity of a sterihzed emulsion of iodoform in glycerine (10 per cent.) is introduced, and the opening closed by stitches. In this way it is often possible to cure a chronic abscess at one sitting. The treatment is most likely to be efficacious when all active bone or joint disease has disappeared, and residual abscesses are the most favour- able of all. The good results are probably due in part to the liberation of iodine and its antiseptic influence over the tubercle bacilli ; but the stimulating effect on the tissues in the direction of leucocytosis by the operative manipu- lations and the injected material cannot be overlooked. Where the disease is more active, it is often wiser to make an mcision into the abscess sufhcientlv large to introduce the finger. Through this opening diseased bone can pos'sibly be removed and the lining wall scraped, and for this purpose a Barker's flushing gouge is often useful. The instrument con- sists of a gouge or sharp spoon with a long hollow handle, which communicates by a tube with a reservoir of fluid placed at some height above the patient. During its application the constant rush of w^ater or lotion through the handle clears the gouge and removes the debris. It is admirably adapted for certain cases, but its use needs considerable care, as the sharp edge can readily scrape through an abscess wall or lay open a vein. If much bleeding occurs, the cavity should be irrigated with hot sterilized salt solution. The wounds are subsequently closed after injecting the iodoform emulsion, and an a,ttempt is made to gain immediate healing of the denuded cavity by bringing the sides into apposition by suitable pressure. Not uncommonly the cavity refills in the course of three or four weeks, and the irrigation may then have to be repeated. The fluid withdrawn on this occasion is often blood-stained serum, perhaps smelling strongly of iodoform. It is possible that in such cases a sinus develops sooner or later, and has to be dealt with by simple drainage. It is often a matter of considerable difficulty to secure the healing of a tuberculous sinus, owing partly to the existence of diseased bone or other trouble at its extremity, partly to defective drainage, and also in part to the exist- ence of tuberculous tissue in its wall; the added presence of a pyogenic in- fection will still further delay healing. Not unfrequently sinuses of this type burrow widely, and it is sometimes difficult to ascertain the extent of the mischief with a probe. In such cases help may be obtained by injecting the sinus with a paste consisting of bismuth subnitrate i part and white vaseline 2 parts, and examining the extent of the trouble by radiography. This process has the advantage of hastening healing of the sinus owing to the chemotactic, bactericidal, and astringent influence of the paste. In acute suppurative lesions, or where large cavities are involved — e.g., in empyema this proceeding should not be employed, as toxic effects may follow, and even cause death ; the removal of the bismuth paste for toxic troubles is hastened by injecting the sinus with warm oil. Of course, all ordinary surgical measures —e.g., removal of diseased bone or foreign bodies, and free exit for discharges — must be provided when necessary. A MANUAL OF SURGERY Glanders. Glanders is primarily a disease of the horse, ass, or mule, which is trans- mitted to men by direct inoculation, and hence is usually seen only in stable attendants and those brought in contact with such animals. The disease is due to a definite micro-organism, the Bacillus mallei, -which was isolated about 1882 by Schutz and Loffler, ami has since been cultivated outside the body ; the ex- perimental evidence as to its being the cause of the malady is (juite complete. In Horses and other animals glanders manifests itself by a formation of larger or smaller rounded swellings in the mucous membrane of the nose, which break down and ulcerate, giving rise to a thin, sero-purulent discharge, and perhaps to destruction of the bones and cartilages. Ihe lymphatic glands, especially those under the jaw, early become enlarged, constituting the ' farcy buds ' of farriers, and by their ulceration may leave ragged, foul, sujipurating sores. The lymphatic trunks to and from the glands are involved (' corded veins '), whilst the lungs and internal viscera may also be infected, and undergo destructive changes. The disease is often chronic, lasting perhaps for years; any undue strain put upon the animal may lead to an acute outbreak, which is fatal in six to twelve days. In Man, glanders generally starts about the hands and face, but occasionally in the nasal mucous membrane. In acute cases the incubation period lasts from three to five days, and is succeeded by the occurrence of malaise and febrile disturbance, followed by severe pains in the bones and joints. The site of inoculation becomes swollen and angry, whilst the lymphatics leading from this to the nearest glands are enlarged and infiamed. An eruption of papules, which somewhat resembles those of small-pox, occurs around the primary lesion, on the face, and in other parts of the body; but each papule, as also the primary lesion, breaks down and goes on to the formation of an ecthymatous-looking ulcer. It is not an uncommon feature of these sores, when placed over a bony surface, to involve the periosteum and lay bare the subjacent bone. Similar changes occur in the viscera, muscles, and joints, and these being associated w-ith high fever of an asthenic type may suggest the existence of pjsemia. In such cases death may ensue in seven to ten days. In chronic glanders similar symptoms are met with, but the course is slower; there is little or no fever ; the disease is less extensive, and intermissions are not uncommon. Total recovery is stated to occur in 50 per cent, of the cases. It may affect the nasal mucosa, leading to chronic ulceration, but more com- monly it appears in the shape of chronic abscesses, which often extend deeply, even down to the bones, and are very difficult to deal with. In one case the disease gradually spread down along the peronei muscles, and in spite of repeated scrapings and the application of pure carbolic acid, the process was only arrested at the point where the peroneus longus disappears into the foot. It is important to determine the Diagnosis as early as possible, in order to undertaken energetic local treatment. The local lesions are distinguished from small-pox by the presence of the characteristic bacilli. in the discharge, by the fact that they involve the subcutaneous tissues more extensively, and by the absence of umbilication. Chronic cases resemble syphilis and iuherculosis, but the history of exposure to infection from animals suffering from the disease is most important, as al.so the result of cultivations made from the discharge. When the bacilli are grown on potatoes, a colony of a yellowish, honey-like character forms in two or three days, which gradually turns to a chocolate- brown colour. Inoculation of the peritoneal cavity of a guinea-pig with some of the secretion leads to acute orchitis in two or three days, the testicles being enlarged and the skin over them reddened; the affection usually runs on to suppuration. Mallein, a sterilized culture of the organisms, may be used for diagnostic purposes in animals, the injection of a minute dose causing a sharp febrile reaction if glanders is present; but it is of no use for diagnosis or treat- ment in the human subject. Treatment in acute cases can be successful only when undertaken early, and before general infection has ensued. The local foci should be thoroughly SPECIFIC INFECTIVE DISEASES 189 extirpated, either by the knife, or by scraping and applying some active cauterizing agent. The same treatment must be adopted m chronic cases, and may then need frequent repetition. Leprosy. Leprosy (syn.: lepra, or elephantiasis Grcscorum) is a general infective disease due to the Bacillus Icprcs, characterized by the formation of granulation-hke neoplasms, which arise primarily in connection with the skm and nerves The bacillus of leprosy closely resembles that of tuberculosis, and, like it, is Gram-positive and strongly acid-fast, staining by Ziehl-Nielsen's method. Leprosy bacilli are usually straighter and more uniform than those of tubercle; and when seen in sections of leprous material they are often present in far larger numbers than are the tubercle bacilli in tuberculous tissues; they are usually packed together hke bundles of cigarettes (Plate III., Fig. 29) Numerous attempts have been made to cultivate them, and a few doubttui successes have been claimed. All attempts to inoculate ammals have tailed, and inoculation constitutes the best and most definite test between the two Leprosy, though formerly common in this country, is now only observed in imported cases. In Iceland, Norway, Russia, and the East, it is still fre- quently met with, although the method of segregation of lepers enforced in Norway has greatly diminished the number in that country. It is apparently very slightly contagious. The medical attendants and nurses in leper hos- pitals rarely contract the disease, and inoculation experiments m criminals have led to negative results. The late Sir Jonathan Hutchinson held strong y that infection only takes place in persons who eat badly-cured or partially decomposing fish.' Opinions diliEer as to whether the disease is transmitted to the descendants, but probably this is not the case. Symptoms.— Two chief varieties of leprosy exist, viz., the tuberculated, and the anaesthetic or non-tuberculated; but the two are often associated. _ Tuberculated or Cutaneous Leprosy is the form most commonly seen m Europe. Nothing may be noticed for months or years after exposure to tne contagion, and then, after a period of malaise, associated with d^^spepsia, diarrhcea, and drowsiness, a distinct febrile attack is noted, lasting for da.ys or weeks ; it may be ushered in by a rigor, and the temperature is usually of a remittent type.' This is followed by, or associated with, the appearance of shiny red, hvper^mic spots, which are from the first infiltrated, slightly raised, and hjTperjesthetic ; they are usually situated on the forehead or cheeks on the outer side of the thighs, or on the front of the forearms. They ma}- fade away and disappear entirely, and then again become evident, or fresh patches may be developed, and always with febrile symptoms. After a variable period ' tuberculation ' ensues: numbers of httle pink nodules form over the site of one or more of the er\^hematous patches, and these gradually increase in size and coalesce, until possibly thev become as large as a walnut or hen s egg and are then of a brownish-yellow colour. Almost any part of the surface of the body may be invaded in" this manner, but the face is especially prone to be involved,' and the resulting disfigurement is very marked a curious leonine appearance being imparted to the features (Fig. 44). The nodules are more or less anaesthetic from the pressure of the infiltration on the nerves, and the ultimate result of the process may vary considerably; resolution sometimes occurs, or the nodules may be transformed into depressed and pigmented cicatrices, or ulceration may ensue. Visceral comphcations and enlargement of the lymphatic glands follow, any fresh deposit being associated with febrile phenomena. The testes atrophy, and sexual power is lost m both sexes. Death is usually due to septic phenomena, larjmgeal obstruction, or disease of the lungs or kidneys; but the patient may live for many years. The nodules consist of masses of granulation tissue, and scattered tfirougti them are numbers of large cells, containing multitudes of bacilli. Ansesthetic or Non-tuberculated Leprosy is the most common form met ^^^.tn in hot climates . The earliest phenomena consist in a certain amount ot maiaise I go A MANUAL OF SURGERY without appreciable lever, together with sharp tingling or lancinating pains and tenderness along the course of certain peripheral nerves. The ulnar, median, peroneal, and saphenous nerves are those most often affected. This is followed by muscular weakness, running on finall}' to paralysis, various modifications of sensation, and trophic phenomena, involving at first only the skin, but later on attacking bones, joints, and muscles. Circular yel- lowish-white patches are observed in the skin, spreading peripherally, and tending to run together, forming large irregular ovals; the border is often Fig. 44. — Leprosy. (From a Photograph kindly lent by W. Thelwall Thomas, Esq., of Liverpool.) The patient had lived as a sailor, and contracted leprosy abroad many years before. The facial aspect is very characteristic, and the forearms are enlarged owing to leprous deposits in the subcutaneous nerves. raised, and hypersensitive, but the central portions become atrophic, dry, white, and anaesthetic. The anaesthesia gradually spreads, and serious lesions, partly due to trauma, partly arising from trophic changes, result. The muscles atrophy and contract, and give rise to deformity, the hands sometimes be- coming markedly ' clawed,' as in ulnar paralysis. Interstitial absorption of the bones of the peripheral portions of the limbs may lead the fingers, toes, and other portions to shrivel and disappear, preceded by ankjdosis of the joints. The affected nerves can usually be felt distinctly enlarged and tender. SPECIFIC INFECTIVE DISEASES 191 Visceral lesions arc not so marked in this as in the other form of the disease, and the patient may retain a considerable degree of health and strength, while his sexual powers are not much interfered with. Finally he dies from general debility, or from various complications, but the case may last twenty or more years. The Treatment is still very unsatisfactory. Chaulmoogra oil, administered both internally and externally, is the drug most frequently depended on, whilst intramuscular injections of corrosive sublimate have been employed with some success. Some good results have been attributed to the use hypodermically of Nastin (Deycke), a neutral fat extracted from cultures of the Streptothrix leproides, obtained from leprous nodules. It is employed in combination with benzoyl chloride (Nastin B), and acts by withdrawing fats from the lepra '^ bacilli, which are thereby killed. Hypodermic injections cause a reaction of an inflammatory nature and necrosis of the leprous tissue. Amputation of extremities is sometimes useful in late stages of the disease. Actinomycosis. Actinomycosis is a disease of man and cattle, due to infection by various types of a group of streptothrices called Actinomyces (ray fungus). The organisms found in man are rarely identical with those present in the bovine variety, the differences being mainly in the staining reactions. Actinomycosis in Cattle is usually acquired by eating infected barley or other cereals, fragments of which are sometimes found in the primary lesion. It most commonly affects the tongue or jaw, and causes a chronic fibrosing inflammation (the wooden tongue, big jaw, or ' osteo-sarcoma ' of cattle). These often suppurate in many places, producing multiple chronic abscesses, which discharge externally and leave a diffuse inflammatory mass riddled with sinuses. The pus from such abscesses contains small yellow or brown gritty bodies (often looking like grains of iodoform) which consist of colonies of the fupgi, sometimes undergoing calcareous changes. The structure of these colonies may be made out by crushing the particles between two slides 192 A MANUAL OF SURGERY and staining the film thus produced, but is better seen by an examination of sections, liat h colony consists of a tangled mass of mycelium, the central portion of which often shows the presence of ' chain sj)ores,' whilst the peri- pheral part has a definite radial arrangement, from which the organism derives its name. The mycelial filaments which project from the outer portion of the colony are often greatly thickened, and appear in the form of Indian clubs, the narrow ends being pointed inwards (Fig. 45). These ' clubs ' were for- merly thought to be rej^roductive organs, but are probably caused by a degeneration of the sheaths of the filaments. In Man the disease is very similar in its clinical characters, and may be caused by a number of organisms belonging to the streptothrix group, so that, strictly speaking, it is not a specific disease. The organisms form colonies in the tissues resembling those seen in cattle, but the radially-arranged clubs at the periphery are difficult to stain, and hence usually appear to be absent (Fig. 46). The cultural characters in different cases are not constant, but all the .streptothrices which affect man stain by Gram's method. Actinomycosis is found to be not uncommon when a systematic ex- amination is made of the pus, etc., from all patients treated ; when this is not done, a considerable number are diagnosed as tuberculosis or sy- philis. It usually occurs in farmers, millers, and others who are brought in contact with grain, and in a few cases infection from these materials may be definitely traced. In many cases the fungus enters the body from a carious tooth or from the tonsil, and the primary lesion is usually somewhere in the region of the mouth. Less frequently it may occur in other parts of the alimen- tary canal, especially in the caecum, appendix (causing a condition which may not be diagnosed from ordinary appendicitis in the absence of a microscopic examination), or in the The apparent absence of the radially- liver, giving rise to a very character- arranged clubs ' is very obvious. istic reticulated swelling, in which diffuse suppuration may occur. Again, it may be primary in the lung, causing lesions similar to those of tuberculosis, and often giving rise to localized empyemata. The skin may also be affected, but in the majority of cases only by extension from the deeper tissues. Lastly, a few cases of primary actinomycosis of the central nervous system have been recorded. The structure of these lesions resembles that of a tubercle, except that giant cells are perhaps less frecjuent (the disease being usually more rapid), and the centre of the nodule is occupied by a characteristic colony of the fungus. At a later period the lesion breaks down and forms pus, containing the granular nodules described above. The disease is very chronic, and has a tendency to spread locally ; although not dangerous in itself, it may become so by attacking important organs, or by generalization, giving rise to pyaemic abscesses in all parts of the body. The commonest site for the primary lesion is close to the angle of the jaw, where it constitutes a cervico-facial growth of tolerably characteristic appear- ance. At first the mass has a smooth, regular, and even surface, and merges gradually into the surrounding tissues; the skin over it is usually hyperaemic. As time passes, little nodular excrescences, with a peculiar yellowish apex, form here and there on the surface of the tumour, and these finally soften, point, and burst, giving exit to a small amount of glutinous pus, in which the actino- FiG. 46. — Colony of Human Actino- myces, AS SEEN IN Pus. SPECIFIC INFECTIVE DISEASES 193 myces can be demonstrated. When all the mycelium has Deen Uib- charged, the abscess contracts and the wound closes. The cicatrization induced by the constant repetition of this process makes the surface of the mass curiously nodular and puckered (Fig. 47), and this appearance, when present, is almost pathognomonic. At other times sinuses persist, and the affected area may become riddled with them. Trismus is an almost constant symptom in the cervico-facial form of the disease, coming on early, and being apparently independent of the size of the mass or its involvement of nerve... Treatment consists in the administration of large doses of iodide of potas- sium (grs. 20 to 30 three times a day) or of some of the organic preparations of iodine, which seem to have almost as great an influence in this disease as in syphilis. This alone may suffice when there is no open wound ; but if open sores are present, surgical measures must also be employed. Extirpation of all the infiltrated tissue, either by the knife or by vigorous scraping after opening up sinuses, should be undertaken, and the part fieely cauterized; :^ Fig. 47. — Cervico-Facial Actinomycosis. (By kind Permission of Sir Malcom Morris.) in fact, it must be treated in exactly the same way as a diffuse tuberculous mass. This can, however, only be carried out very partially in the visceral affections, where the disease may prove fatal, n-ot so much from the primary affection as from associated pyogenic complications. . . . ^ Mycetoma or Madura Foot is a condition somewhat akin to, but not identical with, actinomycosis. It occurs in natives of India and some other tropical countries, and is induced by walking bare-footed, infection following some slight abrasion or injury. It is characterized by the development of black or yellow nodules, in the centre of an indurated inflamed area ;• the nodules break down and give exit to pus, which contains blacMsh nodules constituted by the organism. Gradually these abscesses spread throughout the foot., which becomes disorganized and distorted, and the disease may even encroach on the leg if neglected. The affection is extremely chronic, and merely spreads by local extension. Treatment consists in amputation of the limb, if limited scraping and disinfection are insufficient. The administration of iodides is useless. 13 CHAPTER IX. TUMOURS AND CYSTS. Although the term ' tumour ' is often used for any abnormal swelling which may be met with in the body, yet lor scientific purposes its application is much more limited. A tumour may be defined as ' a mass of new formation that tends to grow or persist, without fulfilling any physiological function, and with no typical termination.' The fact that rt has no typical termination dis- tinguishes it from inflammatory overgrowths, which always lead sooner or later to the formation of fibro-cicatricial tissue or some modification of it ; inflammatory growths, moreover, ma}' disappear completely, and often diminisli in size temporarily. Pure hyper- trophies are excluded by this definition, since they always depend more or less on some increased physiological function, and are composed of an increased development of normal tissiies, as, for instance, the blacksmith's biceps. Congenital overgrowth of a limb or portion of a limb also occurs, and is known as ' gigantism '; it cannot be considered a tumour, being merely an exaggerated development of normal tissues. .etiology. — The most definite fact known is that in a considerable number of cases (variously calculated at 7 to 14 per cent.) they follow some injury or irritation, which determines an abnormal development of the tissues of the part. Thus, an adenoma of the breast is often attributed to a blow, and tlie irritation of a clay pipe may produce epithelioma of the lip. In India the natives of Kashmir wear under their robes an earthenware pot or kangri, suspended from the waist, and containing smouldering charcoal ; the heat of this leads to chronic eczema of the abdominal wall, and this is in turn frequently followed by squamous-celled carcinoma. In some cases the irritation may be due to chemical substances such as soot (in the case of chimney-sweeps), tar, or petroleum, all of which occasionally lead to the production of epithelioma in persons brought much into contact with them ; except in these cases, occupation is not known to exercise any influence m the causation of tumours. The question of heredity as a predisposing factor is still unsettled. It was formerly thought to be of considerable importance, but recent observations and statistics have not strengthened this \aew. 19.1 TUMOURS AND CYSTS 195 The geographical distribution of tumours has only been inves- tigated in the case of cancer. The result tends to show that the disease is most common in low-lying, damp, well-wooded areas, especially if they are liable to periodical floods, as, for example, the Thames Valley. It also seems proved that certain houses claim more than their average proportion of victims from cancer; this has been taken to indicate an infectious origin for the disease, but other interpretations are possible. The age-incidence varies with the type of tumour. Most innocent forms may occur at any age, though to this rule there are several interesting exceptions — e.g., adenomata of the breast and ftbro- myomata of the uterus, which grow only during the period of functional activity; and certain osteomata, which arise from ossi- fying cartilage and continue their growth only during the acti\nty of that structure. In the malignant tumours the age-incidence is better marked. Sarcomata occur at all ages, but are especially common in the first half of life, whilst carcinomata are rare before the age of thirty, and most common after forty. The effect of sex on the incidence of the innocent tumours and the sarcomata is not marked. Women are more liable to carcinomata than males, in large measure owing to the frequency wth which this disease attacks the uterus and breast ; cancer of the mouth and other portions of the alimentary canal is more common in men. Many theories have been brought forward to explain the patho- genesis of tumours, but the only ones that need be mentioned are the three following: (i) The parasitic theory rests mainly on analogy with undoubtedly infectious diseases, and has been formulated chiefly for the malignant growths. There is at first sight a close clinical similarity between cancer and the infective granulomata, especially tubercle; in each there is a primary lesion marked by invasion and destruction of tissues, followed by secondary growths in the glands or internal organs, reproducing the structure of the primary focus. But the analog}^ is only superficial ; the secondary tubercles are due to the carrying of the infective agents (the bacilli) in the blood or lymphatic stream to distant regions, where they are deposited, and continue to grow and give rise to an inflammatory reaction. The secondary nodules of cancer are caused by the transference in the blood or lymph of actual cancer cells derived from the primary tum.our, which are deposited elsewhere, and con- tinue their growth undisturbed, in spite of their change of en\dron- ment. So-called ' cancer parasites ' have been described by numer- ous pathologists, but are now generally recognised as degenerated leucoc3^tes or red corpuscles within the cancer cells, or as portions of nuclei, etc. A few investigators claim to have cultivated blasto- mycetes from cancers, and to have produced cancers by the injection of the cultures into animals, but these results have not been generally accepted. Recent researches, though not solving the problems of the origin and nature of cancer, have yielded much valuable and suggestive 196 A MANUAL OF SURGERY information. Most of these researches have been carried out in mice, the tumours of which (adeno-carcinoma of the breast, sarcoma, chondroma, etc.) are inoculable into other animals of the same species. The mouse is, however, the only animal in which carcinoma has been successfully propagated (Bashford). It has been possible to transfer mouse-cancer to rats, but the disease quickly dies out. It is essential that living cells or fragments of tissue should be inoculated if successful results are to follow. The fragment con- tinues to grow in its new host, and, since the transplantations can be carried on (as far as is known) indeftnitely, a minute portion may continue to develop in one animal after another until many pounds' weight of cancer has been produced. It would appear, therefore, that the essential character of a malignant cell is its power of indehnite growth and division independently of the surrounding tissues, provided, of course, that these are of suitable nature. The connective tissue of the graft atrophies and disappears. The inocu- lation of these tumours is not comparable with that of tubercle or other infective diseases. In the latter case, any cehs derived from the first animal soon die, but the micro-organism continues to live and produce fresh tissue changes in the new host. In the former, the cells themselves five and divide, and do not induce any cancerous changes in the cells of the second animal. Hence there is some analogy between these cancer cells and the known parasites, which are capable of indefinite life and subdivision in suitable hosts ; more- over, if cancer is actually due to a parasite (which appears more and more improbable), this must be contained within the malignant cell. Inoculation experiments are followed by a comparatively small proportion of successes, indicating that conditions must be present in the tissues or blood of the host which are favourable to the growth of the tumour. Some tumours are, however, highly virulent, yield- ing a large proportion of successes, and there is usually an increase in virulence brought about by repeated inoculations. The question of immunity has also been raised. That natural immunity exists follows from the facts that not all inoculations are attended by success, and that mice from different localities show very different degrees of susceptibihty to the same tumour. That immunity can be acquired appears from the observation that a mouse unsuccessfully inoculated with a tumour of low virulence becomes refractory to tumours of great infective power to normal mice. 2. The theory of foetal residues was originated by Virchow's sug- gestion that in the ossihcation of cartilage small islets might be left, which subsequently grow and develop into chondromata; the idea was at a later date expanded by Cohnheim to include all tumours. It certainly affords an explanation of some varieties of growth, such, for instance, as the dermoid cysts, which originate in portions of epidermic structures left behind during embryonic development; but it fails to explain the origin of most tumours. 3. Ribbert's theory of tissue tension is especially applicable to the. carcinomata, and attributes the initial defect to a weakness in the connective tissues in proximity to the epithelial cells, so that TUMOURS AND CYSTS 197 the latter are allowed to proliferate and invade the surrounding structures. The balance of evidence seems decidedly opposed to this theory, although it affords a satisfactory explanation of the frequency of carcinomata in advanced life, when the vitality and resisting power of the tissues may be assumed to be lowered. Tumours may be divided into two great classes from a clinical standpoint, viz., the benign and the mahgnant. Benign or Simple Tumours are characterized by their more or less exact limitation, being frequently encapsuled, and by their method of growth. The surrounding tissues are merely pushed aside and compressed by the increasing growth of the part ; pain and atrophy are sometimes caused by this pressure. The capsule is formed by an ensheathing layer of fibro- cellular tissue, the outcome of the chronic irritation and inflammation engendered by the growth ; hence enucleation is easy, and recurrence uncommon. They are not unfrequently multiple, and may be hereditary ; but there is no tendency to produce secondary growths. They cause no cachexia and do not threaten hfe unless developing in or upon some part whereby the vital functions are impaired. Malignant Tumours, unless removed by operation, are almost in- variably fatal. The following are the chief characteristics of mahgnancy: (i) The primary growth is usually single, rarely multi- ple. (2) It progresses steadily and constantly, but with varying rapidity in different cases. (3) The local development is charac- terized by an infiltration of the surrounding tissues, which are gradually destroyed and replaced by the tumour substance. A capsule is rarely formed, or, if at all, only in the early stages, and thus the limits of the growth are not clearly defined. Moreover, many varieties spread locally along the efferent lymphatics, and hence, although the growth may appear to have been completely excised, recurrences are very common, owing to the non-removal of these invisible extensions of the disease into apparently normal tissue. If a malignant tumour with all its ramifications is com- pletely removed, it does not recur. (4) When a mahgnant tumour invades the skin, it usually leads to ulceration and is very Hable to secondary infection, and then not uncommonly a foul fungating mass results (the fungus hcematodes of the older pathologists). (5) Secondary deposits due to embohc dissemination of the cells of the growth are often found in neighbouring lymphatic glands or distant viscera. (6) Cachexia develops injthe later stages, partly due to the pain, partly to the pressure of the growth on important structures, and in part to the absorption of toxic products from the tumour. The patient becomes thin and emaciated, the face drawn and with an expression of pain on it ; the appetite is impaired and the skin often sallow and earthy-looking. Pyrexia is usually absent unless ulceration of the growth occurs, as is usually the case in the stomach or intestine; some rapidly-growing sarcomata of bones are also associated with fever. (7) Finally, death ends the scene, after a longer or shorter period of suffering. The degree of malignancy varies with different tumours. In 198 A MANUAL OF SURGERY some the local phenomena predominate, whilst in others the con- stitutional symptoms are the more important. Thus, rodent ulcer is slow in its progress, and produces no visceral deposits; it destroys life merely by implication of vntal parts. Melanotic sarcoma, on the other hand, may produce only a small i)rimary growth, but the most extensively diffused secondary deposits may form in the viscera. The sarcomata are usually disseminated by the blood-stream, and hence secondarv growths are not very common in lymphatic glands, whilst the carcinomata spread bv means of the lymphatics. Even among the latter considerable differences are manifested; thus, in glandular cancer secondary growths occur both in the lymphatics and the viscera; whilst in squamous epithelioma neighbouring lymphatics are affected, but the viscera usually escape. As a general rule malignant tumours differ structurally from the innocent forms in deviating more widely from the normal histology of the region in which they develop ; thus, a simple adeno-fibroma of the breast approaches more closely to the structure of the normal mammary gland than does an adeno-carcinoma of the same region. This deviation from the normal is called anaplasia, and in general the greater the degree of anaplasia the greater the malignancy. It is seen in the structure of the cells as well as in their arrangement, and in highly malignant tumours the constituent cells to a large extent lose their distinctive appearance [e.g., prickle-cells lose their prickles, etc.), and revert to more simple forms. Highly specialized functions are also lost or badly performed. Classification of Tumours. — The following is a practical scheme of classification, based partly on the structure of the tumour, and partly on that of the tissue from which it originates : I. Tumours derived from the Connective Tissues : {a) Of embryonic tvpe : Sarcoma. (b) Of adult type: Myxoma, lipoma, fibroma, etc. II. Tumours composed Wholly or Chiefly of Epithelium. — These may resemble papillse or glands, or may infiltrate the connective tissue in a wholly irregular way, and hence may be subdivided as follows: (a) ^Tumours resembling papillse: r Squamous-celled. f , ' I Papilloma \ Cuboidal-celled. [ Columnar-celled. {h) Tumours resembling glands: A 1^ ™ rCuboidal-celled. Adenoma ^ ^ , ,-. . \ Columnar-celled. (c) Atypical tumours: {Squamous-celled (epithelioma). Cuboidal-celled (glandular carcinoma). Columnar-celled. III. Tumours growing from Endothelium : Endothelioma and perithelioma. IV. Tumours formed by the Inclusion of Part of another Embryo ; Teratoma TUMOURS AND CYSTS 199 I. The Connective-Tissue Group of Tumours : (i) Tumours composed of Embryonic Connective Tissue. Sarcoma ( = a flesh-like tumour; Greek, crap^, flesh). — A sarcoma is a mahgnant tumour which consists of a parenchyma, formed of cells which have taken on the power of continued and apparently limitless growth, and of a more or less inert supporting network or stroma consisting of fibrous tissue, bloodvessels, etc. It is charac- teristic of the sarcomata that these two elements are intimately mingled together, each parench^nna cell being separated from its neighbours by delicate fibrilte of the stroma; in the carcinomata the parenchvma cells occur in masses or alveoli which are enclosed by, and sharply marked off from, the stroma. Sarcomata are of mesoblastic origin, and the parenchjana cells resemble those from which the connective tissues are formed in the embryo both in shape and in their capacity for continued growth; hence they are often referred to as embryonic connective-tissue cells. Inflamma- tory new formations are also composed of mesoblastic cells which have assumed the power of growth, and in both cases these em- bryonic cells may undergo organization into more mature forms of connective tissue, such as fibrous tissue or bone. There is, how- ever, this marked difference between the two : the inflammatory new- formations arise as the result of a definite irritant, and cease to spread when that irritant ceases to act; whereas the sarcomata usually arise without apparent cause, and continue to spread indefinitely. A sarcoma may at first be well defined or even encapsulated ; but many forms from the first, and all later on, infiltrate the surrounding tissues, replacing them with their own particular structure, a process which can be well observed in sarcomata of muscles. The blood- supply is very abundant, and, indeed, may be so free as to cause the tumour to pulsate. The vessels consist of spaces or clefts within the tumour substance, and are lined merely by the most delicate endothelium ; the arteries and veins in the neighbourhood are much dilated. Interstitial haemorrhage is frequent, owing to the thinness of the vessel walls, and cysts may in this way be produced. Dis- semination is usually dependent on the relation of the tumour to the veins. As already stated, the veins communicate with spaces hollowed out of the tumour substance; into and along these the sarcomatous tissue may burrow, until the apex of this intravascular growth projects into the lumen of a vessel in which the blood is freely circulating. It may be detached by some shght mechanical injury, and is then carried away as a malignant embolus ; if a large portion is set free, as in sarcoma of the kidney, it may lodge in the right side of the heart, or in the lungs, and cause a fatal result. Smaller emboli are either detained in the lungs, or pass through into the general circulation, giving rise to secondary growths wherever they are arrested ; general visceral implication is often secondary to the pul- monary growths. Occasionally dissemination by way of the lym- phatic glands is met with, especially in melanotic sarcoma of the skin, lympho-sarcoma, and sarcoma of the tonsil, testis, and thyroid 200 A MANUAL OF SURGERY body, and tliis in spite of the fact that lyni})liatics are not known to be present in sarcomata. The various forms of sarcoma described ])elo\v liavc a tendency to become organized into tissues which ])ear a close resemblance to the normal connective tissues, and tumours in which this process has taken place to a marked extent often receive special names — e.g., fibro-sarcoma, in which the parench^ona cells become organized into fibrous tissue; osteo-sarcoma, in which they develop into bone; chondro-sarcoma; and lipo-sarcoma. The secondar}- deposits usuallv resemble closely the parent tumour; thus masses of osteoid ,, _,^^ _ -,^.^ :• ■..-,- tissue may develop in >^c5^*^'i*^^"U^^''^"^--W - •''-' *^^ ^^"Ss when the ^'^:&*f,>^'''^^:.'a'^:T^ - -;^ '-^^v^sS?^ primary growth is an Y^^i:.r:W-^^^'i^^ '•'.'. ' - A '**--'^-^--;*'^"-» osteo-sarcoma. tjg'-" .j'^^y'ri .> ''S****; — *4"-: ^"iv'-'ri'^- IS y' Degenerative changes '^^"^^p*,t^^" "^V--^ /'^'^'ir"-^^-'^"''' of a fattv or mucoid older por- coma, cystic malig- tumour affected. is frequent er varieties, ion is not the more X^^K^^^^Z^^^^^'^^'W^MB'^ On naked-eye exam- -^- , .:^>j^.>^.*i*;>^':^,^.^tTS^ "of ^^H,'*^^"*^!' Ji^^ the giant cells tubercle; they may be regular in OutUne, or Fig. 58.— Myeloma, showing the Multi- ° 1 J • + rv, NUCLEATED MYELOID CeLLS (MyELOPLAXES) proiongea mto numer- lying amongst the More Abundant OUS interlacing pro- Round and Spindle Cells, (x 100.) cesses, although these latter are usually not very evident. There is also no definite arrangement of cells around them, as in the tubercular giant-cell systems. These tumours are soft in consistency, and on scraping a slimy fluid is obtained. They are very vascular, and may pulsate. Haemorrhage into their substance is common, giving rise to cysts, filled with serum and a yellowish fibrinous clot. When fresh, the growing edge is of a][dark maroon colour on section, and has been 212 A MANUAL OF SURGERY likened to the appearance of a pomegranate; when preserved in spirit, these tumours are always of a characteristic brown colour, owing to the formation of haematin. They never give rise to secon- dary deposits. Their growth is tolerably rapid, and they may attain enormous dimensions. For particulars as to tlunr clinical characters, see Chapter XXI. Diffuse Myelomatosis, or myelojmthic albumosuria, is a condition in which the manovv oi t\\v vi^rtebrae, sternum, and ribs, and occasionally of the long bones, is transformed into a structure closely resembling that of the myelomata. The bony tissue is absorbed, and deformity or spontaneous fracture may result. It is associated with the presence in the urine of albumosc, which is precipitated at a comparatively low temperature, and redissolved on boiling. Myoma. — Myomata almost always consist of tinstriped muscle fibres (Leiomyoma or fibromyoma), forming rounded and often encapsuled tumours, the cells of which are long and fusiform, and contain a rod-like nucleus. Bundles of these cells are grouped together into fasciculi, which are arranged more or less regularly. The tumours themselves are not very vascular, but vessels of con- siderable size are found in the capsule. It is often difficult to dis- tinguish these tumours microscopically from fibromata on the one hand, and from fibro-sarcomata on the other. From the former they are known by the fact that individual cells can be recognised, and by the absence of wavy tendinous fibrillge; from the latter the distinction depends on the facts that other types of tissue may occur in the sarcoma, and that the growing edge is usually more or less embryonic in character, whilst a myoma is of the same structure throughout. Again, in a myoma the bloodvessels have distinct and definite walls, and in a sarcoma they are simply clefts or passages in the tumour substance. Myomata are met with in the uterus, occasionally in the prostate, and more rarely in the walls of the alimentary canal or in the ovary. Secondary changes sometimes occur — e.g., mucoid softening, calcifi- cation, ulceration with profuse haemorrhage, and possibly consequent inflammation, whilst malignant disease may supervene. Tumours consisting of striped muscle fibres (Rhabdomyoma) have been described, but are exceedingly rare. Neuroma. — True Neuroma is seldom met with, only five undoubted cases being on record. It consists of a mass of newly-formed ganglion cells and nerve fibres, which may be medullatcd or not. It affects children or young people, and usually involves the sympa- thetic system. The tumours may attain considerable dimensions, are often multiple, and may be quite soft, like a lipoma, or firm. They are insensitive and innocent, and may be freely removed if necessary. False Neuromata, or those developing in connection with the sheaths of nerves, are more common, and may be described under three headings : I. Localized Pseudo-Neuroma, which may be innocent or malig- nant, the former being a fibroma or myxoma, the latter usually a TUMOURS AND CYSTS 213 sarcoma. It may project from one side of the nerve, or more frequently the nerve fibres are spread out over it. It moves more freely at right angles to the axis of the nerve than along its course. When developing from a small nameless subcutaneous twig, it is termed a painful subcutaneous nodule, and gives rise to intense radiating neuralgic pain, especially when compressed or irritated, or when exposed to cold. A false neuroma growing from a larger mixed nerve [trunk neuroma) is less painful, because there are rel- atively fewer nerve fibrillae, and the mass is less exposed. A growth on a pure motor nerve, though sensitive, is not associated with radiation of pain. It is uncommon for tumours of this type to cause complete paralysis or anaesthesia, unless they are of a mahg- nant nature. They occur most frequently in healthy adults, and in women a little more commonly than in men. Treatment. — A neuroma, if painful, should be removed, care being taken, if possible, not to interfere with the continuity of the nerve fibrillce, the section of the sheath being made in the long axis. If this cannot be accomplished, the nerve must be divided, the growth removed, and the ends subsequently sutured together. In remov- ing a pamful subcutaneous nodule it is unnecessary to endeavour to save the nerve. The malignant pseudo-neuroma, as already stated, is sarcomatous in character, and develops at first in the sheath of the nerve, spread- ing longitudinally, but subsequently involves the tissues around. Chnically, it presents at first the phenomena of a simple growth, but its course is more rapid and painful, and if involving a motor nerve paralysis is induced. The main nerve trunks are usually affected, and it may be possible to treat the case by amputation ; failing that, nerve section above the growth may be required to relieve the pain. 2. Diffuse or Generalized Neuro-Fibromatosis. — This consists of a diffuse thickening of the nerve sheaths, causing multiple elliptic or spherical tumours, or a generalized enlargement. The growths may be encapsuled and limited, or not; they may be few in number, or hundreds may be present, and they are usually whitish and firm in texture. They originate from the endoneurium of the primary nerve bundles. Any part of the peripheral nervous system may be affected, including the sympathetics, but it is most common in con- nection with the cranial nerves and the large plexuses of the trunk. The actual symptoms are sometimes very slight, but the tumours may be sensitive to pressure, and some of them, more exposed than the others, may be exquisitely tender. Motor phenomena are rare, and paralysis is usually due to involvement of the nerve roots in the spinal canal, or to the supervention of sarcoma, which is a not uncommon termination. The disease may start at any time during life, and, although progressing slowly, sooner or later ter- minates fatally. No known treatment is of any avail, but should any particular tumour become large and tender, it may be removed. A Plexiform Neuroma is a special modification of this process, occurring congenitally or in young people, and usually involving the 214 A MANUAL OF SURGERY trigeminal or superficial cervical nerves; it may be associated with the former condition. The overgrowth is of a softer, more gelatinous type (myxo-hbromatous), and the resulting tumour consists of a plexus of thickened, tortuous, venuiform strands, of soft consistence, held together by loose connective tissue, but easily se})arable into their constituent elements, which are of a nodulated character, so that the dissected mass looks ' not unlike grains of boiled tapioca on a string ' (Alexis Thomson). The plexiform neuroma is almost always subcutaneous, but often dips deeply between and into the substance of muscles. When limited in extent, the growth may be dissected out, and this is usually required for cosmetic purposes. The final prognosis is rather better than in the former condition, as secondary sarcomatous changes are rare. In this affection one not unfrequently ob- serves a large develop- ment of fibrous growths of the skin, similar to what we have already described as molluscum ftbrosum. On careful microscopical examina- tion of specimens stained by Weigert's method, the presence of nerve fibrilke can be demon- _>^ ^^^^^S^' strated in these growths, ^K^^i- Hh^ ' showing that they are really ncuro-fibromatous in origin. So excessive does this overgrowth occasionally become that a form of elephan- tiasis is produced — e.g., the irregular hyperplasia of the scalp tissues known as a pachy- dermatocele. The association of molluscous tumours with neuro- fibromatous changes in the nerves and cutaneous pigmentation constitutes the affection known as Recklinghausen's disease (Fig. 59). 3. The bulb formed upon the proximal end of a nerve after its division is sometimes described as a neuroma (Traumatic Neuroma). It consists of a mass of fibro-cicatricial tissue containing spaces, within which are numbers of newly-formed axis cylinders (p. 372). Fig. 59. — Multiple Molluscous 1 umouks AND Pigmentation of Skin (A) in a Case of Recklinghausen's Disease. (For the loan of this block we are indebted to Dr. F. Parkes Weber.) Gliomata are tumours arising from the neuroglia of the brain and spinal cbrd, and occasionally in the retina. Most of the TUMOURS AND CYSTS 215 growths occurring in the retina, and supposed to be ghomata, are in reahty round-celled sarcomata; the distinction is one of some importance, since true gliomata are never followed by secondary growths. They consist of cells (which may be round, spider-shaped, or spindle-shaped) and of fibres; these occur in varying proportions in different cases, giving rise to the hard and soft var'eties. Their colour often closely resembles that of the brain itself, and there is usually no shaip line of distinction between the tumour and the surrounding tissue. They vary greatly in rapidity of growth and in vascularity, but are always benign in nature. Angioma is the term applied to conditions in which a new forma- tion of bloodvessels occurs ; aneurisms and varicose veins are, obvi- ously, not included in this category. For a description see p. 352. Lymphadenoma and Lymphangioma. — The primiary tumours de- veloping in connection with lymphatic glands and vessels are described at p. 368. Odontoma. — Timiours originating from somxC abnormal condition of the teeth or teeth-germs are known as ' odontomes.' Bland Sutton, in h"s work on tumours,* has described seven different varieties, several of which are, however, rarely m.et with in man. The more important of these are as follows: (i) Epithelial Odon- tome. In this condition, also known as ' fibro-cystic disease of the jaw,' the mandible is most commonly affected. A tumour forms, consisting of spaces lined by epithelium, which are developed as irregular outgrowths from the enam^el organ. It occurs most fre- quently in young adults, and may give rise to a growth of enormous size. (2) Follicular Odontomes, or, as they are often termed, * dentigerous cysts,' are produced by the developm^ent of a cavity around a misplaced or ill-developed tooth of the peraianent set, which often lies horizontally, so that its eruption is impossible. (3) Fibrous Odontomes are the result of a thickening and condensa- tion of the connective tissue around a tooth sac. They are most frequently observed in the lower animals, but are also said to occur in rickety children. (4) Radicular Odontome is the term applied to a tumour composed of cement, developing at the root of a tooth. It gives rise to severe pain, and may cause suppuration in the sur- rounding bone. (5) Composite Odontomata consist of a conglomiera- tion of the various forms of tissue entering into the formation of a tooth, and developing in the neighbourhood of the jaw. They may be very large, and probably some of the bony tumours described as osteomata of the antrum are of this nature. (See also Chapter XXVIII.) II. Tumours of Epithelial Origin. The various tumours grouped under this heading are composed mainly of epithelium, with a variable admixture of connective tissue. They are derived from pre-existing epithehal structures, and vary in * Bland Sutton, ' Tumours and Cysts.' Cassell and Co. 2l6 A MANUAL Ol- SURGERY the arrant,a'im'nt and character of the ei)itheHum witli the site of origin. Ki)itheUal cells can practically be of onlv three tvpes: (a) The spheroidal or cuboidal, in which the three diameters are more or less equal ; (/;) the Hat or squamous, in which two diameters are long and one very short; and (c) the colunmar, in which one diameter is long and two are short. These three forms of cells are found in most of the groups of epithelial tumours. In some the structure conforms more or less to the normal type, and then the growth is probably of an innocent nature, as in the papillomata and adenomata; but when the structure becomes atypical, the tumour is likely to be malignant and of a cancerous nature. Papilloma. — This term ought really to be limited to tumours formed by an overgrowth of papilla;, and since papillae are confined to regions covered with -i^> epithelium of epiblastic origin, they are, strictly speaking, only found in the skin and the so-called 'mucous membranes,' which are morphologically of the same nature — i.e., that lining the mouth, vagina, larynx, anus, etc. They consist of the same structures as a normal papilla, there being a cen- tral core of mesoblastic tissue (connective tissues, vessels, etc.) covered by squamous epithelium, which may or may not undergo excessive horny development, and, like the normal papilla;, of which they are an exaggeration, they project outwards from the general surface of the body, and never invade the subcutaneous or sub- mucous tissues (Fig. 60). The term is, however, often used loosely to indicate a growth composed of a mesoblastic core with an investment of epithelium; thus, we speak of papillomata of the large intestine, although in this region true papilhe do not occur. Hence it becomes convenient to classify the papillomata according to the nature of the epithelium with which they are covered. (i) Those covered by squamous epithelium occur in the skin, mouth, larynx, etc., and consist of bundles of papilhe, which undergo extensive proliferation and frequently branch, forming secondary papillae. If the epithelium undergoes keratinization, as in the common warts, they become hard, and may constitute horn-like outgrowths. When they occur in moist situations — e.g., between Fig. 60. — Section of a Warty Papilloma to show the arrangement of the Epithelium. The normal skin is seen on each side running into the hypertrophied papillae, over which is heaped up a mass of thickened keratinized cuticle. There is no invasion of the sub- cutaneous tissues, as in an epithelioma (cf. Fig. 62). TUMOURS AND CYSTS T.l'J the toes, on the prepuce, or growing from mucous membranes (except that covering the vocal cords) — this formation of horny substance is usually very imperfect, and the papillomata remain soft. It must be pointed out that many of the squamous papillo- mata are of infective origin, and not true tumours at all — e.g., the venereal warts, condylomata, and mucous tubercles. There are also some reasons for thinking that warts may be infective and due to the action of a micro-organism. Not unfrequently a papilloma which has become irritated may take on malignant action and be transformed into an epithelioma, a change which would be charac- terized clinically by the base becoming infiltrated. The papillomata which develop in the bladder and pelvis of the kidney are covered by many-layered transitional epithelium, and usually form long slender fimbriated tufts containing dehcate bloodvessels, which readily give way and may lead to consider- able haemorrhage. Not unfrequently they occur in conjunction with malignant growths. (2) Papillomata covered by ciihoidal or spheroidal epithelium occur in glandular structures, especially in the breast, kidney, etc. (3) Papillomata covered by columnar epithelium are some- times found projecting into cystic cavities in other tumours, as in the prohferous ovarian cysts and in duct carci- noma of the breast, as also into dilatations of other ducts. The ' papil- lomata ' of the intestine are usually either adenomata or fibromata. Adenomata consist of new growths arising in connection with secreting glands, and in structure simulating somewhat closely the organs from which they rise (Fig. 61). They differ from them, however, in that they are incapable of producing the character istic secretion, that they are devoid of ducts, and that the mimicry is incomplete, since the alveoli are less perfectly developed, and may be entirely occupied by several layers of epithelial cells. The epithelium, which from the nature of the case is spheroidal, cuboidal, or columnar in shape, does not pass beyond the basement membrane into the connective Fig. 61.- -FlBRO-ADENOMA OF THE BREAST. (X30.) 2i8 A MANUAL OF SURGERY tissue, and by this lack of inliltration they are distin/^uished from cancerous tumours. A variable amount of connective tissue is always present, and may be normal in texture, or may manifest various modiiications. Adenomata are single or multiple, and usually encapsuled, being merely connected with the original gland by a pedicle, through which the vessels enter. When growing from mucous membranes, they sometimes become pedunculated, as in the so-called polypus recti. The alveoli in some cases become distended with effusion, giving rise to a cysto-adenoma or adenocele, and sometimes the tumour projects into these, consti- tuting intracystic growths. They are free from malignancy, except that occas'onally the connective tissue undergoes a sarcomatous change; more rarely carcinoma supervenes, especially in the breast. When of large size, they may cause trouble by compression of im- portant structures. Any glandular organs may become affected with adenoma — e.g., the breast, thyroid body, prostate, testis, etc. They are also found as congenital tumours in connection with the thyroid body, post-anal gut, and possibly the kidney. Carcinoma, — The malignant forms of epithelial new growth are known as ' cancers ' or ' carcinomata,' and are characterized by the appearance of a primary growth, which, by its continued develop- ment, infiltrates and destroys the neighbouring tissues, incorporating them into its substance. If superficial, the growth undergoes necrotic changes, resulting in ulceration, which frequently becomes horribly offensive owing to the supervention of a mixed infection. The disease spreads along the lymphatics, and involves neighbouring lymphatic glands, which may also break down, or suppurate, and ulcerate ; and finally general dissemination to the viscera may occur, the lungs, liver, brain, and bone-marrow being specially liable to invasion. Any epithelial surface or organ may be affected by cancer, but it is most frequently seen in parts which are exposed to injury or chronic irritation. In the male, the stomach is the organ most frequently affected, and then follow in order the intestines, tongue and mouth, etc. Eighty per cent, of all cancers in the male sex affect the intestinal canal; in the female, cancer of the uterus, sexual organs, and breast, account for nearly 80 per cent, of all cases of the disease. It is not very common in early life, but increases in frequency after thirty years, and reaches its maximum incidence between forty and fifty-five years of age. Cancers are classified as epithelioma, columnar cancer, or spheroidal-celled cancer, according to whether the epithelium from which the tumour is derived is of the squamous, columnar, or spheroidal type. The term ' celloid cancer ' is used to indicate a degenerative change occurring in some forais. The essential character of a cancerous growth consists in an unlimited multiplication of the epithelial cells in the organ or tissue attacked. The cells thus affected lose to a greater or less extent that interrelation which normally makes them grow into glands or other structures, so that in the mahgnant tumours the epithelial TUMOURS AND CYSTS 219 cells form masses which show a varying degree of resemblance to the glands, etc., of the normal part: in general, the greater the malignancy, the greater the anaplasia, until in the most malignant forms the epithelium is arranged in masses or alveoh, bearing not the slightest resemblance to the structure from which it springs. There is also an alteration of the mutual relations between the epithehal cells and the connective tissue of the part. The former take on unlimited powers of growth, but are not (as is the case in innocent tumours and in epithelial proliferation due to irritants or other causes) limited by normal basement-membranes and other mesoblastic elements, but burst through these, producing infiltra- tion of surrounding tissues. Columns of epithehal cells can be seen to penetrate into the tissues (Fig. 62), following the Hues of least resistance, and usually extending deeply along the lymph-clefts. There is thus no longer a sharp and definite fine of demarcation between the epi- thelial and con- nective-t i's[s u e portions of the tumour, but the two are inextric- ably blended. The epithelial cells ^ themselves are also F^^- 62.-Section of an Epithelioma. anaplastic losing The normal skin is seen oh each side running into the thpir morp ^npHal growth, which dips down into and invades the their more special- Underlying tissues This diagram should be com- 1 Z e d characters, pg,red carefully with Fig. 60. and reverting to simple masses of protoplasm which have lost all powers except that of growth and subdi\'ision. They often differ greatly among them- selves in size, character of nuclei, etc., and in rapidly-growing carcinomata numerous mitoses (which may be irregular, tripolar, or multipolar) may be seen. Marked changes occur in the connective tissues around the cancer ; they are irritated by the growth, and become infiltrated with small round cells (IjTnphocytes) and plasma cells, which undergo a greater or less degree of organization, leading to the development of a stroma of variable density and vascularity around the epithelial columns. In chronic cases the stroma is usually fibro-cicatricial in type, and contains few bloodvessels; in the more actively growing parts and in acute cases the stroma is comparatively small in quantity, more cellular, and decidedly vascular. When ulceration has occurred, polynuclear leucocytes are usually abundant, and other inflamma- tory manifestations may be seen ; pyogenic bacteria may sometimes be detected in the growth. Cancerous tumours are not necessarily tender to the touch, but a considerable degree of pain, usually of a neuralgic type, is often complained of, especially in the harder forms, when tissues get dragged upon by the contracting stroma. A MANUAL OF SURGI'RY The enlaigoinent of the neighbouring lyni])hatic ghmds is usually an early and important sign, l)ut it must be remembered that, when the primary growth has a dirty ulcerating surface, the enlargement may be largely due to the absorjition of toxins, and treatment directed to cleansing the surface of the sore may lead to a disap- pearance of the enlargement. T. Epithelioma {syii. : Squamous Epithelioma, Epithelial Cancer). — By this term is meant a cancerous tumourgnnving from skin or from those portions of the mucous membranes which are covered with squamous epithelium. Epithelioma is usually met with in middle-aged or elderly individuals, occasionally in young adult life. Any part of the skin may be the site of this tumour, as also the mucous mem- brane of the mouth, pharynx, and oesophagus, and that lining the genito-urinary tract. It com- monly results from some long- continued irritation, as in the lip or tongue, wliilst upon the penis it is always associated with a long foreskin. Old scars, espe- cially if they become ulcerated, are likely to be invaded, and the disease may supervene on in- FiG. 63. — Typical Epitheliomatous tractable lupus. Ulcer, showing Heaped-up Mar- Clinically, epithelioma may be looked upon as a malignant wart, which not only grows outwards from the surface, but also bur- rows deeply into adjacent tissues (Fig. 62) ; sooner or later ulceration follows. Several characteristic forms are described: (a) It may occur as a nodular indurated mass, with hard everted edges and central ulceration, giving rise to a somewhat crateriform ulcer (Fig. 63). (b) The destructive process may extend equally with the new formation, leading to the appearance of a depressed sore, with sharply-cut edges, closely resembling a rodent ulcer, (c) Occasion- ally the superficial outgrowth is excessive, and the destructive pro- cess limited, giving rise to a projecting caulifiower-like mass, which is soft and easily bleeds {malignant papilloma), {d) A chronic epi- thelioma is sometimes seen, in which the fibrous stroma contracts and compresses the columns of epithelial cells; the surface is then indurated and wart-like, with but little ulceration, whilst the base is very hard, and the progress of the case much less rapid than in other forms. This form is not uncommon in the lip. The disease, as a rule, early infects neighbouring lymphatic glands. GINS AND Deep Central Crateri- form Excavation. (College of Surgeons' Museum.) TUMOURS AND CYSTS 221 which become the seat of a similar growth, and, if superficial, sooner or later involve the skin and give rise to characteristic ulceration. As the disease progresses, more distant groups of lymphatic glands are attacked; it is unusual to find this form of cancer disseminated Fig. 64. — Epithelioma of Lip. The epitheliumjat the;.left-hand margin of the figure is normal, whilst at A the altered appearance of the cells indicates that they have become malignant; at B, C, D, they are growing down into the stroma in irregular columns;' B indicates a small cell-nest, and C passes through one half an inch from its extremity. The connective-tissue stroma is inflamed. This is most marked at F. through the internal viscera. The glands sometimes become cystic, especially in the neck, and on cutting into them a thin, turbid"'fluid hke sero-pus escapes, mixed perhaps with white masses of epithelial debris; from time to time similar material is discharged through the resulting sinuses. Ulceration into the main vessels of the neck may 222 A MANUAL OF SURGERY also follow, and cause death from haemorrhage; otherwise the fatal event is due to cachexia and exhaustion. Microscopically, an epithelioma consists of columns of epithelial cells (Fig. 64), ramifying in the subcutaneous tissues, and interlacing freely with each other, so as to produce an irregular network, the meshes of which are occupied by a fibro-cellular stroma, which is frequently infiltrated by an inflammatory exudate of small round cells (largely lymphocytes or plasma cells). The true cancer cells are derived from the prickle-cell layer of the epidermis, but in some rapidly-growing cases the cells undergo so much alteration that the prickles are difficult to find. The cells in contact with the stroma are usually regular, and resemble the basal layer of normal skin; A Fig. 65. — Epithelial Cell-nest, from an Epithelioma of the Mouth. A, Stroma, with collections of small round cells; B, layer of basal epithelial cells ; C, prickle cells, which at D have become flattened ; E and F show the final stage, the cells being transformed into badly-formed keratinous scales. the cells next to this are polygonal in shape, and in the deepest layers may become flattened and undergo imperfect keratinization. This differentiation is best seen in the cell-nests (Fig. 65) which develop in the substance of the columns; they are most common in comparatively chronic cases, and may be absent in the rapidly- growing forms. 2. Spheroidal-celled Cancer usually develops in connection with glands, and may be looked on as a malignant form of adenoma, bear- ing the same relation to the latter as does an epithelioma to a benign papilloma. The epithelium of the glandular acini, from which it originates, is not retained by the basement membrane, but travels TUMOURS AND CYSTS 223 beyond it along the lymphatics into surrounding parts, which are transformed into the tumour substance by a process already de- scribed. The amount of stroma varies considerably, and according to whether it is abundant or small in quantity, the tumour is hard or soft in consistence, and slow or rapid in growth. To the former type the term Scirrhus is apphed ; to the latter, Encephaloid. Scirrhtis is met with most frequently in the breast, but also occurs m the prostate, pancreas, and pyloric end of the stomach. On naked-eye examination a scirrhous tumour appears as a hard nodular mass, the hmits of which are imperfectly defined. When cut across, it creaks under the knife, and presents a yellowish- white surface,' which rapidly becomes concave owing to the contraction of the nbrous stroma. It has often been compared to the section of an unripe pear or turnip, both on account of the grating sensation imparted to the knife and from its appearance. On scra- ping the cut surface 'i*?5?^i^J- iriv ^*"'^'^ with the blade of a t^^^^A'^'''^','^^'"'^^^ knife, a typical cancer :^' :l'??i^ ^^I^SC > **^((^ % '^.^ A. • thereby a peculiar stinging pain, which is very characteristic Ihe head remains fixed in the deeper part of the pocket, whilst the abdomen becomes greatlv distended in the course of a few days, constituting a sac, containincr a lars^e number of eggs. Great irritation is caused thereby, and inflammatory phenomena, with perhaps swelling of lymphatic glands, especially if the sac is crushed or burst. Left to itself, the ova are set free, and escape externally to develop into vermiform larvae. Treatment consists m enlarging the burrow bv means of a blunt needle or probe, and digging out the jigger complete, taking care not to burst the sac. The small opening is touched with tincture of iodine, but if suppuration is present, fomentations will be required. Snake-bites require but little notice here, as they are exceedingly rare in this country, the common adder [Pehas bents) bemg the only venomous one likely to be met wdth, and even with this the poison is not sufficiently virulent to do much hann unless the individual attacked is a child or a person in a very bad state of health. Ihe poison is conveyed to the wound from the glands and poison sac situated on either side of the upper jaw through fine canals m the speciahzed teeth, which open at their apices; these teeth are so delicate in some snakes that it mav 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 m bad cases, merging into coma. The Treatment consists in preventing the absorption of the virus by tying a hgature 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. In India and other countries many varieties of poisonous snakes are met with, and wounds are frequently fatal; indeed, in India it is stated that 12,000 individuals are yearly destroyed m this way. 1 he s\Tnptoms come on rapidly, and are extremely severe, although they are modified according to the variety of snake. Treatment consists in the immediate apphcation of a hgature round the limb above the wound, which is excised, or squeezed and sucked after incising, so as to encourage bleeding. The wound is then packed with crystals of permanganate of potash, or soaked m a concen- trated solution of the same or of peroxide of hydrogen. If the patient sur\dve, the ligature is removed from the hmb after a few hours.* Strychnine and stimulants are required to counteract the depressing effects of the poison, and Calmette's antivenene, if obtainable, may also be employed; it consists of the blood-serum of a horse that has been immunized by the injection of graduaUy increasing doses of cobra venom. The dose required vanes with the size of the snake— from 10 to 40 c.c. or more— and to be bene- ficial must be injected Nvithin an hour of the bite. The Anatomical Tubercle, or Butcher's Wart {Veniica necrogenica), * Leonard Rogers, Brit. Med. Jour., November 11, 1905- 252 A MANUAL OF SURGERY consists in a papillomatous dev^elopment usually on the knuckles or wrists of those who are exposed to wounds either in the deadhouse or slaughter-house. It is in all probability a manifestation of tuber- culous infection, and, indeed, resembles somewhat closely the appear- ance of lupus when it develops on the hands. Treatment consists in the application of a powerful caustic, whilst in bad cases it is necessar\- to scrape the surface before cauterizing. Poisoned Wounds of the Fingers are not uncommon, arising from the infection ol pricks, scratches, and abrasions, and sometimes giving rise to serious consequences, and especially when the patient's occupation brings his hands into contact with infective material. The dissecting-room used to be a fertile source of infected fingers, but the care now taken in the preparation of the cadaver has almost abolished this form of trouble. Pathologists and the attendants in the post-mortem rooms are liable to infection of this kind in spite of the use of rubber gloves; surgeons operating on cases of septic peritonitis, or nurses, especially when attending patients suffering from puerperal fever, may also be infected by pricking the finger with a needle or pin. The resulting lesions vary much in their character, from a mild suppurative foUicuHtis to various forms of inflammation of the nail m^atrix or subcutaneous tissues (constituting a whitlow), whilst the worst cases may develop a grave cellulitis, with perhaps suppuration of the axillary glands and septicremia. ]\Iost of these conditions are described elsewhere, but it will be convenient to deal here with the subject of whitlow, (For Affections of the Xail Matrix, see p. 407.) A Whitlow {Paronychia or Panaritium) occurs in four different forms, of which one is a localized inflammation of the skin, another a true cellulitis, a third is a teno-synovitis, and the fourth involves the terminal phalanx. [a) The Subcuticular whitlow (or purulent blister) consists merely in a development of pus beneath the cuticle which separates it from the cutis vera. It is painful, but otherwise of little importance. A boracic fomentation, preceded by the removal of the loose cuticle, is all that is needed in its treatment. {h) 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 do\\Ti the arm. Gradually both these symptoms increase in amount, the back of the finger becoming oedematous, and the pulp more or less red. The swelhng is at first hard and brawnv, and even when pus is present it may be difficult to detect fluctuation unless the abscess is nearly pointing. Constitutional sjonptoms are not, as a rule, very severe, though the intensity of the pain mav exhaust the patient. The hand should be elevated, and the finger fomented or poulticed, or treated by Klapp's suction-balls. When pus has formed, a free longitudinal incision in the middle fine should be early adopted; but, though WOUNDS 253 free, it must not extend too deeply, or the tendon sheath may be opened and infected. Occasionally the pus forms at one or other side of the ftnger, and the incisions must then be suitably modified. Antiseptic fomentations constantly changed and baths must be utilized after such an incision, the constant moisture adding greatly to the patient's comfort. Bier's plan of treatment may advisably be repeated after incision. (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, only more severe, because the process is often more extensive. As special features may be mentioned, the in- abihty of the patient to bend the finger, and the extreme pain caused on attempting to extend it, owing to the involvement of the'tendon and its sheath. The swelling also is more marked, and often extends to the dorsum of the finger, where localized collections of pus form a communication with the sheaths by a narrow neck; these are due to the yielding of weak spots in the postero-lateral aspects of the sheath. Infection of the inter-phalangeal joints, or even of the bones, resulting in caries or necrosis, may occasionally follow. Extension to the palm, and even to the fore- arm, is very likely to occur, owing to the arrange- ment of the tendon sheaths (Fig. 80) ; this is almost always the case when the little finger and thumb are involved, as the sheaths run along the tendons under the annular hgament. (In the little finger, however, there is sometimes a short break in the continuity, which is easily overstepped.) With the other fingers there is a definite gap between the tendon sheaths and the main palmar sheath (or bursa), and hence extension upwards is due to a proximal rupture of the sheath and infection of the connective tissue space in the palm, where it may be hmited, or whence infection may spread to the palmar bursa or directly into the forearm under the annular hgament. Involvement of the palm is recognised by the part becoming swollen and tender, whilst the general symptoms are aggravated. The intercarpal articulations may be secondarily affected, and necrosis or caries of carpal bones, especially of the os magnum, may follow. Extension to the forearm is usually due to infection of the tendon sheaths, but may spread along the connective tissue planes. The annular ligament constitutes an unyielding barrier, above which the forearm becomes swollen, hard, and brawny. The pus usually follows a definite course, being placed between the tendons of the flexor profun- dus and the pronator quadratus, and then travels up in close proximity to the interosseous septum along the median nerve or ulnar vessels. Fig. 80. — Diagram of Synovial Sheaths OF Flexor Ten- dons OF Hand. 254 A MANUAL OF SURGERY Lymphatic infection may be associated with any of these mani- festations, in the form either of an acute lymphangitis or acute inflammation of the epicondyloid or axillary glands, in the lattei instance being perhaps associated with an axillary celluhtis. Natur- ally the constitutional results will be greatly increased by these complications. Free and early incisions are required either in the middle line or on either side of the finger in order to secure effective drainage of the sheath, and thereby to prevent as far as possible the formation of adhesions, or to keep the tendons from sloughing. It may sufhce to limit the incisions to the interarticular segments of the fingers, but frequently it will be necessary to make an incision the whole length of the finger. Extensions to the dorsum must be treated by counter- openings. If the connective tissue space of the palm is involved by extension from the index, middle, or ring fingers, the incisions employed in dealing with these sheaths must be carried up into the palm, but precautions must be taken not to infect the sheaths of the thumb and little finger. As a rule this palmar in- cision need not encroach on the superficial palmar arch, but even if it does it is of little consequence, as the vessel is easily secured. Involvement of the thumb and little finger will require more extensive in- cisions for satisfactory drainage (Fig. 8i), whilst extension to the forearm will in- volve opening up the deep space between the flexor profundus and the pronator quadratus, and this is best accomplished by lateral and not by central incisions, the more superficial tendons being drawn forwards. In addition to effective drain- age, fomentations will be required, as also immersion from time to time in hot baths; and when the dis- charge of pus is lessening. Bier's hypera?mia induced by the appli- cation of a rubber bandage above the elbow will be most beneficial. The iisual constitutional treatment for an infective disease will be needed, and the patients usually require much improvement of their general health. Unfortunately, however, patients often come under observation late in the case, and the mischief often extends in such a manner and to such an extent as to render amputation the only feasible method of treatment. {d) The Subperiosteal whitlow may be merely a complication of the thecal variety; but it occasionally starts as an acute necrosis of the terminal phalanx, arising either idiopathically or as a result Fig. 8i. — Incisions for dealing with various Forms of Whitlow and THEIR Extensions into THE Hand or Forearm. WOUNDS 255 of infection from the nail matrix. The inflammation may be limited to the end of the finger, or may spread to the palm. Free incisions, and the removal of the bone, if dead, are necessary, followed by antiseptic fomentations or baths. Repair of Wounds. When any of the tissues or solid organs have been divided or injured, the reparative activities of the body early assert themselves in order to make good the defect, unless they are for a time diverted by the necessity of overcoming an invasion of bacteria, and even then the means employed by Nature to conquer the microbes are useful in determining the early stages of repair. It matters little what tissue of the body is involved, for in all the reparative process is the same, although modified somewhat by the local conditions In the majority of cases the ultimate result is a production of cica- tricial or scar tissue, which serves as the bond of union between the divided structures, and varies in amount with the closeness of approximation, the maintenance or not of rest to the part, and the degree of inflammatory disturbance in the wound. In a few tissues a further stage — viz., that of regeneration of the injured parts — is reached; in this there is a preliminary formation of granulation tissue, which is subsequently invaded and replaced by a develop- ment from the parenchjnna of the affected tissue or organ, but this can only occur when the parts are accurately brought together and perfect asepsis is present. Striped muscle, bone, tendon, nerves, and some glandular structures may thus be regenerated; the skin and subcutaneous tissues, rarely; the spinal cord, never. The general facts as to the process of repair may be stated as follows: 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 in their turn are slightly dilated, partly as a result of this obstruction and partly from the reflex irritation of the injury. The surface of the wound is generally covered with a film of lymph or blood-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, disin- tegrate, and finally absorb, any blood-clot which is present. After their work is completed, they disappear, either finding their way back into the circulation, or being destroyed by the fibroblasts. These cells are derived from the surrounding vessels, and are accom- panied by a certain amount of plasma, so that the early manifesta- tions of a slight inflammatory reaction are simulated, and this, if it does not extend beyond certain limits, is a beneficial proceeding. If much tissue has to be absorbed, or when a foreign body such as a suture is buried, giant cells are likely to make their appearance. 2.56 A MANUAL OF SURGERY {b) The exudation of leucocytes is soon followed by the appear- ance of a number of large oval cells with abundant protoplasm and large vesicular nuclei, known as fibroblasts. These cells are mainly derived from those composing the tissues of the part, either from the connective-tissue corpuscles or the endothelial cells lining the capillaries, lymphatics, or lymph-spaces. The ingenious researches of Zeigler and his school, who inserted into the peritoneal cavity glass chambers composed of two pieces of thin cover-glass, cemented a short distance apart, and watched the process of organi- zation in this narrow space, have shown definitely that some at least of the fibroblasts are wandering cells derived from the blood: it is possible that these cells are in their turn derived from the endothelium, and that the endothelial cell is the fibroblastic cell Fig. 82.— Granulation Tissue from the Base of ax L'lcer. (x 60.) par excellence. Whatever their origin, they soon form a layer of cellular tissue which lies upon the surface or between the lips of the wound, whilst the pre\aously effused leucocytes disappear. [c] The vascularization of this cellular layer forms the next stage in the process. This is brought about by the outgrowth from the walls of the nearest capillaries of solid rods of protoplasm (Fig. 83, 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 of another vessel (Fig. 83, h), or occasionally they unite with the vessel from which they started. After a time these protoplasmic threads become canalized (Fig. 83, c), and a communication is established between them and the mother vessel, so that blood passes into them. The new capillary wall, at first homogeneous, WOUNDS 257 soon becomes lined with definite endothelial cells, and strengthened by connective tissue derived from the fibroblasts around. By this means a soft vascular tissue is produced, known as granulation tissue (Fig. 82), consisting of loops of capillaries supported by large nucleated cells with a varying amount of intercellular substance, which becomes fibrihated in texture. The capillary loops arise in leashes from small terminal arterioles, and it is to this arrange- ment that the granular appearance of the developing tissue is due; each granulation, as it arises, is about the size of a pin's head. {d) The transformation of this granulation tissue into fibro-cica- tricial tissue is next proceeded with. The fibroblasts become spindle- shaped, and finally long and narrow, with pointed extremities, which often branch (Fig. 84); the nuclei also become long and narrow. Fig. 83. — New Vessel Formation. (After Tillmanns.) a, A small bud-like projection from the wall of a capillary; b, the union of such buds one with another; c, the canalization of these processes. and lose their vesicular appearance. Around them is developed a fibrillated structure of a collagenous material, which is finally transformed into the fibrous tissue of the scar ; the actual arrange- ' ment of this material varies with the physical characters and condition of the wound. By the contraction of these fibres the fibroblastic 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 epithehum in the neighbourhood of the wound, and especially from the deeper layers of the rete Malpighii. 17 258 A MANUAL OF SURGERY As alread}? stated, the general process of repair sketched above is modified according to the character and condition of the wound. The following modifications are met with in surgery: w -». ^ \ % w .* . - % '*■'■■ .• • * 9^ m ^* " • \y. • < ^ ^ '$^ r ^^ '^ '■• f. ^ ^ '•'^..^**?:^.* % Fig. 84. — Granulation Tissue in Process of Organization. ( x 250.) I. Healing by First Intention or Primary Union occurs in cleanly- cut aseptic wounds where the lips are unbruised and brought ^f^' r: Fig. 85. — Diagram of Healing by First Intention. (After Billroth.) The wound is occupied by a fibro-cellular growth, into which loops of capil- laries extend, constituting granulation tissue, whilst the epithelium has united across the surface. together, so that no extensive collection of blood or discharge between them is possible. A thin layer of blood-clot hes between WOUNDS 259 the surfaces of the wound and penetrates into their irregularities, and the contraction of this clot is at first the chief means of keeping the deeper parts in apposition. There is but a microscopic hne 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 Figs. 85 and 86.) 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 hps of the wound are not, or cannot be. Fig. 86. — Section of a Wound Healed by First Intention Ten Days AFTER its Infliction. The epithelium is drawn in to form a V-shaped notch, and beneath is a mass of fibro-cicatricial tissue with comparatively few cells or vessels evident. approximated ; as also (6) 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 infection has prevented the occurrence of primary union. When a small amount of aseptic dead tissue is present, it is removed, as previously described (p. 109), by an invasion of leuco- cytes from the surrounding vessels, which disintegrate and gradually absorb it. These are followed by the fibroblasts, which form a layer of granulation tissue on the surface of the wound (Fig. 87). If there is much slough to be dealt with, the vitahty of the granula- tion tissue cannot be maintained beyond a certain distance from 26o A MANUAL OF SURGERY its source of nutrition, and so by a process of simple anamic ulcera- tion the unabsorbed dead portion is cast off and a granulating surface remains. If bacteria are present in the slough, inflammation occurs in the adjacent living tissue, and this brings about a similar result, though accompanied by suppuration and fever. When, however, there is a simple loss, of substance, with no bruis- ing or infection of 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 sur- face and forms a layer of fibrin, entangled in the meshes of which arc a number of white corpuscles, so that the wound becomes covered with a film of whitish-yellow material known as lymph. This gradually increases in amount and thickness, and is vascu- ^.■9 Fig. 87. — Diagrammatic Representation of Healing by Granulation. (After Billroth.) larized from below into granulation tissue, this process occupying from four to seven days. The heahng of a granulating wound is brought about by the conversion of the granulations into fibro-cicatricial tissue, and by the surface becoming covered with cuticle. The contractile ten- dency inherent m all cicatricial tissue produces two results from its presence in ihe base of the wound beneath the superficial layer of granulations: (i.) The surface area of the wound 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. When the granulating surface is very extensive, contraction may proceed to such a degree as to obliterate many of the vascular channels, and by thus depriving the superficial tissues of their adequate nutrition, the healing process mav be indefinitely prolonged, (ii.) The depth of the wound is diminished, partly by the continuous growth of granulation tissue from below upwards, but mainly by the contractile base lifting the deeper structures to WOUNDS 261 the surface. If the base of the wound cannot be raised, the super- ficial parts are drawn down, and 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. 105). It is sometimes possible to hasten the healing of an extensive granulating wound by drawing together the two margins so that the two surfaces are brought into apposition. Exudated lymph sticks the surfaces together in the first place, and subsequently granulations develop and bridge the gap. This union of granu- lating surfaces is often helpful in the closure of abdominal wounds left by the drainage of deep abscesses. c Fig. 88. — Scar from Recently Healed Superficial Wound. (Low Power.) The epithelial surface is regular and devoid of papillae; the scar tissue has an abundance of cells scattered through it, as well as some very obvious vessels, which would almost entirely disappear at a later date. 3. Healing under a Scab is a proceeding that can only take place 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 infection be present, pus is likely to accumulate beneath the scab and may cause trouble. 4. Healing by Organization of Blood-clot can only be watched in strictl}' aseptic wounds where there is definite loss of substance, as in the deep channels sometimes made in the treatment of bones 262 A MANUAL OF SURGERY thickened bv chronic osteitis, but of course it occurs in all subcu- taneous wounds where there is effusion of blood. The dark coaguluni shows no trace of change for some days, but gradually the peripheral portions become granular and yellowish-white in colour; granulations appear in this peripheral portion, and in time spread through the whole mass from periphery to centre, and then repair 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 scaffolding for the building up of the granulation tissue which replaces it. A similar result may be obtained by filling a cavity with grafts of sterile sponge or decalcified bone. 5. Healing of a Detached Portion of the Body is not unfrequently seen when parts of the nose, external ear, or finger-tip, are separated. The loose portion is carefully cleansed, reapplied accurately, and fixed firmly, though gently, into position. If it lives, union occurs by first intention; if it dies, but remains aseptic, it constitutes a cover or scab, under which healing by granulation occurs. A Scar is a mass of fibroid tissue covered by epithelium, which has been formed in the repair of a wound (Figs. 86 and 88). 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 fibrous tissue more abundant, and the vessels 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. L3nnphatics, nerves, hairs, and cutaneous glands are all absent, except perhaps at the periphery, and the epithelial covering itself is merely a uniform laj-er without papillae. The Pathological Phenomena connected with scars are as follows: I. Excessive Contraction, which may lead to great deformity, especially when the wound has occurred in the flexure of any of the joints. A w^eb-like mass of fibroid tissue then forms, hmiting movement, and requiring operative interference. A seriously burned hand may by cicatricial contraction be fused into an un- sightly mass, rendering the fingers of little use; similarly, the chin may be drawn down and practically fixed to the sternum, and the lower lip everted, as the result of a burn on the front of the neck, ihe Treatment of such conditions consists in dividing or excising the cicatrix, and thus freeing the parts, during which process it must be remembered that deeper structures of importance, such as the main vessels and nerves, may be adherent to the under surface, 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 WOUNDS 263 of time it may be advisable to do this slowly, even by gradual extension with a weight and pulley, so as to avoid the risk of lacerating the deeper parts, which are usually contracted second- arily. The raw surface thus produced is covered with epithelium by Thiersch's method or Wolfe grafts. Of recent years it has been proposed to treat such cases by in- jections of thiosinamin or fibrolysin,* administered hypodermically. A solution of 10 parts of the drug in 20 parts of glycerine and 70 of distilled water, is apparently the best, and in the adult the dose may range upwards from | c.c. Interesting results have been published of cures of many different conditions due to developments of scar tissue, and it is supposed that they are due to an active leucocytosis induced by the drug. Possibly the internal administration of iodolysin (an ethyl-iodide of thiosinamin) may be even more useful. Care must be taken in the use of this remedy in old people, as it is impossible to limit its action to the scar that it is desired to soften. Cases have been known in which the walls of arteries in a condition of arterio-sclerosis have been acted upon, and the patient's death resulted from purpura or cerebral haemorrhage. 2. Overgrowth of the scar tissue is sometimes met with, con- stituting what is known as the false or Alibert's Keloid (Plate II., Fig. 2). 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 occupies the region of the old scar, and may possibly send claw-like processes into neighbouring healthy structures. It consists merely of a hyperplasia of the scar tissue, but as to its aetiology nothing is known. With the exception of somewhat severe pruritus or itching, its presence entails no inconvenience, although if it occurs on exposed parts it may be very disfiguring. Removal is useless, since the keloid almost always recurs in the new cicatrix and in the stitch holes. After a longer or shorter interval it often disappears spon- taneously. Exposure to X rays or to radium is beneficial in these cases, although the treatment may be of long duration. 3. Ulceration of Scars is usually an evidence of defective nutrition, or of local irritation. It is always chronic and difficult to heal. Local protection and stimulating appHcations, together with general tonic treatment, are required. 4. Painful Scars arise from either the imphcation of a nerve ter- minal in the cicatrix, or the pressure of a contracting scar upon the bulbous end of a divided nerve, as in amputation stumps. The pain is often very persistent and wearing, and may radiate widely. Operation is usually necessary in order to free the nerve from the scar tissue or to excise it. 5. Malignant Disease of Scars, or of old chronic sores but partially healed, is of an epitheUomatous type, and appears as a hard ulcerated * Thiosinamin is prepared by warming oil of mustard with an alcoholic solu- tion of ammonia. Fibrolysin is a mixture of thiosinamin with salicylate of soda. 264 A MANUAL OF SURGERY tumour with everted edges and a thickened base [Marjolin's ulcer). The progress is very 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 Ij'mphatic implication will be noted. As soon, however, as the malignant growth invades healthy tissues, the usual phenomena show themselves. The diseased tissues, which are often very dirty and offensive at first, may be freely dissected out, having regard to subjacent structures, and the wound closed by some plastic method, or amputation may be required. General Conditions connected with Wounds. I. Shock. — By the term ' shock ' is meant a general depressed condition of the system associated with a marked fall of blood- pressure, resulting from the transmission of some energetic stimulus to the vital centres in the medulla, either from the peripheral sensory or sympathetic nerves of an injured part, or from the emotional centres. Local Shock is a curious condition of insensibility to pain on handling, which is sometimes present after severe injuries, and is especiall}^ seen in gunshot wounds. Possibly it is due to some temporary paralysis of the sensory nerves. The term coUapse is applied to a condition ver}^ similar in nature to shock, but differing from it mainly in its onset, which is gradual, and often preceded by some exhausting disease, and by the fact that muscular relaxation is more complete. The collapse of cholera is one of the most typical manifestations, but any condition associated with loss or derivation of fluids from the vessels may give rise to it — e.g., prolonged vomiting or serious haemorrhage. If at the same time toxic absorption is taking place, the sj^mptoms are still more marked; thus in acute peritonitis the two factors, removal of fluid from the circulation and toxaemia, are proceeding concurrently. Shock usually tends to recovery, unless the lesion is of a serious nature, and then collapse may supervene and prove fatal; thus, after rupture of the intestine the immediate symptoms are the result of shock, but they are quickly followed by the col- lapse due to acute peritonitis. Our knowledge of this subject has been largely increased of late years by the researches of Crile in America, and J. D. Malcolm in this country, and it is now clearly recognised that the essential cause of shock is the division of, or injury to, the sensory or sympa- thetic nerves. Experimentally it is easy to demonstrate that a marked fall of blood-pressure results from dividing or crushing a sensory or mixed nerve, and that clean division is less harmful than bruising or crushing. It is therefore obvious that the degree of shock will vary with the abundance or not of the supply of sensory nerves to the injured parts; organs like the testis, hand, small intestine, etc., will be productive of much shock when injured. Cceteris paribus, deep wounds are more productive of shock than superficial, but a very extensive superficial lesion may be more harmful than a limited deep one. Thus, a scorch or burn involving half the surface of the body is more productive of shock than the complete incineration WOUNDS 265 of a liaud ur foot. Operations on the head or the brain arc followed by comparatively little shock, whilst the upper part of the abdomen is more susceptible to depressing influences than the lower. Opera- tions on the kidneys and urinary passages are associated with little shock. Ihe charactev of the injury, whether clean-cutting or crushing, is also important. Surgical operations which involve traction on important nerve trunks or centres are followed by a greater degree of shock than when nerves are simply divided ; hence clean manipu- lations and the avoidance of rough bungUng handiwork are pre- ventives of shock. Shock is also increased by anything that lowers the general tone of the body, such as loss of blood, exposure to cold, want of food, or toxic absorption. The nervous susceptibility of the patient and the expectation or not of the injury are most important factors in the production of shock, for the more highly organized the nervous system, the greater is the amount of shock experienced, and vice versa. When the whole nervous system is maintained in a state of tension, anxiously expecting the receipt of some painful impression, the effect produced will naturally 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 maj^ be subse- quently greater. Thus, in the keen excitement and nervous tension of a battle, soldiers have 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 vary with the injury inflicted, from a shght momentary giddiness and faintness (closely simulating an attack of syncope or a fainting fit) to immediate and complete prostration, insensibiht3^ and even death. The pulse, at first small and weak, soon becomes irregular, extremely rapid, and often imperceptible; the countenance is pallid and shrunken, and the brow covered with cold sweat; the respirations are slow and shallow, whilst the tem- perature is usually subnormal. After an interval, the length of which depends on the severity of the lesion and the treatment adopted, reaction occurs, being intro- duced by increased depth and frequency of the respirations; the pulse becomes slower and fuller, the surface warmer, whilst con- sciousness and muscular power are gradually restored. During this period it is not unusual for an attack of vomiting to supervene. Sometimes reaction is accompanied by irritability, either of the mental or muscular sj/stems, in the one case leading to traumatic dehrium, which is always of grave import, and in the other to intense restlessness, as in the shock which follows extensive burns. It is probable that both these conditions are largely due to toxaemia. The term erethitic shock is sometimes applied to these manifesta- tions. 266 A MANUAL OF SURGERY Occasionally the evidences of shock are tlelayed in their appear- ance for some time after the injury, and come on graduall3^ Especi- ally is this the case after railway accidents when no great injury has been experienced; for a time the anxiety and excitement 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 neurasthenia than of real shock (see Chapter XXIV.). 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 at all character- istic, and consist merely 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 ex- planation of the phenomena of shock is by no means simple, and several factors are probably needed to produce the complex result. I. Reflex inhibition of the heart's action through the cardio-inhibi- tory centre in the medulla explains the early syncope with slow pulse. It is well known that if a frog's abdomen is opened and the exposed intestine sharply struck, the heart stops in a condition of diastole, whilst if the vagi are previously divided, no effect is pro- duced. Any severe peripheral injury may lead to such a result, especially those directed to the great sympathetic centres in the abdomen which are closely 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 ; but, as a rule, this inhibition of the heart's action is never prolonged in mammals. 2. The causation of the shock which follows lengthy operations is still a matter of discussion. Crile,* who has studied this subject experimentally, shows that stimulation of the central end of a divided sensory nerve causes a rise of blood- pressure at first ; but if the stimulation is repeated often, this rise gradually diminishes, disappears, and in time is represented by a fall. This he attributes to exhaustion of the vasomotor centre in the medulla; the blood collects in the splanchnic area as a result of paralytic distension, and hence the supply to the brain and surface of the body is diminished to a dangerous degree. Obviously, any considerable haemorrhage will aggravate the symptoms. In con- firmation of this idea is the fact that pre\aous cocainization of the nerve hinders the rise or fall of blood-pressure, evidently by blocking the upward extension of the stimuli. Crile's explanation has been recently questioned by Malcolm, j who points out that in lengthy * ' An Experimental Research into Surgical Shock,' by G. W. Crile. J. B. Lippincott Co., 1899. t ' Remarks on Shock,' Brit. Med. Journ., December 9, 1905. WOUNDS 267 abdominal operations with much shock this portal engorgement does not become obvious, and suggests that the cause of the shock is not paralysis or exhaustion of the vasomotor mechanism, but a gradually ascending contraction of the arteries from the surface towards" the centre, which keeps the blood more and more in the central parts of the body, and deprives the periphery, and, finally, the brain itself, of its necessary blood-supply. Diagnosis. — i. From the general results of hceynorrhage. Rest- lessness and thirst are then prominent signs, together with a sense of d\'spncea, causing rapid respiratory efforts; the mental condition, moreover, is less affected, and the patient is generally sensible; the surface is exceedinglv blanched, and the pulse may have a marked hc-emorrhagic wave. " 2. In concussion of the brain there are super- added to the s\-mptoms of shock those more particularly connected . wth the region affected, i e., the intellectual centres, so that un- consciousness 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 under the influence of an ancBsthetic, the patient's pulse usuallv becomes weak and rapid, and the coun- tenance pale. This condition closely simulates shock, and is often distinguished from it only by the progress of the case. Under such circumstances, if vomiting is plainly imminent, it is sometimes wise to increase the amount of anaesthetic, as the patient is usually not fullv under its influence. Treatment. — In shght cases very httle is needed beyond resting quietly for a few minutes, or the exhibition of some aromatic stimu- lant to the nostrils, such as ammonia or smeUing-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 temperature. A very simple, but successful, plan of raising the bodily temperature is to place under the bedclothes, which are supported on a cradle, one or more electric lamps of such strength as to bring the tempera- ture of the air around the body to 100° to 105° F. This has proved of much value in combating "the severe shock following burns in children. The injection of hot saUne fluid (i drachm of chloride of sodium to I pint of water) into a superficial vein, the rectum, or the subcu- taneous tissues (submammary or gluteal, for choice), has been employed with considerable success of recent years. The modus operandi of intravenous or intrarectal infusion is described else- where; the fluid should be introduced at a temperature between 105° and 110° F. Where there has been much loss of blood, the intravenous infusion of 2 or 3 pints may be useful to begin with, but as a rule rectal infusion is sufficient. According to Crile, a most valuable remedy for shock is the intra- venous injection of a solution of adrenahn (i in 50,000 or 100,000 parts of normal sahne solution), a few cubic centimetres being allowed to enter the circulation each minute. Pituitary extract 268 A MANUAL OF SURGERY also has a powerful effect in raising the blood-pressure, and slowing the too rapid action of the heart in shock. Drugs, such as strychnine or digitalin, are not of much use, but a small enema of hot strong coffee is sometimes very valuable in tiding the patient over the period of depression. Alcohol is usually undesirable. An important question is often raised as to the advisabiUty 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 crushed limb, is e\'idently prolonging the condition. Under these circum- stances a hypodermic injection of morphia may improve matters by relieving pain; otherwise the local lesion should be at once dealt with, and it will be often found that, as the patient passes under the influence of the antesthetic, the pulse improves, and the state of shock disappears, the ansesthetic shielding the medullary centres from the painful afferent stimuli. Shock may to a large extent be prevented during operation by a careful attention to such details as not purging or starving the patient unduly beforehand, keeping him well covered and as warm as possible, by maintaining the temperature of the operating-room at not less than 70° F., by minimizing haemorrhage, and by rapidity and cleanness of execution. A hypodermic injection of strychnine, or a brandy and beef-tea enema, given just before the operation, is also useful; and in nervous patients a dose of morphia will often blunt their nervous susceptibilities and protect them from shock. It must also be remembered that incomplete anaesthesia tends to increase the shock rather than to prevent its occurrence, although as little anesthetic should be administered as possible, and in bad cases ether rather than chloroform. In any operation, where shock is likely to be severe, its development may often be prevented by commencing intravenous infusion before the operation begins, and continuing it slowly throughout, or by administering ether in con- junction with the sahne solution. Spinal anaesthesia, when avail- able, is useful in preventing shock, since it protects the medullary centres from afferent stimuli ; but the question of the mental effect of the operation on the patient must also be considered; the aboli- tion of consciousness is in many cases a most desirable condition. The recently introduced plan of inducing anesthesia by the so-called anoci-associaiion method, described in Chapter XLV., holds out hopeful prospects of eliminating largely the element of operation- shock. II. Traumatic Fever. — Traumatic fever is that which follows the receipt of an injury, whether simple or compound, or after an opera- tion. Two main varieties are described: (a) Aseptic Traumatic Fever occurs after subcutaneous injuries, such as sprains, contusions, fractures, etc., and after aseptic operation wounds or compound injuries, where micro-organisms are absent or impotent. The cause is the absorption of fibrin ferment or some WOUNDS 269 other chemical substance, which has a stimulating effect upon the thermogenic centres. Probably the use of irritating antiseptics in the wound, the retention of serous discharges, and the accumulation of blood, are the chief causes of the pyrexia. Occasionally fever is observed in cases where we have no" grounds for supposing that absorption is taking place ; it may then be due to some peripheral irritation, e.g., a badly-fitting sphnt, and disappears immediately on the removal of the cause. The symptoms are those of shght pyrexia, reaching 100° or 101° 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 hmited, it is of no prognostic importance. {b) Symptomatic Traumatic Fever is caused either by the absorp- tion of the products of putrefaction, resulting from the vital activity of organisms in discharges, blood-clot, or dead tisue; or from the absorption of the toxins connected with a development of parasitic organisms in the wound or its surroundings ; or from the superven- tion of some general infective disorder. All these different con- ditions have been dealt with elsewhere (p. 91). III. Traumatic Delirium.—Although dehrium is merely a symp- tom, it is occasionally of so pronounced a character as to demand special attention. Three forms are described : [a) The Active Delirium w^hich accompanies severe injuries, par- ticularly in plethoric, and often in previously healthy individuals, whose environment has been suddenly changed from that of every- day hfe to a sick-bed in a hospital ward. Infection of the wound is usually present, and the dehrious state is associated and runs a parallel course with the fever. It is not usually of a violent type, although the patient may be irrational and restless ; he moves the injured part without any evident appreciation of the pain which, if conscious, he must suffer, but he is easily restrained by the ex- hibition of firmness and tact on the part of the attendant. The symptoms are most marked at night, and commence at the end of forty-eight hours, lasting, 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 fight, but nourishing ; the bowels are thoroughly opened, and an icebag to the head may be useful. The wound should be • freed from any purulent accumulation. [b] Delirium of a Low Muttering Type is met with in individuals of low \dtafity, exhausted by dissipation, drink, disease, or faulty hygienic surroundings. It is commonly associated with fever of an asthenic type, such as is seen towards the end of infective diseases. The patient usuaUy lies on his back, staring vacantly upwards, is incoherent, takes no notice of surrounding objects, and is observed to pick at the bedclothes and mutter to himself unintelfigibly. There is often, in addition, an involuntary escape of urine or faeces. 270 A MANUAL OF SURGERY The mouth is generally open, the tongue dry, brown and cracked, and viscid mucus collects about the teeth (sordes). The Treatment should be directed to careful nursing and feeding, as by that means alone can the patient be saved. (c) Delirium Tremens is observed in individuals who, previously of intemperate habits, 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 sleep- lessness and wandering at night, or the patient ma}- have short snatches of sleep, from which he awakes semi-delirious, ihis gradually increases, and is followed by violent delirium, in which 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 exitement he is with difficulty restrained from jumping out of bed ; in many instances these patients are remarkably cunning, and, managing to elude the vigilance of their attendants, will succeed in escaping from the room by the door or window, and may inflict serious, and even fatal, injuries upon themselves or others. There is always a tremulous condition of the extremities and of the tongue, which is white and coated, whilst the bowels are obstinately con- fined. The pulse and temperature vary considerably, 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 the case of a fractured leg, the struggles of the patient will cause considerable displacement of the limb, and necessitate constant attention to prevent further mischief. The limb should never be fixed to the bed, but slung in a Salter's swing or immobilized in plaster of Paris. Treatment. — In cases where an attack of delirium tremens is con- sidered imminent, either from the previous history of the patient, the tremulous state of his hands and tongue, or his sleeplessness, the best treatment to adopt is to support the strength by suitable, easily digested food, combined with free purging and, if need be, soporifics, such as chloral, bromide, paraldehyde, or morphia. Paraldehyde is perhaps the safest, whilst morphia must be ad- ministered cautiously; under such a regimen the symptoms usually soon disappear. In the acute maniacal attacks the patient must be fully controlled and guarded, but with as little manifestation of retraint as possible ; faihng other drugs, hyoscin in doses of tt^ to j-^o grain will sometimes succeed in quieting the patient, but must be used with great care, as it is a severe depressant. Nourishing food of a fluid type should be administered during the quiet intervals, and free purging is of course essential. The patient usually re- covers from a first attack, but in the later ones may die of heart failure or exhaustion. CHAPTER XI. THE GENERAL TECHNIQUE OF OPERATIVE SURGERY. No one who has been brought up in the modern school of antiseptic or aseptic surgery can have any idea of the horrors that were per- petrated under the name of surgery by our ancestors. Aneesthesia was unknowm, and perhaps this was an advantage rather than other- wise, as it hmited the number and the scope of operations. Patients had to be forcibly restrained during the procedure; haemostatic forceps were not in existence, and the operating theatre was not the quietly decorous spot that it now is, but rather resembled the shambles. The wards were a hotbed of surgical fever, and erysipelas, pyaemia, and other manifestations of pyogenic infection led to an appalhng post-operative death-rate. Hospital gangrene, wound phagedena, and other affections now happily extinct, were common enough, and not unfrequently wards had to be entirely closed in order to hmit the ravages of such diseases. The almost synchronous discovery of anaesthesia and antisepsis has transformed surgery, and from being an art dangerous, barbarous, and almost repulsive, it has been changed into a scientific procedure, beautiful in its details and beneficent in its results. In this connection the names of Simpson, who fought the battle of anaesthesia, of Spencer Wells, who popu- larized the use of haemostatic forceps, and of Lister, who first appHed to surgery the principles that were being taught by Pasteur as to the microbic origin of disease, will ever stand out as three of the greatest benefactors of the human race. The Antiseptic plan of treating wounds, as originally introduced by Lord Lister, is an outcome of the germ theory of putrefaction. It has for its object the prevention of bacterial development in wounds bv the use of chemical agents, some of which are true germi- cides, capable of destroying the bacteria, whilst others merely pre- vent or inhibit their growth. Amongst the multifarious antiseptic agents which have been used, the most prominent are carbolic acid, corrosive sublimate, biniodide of mercury, iodine, iodoform, formahn, boric acid, salicylic acid, etc. Carbolic Acid, the first antiseptic employed by Lister, has a direct germicidal 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 271 272 A MANUAL OF SURGERY known as pure or liquefied carbolic acid, which is a powerful though super- ficial caustic, and may be applied without much fear to infected living tissues — e.g., to tuberculous sinuses or wounds — after scraping them, in order to destroy any portions of tuberculous material which may have escaped the spoon. Excess of the acid may be washed away with absolute alcohol, which quickly dissolves it. The liquid carbolic dissolves in water on the application of warmth, and the 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. It is most important to ensure the complete solution of the acid, as otherwise globules of it may be deposited on the hands or in the wound, and may do much harm. Carbolic acid is frequently somewhat crude and impure, and many of the irritative and toxic phenomena are due to cresylic acid and other substances which 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 giddiness, nausea, and vomiting, in bad cases progressing to a condition of collapse; diseased kidneys may be seriously affected. Weaker solutions are more readily absorbed than the liquefied or pure acid. It must be remembered that children and some adults are peculiarly susceptible to its action, and its application to large wounded surfaces, e.g., burns, is inadvisable. On the other hand, its great affinity for all greasy and oily substances renders it a valuable antiseptic for emergency work, as it penetrates into the skin more readily than other agents. A solution in olive oil (i in 20) or vaseline is some- times used as a lubricant for catheters, etc., but is not very satisfactory. Corrosive Sublimate is usually employed in solutions of i in 2,000, i in 1,000, or I in 500. Occasionally the last of these three solutions has 5 per cent, of carbolic acid added to it, constituting what is known as Lister's strong mixture. Sublimate solutions are inhibitory in action rather than germicidal, but are potent and reliable, especially in purifying the skin; when mixed with albu- minous fluids, such as blood, an insoluble albuminate of mercury forms, which is ineffective as an antiseptic. They have less power of penetration than carbolic acid, and have less 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 ot 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 appearance. It must be remembered that individuals very sensitive to the action of mercury may be salivated by this agent, and espe- cially when used frequently for irrigating cavities to which a free exit is not provided. Symptoms of acute intestinal irritation, cramps, vomiting, and blood-stained diarrhoea, may also be caused. Biniodide of Mercury is a potent antiseptic, which has been chiefly employed in the form of a i in 500 solution in 70 per cent, methylated spirit for the purification of the hands or of the skin of the patient. It is, of course, extremely toxic. A I in 2,000 aqueous solution is also employed for the hands, and is less harmful to instruments than the perchloride. 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 for infants. It is also useful when antiseptic fomentations are required in treating inflammatory phenomena, and in ophthalmic surgery. Iodine is a most valuable antiseptic, and at the present time is largely employed to sterilize the skin before operations in alcoholic solutions, varying from 2 to 5 per cent. To be effective it is essential that the skin be pre- viously freed from moisture or grease. In weaker solutions iodine is useful to irrigate suppurating cavities, or may be employed as a bath in which to immerse inflamed parts. Iodoform is a yellow powder of characteristic and unpleasant odour, which probably acts by being decomposed in the tissues and slowly giving off iodine. Commercial iodoform is usually contaminated with a variety of germs; it is therefore wise to wash the iodoform before use in i in 20 carbolic lotion. Its THE GENERAL TECHNIQUE OF OPERATIVE SURGERY 273 chiol' value is in foul or tuberculous wounds, and, indeed, it seems to have a specific inhibitory action upon the development of the B. tuberculosis. It may be suspended in glycerine (10 per cent.), ami after sterilization by im- mersing the vessel in which it is contained in boiling water for half an hour, this can be 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 of very variable type may follow from undue absorption of the drug. Gastro-intestinal disturbances, vomiting, diarrhoea, colic, etc., may be the chief symptoms, but delirium and collapse often supervene. There is alwavs an abundance of iodine in the urine. Various substitutes have been proposed in order to avoid the unpleasant smell — e.g.. aristol. orthoform, etc. — but they are of doubtful value. Chinosol is a yellow substance, harmless and free from toxic qualities; it is easily 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. Its solution is somewhat soapy, 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; the^^ 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 per- oxide of hydrogen, which is sold as a fluid capable of setting free 10 to 20 times its volume of nascent oxygen. It is quite unirritating, and may be poured directly into an infected 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 sloughs or foreign bodies. Its use is particularly indicated in the treatment of dirty 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. Formalin is a powerful antiseptic, and consists of a 40 per cent, aqueous solution of formic aldehyde. It is decidedly toxic, even in a i per cent, solution. It blackens steel instruments, gives off an irritating vapour, and hardens the skin to an unpleasant degree. The Aseptic Method of treating wounds consists in the elimination of chemical antiseptics as far as possible, and the substitution of heat, drv or moist, as a steiilizing agent. Every efficient antiseptic is more or less toxic and irritating, and there can be no question that, from an ideal standpoint, the less they are introduced into wounds, the better. No more satisfactory germicide can be imagined than heat, in the form either of boiling water or of steam under pressure, and it is claimed that if e\'er3i:hing brought in contact with the wound is aseptic, then no antiseptics need be employed. Dressings, swabs, towels, aprons or coats, and caps, are sterilized in drums or kettles b\^ means of steam at ordinary pressure, or by superheated steam at high pressure. The latter, of course, is the more satisfac- tory, o\ving to its greater penetrative power, but the former can be effective if the drums are so constructed as to permit a free passage of steam through the articles to be sterilized, and if the latter are packed loosely and not tightlv. The drum is first lined wdth a layer of lint or gauze, and a similar covering must be placed over the contents beneath the lid. A shding shutter, or some suitable con- trivance, allows the entrance of steam into the drum. \Mien the drum is removed from the sterihzer, this shutter is closed, and the 274 A MANUAL OF SURGERY contents may be expected to remain sterile for a day or two, but not for long unless hermetically sealed. For small establishments a Schimmelbusch's low-pressure dressing steriHzer or a small high- pressure (from 5 to 15 pounds) steam sterilizer answers excellently; but for large hospitals an extensive and expensive plant must be installed, and probably some variety of the Washington-Lyon sterilizer is the best. For private practice suppHes of effectively sterihzed articles in hermetically sealed tins or drums can now be obtained from many instrument makers and chemists. Of course, there are two elements in an operation which can never be sterilized apart from chemical antiseptics- — viz., the skin of the patient and the surgeon's and assistants' hands — and thus the most complete aseptic precautions can never entirel}' eliminate chemical agents. Moreover, it must not be forgotten that the air itself holds numberless germs which cannot be excluded from the wound, and that such germs are more numerous in crowded cities and in places where sick people are likely to congregate. To obviate this, most elaborate precautions have often been taken in order to filter the air admitted to the operating theatre, and also as to the cleanliness and dress of the surgeon ancl his assistants. Unsterilized persons, and therefore students, are frequently banished from the operating theatre, or placed behind a glass screen, as every additional onlooker must increase the risk in purely aseptic conditions. Then, too, the surgeon ought to be able to rely on assistants and nurses who are not changing every six or twelve months, as there is no second line of defence in the presence of antiseptics to make good errors in tech- nique. Moreover, away from hospital, surgeons are not always able to command aseptic conditions, but may have to operate in very unsuitable surroundings. Hence, in a large teaching hospital, de- voted to the training of students and nurses (and such, we believe, can only be carried out effectively by their active participation in the work), it is quite a question whether it is desirable to maintain a purely aseptic chnique. The actual details of operative technique vary somewhat with different surgeons, but the main principles which govern modern operative surgery are much the same in all, and the following sketch of the preparations required and of the routine usually practised in undertaking an operation may be considered more or less typical of modern methods: I. The Operating Theatre or Room. — The arrangement of this necessarily depends upon considerations of space and finance. It should not be unnecessarily large, and the old-fashioned theatre with tiers of seats overlooking the central area is not desirable. On- lookers should have a low gallery provided for them, but little raised above the floor-space and shut off from it not merely by a rail, but by an effective barrier breast-high. It may with advantage be placed between the operating area and the source of light, but clear of the window, or to one side, and should be entered by a separate passage and not through the theatre. A north light is desirable. THE GENERAL TECHNIQUE OF OPERATIVE SURGERY 275 and it should come, not from the top, but from the side, in the form of what is known as a ' studio hght.' The walls should be free from ledges on which dust may accumulate, and hned with white tiles or glazed bricks, or, better still, present a smooth surface painted with white enamel, which can be washed down with a hose; of course all corners should be rounded. The floor must be impermeable, and slope towards an open channel on one side of the theatre, so as to allow of suitable flushing with a hose. All shelves must be made of glass, but the fewer fixtures in the actual theatre the better. The heating arrangements should be such that the temperature can be raised, if necessary, to 75° or 80° F. Attached to the theatre should be a suitable series of smaller rooms for the anaesthetist, for sterilizing purposes, etc. In a private house the room must, if possible, be carefully pre- pared beforehand. The carpet should be taken up and curtains removed. The walls should be wiped over with an antiseptic solu- tion, and the floor thoroughly scrubbed ; all unnecessary furniture is removed. Should the operation be an emergency one, without time for such complete preparation, it is often wiser to leave things alone, and not stir up dust and dirt by a hurried attempt to make the place look a httle better than it really is. A suitable supply of hot and cold boiled water must be secured beforehand, and basins and dishes, etc., should, if possible, be previously boiled. 2. Ihe Surgeon must remember the very grave responsibiUty that rests upon him in undertaking many of the modern operations, and he must be wilUng and ready to submit himself to the strictest regime. In a general hospital the surgeon will probably lay aside his outdoor clothes and boots, and don an operating suit consisting of a soft white shirt, white ' drill ' trousers, and a pair of clean shoe? ; he will then proceed to purify his hands and arms, and finally puts on a sterilized gown reaching lo the wrists, a sterihzed cap and mask covering the whole face except the eyes, and sterihzed gloves reach- ing over the lower end of the sleeves. The assistants will be simi- larly prepared. Where such a complete change is impossible, the shirt-sleeves must be turned up well above the elbow'S, and other preparations made as before. During the operation unnecessary talking is forbidden, and if one has to cough or sneeze the head is turned completely aside. Similar rules hold good in regard to the nurses, whose arms should be bare to the elbows, and who should wear sterihzed coats ; the hair must be covered by a sterihzed cap, even if a mask is not considered necessary. 1 he hands and arms must be as thoroughly and effectively puri- fied as if no aseptic coverings were available. They are scrubbed thoroughly with soft or ether soap and hot water: the nails are cut if need be, special attention being directed to the semilunar folds of skin at the base, where infected material is apt to collect. For this purpose a purified nail-brush is employed with advantage, and if a runninsf stream of hot w^ater can be obtained, so much the better. 276 A MANUAL OF SURGERY The hands and arms are tlien bathed in an efficient antiseptic solu- tion- — e.g., a I in 500 solution of iodide of mercury in 70 per cent, methylated spirit for one minute, and then in a i in 2,000 sublimate solution. The hands and arms, once purified, should not be dried except on a sterilized towel. It is possible that complete steriliza- tion of the hands is not effected in this way, but the surgeon must always aim at obtaining it. On several occasions when our hands and those of our assistants were tested bacteriologically after this method of preparation, they were found to be sterile, even scrapings from beneath the nails giving no reaction. The majority of surgeons nowadays use thin rubber gloves, which can be sterilized by dry heat, or boiled in water without soda; if dry, they can be easily shpped on after dusting them inside with a sterilized powder, such as boracic acid or French chalk ; the hands must, of course, be dried previously. Boiled gloves are best put on by everting them, and thoroughly anointing the interior with steriUzed glycerine; or the hand may be immersed in methylated spirit, and the gloves then slip on easily. They are made so thin that the delicacy of touch is but little impaired, especially when the use of such gloves has become habitual. They can be slightly roughened on the exterior, so that even slippery structures, such as intestine, can be held. They should fit accurately and extend well above the wrist. Care must of course be taken to ensure that the fingers of the gloves are not punctured. Cotton gloves are used by some surgeons, and several pairs may be required during a single operation ; they do not appear to be so satisfactory as the former. Assistants and nurses taking any part in the operation should also wear gloves, especially if the handling and wringing out of swabs is entrusted to them. Much of the success of an operative clinique depends upon the methodical and effective organization of the same. It is desirable that all unnecessary hands should be eliminated, and therefore everything likely to be needed should be laid out within reach of the surgeon and his assistants on suitable side-tables, so that they may be able to take up instruments, figatures, and sutures, etc., without being touched by others. 3. Instruments are sterilized by boiling in a weak solution of bicarbonate of soda (i per cent.) for five or ten minutes, or more if they have been previously used for a dirty case. To prevent them from rusting, they should be carefully plated, and the water ought to boil for some minutes before they are immersed, in order that the suspended air may be driven off. After boiling they may be laid out on a sterihzed dry towel and covered over with a similar towel till they are required, or kept in a weak antiseptic solution — e.g., carbolic lotion, i in 60. Mercurial solutions should be avoided, as they spoil the instniments. If during an operation an instrument which has not been previously sterilized is required, it may be quickly purified by immersing it for half a minute in liquefied car- bolic acid, the excess of which is removed by washing thoroughly in THE GENERAL TECHNIQUE OF OPERATIVE SURGERY 277 alcohol or hot sterilized water. The same process or re-boiling must be adopted for any instrument which falls on the floor or becomes otherwise soiled. Special care must be chrected towards the forceps, to see that the serrations are freed from dried blood-clot and other dirt. H.nemostatic forceps should be opened before boiling. 4. Swabs have now so completely taken the place of sponges in surgery that it is unnecessary to consider the preparation of the latter. Swabs are made of absorbent wool wrapped in a single square layer of gauze the corners of which are tied across and tucked in ; or they may be composed of gauze alone, folded over, and perhaps stitched so as to leave no free edge which may fray out ; or they may be formed of larger squares of absorbent material, such as Gamgee tissue. A sufftciency of these, suited in size and shape to the re- quirements of the case, is provided before the operation. They are sterilized in a suitable autoclave or sterilizer, and kept in the drum until required, when they are removed by sterile hands or instru- ments to a sterile receptacle, being used dry or after immersion in lotion. In case of need, where a sterilizer is not available, they may be boiled and then kept either in boiled water, covered over till required with a steriHzed cloth, or in an antiseptic solution ; or maj^ be dried in an oven after being enclosed in a suitable cloth. Cloths and gauze strips for abdominal operations are prepared in a similar manner. In these cases a careful record must be kept of the numbers used, so that all may be accounted for afterwards; indeed, it is wise always to have swabs, etc., done up in packets or bags containing a known number, such as a dozen. 5. The Ligatures and Sutures demand very thorough purification, which varies with the material used. Silkworm-gut, horsehair, and silver wire, which do not imbibe fluids or become absorbed, merely require to be boiled, but silk and catgut need much more care if stitch suppuration is to be avoided. Silk must be boiled for twenty or thirty minutes, and should be wound loosely on reels or winders, so that the deeper strands may become sterile as well as the super- ficial. It may be used at once or after being kept in spirit or in some antiseptic lotion, such as a solution of subhmate (i in 1,000), for a week or until required, so that its strands may become well impreg- nated with the salt. An important precaution in the use of silk is to soak it in sterilized water before use, especially if it has been kept in spirit; the object of this is to protect the tissues from the caustic action of the latter, and thereby hinder stitch suppuration. More- over, silk should never be used with ungloved hands ; the strands cut through the epidermis and become contaminated by germs lying in the deeper layers of the skin, and stitch suppuration may result. Catgut is still more difficult to purify, inasmuch as boiling in water is out of the question. Lord Lister claimed that catgut, prepared according to his directions (p. 290), remains actively antiseptic for an indefinite period, and that it suffices before use to immerse it in a I in 20 solution of carbohc acid for a quarter of an hour. The majority of surgeons, however, prefer to sterihze it before use, and 278 A MANUAL OF SURGERY especially so if they used non-chromicized gut or catgut which has been hardened in a 5 per cent, solution of formalin for twenty-four hours. Many different processes have been recommended, but perhaps the simplest and most effective is that known as the ' iodine ' method. The catgut is wound loosely on a glass spool or winder, and immersed in a solution containing iocline, i part ; iodide of potassium, i part; and distilled water, 100 parts. It is kept thus in the dark for seven to ten days, and then removed and kept dry, wrapped in sterile gauze. Before use it is placed for a few minutes in spirit (rectified or methy- lated), so as to dissolve out a little of the excess of iodine present. Catgut so prepared is not only aseptic, but also actively antiseptic, and rarely causes trouble in the tissues (except, perhaps, in delicate children). An extensive experience of this material for some years has proved its reliability and value. Various instrument-makers provide sterilized catgut in sealed glass tubes, which can usually be trusted. 6. The skin of the patient is carefully prepared before operation, the length of such treatment depending on the cleanliness or not of the part and the urgency of the case. The skin is first shaved, if necessary, and washed with soft or ether soap and hot sublimate lotion (i in 2,000) ; acetone or turpentine may be used to remove grease and excessive dirt. It is then flushed with biniodide of mercury in spirit (i in 500), or with carbolic lotion (i in 20), and afterwards the stronger antiseptic is washed away with a weaker solution either of carbolic acid or subhmate. The part is finally wrapped up in an anti- septic compress — i.e., of gauze or lint, soaked in i in 40 carbolic or I in 2,000 sublimate solution. At the time of operation the same pro- cess may be repeated. It must not be forgotten that a very vigorous use of carbolic acid may be followed by local irritation, as well as by its absorption into the blood-stream, especially in protracted operations and in children. Care must also be taken that the patient does not lie in a pool of antiseptic lotion which has run down during the washing and collected under the sacrum ; many a bad antiseptic burn has resulted therefrom. Again, not only does the quality of the skin vary in different individuals (as may be illustrated by contrasting that of a coal-heaver, who possibly bathes once a year, with that of a child or lady, which is soft, clean, and dehcate), but it also differs in various regions of the body, and hence the process of purification must be modified according to the character and thickness of the integument . Any part where dirt may accumulate demands scrupu- lous attention — e.g., the umbilicus, external ear, toes, or corona glandis in persons with long foreskins. A word of warning is also needed as to the too vigorous use of a nail-brush leading to a trau- matic dermatitis, or even waking up into activity germs which other- wise would have lain dormant in the deeper layers of the uninjured skin. It may be again mentioned that in cases of emergency it is wiser to trust in carbohc lotion than in sublimate, as the former unites freely with the grease of the skin, and hence penetrates more deeply. This method of preparing the patient has, however, been largely THE GENERAL TECHNIQUE OF OPERATIVE SURGERY 279 displaced by the discovery of the penetrating antiseptic properties oi iodine, to which Mr. Waterhouse drew attention {Lancet, April 16, 1910). The all-essential element in the use of this agent is that the skin to which it is appUed must be quite dry; moisture causes the cells of the prickle-celled layer to swell up, and hinders the action. It may therefore be employed directly in casualty work to a dirty skin without washing. In operative work the part to be purified should be shaved and washed twelve hours before, and wrapped in a sterihzed towel ; the iodine is painted over two hours before opera- tion, and the sterile covering replaced ; and finally on the operating table the parts are painted once again. The solution employed should be one containing 2 or 2*5 per cent, of iodine in rectified, not methylated, spirit ; the latter causes intolerable irritation of the eyes. The iodine method is quite rehable, if the precautions noted above are taken, but occasionally it causes some irritation of dehcate and sensitive skins. 7. The area of operation is surrounded by mackintoshes, which should always be purified or sterihzed, and these in turn are covered with dry sterihzed towels, fixed to the skin by suitable towel-chps. FaiHng dry sterihzation, the towels may be boiled, and subsequently dried by baking in an oven, or soaked in an antiseptic solution. During an operation irrigation or flushing is unnecessary, unless the proceedings are prolonged, and then hot sterihzed salt solution should be employed for the purpose ; but a final flushing with carbohc lotion (i in 40) or with sublimate (i in 2,000) is somerimes useful, especially when operating under conditions which are not ideal as to surroundings and technique. The objection to such flushing is that the lorion is more or less of an irritant, and determines a certain amount of subsequent oozing and effusion, which will necessitate drainage. More particularly, when deahng with the peritoneal cavity or interior of a joint, the less one employs antiseptics the better ; they lead to a desquamation of the dehcate endothehal Uning which it is so important to maintain intact. 8. Before closing the wound absolute hsemostasis should be secured, and then the wound may usually be stitched up completely and without drainage. It is important to build up again the divided tissues of the part by suitable buried sutures, so as not only to secure more perfect apposition, but also to obhterate ' dead spaces ' in which blood-clot or effusion may collect. In this way wounds through fleshy and vascular structures — e.g., an amputation through the thigh— may sometimes be completely closed up without drainage. On the other hand, where accurate apposition of tissues and ob- Uteration of cavities cannot be obtained, as after clearing out the axilla, and where some amount of oozing may be expected, it is advisable to insert a suitable drainage-tube, and stitch it flush with the surface. It is removed at the end of forty-eight hours at most ; in such cases the removal of the discharge and the changing of the soaked and perhaps stiffened dressings add materially to the comfort of the patient. 28o A MANUAL OF SURGERY When the operation has been completed, the skin around is cleansed with lotion, but only after a piece of dressing has been placed as a protection over the wound. This cleansing should always be accom- plished by wiping peripherally away from the wound, and any swab utilized for this purpose should not again l)e allowed to touch it. 9. Finally, a carefully arranged Dressing is applied, and the part bandaged and placed at rest on a splint or in a sling, if such is indicated by the requirements of the case; absolute rest and quiet are essential if rapid healing is to be obtained. Lord Lister pointed out some years back that the main essentials of a good dressing consisted in its containing some trustworthy anti- septic ingredient; in this agent being so stored up that it cannot be dissipated before the next dressing; in its being entirely unirritating; and in the capacity of the fabric readily to absorb blood or serum that may ooze from the wound. The original antiseptic dressings — viz., the carbolic and eucalj^ptus gauzes, and even the alembroth gauze and wool — failed to fulfil these requirements ; 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 soaked for some hours in carbolic lotion (i in 20), and applied to the wound without fear after wringing it out of a i in 40 solution; or it may be sterilized and applied dry. A sufficiency of this is employed so as to cover in a wide margin of skin all round the wound, and, finally, over all a liberal covering of sterilized or antiseptic wool, so as to diffuse the pressure, which is applied by means of careful bandaging. 1 he best material for bandages is butter-cloth, since it is light and adapts itself easily to the outUnes of the part. Other dressings, such as boric lint, iodoform gauze, etc., are occasionally employed, but they are not so satisfactory for general use as the cyanide gauze. Many surgeons employ simple sterilized gauze without any anti- septic ingredients, and where complete asepsis has been maintained and no great amount of discharge is expected, this will suffice ad- mirably. An antiseptic dressing is, however, an extra safeguard that may be wisely adopted, and especially in cases where a good deal of post-operative oozing is likely to occur. Thus in a case of excision of the astragalus, where by an oversight the dressing, though badly soiled, had been left untouched for a week, the bandage and aseptic wool soaked with a blood-stained discharge stank; but on removing them and taking off the underlying cyanide gauze, the foetor gradually diminished, and the wound was found to be un- infected, and ran an ordinary course to repair. The bacteria, which were attacking the parts from without, were unable to penetrate the cyanide gauze, which probably saved the boy from losing his foot. 10. After-Treatment. — If no drainage-tube has been employed, and the dressing is not soaked through, it may be left untouched for seven or eight days, 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 drainage-tube has been inserted, it is usual to take it out at the end of twenty-four or forty-eight hours ; THE GENERAL TECHNIQUE OF OPERATIVE SURGERY 281 there is no advantage in retaining it longer, since it is only required for the removal of "the sero -sanguineous fluid which exudes imme- diately after the operation. Should this early discharge be very abundant and soak through the dressings, there is no actual need to remove them and re-dress during the first twenty-four hours, if cyanide gauze has been employed ; all that 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 be repeated a second time. But where merely sterile gauze has been used, it is wise to redress the wound completely. The after-dressings of the wound need to be conducted with the same precautions as to asepsis of hands, instruments, etc., as the original operation, and not a few instances of infection at the first dre'ssing occur. It is essenrial that everything hkely to be required should be prepared before the dressings are removed, so that ex- posure to the air may last as short a rime as possible. If the first dressing is undertaken after twenty-four or forty-eight hours, and all is going on sarisfactorilv, the tube is removed, and the wound re- dressed in exactlv the same way as formeriy, though probably much less gauze will be required. If the case is left for eight da^^s, the sritches can probably be taken out, and the skm mcision will then be found united. A small dressing of cyanide gauze is apphed, fitring closely to the scar, and sealed down with flexile collodion, which wall not only prevent the gauze from sHpping, but will also by its con- traction serve to steady the parts. This should be covered with wool and a bandage, so' as to support the parts, and may be finally removed at the end of another week. An open method of treating certain operation wounds has been recently adopted with considerable advantage. Absolute haemostasis is the first essential, and the wound must be completely closed wath- out drainage. It is carefully dried and painted over with 2 per cent, solution of iodine in spirit. 'A sterilized towel may be placed around the part for the first twenty-four hours ; but this may be discarded after^vards, and the wound is left uncovered, and merely painted wth the iodine solution daily. In the case of children some arrangement of the bed-clothes must be devised to keep their fingers away from the part. Hernia operations and similar wounds do excellently under this regime. CHAPTER XII. H ^ M|0 R R H A G E. By the term hemorrhage is meant any escape of blood from the vessels, whether insignificant and immediately arrested by natural means, or more excessive and requiring treatment to prevent its continuance. Although most commonly due to some injury, whether subcutaneous or inflicted through the skin, it may be pre- disposed to by weakness of the vascular tissues, especially if asso- ciated 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 started. The character of the bleeding differs according to the vessel from which the blood escapes. Arterial Haemorrhage consists in a flow of bright red blood, which escapes at first per 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 sufficiently abundant. If, however, it is derived from a deep artery, the blood may well up from the depths of the wound and not 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 jugular, the blood may escape with a very definite spurt, owing to respiratory or other influences. Capillary Haemorrhage is marked by general oozing from a raw surface, the blood trickling down into a wound, if present, and filling it from below upwards. By Extravasation of Blood is meant the pouring out of blood from a wounded vessel or vessels into the lax areolar planes immediately adjacent, which become swollen and boggy. The usual constitutional signs may be manifested as a result of such extravasation, and, indeed, fatal haemorrhage may occur in this way without any escape upon the surface of the body. Subcutaneous or submucous hccmor- rhage is also met with in the form of small localized petechise, arising from injuries, or from changes in the blood or vessel walls (as in purpura, scurvy, and septicaemia). Epistaxis is the term given to bleeding from the nose. By Haematemesis is meant the vomiting of blood; it may either have been swallowed, as in some cases of fractured base of the skull, where the pharyngeal mucous membrane 282 HEMORRHAGE 283 has been torn, or it may have originated from the upper part of the intestinal traet. If it has remained in the stomach any length of time, the blood becomes curdled and brownish in colour, somewhat resembling coffee-grounds, from the action of the gastric juice upon it. When gastric hcemorrhagc is more active, the blood is bright red in colour, and may be vomited in the form of large clots Haemoptysis is the title given to the escape of blood from the air passages, whether it results from injury or disease. The characters vary with the quantity lost; in the milder cases it is usually bright red and frothy from admixture with air ; in graver cases, when larger vessels are involved, the blood may escape unaltered, and be so abundant as to asph^^xiate the patient. Hsematuria [q-v.) is a con- dition in which blood is passed in the urine. By Melsena is meant the passage of dark tarry blood with the faeces; it is always an e\ndence of disease or injury of the intestinal canal 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 membrane usually retains its bright red colour. Constitutional Efiecls. — If the haemorrhage is severe, as from division of a large artery, death results from syncope. The surface of the body becomes cold, clammy, and pale; the hps, ears, and eyehds are livid; the patient gasps, his respirations become quick and sighing, and death ensues after perhaps a few convulsive twitches of the Hmbs. If the haemorrhage is not so great as to kill immediately, the patient faints, and on recovery is in a condition of severe collapse and weakness, which continues for some time; he is also liable to recurrent attacks of syncope, especially if the bleeding recurs. If the haemorrhage is concealed and of moderate severity, as from ulceration of the stomach or duodenum, or by shpping of a ligature after an abdominal operation, the patient rapidly becomes pro- foundly anaemic, and his face shrunken and drawn as a result of the dehydration of the tissues of the cheeks. The organs of the body generally suffer from want of oxygen, and hence the patient feels as if he were being suffocated, and is extremely restless, tossing about in bed, and clamouring for open windows and more air {air- himger). Any sudden exertion, or even sometimes the attempt to sit up, is followed by a sensation of faintness or actual syncope; noises are heard in the ears, the sight becomes dim, or is even tem- porarily lost (amblyopia), and severe headache may be complained of, all arising from cerebral anaemia. The pulse often becomes what is known as hemorrhagic in character — i.e., frequent — and com- pressible, but collapsing entirely between the beats, and markedly dicrotic. These pecuUar features are due to the sudden passage of a small amount of blood through a vessel which is practically empty. From the defective vis a tergo, oedema of the extremities may result. During the continuance of haemorrhage the blood-pressure neces- sarily falls; but unless the loss is great, it quickly rises again to the normal after the bleeding has ceased. This rise in blood-pressure is 284 A MANUAL OF SURGERY 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 by an increased flow of lymph into the circulation. For the changes that occur in the blood as a result of h.'emorrhage, see p. 58. The ha:-moglobin is gradually restored, and an increase of i per cent, daily is about the normal rate (Emery). Children and elderly people alike bear the loss of blood badly; but whereas children rapidly recover from the immediate effects, elderly people do not. General Treatment. — When the loss of blood has been severe, the patient must be kept quiet with the head low, whether syncope is present or not. Ihc foot of the bed or couch should be placed on blocks or on chairs, so as to assist in the maintenance of the circula- tion to the medullary centres. Stimulants may be necessary to maintain the heart's action, but should never be given iMtil the bleeding has been effectively controlled, as otherwise they may increase or re-start it. If death appears to be imminent, the arms and legs should be bandaged, or the abdominal aorta compressed, in order to confine the blood as much as possible to the head and trunk. ' No patient should be allowed to die of haemorrhage.' Such was the dictum of the late Mr. Wooldridge, of Guy's Hospital, based on a knowledge of the value of transfusion and infusion. By Trans- fusion is meant the transference of blood from one individual to another; it has now, however, been recognised that the success of this proceeding depends on the introduction of a sufficient quantity of fluid as a temporary substitute for the blood which has been lost, rather thdn on its quality ; for it has been proved that the transfused blood of another person is rapidly destroyed and eliminated. Hence transfusion has now been replaced by the Infusion of some bland fluid, isotonic with blood-plasma, into the vessels, and by this means greatly improved results have been obtained. The apparatus re- quired is a metal or glass cannula, the end of which is bulbous, blunt, and bevelled, which can be inserted into a vein, and connected by means of a rubber tube with a reservoir containing the fluid (Fig. 89) . A vein — e.g., the median basilic or internal saphena — should be ex- posed, tied below, and opened by a longitudinal or oblique incision; the cannula, filled with lotion so as to exclude air, is then inserted, and a ligature placed round the vessel, so that on withdrawal it can be tightened. The amount injected varies with the circumstances and the effects produced, but, to be efficacious, some 2 or 3 pints are usually needed; this may be repeated, if necessary, but rectal infusion will often suffice in the later stages. As to the material, a warm saline solution is the best, consisting of a drachm of chloride of soda to a pint of sterilized water (or about 0-6 per cent.), at a temperature of 105° to 110° F. Tabloids or tablets of the dried salt are dissolved in a small quantity of boiling water, and this is then diluted to the required bulk and temperature. Of course, the apparatus is carefully sterilized by boiling, and no air must be admitted. The injection is made slowly, so that the solu- HAEMORRHAGE 285 tion may be mixed gradually with the blood. It has been found by experiment that after an infusion following hiiemorrhage the specific gravity of 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. This suggests that the increased amount of fluid is ab- sorbed into the tissues, and explains why it is sometimes necessary to repeat the injection more than once. In the later stages of recovery from hemorrhage and in cases of shock the introduction of warm sahne solution into the rectum {proc- toclysis), or through an exploring needle connected with a tube and Fig. -Infusion into Vein of Forearm. Above, a useful form of metal cannula is represented ; below, the arrangement of the ligatures on the vein. funnel into the loose connective tissues of the buttock, abdomen, or submammary region [hypodermoclysis] , is exceedingly valuable. In the latter case the funnel or receiver must be held at some height (5 or 6 feet), in order to gain sufficient pressure, and by this means a pint or more may be slowly injected; a carefully steriHzed syringe and a large needle may be employed for the same purpose. During the injection the part should be gently rubbed so as to distribute the fluid. For method of proctoclysis, see Chapter XXXV.). Natural Arrest of Hsemorrhage. The process is much the same for arteries, veins, or capillaries; but since the arrest of arterial haemorrhage has been more thoroughly investigated, and is the most important, we shall deal mainly with it. 286 A MANUAL OF SURGERY The Temporary arrest of arterial hitmorrhage is brought aljout 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 merest scratch. The coagulability of the blood varies in different subjects, and is influenced by various conditions — e.g., the amount of calcium salts present. In hcemophilia the blood coagulates with difficulty, and therefore hiemorrhage is always a serious phenomenon in this affection. Loss of blood increases the coagulability to a certain degree. (2) Diminution in the force of the heart's action always follows haemorrhage from ana-mia of the cerebral centres — a beneficent provision whereby coagulation is facilitated and the flow of blood checked. Un,til the vessel has been -'""KCj^sN-it ■ » - - efficicntlv secured, stimulants should '^■J^/.^v^A 'y^^^ ' therefore he carefully avoided. Kr" ^^''"\.*»^V<* (3) Changes in and around the [{f' ^MB^ . »»r "l^^\\^"' - '1^ ^^^ vessel play a most important part fifHHI^''^ ""^"i'^'S^ '\i»l •'!,' in completing the process. They consist in the retraction of the artery within its sheath by reason of its inherent longitudinal elas- ticity ; if, however, it is only divided partially (or, as it is called, ' buttondioled '), this condition can- not obtain, and the haemorrhage is more likely to continue. As a result of this retraction, the rough and uneven inner lining of the sheath is exposed, and upon this the blood coagulates as it flows, thus gradually producing what is known as the external coagulum. At the same time the transverse muscular and elastic fibres in the vessel wall cause contraction of the open mouth, and thus the external coagulum is able to increase in size by fresh deposits of fibrin, until at last its resistance is too great for the chminishcd cardiac impulse to overcome, and the sheath is filled with clot, which extends to the divided mouth of the vessel. From this an internal coagulum next develops, which sometimes extends upwards as far the neaiest patent branch. Thus the haemorrhage is arrested for the time being, and preparation made for — The Permanent closure of the wound in the artery, which merely consists in a modification of the general process of repair. Ihe vessel wall contracts upon the internal coagulum, with which, how- ever, it does not unite, except at and near its base. As a result of Fig. 90. — Organized Thrombus IN Vessel, showing the Newly- formed Connective Tissue oc- cupying the Lumen of the Vessel, and Vascularized from the Vasa Vasorum. (Tillmanns.) Two giant cells arc seen in the centre. HEMORRHAGE 287 the injuiy, a simple plastic arteritis is set up, evidenced by a hyper- semic condition of the vessel wall and its infiltration with leucocytes, which also in\'ade the coagulum and cause its base to become decolorized. The leucocytes break up the clot, traversing the natural lines of cleavage which result from its contraction, and gradually remove it, a few giant cells occasionally assisting in this process (Fig. 90). The tunica intima proliferates concurrently, causing a secondary infiltration with the larger fibroblastic cells in that part of the thrombus which is adherent to the vessel wall (Fig. gi) ; whilst a growth of granulations springs up in those parts of the vessel wall where the apex of the clot lies free and unadherent, new vessels being derived from the vasa vasorum. The free conical extremity of the clot contracts, and is gradu- ally removed, partly? by the activity of leucocytes which infiltrate it from the base, partly by the erosive action of the surrounding granula- tion tissue. A similar set of changes occurs at the distal side of the hgature in an artery tied in its continuity. The ligature itself may be infiltrated by leucocytes, and replaced by granulation tissue, or may be encapsuled. A rod of granulation tissue is thus developed, blocking the vessel, and this, by the usual process of repair, is transformed into a firm cica- tricial cord in the course of a few months (Fig. go). It must be clearly understood, however, that the presence of a coagulum is by no means essential to the obliteration of an artery. Thus, if the walls are merely brought into close and accurate apposition by a ligature without dividing the inner or middle coats, a proliferative endarteritis without any clot formation results which is quite sufficient for the occlusion of the vessel. The arrest of haemorrhage from veins and capillaries is more easily accomphshed, the collapse of the walls, and the absence of blood- pressure facilitating the process. The later steps are similar to those occurring in an artery, except that there is but little internal coagulum. o n Fig. 91. — Diagram of Early Stage of Organization of Thrombus, to show THE Infiltration of the Clot with Leucocytes and Connective -Tissue Cells derived from the Endothelium. (TiLLMANNS.) A, Tunica media; B, tunica intima, under- going proliferative changes, and there- fore thickened ; C, blood-clot lying in lumen of vessel, becoming infiltrated with leucocytes (small dark cells) and larger fibroblasts derived from the endo- thelium. 288 A MANUAL OF SURGERY Surgical Treatment of Haemorrhage. I\Iany different methods are needed, under varying circumstances, for the effective arrest of haemorrhage. It may be laid down as a prehminary axiom, that digital pressure over the hlecding-poinl will always check temporarily the most furious outburst, whilst means for its permanent stoppage are being arranged. Where the bleeding is general and does not come from any one par- ticular vessel, the following measures can be utilized: 1. Position. — When the bleeding is from one of the extremities, especially the lower, elevation by emptying the veins will determine a reflex contraction of the arteries, and thereby assist ha^mostasis. 2. Cold may be employed in the form of ice, cold water, or lotion, or simple exposure to the air, all clots, sw-abs, pledgets, etc., being removed for this purpose; it must, however, be remembered that ice and unsterilized water may convey infective germs. Such treat- ment is of most value for general oozing from vascular structures or into ca\Tties, such as the mouth, vagina, or rectum. 3. Hot Water (130° to 160° F.) is a powerful hBemostatic. It is supposed to act by stimulating the involuntary muscular fibres of the vessel wall; but probably the coagulation of the albumin of the blood is an important factor, as unless the water is hot enough to blanch the surface of the wound, the bleeding is not stayed, but rather encouraged. 4. Cauterization is but little used as a haemostatic, except for the bloodless removal of vascular tumours, either as a galvano-cautery, a Pacquehn's knife, or, in the case of piles, as the ordinary clamp and cautery. Occasionally, however, it is used for bleeding in tissues which are infiltrated and thickened by chronic inflammation so that a ligature cannot be applied. It must be remembered that in order to seal effectually the mouths of the vessels, the cautery- must be at a dull red or black heat ; a bright redhot iron cuts through a vessel as cleanly as a knife, and does not stop the haemorrhage. 5. Chemical Agents may be used to assist in checking haemor- rhage from spongy tissues, or from deep cavities or organs, and act in diverse manners, [a) They may act locally as styptics by causing direct coagulation of the blood — e.g., liq. ferri perchloridi or pernitratis, tannic or gallic acids, alum, nitrate of silver, st3-ptic colloid, etc. In employing these, the surface of the wound must be cleansed and dried as far as possible, and the styptic then applied on lint or gauze. Unfortunately, the more active, such as liq. ferri perchloridi, are actively caustic, and may cause sloughing; it is seldom that such a drug is employed, {b) fhey may increase the coagulability of the blood, and of these lactate of calcium is the most effective. It is usually administered per rectum in a small enema containing 15 grains, and this may be repeated two or three times in a day. The use of this dnig before operations which are expected to be^very sanguinary has been most satisfactory in many HEMORRHAGE 289 cases, (c) They may be effective as vaso-constriciors, and of these tlie chief is adrenalin, the active extract of the suprarenal organ. It is probably more valuable in preventing than in checking haemor- rhage, and is largely used in intranasal work; it is prepared in the dry form, smce it loses its power when kept in solution more than an hour or two. The addition of cocaine to its solution increases its activity, {d) A large class of drugs of the astringent class are employed empirically under varying circumstances to assist in hsemo- stasis — e.g., turpentine, hamamelis, ergot, acetate of lead, etc. — but it cannot be said that their action, though appreciated, is fully understood, {e) Finally, it is most important in cases of internal hemorrhage, as from the lungs or gastro-intestinal canal, to keep mind and body quiet, and there is no agent under these circum- stances more valuable than opium and its salts. 6. Direct Pressure, as already mentioned, when available, is always effective — at any rate, for a time. General oozing from cut surfaces, which can be brought into apposition as in an amputation wound, may be checked by applying a firm bandage over them. In cavities or hollows, either natural or made by operation, bleeding may be stopped by packing with strips or graduated layers of sterilized gauze or lint. Such dressings should be retained firmly in position for twenty-four hours, after which, if no further hcemor- rhage has occurred, the bandages may be slackened; but it is usually advisable to retain the deep plugs for another day or two. When the bleeding is more serious, and originates from some definite vessel or vessels, more precise measures have to be adopted. Digital pressure over or on the cardiac side of the bleeding spot suffices to arrest it for a time, whilst preparations are being made to secure the wounded vessel. If possible, a ligature should be applied with anti- septic precautions, but other means have been used: 1. Acupressure was introduced by the late Sir James Simpson in order to obviate the use of ligatures, but is now only used in excep- tional circumstances. A needle was passed either under the vessel from the skin, or over the vessel from the surface of the wound, and with it was 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 for 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 provided with a catch; those known by the name of Spencer Wells or Greig- Smith are the most convenient. In deahng with small vessels, it is quite suffi,cient to leave the forceps apphed for a few minutes, perhaps twisting them before removal ; but with the larger it is advisable to apply a Hgature, although it is claimed for the Greig-Smith pattern that the artery is so thoroughly crushed that this is unnecessary. In deep wounds, where it is difficult, or almost impossible, to tie the vessel, the forceps may be incorporated in the dressings, and not removed for twenty-four hours or longer, according to the size of the vessel. 19 290 A MANUAL OF SUliGERY 3. Torsion was formerly used as a means of sealing the ends of divided vessels, before aseptic ligatures were introduced. It is still occasionally employed for small vessels after forcipressurc, and is specially useful in skin-grafting. 'Ihc effect is to cause rupture of the inner and middle coats just above the spot grasped, and these curl upwards into the lumen of the vessel, whilst the outer coat is twisted up beyond. A coagulum forms upon the injured structures, and the subsequent processes to secure permanent occlusion are similar to those described above. 4. Ligature is at the present day the method most frequently used for arresting bleeding from a definite source. The material should be of sufficient strength to secure the vessel, of sufficient resistance to maintain its hold in spite of being soaked in the body fluids, and yet of such quality as to be absorbed, or so pure and unirritating as to become encapsuled in the tissues. Catgut suitably prepared is frequently employed. It is obtained from sheep's intestines by allowing them to putrefy in water, and then scraping away the mucous and muscular coats, leaving only the elastic basement membrane of the submucosa; this is dried and twisted into the long strands of commercial catgut. When soaked in blood-serum, this substance swells up into a soft, pulpy mass in half an hour, so that it is necessary to harden and render it more resistant before use, as well as to sterilize it thoroughly. It is most effectively prepared by immersion in a mixture of chromic and sulphurous acids in accordance with Lord Lister's original instruc- tions.* The length of time that catgut remains unabsorbed in the tissues varies with the length of its stay in the chromic acid solution, and material calculated to last ten, twenty, thirty, or forty days can be obtained from instrument makers. It is always essential to sterilize catgut thoroughly before use, and the best methods have been discussed at p. 277. Sterihzed silk and linen thread are also employed, whilst anima tissues, 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 an ox, as a material for tying vessels in their continuity, and excellent results have followed its employment. Pagenstecher's celluloid ligature may also be con- sidered a safe and harmless material, and can be sterilized by boihng. 'Ihe immediate effect of a ligature on the arterial xvall, if the vessel has been tied in the usual way, is to divide the inner and middle coats, which are separated from the outer, and curl up slightly, whilst the outer coat is constricted and thrown into folds within the grasp of the hgature (Fig. 92). If an artery is tied in its con- tinuity, the same effect is produced on each side of the ligature. The changes already described, by means of which the artery is obhterated and transformed into a fibro-cicatricial cord, manifest themselves in due order. If the ligature, however, is infected and irritating, it has to cut its way out through the vessel wall by * Brit. Med Journ., January 18, 1908. HEMORRHAGE 2gi an ulcerative process akin to the separation of a slough, thus ex- posing the patient to the risk of secondary haemorrhage. Division of the inner and middle coats is not an essential element in gaining satisfactory occlusion of a vessel, for it can also be effec- tively accomplished by bringing the vascular tunics into close approximation with a broad animal ligature applied by what is known as a ' stay knot ' (p. 32S) without harming the tunica intima. Arterial Haemorrhage. Three forms of arterial haemorrhage are described — viz., primary, reactionary, and secondary. I. Primary Arterial Haemorrhage is met with under two conditions — (i) From an open wound; or (2) where an artery is ruptured or punctured subcutaneously, so that extravasation occurs into the tissues. A. 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 its Treat- ment may be enunciated as follows : 1. The vessel must he secured at the bleeding-point, an operation to expose it being undertaken if necessary. However infiltrated the part, the rule of cutting down to expose the wounded vessel is to be adhered to, and this for two reasons: {a) It is often impossible to know the exact source of the haemorrhage unless it is laid bare. Thus, the bleeding from a punctured wound of the front of the leg, which was apparently derived from the anterior tibial artery, was proved on incision and careful dissection to come from the peroneal, the wound extending backwards between the bones. In the axilla and groin such uncertainty often exists, {b) Proximal hgature of a vessel at some distance above the bleeding spot is often insufhcient to arrest the haemorrhage, since the collateral circulation is quickly estabhshed. In one or two regions, however, such as when the vessel wounded is the deep palmar or plantar arch, or one of the secondary branches of the external carotid in the pterygoid region, the dissection to expose the bleeding-point may be so difficult and dangerous, or so Hkely to be followed by damaging adhesions, that the above-mentioned rule is departed from and proximal hgature is permissible. 2. Both ends of the wounded vessel must be secured if it is completely divided, whilst if it is only punctured, a hgature must be placed on each side of the puncture, and the complete di\dsion of the vessel Fig. 92. — Effect of Ty- ing A Ligature firmly AROUND AN ArTERY. The ligature was tied at two levels, and the ar- tery then laid open longitudinally. 292 A MANUAL OF SURGERY effected. The readiness with which a collateral circulation is estab- lished justifies such treatment in the case of all arteries of large size. 3. It is only needful to undertake the measures detailed above in cases where primary hcemorrhage is actually proceeding. If it has been once arrested, it is unnecessary to search for the bleeding spot ; the wound should be dressed with the utmost care not to dislodge clots or disturb the parts. If, however, the patient is very faint and collapsed, and the surgeon has reason to anticipate that a large trunk has been injured, 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. In the actual treatment of any particular case, temporary arrest of the bleeding may usually be effected hy digital compression either of the bleeding-point or of the main trunk at a favourable spot nearer to the heart, ajainst some resisting structure, such as a sub- jacent bone. The common carotid is controlled by grasping the neck from behind, and compressing the artery by the fingers placed along the anterior border of the sterno-mastoid against the trans- verse process of the sixth cervical vertebra (Chassaignac's tubercle). Such pressure will also control the vertebral and inferior thyroid vessels. The subclavian is to be compressed in the third part of its course against the first rib by the finger or thumb placed immedi- ately behind the clavicle, in the angle between it and the sterno- mastoid, the pressure being made downwards and inwards. A good deal of force is sometimes required in order to maintain the pressure, and this may be gained by superimposing the fingers or thumb of the other hand. When the pressure is to be kept up for some time, the padded handle of a door-key may be employed in the same way, or an incision may be made and the vessel exposed, and controlled by direct digital pressure. The facial artery is compressed against the lower jaw just in front of the masseter muscle; the temporal artery against the zygoma just in front of the ear; the occipital at a spot about i\ inches from the occipital protuberance against the superior curved line. To control the brachial artery, the arm should be grasped from behind, and the fingers pressed inwards along the inner margin of the biceps against the humerus. The abdominal aorta is controlled in slim individuals with ease by pres- sure through the abdominal wall against the body of the third lumbar vertebra a little above and to the left of the umbilicus — i.e., just above its bifurcation; in stout persons this is impossible. The common femoral artery is best compressed immediately below Poupart's ligament. The surgeon should stand on the same side of the patient as the artery to be controlled, and use the finger-tips to press the vessel directly backwards against the pubic ramus. The fingers of one hand placed over the other may sometimes be necessary to maintain sufficient command. Care must be taken not to let the vessel roll aside, and so escape compression. As digital compression cannot, however, be comfortably main- tained for long, mechanical compression of a limb, as by a tourniquet H.HMORRHAGE 293 or elastic bandage, must be requisitioned. A useful contrivance in cases of emergency is fashioned out of a large handkerchief, which is knotted loosely round the Hmb, and tightened by the rotation of a piece of wood inserted beneath it ; a pad is also placed over the main artery, which is thereby compressed. The wound is then, if need be, enlarged by incisions, which, whilst laying the parts freely open, should inflict the least possible damage on surrounding structures. All coagula are removed, the parts are purified, and a search made for the wounded vessel. It may be needful to relax the tourniquet, and allow a jet of blood to escape, in order to ascertain its position. Both ends should be sought for and tied, a proceeding often easier said than done. This especially appHes to the distal end, which retracts, and possibly does not bleed at the time of operation, but may do so when the collateral circula- tion becomes established. B. For Subcutaneous Rupture of an Artery, see p. 299. n. Intermediate or Reactionary Arterial Haemorrhage is the term applied to bleeding which recurs within twenty-four hours of an accident or operation. It may result from two chief causes: {a) Defective apphcation of a Hgature, which comes undone from being badly tied (a ' granny ' knot), or sHps off from including within its grasp other structures as well as the arterial wall; or {b) the coagula lying in the mouths of divided vessels are not suffi- ciently firm to withstand the increasing blood-pressure which supervenes after the shock has passed away, or which may be due to excitement or the injudicious administration of stimulants. It is usually due to the second of these causes, and is then not very serious, inasmuch as it can only arise from the smaller vessels, all the larger ones having probably been recognised and tied during the operation. Treatment. — Elevation and the pressure of a firm bandage are often quite sufficient to arrest this form of bleeding ; but if unsuc- cessful, the wound must be opened up, washed out with hot salt solution, and any bleeding vessels tied. The actual cautery may even be employed to check oozing from cicatricial surfaces, and if it is not allowed to touch the skin, and the wound kept aseptic, no delay in heaUng need be occasioned. Should the bleeding persist, the wound should be firmly packed. III. Secondary Haemorrhage. — Under this title are included all forms of hsemorrhage from wounds which occur after the lapse of twenty-four hours. It is usually due to infection, and was formerly very common, often leading to a fatal termination ; since the intro- duction of antiseptic surgery it is but seldom seen, except where asepsis cannot be fully maintained, as in the mouth, pharynx, etc. The Essential Cause is almost always infection of the wound. In a vessel which has been divided and ligatured, as on the face of an amputation stump, the projecting end of the vessel beyond the ligature is practically dead tissue, and therefore readily attacked by bacteria, w^hich transform it into a slough which, together with the 294 A MANUAL OF SURGERY infected ligature, has to be cast off, and, when this happens, bleed- ing may occur. In addition to this, however, the infection of the wound involves a suppurative inflammation around the vessel (peri- arteritis), which results in a softening of the vascular tunics by the bacterial toxins, and this may progress in time to such an extent as to render them incapable of resisting the blood-pressure, so that, sooner or later,, they give way. This latter condition is especially seen in vessels tied in their continuity, and also occurs in the secondary haemorrhage which is sometimes seen in connection with abscesses in the neighbourhood of large vessels. Anything which interferes with the \atality of the vessel wall may serve as a Contributory Cause, such as the separation from its sheath for too great an extent, thereby cutting off its blood-supply; or a diseased condition of the arterial wall, as from atheroma, or an unhealthy condition of the patient's blood, or undue elevation of blood-pressure, as in Bright's disease. After ligature of large vessels, such as the innominate, first part of the subcla\aan, or common iliac, secondary haemorrhage may occur apart from infection, if the inner and middle coats have been divided by the ligature. The crumpled-up outer coat exposed just above the ligature by the retraction of the inner and middle coats is insufficient to withstand the blood-pressure in such large vessels, and undergoes an aneurismal dilatation, which is certainly followed by haemorrhage at an early date. The Phenomena are almost always preceded by those of infection of the wound, to which a slight occasional loss of blood is added. This continues with more or less frequency and severitv, until the patient is either worn out by the constant repetition of small losses, or 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 smaller vessels, and can be easily dealt with. When, however, it does not superv^ene till late, as on the tenth or twelfth day, it usually arises from the larger trunks, and is increasingly severe. WTien originating from a vessel tied in its continuity, it generally comes from the distal end, since repair is here less effec- tive than on the proximal side of the hgature, and resistance to bacterial infection less vigorous. The explanation of this is that the vasa vasorum reach the artery from the sheath, and run with the blood-current. The separation of the sheath and the applica- tion of the ligature necessarily cut off the blood-supply of the vessel wall just distal to the ligature. Treatment. — The case must be watched night and day imtil the wound is healthy, as although the bleeding may have ceased for a while, it may break out again at any time. If the wound is in a hmb, a tourniquet should be lightly adjusted above it as a precau- tionary measure, so that at a moment's notice it may be tightened. When arising from an artery entirely divided across, as in an ampu- tation stump, elevation of the part after redressing and firm ban- daging may be all that is needed in early cases. A recurrence will H/EMORRHAGE 295 necessitate the opening up of the wound, and the apphcation of ligatures to the bleeding vessels, if practicable. The actual cautery may be employed where the tissues are too rotten to hold a ligature. Sloughs may be cut or scraped away, and the wound packed with gauze and firmly bandaged. If this fails, the artery must be tied just above, or re-amputation performed. When the bleeding comes from the main vessel near the trunk, as after amputation at the shoulder or hip, proximal hgature can alone be depended on, should local treatment be unsuccessful. When coming from an artery tied in its continuity, the wound is opened up, and the artery secured again above and below, whilst every effort is made to combat the infection. Faihng this, proximal hgature may be practicable, but for the large vessels of the trunk pressure may be the only resource. Should re-Hgature at a higher spot fail or be considered inadvisable, as is often the case in the leg, amputation must be undertaken without delay. Venous Hsemorrhage. Bleeding from the smaller veins rarely requires much attention, in that the walls, when once divided, rapidly collapse, and this effectually checks further loss of blood; but if the larger veins are involved,^ or if the walls are thickened and rigid, as in varix, a very considerable amount may be lost, the blood welhng up in a dark, purpHsh stream from the wound, and rendering its arrest the more difftcult from the fact that, except in veins of the largest size, there is no definite jet or gush to guide one to the wounded spot. Treatment. — Divided veins are usually tied in the same way as arteries, but it is often possible to secure a puncture or tear in a large vein by a lateral Hgature without occluding its whole circum- ference. In amputations it is usual to tie both the main artery and vein. Where it is difficult to reach a vein in order to tie it, the wound may be packed. Secondary Hsemorrhage from veins is not common, but arises occasionally from infection around a large vein, which has been punctured and a lateral hgature appHed, or a branch of which has been tied at its point of union with the main trunk. Under aseptic conditions repair of the wounded venous wall is effected without cessation of the circulation in the main trunk. If the wound becomes infected, the hgature is invaded by germs, as also the portion of vein wall within its grasp. In the smaller veins the inflammation induced will result in a protective thrombosis ; but in a large vessel, such as the internal jugular, where the blood-stream is rapid, thrombosis may be hindered in its occurrence, and haemorrhage may result from the wall giving way. The bleeding from cases of this description will usually be severe, but can be easily controlled by pressure or hgature of the whole trunk above or below the wound. The Entrance of Air into Veins is, fortunately, a rare occurrence, as it is always fraught with grave danger to the patient, inasmuch 296 A MANUAL OF SURGERY as it interferes seriously with the circulation, and mav even cause death. The air sucked into the veins is carried up to the right side of the heart, and there becomes entangled in the columnie earner, and is churned up into a frothy spumous mixture, which the heart can only eject with difficulty. The Cause is usually a wound of some vein in what is known as the ' dangerous region ' of the neck (lower portion) or axilla, or even of such unlikely structures as the pelvic veins or cranial sinuses. During inspiration the movements of the thorax exercise an aspira- tory or suction effect upon the blood in the larger veins, and hence an}^ condition which prevents the collapsing of the walls of the veins, or brings about what is termed their canalization, predisposes to this accident. Thus they may be held open at spots where they pierce the deep fascia or the platysma; if the coats are thick and rigid from inflammation, or surrounded by indurated tissue, or buttonholed as by excision of a portion of the walls or division of a branch close to the main trunk, or if undue traction is exercised upon the pedicle of a tumour containing a wounded vein, then the orifice may remain patent, and air can be sucked in. If, however, the veins are ver\' distended, as is often the case in the operation of tracheotomy, then a wound, even in the dangerous area, usually results in loss of blood rather than entrance of air. The chief sign is a hissing, gurgling, or sucking sound, which is quite characteristic. A few bubbles of air may also be seen clinging about the aperture in the vessel. If only a smaU amount has entered, or. if the entry is made slowly, no bad results may follow; but the usual effect is to produce severe faintness, and if the patient is conscious, a feeling of dyspnoea and distress. The pulse becomes rapid and almost imperceptible, the pupils widely dilated, and death may follow, preceded perhaps by convulsions, although the fatal issue may be postponed for a few hours. If the patient sur- vives, no after-effects remain. Treatment. — ^This accident can usually be avoided by dealing cautiously with all veins in operations about the neck, securing them, if possible, by ligature or forceps before their division. Should it occur, any fresh entrance must be at once checked by placing a finger over the bleeding-point or pouring lotion into the wound. The wound in the vein should be at once closed. To combat the general symptoms, it is essential to maintain a good supply of blood to the brain. The head is lowered, and, if need be, the limbs raised and bandaged, or the abdominal aorta compressed. Stimulants and artificial respiration are used in order to maintain the heart's action and to overcome the pulmonary obstruction. Warmth and friction are also applied to the extremities. Methods of Dealing with Haemorrhage from Special Sources. Secondary Branches of the Carotid. — It may be difficult to secure the divided ends. of these vessels either in the neck or head, e.g., in a cut throat or a punc- tured wound of the pterygoid region. Under such circumstances, ligature of HAEMORRHAGE 297 the external carotid between the superior thyroid and lingual has been recom- menilcd as more satisfactory than tying the common carotid, since the cerebral circulation is not thereby affected. Vertebral Artery, — The source of such bleeding may be difficult to ascertain, as It is scarcely possible to compress this vessel without also including the carotid; and hence mistakes in diagnosis have often arisen. It may be feasible, however, to control the carotid alone by pinching it up by the fingers placed on either side of the sterno-mastoid, without interfering with the verte- bral. Treatment must follow the usual course of cutting down and tying at the bleeding-point, if possible. To do this, the incision must be enlarged, or a new one made along the posterior border of the sterno-mastoid in order to define the transverse processes of the vertebrae. In the upper part of its course the vessel may be secured by clipping away a transverse process if necessary, due care being taken of the nerve roots ; otherwise plugging of the vertebral canal or the use of st}T)tics must be depended on. It is most essential that the carotid should not be tied by mistake in these cases, as thereby more blood is directed to the vertebral trunk, and the bleeding is correspondingly increased. The Internal Mammary Artery rarely calls for treatment, since an accidental wound of this vessel is usually com- plicated with some graver mischief to heart, liver or lungs. If recognised, tie at the bleeding spot, possibly removing a costal cartilage to gain access. The vessel lies about h inch outside the border of the sternum. Intercostal Haemorrhage usually re- sults from penetrating wounds also involving the rib, and is not easily stopped on account of the position of the vessels in the groove. Treatment. — Incise the periosteum longitudinally along the lower border of the rib, and detach it and the vessels from the groove; or remove a portion of the bone, and thus expose the bleeding- point ; or in some cases a suture passed round the rib a little above the injury has sufficed; or again, pressure may be employed by pushing a piece of aseptic gauze," hkea pocket, tlxrough the wound in the pleural cavity, and then stuffing it tightly with wool or strips of gauze, so that onTpulling^upon it the vessel may be effectually compressed. Wounds of "the Palmar Arches were formerly much more dreaded than they are at present, when effective asepsis and the use of the elastic tourniquet allow us to explore the depths of a wound without much danger or difficulty. The position of the wound \\i\\ usually indicate whether the bleeding comes from the superficial or deep arch, but in case of doubt it is well to remember that pressure on the ulnar trunk mainlv affects the superficial arch, whilst pressure on the radial \yi\\ chiefly influence the deep. A wound of the super- ficial arch presents little troublein treatment, as it can be readily secured by catch forceps and ligature ; but the deep arch is not so easily dealt with. It lies just over the bases of the metacarpal bones (Fig. 93, d), and to expose it the wound must be freely enlarged by a longitudinal incision, and the tendons turned on one side or separated. It may be possible to secure the vessel by forcipressure forceps, and these may be left on for twenty-four hours if a ligature cannot be applied. Of course, the strictest asepsis is needful m such Fig. 93. — Hand, to show Position OF Palmar Arches. A, Radial artery ; B, ulnar artery ; C, superficial arch : D, deep arch. 298 A MANUAL OF SURGERY cases, and passive movement ol the fingers must be early undertaken, in order to prevent troublesome adhesions, bailing such means, or in infected cases, the wound is packed with sterilized gauze, and over this the fingers are firmly bandaged. The patient is kept in bed for a few days, and the arm elevated. Pressure on the main vessels above is scarcely necessary if 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 be touched for three or four days. If, in spite of this, bleeding recurs, the main vessel or vessels of the limb must be tied. Ligature of the ulnar and radial arteries at the wrist is generally insufficient to control it, as there is often a communicating branch 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, however, by pressure that such would be efficacious; for occasionally there is a high division of the brachial, or a vas aberrans may exist, which would compel the surgeon to tie the third jjart of the axillary. Bleeding from the Plantar Arch must be conducted on similar lines. The Gluteal, Sciatic, or Pudic arteries may be wounded by stabs in the buttock. Treatment. — Enlarge the wound in the direction of the fibres of the gluteus maximus, i.e., downwards and outwards, and secure the bleeding vessel. The gluteal trunk emerges from the pelvis at the junction of the middle and inner thirds of a line from the posterior superior iliac spine to the great trochanter; the pudic crosses the ischial spine at the junction of the middle and lower thirds of a line from the posterior superior iliac spine to the tuber i.schii. The sciatic emerges from the pelvis just above and a little external to the latter spot. The pudic may also be divided in the perineum by a penetrating wound. Failing ligature of any of these arteries at the seat of bleeding, the internal iliac may need to be secured. Haemophilia. By haemophilia, or the hsemorrhagic diathesis, is meant a disease, either congenital and hereditary, or casual and accidental, characterized by a ten- dency to persistent and uncontrollable bleeding from slight wounds, whether open or subcutaneous. This condition is often associated with extravasation of blood into the joints, and certain consecutive phenomena (Chapter XXIII.). The family history of the hereditary cases is interesting, the disease being usually transmitted through the females of one or more generations to the males, whilst the former may escape entirely. The cause of this affection does not lie in the vessels, but in the blood, and is probably due to an insuffi- ciency or imperfection of the fibrin ferment, or to the presence of some anti- coagulable substance. Unless haemorrhage is actually occurring, nothing abnormal is noticed, but any injury is sure to be followed by excessive bleed- ing; spontaneous subcutaneous ecchymoses frequently occur, as also bleeding from the mucous membranes. Hence no operations must be undertaken on such patients unless absolutely urgent, even such a small matter as the extraction of a tooth having proved fatal. The Treatment of ha;mophilia should be directed more to correcting the defect in the blood than to pursuing the usual practice in dealing with haemor- rhage. The application or administration of haemostatics, and of substances which tend to promote coagulation and the formation of fibrin, should be resorted to. Calcium lactate, lo to 20 grs. in ^ pint of water given by the rectum, or 5 to 10 grs. by the mouth, repeated two or three times a day, is decidedly useful, whilst fibrin ferment, suprarenal extract, and cocaine should be employed locally. Position and pressure are attended to, and in severe cases the actual cautery may prove useful, or the prolonged application of cold. The subcutaneous or oral administration of sterilized horse or rabbit serum in doses of from 10 to 30 c.c. has been recently recommended. Anti- diphtheritic serum may be employed instead. CHAPTER XIII. INJURIES AND DISEASES OF ARTERIES— ANEURISM- LIGATURE OF ARTERIES. Injuries of Arteries. Contusion of an artery is the result of \'iolence applied directly to the vessel wall. If atheroma or calcification exists, thrombosis often follows sHght injuries, and dr\' or senile gangrene may ensue ; but in healthy arteries a good deal of \aolence is needed to produce such an effect, as their natural elasticity enables them to \ield or shp aside, and thus the consequences are usually insignificant. Rupture or Laceration may also fohow blows or strains, or may result from fractures or dislocations, or from attempts to reduce old-standing dislocations, or to break down intra-articular adhesions. If the rupture is partial, the inner and middle coats are usually torn, and by projecting into the lumen of the vessel constitute a valve which" prevents the passage of blood, and leads to subsequent thrombosis and occlusion. In cases where the lesion is Hmited to one side of the vessel, the clot may become organized over that spot, narrowdng but not interfering" with the lumen, and lea\ang an area of weakness from which an aneurism may subsequently develop. A dissecting aneurism (p. 311) may also result under special circumstances from such an accident. WTien comphcated with an infected wound, an ulcerative form of peri-arteritis may ensue, gi\ing rise later on to secondary haemorrhage. Complete Rupture of an artery often leads to but httle haemorrhage in a severe lacerated wound, "such as is produced when a hmb is torn off: the inner and middle coats give way at a higher level than the adventitia, and curl up within it, whilst the outer coat and sheath contract over them, and thus prevent bleeding. If, how- ever, the artery is ruptured in a subcutaneous injury, such as a fracture or dis'location, extensive interstitial extravasation often ensues. A similar condition may ensue from a punctured wound of a vessel, where the track leading to it is vahnilar or becomes closed by clot or some external application. Symptoms. — ^Ihe patient usually feels a snap, as though some- thing had given way, accompanied by a sudden pain, localized to 299 300 A MANUAL OF SURGERY the injured part, and often shooting down the limb in tlic line of the vessel, i hese are sueceeded by the following phenomena: (a) Locally, the formation of a diffuse, rapidly inereasing swelling, the skin over which is at first normal, but soon becomes distended 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 at first, and some amount of thrill and bruit, synchronous with the heart's action, although these subsequently become less obvious, {b) Dis- tally, diminished sensibility in the limb quickly follows, together with loss of pulsation in the 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 oedematous if the extrava- sated blood presses upon the venous trunks, [c) Generally, the signs of htiemorrhage and shock manifest themselves in varying degree, according to the amount of blood lost and the character of the violence. Results. — (i) The swelling may increase steadily in size until the skin becomes so distended as to rupture or slough, and then, if help is not at hand, the patient dies of haemorrhage. Occasionally the bleeding continues into an internal cavity, or into the tissues of a limb, to such an extent as to cause death without any external loss of blood. (2) Suppuration, accompanied by the general signs of fever, may result from auto-infection, or from the entrance of bacteria through the small valve-like wound. The whole swelling becomes red, hot, oedematous, and excessively tender, looking like a large abscess. Rupture and external haemorrhage will probably conclude the case if surgical assistance cannot be obtained. (3) The pressure of the extravasated blood upon the veins or on the arteries needed for the collateral circulation may determine gawgr^fi^ of the extremity, which is almost always of the moist type. {4) The process may become more or less limited after a time by coagulation occurring in the divided mouth of the vessel, which is 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 communicating with an open wound — viz., to cut down on and tie both ends. The circulation is first temporarily arrested by an elastic or other tourniquet, a free incision made, and all coagula removed. The bleeding-points are then sought for and tied, the tourniquet being relaxed to allow them to become evident. If the distal end cannot be found, the wound is not closed, but should be packed with gauze, and allowed to granulate, a tourniquet being kept loosely about the limb ready to be tightened at any moment, if necessary. When suppuration is threatening, the same plan must be adopted — viz., free incision and tying the ends of the vessel if they can be found; but in cases where from the oedematous and unhealthy state of the surrounding parts this is impracticable, it INJURIES AND DISEASES OF ARTERIES 301 will be necessary either to tie the main trunk on the cardiac side of the rupture, or to trust to pressure. If gangrene is imminent, or if secondary hc-emorrhage occurs, amputation is usually the only resource. Penetrating Wounds of arteries, if completely dividing the vessel, are always followed b\- haemorrhage, although the blood may be unable to escape externally. If a large artery is cleanly cut across, the bleeding is copious, whilst from a small vessel it soon ceases, owing to the contraction and retraction of the coats. When an artery is ' buttonholed ' — i.e., when a small segment of the w^all is cut through — the hcemorrhage is often continuous and prolonged, since retraction cannot take place. The treatment of this condi- tion consists in completing the division of the injured trunk, if it is a small one, thus allowing of contraction and retraction, or, if the vessel is of large size, in tying it above and below the opening, and dividing it between the ligatures. If the wound is in the long axis of the vessel, it gapes but Kttle, and the loss of blood is often slight, whilst if transverse or obhque, both contraction and retraction tend to increase the size of the opening, rendering it more nearly circular, and therefore the haemor- rhage in such cases is considerable. If an 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 main trunk must be tied above and below the wound, and divided between the hgatures, and the distal end of the di\dded branch also secured. A good many attempts have been made of late to effect the union of wounds in the walls of arteries without causing their obhteration, and wath some success. Small longitudinal wounds may certainly be sutured, the stitches being of the finest silk and apphed so that the edges of the tunica intima are brought accurately into apposi- tion; Heidenhain reports a case where a wound 1-5 centimetres long in the axillary artery was successfully sutured in this way. End- to-end union of a divided artery has also been effected,* the method usually adopted being that suggested by Carrel in 1902. 1 he vessel is controlled above and below by suitable haemostatic clamps, such as Crile's; blood-clot is washed .out of the cut ends by sterile salt solution, and the adventitia is trimmed off. The suture material employed must be the very finest silk sterihzed in vasehne. The anastomosis is effected by the use of a circular continuous suture, or better by a continuous mattress suture through the intima, and a reinforcing continuous running stitch outside. The difficulty Hes not so much in effecting union as in doing so without deteraiining thrombosis either at the site of anastomosis or at the point of appHcation of the clamps. The greatest gentleness is obviously necessar\^ in all these manipulations. In punctured wounds of arteries the size of the penetrating body * J. B. Murphy, Medical Record, January 16, E897. 302 A MANUAL OF SURGERY is all-important. A vessel may be traversed by a needle without haemorrhaj^e or any subsequent ill effect, but a larger puncture results in extravasation. If it ceases after a time, the blood-clot is absorbed, and the wound in the vessel closed by a cicatrix, which may subsequently yield to the blood-pressure, and give rise to a circumscribed aneurism. This occurrence is not unfrequent 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 follow penetrating injuries which involve an artery and vein lying in close contact — e.g., at the bend of the elbow between the median basihc vein and the brachial artery, in the neck between the internal jugular and carotid, in the groin between the femoral vessels, and occasionally in the orbit. They are also met with in military surgery, owing to the shape of the modern bullet and the limited amount of danger caused by it in the soft tissues. Two conditions may result. An Aneurismal Varix is produced l)y a direct communication between an artery and a vein, no dilated passage intervening between the vessels (Fig. 94, A). The venous walls, unfitted to withstand arterial pressure, are thereby dilated and rendered varicose. A pulsating venous tumour results, the dilatation extend- ing for a variable distance above and below the opening, and at each beat of the heart a loud whizzing sound can be heard, likened by some authors to that caused by an im- prisoned bluebottle buzzing in a thin paper bag. On palpation the thrill of the blood as it enters the vein can often be detected. Treatment. — Nothing is usually required beyond the application of an elastic bandage or support to prevent further enlargement. Should pain or inconvenience arise in spite of this, it may be pos- sible to repair the wound in the arterial wall by suture, or, failing that, the artery must be secured above and below the abnormal communication with the vein. Occasionally the latter is so dis- tended that it has to be removed before the artery can be reached. A Varicose Aneurism differs from the above in that an aneurismal sac exists between the artery and the dilated vein (Fig. 94, 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 of newly-formed cicatricial tissue; it is almost certain to become Fig. 94. — Diagrams of A, Aneurismal Varix and B, Varicose Aneurism. A, Artery ; V, vein aneurism. AN, INJURIES AND DISEASES OF ARTERIES 303 diffuse. The physical signs arc similar to those of aneurismal varix, except that the aneurism can sometimes be detected by palpation, whilst a soft bruit may be heard over it. Surgical Treatment is always required in these cases. Simple ligature of the artery above and below the abnormal communica- tion will usually sufhce, allowing the blood in the sac to coagulate ; the veins will subsequently diminish in size, when the arterial blood-pressure is removed. Not unfrequently the vein overlaps the artery, and has to be tied and removed before the sac of the aneurism is reached; it is then better to excise the sac and tie the artery above and below. Inflammation and Degeneration of Arteries. 1. Traumatic Arteritis is the result of injuries; such as total or partial division of the vessel, laceration, bruising, etc. The phe- nomena are merely those of repair, resulting in closure of the wound or occlusion of the vessel ; they have been already described. 2. Infective Arteritis results from bacterial invasion of the arterial wall, and that usually from without (peri- arteritis) and in connection with infec- ted wounds and hgatures, or spreading ulceration It is characterized by hyperfemia and softening of the vas- cular tunics, the fibres of which lose their cohesion with each other, owing to the peptonizing action of the toxins. In the smaller arteries thrombosis usually occurs and seals the vessel; but in the larger there is considerable danger of bleeding. Secondary haemor- rhage from arteries tied in their con- tinuity is generally due to this cause, as also bleeding from phthisical cav- Fig. 95. ities, the vessels having previously lost the support of surrounding tissues, and being more or less dilated or aneurismal. 3. Embolic Arteritis. — ^\Vhen a vessel is blocked by a simple embolus, obliteration is the usual consequence. If the embolus is infective, as in pysemia or infective endocarditis, an abscess may develop; but if the irritant is less intense, the process may stop short of suppuration, and yet an aneurismal dilatation of the softened wall takes place. The latter process is the most common cause of spontaneous aneurism in children and young adults. 4. Acute Endarteritis is usually seen in the aorta associated with acute endocarditis, or sometimes in the smaller vessels near in- -Atheroma of Aorta. 304 A MANUAL OF SURGERY flamed wounds. 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. 5. Arterio-sclerosis is the term now applied to a degenerative and inflammatory affection of the arteries, formerly known as chronic endarteritis. It usually commences about middle life, and is in many cases merely a physiological sign of the incidence of senility due to the w^r and tear of life. In younger patients and in its more severe fornis it generally depends on some form of chronic intoxication — e.g., syphilis, gout, alcohohsm, or lead-poisoning. It Fig. 96. — Secmon of Atheromatous Cerebral Artery, x 50. (ZlEGLER.) a, Intima considerably thickened ; h, bounding elastic lamella of intinia; c, media; d, adventitia; e, necrosed denucleatcd tissue with masses of fatty detritus; / and /^ detritus with cholesterine tablets; g, intima infiltrated with leucocytes; h, infiltration of adventitia with leucocytes. is also induced by excessive and particularly intermittent muscular strain; by cachexia, the result of malignant disease, tuberculo.sis, or inanition ; it may follow as a sequela of acute infections, such as enteric fever or acute rheumatism; or may arise from any condi- tion which leads to persistent increase in the arterial tension — e.g., chronic Bright's disease. The primary changes probably consist in a degenerative loss of elasticity in the middle and outer coats, which is followed by a secondary hyperplasia of the tunica intima. The later changes vary somewhat, according to whether the affection is localized (nodular variety) or diffuse. INJURIES AND DISEASES OF ARTERIES 305 Nodular artcrio-sclcrosis is most common in the aorta and large vessels, and often starts in the convexity of the aortic arch at the spot where the impact of the blood-stream is felt as it is ejected from the ventricles (Fig. 95), or in places where the vessel passes over or around some bony projection, or at the bifurcation of a main artery. In the early stages scattered raised patches are seen on the inner lining of the vessel, translucent and grayish in aspect, and of variable size ; the overlying endothelium is smooth and intact. In the later stages fibrosis may occur in the patch, which becomes dull white in colour, and at length calcification may ensue, giving rise to an atheroma- tous plate. In other cases the process may be followed by fatty degeneration, the patches becoming yellowish in colour and irregular in outline; the}- are small at first, but increase in size, and coalesce one with another. The contents are now fluid or cheesy in consistency, constituting the so-called ' atheromatous abscess ' (Gr. dOijpyj, 'gruel' or 'pap'), although no true pus exists, the pultaceous material con- sisting of fatt}' granules and debris, with oil globules and plates of cholesterine (Fig. 96, f^) . It may be absorbed entirely, lea\-ing a weakened spot in the wall of the vessel, from which ananeurismmay arise ; or it may be infiltrated with lime salts, and consti- tute an atheromatous plate ; or the tunica intima may give wav over it, allowing' the contents to be swept into the general circulation, 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 immediate ill result 'follows the breach 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 opening into the substance of the wall and strip up the inner from the outer layers, constituting a ' dissecting aneurism ' ; or a localized thrombus mav form, causing occlusion of the vessel. Diffuse Arieno-sclerosis occurs in elderly indi\-iduals, commonly in the smaller vessels, and may be associated with the nodular variety Fig. 97. — Syphilitic Arteritis u ?,^'> X 150. (ZlEGLER.) a, Intima greatly thickened by newly-formed libro-cellular tissue ; b, fenestrated elastic lamina of Henle; c, muscle fibres of media, infiltrated towards the left; d, adventitia thickened by cell infiltration and h^-per- plasia. 3o6 A MANUAL OF SURGERY in the aorta. The changes arc similar to those described above, but usually terminate in fibrosis and contraction of the lumen of the vessel; the changes in the intima are followed by thickening of all the coats, but degenerative phenomena are unusual. In the smaller arteries of the brain this change may interfere seriously with the functions of the part ; whilst in the vessels of the limbs it may result in what is known as Endarteyitis obliterans, and lead to gangrene. In some instances even the main trunks may be involved in this affection. 6. Chronic Syphilitic Endarteritis is chiefly met with in the late secondary or tertiary stages, and is characterized by an overgrowth of the tunica intima (Fig. 97, a), which is subsequently associated with infiltration of the media (c), and much more so of the adven- Fig. 98. — Syphilitic Endarteritis from Near a Gumma, x 120. titia {d). The change occurs in small arteries, especially those of the brain or kidnej^s, or in the neighbourhood of gummata (Fig. 98), 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 circumference of the vessel, and not merely patches; (3) the newly-formed tissue becomes vascular, and does not undergo fatty degeneration; and (4) it leads to narrowing or occlusion of the vessel rather than to weakening and dilatation. When involving the cerebral arteries, various forms of monoplegia, or even hemiplegia, may result. 7. Chronic Tuberculous Endarteritis of a similar type is met with in all places where tubercle is actively developing; in fact, tubercles INJURIES AND DISEASES OF ARTERIES 307 are often fomicd around arterioles, and lead to their obliteration. The tuberculous endarteritis may, however, spread widely beyond the focus of the mischief, and in almost any portion of pulpy granulation tissue this change can be seen. 8. Primary Calcareous Degeneration (Fig. 99) is chiefly met with in the smaller arteries of the extremities. It occurs in elderly people at the same time of life as the calcification of cartilages, etc., and commences by the deposit of lime salts in the muscular fibres of the tunica media, constituting a series of calcareous rings which trans- form the elastic expansile vessels into rigid tubes hke gas-pipes, 3/5 Fig. 99. — Primary Calcareous Degeneration of Arteries. (From College of Surgeons' Museum.) through which alone can pass a fixed and unchangeable minimal supply of blood. It is often associated with generahzed arterio- sclerosis. The affected limb passes into a condition of chronic anaemia and impaired nutrition, resulting in coldness of the feet or hands, cramps and spasms of muscles, sensations of pins and needles, etc. The endothelium is not removed except in the later stages, and then thrombosis maj^ be produced, or a similar result may arise from the lodgment of an embolus. Senile gangrene (p. 114) is a common termination. 3o8 A MANUAL OF SURGERY 9. Amyloid Degeneration of the viscera commences in the arterial walls, but is described elsewhere (j). 8}). The Effects of Arterial Inflammation and Degeneration are botli local and peripheral. Locally, Thrombosis may ])c produced when- ever the lining endothelium is removed and a raw surface exposed, upon which fibfin can collect. Under this fibrinous coating repair is often effected without further complication: but if the blood- stream is retarded, or the lumen of the tube narrowed, complete thrombosis may follow, the clot extending some distance up or down the vessel, or even from a branch into the main trunk, which may be blocked by this means. Aneurism is also a result of any weakening of the arterial tunics. Obliteration of the artery is caused, either by thrombosis, or by excessive proliferation of the tunica intima (as in syphilitic or tuberculous disease), or by gradually increasing pressure from without. Lastly, Spontaneous Rupture is occasionally pro- duced. Peripherally, defective blood-supply and consequent lowered vitality are the most marked results of arterial disease, leading to various forms of ulceration and gangrene. Thus, senile gangrene is due to calcareous changes in the arteries, fatty degeneration of the heart follows atheroma of the coronary arteries, whilst softening of the brain may ensue from various affections of the cerebral vessels. Similar results may also arise from emboli detached from areas of local disease. Aneurism. An Aneurism is a sac filled with fluid or coagulated blood com- municating w^ith the interior of an artery, the walls of which have become dilated. Causes. — i. Changes in the Vessel Walls, by which their resistance to the intravascular pressure is diminished. Many varieties of disease, e.g., atheroma, predispose to aneurismal dilatation, especially if occurring in syphilitic ^r gouty men about middle life, in whom, although the arterial tunics may be weakened, the power of the heart and the resulting blood-pressure are by no means diminished. The diffuse form of arterio-sclerosis (often associated with calcification) of the peripheral arteries is antagonistic to aneurismal dilatation. An}^ injury, a contusion, a penetrating wound, or a strain, may so inter- fere with the integrity of the vascular coats as to result in aneurism, and, indeed, a cicatrix in an arterial wall must always be looked on as a weak spot predisposing to dilatation. The lodgment of an infected embolus in the smaller arteries is stated to be one of the most common causes of spontaneous aneurism in young people. 2. Increase in the Blood-Pressure is another factor, especially when due to heavy strain or exertion, which leads to irregular excite- ment and increased action of the heart. Steady laborious employ- ment, such as is seen amongst artisans and mechanics, or regular exercise, does not appear to predispose to this condition; but irregular intermittent efforts, in which for the time being every ANEURISM 309 power is strained to its utmost, are very liable to determine its occurrence. A day's exertion in the hunting or shooting field by an elderly man, accustomed to sedentary occupations, is often the cause of some vascular lesion, such as aneurism, apoplexy, etc. Hence aneurisms are more frequently seen amongst men than in women, in the proportion of seven to one ; whilst they are much more common among the dwellers in Northern chmates than in the more lethargic and ease-loving inhabitants of the South. The energy and activity of the Anglo-Saxon race especially predispose them to this disease. Structure of an Aneurism. — The sac consists more or less evidently of a distension of all or part of the original walls of the vessel whilst it is small; but as the aneurism increases, the original structure is re- placed by a mass of newly- formed fibrous tissue, due to a condensation and matting to- gether of the surrounding struc- tures, with or without an in- ternal lining of laminated fibrin deposited on parts where the endothelium has disappeared. The contents of the sac depend on the character, age and size of the aneurism. Whilst still small and with a complete endothelial lining, it contains fluid blood ; but as the tumour grows, and especially if of the sacculated type, fibrin is de- posited in layers which gradu- ally encroach on the cavity, and may in time completely fill it, so that in rare cases a spontaneous cure results. The oldest laminse are dry and yellowish- white in colour ; those more recently deposited are softer and more reddish, whilst the last formed is merely hke ordinary blood coagulum. No single lamina covers the whole area, but layer is arranged over layer (Fig. 100) in such a manner that the oldest and necessarily the smallest laminse are nearest to the sac wall. Three chief forms of aneurism have been described : the fusiform, sacculated, and dissecting. I. The Fusiform Aneurism (Fig. loi. A) is one in which the whole lumen of the vessel is more or less equally expanded, so that the swelhng is tubular in character. It is generally due to a widelv- FiG. 100. — Sacculated Aneurism. (Museum of Royal College of Surgeons.) The small mouth of the saccule is clearly seen, and the cavity is nearly filled with laminated clot. 3IO A MANUAL OF SURGERY extended disease of the arterial walls, and lience is more common in the larger internal vessels, such as the aorta, than in those of the extremities. The tunica intima is usually represented throughout the whole extent of the sac, but is thickened and atheromatous in patches, the margins and surfaces of calcareous jjlates being indi- cated by flocculi of fibrin, which are attached to them, although no regular laminated deposit may be present. Ihe tunica media is stretched, atrophied, and in the later stages practically non-existent, whilst the adventitia is much thickened by inflammatory new for- mation and by incorporation with the surrounding tissues. '1 he progress of fusiform aneurisms is generally slow, so that in some situations, e.g., the thorax, they may attain enormous dimensions, and cause grave pressure symptoms. A natural cure is almost Fig. ioi. — Diagrams of Fusiform, Sacculated, and Dissecting Aneurisms. In the fusiform (A) the walls are expanded, but more or less normal in texture ; in the sacculated (B) the normal structure of the arterial wall ceases abruptly at the commencement of the saccule; in the dissecting (C) the arterial wall is split into two lamellae. The interrupted fine line is supposed to represent the intima; the continuous dark line, the media; and the continuous fine line, the adventitia. impossible, and hence, if unchecked by treatment, rupture of the sac is likely to occur, especiall}' if, as often happens, one portion of the wall yields more rapidly than another, thereby inducing a local- ized sacculation. 2. A Sacculated Aneurism (Figs. loo and loi, 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 may spring from a fusiform aneurism. It communicates with the interior of the artery by an opening of variable size. All traumatic aneurisms, whether due to the yielding of a cicatrix, or to the partial division of the coats of the vessel, are of this type, which is hence found most commonly in the extremities. The inner and middle coats can usuallv be traced ANEURISM 3" as far as the mouth of the saccule, but there they are suddenly lost, the wall being constituted by a mass of fibro-cicatricial tissue, upon which laminated fibrin readily forms, thus increasing its thickness and power of resistance. Their progress is, however, much more rapid than that of the fusiform, generally ending in rui)ture or diffusion, although occasionally a natural cure results. 3. A Dissecting Aneurism (Fig. loi, C) is one in which the blood forms a cavity within the wall of the vessel by stnppmg up the inner from the outer half, the hne of cleavage being withm the middle coat, half going with the adventitia, half with the intima. It is usually the result of extensively diffused atheroma. The blood thus driven into a cul-de-sac may remain hmited to this cavity for some time, or it may find its way outwards and become diffused, or burst back through another atheromatous spot in the interior of the vessel. The condition occurs chiefly in the thoracic or abdominal aorta, but cannot be recognised ante-mortem. Symptoms and Signs of a Circumscribed Aneurism.— These may be 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, so that if the tumour is hghtly grasped in any position the fingers are separ- ated. A definite thrill can often be felt as the blood enters the sac at each heart-beat. If the supplying vessel is compressed on the proximal side, the pulsation ceases, and the tumour diminishes m size and becomes softer; this is more marked in fusiform than in sacculated aneurisms. The appUcation of pressure to the sac itself, whilst the afferent trunk is compressed above, may still further diminish its size. On removing the pressure, the sweUmg 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 compres- sion is very prolonged. On auscultating the tumour, a bruit of variable character may be heard; usually it is loud, harsh, and systohc, but sometimes quiet and musical. It is occasionally double in some forms of sacculated aneurism, and m the aorta when regurgitation through the aortic valves is also present. The bruit is loudest and most rasping in the fusiform vanety, and may be absent in the sacculated form, when the mouth is small and the cavity nearly full of clot. ■ • ■ -u The Extrinsic Signs of aneurism are those occurring m neigti- bouring or distal structures from its constantly mcreasmg size and pressure, and the interference produced by it with the circulation. The pulse on the distal side is diminished and delayed, its diminution being caused partiy by the obstruction experienced, but also m some cases by the pressure of the sac upon the trunk above or below the tumour. The delay is due to the interference with the transmission of the heart's impulse by the intervention of the aneurismal sac. 312 A MANUAL OF SURGERY The smaller vessels engaged in establishing collateral circulation may be compressed by the sac, and thus the vitality of the limb impaired. Pressure on the accompanying vein or veins results in diminution of their calibre, and possibly a localized thrombosis, together with distal congestion and oedema. Compression of nerves occasions neuralgia, spasm, or paralysis. Muscles are displaced, expanded, and attenuated ; 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 constricted and even laid open by ulceration. It is interesting to note that resisting tissues, Hke bone, are much more liable to be eroded than elastic, yielding structures, such as cartilage; where the vertebral column is encroached upon by an aneurism, the bones are always destroyed more than the intervertebral discs. A certain amount of compensatory hypertrophy of the heart is often present. Fibrinous masses are occasionally set free as emboli, and lead either to a spontaneous cure, or to gangrene of the parts supplied by the vessel, or to death if the brain is involved. Gangrene may also result from the diminished blood-supply to peripheral parts; it is usually of the dry type, involving merely one or two fingers or toes, unless the veins are compressed, when it may be of the moist variety. The Differential Diagnosis of a circumscribed aneurism is usually not difficult, but the following conditions may simulate it somewhat closely: i. A tumour or chronic abscess situated near an artery, and deriving transmitted pulsation from it, is recognised by the impulse being merely heaving in character, and not expansile ; by the pulsa- tion ceasing entirely if the tumour is lifted from the vessel, or allowed to fall away from it by assuming a suitable position ; b}^ the size of the tumour not diminishing if the pulsation is stopped by pressure on the vessel above; and by the fact that after stoppage of the pulsation the first beat is equal to the subsequent ones, whereas in an aneurism it almost always requires more than one beat to re- establish the strength and force of the impulse. Moreover, the pulse below is not affected in the same way or to the same extent as when an aneurism is present. 2. An artery is sometimes pushed fonvards by an underlying growth, and its pulsation in a more than usually superficial position may suggest an aneurism. The distinguishing features are the Hmitation of the pulsation to the line of the vessel, and the absence of pulsation in the underlying growth. 3. A pul- sating sarcoma or ncevus is known by being rarely limited exactly to the line of the artery, pulsation being present in situations where an aneurismal dilatation could not be felt, and being less forcible and regular in its character. The consistency of the swelling is more variable, 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 hmits are not so accu- rately defined. 4. The pain caused by an aneurism may lead it to ANEURISM 313 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. Natural Terminations and Results. — i. Spontaneous Cure, though very unusual, may occur in sacculated aneurisms, [a) 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 occupy the whole cavity and close up its mouth. This condition can only obtain in saccules with small mouths, and in vessels of the second magnitude, 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, ip) It may arise as the result of the sudden coagulation of all the blood in the sac from 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, 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 be seen anon, is attended with serious danger to life and limb. The sac becomes more and more firm, the pulsation less forcible and distinct, the bruit diminishes, and finally consolidation is effected, a firm fibroid tumour alone remaining, which gradually shrinks, whilst the collateral circulation is opened up so as to supply the limb below. It is sometimes by no means easy to recog- nise the fibroid mass which results from a consolidated 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 which can be ascertained by a physical examination. 2. Diffusion and Rupture result from yielding of the walls of an aneurism, as an outcome of some mechanical injury or from simple over-distension. When an internal aneurism gives way, the patient usually ex- periences a sensation of pain in the part, and becomes pale, cold, and faint, possibly dying within a few minutes or, at most, hours; or there may be a sudden gush of blood from the mouth if the trachea or oesophagus has been opened. Sometimes internal aneurisms leak slowly, and the final stage lasts some days. When an external aneurism yields, it may do so slowly or quickly. If the blood becomes effused slowly (a leaking aneurism) , the tumour gradually increases in size, and its outline is less clearly limited; the pulsation diminishes in force and distinctness, and the signs of pressure upon the veins or nerves become more urgent, until gan- grene sometimes supervenes. If the sac yields suddenly (a ruptured aneurism), 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 314 A MANUAL OF SURGERY even deatli from syncope, if the skin gives way. Su})])uruti(jn may also occur in tliese cases. 3. Suppuration is an exceedingly serious, but by no means a usual, complication. It may arise in the following ways: (u) After liga- ture of the main vessel, especially when the wound becomes infected, 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 there is great tension upon surrounding parts. Auto- infection or the presence of an infective embolus may finally de- termine the suppurative process. The tumour shows signs of in- flammation, becoming hot, red, painful, and swollen, and the skin over it may pit on pressure ; whilst fever and general constitutional disturbance are also present. Sooner or later, if left to itself, the tumour points at one spot and bursts, 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 haemorrhage and toxaemia, unless efficient treatment is adopted. Occasionally, but very rarely, the afferent trunk be- comes plugged by a thrombus, and spontaneous cure may thereby be induced. Treatment of Aneurisms. I. General Treatment is employed as an accessory to surgical measures, or must be depended on entirely in cases where local means are impracticable, as in internal aneurisms. In plethoric 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 bowels should be kept gently open, and constipation and straining avoided. 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 usually prescribed, on account of the frequent associa- tion of aneurism with syphilis; and calcium lactate (grs. 5, t.d.s.) may be useful in increasing the coagulability of the blood. The diet must be suitably diminished, and only highly nutritious material allowed, and that mainly of the nitrogenous type, with as little fluid as possible (not more than about a pint a day). In weakly individuals, whilst strictly enjoining a recumbent pos- ture, the surgeon should prescribe iron and a somewhat more liberal diet, in order to improve the quality of the blood. II. Surgical Treatment. — A. Ihe ideal plan consists in dealing with the arterial wall ho as to obliterate the aneurism, but without occluding the original lumen of the vessel, according to the sugges- tion of ]\Iatas* of New Orleans. This is obviously only possible in selected cases of sacculated aneurism, but a number of satisfactory results have been reported. The circulation is controlled tempor- arily, and the aneurism laid freely open, so that its interior can be * Annals of Surgery, February, 1903. Also Report of International Con- gress of Medicine, London, 1913, Section VII., part ii. ANEURISM 315 emptied completely and carefully examined. The orifices of the smaller collateral branches are secured by purse-string sutures, and the margins of the main opening are approximated by a row of Lembert's sutures, if need be, over a piece of rubber catheter, which is subsequently removed ; the continuity of the original vessel being thus restored, the aneurismal walls are brought together by superimposed rows of Lembert's sutures. It is probable that in many instances the artery becomes obliterated in spite of the surgeon's care. In unsuitable cases, e.g., fusiform aneurisms, the surgeon may operate with the intention of obUterating the cavity of the sac. 1 he openings of the main vessel, above and below, are first secured from ^^•ithin, as also any smaller branches, and then the cavity is obhterated by rows of stitches as before. In neither of these plans must the sac be detached from its surroundings. B. Complete Extirpation of the aneurismal sac, as if it were a tumour, may be looked on as the best method of treatment in the majority of cases. The limb is exsanguinated by elevation, and in suitable cases the aneurism is removed without opening it, and the vessel secured by Kgature above and below, as also any branches which may arise' from it. Sometimes, however, it is necessary to open it and turn out its contents before attempting its extirpation, which is often a matter of considerable difficulty owing to the ad- hesions present. Not unfrequently the vein will be encroached on in this dissection, and it may have to be removed ; bad results are not hkely to follow, since the pressure of the sac has already probably estabhshed an efficient collateral venous circulation. The results of this operation are most satisfactory, since the length of treatment is curtailed, and all chances of local recurrence are removed. Gangrene also is uncommon, since only one set of col- lateral circulation is caUed upon, \dz., that required to bridge the gap made bv removing the aneurism, whereas in the Hunterian operation a double set is needed, viz., at the site of the ligature, and round the consolidated aneurism. C. The deposit within the sac of fibrin, which shall subsequently organize and thus lead to the obhteration of both sac and sup- phdng vessel, was the ideal aimed at by the earher surgeons, and has still to be relied on in many cases. It is obvious that a slow and gradual deposit of laminated fibrin is hkely to be more satisfactory than the sudden distension of the sac with soft red clot. The various plans adopted with this end in view are as follows : I. Compression of the main vessels, usually on the proximal side of the aneurism, was much vaunted by the Dubhn school of surgeons in the last century, and gave not a few good results. It may be applied either continuously or at intervals. If intermiUent, the main vessel leading to the aneurism is controlled by means of fingers (digital compression), or by mechanical contrivances (such as a tourniquet or a conical bag filled with shot), for as long a period as the patient can bear, which usually does not exceed thirty minutes, especially if there is any nerve in the immediate neighbourhood. 3i6 A MANUAL OF SURGERY There seems to be no necessity to arrest completely the flow of blood through the sac, so long as the blood-pressure is sufficiently diminished to permit of coagulation within it. Continuous pressure under an anaesthetic aims at the entire stoppage of the circulation through the sac, so as to allow not only of its contraction, but also in some instances of the rapid coagulation of its contents. Such pressure may be effected by the fingers of relays of dressers, taking shifts of ten to fifteen minutes at a time. It is well to arrange for some weight, such as a conical shot-bag, to rest upon the thumb or finger employed, so as to reheve muscular strain. Although in suitable cases compression may be given a trial before ligature, yet it is unwise to persevere with it for too long, especially in plethoric individuals with high arterial tension, if signs of im- provement are not quickly observed, lest the collateral circulation be increased to an undesirable extent, and the success of the sub- sequent operation jeopardized. On the other hand, in feeble, weakly patients, where gangrene of the limb might be anticipated, the opening up of the collateral circulation b}' compression, even if the aneurism is not thereby cured, is by no means a disadvantage. Necessarih', the skin to which pressure is apphed must be pro- tected from local irritation by shaving and removal of hairs, and the use of a dry aseptic dusting-powder, whilst the surface of any pad employed must be perfectly smooth. 2. Ligature of the main vessels leading to or coming from the aneurisnial sac must next be considered. The oldest procedure, the Operation of Antyllus, consisted in lavnng open the sac, turning out the clots, securing the vessel above and below, and allowing the wound to heal by granulation (Fig. 102, A). Performed, as it was originally, without antiseptics, it was naturally attended with great mortality from secondary haemorrhage. In Anel's Method (Fig. 102, B) the artery w"as tied just above the sac on the cardiac side, with no branch intervening ; this also proved dangerous, since secondary haemorrhage frequently resulted, either from suppuration within the sac, or from injury to the sac during the operation, or from yielding of the arterial wall at the site of ligature from septic peri-arteritis. At the present time it is not unfrequently undertaken successfully. Hunter's Operation (Fig. 102, C), which consists of ligature of the main vessel on the cardiac side at some distance from the aneurism, was first performed by him in 1785. The object is not to cut off absolutely the blood-supply to the sac, but to allow the blood to enter it with a greatly diminished impulse, and in small amount at first, thus permitting of the contraction of the sac wall and of the gradual deposit within it of fibrinous clot, which in time becomes organized into a mass of firm fibroid tissue. It is desirable, though not essential, that no branch of large size should intervene between the point of ligature and the sac. The operation is contra-indicated (i) in cases where serious cardiac disease co-exists, or when an internal aneurism is also present, rendering undesirable any sudden ANEURISM 317 increase of the blood-pressure, as by occlusion of a main vessel; (2) where pressure over the vessel does not control the circulation through the sac; (3) where the peripheral vessels are extensively calcified; (4) where gangrene of the hmb is threatening or present; or (5) where bones or joints have been seriously involved. Distal Ligature is only practised for aneurisms situated in positions where it is impracticable to deal with the artery on the cardiac side of the sac, such as the innominate, lower part of the carotid, or first part of the subclavian. Brasdor's Operation consists in tying the main trunk beyond the sac, so as totally to cut off the circulation through it (Fig. 102, D). In Wardrop's Operation a ligature is placed on one or more of the distal branches (Fig. 102, E). In the former the sac gradually contracts, and thus allows of the deposit of fibrin; in the latter proceeding, where the circulation is only Fig. 102. — Methods of applying Ligatures for Aneurisms. A, Method of Antyllus; B, Anel's operation; C, the Hunterian operation; D, Brasdor's operation; E, Wardrop's method. partly 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 correspondingly lessened. It is not unusual, after the application of a ligature to a main artery for aneurism, to observe a return of pulsation in the sac after a day or two. In the majority of cases this only continues for a short time, and is by no means an unfavourable sign, indicating the re-estabhshment of the collateral circulation; but if it commences a week or ten days after the operatiori, it is more likely to persist. It is most frequently seen in cases where the main vessel has been tied at some distance from the sac, as in the superficial femoral for popliteal aneurism, and where one or more large and important collateral branches carry blood into the artery below the hgature or directly into the sac. The early recurrence of pulsation needs no treatment in most instances ; but when it comes on at a later stage, it demands serious attention. Rest, elevation of the hmb, and 3i8 A MANUAL OF SURGERY judicious pressure over the trunk above the site of ligature, should tirst be tried. These failing, the following courses are open: {a) The artery may be again tied, either nearer the sac when feasible, or further away from it; {b) where the aneurism can be reached, it may be cut down on and dissected out, the best course to adopt if it be practicable; or (c) amputation just above the aneurism may be called for as a last resource. 3. The Introduction of Foreign Bodies into the Sac [Moore's Method) has not been followed by much success, although a few cases of abdominal aneurism seemed to have derived temporary benefit from it. Steel wire has been usually employed; it is firmly wound round a cotton reel to give it a spiral coil, and inserted into the sac through a very fine cannula. Varying lengths from 10 feet to 26 yards have been introduced. 4. The combination of this last method with electrolysis (as originally suggested and practised by an Italian, Corradi, in 1879) has been attended by some very happy results, especially in the hands of Stewart of Philadelphia.* He introduces a variable length of gold or silver wire (No. 30 gauge), preferably the former, through a small cannula, and then performs electrolysis through the wire which is attached to the positive electrode, whilst the negative electrode is placed on the back. Ihe current is gradually increased up to 60 or 80 milliamperes, and the whole proceeding lasts about thirty minutes. Finally, the wire is cut short and the end pushed into the sac, and the opening Hgatured. Several brilliant results have followed this plan of treatment, including the cure of an innominate aneurism, the patient living for three and a half j-ears, and of an aneurism of the abdominal aorta; dealt with by trans- peritoneal^operation. An ingenious contrivance has been designed by Messrs. D'Arcy Power and Colt for this purpose. It consists of a fine wire wisp or cage, which can be introduced closed as a cartridge through a special cannula, and pushed by a ramrod into the sac, where it expands of itself umbrella-fashion, thereby exposing a large surface of ware on which coagulation can occur; it is also arranged for electrolysis. Satisfactory results have attended its employment. D. Quite distinct in principle from the preceding plans is that associated with the name of Sir William Macewen, who looks on blood-clot as undesirable material to work with for the cure of an aneurism, and directs his attention to thickening the walls of the sac to such an extent as to determine its occlusion, or to prevent its subsequent dilatation. To this end he employs Acupuncture, intro- ducing several fine needles into the sac and leaving them to be played upon for a time by the blood-stream, so as to scratch and irritate the further wall of the sac, and thus cause an inflammatory hyperplasia, which shall subsequently organize into dense fibro-cicatricial tissue. The process must be repeated as often as is considered necessary. In his own hands excellent results have been obtained; but whilst * British Medical Journal, August 14, 1897; Philadelphia Medical Journal, June 25, 1898. ANEURISM 319 admitting its value for internal aneurisms, we cannot but think that for those involving peripheral vessels other methods would be more rapid and equally effective. E. Amputation may be required in the treatment of aneurisms under a variety of circumstances: [a) When extensive gangrene of the Hmb has occurred or is imminent ; {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 eroded to such an extent as to impair the utihty of the hmb; and, finally, (/) in a few cases of subclavian aneurism amputation at the shoulder- joint has been practised in order to diminish the amount of blood flowing through the sac. The Treatment of a Diffuse Aneurism varies somewhat according to whether the diffusion is slow or rapid. In a leaking aneurism the main vessel leading to the swelhng must be tied, if this has not already been undertaken, and the influence of this measure, com- bined with rest, elevation, and careful general treatment, observed. Should the process not be stayed, the case is treated as a diffuse or ruptured aneurism by laying open the sac, after exsanguinating the hmb by elevation and the use of an elastic band, and securing, if possible, the main vessel above and below, as also any branches which may open into the sac, if they can be found. If there is any e\ddence of incipient gangrene, or if secondary haemorrhage super- venes, amputation must be undertaken. In such cases everything will depend on the efficient maintenance of asepsis. The Treatment of an Inflamed Aneurism is always a matter of anxiety from the risk of recurrent and fatal haemorrhage. If the main trunk has not been previously tied, this should at once be undertaken so as to reduce the blood-pressure in the sac, and the effect carefully watched; an ice-bag should also be apphed to the part, and the limb elevated. If no good result follows, or if the artery has already been tied, nothing remains but to lay the sac freely open and endeavour to secure, by ligature, the main trunk above and below, as well as any smaller branches. Unfortunately, the walls are often soft and rotten, so that hgatures cut out ; should bleeding supervene, the ca-vity may be packed with gauze in the hope of checking it, and determining repair by granulation, but more often amputation will be required. Special Aneurisms. Aneurism of the Thoracic Aorta is most commonly of the fusiform tj'pe in the early stages, but a hmited sacculation often supervenes as the disease advances. The symptoms vary with the part affected, (i) In the ascending part of the arch the swelhng rarely reaches a great size, especially if it is intrapericardial, the sac usually rup- turing before marked pressure signs are evident. (2) WTien arising from the transverse part of the arch, the symptoms vary with the direction taken by the enlargement. If it projects 320 A MANUAL OF SURGERY Upwards, a pulsating tumour may appear at the episternal notch, and cerebral effects may then ensue from interference with the circulation through the carotids, or from pressure on the venous trunks. If it extends anteriorly, it may form a large pulsating tumour to the right of the sternum with comparatively slight pressure effects, except the pain arising from its erosion of the thoracic wall. If the enlargement takes place either posteriorly or downwards within the concavity of the arch, symptoms of dyspnoea and dysphagia are early produced from the close contiguity of the trachea, oesophagus, and pulmonary vessels. Pressure upon the left recurrent laryngeal nerve, as it passes round the aorta, results in spasm of the laryngeal muscles, especially of the crico-ary- tenoideus posticus, producing suffocative attacks of dyspnoea and a loud metallic or brassy cough, which is very characteristic. At a later date the nerve is paralyzed, and then the voice becomes affected, and the vocal cord fixed and immobile, but without serious dyspnoea. Laryngeal or tracheal stridor may be noticed in these cases, and a dragging down of the trachea synchronous with the heart's action (the so-called 'tracheal tug'). Radiographic examination is a valuable means of diagnosis, since the aneurism gives a dark shadow on the screen or plate. (3) 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 swelling. The only pro- minent symptoms are pain, clue to erosion of ribs or vertebrae, and interference with deglutition, which may be so great as to suggest the presence of an cesophageal constriction ; in fact, before a bougie is passed in any case of dysphagia it is alwa^-s advisable to make certain by radiography that an aneurism is not present. Ausculta- tion in the left vertebral groove may also reveal the existence of a systolic bruit where such a condition exists. Treatment. — Little can be done beyond ordinary medical measures, such as rest, diet, and the administration of iodide of potassium. When the aneurism has projected in front, the intro- duction of coils of iron wire or horsehair has been attempted, and in one or two cases with partial or temporary success ; whilst Stewart's method of electrolysis and Macewen's plan of acupuncture have been used with some benefit for supposed cases of sacculated aneurism. Dyspnoea may be at times severe, but tracheotomy should never be undertaken, death seldom resulting from this cause. Ligature of the right carotid and right subclavian, or of the left carotid alone, has been adopted in cases of aneurism of the ascending aorta or of the arch. A certain amount of improvement followed some of the operations, but it is quite possible that this was as much due to the enforced rest in bed as to the operation. Of course, if the lower end of the carotid is involved in the aneurismal swelling, distal ligature may do some good, as in a case of our own,* where the left carotid and subclavian were tied, with a short interval between ♦ British Medical Journal, December 3, 1898. ANEURISM 321 the operations. The patient's condition improved greatly for a time, and she was able to return to work, but the aneurism finally burst into the left pleura about three years after the first operation. Innominate Aneurism is usually of the tubular variety, and fre- quently associated with a similar enlargement of the aorta. It presents a pulsating tumour behind the right sterno-clavicular articulation — i.e., between the heads of origin of the sterno-mastoid — projecting either into the episternal notch or outwards into the subclavian triangle, and perhaps pushing the cla\icle forwards. The pulse in both the right temporal and radial arteries is diminished; oedema of a brawny character of the right side of the head and neck, and of the right arm, is caused by pressure on the right innominate vein, whilst less commonl}' similar changes on the left side ma\' follow compression of the left vein or of the superior vena cava ; pain shooting into the neck and arm is often pro- duced by impHcation of the brachial nerves; hyperemia and sweating of the right side of the face with dilatation of the right pupil may result from irritation of the sympathetic trunk. Dys- pncea is induced by direct pressure on the trachea, which may be displaced or flattened, or by compression of the right recurrent laryngeal nerve. Dys- phagia occurs from pressure on the oesophagus. The course of the case is slowly progressive, and death most commonly results from asphyxia or from rupture of the sac. Treatment. — ^Rest and the ad- ministration of large doses of iodide of potassium may cause improvement, but distal ligature is the most hopeful proceeding. It is obviously impossible to cut off all the blood passing through the sac to the three main divisions — \az., the carotid, subclavian, and vertebral — with safety to the patient (Fig. 103). Ligature of any one of these by itself offers but little prospect of improvement, whilst t\-ing both carotid and subcla\nan, with an interval of more than a week between the two operations, has practically the same effect as a single ligature, for b}' that time the collateral circulation will have been estabhshed. Simultaneous ligature is doubtless the best plan of treatment to adopt ; it places the sac in the best possible condition for the deposit of fibrin, whilst the additional step of tynng the third part of the subcla^aan does not add materiallv to the risk of the operation, which is mainly due to the effect "on the cerebral circulation. Should these operative Fig. 103. — Application of Liga- tures FOR Innominate Aneur- ism. (After Erichsen.) lA, Innomiiiate aneurism; S, sub- gclavian artery; C, carotid; V, verte- bral arterv. 322 A MANUAL OF SURGERY measures seem undesirable, recourse must be hud to Stewart's or Maccwen's method. Aneurism of the Common Carotid is usually situated at the upper part of the truuk near thr liifurcation, and more often on the right than on the left side. The root of the right carotid is also not unfrequently dilated, but the intrathoracic portion of the left carotid is rarely affected, except in conjunction with the aorta. No other external vessel is so frequently the seat of aneurism in women. The ordinary intrinsic signs of an aneurism are present, and the pressure symptoms are mainly referable to interference with the cerebral circulation, to irritation of the cervical sympa- thetic trunk, or to pressure upon the larynx, pharynx, or trachea. The progress of these cases is usually slow. Diagnosis. — (i) From similar disease at the root of the neck the dis- tinction is often made with difficult}', since either an aortic, inntmii- nate, or subclavian aneurism ma\' push upwards so as to simulate it somewhat closel3^ Percussion and auscultation of the upper part of the chest, together with a careful investigation into the history of the case, and a digital examination of the limits of the pulsating mass, may suffice to determine the point. The pressure effects must also be carefully considered. ' Pressure on the left recurrent laryngeal nerve would distinguish an aortic aneurism from one on the right vessels ; pressure on the right nerve in like manner excludes an aortic aneurism. Pressure on the left innominate vein indicates aortic aneurism rather than innominate; compression of the internal jugular or subclavian vein only points to carotid or subclavian aneurism. A " tracheal tug " indicates an. aneurism of the aorta ' (Pearce Gould). The differences in the peripheral pulses in the radial and temporal arteries may also give useful information. If the left radial pulse is alone aneurismal, the root of the left sub- clavian is diseased, whilst if the left temporal is also affected, it suggests an aneurism of the transverse part of the arch beyond the innominate. When both radial and temporal vessels on the right side show signs of interference with the pulse, innominate aneurism is probably present, whilst an affection of only one of these branches indicates that the corresponding carotid or subclavian is dilated. One source of fallacy must not be forgotten, viz., that any one of these trunks may be occluded or compressed by a neighbouring aneurism without being dilated, and hence the quality of the pulse must be taken into consideration rather than its actual volume, and to this end the sphj^gmograph is a useful adjunct in diagnosis. (2) From abscess, tumours, or enlarged glands with a transmitted impulse, a carotid aneurism is recognised by an application of the general principles detailed above (p. 312). (3) Pulsating or cystic goitre may be distinguished from a carotid aneurism by noting that the goitre is not as a rule limited to one side of the neck, the isthmus being also involved; that the most fixed part of the tumour is in the median line, and not under the sterno-mastoid muscle ; and that the swelling moves up and down during deglutition, an aneurism re- ANEURISM 323 ^maining fixed. (4) An aneurism close to the bifurcation may be simulated by an abnormal arrangemenl of the terminal branches, the external carotid crossing the internal from behind forwards, and being pushed outwards sufficiently to cause a pulsating swelling beneath the skin. This condition is usually symmetrical, and can be recognised by careful palpation. Treatment. — Ligature of the carotid above or below the omo-hyoid is the treatment usually adopted, and generally with great success. If the aneurism is near the root of the neck, the distal operation (Brasdor's) must be undertaken. Aneurism of the External Carotid is seldom met with, except as an extension of one involving the bifurcation. The usual pheno- mena are presented near the angle of the jaw, and well above the thyroid cartilage. Pressure results are early experienced, e.g., paralysis of one side of the tongue through implication of the hypo- glossal nerve, aphonia, or dysphagia. In suitable cases, the sac may be dissected out after securing the branches arising from it; failing this, the common trunk must be tied. Aneurism of the Internal Carotid (extracranial portion) presents symptoms which closely resemble those caused by an aneurism of the bifurcation or of the external carotid, except that the sweUing projects more into the pharynx, from which it is separated merely by the pharyngeal wall. It appears as a tense pulsating tumour, placed immediately under the mucous membrane, and looking dangerously like an abscess of the tonsil. The Treatment consists in tying the common carotid. Intracranial Aneurism occurs more commonly upon the internal carotid and its branches than upon those arising from the vertebrals, although the basilar artery is more often affected than any other single vessel. The aneurisms are generally fusiform in character, and their origin is often obscure, being attributed to a blow or fall; in children they are stated to result from the lodgment of infected emboli. They sometimes cause no symptoms until the patient is suddenly seized with a rapidl}^ fatal apoplexy from rupture of the sac. Symptoms, if present, are due rather to compression of the brain than to erosion of the more resistant bony structures. Pain 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. Sight, hearing, and other functions of the brain, may also be impaired, but physical changes in the eyes, such as optic neuritisor 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 internal carotid artery, and even this will be of little use if the basilar is affected. Orbital Aneurism. — Protrusion of the eyeball, together with pulsation, which can be felt or even seen (pulsating exophthalmos), is always an indication that some vascular lesion is present within 324 A MANUAL OF SURGERY the orbit, {a) It is occasionally congmZ/rt/, aiul then probably due to the presence of a deep cavernous angioma, {b) It is most fre- quently traumatic in origin, resulting from a penetrating wound, or a blow on the head, which may have caused a fracture of the base of the skull ; in these the lesion present is generally an aneuris- mal varix between the internal carotid and the cavernous sinus. (r) It may be non-traumatic , and result from an aneurism of the ophthalmic artery, or from thrombosis of the cavernous sinus. '1 he patient complains of intra-orbital pain and tension; the con- junctival and retinal vessels are distended, and a marked bruit may be present on auscultation. The movements of the eyeball are limited, vision is impaired, and the cornea may become opaque from exposure; finally, the whole globe may be disorganized. A marked mitigation of all s3'mptoms usually follows compression of the carotid. Diagnosis. — Sarcoma of the orbital wall may exhibit many of the characters of intra-orbital aneurism. Careful palpation will, how- ever, generally demonstrate the existence of a definite tumour; the pulsation, moreover, is less marked, and the bruit less distinct. The distortion of the eyeball and ocular axis is often considerable in malignant tumours, but vision is not so early affected. Treatment. — Ligature of the internal carotid is the only means which holds out any prospect of benefit, except in the congenital cases, where electrolysis has been very successful. Subclavian Aneurism is most frequently seen in men, and par- ticularly in those who carry weights on their shoulders; the right vessel is more often affected than the left. Any part of the artery may be involved, but the greatest dilatation naturally occurs in the third portion. A pulsating tumour develops in the subclavian triangle, which may project above the clavicle, but often extends backwards, outwards, and downwards, causing pressure effects upon the veins and nerves of the arm, and also hiccough by irrita- tion of the phrenic. Occasionally it encroaches on the dome of the pleura and apex of the lung, and has been known to burst into the pleural cavity. It does not increase in size very rapidly, being surrounded by dense unyielding structures, and never compresses the trachea or oesophagus. No special difficulty presents itself in diagnosis as a rule, although in the early stages it may be somewhat simulated by a normal artery pushed forwards by an exostosis of the first rib, or by a supernumerary cervical rib. The Treatment of subclavian aneurism is surrounded with difficul- ties, and the results hitherto obtained have been most unsatisfactory. Extirpation has been undertaken with success after turning up the middle third of the clavicle, as also Matas' operation, but the aneur- ism is seldom sufficiently limited to allow of these proceedings Stewart's method of electrolysis, and needling the sac according to Macewen's method, have been adopted with occasional success, but cannot be relied on. Ligature of the innominate trun1< suggests itself as the operation to be adopted for cure by the Hunterian method.' ANEURISM 325 and recent records wonld certainly encourage one to repeat it in any suitable case, combined with simultaneous ligature of the carotid, so as to avoid backflow of blood. Ligature of the first part of the subclavian is occasionally possible, and a few successful cases have now been reported, although the first nineteen cases in which it was attempted died. As a last resource, the plan suggested by the late Sir WiHiam Fergusson may be followed, viz., amputation at the shoulder -joint and distal ligature as near the sac as possible. Distal hgature alone is usually unsuccessful, since the great bulk of the blood needed for the nutrition of the arm still passes through the sac, and there is no means of checking this except by the removal of the hmb. Axillary Aneurism is usually the result of falls on the outstretched arm, or injuries to the shoulder, such as fractures or dislocations, or of attempts to reduce them. A pulsating tumour develops, and its pressure causes pain, local and neuralgic, or oedema of the arm. When the upper part of the vessel is affected, the pulsation is felt immediately below the clavicle, and may project up into the neck, displacing the clavicle forwards; if placed lower down, the aneurism occupies the axilla. The progress of the case is often rapid, and the thoracic cavitv may even be encroached on. Treatment. — Com- pression (digital) or ligature of the third part of the subclavian artery is required, but 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 of the forearm, require no special notice. They are almost invariably traumatic in origin, and should be treated by extirpation. Abdominal Aneurism. — The abdominal aorta may become the seat of aneurism, either at the upper part near the coehac axis, or at the bifurcation. A pulsating tumour is observed near the middle line, and either close to the umbihcus or in the epigastric notch; the pulsation is expansile in type, and remains the same in character whatever the position of the patient. Pain, locaHzed in the back from erosion of the vertebrae, or neuralgic from pressure on the solar plexus or lumbar nerves, is the chief symptom, whilst oedema of the lower extremities may arise from compression of the vena cava. There may be some concurrent derangement of the intestinal func- tions. Occasionally aneurisms form independently on the spleiiic, hepatic, or mesenteric vessels. Diagnosis. — Many conditions give rise to epigastric pulsation. Cardiac pulsation may be felt in the epigastrium when the heart is dilated, but should be easily recog- nised; as also an impulse transmitted from the aorta through a collection of faeces or a cancerous growth. The examination of such a case, if need be under an anaesthetic, should be conducted not only in the dorsal decubitus, but also in the genu-pectoral position, so as to remove the weight of the viscera from the aorta, when the pulsation will cease or be much diminished. Radiography is of great service in the diagnosis of these cases. 326 A MANUAL OF SURGERY Treatment. — Failing medical treatment by rest and diet, compres- sion was formerly relied on, being applied either on the distal or proximal aspect of the sac. The method is, however, clumsy and liable to bruise the abdominal viscera. More recently treatment by needling the sac has been employed, and certainly in Macewen'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 electrolysis, cured an aneurism as large as an orange; the abdomen was opened, and electrol3'sis was maintained for thirty-seven minutes. Iliac or Inguinal Aneurism arises from either the common or ex- ternal iliac, or from the common femoral; it is frequently sacculated in tj'pe and lobulated in shape owing to the pressure of fascial or other structures. The symptoms are very tvpical, and diffusion is certain to ensue sooner or later. The Diagnosis cannot be well mistaken in the early stages, but later on, and specially when situ- ated high in the iliac fossa, it may be difficult to distinguish from a pulsating sarcoma. Treatment. — Extirpation is, of course, the best plan to adopt if it be possible, but more frequently one must depend on proximal ligature. For an inguinal aneurism, the external ihac may be tied with every prospect of success. If the aneurism is situated higher, ligature of the common ihac may be undertaken (transperitoneal operation), or even of the aorta. The latter opera- tion has been performed in ten instances, and in all a fatal result followed, although two patients lived thirty-nine and forty-eight days respectively. Failing any of these methods, compression of the aorta or common iliac may be emploved. Aneurisms of the Gluteal and Sciatic Arteries are usually traumatic in origin, and present as pulsating swellings in the buttock, the gluteal situated at the upper part of the sciatic notch, whilst the sciatic lies more deeply, and may be partly intrapelvic. Pain in the limb from pressure on the sciatic nerve is a prominent symptom, especially in the sciatic variety. The Diagnosis is by no means easy, especially from a pulsating sarcoma. Treatment. — \\'hen the diagnosis is established, transperitoneal ligature of the internal iliac artery should always be adopted. If the sac is laid open from the buttock as a result of a mistaken diagnosis, the old-fashioned plan of treatment must be followed, viz., to turn out the clots and secure the bleeding-points. Femoral Aneurism is the title given to one forming in the course of the superficial femoral artery. It is not uncommonly tubular, and occurs almost invariably in males. Treatment consists either in extirpation, or ligature of the common or superficial femoral trunk. Popliteal Aneurism occurs almost invariably in men, constituting a pulsating tumour in the ham, rendering the knee painful and stiff, and so much do the symptoms resemble those of chronic rheuma- tism that in every such case the popliteal space should be examined. The limb is usually kept semiflexed, and the aneurism often increases rapidly in size. If the main swelUng is situated in front of the LIGATURE OF VESSELS 327 vessel, there is some likelihood of the knee-joint becoming implicated and neighbouring bones carious; when it extends posteriorly, diffusion is not uncommonly followed by gangrene, on account of the pressure exercised, not only upon the vein, but also upon the articular branches of the popliteal artery, which are most important factors in maintaining the collateral circulation. The Diagnosis has to be made from chronic enlargement and abscess of the pop- liteal glands, but in these there is less disturbance of the circulation in the foot; from bursal tumours, by their want of mobility and pulsation; or from solid tumours, e.g., pulsating sarcoma of the femur or tibia, by attention to the general principles already enunciated. In a few instances spontaneous cure has resulted from the pressure of the sac upon the artery above. Treatment. —Compression has been eminently successful in many of these cases. Ligature of the femoral artery at the apex of Scarpa's triangle is, however, the plan most commonly adopted, and wath the greatest success. In cases where either of these methods has failed, or where the aneurism has become diffuse or recurred, extirpation of the sac is the best course to adopt. Ligature of Vessels. This operation is performed to arrest the flow of blood to the peripher}', in order either to check haemorrhage, or to promote the cure of an aneurism, or to diminish the rate of growth of some tumour, or to influence beneficially some peripheral organ by re- ducing its blood-supply, or as a preliminary to removing some vascular structure, such as the tongue. Operation. — The artery is examined as far as is possible, so that a healthy portion may be selected for applying the ligature. The various structures {raUying-po-ints) met with on the way to the artery are recognised, and drawn aside, if need be, so as to lay bare the sheath of the vessel, which is opened over the artery by a longitudinal incision about | inch in length. The aneurism needle is inserted unarmed, and gently manipulated up and down, so as to free the vessel all round, a matter of no great difficulty if the sheath has been correctly opened and the arterial wall exposed. The ligature may then be passed through the eye of the needle, and carried round the vessel, tied in a direction exactly at right angles to the longitudinal axis; in doing so the artery must not be dragged out of its sheath, but the ligature should be tightened by the tips of the forefingers meeting upon it. The opening in the sheath should be closed over the ligature by a fine buried stitch, and the various structures displaced in reaching the vessel are similarly secured in good position. Method of Application of the Ligature. — In the smaller vessels and those of medium size all that is needed for security is a reef knot tied firmly; but in the largest trunks — e.g., the innominate, first part of the subclavian, and common iliac — it is advisable to employ 328 A MANUAL OF SURGERY what is termed the stay knot (Fig. 104). Two strands of Hgature are passed round the vessel side by side and half-knotted; the two ends on each side are then taken up together and tied across in one knot. The degree of tension used in these cases is such as to approximate completely the vessel walls, but without rupturing the inner or middle coats, thereby minimizing the risks of secondary haemorrhage. Broad strands of animal ligature — e.g., gold-beater's skin or ox aorta — should be employed in these cases. Some surgeons recommend that two ligatures should be applied to the artery, and the vessel divided between them. This plan is suggested to' avoid longitudinal traction on the site of ligature, which necessarily results from the fact that all arteries in the body are main- tained more or less upon the stretch, as evidenced by their retraction when divided ; it is supposed that secondary haemorrhage is pre- disposed to by this condi- tion With modern aseptic methods this precaution is of little significance. The rule usually followed is to pass the needle from inipoytant structures, such as the vein, but really this is a matter of little import- ance when the above direc- tions have been carefully carried out, and especially in superficial vessels. Should the vein he acci- dentallv punctured, the needle must be at once withdrawn and the puncture in the vein secured by ligature, whilst the artery is tied a little higher or lower. In dealing, however, with the smaller vessels, where the vense comites are in close contact with the arteries, no harm will attend their inclusion in the ligature. After-Treatment.— The patient must be kept at rest for at least three weeks in order to secure permanent obliteration of the artery and the effective development of a collateral circulation, especially in dealing with the larger vessels and in elderly people. When the main artery to one of the extremities has been tied, the limb should be wrapped in aseptic wool and slightly raised, and if there is any likelihood of gangrene, it should be thoroughly purified. There are two great dangers liable to follow the ligation of an artery in its continuity: 1. Secondary Hsemorrhage {vide p. 293). 2. Gangrene may arise from a variety of causes: {a) From simple loss of vitality, owing to a defective collateral circulation, as when the peripheral vessels are calcareous and rigid. The tissues which receive the smallest amount of blood die first, e.g., the fingers or toes, or the subcortical white substance of the brain. Severe loss of blood after the operation, as from secondary haemorrhage, may also deter- FiG. 104. — Stay Knot. LIGATURE OF VESSELS 329 mine tissue necrosis. Under such circumstances it almost always takes on the dry form, [h) Interference with the venous return, as by injury to the vein during operation, or the pressure of a tight bandage, or thrombosis induced subsequently by infective periphle- bitis, Ts very likely to cause gangrene, and then it is of the moist t\'pe. (r) Unsuitable after-treatment, such as too great elevation of the limb, the injudicious application of an ice-bag or hot-water bottle during the period of chminished vitality immediately following the operation, or even an attack of erysipelas, may also bring about the death of some of the tissues. 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 infection is present, giving rise to fever and general disturbance, it is wiser to remove the limb well above the line of demai'cation. The Innominate Artery has now been tied with success on at least six occa- sions out of a total of about thirty operations. An incision is made along the lower third of the anterior border of the sterno-mastoid, and is prolonged down- wards to sweep over the upper edge of the episternal notch. The platysma and the superficial and deep fasciae are divided, and the anterior jugular vein secured if necessary between two ligatures; the sterno-mastoid is drawn out- wards, and its inner tendinous fibres are divided, whilst the sterno-hyoid and -thyroid muscles are severed close to the sternum and drawn inwards. The carotid sheath is now laid bare and opened at its lower part, so as to expose the carotid artery and enable it to be tied, and by followdng this downwards the innominate trunk is reached. In some cases it may expedite matters to remove portions of the sternum and inner end of the clavicle. The right internal jugular and innominate veins lie to the outer side of the artery, but if much engorged may project over it, and must then be drawn aside by retractors, whilst the inferior thjToid plexus may course directly do\\-nwards to reach the left innominate vein, which crosses the vessel. To the outer or right side and behind the veins are placed the vagus nerve and pleural sac, and these must be carefully separated from the artery, whilst the needle is passed from without inwards, and from below upwards. A double-curved aneurism needle will probably be required to effect this. A broad animal ligature should be used for this vessel, and the inner and middle coats must not be di\'ided. Collateral Circulation. — Intracranial : Vertebrals and carotids in the circle of Willis. Face and Neck : Branches of the two external carotids across middle line. Trunk : First aortic intercostal with superior intercostal of subclavian ; upper aortic intercostals with thoracic branches of axillary and intercostals of internal mammary; deep epigastric and phrenic with terminal divisions of internal mammary. The Carotid Artery may be tied either above or below the level at which it is crossed bv the anterior belly of the omo-hyoid. The line of the vessel is indi- cated by that drawn from the sterno-clavicular articulation to a point midway between the angle of the jaw and the tip of the mastoid process, the bifurca- tion being on a level ^vith the upper border of the thyroid cartilage. Ligature above the Omo-hvoid. — The vessel is here more superficial, and the ligature is applied on a level with the cricoid cartilage. The patient lies upon the back, with the chin raised and the head turned towards the opposite side. A 3-inch incision is made in the line of the vessel, the centre on a level with the cricoid (Fig. 105, D). The skin, platysma, and fasciae are divided, and the anterior edge of the sterno-mastoid defined. The deep fascia is incised along its inner border, so that it may be drawn aside by a retractor; the sterno-mastoid branch of the superior thyroid artery may be divided at 330 A MANUAL OF SURGERY this stage. On the inner side of the wound the omo-hyoid muscle must now be looked for, tremling forwartls and upwards from under to\er of the sterno- mastoid. In the angle formed liy these two structures the pulsation of the vessel should be felt 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 needle is passed from without inwards, and if the sheath has been efficiently opened, the vagus nerve will nm no risk of being included. Ligature below the Omo-hyoid. — A similar incision is made, but lower in the neck, reaching from the cricoid cartilage nearly to the sterno-clavicular joint. The sterno-mastoid is drawn outwards, and perhaps the anterior fibres may need to be divided ; the sterno- hyoid and -thyroid muscles are retracted inwards or divided, and the omo-hyoid can usually be drawn upwards. The sheath is thus exposed, and opened on the inner side, the needle being passed as in the previous operation. It must be remembered that both internal jugular veins are directed towards the right side in the lower part of their course, and hence the left vein is likely to lie somewhat in front of the artery. The inferior th\Toid veins may also be seen, and need to be drawn aside or ligatured. The effects of ligature of the carotid upon the brain are of great interest and importance. Statistics prove that about 25 per cent, of the patients develop cerebral symp- toms, either immediately in the form of syncope from cerebral anaemia, or in the course of a few days from cerebral softening, causing hemiplegia. A fatal issue is likely to result in about half the cases thus affected. Collateral Circulation. — Intra- cranial : Circle of Willis. Extracranial : Communications across the middle line of branches of the external carotids and vertebrals; inferior th>Toid with the superior thyroid; profunda cervicis with princeps cervicis of occipital ; superficial cervical ivith branches of occipital and vertebral. Ligature of the Internal Carotid. — An incision is made along the anterior border of the sterno-mastoid, its centre being opposite the great cornu of the hyoid bone; the muscle is pulled backwards, and the ]wsterior belly of the digastric is seen and drawn up. The external carotid is displaced forwards, and then the internal carotid in its sheath appears. The latter is opened, and the aneurism needle passed from the jugular vein. The Collateral Circulation to the brain is maintained by the circle of Willis. Ligature of the External Carotid is occasionally required, the site of election being between the superior thyroid and lingual branches. An incision is made along the anterior border of the sterno-mastoid, 3 inches in length, its centre corresponding to the great cornu of the hyoid bone. The edge of the muscle is defined and drawn outwards, and the posterior belly of the digastric sought Fig. 105. — Incisions for Various Oper- ations ON Head and Neck. A, Flap incision used in trephining for meningeal haemorrhage; B, flap incision for operation on roots of the fifth nerve ; C, incision for ligature of lingual artery; D, for ligature of common carotid; E, for ligature of vertebral artery; F, for ligature of the third part of the sub- clavian; G and G^, incisions used for tying first part of axillary; H, for liga- ture of internal mammary arterj^. LIGATURE OF VESSELS 331 for above the hypoglossal nerve lying just below it. ihe sheath is now opened below the tip of the great eornu, and the need e passed from without TnwaJds The operation may" be rendered dilftcult by the presence of enlarged SSs or veins, espeeially the lingual, facial, and superior thyroid, which 1 e fnkonrof the vessel. The superior laryngeal nerve is placed immediately behind it, and must be avoided. ^„„;oi CoUateml Ciyculation.-Vrde ligature of the common carotid (extra-cranial ^'"^Ligatoe Of the Lingual Artery is chiefly employed as a preliminary to removal of the tongue for mafignant disease. The vessel can be secured either close to its origin Irom the external carotid, or in the submaxillary triangle under cover of the hyoglossus muscle. , • 1^ 1 4.1, 4-v,^ In Z SubmaxUlary Triangle.-The patient lies on his back with the shoulders raised, and the head Extended backwards and turned to the opposite Fig. 106.— Ligature of Lingual Artery. (Tillmanns.) The submaxillary gland (Gs) has been drawn over the side of t^e Jaw with a hook; I, external carotid; 2. internal jugular artery; ^^''^^^''^.^ll^'y'. 4, ranine branch of facial artery; 5, hypoglossal nerve M dig, digastric M styl. stylo-hyoid ; M myho, mylo-hoid ; M hyogl, hyoglossus. The place where the artery is tied is indicated by a window m the hyoglossus, through which it can be seen. side A crescentic incision with its convexity downwards is made com- mencing about I inch below the symphysis menti, ^^^ extending back to the sterno-mastoid. the centre opposite the great cornu of the ^^y^^J Ji°^^/5;|- J°^: C) The integument and platysma are divided, the lower bolder of the suD maxillary gland is defined, and along it the deep fascia is incised The gfana Snow dLwn upwards and held over the margin of^he jaw with a retractor (Fi- 106 Gs). On opening up the wound thoroughly the two bellies of tlae digastric muscle (M dig) ar"e seen converging to the hyoid bone the anterior be^fy passing superficifl to the fibres of the mylo-hyoid --^l^ (^jS which course nearly transversely to the mandible, and of which the posterior fibres may be divided with advantage. The digastric tendon is drawn c^own with a blunt hook, and in the space thus cleared the ^^yog^^^^X "d (M hvogl) becomes evident with its fibres passmg vertically "P^^"^^' ^^Jj resting upon it the hypoglossal nerve (5) c our smg forwards to get under cover of the mylo-hyoid, and either above or below it the ranine ^^m . The fibi es oi the hyoglossus are now divided transversely midway between the nerve and 332 A MANUAL OF SURGERY the hyoid bonu, and in the oj)ening made by their retraction is seen the artery (3), lying on the mitldle constrictor. Should it not be found in this situation, the incision in the hyoglossus should be extended backwards, and the vessel will then usually come in sight. In the Neck Close to its Origin — ^An incision is made along the anterior border of the sterno-mastoid similar to that needed for ligature of the external carotid. The muscle is drawn backwards, and the great cornu of the hyoid bone defined. The small space is now cleared between that bony process anil the posterior belly of the digastric, in which the artery can be felt resting upon the middle constrictor, and secured just as it rises from the external carotid. The Facial Artery may be exposed and tied through a horizontal incision, I inch m length, made directly over the vessel as it crosses the lower border of the jaw immediately in front of the masseter. The Temporal Artery is reached in front of the auditory meatus through a vertical incision, and must be carefully isolated from the auriculo-temporal nerve. The Occipital Artery is tied through an incision extending from the apex of the mastoid process backwards for about 2 inches towards the occipital pro- tuberance. The posterior fibres of the sterno-mastoid, the splenius, and trachcio-mastoid, are divided so as to expose the artery as it emerges from the groo\x^ on the under surface of the mastoid process, where it is easily secured. The Subclavian Artery has been tied in each part of its course, but most frequently in the third. Ligatures of the first and second parts are such unusual proceedings that we must refer students to larger textbooks for descriptions. For Ligature of the third part 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 drawn down by the left hand, and an incision 3 or 4 inches long made over the clavicle (Fig. 105, F). On releasing the skin it retracts upwards, so that the wound comes to be situated about 5 inch above the clavicle, and thus the external jugular vein is more efficiently protected. The incision should be placed with its centre about i inch to the inner side of the middle of the clavicle, and should expose the space between the sterno- mastoid and trapezius muscles, the fibres of which are divided to a suitable extent if they encroach abnormally upon the bone. The external jugular and other veins often give the surgeon much trouble; they are either drawn aside or, if necessary, divided between ligatures. The deep fascia is incised in the line of the wound, care being taken to avoid the transverse cervical and supra- scapular arteries, the former of which is above the line of operation, whilst the latter is hidden behind the clavicle. The posterior belly of the omo-hyoid, if seen at all, is drawn upwards. Various layers of fascia must be carefully cut or torn through until the nerves of the brachial plexus appear; the finger can then readily define the scalene tubercle on the first rib. The subclavian vein is situated in front of the finger, but 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 above and external to it, the lower cord passing down behind. The needle is insinuated from above downwards, and must be kept very close to the artery to prevent all possibility of in- cluding 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 difficulty may be experienced in finding the vessel. The chief dangers arise from wounding the pleural cavity, or the superficial veins, or from ligaturing one of the cords of the brachial plexus. Collateral Circulation. — Thoracic set : Branches of the aortic intercostals and internal mammary with thoracic branches of axillary. Scapular set : Suprascapular and posterior scapular with subscapular and its dorsalis branch in the venter or on the dorsum of scapula. Acromial set : Suprasca]:)ular 'cvith acromio-thoracic. The Internal Mammary Artery (Fig. 105, H) may be exposed and tied by dividing the intercostal aponeurosis and muscles for an inch or more from the outer edge of the sternum, from which it is distant about i inch. LIGATURE OF VESSELS 333 Ligature of the Vertebral Artery has been undertaken for wounds, for secondary haemorrhage after ligature of the innominate, and m the treatment of epilepsy but without much permanent bencht m the last case. An incision is made along the lower halt of the posterior border of the sterno-mastoid (Fi"- los E) the platysma and deep fascia are divided, and the muscle drawn forwards' The scalenus anticus is clearly defined, together with the phrenic nerve The interval between it and the longus colli muscle can now be demon- strated, with the ascending cervical artery lying upon it. The anterior trans- verse process of the sixth cervical vertebra must be made out. Just below this the vertebral vessels are found entering the canal m the transverse pro- cess and the vein which is placed anteriorly, is drawn outwards to allow the needle to be passed from without inwards. A few sympathetic twigs are often included in the ligature, and may cause contraction of the pupil. Ligature of the Thyroid Vessels is sometimes used as a means of arrestmg the growth of a goitre. . . 4. -^^ The superior thyroid artery is tied through an incision along the anterior margin of the sterno-mastoid, which has its centre opposite the upper border of the thyroid cartilage; the external carotid is defined, and the superior thyroid secured at its origin. ... , ,, -^^^^ The inferioy thyroid artery is reached through an mcision along the inner border of the sterno-mastoid, extending upwards from the clavicle for 3 inches This muscle and the subjacent carotid sheath are drawn outwards, the sterno- hyoid and -thyroid usually needing to be divided. The transverse process of the sixth cervical vertebra is sought for, and the vessel found passing inwards immediately below. It is taken up just behind the carotid, and as far from the recurrent laryngeal nerve as possible. ^ .. 1 The Axillary Artery is tied for punctured wounds of the axilla, as a distal operation for subclavian aneurism, occasionally for wovmds of the palmar arch and possibly for secondary haemorrhage from the brachial. iwo classical operations are described and practised in classes on operative ^""^rYioature of the first part of the vessel is usually undertaken through a curved incision with its concavity upwards, extending from tlie coracoid process to just below the sterno-clavicular joint (Fig. 105, G^). The clavicular origin of the pectoralis major is divided, and the costo-coracoid membrane exposed and divided. Branches of the acromio-thoracic axis are displaced, and the main trunk is exposed by a blunt dissector and forceps. The vein lies withm and below, and the cords of the brachial plexus above and to the outer side. The divided muscular fibres should be subsequently sutured together An incision which gives an unusually good approach and involves less division of muscular fibres is one which follows the lower border of the clavicle from its centre outwards to the coracoid process, and then turns down to he over the interspace between the pectorahs major and deltoid muscles (tig 105 U). This intersection is opened up and the outermost fibres of the pectoralis which arise from the clavicle are divided. The costo-coracoid membrane is thus exposed, and the cephalic vein will act as a guide to the vessels 2. Ligature of the third part of the artery is performed from the axilla, the arm is fully abducted, and the surgeon stands between it and the body An incision is made in the course of the vessel (Fig. 107, A) . The inner border of the coraco-brachialis muscle is clearly defined, and drawn slightly outwards, and the median nerve, together with the musculo-cutaneous trunk, at once comes into view. On drawing these inwards, the artery itself is seen, with the vein to the inner side. The needle is passed from the vein Collateral Circulation .—li above the acromio-thoracic, the same as tor tne third part of the subclavian (g-.w.). . ,• , ^ o-(-oi= „„v/. If above the subscapular and circumflex: Long thoracic and mtercostals wit thoracic branches of subscapular; suprascapular and posterior scapular w/s^.— An incision about i inch in length is made directly up- wards from the liexure of the wrist in the line of the vessel (Fig. 107, F). The deep fascia is opened, the tendon of the flexor carpi ulnaris drawn to the inner side, and the vessels are then seen, accompanied by the nerve which lies to the ulnar side of the artery. 2. /«. the Middle of the Forearm. — An incision is made along a line drawn from the anterior edge of the tip of the inner condyle to the radial side of the pisiform bone (Fig. 107, G). The white line indicating the intermuscular septum between the flexor carpi ulnaris and flexor sublimis digitorum is then sought for and opened up; it is often very slightly marked, and may be difficult to distinguish. If the correct interspace has been opened, the surgeon is directed towards the ulna, and readily finds the vessels under cover of the flexor carpi ulnaris, with the nerve lying a little way to the inner or ulnar side. 3. The upper limit of the idnar artery can be reached through an oblique incision along the upper border of the pronator teres, thus opening up the ante- cubital fossa, and exposing the bifurcation of the brachial. Radial Artery. — The line of the vessel extends from the middle of the bend of the elbow to the interspace at the wrist between the flexor carpi radialis and the supinator longus. It then turns outwards, and may be felt beating in the space described by French anatomists as ' la tabatiere ' (or snuff-box) , between the tendons of the extensor primi and extensor secundi internodii muscles. 1. At the Back of the Wrist the vessel may be secured by opening up the above-mentioned intertendinous hollow, where the artery is found coursing onwards to the base of the first interosseous space. The incision is placed obliquely between the tendons, extending from the back of the styloid process of the radius to the base of the first metacarpal bone. 2. Above the Wrist an incision is made in the line of the vessel (Fig. 107, E), which is found after division of the fascia between the supinator longus, and flexor carpi radialis. 3. In the Middle or Upper Third of the Forearm an incision is made in the line of the vessel (Fig. 107, D), and the inner border of the supinator longus sought for and retracted. The vessels are found under cover of this structure, with the radial nerve to the outer side, though separated by an interval above. Ligature of the Abdominal Aorta* has been undertaken in fourteen instances for severe primary or secondary haemorrhage, or for diffuse inguinal or iliac aneurism, when no other method of treatment was practicable. All these cases have proved fatal, in most instances from infection and secondary haemorrhage. The operation consists in opening the abdomen through an incision slightly to the left of the middle line, having the umbilicus on a level with its centre. The intestines are retracted, and the posterior laj^er of the serous membrane covering the aorta carefully divided ; there is then no diffi- culty in passing a ligature around the vessel. Possibly it would be well to prevent excessive backflow of blood by securing one or both of the common iliac trunks in addition; such would in no way interfere with the collateral circulation. The Common Iliac Artery extends for a distance of 2 inches from the bifurca- tion of the aorta opposite the left side of the body of the fourth lumbar vertebra to the front of the sacro-iliac synchondrosis. It may be reached through an incision made in the median line with its centre a little below the umbilicus. The vessel is sought for and exposed by an incision through the posterior layer of the parietal peritoneum, and a ligature passed and tied . The ureter which crosses the artery just above its bifurcation must be carefully avoided. Collateral Circulation. — Blood reaches the external iliac and its branches by means of the anastomosis of the lumbar arteries with the circumflex iliac, and of the superior epigastric, lumbars, and intercostals with the superficial and deep epigastric. The internal iliac and its branches are supplied by the union of (a) the lumbar branches with the ilio-liimbar; [b) the middle sacral with * See Tillaux and Riche, Revue de Chirurgie, January, February, and March, 1901. 336 A MANUAL OF SURGERY Fig. io8 Incisions for the lateral sacral ; (c) the retropubic anastomosis of the two obturator arteries; and [d) the communications of the pudic, haemorrhoidal, and vesical trunks with those of the opposite side. Ligature of the Internal Iliac Artery is occasionally performed for haemor- rhage from, or aIK•u^i^^m of, one of its branches, the gluteal being that most commonly affected. The trunk is a short one, at most i^ inches in length, and is best reached by opening the abdomen in the middle line below the umbilicus (Fig. io8, C), pushing aside the intestines, and searching for the bifurcation of the common iliac. The pos- terior layer of the peritoneum is then care- fully incised, the ureter avoided, and an armed aneurism needle passed without wounding the vein. The Collateral Circulatimi is the same as that given for the internal iliac division of the common iliac. The External Iliac Artery is easily acces- sible in any part of its course, which measures from 3i 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 Poupart's ligament. Many suggestions as to the best means of reaching the artery have been made, and both trans- and extra-peritoneal methods have been adopted. It is so readily secured, however, by the latter that it seems unneces- sary to open the peritoneum. There are two chief forms of extraperitoneal operation. Astley Cooper'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 | inch above it, and extending upwards and outwards to about I inch internal to the anterior superior spine (Fig. 108, G). The external oblique apo- neurosis is divided along this line, and the exposed lower margins of the internal oblique and transversalis muscles arching over the inguinal canal are drawn upwards by retrac- tors. The transversalis fascia and loose subperitoneal fat are now opened with forceps and director, and the vessel is felt pulsating immediately under the finger. The epigastric and circumflex iliac arteries must not be damaged during this manipu- lation, since they are important factors in the collateral circulation. The needle is passed from within outwards, the ligature tied, and the divided muscular and aponeurotic structures united by buried sutures. Abernethy's Modified Operation is more commonly utilized. The incision, about 4 inches in length, extends from a point i.^ inches within and above the anterior superior iliac spine to just external to, and 4 inch above, the middle of Poupart's ligament (Fig. 108, F). Through this the aponeurosis of the external oblique is divided along the course of its fibres, as al.so the internal oblique and transversalis. The transversalis fascia is now carefully incised ; it varies considerably in thickness, being sometimes well developed, but is Operations on Lower Part OF Abdomen and Upper Part of Thighs. A, Mott's incision for retro- peritoneal ligature of com- mon iliac artery; B, Mar- cellin Duval's incision for the same; C, incision for trans- peritoneal ligature of inter- nal iliac artery; D, incision for excision of hip by the anterior method ; F, Aber- nethy'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, liga- ture of femoral artery in Hunter's canal. LIGATURE OF VESSELS 337 occasionally so attenuated as to be scarcely recognisable. The fingers are now introduced into the wound, and the peritoneum and its contents stripped from the iliac fossa, and drawn inwards and forwards, where they are kept out of the way by a broad spatula, in the space thus opened up one can see the iliacus muscle covered by its fascia, and to its inner side the rounded outline of the 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 inner side, and the needle passed from within outwards. If the transversalis fascia has not been properly opened, it is quite possible to strip it up together with the peri- toneum, and carry the vessels forwards with it, when they m.ay be found under cover of the spatula. Of these two operations, the latter is probably the better. By Cooper's method the artery is tied very close to important collateral branches, whilst but a small portion of the trunk is exposed, so that if this is diseased and un- suitable for the application of a ligature, no further choice is possible. In Abemethy's, on the other hand, the vessel is tied well away from collateral branches, and if the exposed portion of the trunk is diseased, the common iliac can be reached and secured without much difficult}' by extending the incision upwards. The wound also involves muscular tissue, and therefore better repair is secured with less likelihood of a subsequent hernia. Collateral Circulation. — -Anterior set : Superior epigastric of internal mam- mary, lumbar, and lower intercostals with superficial and deep epigastric in sheath of rectus. Posterior set : Gluteal and sciatic with internal and external circumflex and first perforating of profunda at back of great trochanter (crucial anastomosis) . External set: Ilio-lumbar and gluteal with deep and superficial circumflex iliac and ascending branch of external circumflex. Internal set : Obturator with internal circumflex; and terminal divisions of internal pudic with superficial and deep external pudic. The Common Femoral Artery is but rarely ligatured, except as a preliminary measure in amputation at the hip-joint, since the number of branches arising from it is likely to interfere with its sound occlusion, and the collateral circula- tion is better after ligature of the external iliac. It ma}' be reached b}' a vertical incision over the line of the vessel, extending both a little above and below Poupart's ligament. The superficial lymphatics and veins must be carefully avoided, the fascia lata divided, the sheath exposed and opened, and the ligature passed from the inner side. Collateral Circulation. — Internal set : Obturator with internal circumflex, and internal pudic with external pudic. External set : Circumflex iliac with ascending branch of external circumflex. Posterior set : Gluteal and sciatic with internal and external circumflex, and first perforating ; comes nervi ischiadic! with perforating of the profunda and muscular of popliteal. The Superficial Femoral Artery is indicated by a line drawn from midway betAveen the anterior superior spine and the symphysis pubis to the tuberosity of the internal condyle, the limb being flexed, abducted, and everted. It may be secured at ' the site of election ' — i.e., at the apex of Scarpa's triangle — or in Hunter's canal. Ligature at the Apex of Scarpa's Triangle. — -A 4-inch incision is made in the line of the artery, the centre being about 4 inches (or a hand's breadth) below Poupart's ligament (Fig. 108, H). The integument and fasciae are divided, the inner border of the sartorious exposed, and the sheath found immediatel}' behind it, the muscle being dra^vn slightly outwards; the middle cutaneous nerve is perhaps brought into view. The vein is placed behind the artery at this level. Collateral Circulation. — External circumflex with lower muscular of femoral, anastomotica magna, and superior articular of pophteal. Profunda f emoris by its perforating and terminal branches with the muscular and articular branches of femoral and popliteal. 338 A MANUAL OF SURGERY Ligature in Hunter's Canal. — An incision 4 inches in length is made along the line of the artery in the middle of the thigh (I'ig. luS, K). The sartorius is exposed by division of the fascia lata, its liljres running downwartls and inwards; its outer border should be defined, and the muscle retracted inwards. The aponeurotic covering of Hunter's canal is now in view, stretching between the adductor longus ancl 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, the long saphenous nerve crossing it from without inwards, and the vein passing behind it, to become external lower down. A common mistake made by students in tying this artery on the deatl subject is to burrow down along Fig. 109. — Incisions for Ligature of THE Upper Part of the Popliteal (A), AND of the Posterior Tibial Arteries (B, C, and D). E, Site for Introduction of knife in Tenotomy of TibiaHs Posticus; F, Ditto for Tendo Achillis. Fig. iio. — Incisions for Liga- ture of Anterior Tibial (A AND B) AND Peroneal (C) Arteries. D, Site for Intro- duction OF Knife in Teno- tomy of Peronei. the vastus internus on the outer side of the vessels; this is to be avoided by always keeping close to the under surface of the sartorius until the glistening transverse fibres of Hunter's aponeurosis are clearly visible. Collateral Circulation is maintained through the profunda and its branches. The Popliteal Artery may be tied either just after it has passed through the adductor opening, or in the depths of the popliteal .space, but preferably in the former situation. Neither operation is often required . To tie the upper part, the liml) is fully abducted and everted so as to enable the adductor tubercle and tendon of the adductor magnus to be clearly defined. An incision, 4 inches in length, is then made from the tubercle upwards (Fig. 109, A), and the tendon exposed. The internal saphenous vein and nerve may be seen, but are drawn backwards by means of a broad retractor, together with the sartorius, gracilis, and semi-membrano.sus. If possible, the branch of the anastomotica magna which courses along the tendon should be spared The fascial space behind is now opened up, and the artery found surrounded by LIGATURE OF VESSELS 339 a good deal of loose connective tissue. The vein is usually seen on the outer side, and is here \erv thick and dense, so that in the dead subject it can be readily mistaken for the artery. The" loiaer part is tied through an incision in the middle line of the popliteal space, dividing the deep fascia ami drawing out of the way the heads of the gastrocnemius muscle and the internal popliteal nerve. The vein is superficial to the artery, and is found by following the short saphenous trunk. Collateral Circulation is maintained by the anastomoses around the knee- joint. The Posterior Tibial Artery but seldom requires to be ligatured except for haemorrhage, or on the face of amputation stumps; hence the operations described below are rarely seen away from the dead-house. The line of the vessel is indicated by one drawn from the centre of the popliteal space to a point a finger's breadth behind the internal malleolus. 1. In the Middle of the Calf. — -The leg is placed on its outer side and flexed, and an incision 4 inches long is made a finger's breadth behind the inner border of the tibia (Fig. 109, B), dividing the skin and subcutaneous tissues, the long saphenous vein and nerve being drawn aside if necessary. The tibial origin of the soleus is thus exposed, and incised directly towards the tibia, until the fibrous aponeurosis on its deeper surface is met with. This having been cut through, the muscle is drawn backwards with the retractor, and the vessels, ensheathed in a deep layer of fascia, are seen lying on the tibialis posticus, and with the posterior tibial nerve to the outer side. 2. In the Lower Third of the Leg. — An incision is made midwav betw^een the tendo Achillis and inner border of the tibia (Fig. 109, C). The skin and fasciae, including the upper part of the internal annular ligament, are divided, and the vessels seen lying on the flexor longus digitorum, with the nerve behind and to the outer side. 3. Behind the Malleolus. — An incision is made about a finger's breadth from the malleolus, curving round its lower border (Fig. 109, D). The deep fascia (or, as it is here termed, the internal annular ligament) is divided over the vessels between the tendons of the flexor longus digitorum and flexor proprius hallucis, and the artery is then readilv cleared and ligatured. The sheaths of the tendons should not be opened. The Anterior Tibial Artery is found along a line stretching from a point mid- way between the outer tuberositv of the tibia and the head of the fibula above to the central point between the' two malleoli belo\v. It may be tied in three situations. 1. In the Upper Third of the Leg. — An incision is made exactly in the line of the arterv (Fig. no. A), and the deep fascia incised. The intermuscular space between the tibialis anticus and the extensor communis digitorum is opened. The vessel lies between these muscles upon the interosseous membrane, the anterior tibial nerve being to the outer side. 2. In the Middle of the Leg (Fig. no, B). — The same intermuscular space is opened, being indicated here by a definite white line, due to a slight subfascial deposit of fat. The vessels lie between the tibialis anticus and the deeply- placed extensor proprius hallucis, the nerve usually lying on the artery and needing to be drawn aside. 3. In the Lower Third of the Leg. — An incision is made in the line of the artery, reaching upwards for 2 inches from a point just above the ankle (Fig. Ill, A). The deep fascia and upper part of the annular ligament are divided, and the vessel is found between the tendons of the tibiahs anticus and of the extensor proprius hallucis, the nerve lying to the outer side. Fig. III. — Incisions FOR Ligature of Lower Part of Anterior Tibial (a) and dorsalis Pedis (B) Arter- ies. C, Site for PERFORMING TEN- OTOMY OF Tibialis Anticus. 340 A MANUAL OF SURGERY 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 metatarsal bones. An incision is made in this direction (Fig. iii, B), the deep fascia opened, and the artery found lying between the extensor proprius hallucis, which has now crossed and is internal to the vessel, and the innermost slij) of the extensor brevis digitorum. It is not always easy to find, and for practical purposes the best plan would be to divide the vessel by an incision extending to the bones, and then pick up and tie the bleeding ends. The Peroneal Artery can be reached through an incision along the posterior border of the centre of the fibula, the leg being laid on its inner side (Fig. no, C). The outer edge of the soleus is defined and drawn inwards, the lower fibres of attachment to the fibula being divided if necessary. The flexor longus 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 is then readily found lying in an osseo-aponeurotic canal. CHAPTER XIV. AFFECTIONS OF THE ^VEINS— ANGIOMATA. Venous Thrombosis. By Thrombosis is meant intravascular coagulation in any part of the circulatory system. Normally, the blood remains in a fluid condi- tion, owing to some inter-action between it and the vessel walls. Any factor producing a disturbance of this normal equihbrium may determine thrombosis, and any part of the vascular tract may be affected by it, whether the heart, arteries, veins, or capillaries; but it is in the veins that it occurs most frequently. Causes.— (i) Changes in the vessel i&alls, as a result of which the integrity of the endothelium is disturbed— ^.g., injury (either division, rupture, puncture, compression, or contusion), inflammation or degeneration (as in varicose veins') . (2) Changes in the constitution of the blood whereby its coagulability is increased. In clinical work this is brought about most frequently by infective conditions, which lead to an excess of toxins in the blood. HcEmorrhage up to half of the whole amount in the body also increases ifs coagulabihty, but excess of leucocytes, as in leukaemia, has the opposite effect. . (3) Diminished rate of the blood-stream predisposes to thrombosis it some other condition is present to determine it. lister showed years ago that blood can remain fluid for a long time if confined m a tube formed of a suitable length of healthy vein wall; but when either ot the preceding factors is present, a retardation of the blood-stream materially assists in causing coagulation. Thus, when a vein is pressed upon by a tumour, the obstruction to the blood-flow pro- duces a clot at the spot where the nutrition of the wall is interfered 'N^dth. After fevers, such as typhoid, where the character of the blood is somewhat altered and the action of the heart weakened by changes in the muscular fibres, the defective vis a tergo causes a retardation of the flow in the veins, as a result of which the intra- venous pressure is diminished, and coagulation is probably deter- mined by some sHght injury or pressure which is not noticed by the patient. . -,, The Character of the clot varies with its rate of formation, ^t 341 342 A MANUAL OF SURGERY developed slowly, tlic so-called white tlirombus is met with, con- sisting merely of layers of fibrin, similar to that formed in an aneurism. If the process is more rapid, a certain number of red corpuscles are entangled in the meshes of the clot; sudden coagula- tion produces the ordinary red thrombus, which at first is not ad- herent to the wall, but becomes so later on, especially at its base. Bacteriological examination will often reveal the presence of organisms in the thrombus. ihe Effects of thrombosis may be considered under the following headings: local, distal, and proximal. Locally : {a) The clot may be organized into connective tissue, a fibrous cord replacing the vessel in the same way as was described for arterial thrombosis (p. 287). Three weeks is about the shortest period to allow for the safe fixation of the clot within the vessel. ib) The lumen of the vein may be re-established by the fixation of the thrombus to one side of the vein wall, or by canalization of the clot or of the fibrous cicatrix replacing it, owing to the dilatation of the vessels contained within, (c) The clot may shrink or become loosened in an ampulla or a varicose vein, forming a fibrinous mass, which is subsequently infiltrated with calcareous particles, consti- tuting a vein-stone or PhJeholith. {d) Suppuration ma}^ occur in and around the clot as a result of its bacterial contents. The result will be the formation of an abscess locally, which may be limited, or may spread widely along the course of the vein (periphlebitis), and in all probability the development of pyaemia. This may be hindered for a time by the formation of a cap of healthy red clot, which covers over and protects the infected portion. Distally, congestion of the terminal veins results, and if a main trunk is affected, (edema of the limb follows, and possibly ulceration or gangrene. If, however, the condition affects the femoral vein of a person in the recumbent position, there may be little or no nedema as long as the limb is elevated. In favourable cases collateral circu- lation is soon established by the opening up and dilation of other venous channels, which after a time may become varicose, and, if situated superficially, are often very obvious. Thus, if the external iliac vein is occluded above Poupart's ligament, a greatly increased amount of blood will be carried by the internal saphena vein, and some of it will find its way via the superficial epigastric and pudic veins across the middle line to the internal saphena of the opposite side. These branches become dilated and varicose, and the inverted A of the two superficial epigastric veins is very characteristic. If the inferior vena cava is obstructed, the mammary and epigastric veins become dilated and tortuous, the latter standing out prominently on the anterior abdominal wall (Fig. 112). Proximally, the process may gradually extend upwards, and finally involve larger and more important trunks than that in which it originated. Moreover, a portion of a thrombus may be detached as an Embolus (Fig. 113, B). If the clot is imdergoing molecular disintegration, and only minute portions are set free, they are filtered AFFECTIONS OF THE VEINS 343 of( by the lungs or kidneys, and no symptoms need be caused. If, however, a large portion is detached, urgent dyspnrea and even death occur from obstruction to the pulmonary vessels and subse- quent arrest of the circulation. If the clot becomes infected, and fragments conveying organisms are carried into the circulation, pyemia is the result, preceded, however, in the portal area by pyle- phlebitis — i.e., suppurative phlebitis of the portal trunks in the liver. Venous thrombosis is of most interest to the surgeon when it involves the main femoral or iliac vein, and is then most frequently seen on the left side of the body, possibly spreading to the vena cava, and developing at a later' date in the other limb. It is not an un- common complication of parturition, and is then due to. extension Fig 112— Varicose Condition of the Veins of the Abdominal Wall Secondary to Permanent Obstruction of the Inferior Vena Cava. The original of this photograph is a doctor in active practice, and the throm- bosis of the vena cava occurred twenty-seven years previously, after an accident. On one or two occasions severe haemorrhage has occurred from the dilated veins. of the clotting from the pelvic veins {phlegmasia albadolens). From a similar cause it may follow operations on the pelvic viscera— ^.g., hysterectomy. It is not a rare complication of suppurative appen- dicitis, and may spread from veins divided in the parietal incision, or on the right side from direct involvement of the iliac vein in the inflammatory trouble ; it may develop in the course of typhoid fever; or, finally, any condition or operation which depresses the patient's vitahty and keeps him bedridden with the legs quiet may lead to this trouble. Thus, one of the worst cases we have seen occurred 344' A MANUAL OF SURGERY after a severe operation for glands in the neck, which healed by first intention. The Clinical Signs and Treatment arc as for Phlebitis (p. 346). 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^ — e.g., blood-clot, granulations or fibrinous vegetations from the cardiac valves after acute endo- carditis, atheromatous plates, air-bubbles, fat globules, etc. {b) Infective Emboli consist of either zoogloea masses of bacteria or disinte- grated portions of blood-clot carrying micro- organisms, and are the cause of the abscesses in pyaemia, (c) Malignant Emboli are formed by portions of some malignant growth, from which the various secondary deposits originate; these are met with more frequently in the sarcomata than in the carcinomata. (d) Parasitic Emboli also occur, such as the ova and scolices of the TcBuia echinococcus and the Filaria sanguinis hominis. 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 de- pends much on this. A large embolus started in a peripheral vein lodges in one of the branches of the pulmonary artery, and may cause instant death; a smaller one is arrested in one of the smaller arteries of the lung and may do but little harm, whilst minute ones may possibly pass through the pulmonary capillaries to the left side of the heart, and subsequently become im- pacted in the systemic vessels. Effects of an Embolus. The Local effects of the lodgment of a simple embolus consist, firstly, in the deposit of fibrin upon it, rendering the obstruction complete, if this is not already the case; organization of the thrombus usually follows, although occasionally it may disintegrate and disappear. The local effects of infective, malignant, and parasitic emboli are dealt with elsewhere. The Distal effects of embolic obstruction depend entirely on the relation of the vessel blocked to the surrounding circulation. (i) Should the embolus be lodged in an artery which gives off anastomotic branches below the point of obstruction, or if the capillary anastomosis is abundant, a transient aneemia is all that occurs in most cases. If the artery is small, or goes to unimportant structures, no symptoms need arise from this; but if the vessel is large, or supplies delicate and important tissues, serious results may follow even a temporary arrest of the circulation; thus, embolus of the central artery of the retina always causes permanent blindness, although the retina still lives. (2) Should the embolus block what is called a ' terminal artery ' {i.e., one with no anastomosis between the embolus and the terminal capillaries), or a vessel with insufficient collateral circulation, the obstruction will lead to death of. at any rate, a portion of the anaemic region — e.g., gangrene in a limb, or Fig. 113. — Thrombus and Embolus. (Keen and White.) , Thrombus in situ ; B, [^ embolus detached from the same. AFFECTIONS OF THE VEINS 345 wliite or yellow softening in the brain. In an organ such as the kidney or spleen, the result of embolic obstruction to one of the terminal arteries is the development of an infarct ; i.e., a wedge-shaped area of tissue with the blocked artery at its apex becomes devitalized, and in consequence looks white and feels firmer than the surrounding parts. The tissues cannot be properly stained for microscopic purposes. Sometimes the anaemic area becomes engorged with blood to such an extent as to lead to extravasation, and a firrn, solid patch of a dark red colour results, known as a hsemorrhagic infarct. Whatever its appearance, the infarct is subsequently invaded by granulation tissue developed from the surrounding healthy parts, and this finally results in the formation of a depressed cicatrix containing, perhaps, a few h^matoidm crystals. The conditions necessary for the production of an infarct are met with in the lungs, spleen, kidney, and brain; in the liver the anastomosis is generally too free to allow of its formation, although it has been known to occur. , T> • .i-u Effects of the Lodgment of Emboli in Various Organs.— In the Bram, the middle cerebral artery is most commonly blocked, resulting m immediate hemiplegia, which may be almost entirely recovered from, but commonly leaves some impairment of function. In children the symptoms are less marked but aneurism of the aiiected vessel occasionally follows. In the Central Artery of the Retina, sudden, total, and irremediable blindness is produced ; the branches of the vessel are seen to be almost empty, the retina becomes oedematous, the macula alone retaining its normal colour, appearing as a cherry-red spot, contrasting markedly with the pallid oedematous tissues around. In the Lung, fatal results supervene from obstruction to the mam pulmonary artery; attempts have been made to save life by opening the chest, incising the pulmonary artery, and scraping or pulling out the clot, and subsequently suturing the vessel. It is obvious that such a proceeding is not often likely to be feasible. If one of the smaller branches is blocked, a certain amount of pain and dyspnoea is produced, followed by the formation of an infarct, as indicated by blood-stained sputum, dulness, bronchial breathing, and bronchophony. In the Liver, an embolus of the hepatic artery causes sudden hypochondriac pain, and perhaps a temporary glycosuria. The portal vein and its branches are not unfrequently obstructed by emboli, which, being usually of an infected nature, give rise to pya^mic symptoms (pylephlebitis). In the Spleen, a sudden pain in the left hypochondrium is experienced, the organ becomes enlarged, and a considerable rise of tempera- ture may follow. In the Kidney, sudden pain in the loin and a temporary hiematuria constitute the main symptoms. In the Intestine, localized ulcera- tion or extensive gangrene is likely to follow, according to the size of the vessel obstructed. In the Limbs, the emboli usually lodge at the bifurcations of main vessels, often saddling across the fork, and blocking both branches. Sudden pain is felt at the spot, shooting downwards, and either recovery or gangrene ensues (p. 113). Here, also, it has been attempted to remove or tunnel the clot by open operation, but the results have not been satisfactory; massage to break it up and drive it on may also be tried. Phlebitis. Phlebitis, or inflammation of the vein wall, arises from a variety of causes, and is not uncommon in surgical practice. The following forms are described: I. Simple Phlebitis, in which a more or less localized inflammation of the wall of a vein is attended by thrombosis, which extends for a variable distance up and down the vessel, {a) It may arise from injury, either subcutaneous or open, or from the continued pressure and irritation of a tumour or aneurism ; [h) it may be gouty or rheu- matic in nature, attacking the larger veins of the lower extremity, 346 A MANUAL OF SURGERY or vessels which liave been long subject fo varix. (c) It may follow primar}' thrombosis, either in the main trunk or in a varicose periph- eral vein; or [d] it may be induced by inflammation of the tissues around the vein {periphlebitis), usually of bacterial origin. In the last case the bacteria gradually spread through the vein wall, and finall\- invade the clot. 2. Infective Phlebitis is a much more serious condition, inasmuch as the thrombus resulting tlierefrom is always invaded by micro- organisms, and the disease is often of the spreading type. It arises (a) in traumatic cases where asepsis has not been maintained, the organisms invading the clot which lies in the open mouth of the vein; or {b) as a result of infective periphlebitis in wounds, or in infective inflammation of bones, such as when a suppurative mastoiditis leads to disease of the lateral sinus; and (c) by auto-infection of the clot present in simple phlebitis, as, e.g., in varicose veins. Morbid Anatomy.— The walls of the vein are congested and thick- ened, and the endothelial lining is hypertrophied; the thrombus con- tained in the vessel varies in its characters. If aseptic, it early be- comes adherent to the vein wall and organized, or is absorbed. If infected, it becomes soft and pultaceous, resembling dirty-looking pus; a locahzed abscess may form within the vein, and the suppura- tion may extend for some distance along and around the vein. In the niore favourable cases the spread of the infection is limited by the terminal portions of the clot remaining firm and unaffected. The Symptoms of inflammation of a superficial vein are sufficiently obvious. The vessel becomes swollen, hard, and painful, with localized enlargements or knobs corresponding to the valves or to the pouches in varicose veins. The skin over them is dusky and con- gested, and there ma}' be some < edema of the region from which the blood flowing in the vein is gathered; this, however, rarel}' amounts »to m.uch, since the collateral circulation is alwa^^s abundant. The temperature is usually raised, and the patient feels ill. If suppura- tion occurs, the signs of a localized abscess are noted, and perhaps pyaemic manifestations supervene. When the deeper veins are involved, it may be impossible to detect them on palpation, although a blocked common femoral can usually be felt; but acute deeply-seated pain over the vein and well-marked fever are characteristic evidences of what has occurred. Qidema of a more or less solid character develops, although if the limb is main- tained in the horizontal position throughout the attack this need not occur. Obliteration of the vessel, and any of the local, distal, or general processes detailed as characteristic of thrombosis (p. 342) may result. The onset of an infective periphlebitis is marked by fever and perhaps rigors, whilst the local signs are due to rapid extension of a suppurative inflammation along the vein and its branches, so that a large tract of tissue is very quickly invaded, and diffuse suppura- tion follows. The onset of pyamia is indicated by a repetition of rigors, and the development of secondary abscesses. AFFECTIONS OF THE VEINS 347 Treatment. — In the simple variety tlie limb is kept absolutely at rest to limit the inflammation and prevent the detachment of emboli, and also elevated to assist venous return. Locally, bella- donna fomentations may be applied, or the parts may be painted witli glycerine and extract of belladonna, swathed in a thick layer of cotton-wool, and lightly bandaged. The patient should be kept on an unstimulating though nutritious diet, and the general health attended to. When every sign of inflammation has subsided, and sufficient time has been allowed for the absorption or organization of the clot (three weeks as an absolute minimum — six weeks for choice), massage may be commenced, to assist in the removal of oidema and local thickening, and an elastic bandage is usually serviceable in restoring the circulation. Operation is sometimes undertaken in cases of phlebitis associated with varix, but not when the deeper veins are involved. If abscesses form, they must be opened antisepticalh*. Infective phlebitis is treated in a similar fashion until suppuration occurs, and then the pus must be evacuated, and it is sometimes remarkable to note how quickly the process quiets down w^hen once drainage is effected. A spreading periphlebitis will often involve an extensive area, but the process must be followed up ruthlessly by the knife and the parts laid open. The wounds thus made should be lighth* packed and allowed to granulate; at the same time the limb is raised and kept absolutely quiet. Should pyemic phe- nomena develop, it may be necessary to place a ligature between the disintegrating clot and the heart, and to scrape or wash away the infective material ; thus, in thrombosis of the lateral sinus, following suppuration in the middle ear, the internal jugular vein should be ligatured, the lateral sinus opened, and the clot removed. Of course, such treatment is only feasible in cases where a single trunk is affected. When the process involves the veins of a limb, and cannot be stopped by either of these plans of treatment, the question of amputation may have to be raised. Varicose Veins, or Varix. A vein is said to be in a condition of varix when it has become permanently lengthened, dilated, and more or less tortuous. The superficial veins of the leg, especially the internal and external saphena, are those most commonly affected ; the spermatic veins are often in a similar condition, constituting what is known as a varico- cele, w^hilst piles are primarily due to varicosity of the haemorrhoidal plexus. We shall here only deal with the first of these three mani- festations. Causes. — \''arix is due, in the first place, to some inherited weak- ness of the venous wall, or irregularity in the arrangement of the valves, though possibly this produces no effect until some exciting cause comes into action and throws a strain on the circulation. The facts that varix sometimes appears quite earl}^ in life and without 348 A MANUAL OF SURGERY adequate cause, and often involves the same vein in different members of a family, coniirm this statement. Any condition which leads to frequently repeated or more or less permanent distension of a vein may result in varix — e.g., 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; the pressure of a pregnant or displaced uterus, or of a pelvic tumour. Severe exertion^ — such as occurs in football- playing, hard training, weight-lifting, etc.- — throws a heavy strain on the vein walls, and sometimes leads to the giving way of the valves, usually from above downwards in the legs. This valvular incom- petence results in increasing pressure on the venous walls, which gradually pass into a condition of varix. Obstruction to and occlusion of the deeper veins is another well- recognised cause of varix, and we have already drawn attention to the effects produced by blocking of the common femoral vein and inferior vena cava. A less known instance is the varix of the in- ternal saphena or some of its branches below the knee which follows thrombosis of the venae 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 superficial veins become varicose, usually extending to just below the knee. Any abnormal communication between an artery and a vein also causes varix, from the inability of the latter to withstand arterial blood-pressure {vide Aneurismal Varix, p. 302). The tendency to varix increases with age till the middle period of life is reached, and is favoured by the relaxation of the system resulting from sedentary habits. When once a vein has become varicose and its walls thin and expanded, the valves become incompetent, and the weight of the superincumbent blood still further increases the mischief. Morbid Anatomy .^ — To the naked eye a varicose vein in an early stage appears thickened, distended, and tortuous; the walls are so thick that the vein when cut across does not collapse, but presents a gaping mouth, like an artery; the valves atrophy, and are function- ally useless. After a time the walls become further stretched and irregularly expanded, forming here and there cyst-like dilatations, which are very obvious under the attenuated skin, to which they are often adherent. Microscopically, the change consists in a trans- formation of the normal structures of the vein wall into fibro-cica- tricial tissue. The tunica media is mainly affected, most of the muscular fibres disappearing, whilst the tunica intima is but little changed, and the adventitia thickened. In the pouches the mifldle coat is atrophied, and, indeed, is often completely absent. Clinical History. — The enla^'ged veins are seen ramifying under the skin with a more or less tortuous and serpentine course (Fig. 114). and they often feel thickened. One or more veins may be affected, and the tortuosity may be at parts so marked as to constitute large clusters of dilated vessels, which look bluish under the thin and stretched integument. In other cases a single vein is enlarged, and AFFECTIONS OF THE VEINS 349 Stands out prominently under the skin ; or perhaps one or more cyst- Hke pouches develop in connection with these (Fig. 115). The upper end of the internal saphena is sometimes dilated so as to form a large pouch, in which a marked thrill is felt when the patient coughs, thereby simulating a femoral hernia. In other cases, although this portion of the vein is not dilated, yet its valves are incompetent, and the thrill produced by coughing can be felt even below the knee if that portion of the vein is dilated. The Effects of varicose veins are very varied. The limb often feels heavy and tired; forcible exertion may cause a sensation of tension. H^^l ■ ^^^^^$^1 iS5^' Fig. 114. — Varix of Internal Saphena Veins. The left foot is a good illustration of pes planus (fiat-foot). Fig. 115. — -Varix of Left In- ternal Saphena, showing AN Ampulla above. and after standing or exercise there is usually some cedema of the ankle. The capillaries in the papillae often become dilated, appear- ing as minute reddish puncta, which subsequently run together and form brownish patches of pigmentation. Eczema is induced by the irritation of rough and coarse trousers or dirt, often terminating in actual ulceration. Any lesion, such as a scratch or abrasion, instead of healing readily under a scab, tends to spread and form an ulcer. Injury to the vein may lead to thrombosis and subsequent cure, but coagulation sometimes occurs spontaneously in cysts or acute kinks, especially in gouty subjects. The clot may subsequently shrink and 35° A MANUAL OF SURGERY form a small librinous or calcareous mass, known as a ' phlcbolitli,' but sometimes the thrombosis spreads into deeper or larger veins, and then fragments of clot may be detached as emboli. Occasionally the dilated pouch of a varicose vein gives way, and an alarming rush of blood results; the same may follow the extension of ulceration through the vein wall. The blood under these circumstances is derived, not only from the lower, but also from the upper end; and if 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 standing, in moderate massage, together with the apphcation of either an elastic stocking or an indiarubber bandage. The bowels should be regulated, and the general health attended to. Eczema may be treated by the application of soothing and drying 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). Vari- cose ulcers are suitably treated (p. 103), 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 investigate the history and ascer- tain if the condition is due to thrombosis of the deep trunks, as inter- ference might then do more harm than good. Operation is specially indicated when thin, dilated pouches exist; when elastic stockings cannot be comfortably worn, as in the tropics; when ulcers are present which refuse to heal ; when the condition is very extensive and painful, and especially if large bunches of dilated veins are seen; or when there is a distinct impulse or thrill on coughing, due to valvular incompetence. Various methods of operating have been adopted: [a] Small portions may be rem.oved at several different situations. 1 he skin is pinched up over the vein, and incised by transfixion; the vessel is usually bared by this means, but may need a little clearing. An aneurism needle is passed beneath it, and the vein isolated suffici- ently 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 1 he wound is sutured without drainage and dressed, [b) Long incisions are made, perhaps 6 inches or more, through which larger clusters of veins may be dealt with. The wound should not lie over the most dilated parts of the vessel, as there the skin is often thin and un- healtliy, 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 , AFFECTIONS OF THE VEINS 351 constitutes the groat advantage of the operation, viz., that so many anastonn)sing channels are obhterated. In very bad cases most extensive operations are sometimes required, the incisions involving nearly the whole length of the limb, [c) A simpler procedure has been advocated by Trendelenburg, viz., the removal of a portion of the internal saphena close to the saphenous opening, so as to break the weight of the superjacent column of blood. In many cases, but especially where there is an impulse on coughing, and the vein fills from above, this is essential, though it is also desirable that the enlarged veins lower down should be excised. After an operation for varix the patient should remain in the re- cumbent posture for three weeks, to allow clots to become firm and to permit the circulation to accommodate itself to the new arrange- ments. On first rising from bed, it is well to support the limb for a time by a ' Crepe Velpeau ' bandage. Inflamed Varicose Veins are not unfrequent, and may result in a natural cure of the condition. The symptoms are those of a super- ficial phlebitis, and the treatment indicated for that condition should be followed. In cases where there is much pain it may be justifiable to excise the thrombosed vessels, taking the precaution first to 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 — ij.,<^., in the neighbourhood of the saphenous opening; or when portions of clot are being detached as emboli, giving rise to pulmonary symptoms. Haemorrhage from a Ruptured Vein needs prompt and decisive treatment. The bleeding spot should be commanded by digital compression, and the patient laid on the back with the limb elevated, until either a pad of antiseptic dressing can be applied to the wound, or a handkerchief or bandage secured over it. Venesection. Venesection or phlebotomy is a means of treatment which has largely fallen into disuse of late years, but is still occasionally em- ployed with benefit. When a patient is becoming cyanosed, and asphyxia is threatening either [a) as a result of pulmonary engorge- ment from mitral incompetency, owing to the heart being unable to drive the blood into the systemic circulation ; or {b) as a consequence of some accident involving the chest wall and lungs, whereby the blood-aerating surface is so diminished that it cannot deal with the blood reaching it through the right side of the heart, which hence becomes enormously distended, and threatens to stop in a condition of diastole: or (c) where inflammation of the brain is pending, and the pulse is hard and full; or [d) in a few inflammatory states in strong, full-blooded indi^dduals where the pulse-tension is high — in any of these conditions venesection may be used with advantage. The median basihc vein at the bend of the elbow is that usually 352 A MANUAL OF SURGERY opened, since it is larger than the median cephahc, though placed more directly over the brachial artery, from which it is only separated by the bicipital fascia. Requisites. — A strip of bandage about 4 feet long; a scalpel or lancet; a graduated bleeding-bowl; and finally something, such as a stick or bandage, to be grasped by the hand, so as to cause contrac- tion of the muscles, thus pressing the blood from the deep into the superficial veins along the communicating branch which enters the median jiist below its bifurcation. Operation. — The patient should be seated in a chair or in bed; standing would produce syncope too rapidly, whilst the recumbent posture would allow too great an abstraction of blood before Nature's danger-signal {i.e., syncope) is evident. The skin in front of the elbow having been purified, as also the hands of the surgeon and the Fig. 116. — Venesection. lancet, the bandage is tied round the arm with sufficient tightness to arrest the venous circulation whilst the arterial supply is unimpeded. Grasping the stick firmly causes the veins to become prominent. The median basihc is now steadied by the left thumb, and an in- cision made into it (Fig. 116, A). Blood will flow from it in a full stream, and is collected in the bowl. When sufficient has been withdrawn, the stick is removed from the patient's hand, a sterilized swab is pressed over the bleeding spot, the bandage above is relaxed, and a pad of antiseptic dressing placed over the wound and firaily bandaged in position; the arm is kept at rest for a few days to allow the small incision to heal. Occasionally neuralgic pain is caused by the impUcation of some of the fibres of the internal cutaneous nerve in the cicatrix ; whilst, if the lancet is plunged too deeply, an arterio- venous wound may be produced. Angiomata. Tumours of bloodvessels present varying appearances according to the situation and the character of the vessels of which they are composed. They are frequently of congenital origin or developed soon after birth. They involve most commonly the skin or mucous membrane together with the underlying tissues, and are then known as nsevi ; but they are occasionally acquired and develop in deeper ANGIOMATA 353 organs, such as the liver. According to their structure they are divided into three main groups, the simple or capillary naevus, the cavernous naevus, and the plcxiform angioma. I. The simple or Capillary Naevus (mother's mark) is exceedingly common, and consists of a mass of dilated capillaries held together by a small amount of connective tissue. It is usually located in the skin, but may also involve the subcutaneous tissues; the tubular form of the constituent vessels always remains. It occurs in the form of a slightly raised flattened mass, bright red or purple in colour, according to the relative amount of arterial or venous blood present, and with occasionally a somewhat irregular or nodulated surface, in which larger vessels may be seen ramifying. Several such growths may be present in the same individual, and they are usually quite small, rarely exceeding an inch or two in diameter; they are present at birth or appear soon after. The head and face are the parts most commonly affected. Angiomata of the mucous membranes are often a source of considerable danger and trouble from haemorrhage, especially in the bladder and nose. A more superficial variety known as the port- wine stain often extends widely over the face and neck, and is somewhat dusky in colour; this condition consists merely of a network of fine vessels, and does not project above the surface. Occasionally a nevoid development may be observed having a hnear distribution down the long axis of a hmb, or running trans- versely half round the trunk, and Hmited almost exactly by the middle fine; this condition is known as ncevus unius lateris. It may consist purely of a vascular manifestation, or the skin may be hypertrophied and covered with small soft papillary ex- crescences. The term Spider Nsevus (A^. araneus) is appUed to a small angioma, which develops usually in young people, and generally on the face, from which radiate a considerable series of fine red fines. ^^Tlen irritated they bleed easily, but are readily cured by the appfication of carbonic acid snow or a pointed cautery. It is not uncommon in middle-aged people to find a number of small red spots on the trunk, which sometimes persist for a while and then disappear. These telangiectases (or De Morgan sfots) consist of dilated capillaries, and are possibly degenerative in origin. At one time they were looked on as associated with cancer, and they cer- tainly often occur in women with mammary cancer; but further experience has proved that no such sinister significance is to be attached to them. Left to themselves, simple naevi may remain unchanged or dis- appear ; more often they increase in size more or less rapidly, and may invade surrounding tissues, requiring active treatment in order to check their progress. Sometimes they persist unaltered till middle- hfe, and then may increase rapidly, giving rise to a considerable vascular tumour, purple in colour, and occasionally becoming prominent and pendulous. Such a tumour is soft and easily com- 23 354 A MANUAL OF SURGERY pressible, being in reality a cavernous angioma; it may ulcerate, and profuse haemorrhage may result. Treatment is usually simple in the extreme. Small superficial Ucevi can be completely cured by some form of cauterization, the best results being obtained by the use of carbonic acid snow. Appli- ances for the suppl\- and employment of this agent are (jbtainable at instrument makers. In exposed situations electrolysis (p. 53) may be the best plan to adopt, but excision will often give a good result. 2. A Cavernous Naevus (Fig. 117) most commonly involves the subcutaneous or submucous tissues, but is sometimes associated with a superficial naevus. It consists of dilated spaces where the tubular form of the constituent vessels is lost, the arteries often w^l^ •hx. mi' Fig. 117. — Section of Cavernous Angioma. (Museum of Royal College OF Surgeons.) In one or two of the cavernous spaces thrombi more or les.s'adhcrent can be seen. opening directly into thin-walled cavities lined with endotheUum without the intervention of capillaries. The tumour thus produced is a more or less prominent swelling, soft to the touch, and easily compressible, but re-filling when the pressure is removed. There is usually no pulsation or bruit, although both may be present ; and the mass may be definitely circumscribed, or more or less diffuse. If subcutaneous, the skin over it is somewhat bluish in colour; when the skin is involved, the mass presents a dusky red appearance. Occasionally these growths undergo spontaneous cure from inflam- mation and thrombosis, and cj^sts are sometimes found in the centre of a na^void mass, indicating that a partial attempt at this process has occurred. A similar condition arises in the viscera, especially the liver, and it is not difficult in certain suitable cases to demon- strate that it has been formed by a dilation of the capillaries between the lobules, the liver substance meanwhile disappearing by a process of simple atrophy. ANGIOMATA 355 The Treatment is by no means as simple as in the former variety. The following plans may be mentioned: (i) Excision of the growth should always be adopted where practicable. The bleeding is never great, even if the naivoid tissue is encroached upon by the knife, and only a few vessels will need to be tied. Circular growths should be removed by crescentric incisions, and a little undercutting will usually enable the edges to be approximated easily. In exposed situations Halstead's sub- cuticular suture should be utilized. (2) Where excision is impossible, electrolysis should be emplo3^ed. It consists in the passage of an electric current through the mass, producing chemical and physical changes in the contained blood. For details, see p. 53. 3. Plexiform Angioma. — This term is now usually apphed to an angioma in which the arterial element predominates, although veins and capillaries are also present. The growth is usually seen in young people, and affects most frequently the scalp, especially the temporal or occipital regions. A tumour is produced which is soft and compressible, pulsating forcibly, and with a marked bruit (cirsoid aneurism, p. 724). It usually consists of large obvious dilated pouches, the skin over which is thinned, and may give rise to serious hfemorrhage, or grave infective troubles. Sometimes the growth consists of smaller arteries, and partakes more of the character of an arterial neevus, but the tubular condition of the vessels is often lost. This variety (aneurism by anastomosis) is sometimes found in the interior of bones (p. 596), in some forms of pulsating exophthalmos, and in the scalp. A Nsevo-Lipoma is the name given to a somewhat rare tumour, in w^hich a fatty element is blended with Ucevoid tissue. It is usually of congenital origin, or at any rate appears early in life. It gives rise to a sw^elling, lobulated and doughy, like a fatty tumour, although it is usually a little denser in texture than the ordinary lipoma. It may be possible to reduce its size by compression, but no thrill or pulsation can be detected; a few dilated veins or capil- laries are often seen on the surface. The only treatment is excision. CHAPTER XV. DISEASES OF |THE LYMPHATICS. Rupture or Division of the Thoracic Duct may occur as a result of a penetrating or bullet wound of the neck, or during operations in the supra-clavicular fossa. The main trunk has also been torn in a fracture of the spine, and the lymph has escaped into the pleural cavity. Wounds near the outflow into the junction of the jugular and subclavian veins usually involve one or more of the several branches into which the main trunk divides before opening into the venous system; lymph or chyle escapes, but if the divided vessel is tied, no further trouble arises as a rule. Failing ligature, the wound should be packed with gauze, and the flow generally ceases after a while. Should this not occur, an attempt must be made to anasto- mose the divided end of the duct with one of the deep veins, for a persistent and excessive loss of lymph means the exhaustion of the patient. In a few cases the opening of the thoracic duct has been obstructed or compressed, leading to such backward tension that the recepta- culum chyli has ruptured and the peritoneal and pleural cavities have been filled with a serous or chylous exudation. Virchow described one case where the opening was congenitally absent (in a calf) , and the lymphatics throughout the body were enormously distended, especially those of the small intestine. Acute Lymphangitis, or Inflammation of the Lymphatic Vessels, ensues almost invariably from the absorption and passage along the lymphatics leading from an infected wound of bacteria (usually streptococci) and toxins, which give rise to inflammation of the lymphatic vessels involved and of the tissues around them, and this may even run on to suppuration. Ihe walls of the lymphatics become hyperaemic and infiltrated, and the tissues around are inflamed. Ihe lymph is said to coagulate in the vessels, forming a pinkish clot. The process is usually limited by the nearest lym- phatic glands, which arrest and filter off the toxic products, with or without the occurrence of suppuration; but, in spite of this, a general infection of the system occasionally results. Clinical Signs. — The causative wound may be obviously infected, or is possibly very slight and covered by a dry scab. The charac- 356 DISEASES OF THE LYMPHATICS 357 teiistic appearance is that of fine red lines or streaks following the course of the lymphatics, perhaps up to the nearest glands; the parts thus inflamed are tender and oedematous. If the mischief is limited to the main trunks [tubular lymphangitis), they may be felt hard and cord-like, and the red lines remain isolated from each other; but if all the smaller lymphatic channels of a part are affected [yctifoym lymphangitis), the redness merges into a generalized blush, and the condition is identical with cellulitis. Localized foci of suppuration in the course of the lymphatics often follow, the redness increasing and the parts becoming dusky and brawny, until finally the centres soften and fluctuate. These phenomena are associated with fever and malaise, the temperature rising to 102° or 103°, possibly attended by rigors, vomiting, and diarrhoea. Under suitable treatment resolution rapidly follows, but suppura- tion may occur either in the glands or in some loose mass of cellular tissue traversed by the lymphatic trunks, or as a chain of abscesses in the course of the vessels. Occasionally the lymphatic vessels become permanently occluded, and a form of solid or lymphatic oedema results. Recurrent attacks of this type are not uncommon in connection with chronic eczema or ulcers of the leg, and may lead to elephantiasis. In the worst cases the patient dies from general septicaemia, or from exhaustion following diffuse suppuration. Treatment is at first directed to the causative focus, which must be opened up and purified, so as to cut off the supply of bacteria and toxins to the lymphatics. The limb itself is kept at rest in a slightly elevated position, and fomented, or soaked in a hot bath; Bier's treatment of induced hyperaemia is often useful. Abscesses are opened as soon as they develop. Any subsequent oedema is remedied by massage and firm bandaging, provided no venous com- plications are present. Constitutional treatment consists in the administration of a purge, followed by a light and nutritious diet, quinine and tonics, care being taken that constipation is not thereby produced. Chronic Lymphangitis either results as a sequela of an acute attack, or is met with as a separate condition. It is most frequently seen in connection with venereal disease, the dorsal lymphatics of the penis becoming enlarged, hard, and cord-like, especially in cases of primary syphilis. This is usually accompanied by a solid oedema- tous condition of the prepuce and enlargement of the inguinal glands. Under appropriate antisyphilitic treatment, the swelling quickly subsides. A tuberculous type of chronic lymphangitis also exists in which a primary focus, say, on a finger, is associated with secondary deposits along the lymphatics up the arm. Each nodule is at first of firm consistency, but gradually softens and breaks down. Naturally, such a case is liable to be followed by general dissemination. The treatment consists in the excision, if possible, of each focus. The cheeks and nose are occasionally the seat of a chronic relapsing lymphangitis, due to the absorption of septic material 358 A MANUAL OF SURGERY from sores within the nostril. It is characterized by patches of hypentmia and some amount oi tissue infiltration, and for its cure the causative lesions must be treated. The thick li})s of a tuberculous child are of a similar nature, and due to the constant irritation of cracks along the lip margin. Lymphatics, like bloodvessels, are liable to distension and dilata- tion, which may l)e either congenital or acquired, and are known as Lymphangioma (»r Lymphangiectasis. It is impossible to draw an absolute line of distinction between the two conditions, but the latter term is applied mainl}' to cases where normal lymphatics are dilated and their continuity with the normal lymphatic circulation persists, whilst a lymphangioma is the result of a new formation. Not unfrequently the two conditions develop side by side. Lymphangiomata* are growths composed of newly-formed lym- phatics, together with a variable amount of connective tissue, which is sometimes of a fatty nature. They may be congenital or acquired, but even in the latter case there is probably an underlying con- genital element, which was only awaiting some irritation or localized injury to determine its development. Two varieties may be de- scribed, the capillary and cavernous. (a) The Capillary Lymphangioma is usually congenital in origin, but often increases considerably as the child grows, and may attain large proportions. When developing in the skin, it may be termed a lymphatic naevus, and in origin and development it well merits the title. The patch is usually of a dull yellowish-brown colour, but this varies with the amount of blood present ; it may be smooth-topped like a wheal, or wart-like in appearance, but on examination with a lens each projecting point contains a vesicle. This type of growth is sometimes ver}^ extensive, and may be associated with tumours of the underlying connective tissues. Thus, a large fatty mass was removed from the anterior thoracic wall of a child, the greater portion of the projecting surface of which was covered with a capillary lymphangioma. The only treatment for this condition is excision or cauterization. In the subcutaneous tissues the capillary variety is often associated with large cj-sts of the cavernous type. It constitutes a soft swelling which when cut into has a spongy texture and exudes a large amount of lymph, with some blood. This form is rarely well defined, and may burrow widely, invading and infiltrating the tissues, and, in- deed, in some cases may almost be looked on as of a malignant nature. Free excision is the only cure. [b) Cavernous Lymphangioma. — The lymphatics here lose their tubular condition and give rise to cyst-like swellings which vary much in size. In the skin they are rarely larger than a split pea, and may co-exist with the capillary variety. Any part of the body may be affected, * See Carless, ' Some Cases of Lymphangioma,' Brit. Journ. oj Children's Diseases, February, 1904, p. 56. DISEASES OF THE LYMPHATICS 359 and the lesion manifests itself as a scries of small vesicles, which persist and are unaccompanied by any inflammatory redness, thus serving to distinguish it from herpes. They contain lymph, and, if opened, a considerable flow of this fluid (lymphorrhoea) may result, lasting for some time. They have been observed most frequently on the inner side of the thigh and on the prepuce. Treatment con- sists in excision, or in laying them open and cauterizing the base. In the deeper structures large multilocular cystic sweUings may be produced; these are most frequently seen in the neck, and the condition is often termed a Cystic Hygroma (Fig. 1 18) . The descrip- tion given in Chapter XXXI L would apply equally well to a tumour of this nature in any other part of the body. Removal by dissec- FiG. 1 1 8. — Cystic Hydroma of Neck. (From a Photograph.) The patient was a child of a few weeks. The cyst was opened and the mass partially removed. Recurrence ensued, and a further operation of a very extensive character was required. As the lymphangiomatous tissue had invaded the sterno-mastoid and the parotid gland, it was impracticable to remove it totally. The child finally succumbed to infective lymphangitis and exhaustion. tion is often very difficult, especially in old-standing neglected cases; the limitations of the mass are sometimes very indefinite, and it may be necessary to leave the wound open and pack it, so as to ensure healing by granulation. Lymphangiectases are more frequently acquired than congenital, but the latter condition occurs, and is then probably due to some abnormal development of the lymphatics or to ante-natal inflam- matory mischief. Macroglossia and macrocheilia are congenital enlargements of the tongue and lip, due to lymphatic obstruction and to an associated overgrowth of the connective tissues of the parts. The condition known as Chylous Hydrocele, in which there is an effusion of milky fluid (presumably chyle) into the tunica vaginalis, is probably due to some such obstructive cause. In a case under our care the lymphatics of the spermatic cord were dilated by a similar fluid in a beaded manner. Elephantiasis is a hypertrophic condition of the subcutaneous tissues and skin resulting from chronic lymphatic obstruction. Two 36o A MANUAL OF SURGERY chief varieties are described: (i.) E. arahum, due to a development in the lymphatics of living parasites, viz., the Filaria sanguinis hominis ; (ii.) the non-filarial type, which may arise from many causes, such as the deposit of tuberculous or cancerous material in lymphatic glands; the obliteration of l^'mphatic channels in opera- tions for removing such glands; recurrent attacks of lymphangitis in cases of chronic eczema or ulcer, leading to a graduallv increasing obliteration of lymphatics. The condition generally affects the legs, but the scrotum is not uncommonly involved, and occasionally Fig. 1 19. — Non-filarial Elephantiasis of Both Legs. From a woman who had never been out of England. The cause was not apparent, but had been in action many years. the mammffi, arms, or face. The accompanying illustrations (Figs. 119 and 120) indicate that the non-filarial type may be just as severe as the other (Fig. 121), although this is unusual. Three chief phenomena manifest themselves as the outcome of such obstruction — viz., [a) Solid or lymphatic oedema, a condition in which the subcutaneous tissues become firm, infiltrated, and brawny, but the fluid cannot be expressed from them, as in an ordinary oedema, and hence the part does not pit on pressure, {h) Hyperplasia follows, affecting not only the subcutaneous tissues, which are greatly thickened, but also the skin, which becomes coarse and wart-like in appearance, (c) The warty stage is usually preceded by a develop- ment of vesicles (dilated lymphatics) in the papilUe, and from these DISEASES OF THE LYMPH AT ICS 361 when ruptmcd a considerable ilow of lymph {lymphoyrJum) may follow. If infection supervenes, chronic ulceration and recurrent lymphangitis may ensue. Elephantiasis Arabum [syn. : Barbadoes Leg) requires but little notice here, as it is seldom seen in this country, being mainly limited to the tropics, especially the West Indies and South America. The legs, scrotum, and vulva are the parts most frequently attacked, but the face or breast may also be affected. It manifests itself as a hyperplasia of variable size of the subcutaneous tissues, whilst the Fig. 120. — NoN-FiLABiAL Elephantiasis of Scrotum, Penis, and Thighs. (From a Photograph.) The patient was a young man, and the cause of the trouble suppuration of the inguinal glands after scarlatina; the cicatrices of the incisions requn-ed m order to deal with the glands are plainly to be seen. The scrotum was much enlarged and very solid; the skin over it was covered with papil- lomatous growths, due to lymphatic dilatation. The skin of the penis was much thickened, and the subcutaneous tissues infiltrated. Over the thighs were scattered numbers of vesicles, which, when pricked, exuded lymph, and some of these were becoming transformed into solid fibrous growths. The legs and feet were also in a condition of solid oedema. skin becomes thickened and wart-like, and from it a copious dis- charge of lymph may escape. The parts sometimes attain enormous dimensions, the scrotum even reaching to the ground when the patient is sitting (Fig. 121). The disease persists for many years, and is not directly fatal. The condition is due to the obstruction caused by the develop- ment of the Filaria sanguinis hominis in the lymphatics. These are spread by the agency of mosquitoes, in whose bodies the inter- mediate stage is passed. The dead mosquito, with its parasitic 362 A MANUAL OF SURGERY contents, falls upon the water, and in this medium the ova find an entrance into the human stomach, where the young worm is set free, bores through the gastric mucous membrane, and linally becomes lodged in the lymphatics, especially those of the extremities. Not more than two or three pairs of mature filarise are generally present in the same individual. The body of the female worm (which attains a length of 3 inches) is mainly occupied by the reproductive organs, and a countless number of embryonic lilarise are produced. Some remain coiled up in the lymphatic spaces, and give rise to the phenomena of lymphatic obstruction. Others become uncoiled, and are then about ^^^ inch in length; they find Fig. 121. — Filarial Elephantiasis of Scrotum and Penis IN A Japanese. their way into the blood-stream, sometimes at night [F. nocturna), sometimes in the day [F. diurna), and can be readily seen under the microscope (p. 65). They are taken into the bod}' of a mos- quito with the blood which it abstracts, and thus a fresh generation is developed. The Treatment is extremely unsatisfactory. In the filarial variety, if one can localize the situation of the parent filarije, as has been possible in a few cases, they should be excised; but even then the lymphatic obstruction may persist. This may be dealt with in either variety by elevation of the limb and elastic pressure ; but when the condition is due to lymphatic obstruction in the groin, it may be DISEASES OF THE LYMPHATICS 363 possible to find the dilated lymph trunks and implant them into a tributary of the internal saphena vein {lytnphangcioplasty), so as to relieve the limb of its engorgement with lymph. It has also been suggested to construct artificial lymphatics by introducing a care- fullv steriHzed silk thread through the subcutaneous tissues of the thickened area, leaving it buried therein, and carrying it up into normal tissues (Sampson Handley). This has acted fairly well in draining awa}' the fluid from the brawny- arms, sometimes seen in the last stages of a cancerous breast [q.v.), but it is of httle avail in the lower extremity owing to the counter-influence of gravity. Finally, when a Hmb is involved, amputation may be de- sirable. \Mien the scrotum is affected, the morbid tissue can be freely dissected away, sufficient sl-dn being left to cover in the wound if possible; the penis and testes must first be isolated, and then the scrotum amputated, a tourniquet being used to restrain the bleeding. Affections of Lymphatic Glands. Acute Lymphadenitis, or Inflammation of Lymphatic Glands. — The Cause of this condition is almost always the absorption of some irritative material (toxic or infective) from the periphery. There is always an increased flow of hTnph from an inflamed part, resulting in an enlargement of the glands to which the lymph is carried, which quickly subsides when the inflammatory process is at an end. In infective conditions the enlargement is more obvious and painful, and suppuration frequently results; in fact, the l^TTiphatic glands must be looked on as the filters by means of w^hich many sources of disease are ehminated. It is curious that certain peripheral in- fective conditions are not at all hable to produce h-mphadenitis — e.g., spreading gangrene and many forms of cellulitis; possibly the acuteness of the process causes hnnphatic thrombosis, and thus hinders absorption. A certain amount of peri-adenitis is always present, even in the early stages; it may be of Httle importance, or be so severe and extensive as to constitute a diffuse suppurative cellulitis. Clinical History. — The glandular trouble may be associated with a typical Ivmphangitis, or be independent of it, and the causative lesion may have almost disappeared before the glands become affected. The glands become enlarged and tender, and if super- ficial, the skin over them is red and oedematous, and the surrounding tissues are infiltrated and brawny. When pus forms, softening occurs in the centre of the mass, and fluctuation may become e^-ident ; where there is much loose areolar tissue around the glands, as in the axilla, the pus may burrow widely. Fever, malaise, and all the general phenomena associated with an acute inflammation, are usuallv well marked. Treatment. — The offending wound or causative lesion must be dealt with by such measures as maj^ be needed to hasten its restora- tion to a healthy state. Fomentations or poultices are appfied over 364 A MANUAL OF SURGERY the gland, and the patient, after the administration of a purge, may be given quinine and iron, if necessary. As soon as pus has formed, it shonld be let out by an incision, and the wound dressed anti- septically. I lu' Axillary Glands are usually affected as a result of poisoned wounds of the hand or fingers, although other glands exist lower down in the arm, viz., the supracondyloid, just above the internal condyle. Boils in the axilla and excoriations or infected wounds of the breast may also cause an axillary abscess. In this region a suppurative peri-adenitis is often superadded, extending widely under and between the pectoral muscles, reaching even up to the clavicle {vide axillary cellulitis, p. 87). Care must be taken in opening such an abscess to avoid the main vessels by cutting from above downwards, mid- way between the anterior and posterior axillary folds, whilst Hilton's method should be adopted in all cases where the pus is situated deeply. In the Groin there are three groups of glands: (i) The oblique set, running parallel to Poupart's ligament, and becoming inflamed in affections of the penis, scrotum, perineum, anus, buttock, and lower part of the abdomen; (2) a superficial vertical set, running with the long saphena vein, and receiving lymph from all the superficial parts of the limb, except perhaps those from which the blood is returned by the external saphena vein, the popliteal glands receiving the lymph from this region; and (3) the deep vertical set, receiving he deep lymphatics of the linib. Abscess in the groin is opened by a vertical incision, so as to allow the wound to gape when the patient sits, and prevent pocketing of matter. Suppuration in the glands of the Neck is exceedingly common, arising most often from affections of the scalp (eczema or pediculosis), ear (otorrhoca or eczema), throat, or lips. As to the exact distribution of the lymphatics, we must refer students to anatomical textbooks When opening a cervical abscess, care must be taken to avoid important structures, such as the external jugular vein, and to make incisions across the fibres of the platysma in order to gain space for efficient drainage. Chronic Lymphadenitis. — Three chief varieties of chronic inflam- mation of h'mphatic glands are met with — viz., the simple, S3'philitic, and tuberculous. 1. Chronic Simple Lymphadenitis is a condition resulting from some peripheral irritation, wliich is insufficient to cause an acute attack. Occasionally it is due to blows or to strains, as in over-walking, being then the outcome of obstruction to the lymphatic flow from compression or rupture of the efferent vessels. The glands become enlarged, tender, and painful, but as a rule they are not adherent to one another or to adjacent structures, and show but little tendency to suppurate. This condition often precedes, and, indeed, may be looked on as a predisposing cause of, tuberculous lymphadenitis. The Treatment consists in keeping the part at rest, and removing, if possible, all sources of local irritation. The general health should also be attended to, especially in children predisposed to the develop- ment of tuberculous disease. 2. Chronic Syphilitic Lymphadenitis. — The lymphatic glands are involved in several ways in the course of syphilitic disease: {a) Th i primary lesion is associated with the development of an indolent bubo in the nearest lymphatic glands (p. 157). {b) In the second stage, when general infection has occurred, the glands in many parts of the body are infected in the same indolent fashion (p. 160). (c) In DISEASES OF THE LYMPHATICS 365 the tertiar^^ period the lymphatic glands maj^ undergo a true gumma- tous change, or become enlarged and tender owing to the absorption of infective material from a broken-down gumma. 3. Chronic Tuberculous Lymphadenitis occurs most commonly in children or young adults, and especially in those whose surroundings are unhealthy, and whose general condition is deteriorated by in- sufficient or bad food and want of fresh air. Some local focus of irritation is usually present in the form of pediculosis capitis, decayed teeth, chronic otorrhoea, adenoids, or eczema of the face. As a result of this, neighbouring glands become chronically inflamed, and, as the late Sir T. Burdon Sanderson expressed it, ' the soil is thereby prepared for the seed.' The bacilli are conveyed to the gland by the blood or lymph, gaining access through some breach of surface, or even through a healthy mucous membrane ; or perhaps they may be derived from some deep focus of quiescent tubercle, say, in the bronchial or mediastinal glands. Any lymphoid tissue in the body may become the seat of tuberculous disease; but the glands of the neck, which derive their lymph from the mouth, throat, nose, ears, and scalp, are more commonly involved than any others. Ihe axillary and inguinal glands are not unfrequently affected, whilst tuberculous disease of those in the mesentery gives rise to the affec- tion known as ' tabes mesenterica.' For the general facts as to the pathology of tuberculosis, see p. 176. The earliest manifestation of the disease consists in a fleshy en- largement of the glands, which cannot at first be distinguished from a simple chronic hyperplasia. The gland may be enlarged to many times its natural size, and on section looks pinkish in colour, and is of firm consistence. Microscopically, all that is noticed is a great in- crease in the lymphoid corpuscles, together with some overgrowth and thickening of the fibrous capsule and trabecule. When tuber- culous infection has occurred, the characteristic nodules can be seen under the microscope, but there is at first no change in the naked eye appearances. Caseation follows sooner or later, appearing as foci scattered through the gland, which gradually coalesce to con- stitute larger masses, which may in time involve the whole. Should the case recover without suppuration, the gland gradually shrinks, and becomes small, hard, and often closely adherent to surrounding tissues, whilst the caseous material is absorbed, or undergoes calci- fication. This latter change is often seen in the mediastinal and mesenteric glands, but is not very common in the neck. More frequently suppuration ensues, sometimes from a simple liquefaction of the caseating material, sometimes from a superadded infection with p3'ogenic organisms. Foci of pus develop at various spots in the parenchjoiia, and w^hen once formed, these gradually amalgamate and cause the destruction of the rest of the gland. Several of these abscesses ma}' unite one with another, and thus a large multiloculated cavity containing pus mixed with caseous debris is formed. A certain amount of peri-adenitis is almost always present, though not to any great extent in the early stages; when. 366 A MANUAL OF SURGERY however, suppuration has occurred, the enlarged glands become adherent to one another and to surrounding structures. In the more chronic cases the fibro-cicatricial tissue thus formed may be so extensive as to fix the mass firmly to the deeper parts, such as the main vessels and nerves, rendering removal dangerous and almost impracticable. Important vessels are occasionally eroded b}^ an extension of the suppurative process, and this may lead to fatal haemorrhage. Sooner or later the abscess, if left to itself, bursts at one or several spots, giving exit to the pus and caseous debris, and leaving ulcerated openings, which are surrounded by skin that is undermined, thin, and purplish, and through which granulations protrude. A variable amount of pus escapes from these until all the caseous material has disappeared, so that the condition may persist for many years before healing occurs, and even then the cicatrix is often puckered and more or less keloidal, and may retain its vascu- larity for a much longer period than would a healthy scar. Lym- phatic cedema in the region drained by the affected glands is some- times observed as a late consequence of this affection. Treatment in the early stages consists mainly in improving the general health by means of suitable diet and tonics, such as cod-liver oil and syrup of the iodide of iron, together with residence in a healthy, bracing place, especially at the seaside or on high moorland. All sources of local irritation, septic roots of teeth, enlarged tonsils, adenoids, etc., must be removed so as, if possible, to prevent infec- tion 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 movement is advisable. Small doses of tuberculin are often useful (p. 184). Operative Treatment. — Too much time should not be wasted in palliative measures, inasmuch as the longer the glands are left, the firmer will be the adhesions which they are likely to contract to surrounding tissues, and the more difficult the dissection for their removal. Operation is indicated when the glands persist in spite of suitable care, and still more if they enlarge or show evidences of suppuration. In the neck every effort must be made to avoid operation, but it is well to remind patients or their friends that the scar of an aseptic operation is less obvious than that which follows the opening of an abscess and the scraping out of a gland. When abscesses form, it must be remembered that there is frequently a deep sub-fascial origin, communicating with the superficial subcutaneous collection of pus by a narrow aperture; unless this deep focus is dealt with efficiently, the wound will not heal. It may sometimes be practicable to scrape away all the deep tuberculous material at the time that the abscess is opened; but, failing that, the wound is allowed to heal as far as possible, and then at a later date the whole mass of glands involved in the process is removed. When extirpation of glands is required, the incision varies with the situation of the mass, but every precaution is taken to DISEASES OF THE LYMPHATICS 367 minimize the deformity and searring. In the upper part of tlie neck, when the glands he in front of the sterno-mastoid, an almost trans- verse incision may be employed, or one following the creases of the skin and very similar to that for ligature of the lingual artery (Fig. 122, B). In the lower half of the neck an incision along the anterior or posterior border of the sterno-mastoid (E) will often su;fiice, or if the glands ^..ss?^-^- extend backwards a trans- verse one just above the clavicle (A^). Wlien enlarged glands are present both in front of and behind the sterno-mastoid, as well as beneath it, their re- moval is perhaps most satis- factorily accomplished b}^ a method suggested by Halstead. The incision commences close to the tip of the mastoid process, and, passing forwards just behind the jaw, sweeps across the neck to the middle of the clavicle (Fig. 122, A); a second incision runs trans- versely' just above the clavicle (A^). The flaps thus marked out are dissected up so as to la}^ bare the sterno-mastoid and the enlarged glands. The deep dissection commences from below and behind. The supraclavicular triangle is first cleared, the omo-hyoid muscle being di\dded, but sutures are left on the ends for identifica- tion. The anterior end is drawn up, and serves to raise the sterno-mastoid, which is then divided obliquely (D) below the spinal accessory nerve (C). The divided ends are turned up and do^\^l so as to expose freelv the glands lying on the carotid sheath, which are dealt with from below upwards. Special care must be taken of the nerves and of the internal jugular, but it is better to tie and remove this structure than to leave it in the wound with a number of lateral ligatures applied, which might possiblv be forced ofi bv the suddenly increased intravenous tension induced by the post-anaesthetic vomiting. When all the glands have been removed, the di\-ided muscles are carefully replaced and sutured together, and divided fascis, etc., approximated by buried sutures. In this, as in all neck operations, the skin is brought together by Halstead's intradermic suture, and it is wonderful how little scarring and deformity follow this extensive procedure. The pre-awicular gland Ijang on the capsule of the parotid is sometimes affected, and may cause facial paralysis, either as a result of the sclerosing peri-adenitis, or from injudicious surgery. Any incisions made ^vith a view to remove the gland or to open an abscess therein should be made in the direction of the fibres of the facial nerve — i.e., horizontally. /A' Fig. 122. — Incisions for Removal of Tuberculous Glands from the Neck. A and A^-, For removal of glands from both triangles (Halstead's method) ; B, for remov- ing glands from submaxillary and upper carotid regions; E, for removing glands in lower part of posterior triangle; C, spinal accessory nerve; D, site for di\'ision of sterno-mastoid . 368 A^MANUAL OF SURGERY In the groin, tuberculous glands arc often mistaken for some con- dition due to venereal disease. The history of onset and the extreme chronicity should suffice to establish a diagnosis. Ihe iliac glands will often be found similarly affected, and operations in this region are sometimes very extensive in consequence. Well-marked peri- adenitis is usually present in the iliac fossa, and the glands may be very adherent. Atrophy of the testicle sometimes follows, either from division of the spermatic vessels, or from their imphcation in the cicatrix. Tumours of Lymphatic Glands. Lymphadenoma, or Hodgkin's disease, is characterized by a pro- gressive enlargement of the lymphatic glands and of the l3aTiphoid tissue of the spleen, liver, and other organs. The affected glands and the masses in the viscera are quite characteristic in structure, and have a very different appearance from that seen in simple hyperplasia or in infective processes. The gland is homogeneous on section, the distinction between cortex and medulla being lost. The amount of stroma varies considerably, and the glands are hard or soft according to its relative abundance or not. One type does not appear to pass into the other, and the soft form is, in most cases, more malignant and more rapid in growth than the hard. There is a relative decrease of lymphocytes in the glands, and an increase in the endothelial elements, some of which are multi-nucleated. Nothing is known as to its cause, but it is probably an infective disease. Hodgkin's disease is most common in young adults, but no age is exempt ; it is decidedly more common in males than in females. In some cases the cause of the original enlargement of glands is some inflammatory lesion, such as otitis media or dental caries, but often no such origin can be traced. The glands first affected are usually the cervical, and the disease may remain limited to a larger or smaller group of these for a considerable time before other manifes- tations show themselves ; this condition is sometimes termed benign or localized lymphadenoma . In other cases internal glands become affected first, and this most commonly in the mediastinal group, the retro-peritoneal glands coming next in order of frequency. When the disease is more advanced, lymphadenoid tissue in any part of the body may be affected. The spleen is usually somewhat enlarged, and in about half the cases presents localized grayish- white tumours (the hard-bake spleen). Similar growths may occur in the liver, kidneys, etc., or in the skin. The early symptoms are shght, the only thing noticed being the glandular enlargement. In this stage the glands are soft and elastic, and not adherent to the skin or to one another; they have little or no tendency to caseate or suppurate. When the internal glands are first affected, the earhest symptoms may be those of pressure. This is most marked in the mediastinal group of cases, in which pressure on the superior vena cava is early noted, leading to engorgement of the superficial thoracic veins. DISEASES OF THE LYMPHATICS 369 In the later stages intermittent febrile attacks appear, associated with swelling and pain in the glands, possibly due to a superadded mild pyogenic infection ; periadenitis results, and the glands often fuse together, forming hard masses of large size, whilst the disease becomes generalized. The blood shows a moderate grade of anaemia of the secondary type, with a sHght increase of leucocytes, especially of the lymphocytes. Gradually the pyrexia becomes more con- stant, and the patient passes into a cachectic condition. Diagnosis. — (i) From lymphatic Icitcocythcemia (pp. 65, 67) Hodgkin's disease is recognized by the entire absence of blood changes in the early stages, and by the presence merely of a second- ary anaemia in the later. Moreover, lymphadenoma usually limits itself to regions in which adenoid tissue is normally present ; leucocy- thfemia may develop new growths in any part of the body. (2) From lymphosarcoma it is known by the fact that it is almost invariably limited to the glands, and does not infiltrate surrounding tissues. Lympho-sarcoma is characterized chiefly by its tendency to infiltrate, and also by producing secondary deposits in tissues which are not rich in adenoid tissue. (3) From tuberculous disease of glands the diagnosis is often difficult. Tubercle is more common in the very young, and is more frequently bilateral. The glands have a greater tendency to fuse together as a result of periadenitis, and to sup- purate. In doubtful cases microscopic examination of an excised gland may be required to settle the diagnosis. The Treatment of Hodgkin's disease is, as a rule, most unsatisfac- tory. In the earher stages removal of the enlarged glands is easily effected, but recurrence is the usual result. In the later stages, when several attacks of inflammation have occurred, removal may be most difficult. Probably the best treatment consists in the administration of arsenic and the exposure of the enlarged glands to X rays. Arsenic must be administered in large doses for some considerable time, or possibly salvarsan may be substituted for it. In one case recently treated the happiest results followed the administration of one dose of 0*6 gramme salvarsan and X rays; several previous operations had been f oh owed by relapse. Lymphatic Leucocythsemia is of little surgical interest except in so far as it simulates Hodgkin's disease. The symptoms are much more severe than in the latter, and marked blood changes are present; the number of the leucocytes is enormously increased, reaching 150,000 or more per cubic millimetre, and there is a great preponderance of lymphocytes, which constitute from 90 to 99 per cent of all cells present. There is also anaemia, often of some severity (pp. 65 and 67). Arsenic is valuable, and operative treat- ment useless. Recently X-ray treatment has been employed to the spleen and ends of the long bones with temporary benefit. Lympho-Sarcoma. — This term has been used with very different meanings, but is best restricted to tumours which have a structure approximating to that of lymphadenoid tissue — i.e., which consist of small round cells, resembling, if not identical with, ordinary 24 370 A MANUAL OF SURGERY lymphocytes, set in a reticulated stroma; there is no distinction between cortex and medulla. They closely resemble a small round- celled sarcoma, except that the stroma is more obvious; their sarcomatous nature is evidenced rather by chnical than by histo- logical characters — viz., by the fact that they invade and destroy surrounding tissues. Lympho-sarcoma may commence in any part of the body, but in the vast majority of cases it originates in pre-existing adenoid tissue, most commonly in the glands at the root of the neck, the tonsil, or the mediastinum. It may also affect the intestines (commencing probably in the Peyer's patches) or the testis. When commencing in a region where its development can be followed, it is seen to form a rapidly-growing tumour, which is at first firm, elastic, and painless; later on, however, as it increases in size, it becomes tender, and may cause great pain from pressure on, or implication of, nerves. It early contracts adhesions to surrounding parts, and gives rise to secondary growths in neighbouring glands by direct transmission. The superjacent skin is at first unaltered in colour and texture, but as the tumour increases, it becomes congested and shiny, and con- tains a network of dilated veins. Finally, ulceration occurs, and is followed by the sprouting up of a bleeding fungating mass, similar in character to that formed by any other rapidly-growing malignant tumour. Dissemination of the growth throughout the viscera follows, death resulting from exhaustion and cachexia. The Treatment consists in the removal of the mass, where prac- ticable, without delay. If, however, extensive adhesions exist, this becomes absolutely impossible, and radio-therapy can alone be relied on. Secondary Growths in Lymphatic Glands are a special feature of all cancerous tumours. In the sarcomata they are less common, 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 XVI. AFFECTIONS OF NERVES. The simplest and most common forms of injury to which nerves are hable are Contusions and Strains, causing a sensation of tinghng, or pins and needles, which usually wears off in the course of a few hours. In severe cases variable degrees of loss of power and sensa- tion may ensue, and in hysterical women more or less neuralgia. In patients suffering from gout, syphihs, or rheumatism, a chronic peripheral neuritis is readily induced, often of a some- what intractable type, and this even develops in healthy indi- viduals. Treatment consists in gentle friction with stimulating liniments. Compression of a nerve is usually due to the presence of a tumour or aneurism, or to some displacement or inflammation of bones; in fractures a nerve may be included in the callus formed in the process of repair, the symptoms not appearing till four or ' five weeks after the injury; or it may be met with in the form of crutch palsy, or as a result of spUnt pressure. The early symptoms are those of irritation, e.g., cramp, and spasm of muscles or neuralgic pain; w^hilst later on paralysis and anaesthesia appear, combined sometimes with trophic phenomena. If the compressing cause can be removed, recovery, at any rate of a partial character, follows in time under suitable treatment, such as massage and electricity. Rupture of nerves without an external wound only occurs in con- nection with severe injuries, such as dislocations or fractures, and even then total di\dsion is rare, the sheath retaining its integrity, although the axis cyhnders may have given way. Immediate par- alysis and loss of sensation usually follow, and may persist for a time, although repair not unfrequently occurs, since the sheath remains intact. The doubt alwa^/s existing as to the condition of the sheath regulates the Treatment"^ which must be followed, viz., one of ex- pectancy. Friction and electricity should be applied to the parts, and only when these have failed should operation be undertaken Secondary nerve suture under these circumstances is not a very successful proceeding. 371 372 A ^MANUAL OF SURGERY Total Division of a Nerve.* — The Immediate Effects arc : {a) Par- alysis of the muscles suppHed by the nerve ; (6) complete anaesthesia of the parts supplied by it, which, however, is not necessarily per- manent, since sensation may be conveyed by collateral trunks, the ana;sthetic area passing through gradual stages of partial sensation before recovery is complete, (c) Vasomotor paralj^sis is also pro- duced, the limb becoming hyperajmic and warmer for a few days, and then subsequently colder and insufficiently supplied with blood, {d) The excito-secretory nerves are paralyzed so that glands lose their functions for a time. The Secondary Effects vary with the character of the nerve injured, and are much more comphcated than the former. 1. Changes in the Nerve. — Locally, the two ends retract very slightly, perhaps not more than the twelfth of an inch, and the space thus formed fills with blood, which is quickly absorbed and replaced by granulation tissue, and this in turn by a bulb-like mass of fibro- cicatricial tissue {traumatic neuroma), within which are found spaces filled with fine nervous fibrillae coiled up in loops. After an ampu- tation, most of the divided nerves are found to have developed these typical bulbous ends (Fig. 123), whilst in nerves accidentally severed in their continuity the bulbous mass which forms on the upper end is separated by an interval from the atrophied lower end, though there is usually a fibrous connection between the two. These bulbs are often the seat of severe neuralgia. In a few rare instances immediate union of a divided nerve is supposed to have occurred, as indicated by total and rapid restoration of function. Peripherally, the so-called Wallerian degeneration commences about the fourth day after the accident, in consequence of the separation of the nerve from its trophic centres. It first shows itself in the medullary substance, which undergoes a form of segmenta- tion, becoming broken up into irregular masses of myehn, which are absorbed by leucocytes or connective-tissue cells, and disappear entirely in about a month. The axis cyUnders also degenerate and disappear. The neurilemma cells proliferate in columns and form a fibro-cellular rod, which represents the nerve, and early loses all power of conducting nervous or electric stimuli, although attempts at regeneration are made at both ends. Proximally, degeneration of the medullary sheath occurs., similar to that which is seen in the distal portion, but only extending as far as the next node of Ranvier. It is of but little significance. 2. Changes in the Muscles. — Complete paralysis of motion neces- sarily occurs when a motor nerve has been divided, and the muscles involved slowly waste and undergo degeneration. The atrophy is not noticed at first, and is not so rapid as that arising from infantile palsy, since it is simply due to separation from the trophic centres, and not to their destruction. Deformit}^ may ensue, owing to the * For an elaborate investigation of this subject, see Head and Sherren on ' The Consequences of Injury to the Peripheral Nerves in Man,' in Brain, Summer Number, 1905, part ex. AFFECTIONS OF NERVES 373 unbalanced action of opposing groups of muscles. The electrical changes, too, are important. The faradic current rapidh^ loses its power over the paralyzed muscles, and its effects totally chsappear in two or three weeks, whilst the galvanic excitabihty remains for weeks or months, and even then only slowly diminishes, so that a condition develops in which the galvanic current produces a much greater contraction than the faradic {reaction of degeneration, p. 51). As long as this phenomenon remains, there is a hope that restoration of the continuity of the nerve may be followed by restoration of function; but when the muscles react neither to galvanic nor to faradic stimuh, the case may be looked upon as beyond repair. 3. Various modifications of Sensation are produced. Head and Sherren* have demonstrated that different types of sensory impulse are carried by separate groups of nerve-fibres, and that the peri- pheral distribution of these varies con- siderably, [a) Deep sensation consists in the appreciation of pressure, in- cluding heavy touch and painful pres- sure, and in the recognition of the positions and movements of joints and muscles. These stimuh are carried by motor nerves, and distributed to muscles, tendons, ligaments, etc. Section of all the sensory nerves to the skin of a part does not destroy this form of sensation, {h) Protopathic sensation takes cognisance of painful cutaneous stimuli, and of the effects of temperatures below 20° and above 50° C. The distribution is somewhat indefinite and diffuse, following rather the nerve-root areas than those of the peripheral nerves. The superficial Fig. 123.— Traumatic Neuroma extent supplied by a particular nerve of Posterior Tibial Nerve is only recognised when all other after Amputation of Leg. sensory nerves to the part are divided (From King's College Hos- /-r^- -^ J \ ^1 1 • PiTAL Museum.) (i'lgs. 124 and 125). The overlappmg of these areas will explain the persistence of certain forms of sensa- tion when the nerve apparently supplying that area has been divided. (c) Epicritic sensation includes the appreciation of light touch (as by a wisp of wool), the localization of stimuh, the recognition of moderate degrees of temperature (between 20° and 40° C), and the power of discriminating between two stimuli simultaneously applied, as by the points of a compass ; its distribution corresponds with fair accuracy to that of the peripheral nerves. Section of a purely sensory nerve causes loss of the epicritic and protopathic forms of sensation only, but the area over which the epicritic sense is lost is greater than that over which protopathic * Op. cit., James Sherren, ' Injuries of Nerves and their Treatment,' 1908. 374 A MANUAL OF SURGERY sensation is absent, owing to the overlapping of neighbouring nerve areas. Section of a mixed nerve causes loss of all three types of sensation in any area exclusively supplied by that nerve, but if there is much anastomosis with neighbouring nerves protopathic sensation is little affected. Section of a posterior nerve-root affects protopathic sensation more extensively than the epicritic. In in- complete division or injury of sensory nerves, epicritic sensation is abolished more extensively than protopathic. 4. The blood-suppl}' to a paralyzed part is diminished, and the circulation feeble; hence the extremities usually become cold and their vitality lowered. Chilblains are readily produced, and the unwise application of heat ma}* cause blistering or even sloughing; wounds heal badly, and ulceration from slight irritants is very likely to occur, e.g., corneal ulceration after division of the fifth nerve, and perforating ulcers of the foot. Atrophy of the smaller bones may follow, and ankylosis of the terminal joints of the fingers Fig. 124. biG. 125. Fig. 124 indicates the area of protopathic sensation supplied by the median nerve, as determined by section of all other sensory nerves to the haml. Fig. 125. Ditto for ulnar nerve, (.\fter Sherren.) or toes. In a growing child the development of the part is alwa3^s more or less impaired. If, however, the nerve is partially divided and the ends irritated, more serious changes occur. The skin be- comes thin, atrophic, bluish-red, and shiny (' glossy skin ' of Weir Mitchell), or it may be rough and covered with scaleS; or even oedematous. The cutaneous appendages are also involved, the hairs falling out, the nails becoming rough, brittle, and scaly, and the sebaceous and sweat glands either discharging an abundant secre- tion, or remaining absolutely functionless. 5. In a few cases changes have developed in the central nervous system which are of much interest. In the early stages reflex spasms or paralyses are sometimes met with as temporary phenomena ; but at a later date more serious symptoms may result. Thus, in a glass wound of the median nerve, a healthy man treated at hospital developed a typical epileptic fit whenever the neuralgic bulbous end was touched. The bulb was excised, and the nerve cleanly sutured, but without effect, the epilepsy and pain still remaining. AFFECTIONS OF NERVES 375 The median nerve was divided above the elbow, and a portion removed, but without benefit. Finally, the patient passed into a condition of chronic dementia, and died, no obvious lesions being found on post-mortem examination. Regeneration of a divided nerve must necessarily occur if restora- tion of function is to be obtained. Attempts at regeneration are always e\ddent in the distal segment, whether or not it has been sutured to the upper end, but in the latter case the phenomena are later in appearance and are never carried to perfection, owing to the intervention of the end-bulb. Considerable discussion has arisen as to whether the new axis cyhnders grow downwards from the central end to the peripheral, or w^hether they are developed in the distal segment. Ballance and Purves Stewart, who favour the latter theory, state that the proUferated neurilemma cehs always retain thei/ longitudinal direction, and that about three or four weeks after the division (a Uttle later, if no operation) thin beaded threads begin to show themselves along one side of such a spindle- shaped cell, and, graduallv growing downwards, stretch out towards their nearest neighbours. The union of these small segments constitutes the new axis cylinder, which is gradually covered m by a medullary sheath, also apparently the product of the neurilemma cells, and finallv joins with the central end of the nerve. Halli- burton and Edmunds, and others of the opposing school, teach that regeneration of the axis cyhnders always proceeds from above down- wards, the new fibrillge forcing their way down along the sheath of the nerve, and look on the changes in the peripheral end as merely preparatory — and this opinion is probably correct. In any case the process is slow and takes many months to reach completion. Chnically, the earhest evidence of regeneration is a shght return of sensation, which is at first protopathic, and only slowly becomes of an epicritic tvpe. Motion is generally much later in its restoration than sensation, and may never be enrirely recovered. Under very favourable circumstances it is possible for an interval even as great as i| inches to be bridged over by this process, but such an event is very unusual. The use of a nerve-graft under these condirions may direct the energies of the neuroblastic cells, but the graft is itself quite passive. The Treatment of a divided nerve depends upon its size and function. If small and of shght importance, no special treatment is required ; but any of the main nerves of the extremities must be dealt wnth at once by Primary Nerve Suture. This is best accom- plished by using a domestic sewing needle without cutting edges, or a fine Hagedorn needle, and the finest catgut ; one or more stitches should pass through the nerve, and the rest merely through the sheath. Absolute asepsis is essential in order to obtain satisfactory results, it is most desirable that the nerve should be protected from the pressure of adhesions by wrapping it in gold-beater's skin or Cargile membrane. In wounds involving the nerves about the wrist the deep fascia should also be carefully sutured to prevent the 376 A MANUAL OF SURGERY formation of adhesions between the nerves and tendons to the skin, whereby subsequent mobility would be impaired. If the wound has been inflicted months before, and a bull) has formed, Secondary Nerve Suture must be employed. The nerve is first exposed by a free incision through the cicatrix, the two ends identified and isolated, and the fibrous tissue of the bulb removed to a sufficient extent to expose healthy nerve fibrilla; the divided ends are then brought together with as little tension as possible. To bridge the gap traction upon each end of the nerve may be em- ployed to stretch it, and the hmb subsequently placed in such a position as to relax the parts — e.g., the wrist flexed to a right angle, or the elbow bent (except when dealing with the ulnar nerve above the elbow, flexion of which increases the tension on the nerve). Resection of a segment of bone may be justifiable in certain cases to allow the divided ends to be approximated. Nerve-grafting, in order to bridge over a defect, has not up to the present been followed by much success. A nerve similar in size to that to be operated on is removed from an animal just killed, and carefull}^ stitched in position. Since it merely acts as a carrier to the neuroblastic cells, the same result would possibly be obtained by passing several fine strands of catgut from one end to the other. N erve-anastomosis has been utihzed in a few cases of facial par- alysis, and in a few other instances in order to restore movement. A suitably-placed motor nerve is laid bare, and either the whole trunk or a portion of it united to the divided end of the affected nerve; in time motor phenomena have manifested themselves with some degree of benefit. During the time that the paralysis continues, the limb must be massaged, the fingers or toes worked daily to keep them from getting stiff, and the muscles treated with electricity, and preferably by means of the electric bath, one electrode being placed in a basin of warm saline solution, and the other against the patient's back, and the affected limb dipped in the water till it becomes of a bright red colour. In the intervals the paralyzed muscles should be kept relaxed by suitable splints or apparatus so as to prevent over- stretching by opposing unbalanced muscles, which would subse- quently impair their utility. Anaesthetic parts must also be pro- tected from pressure. In many cases where the original wound has been complicated by suppuration the impaired mobihty is as much due to the inflam- matory adhesions of joints and tendons as to paralysis. Acute Neuritis is not very common. It is usually due to injur}-, gout, or rheumatism, but is occasionally obser^^ed in connection with infected wounds. The nerve may sometimes be felt to be swollen or tender, whilst severe pain of a neuralgic type is often experienced. On microscopic examination the ordinary signs of inflammation are well marked, though mainl}- in the sheath. The Treatment consists of rest to the hmb, together with leeching or dr}-cuppiiig over the AFFECTIONS OF NERVES 377 course of the nerve, combined with belladonna fomentations and suitable general therapeutic measures. Chronic Neuritis, or Perineuritis, is much more common than the former. It consists pathologically in an increase of all the con- nective tissue of a nerve, both around it and between the fascicuh, with compression of the vessels and nerve-fibres. It may result from injury, such as sprains, strains, or pressure, especially when the patient is suffering from syphiHs, rheumatism, or gout, and is met with after influenza and in various toxic conditions, e.g., alcohohsm, diabetes, malaria, etc. It is very common in the fifth nerve, and in the branches of the brachial plexus. The Symptoms vary a good deal with the nerve affected, which can occasionally be felt thickened and tender on pressure. More or less severe neuralgia results, accompanied by loss of power in the case of a motor or mixed nerve. Trophic lesions may also be induced, such as perforating ulcer,, or ankylosis of the terminal joints of fingers or toes. The Treatment in the early stages consists in the administration of anti-diathetic remedies, and, indeed, iodide of potassium, with or without mercury, is generally applicable. Locally, prolonged rest is needed, with counter-irritation in the form of blisters, and later on massage. If there is any paresis, the muscles must be stimulated daily by the faradic current or electric bath ; radiant-heat baths are also valuable, and ionic medication. Pain is combated by aspirin or other drugs, or by administering hypodermically morphia or atropine. Faihng these, acupuncture may be adopted, in which needles are passed into the substance of the nerve, and allowed to remain for a few moments ; this probably acts by reheving the in- flammatory tension within the sheath. Various operative measures dealt with under neuralgia may be called for in severe and pro- tracted cases. For Tumours of nerves, see p. 212. Neuralgia is a condition which either the physician or the surgeon may be called upon to treat ; it is exceedingly common, and may be one of the most terrible afflictions to which the human frame is subject. It is characterized by paroxysmal or intermittent pain of a darting or stabbing type, which follows the course of some particular nerve or nerves, especially the trigeminal. The attack usually com- mences suddenly, and the pain steadily increases until it reaches a chmax, and then gradually 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 sudden noises, a draught of air, etc. Moreover, pressure over the affected trunks may originate, relieve, or increase the pain, whilst the skin affected by them is often intensely tender, and even hyper- aemic and oedematous (the points douloureux of Valleix). Occasion- ally adjacent muscles become spasmodically and sympathetically contracted during the attack, whilst excessive secretion, such as from the lachrymal or sweat glands, is also induced. Herpes is 378 A MANUAL OF SURGERY sometimes met witli in tli(> area of distribution of the affected nerve {e.g., shingles in connection with intercostal neuralgia). Neuralgic manifestations may occur in any sensory or mixed nerve, such as the intercostals or sciatic, or in com])le\ bodies, such as the l)reast, testis, or the larger joints. The Causes of neuralgia are very diverse, and the surgeon often has to look far afield in order to find them. Thus, as predisposing causes may be mentioned the hysterical temperament, anaemia, and depressing circumstances of all kinds, especially mental anxiety and worry. '1 he direct causes may be toxic — e.g., malaria, influenza, lead, or mercury; reflex — e.g., ovarian disease, worms, etc.; central, from disease of the spinal cord or brain ; radical, from pressure on the nerve-roots as they emerge from the spinal canal or cranium; or peripheral, owing to lesions of the trunks induced either by trauma, inflammation, or new growths. In the absence of any recognisable or remediable cause. Treatment consists primarily in attention to the general health, and the local application of counter-irritants and sedatives. Iron and arsenic may be given to anaemic patients; anti-spasmodics, such as valeri- anate of zinc, to hysterical women; quinine or arsenic for malaria; whilst sea-bathing or change of air is often advisable. Iodide of potassium and mercury are beneficial in all cases due to syphilis. When the pain is excessive, morphia, even in large doses, may be required. Empirical remedies, such as aspirin, antipyrine, phen- acetin, menthol, and croton-chloral hydrate will sometimes do good. Neuralgia is a favourable field for hydro- or electro-therapy, or for ionic medication (p. 54) with cocaine or other drugs. When, however, medicinal agents fail, surgical measures are indi- cated in order to allay the patient's sufferings. The following are the more usual methods adopted: 1. In purely Sensory Nerves, such as the trigeminal, destruction of the nerve tissue by the injection into the trunk of alcohol (70 per cent.) has been much used recently. Simple division or neurotomy has often been resorted to, but the relief gained is of a most tem- porary nature, since sensory nerves readily unite after division, and sensation is rapidly restored; hence the operation has fallen into discredit. A more satisfactory proceeding is neurectomy, or the re- moval of a portion of the nerve trunk, which does temporary good even in cases due to central causes, probably by placing the centre in a condition of rest through the exclusion of afferent stimuli. As large a portion of the affected nerve should be removed as possible, and Thiersch suggested a plan of nerve-extraction in which the trunk is laid bare at a suitable spot, and then grasped with forceps and twisted out. Finally, if all such measures have failed, the roots of the nerves may be divided either within the skull or in the spinal canal, or the ganglia connected with their roots may be removed. 2. In a Mixed Nerve, conveying motor as well as sensory stimuli, nerve-stretching has to be mainly relied upon. The trunk is laid bare, AFFECTIONS OF NERVES 379 and traction i-xercisod, l)oth centrally and peripherally, by means of a blunt hook if the nerve is small, or by the fin.t^er placed under it if large. The clinical effect is to abolish the conductivity of the nerve for a time, either completely or partially; but since it is not divided, repair and restoration of function follow. The elasticity and exten- sil)ility of the nerves are considerable, and the force needed to cause their rupture has been accurately estimated. It varies much in different individuals, and allowance must be made for this in all operations. Thus, the sciatic nerve will stand about as much trac- tion as an ordinary man can make with his finger and thumb; it should be apphed steadily and continuously, not in a series of jerks. The effect of stretching is to free the nerve from external inflam- matory adhesions, and to alter the relations between the sheath and its contents. The perineurium has its fibrillae, which are naturally wavy, straightened out, thereby compressing the lymphatic spaces between the fibres, and possibly rupturing the nervi nervorum. The nerve becomes hyper^emic, and the medullar}^ sheath of the tubules may be irregularly broken up. Affections of Special Nerves. The Cranial Nerves. — The Olfactory Nerve may be involved in fractures extending across the cribriform plate of the ethmoid, or in 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 of the skull running into the optic foramen, or divided by penetrating or bullet wounds, leading to sudden irremediable blindness; or it may be compressed by effused blood or inflammatory exudation, either within or outside of its sheath, causing more or less complete loss of vision ; if the hemorrhage has not been very extensive, vision may be in measure restored. Orbital cellulitis not unfre- quently causes pressure on the nerve, either immediately as a result of the inflammation, or subsequently by cicatricial contrac- tion. Syphilitic disease of the sheath, or the formation of a gumma in its neighbourhood, or intra-orbital aneurisms or tumours, may likewise interfere with vision from pressure on the trunk. Optic neuritis (p. 776), or more accurately pap ill oedema, is an oedematous condition of the intra-ocular termination of the nerve in the fundus oculi, due to increased tension of cerebro -spinal fluid; it is a frequent result of cerebral tumours or inflammation, and is generally followed by optic nerve atrophy and blindness. The Third Nerve [motor oculi) being entirely motor, paralytic symptoms are those to be looked for. They may arise from central causes, such as syphihtic or degenerative changes in the floor of the third ventricle; or from -peripheral lesions, such as aneurisms, tumours, gummata, trauma, etc., either in the orbit, sphenoidal fissure, or base of the skull. The Symptoms of complete paralysis are as follows: [a) Ptosis, or drooping of the upper eyehd, from loss 38o A MANUAL OF SURGERY of power in the levator palpebme; {h) external strabismus, or squint, from paralysis of the inner, upper, and lower recti, the eye Ijeing also directed a little downwards from paralysis of the inferior oblique; (c) mydriasis, or dilatation of the pupil, from palsy of the iris; {d) loss of accommodation, from the ciliary muscle being paralyzed; and {e) some slight protrusion of the eyeball (exoph- thalmos), owing to most of its muscles being flaccid and relaxed. Diplopia is the most marked functional result. In consequence, however, of its close proximity to the fourth, fifth, and sixth nerves in the walls of the cavernous sinus and sphenoidal fissure, symptoms referable to these trunks are often associated with the above, as also 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 probably 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 su- perior obhque muscle, results in defective movement of the eyeball downwards and outwards, with diplopia on attempting to look down. The Fifth or Trigeminal Nerve is occasionally torn in head in- juries, giving rise to anaesthesia, with perhaps ulceration of the cor- nea; but such cases are exceedingly rare. Much more common is the affection known as trigeminal neuralgia, or tic-douloureux, which occurs in old people, particularly women. It is to be dis- tinguished 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 its terrible nature. As a rule it commences in the infra-orbital or inferior dental branches, radiating thence to all the other divisions of the nerve. The par- oxysms are not very frequent at first, but they increase both in number and severity, until at last the patient, utterly prostrate, either becomes a morphia habitue, or may even attempt suicide. The condition is often influenced considerably by the general health, and intermissions of varying length occur. The attacks are accompanied by twitching of the muscles of the face, and even of the neck; also by unilateral sweating and hyperemia of the head, and the development of such marked ' points douloureux,' that possibly the patient cannot brush her hair or wash her face on the affected side. Lachrymation is a marked feature during the attacks, and the secretion of saliva or of nasal mucus may be increased. The Cause is imknown; in a few cases tumours of an cndo- theliomatous character have been found involving the Gasserian ganglion, but in the great majority nothing abnormal can be found either in the ganglion or its branches. AFFECTIONS OF NERVES 381 In the Treatment of epileptiform tic all sources of reflex irritation should be relieved or treated, such as carious teeth, errors of refrac- tion, intranasal trouble, ovaritis, etc. A word of warning is needed against the wholesale extraction of healthy teeth for this affection, which may, indeed, be aggravated rather than improved by such treatment. The various analgesic remedies will, of course, be em- ployed, but morphia is often the only drug that gives relief. In most cases Operative Measures sooner or later are required. Alcohol injections* by Schlosser's method is reported to give good results, but further experience is required to demonstrate the permanence of the relief from pain. Neurotomy and nerve-stretching only give temporary relief, and excision even of large portions of the nerve- trunks is frequently followed by recurrence. The only procedure that holds out any certain hope of cure is removal of the Gasserian ganglion, or, at any rate, of its lower half; the facts that the first division of the nerve is not often involved in trigeminal tic, that the nutrition of the eyeball is largely dependent on the maintenance of its nerve-supply, and that the upper part of the ganglion is inti- mately adherent to the outer wall of the cavernous sinus, have deter- mined the practice of leaving intact the ophthalmic portion of the ganglion in the majority of cases. The results of this operation have been very gratifying, and have improved with increased practice and modern methods. At the same time it must not be looked on as devoid of operative dangers or risks ; and hence, if the neuralgia is definitely limited to one division only, injection with alcohol, or an intra- or extra-cranial neurectomy is advisable before attacking the ganglion; recurrence after such an operation, or the primary involvement of two divisions, indicates the major operation. The Supra-orbital Nerve does not very commonly require operation, since neuralgia of this trunk is usually distinct from epileptiform tic, and more amenable to therapeutic measures. The pain often recurs about the same time each day (hence the term brozv ague), and may be treated by giving a pill containing ferri sulph. i grain, quininae disulph. 2 grains, and morphin. hydro- chlor. i\ grain, four hours before the attack is expected, and repeating it every hour till six pills in all have been taken. Should the pain persist, neurectomy may be undertaken. The nerve emerges from the orbit through the supra- orbital notch, lying at the junction of the inner and middle thirds of the upper margin ; it is reached by an incision following the course of the eyebrow, through which the orbicularis is divided along the line of its fibres (Fig. 126, a). By incising the periosteum and depressing it, together with the orbital fat, the nerve can be followed back for some distance, and a considerable portion removed. The Infra-orbital Nerve emerges from the foramen of the same name at a spot about |- inch below the centre of the lower margin of the orbit. It can be reached and divided by a horizontal or curved incision placed over this site (Fig. 126, c) ; but since such an operation is unlikely to give more than tem- porary relief, the root of the second division should be at once attacked if opera- tive procedures are necessary. It is most desirable to divide the nerve behind Meckel's ganglion, and hence the operations which are performed from the face (either Wagner's, which follows the floor of the orbit, or Carnochan's, * For details and methods of injecting the various branches of the fifth nerve, see Purves Stewart, Brit. Med. Journ., September 25, 1909. 382 A MANUAL OF SURGERY which traverses the antrum) arc objectionable, whilst they are almost certain to leave ugly cicatrices (I'ig. 126, d). The pterygoid, or, as it is called, the Braun-Lossen operation, is without doubt the best extracranial method for dealing with the root of the second division. A flap of skin and subcutaneous tissue is dissected forwards from the side of the face (Fig. 105, B), so as to exi)ose the zygoma, which is cleared, sawn through back and front, and turned down together with the masseter. The temporal tendon is thereby exposed, and by drawing this back, and if need be removing the coronoid process completely or in part, it is possible to see into the pterygo-maxillary fossa, and to hook up the root of the second branch of the trigeminal as it emerges from the foramen rotundum and divide it. By severing the nerve also, as it emerges from the infra-orbital foramen through an incision in the face, the whole trunk is set free, and can be removed by traction, all the dental branches being torn across. The displaced structures are then put back in position, the zygoma is sutured with silver wire, and the incision in the skin closed. The results gained by this method have been very satisfactory. It is probable that an intracranial sec- tion of the root of the second division, followed by filling the foramen rotundum from inside by rubber or a metal plug, will give equally good or better results with less risk and deformity. The Hartley- Krause plan of procedure for removal of the Gasserian ganglion is employed. In the third division trigeminal tic usually affects the lingual and inferior dental branches, and should be dealt with at the foramen ovale by intracranial or extracranial section of the trunk. The Inferior Dental Nerve is sometimes, however, the seat of neuralgia, due to compression in its bony canal as a result of dental troubles. It may then suffice to trephine the outer bony wall of the inferior maxilla, making the necessary incision along its lower border, and re- move half its thickness, so as to expose the nerve in its canal. Extracranial section of the third division at the foramen ovale is best accomplished by turning forward a flap of skin and sub- cutaneous tissue from the parotid region (Fig. 105, B), exposing thus the ]:>arotid gland with the socia parotidis and the masseter muscle. The masseter is then divided transversely immediately below the socia parotidis, and the vertical ramus of the inferior maxilla cleared of muscle and periosteum, so as to allow the application of a |-inch trephine just below the sigmoid notch, the remain- ing bridge of bone being subsequently removed by cutting pliers. 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 mandi- ble. By retracting the external pterygoid outwards, the foramen ovale can usuallj' be seen, if electric illumination is employed, and the nerve-trunks divided at the point of exit. A good deal of bleeding often occurs from the internal maxillary vessels and their branches. The wound usually heals well, and leaves but little scar, although some impairment in the mobility of the jaw may result from the cicatrization following disturbance of the muscles and tissues, Fig. 126. Incision for division of supra- orbital nerve; b, line indicat- ing position of supra-trochlear nerve, passing from angle of mouth through the inner can- thus; the short cross-line at its upper end is the incision re- cjuired to expose it; c, position of infra-orbital nerve and in- cision; d, Carnochan's in- cision for neurectomy of the second division. AFFECTIONS OF NERVES 383 Removal 0/ the Gassenan ga-nglion is now usually undertaken thiough the tem- poral region by some modifieation of what is known as the Hartley- Krause method. The pterygoid route* originally I'ollowcd in the pioneer operations by the late Mr. William Rose must be acknowledged to give insufficient exposure to ensure satisfactory removal of the ganglion, and has now been discarded. The Hartley-Krause operation was devised independently by the two sur- geons whose names are associated with it. An 0-shaped flap is marked out in the temporal region, the base situated just above the zygoma. Through this the subjacent bone is removed, exposing the dura mater, which is gently stripped up from the middle fossa of the skull as far as the cavernous sinus. The middle meningeal artery is exposed and tied just above the foramen spinosum, or the foramen may be plugged with purified sponge or wax. Haemorrhage from the small vessels, especially the veins, of the dura mater is sometimes profuse, but usually ceases upon gentle pressure. The dura mater and temporo-sphenoidal lobe of the brain are held up by suitably- shaped spatulae, and the second and third divisions of the nerve are seen run- ning from the ganglion to their foramina, where they are cut across. The dural sheath of the ganglion (cavum Meckelii) is opened, the ganglion itself detached from the bone, and as much of it as is thought necessary removed. The cavernous sinus may be wounded in this stage, or the dura itself give way and cerebro-spinal fluid escape. Removal of the spatulae allows the brain to re-expand, and the wound can then be closed. Special care must be taken of the eye, as its nutrition is likely to suffer. The conjunctival sac should be washed out before operation with warm sublimate solution (i in 2,000), and the lids stitched together. These stitches are removed on the fourth or fifth day, and the conjunctiva washed with warm boracic lotion, but a pad should be kept over the eye for at least a fortnight. The Sixth Nerve may be torn or compressed, either in its intra- cranial course along the inner wall of the cavernous sinus, or as it passes through the sphenoidal fissure, or in the orbit, as a result of penetrating wounds or blows. Its division causes paralysis of the 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) Intracranial Lesions. — If simply cortical, as from pressure, haemorrhage, degeneration, etc., a limited portion of the opposite side of the face is usually involved. If subcortical, 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 affected, the associated movements of the eyelids being left. If the lesion is situated in the pons, the deep facial centres may be im- plicated, and then paralysis with rapid atrophy of the facial muscles ensues on the same side as the lesion, together with loss of power of the opposite arm and leg (crossed paralysis) . If the root of the nerve between the centres and the internal auditory meatus is involved, the whole of the same side of the face is paralyzed, accompanied, as a rule, by deafness. (b) Cranial Lesions. — There are two not uncommon causes grouped under this heading, viz., (i.) fracture of the base of the skull, in- * For a description of this operation, see Rose, ' On the Surgical Treatment of Trigeminal Neuralgia ' (Lettsomian Lectures, 1892) : Bailliere, Tindall and Cox; and J. Hutchinson, 'The Surgical Treatment of Facial Neuralgia'; Bale, Sons and Danielsson, Limited. 384 A MANUAL OF SURGERY volving the petrous bone, the paralysis supervening either imme- diately after the injury from laceration, a rare phenomenon, or some weeks later from implication in organizing blood-clot or callus, the usual cause; or (ii.) as a complication of chronic otorrhcea, due to compression or inflammation of the nerve in the aqueductus Fallopii. In both these forms the palsy is complete on the side affected, and owing to the communication of the facial with the petrosal nerves in this part of its course, there may be unilateral drooping of the velum palati, the uvula being deflected towards the sound side. (c) 'Extracranial lesions from injury, inflammation from exposure to cold, or the pressure of a tumour, e.g., malignant disease of the Figs. 127 and 128. — Right-sided Facial Paralysis. On the left hand the face is in a position of rest; on the right hand an attempt has been made to close the eyes, that on the paralyzed side remaining open, and the eyeball rolling upwards and outwards, whilst the asym- metry of the face becomes more manifest. parotid. This variety has been called ' Bell's palsy,' and is usually characterized by the whole side of the face being affected, but with- out implication of the palate or uvula. The general Signs of facial paralysis (Fig. 127) are as follows: The side of the face is immobile and expressionless, all the natural folds and wrinkles being lost ; the eye cannot be completely closed, and on attempting to do so (Fig. 128) the eyeball is usually seen to roll upwards and outwards; ulceration, and even perforation, of the cornea may result from this exposure. From the drooping and relaxation of the lower eyelid, the apposition of the punctum lachry- male to the conjunctiva is imperfect, and thus tears escape over the AFFECTIONS OF NERVES 385 face (epiphora), a condition aggravated by the loss of tlie suction- like action of the lachrymal sac, owing to the associated paralysis of the tendo oculi and tensor tarsi. On attempting to move the face, as in laughing or showing the teeth, the muscles on the non-paralyzed side are alone contracted, and marked asymmetry results from the drawing over of the opposite side. The lips cannot be closed firmly, and hence whistling and such-like actions are prevented. Food collects between the cheek and the teeth, owing to paralysis of the buccinator, and the patient after a meal has to clear out the debris with a spoon or his fingers. The Treatment of facial paralysis must, if possible, be directed to its cause. Accidental division of its extracranial portion must be followed by suture, either immediate or secondary. When due to the pressure of a tumour, it may be possible to free it by operation. In cases caused by cold, medical treatment, including massage and electricity, must be relied on, and will usually prove effective. When the paralysis persists, and especially if due to some cranial lesion which cannot be reached, nerve -anastomosis may be under- taken, the whole or a portion of the spinal accessory or hypoglossal nerve being united to the divided peripheral end of the facial nerve. The results hitherto obtained in a few cases have been encouraging ; facial movements slowly return, but are first elicited by and accom- panied with movement of the shoulder or tongue; in time, however, they become more independent, but are rarely quite free. How- ever, the operation gives a certain amount of muscular power, and may remove the facial asymmetry so characteristic of this lesion. Facial Tic (or histrionic spasm) consists of a clonic contraction of the facial muscles, due to some central lesion in the pons or cortex, or the reflex result of an irritative lesion of the nasal mucous mem- brane or of the teeth. The condition causes great discomfort to the patient, and may involve the whole side of the face, or merely one part of it, such as the orbicularis oculi. Treatment consists in the administration of nerve tonics or antispasmodics, in the removal of sources of reflex irritation, and, failing that, in stretching, or even in severe cases dividing, the /acta/ w^n'g. Operation. — The facial nerve is exposed immediately below the ear, its posi- tion being indicated by a horizontal line dra\\-n from the middle of the anterior border of the mastoid' process, and usually corresponding to the point where the mastoid meets the lobule of the ear. The incision extends from just behind the external meatus along the anterior border of the sterno-mastoid muscle to the level of the angle of the jaw. The parotid gland is separated from the muscle, and both are well retracted, exposing by this means the posterior bellv of the digastric. The facial nerve is found above this, running directly forwards from the centre of the mastoid process. The great auricular nerve is divided in the superficial incision, and the posterior auricular vessels ^\-ill require a ligature. The internal jugular vein is close to the posterior margin of the wound. The operation is a deep one, and by no means easy in a patient with a thick neck. The effect of stretching the nerve is to paralyze It temporarily, but the ultimate results have been by no means encouraging, only one case out of twenty collected by Godlee being successful. 3»6 A MANUAL OF SVRGERV The Auditory Nerve may be injuicd in fractures of the base of the skull, either one ox both sides being involved. Incurable deafness usualh' results, often associated with facial palsy. It is a little doubtful what effect would be produced by injury ol the Glosso-pharyngeal Nerve, but in one case in which it was sup- posed to be compressed tlie j)atient suffered from difficulty in swallowing and speaking, together with i)ersistent ulceration of the tongue; death resulted fnjm (edema of the glcjttis. A severe crushing injury to the Pneumogastric Nerve may prove reipidly fatal from lieart failure or ])ulnionaiy congestion, but less serious lesions result in palpitation, vomiting, and a sense of suffoca- tion; such phenomena sometimes manifest themselves after head injuries, especially fractures involving the posterior fossa, and indi- cate that the jugular foramen has been encroached on. The nerve is also exposed to injury in operations about the neck, e.g., ligature of the carotid, or removal of tuberculous or malignant glands. Irritation causes vomiting, coughing, or perhaps a temporary inhibi- tion of the heart's action; one-sided division sometimes does com- paratively little immediate harm, but if both nerves are divided, death results from laryngeal paralysis or from such complications as oidema or congestion of the lungs. The effect on the larynx of these lesions is described elsewhere (p. 906), but one meiy note here that in the early stages compression- paralysis of the recurrent laryngeal nerve, as by an aneurism, affects the abductor muscle (crico-arytenoideus posticus), the result being that the cord involved is approximated to the middle line, and then the voice is not impaired, although dyspmea is present. At a later stage compression-paralysis corresponds to the phenomena pro- duced by complete section of the nerve, as in an operation for goitre, viz., the cord lies in the cadaveric position, i.e., half-way between its position in phonation and deep inspiration; in this, breathing is unimpaired, but the voice is husky. 1 he Spinal Accessory Nerve may be irritated, either at its exit from the skull l)y a fracture running through the jugular foramen, or in its peripheral course by inflamed lymphatic glands, etc. It is occa- sionally divided in operations for the removal of tuberculous or malignant glands, and in children this may cause serious deformity from drooping of the shoulder, especially if the branches of the cervical plexus supplying the trapezius are also severed. Clonic spasm of the sterno-mastoid and trapezius is generall}' due to central changes, and it is for this form of spasmodic torticollis that stretching or division of the spinal accessory nerve is employed. Operation. — i lie ntiAf runs downwanls and backwards at right angles to the centre of a line passing from the angle of the jaw to the ajjcx of the mastoid process; it enters the deep asj^ect of the sterno-mastoid about 3 inches below that sj)ot. An incision is made along the anterior border of the sterno-mastoid, reaching from the ear to the cornu of the hyoid bone. The fascia is divided, and the muscle drawn backwards to expose the posterior belly of the digastric, from under the lower border of which the nerve emerges, passing first in front. AFFECTIONS OF NERVES 387 ami Iheii hilow the transverse process of the atlas, which ean be readily felt. The operation has not given good results, since, even ii the twitching of the head and neck ceases, the spasmodic phenomena often recur elsewhere. The Hypoglossal Nerve may be accidentally divided in an opera- tion, or compressed by an aneurism of the external carotid, t)r 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, penetrating wounds, or during operations. No very serious results follow, except in the case of the Phrenic Nerve, division of which may cause instant death by paralysis of the diaphragm, although when but one nerve is divided the patient can survive. Irritation of the nerve gives rise to spasmodic cough or hiccough. The Brachial Plexus may occasionally be divided by cuts or stabs in the lower part of the posterior triangle, and the accident will be characterized by the motor or sensory phenomena corresponding to the particular nerves involved; obviously the upper nerves of the plexus are most exposed to this form of injury. Treatment consists in laying the parts open by a suitable incision, finding the divided ends, and performing primary nerve suture. Tears or contusions of the plexus, a more common accident, may be complete or partial, and result from injuries in which the arm is dragged suddenly upwards, as when in falling a person clutches at some projecting body, or from forcible depression of the shoulder in a fall whilst the head is driven towards the opposite side, the nerve- roots being thereby wrenched from their attachments, or the nerve- trunks compressed by the clavicle against the first rib. Long- continued hyper-extension and abduction of the arm, as during an operation in the Trendelenburg position, also cause undue traction of the roots of the plexus, especially of the fifth and sixth nerves. A fracture of the clavicle by direct violence may result in injury of the plexus, as also the pressure of a cervical rib. Dislocation of the head of the humerus into the axilla, or the attempts to reduce it, may also be responsible for injuries, especially to the inner cord. The lesions consist either of a complete rupture of the nerve-trunks, or of a partial rupture with hsemorrhage into and around the sheaths. If the sheaths remain untorn, repair is usually established after a time; but where a complete laceration has occurred, much cicatricial tissue is Hkely to form, and unless operation is under- taken, repair is improbable. Symptoms.— Sometimes the whole arm is paralyzed, and lies flaccid and arnxsthetic by the patient's side. Sensation is alone present down the inner side of the arm as far as the elbow (inter- costo-humeral nerve), and for a more limited portion on the outer side. Paralysis often involves the pectoralis and scapular 388 A MANUAL OF SURGERY muscles, but the rliumboids and serratus magnus retain their nerve- supply. More frequent!}' the manifestations correspond to that seen in the brachial birth palsy, due to the forcible stretching and tearing of the root of the hfth cervical nerve, and sometimes in part of the sixth. It is caused by overstretching of the head during delivery, and may occur equally in vertex or breech presentations ; but is usually unilateral, and affects more frequently the left arm. The result in this, as is traumatic cases, is the appearance of what is known as the Erb-Dnchenne paralysis, i.e., loss of power of the deltoid, biceps, spinati, brachialis anticus, and supinators, together with anaesthesia or paresthesia in the region supplied by the fifth root. The arm is adducted and rotated in at the shoulder, and the fore-arm is extended and pronated. The lesion in infants is not likely to be noted at birth, but becomes apparent in a few weeks. If the injurv is limited to the inner cord of the plexus, the symptoms produced are chiefly localized in the hand where the intrinsic muscles, both of the median and ulnar groups, are paralyzed, together with loss of sensation along the inner side of the arm and fore-arm. Occasionally the effect is more limited, as when a blow on the back of the neck leads to paralysis of the serratus magnus and rhomboids, and to the subsequent development of a ' winged scapula.' Treatment necessarily varies with the situation and probable degree of the injury. Obvious causes of pressure, such as the de- pressed fragments of a broken clavicle or the callus derived therefrom, must be removed. A diagnosis of complete rupture of the nerves can only be made in most cases, however, after the development of the reaction of degeneration, and hence expectant measures must be adopted in the early stages. The arm is kept to the side, and fomentations applied to relieve the pain. After a while massage and electricity are employed, and it is most interesting in many cases to watch the gradual restoration of power and sensation to a paralyzed limb. The appearance of the reaction of degeneration indicates that the period of inactivity is over, and an attempt must be made bv operation to restore the continuity of the nerves. They are exposed by a curved incision running parallel to the clavicle, and following up the posterior border of the sterno-mastoid. The scalenus anticus is defined, and the nerve-roots found emerging from be- tween it and the scalenus medius; cicatricial tissue is removed; the ends of the nerves are freshened and sutured together. The results of such operations have been, on the whole, encouraging. Neuritis and neuralgia of the brachial plexus occur, and are treated along the usual lines. Should the neuralgia persist and prove uncontrollable, or if clonic spasm of the muscles of the arm and shoulder develop, stretching of the brachial plexus may be required. The Circumflex Nerve is liable to injury from its exposed position, winding round the outer side of the neck of the humerus about a finger's breadth above the middle of the deltoid. Blows upon the shoulder may in this way cause paralysis; it is sometimes torn or AFFECTIONS OF NERVES 389 compressed in fractures of the surgical neck of the humerus, or in dislocation of tlie sh(nilder, or it may be impacted in the callus arising from the former injury. Paralysis of the deltoid and teres minor follows, evidenced by inability to raise the arm from the side, whilst the wasting of the former muscle causes undue prominence of the acromion. There may be temporary anaesthesia over the pos- terior fold of the axilla, but this does not last long. No operative treatment has been adopted, although there is no reason why it should not be attempted in suitable cases. The Musculo-spiral Nerve is not unfrequently damaged in frac- tures and dislocations of the upper extremity of the humerus, but is chiefly exposed to injury in the musculo-spiral groove, where it hes close to the bone. It is implicated with or without other nerves in crutch palsy, or by lying asleep with the arm across the edge of a chair or table, as so frequently occurs in drunken people (' Satur- day-night paralysis '). It is not unknown after operations when the outstretched arm has rested on the edge of the table, or when the Trendelenburg position has been adopted and the arms have been kept above the patient's head, the upper end of the humerus pressing against the brachial plexus. In this position the arms should not be raised to more than a right angle with the trunk, or may be folded across the chest. The resulting paralytic symptoms are not con- fined to the musculo-spiral nerve. Total division of the nerve causes the following symptoms : A. Anaesthesia. If the nerve is divided in the upper third of the arm — i.e., above the origin of its external cutaneous branch — there is loss of both epicritic and protopathic sensation over the radial half of the dorsum of the hand, of the epicritic a little more than of the protopathic. Section of the radial nerve in the upper third of the fore-arm causes no loss of sensation, which is supphed to the back of the hand by the external cutaneous of the brachial plexus ; but section in the lower third causes a hmited loss of epicritic sense over the back of the thumb. B. Paralysis of the following groups of muscles: (i.) Of the extensor of the fore-arm (triceps); hence the fore- arm can only be extended by its own weight, (ii.) Of the long and short supinators; hence the hand is pro- nated, the only supinator remaining being the biceps, (iii.) Of the radial and ulnar extensors of the wrist ; hence wrist- drop (Fig. 129), a condition also present in certain lesions of toxic or central origin, e.g., lead palsy, (iv.) Of the extensors of the fingers and thumb, which either hang hmp and motionless, or may be bent up into the palm from the unopposed action of the flexor muscles. If, however, the wrist and proximal phalanges are sup- ported and extended, the terminal phalanges can be straightened by the action of the interossei and lum- bricales. 390 A MANUAL OF SURGERY Treatment consists in massage and electricity applied to the muscles, whilst fixation of the deformity and secondary changes in the length of the muscles are prevented by the application of a palmar splint. The absence of improvement, together with the appearance of the reaction of degeneration, indicates that the nerve has been torn across, and indicates the necessity for operative treatment. The nerve is laid bare at the site of injury, scar tissue removed, and the ends approximated and sutured, if possible. Should this be impossible, nerve-grafting may be attempted. Operation. — The musculo-.spiral nerve can be exposed on the outer side of the arm after it has traversed the external intermuscular septum, where it lies between the brachialis anticus and supinator longus. To define this inter- section the fore-arm is semi-ffexed and pronated, and an incision made extend- ing from the centre of the crease of the elbow upwards and outwards along a line made by prolonging upwards the radial border of the fore-arm, which in Fig. 129.- — Wrist-drop from Paralysis of the Musculo-spiral Nerve. (TiLLMANNS.) this position corresponds with the supinator longus muscle. The interspace is opened up, and the nerve found together with the termination of the superior profunda artery. From this point the nerve may be traced upwards, if necessary, by dividing the intermuscular septum, and retracting or dividing the triceps. To expose the upper part of the nerve as it enters the groove, the arm is placed over the body, and the posterior border of the deltoid defined. An oblique incision is made a finger's breadth behind this, and the intersection between the long and outer heads of the triceps found. By opening up this space the finger can be passed down to the bone, and the nerve, together with the superior profunda artery, readily exposed. Where the nerve is impacted in the callus arising from a fracture of the middle of the shaft of the humerus, it is often best to expose it by a median incision down the back of the arm, splitting the triceps, the centre of the wound being opposite the insertion of the deltoid. The Median Nerve may be damaged in fractures and dislocations of the humerus, but is most frequently injured just above the wrist by glass wounds, due either to bursting of bottles, etc., or to thrust- ing the hand and arm through a window. Paralysis necessarily results in these cases, with the following symptoms: If divided just above the lerist : A. Anaesthesia. Loss of epicritic sensation over the palmar aspect of the radial side of the hand, over the front of the AFFECrrONS OF NERVES 39^ thiimli, index, micldlc, and half the ring fingers, and over varying portions of the dorsum of tlie same (Fig. 130); loss of protopathie sensation including analgesia to pin- pricks over a much more limited portion, varying con- siderably in different cases with the area of distribution of the terminal branches of the external cutaneous and ulnar nerves. B. (i.) Paralysis of the outer group of the short muscles of the thumb {i.e., abductor, opponens, and outer half of the flexor brevis pollicis), so that the thenar eminence wastes, and the move- ment of ' opposition ' is impaired, the thumb remaining ex- tended by the side of the fingers (Duchen- ne's ' ape-hand ')" (ii.) Paralysis of the outer two lumbrical mus- cles, causing loss of power of flexion at the metacarpo- fig. 130. — Division of Median phalangeal joints of Nerve above the Wrist. the index and middle (After Sherren.) fingers. Xhe shaded parts indicate the area The great impairment of mo- over which epicritic sensation is bihty in the hand and fingers lost so often seen in these cases +i, 4. • depends not so much on paralysis of muscles as on the fact that m the majority of them the synovial sheaths of the wnst are also laid open and involved in septic inflammation, which leads to the formation of diffuse adhesions. Hence the progress is often un- satisfactory, even when the nerve has been skilfully sutured. If divided at the bend of the elbow or in the arm, to the above- described symptoms are added : (i.) Loss of pronation from paralysis of the two pronators, (ii.) Paralysis of the flexor carpi radiahs, causing defective wrist flexion on the radial side and impaired radial abduction, (iii ) Paralysis of the flexor longus polKcis, of the flexor subhmis, and the outer half of the flexor profundus digitorum, leading to loss of power in the hand-grasp, especially on the radial side, and perhaps hyper- extension of the wrist, (iv.) Paralysis of the palmaris longus. The Ulnar Nerve is exposed to injury at the wrist, as also m the hollow between the olecranon and the inner condyle of the humerus, and paralysis may be caused by wounds, fractures, blows, imph- cation in callus, etc. The symptoms are very characteristic. // divided at the elbow : ,• 1 c A. Analgesia or loss of protopathie sensation of the httle finger 392 A MANUAL OF SURGERY and ulnar border of the palm, back and front, seldom of the ring linger; anaesthesia to light touch (loss of epicritic sensation) of the ulnar side of the front of the wrist and palm, of the back of the hand, and of the little and half the ring fingers, back and front (Fig. 131). P>. (i.) Paralysis of the flexor carpi ulnaris, causing weakness in flexion and in ulnar adduction of the wrist, (ii.) 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 lumbricales and of all the interossci ; hence, loss of adduction and abduction of the fingers, with flexion of the two last phalanges in each Fig. 131. Fig. 132. Anaesthesia resulting from Division of Ulnar Nerve. (After Sherren.) In Fig. 131 the nerve was divided above the origin of the dorsal branch; in Fig. 132 below that branch close to the wrist. The continuous dark line indicates the limits of the loss of epicritic sensation; the shaded area shows the loss of protopathic sensation. finger and hyper-extension at the metacarpo-phalangeal joint {main- en-griff e) or claw-hand (Fig. 133). 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 trans- versus, adductor obliquus, and deep portion of flexor brevis), and of the palmaris brevis. If divided just above the wrist, the anaesthesia only involves the palmar aspect of the hand and back of the terminal phalanges (Fig. 132), whilst the paralysis merely affects the short palmar muscles. Additional impairment of movement may, however, arise from septic inflammation of the long tendons and their sheaths. Treatment. — If divided, the nerve must be dealt with (according to the rules already given) at the injured spot. The Intercostal Nerves are frequently the seat of severe neuralgia, cither from a chronic neuritis, probably of toxic origin, from com- pression by tumours or inflammatory lesions of the ribs, or from injury or pressure directed to the nerve-roots as they emerge from the spine, as in spinal caries (girdle-pain) . Herpes zoster or shingles AFFECTIONS OF NERVES 393 is sometimes associated with such pain, and may be followed by some amount of an;esthesia. The Twelfth Dorsal Nerve is not unfrequently the seat of neuralgia of a somewhat severe type, following its distribution to the anterior abdominal wall and buttock, and occasionally leading to a mistaken diagnosis of some abdominal lesion, e.g., appendicitis or chronic ovaritis, and not a few operations have been unnecessarily under- taken in consequence. In some cases it is caused by the undue pro- jection of the tip of the last rib, which becomes injured and inflamed, the nerve becoming adherent thereto; removal of the rib or its tip suffices to cure the patient. In not a few cases of operations on the kidney the nerve becomes en- tangled in the scar, and this is a source of most troublesome pain, the only cure of which is to cut down, free the nerve, and pull out its central end. Sciatica, or neuralgia of the great sciatic nerve, is a most painful affection, and often exceedingly intractable. It may arise from the following Causes: [a) Inflammation of the neurilemma (acute or chronic), the result of cold, injury, gout, rheumatism, syphilis, and many toxic agents; ip) pressure upon the extrapelvic portion of the nerve, as by aneurisms, tumours, or old-standing dislocations of the head of the femur on the dorsum ilii ; (c) similar pressure upon the nerve in the pelvis, or as it emerges through the sacro-sciatic notch, as from sarcoma or osteoma of the pelvic bones, rectal or uterine cancer, a pregnant uterus, or uterine fibroids ; {d) pressure upon the nerve- roots in the spinal canal, as from caries or sarcoma; [e) chronic diseases of the spinal cord, such as tabes. The Symptoms are very characteristic, the pain shooting down the back of the thigh and being often referred to the toes. It is of a paroxysmal nature, and may be brought on by pressure over almost any part of the nerve or by movements of the thigh, and hence the patient's gait is stiff and shambling. Tenderness in the fine of the nerve is felt when the cause is a peripheral neuritis, and the trunk may sometimes be detected on palpation as a thickened cord. The limb is usually kept slightly bent, but complete flexion of the thigh on the pelvis is an impossibility ; and if, when the patient is standing against a wall, the limb can be raised to a right angle with the knee extended, it is certain that sciatica is not present. Careful examina- tion of the patient's pelvis must be made before determining that a case is ' merely sciatica,' especially if the pain has lasted any time. The Treatment necessarily varies with the cause. If due to Fig. 133. — Claw-hand (Main- en-Griffe) from Ulnar Paralysis. (After Byrom Bramwell.) 394 A MANUAL OF SURGERY neuritis or perineuritis, general anti-svphilitic or anti-rheumatic measures may be adopted, and blisters or sedative remedies in the more acute cases apjilied to the back of the thigh. Hypodermic injections of mf>rphia and atropine may also be useful; but if all the usual anti-neuralgic remedies have been exhausted without benefit, dretchin^ of the nerve may be employed. This may be accomplished without operation by tiexing the thigh upon the abdomen and then extending the knee; in cases of sciatica an anaesthetic will be required for this, but it may be attempted before undertaking operative procedures. The nerve is best exposed for stretching at the point where it emerges from under cover of the ghitcus maximus, midway between the tuber ischii and the great trochanter. The patient Hes in the prone position with the Hmb sHghtly flexed, and a 4 or 5 inch incision is made vertically downwards from the gluteal fold in the middle line of the thigh. The lower border of the gluteus maximus is first exposed, and its fibres are seen running downwards and outwards. The hamstring muscles emerging from under it are drawn inwards, and the nerve is found ensheathed in loose connective tissue; it is stretched, by a finger hooked under it, both pcrijiherally and proximally. The External Popliteal Nerve may be divided during a subcu- taneous tenotom}' of the biceps, to which it lies immediately in- ternal; or compressed, as it winds round the neck of the fibula, by strapping, bandages, or splints; or it may be injured in fractures of the neck of the fibula. Total division causes anaesthesia of the dorsum of the foot, and of a varying portion of the front and outer side of the leg, together with paralysis of the extensor and peroneal groups of muscles. In the earlier stages inability to dorsi-flex the foot results in a condition of ' drop-foot,' but later on the contrac- tion of the unbalanced opposing groups results in the paralytic form of talipes equino-varus. The nerve may be exposed by making an incision ij inches long to the inner side of the biceps tendon, terminating at the neck of the fibula. The knee is then flexed, and the nerve is readily found embedded in the loose cellular tissue of the popliteal space. The Internal Popliteal Nerve is much less exposed to injury owing to its more sheltered position. Division results in loss of epicritic and protopathic sensation over the sole of the foot, and of epicritic sensation for the plantar surface of all the toes and for the dorsal aspect of the outer four; also 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 likely to ensue. The nerve is laid bare, by a vertical incision in the middle of the popliteal space, which should avoid the short saphena vein. After division of the deep fascia, the nerve is the most superficial structure. If the Tibial Nerves are divided, the resulting effects are more limited; thus, paralysis of the extensors of the foot and paralytic talipes equinus result from division of the anterior tibial ; and par- alysis of the short and long flexors of the foot and of the interossei, with resulting talipes calcaneo-valgus, follow lesions of the posterior tibial. The nerves may be exposed in the same way as the accom- panying arteries (p. 339). AFFECTIONS OF NERVFS 395 The Sympathetic Nerve-trunk in the neck is occasionally com- pressed by aneurisms or tumours. If merely irritated, dilatation of the pupil on the same side and unilateral sweating of the head and face arc produced; but, if divided, the pupil is contracted from un- balanced action of the third nerve. It has also been completely excised on both sides in the treatment of Graves' disease and for glaucoma, and the operation appears to be of some value. The Nerve-Roots. It is a well-known fact that during the development of the embr^^o the primitive spinal cord, which was originally co-terminous with the trunk and with the vertebral column, graduall}' lags behind in its growth, so that at birth and subsequently it does not extend down the canal further than the lower border of the first lumbar vertebra. This necessarily involves a displacement of the attachment of the spinal nerves upwards, so that these points of origin of the nerves do not correspond to the inter-vertebral foramina, and a variable length of the nerve exists within the canal formed at first by the junction of the anterior or motor ramus with the ganglionated posterior or sensory ramus. In the cervical region each spinal segment is about one vertebra above its corresponding body; in the upper dorsal region this interval amounts nearly to two vertebrse; whilst all the spinal segments corresponding to the lumbar, sacral, and coccygeal nerves are crowded between the tenth dorsal and the first lumbar vertebrae. The nerve-roots after this downward intraspinal course pass through the intervertebral foramina, where they are exposed to injury and pressure, and after various divisions and combinations constitute the peripheral nerves. It must be remembered that almost all the peripheral nerve-trunks are derived from a number of nerve-roots, and the complex distribution of these has been care- fully worked out. It follows that the distribution of sensation over the trunk according to the nerve-roots is a very different thing to that of the peripheral nerves, and the practitioner and student must carefulty study the diagrams appended (Figs. 134 and 135) in order to familiarize themselves with this arrangement. Particularly noticeable is the amount of overlapping of sensory areas, a pro- vision whereby defective sensation due to localized injuries may be minimized. Sherrington has shown that in apes cutaneous anaesthesia will not result from the division of any two consecutive posterior nerve-roots, but only^ when three are divided; this has been confirmed in man. The control of muscles or groups of muscles is similarly distributed over two or three consecutive nerve-roots, presumably with a similar object; whilst the nerve-fibres from muscles, tendons, ligaments, etc., upon which the muscular tone and control of the limbs so much depends, also enter the cord by several nerve-roots. Pressure on the nerve-roots may be caused by tumours of the spine or spinal cord, by tuberculous or gummatous lesions, or by callus or 396 A MANUAL OF SUnGRRY Fig. 134.— Nerve-root Areas: Anterior Aspect of Trunk. (After Head and Osler.) Al'l'ECTlONS OF NERVES 397 Fic 135.— Nerve-root Areas: Posterior Aspect. (After Head and OSLER.) 3y« A MANUAL OF SUliGEUY adhesiuns loniung abt)Ut the intervertebral foramina. Intense neur- algia is the most prominent symjjtom, together with hyperiesthesia ; this, it will be noted, always follows the nerve-root areas, and not those of the peripheral nerves. Herpes zoster may be induced by the affection, and in tinu' an;estliesia may follow. Division olt the Posterior Roots (Forster's operation) lias now been undertaken lor a variety of conditions, and may be looked on as justiliable in suitable cases, such as — (i) Intractable neuralgia, due either to irremovable pressure or to an ascending neuritis, where medical methods are of no avail. (2) To relieve persistent visceral crises and the lightning pains of tabes dorsalis. The crises are supposed to be due to the irritation in these organs of sensory sympathetic fibres, which enter the cord in the posterior nerve- roots. (3) The relief of certain spastic deformities, more particularly of the legs, has been, perhaps, the most successful result of this operation. This proceeding is based on the presumption that interference with the upper motor pyramidal track {i.e., between the cortex and the spinal centres) not only impairs the passage of excito-motor impulses, but also hampers the conduction of in- hibitory impulses from cortex to spinal centre. The result of this is that peripheral stimuli reaching the centres from below have an undue power of producing reflex activity, and hence, in such con- ditions as the cerebral diplegia of children, spastic contraction of muscles is induced, and the mere placing of the foot on the ground in the attempt to walk produces such spastic contortions as to render progress impossible. The distribution of afferent stimuli through at least three nerve-roots renders it possible to divide suitably selected nerve-roots in order to minimize this spastic condition without producing anaesthesia or ataxia, providing that not more than two consecutive posterior nerve-roots are ever severed. The result of such a procedure is that the spasticity gradually diminishes, and after suitable freeing of contracted muscles (by massage, forcible movements, or even by tenotomy, myotomy, etc.) and educational exercises, walking becomes possible. The Operation itself for a spastic condition of the legs is conducted usually in two stages. The first consists in removal of the laminae of the whole of the lumbar vertebrae, and in opening the upper ])art of the sacral canal. A guiding stitch is introduced into the muscles opposite the tip of the fifth lumbar spine to act as a landmark to assist in the identification of the nerve-roots. The first sacral roots leave the dural canal at this level. The removal of the laminae must be wide, and should include the internal articular processes, so as to allow of a clear recognition of the deeper parts. After a suitable interval the wound is reopened, and the spinal membranes incised; it is desirable to do this without h;emorrhage, thereby rendering identification of the nerve-roots more satisfactory. In most cases of cerebral diplegia or spastic })araplegia it suffices to divide the jxjsterior nerve-roots of the second, third, and fifth lumbar nerves, and that of the second sacral. CHAPTER XVII SURGICAL DISEASES OF THE SKIN AND OF THE CUTANEOUS APPENDAGES. A Boil or Furuncle is a localized inflammation of the skin, usually terminating in suppuration, due to infection with staphylococci of a hair follicle or sebaceous gland. Experimentally, a plentiful crop of boils can be produced by rubbing a culture of staphylococci mto the skin, and clinically there is little doubt that a similar mfection is the rnost common cause of this condition. The secondary or satellite boils which form around a primary one are due to the friction upon the healthy integument of dressings, covered with pus and microbes. People with coarse skins and a tendency to comedones are specially liable to the occurrence of boils, but some depressing con- stitutional condition, such as chronic Bright's disease or diabetes, is often present in patients who suffer from recurrent crops of boils. A gangrenous inflammation ensues after infection, resulting in the death of the hair follicle, or of the sweat or sebaceous gland in- volved, and of the surrounding connective 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 to this granulation tissue merging into healthy skin and connective tissue. Signs.— A boil commences as a small red irritable pimple, from which a hair may often be seen to protrude; it increases gradually in size, becoming more and more painful, until it forms a conical tumour, deep red in colour and exquisitely tender. A small whitish spot appears in the centre, and around this so-called core yellow pus can be seen. Finally it bursts, discharging the pus, and subse- quently the core or slough comes away. The process is then at an end, and the wound rapidly heals by granulation. Occasionally the inflammation extends more deeply into the subcutaneous tissues, constituting a ' carbuncular boil. ' Lymphangitis sometimes follows, and the neighbouring lymphatic glands may become sympatheti- cally enlarged and painful, but rarely suppurate. A boil sometimes subsides without suppuration, leaving the parts thickened and infiltrated, the condition then being known as a ' blind boil' 399 400 A MANUAL OF SURGERY Treatment. — Many boils may be left to burst naturally, though possibly the process may be checked by painting them twice daily with iodine (2 per cent.) and applying KIapj)'s suction-glass two or three times a day. Where pus has formed, an incision is made, and the suction-ball persisted in till the slough has come away. In the later stages the skin around should be thoroughly purilied, and the pus and core received on })ortions of wool soaked in carbolic lotion (i in 20), and the cavity lightly swabbed out with pure carbolic acid. A small collodion dressing is then a])j)lied. Tonics, such as iron and quinine, are usually recjuired, except in plethoric individuals, in whom a spare diet and abstinence from stimulants may be recommended. A change of air to a bracing seaside place is often advisable, especially when a succession of boils has appeared. In the more persistent cases a staphylococcal vaccine may be employed with advantage, and the boils will probably be quickly cured or aborted (p. 26). A Carbuncle is a more extensive infective gangrene of the sub- cutaneous tissues, due to a local invasion with pyogenic microbes, the commonest being the Staphylococcus pyogenes aureus. It occurs in individuals run down by any general debilitating condition, such as albuminuria or diabetes, in whom the germicidal powers of the tissues are much depreciated; it is also occasionally met with as a sequela of acute fevers. The exciting cause may be some blow or squeeze, resulting in extravasation of blood or some local diminution of vitality; into this area cocci are implanted either by auto-infec- tion, or more usually through the sweat-glands or hair follicles, or through some slight superficial abrasion. Signs.- — A carbuncle commences as a hard, painful infiltration of the subcutaneous tissues, the skin over which becomes red and dusky. The swelling gradually increases in size in all directions, until a diameter of many inches may be reached. As it extends peripher- ally, the central parts, which were formerly brawny, become soft and boggy, and the overlying skin shows evidences of yielding to the pressure within. Vesicles form on the surface, and finally pustules; these in turn burst, and allow a tardy exit to the ashy-gray sloughs and purulent discharge accumulated below. Fresh openings gradu- ally develop, leading to a cribriform condition of the cutis; some of these apertures enlarge and run into one another, producing a central irregular crateriform opening, at the bottom of which lies the necrotic tissue. As the violence of the inflammation subsides, the sloughs gradually separate, leaving a clean granulating wound. Carbuncles most frequently occur on the back, the nape of the neck, the shoulders, and nates, where the vitality of the tissues is never very active; when they form on more vascular parts, such as the face and lips, the consequences may be even more serious, since infective thrombosis of the large veins may follow, and this may quickly spread up to the cavernous sinus. The soft and spongy tissue of the cheek is a very favourable place for the extension of SURGICAL DISEASES OF 'THE SKIN 4"^ the necrotic process, and there may be a wide area of mischief under an apparently insignificant superficial lesion. A carbuncle is usually single, and may be accompanied by lymphangitis and a painful enlargement of the nearest lymphatic glands. There is often considerable constitutional chsturbance of an as- thenic type, although the temperature is not necessarily much raised. A temporary glycosuria is sometimes present, and dis- appears as the condition improves, but occasionally the gravest symptoms of blood-poisoning (pyaemia or septicemia) may super- vene. Treatment.— In the early stages Bier's treatment by induced hyperemia may be successful in preventing suppuration, but where the organisms are at all virulent or the focus large, it will probably fail. In the later stages the most satisfactory treatment is to lay the carbuncle freely open under an anaesthetic, and scrape with a sharp spoon or cut away all sloughs until healthy tissue is reached, and then to disinfect the cavity thoroughly with pure carbolic acid or peroxide of hydrogen (lo volumes). The hollow thus formed is packed with gauze soaked in an iodoform emulsion (lo per cent.), and allowed to heal by granulation. Another less radical proceeding is to make a free crucial incision, and allow the sloughs to separate naturally, assisting matters by antiseptic fomentations or Klapp's suction-glass. Good food, iron, quinine, and alcohol according to judgment, must be administered, whilst appropriate medicine {e.g., codeia or opium) and hmitation of diet are necessary in diabetic patients. A Corn [clavus] is a localized outgrowth of the epidermic layer of the skin, together with a central ingrowth of a hard, horny plug, which compresses and causes atrophy of the underlying papillae, con- stituting a cup-shaped hollow, whilst the surrounding papillae are hypertrophied. It is the presence of this central plug that consti- tutes the difference between a true corn and a simple callosity or diffuse overgrowth of the epidermis. Any abnormal pressure is capable of producing either condition, granting that it is not sufift- ciently severe or intense to lead to ulceration; but it is rare to find corns except on the feet, and the chief cause is badly-fitting boots. Two kinds of corns are described, viz., the hard and the soft. The hard corn usually occurs on the httle toe, or over the head of the metatarsal bone of the great toe, or over the heads of the first phalanges of the other toes, especially if there is any tendency to hammer-toe. They form more or less conical swellings, with a dark, dry, central plug, and are often very painful, especially when rain is threatening. Suppuration sometimes occurs beneath a corn, and the pain then becomes acute. If it is not attended to early, the pus may burrow and cause necrosis of deeper parts or a destructive arthritis. Treatment consists in paring the corn, after softening with hot water or treating with salicyhc acid plaster (lo or 20 per cent.), or 402 A MANUAL OF SURGERY painting with a solution of salicylic acid in collodion.* A ring of felt plaster may subsequently be worn, but attention must be directed to the boots, and the cause of the trouble removed. Occa- sionally, where the toe is deformed, or disease of the bone or joints has dexcloped, it is necessary to perform amputation. A soft corn occurs between the toes, and owing to the absorption of sweat the surface looks white and sodden; it is often extremely painful. Treatment consists in removing the thickened cuticle after the use of salicylic acid. The parts are very carefully cleansed night and morning, and spirit of camphor painted on at night, whilst cotton-wool is worn between the toes during the day. Failing this, the corn must be removed by operation. The toes are held widely apart, and the incisions run transversely between them, so as to include the corn. The wound ran be readily closed bv sutures. Perforating Ulcer of the Foot forms on some part of the sole and progresses deeply so as to involve sooner or later the bones and joints. It is usually due to two main factors, viz., ancesthesia of the sole, and more or less persistent traumatism, such as arises from wearing a tight boot or from the presence of a nail, which is not noticed owing to the concurrent anaesthesia. It is therefore likely to be met with: (i) In certain central nervous diseases — e.g., tabes dorsalis, syringomyelia, spina bi- fida, etc. ; (2) in diseases such as diabetes, syphilis, alcoholism, etc., which lead to peripheral neuritis; and (3) as a sequence of traumatic lesions of the nerves affecting any portion of their course from the spinal cord downwards. (4) Perforating ulcer is occasionally due to pure plantar lesions, apart from an}' nervous influence, e.g., a suppurating wart or cf)rn, * The following is a useful formula: R. Acidi salicylici, gr. xv. Ext. cannabis ind., gr. viii. Sp. vini rect., nixv. iEtheris, mxl. Collodion flexile, iillxxv. M. Ft. pigm. Si",: To be painted on with a brush three times a day for a week. — R. Crocker. Fig. 130. — Perforating Ulcer OF Great-toe, penetrating to Bones and causing Necrosis. The scar of an old healed ulcer[ of similarjtype is seen on the'outer side of the foot. SURGICAL DISEASES OF THE SKIN 403 or even a chronic epithelioma. The skin under the head of the first metatarsal is the part most frequently affected, but any spot to which undue pressure is directed may become involved, and not un- commonly several such sores may be seen on the same foot. A corn or callosity first forms, and under this a bursa, in which suppu- ration takes place; the pus, finding a difficulty in coming to the surface owing to the thickness of the cuticle, spreads deeply into the soft structures of the sole, and the suppuration may even involve bones and joints. A typical perforating ulcer presents the appear- ance of a sinus passing down to the deeper parts of the foot, and even extending through to the dorsum; the orifice is surrounded by heapcd-up and thickened cuticle (Fig. 136). There is sometimes but little discharge and often no pain, but when bones or joints are aft'ected, free suppuration may occur. If allowed to progress with- out treatment, the bones and joints of the foot may be destroyed ex- tensively, or may be welded together into a solid painful mass, in either case necessitating amputation. A cure can sometimes be determined in the early stages by removing the thickened mass of cuticle and purifying or excising the sinus; the cavity thereby formed is packed with gauze and allowed to heal by granulation. Should this fail, or if bones or joints are involved, amputation will be required. A Wart (verruca) is a papillary overgrowth of the skin, which may manifest itself in many different appearances. The common wart is a horny projection about the size of a split pea, usually seen on the hands of young people; its surface may be smooth or irregularly filiform, and its colour varies with the amount of dirt ingrained on the surface. When smooth-topped, they are sometimes extremely numerous, and may be a little difficult to distinguish from lichen planus. In parts where there is a certain amount of moisture warts become soft in character, and form large vascular masses — e.g., venereal warts. The best method of treating ordinary warts is to paint them with glacial acetic acid, or some other caustic, every two or three days, after softening and removing the horny crust with salicylic acid. Ionic treatment with salicylates is also of value. Verruca Neerogenica (see p. 251). A Chilblain [pernio) is an inflammatory hyperemia, usually in- volving the fingers, toes, or ears, and determined by exposure to cold. It is generally seen in young people with defective circulation, whose fingers and toes easily go dead. After the period of anaemia and pallor, the part begins to itch or burn, and becomes red, swollen and shiny. Exudation occurs into and beneath the skin, and in bad cases a blister with blood-stained contents forms; when this bursts, troublesome ulceration ensues. To prevent the formation of chil- blains the patient's circulation must be improved, and exposed parts kept warm. In the earlier stages treatment by induced hyper- aemia is most valuable; an elastic bandage may be worn for six 404 A MANUAL OF SURGERY hours or so daily, whilst locally the parts may bo painted with tinc- ture of iodine or a solution of ichthyol. When the chilblain breaks, simple antiseptic precautions may suffice, but a more stimulating application is usually required, and Peruvian balsam or resin ointment will be found useful. Tuberculous Af!ections o£ the Skin. -Lupus Vulgaris is a chronic inflammation of the skin of tuberculous origin. It is met with in children and young adults, rarely commencing after the age of thirty. Its most common situation is the face, generally starting on the nose or cheek. It is rare on the scalp, but fairly frequent on the trunk and extremities. The mucous membrane of the nose and mouth is also attacked, but usually by extension from the skin. It is not often symmetrical, except when commencing on the nose. Fig. 137. — Non-ulcerating Lupus of Cheek. (From a rHOTOGRAni.) Clinical Features. — The earliest manifestation of lupus consists in the formation of one or more shot-like nodules in the deeper layers of the skin, which are surrounded by a zone of hyper?emia and infil- tration. These nodules are not particularly hard to the touch, but when of any size can be demonstrated to be of a brownish-orange tint, especially if they are devascularized by the pressure of a glass slide, and then the colour somewhat resembles that of apple-jelly. Gradually the process extends, and usually more rapidly in one special direction, following the course of the vessels. At the same time the integument becomes infiltrated and transformed into granulation or cicatricial tissue, covered by a layer or two of epi- thelium (Fig. 137), and owing either to degeneration of the tuber- culous nodules, or to a lack of vitality, arising from compression of SURGICAL DISEASES OF THE SKIN 4"5 the vessels by the ccnitraction of this new formation, ulceration is very liable to follow. In the extremities the lupoid growth not un- frequently takes on a warty aspect, somewhat similar to the ana- toinical wart ' occasionally seen on the knuckles of post-mortem porters (p. 251). . -x 1, 1 + ^-v,^ A Lupoid Ulcer usually spreads at one margin as it heals at the other, and hence under typical circumstances is more or less cres- centic in shape. The surface is covered with granulations, often ot a protuberant nature. The edges are raised and infiltrated, and scattered lupoid tubercles are readily distinguishable, extending into the healthy tissues, which are usually red and congested^ A con- siderable amount of sero-pus is often secreted, and this by drying forms thick scabs. Any cicatrix which results from natural pro- cesses of cure is thin and vascular, easily breaking down from slight irritation. The process extends gradually, with or without inter- missions, from the seat of its first appearance; it is as a rule lirnited to the cutaneous tissues; but when it attacks the nose, the cartilages are often involved and destroyed, whilst if it involves the palate or septum nasi, perforation is very hkely to ensue The disease is practically painless, and does not at first affect the gerieral health. Neighbouring lymphatic glands may become inflamed and ma few instances are the seat of a tuberculous deposit. Lett to itseii, it tends sooner or later to come to an end, the ulcerated parts cica- trizing, but leaving indelible traces of its ravages m the shape ot obvious scars, with often considerable loss of substance Occasion- ally it persists, in spite of treatment, and then an epithelioma may in time develop on the site of the mischief, running a rapid course owing to the vascularity of the part. ■ ^ r . Pathological Anatomy.— The characteristic microscopical feature of lupus lies in the formation of nodules around the smaller vessels of the skin (Fig. 138), consisting chiefly of a mass of ro^nd cells within which may perhaps be observed a giant cell and endothehoid cells, arranged in the same way as in tubercle. The structures around are infiltrated and hyperffimic; as the disease progresses, ttie original tissue of the part disappears, and is replaced by granula- tion or fibro-cicatricial tissue. The bacilli are by no means readily found, and are always few in number. , , ^ . . • a^^ ' The Diagnosis of lupus from syphilitic and other destructive affec- tions of the skin turns on the presence of outlying nodules beyond the spreading edge of the lesion, together with the apple-] elly-iike granulations, and the thin, congested character of any cicatricial tissue present, whilst the slow, though continuous, progress, and ttie tendency to heal at one part as it spreads at another, are also sugges- tive of its presence. The age and constitution of the individual, and the persistence of the disease in spite of treatment, must also be taken into account. -..^ , r +..00^= The Treatment of lupus has been greatly modified of recent years , owing to the discovery of the remedial properties of F^^^en iigtit, X rays, and other agents. Of course where practicable, excision ot 4o6 A MANUAL OF SURGERY the whole area of disease is the quickest and safest cure; but it is seldom available. In the Finsen-light cure (p. 51) each sitting lasts for one and a quarter hours, and an attendant whose eyes are shielded by dark glasses controls the crystal water-chamber, keeping it firmly against the skin, and slightly shifting it from time to time so that an area about as large as a shilling shall be acted upon at each seance. Slight inflammatory phenomena follow, and a local leucocytosis supervenes, as a result of which the disease disappears, and a soft Fig. 138. — Spreading M.\rgix of a Patch of Lupus. (Zieglek.) a. Normal epidermis; b, normal cerium with sweat-gland (i) ; c, focus of lupoid tissue; d, vascular nodule surrounded by diffuse cellular infiltration; e, non-vascular nodule;/, strings of cells in course of lymphatics; g, lupoid ulcer; h, proliferating epithelium. supple scar is produced, which is very little obvious. It has been found of most value where ulceration is absent and the ])atch not of great size. X-ray treatment is also valuable. Ihe same precautions as to protecting healthy parts must be observed as in treating cancer^ (p. 57). The best results have been obtained by using a tube of comparatively low vacuum, and by working for a definite inflamma- tory reaction, and then stopping till this has disappeared. The length of the treatment necessarily varies, but, as a rule, three to six exposures a week of not more than ten minutes each will suffice. The X rays appear to act best on the ulcerative and fungating forms of lupus, which clear up and heal ; but the cure is only up to a point, as the scars are frequently found to contain small nodules over which the rays have no further influence. For these the Finsen light may be employed beneficially ; but in the absence of this agent they should be dealt with by scraping with a lupus spoon, and subsequently applying solid nitrate of silver, acid nitrate of mercury on a SURGICAL DISEASES OF THE SKIN 407 match end, chloride of zinc as a paste, or even the actual cautery. In some bad cases with much ulceration and when there is a super- abundance of granulations it may be wise to remove these with a sharp spoon as a preliminary measure, and then hand the patient over to the radiographer. The surgeon must remember, however, that he is not operating to cure the disease, but merely to lay bare the deeper tissues in order that the rays may reach them more effectively. He must not include in the scope of his operation healthy tissues. Tuberculin probably renders the disease more amenable to local measures, and prevents recurrence after its destruction, but by itself seldom cures.- The patient's health also must be attended to, and a course of suitable tonics administered. An open-air life, as nearly assimilated to the sanatorium type as possible, is also desirable. Lupus Erythematosus is a disease the nature of which is not yet satisfactorily determined. The appearance of the affection is toler- ably characteristic ; it is usually situated on the face, and in the most typical cases symmetrical patches are formed over the root of the nose and cheeks, corresponding in appearance to a butterfly with outspread wings. Ihe condition frequently invades the forehead, ears, and scalp,' and occasionally appears on the trunk, being then unilateral. It appears as a smooth hyperaemic surface, covered with a branny desquamation; the scales consist of inspissated sebum, and are continuous with deep plugs, which can be traced into the mouths of enlarged sebaceous follicles. As the disease spreads peripherally, the older and central portions are transformed into cicatricial tissue of a pale, thin and white type, in marked contrast to the hyperaemic condition of the advancing margin. It is usually seen in adults, and more frequently in women than men. Progress is exceedingly slow, and ulceration uncommon, except when the ears or scalp are in- volved; in the latter region the hair is often lost. Epithelioma has also been known to follow this affection. The Treatment consists in attention to the general health, together with the local application of weak tarry and mercurial preparations. The X rays and Finsen light act rapidly, but must be used with caution, since the inflammatory disturbance caused by them is considerable. The so-called Tuberculous Ulcers differ from the lupoid in the fact that they always result from the breaking down of a subcutaneous focus, and hence may be connected with diseases of bones, joints, lymphatic glands, or simply of the connective tissues. Their characters and treatment have been already indicated (p. 183). Other cutaneous manifestations of tubercle are recognised, but need scarcely be mentioned here. Ai¥ectious of the Nails. A Paronychia (panaritium, or ' run around ') is a condition fre- . quently seen in surgeons, nurses, or others who have to expose their hands to infective material, as a result of infection of the semi- 4o8 A MANUAL 01- SURGERY lunar fold at the base of a nail. It is often preceded by a ' hang- nail ' which gives entrance to the organisms, and the patient's general condition may be unsatisfactory ; not uncommonly, however, it is seen in hospital nurses and others who have just returned from a holiday, suggesting that they need to become immunized to their surroundings. 1 he skin at the side of the nail becomes swollen and hyperremic, and on pressure is tender to the touch; gradually the pain increases and is particularly troublesome at night, perhaps preventing sleep. A certain amount of discharge may occur through the semilunar fold, but a sufficient exit is rarely given by natural processes. Unless effective treatment is undertaken, the suppuration spreads around the root of the nail to the other side, and also burrows beneath the nail, separating it from the matrix. Granulations spring up freely from the semilunar fold, and thereby discharge is often prevented from escaping. Treatment in the early stages is by fomentations and the use of a Klapp's suction-ball; the skin at the side of the nail is pared down, and if pus appears, a longitudinal incision parallel to the margin of the nail through the inflamed tissues will give exit to the pus, and often sufiices to cure the case. If the pus has burrowed beneath the nail, one or more incisions must be made radially through the semilunar fold (Fig. 139), so as to expose the base of the nail, and permit all the loosened portion to be cut away from the matrix by sharp scissors ; in some cases all the base Fig. 139.— In- of the nail has thus to be sacrificed. The terminal cisioNs FOR portion may, however, be left, as it is serviceable Treatment vvhile the new nail is forming. Abundant granula- cHiA " ^^^^"^^ spring up from the matrix, and these may need to be kept in check by nitrate of silver. Onychia Purulenta is the term applied to a suppurative lesion of the nail matrix which results in the destruction and separation of the whole nail. It may commence on one side as a paronychia, or may be due to infection of the matrix by penetrating foreign bodies. It also occurs in tuberculous and syphilitic children where the matrix is transformed into granulation tissue with but little sup- puration, and the whole digit becomes swollen and bulbous {onychia maligna). Treatment consists in avulsion of the nail, and in syphilitic cases this must be supplemented by the administration of mercury generally, and the application of an oleate of mercury ointment (5 per cent.) locally. Ingrowing Toenail is an ulcerated condition of the soft parts pro- jecting over the side of one of the toenails (usually that of the great- toe), and due either to the pressure of pointed or badly-fitting boots, or to neglect in trimming the nails. 1 he fold of skin is thus pressed by the boot over and against the nail when the patient walks, and in order to diminish the pain and irritation caused thereby, he often tuts away the projecting angle of the nail, but leaves a deep corner SURGICAL DISEASES OF THE SKIN 409 which still further irritates the soft parts. Ulceration ensues, ac- comi)anicd by an offensive discharge and so much pain as to prevent the patient from walking. The matrix of the nail may also become inflamed, and onychia result. In the earliest stages, further progress can often be prevented by careful attention to the nails, by the use of square-toed boots fitting easily, and by introducing small plugs of aseptic wool to press back the overhanging fold of skin. A cure can sometimes be effected by excising an oval portion of skin from the side of the toe and close to the nail. The edges of the incision are drawn together by horsehair, and thus the overgrowing fold of skin is drawn away from the nail (Fig. 140). When ulceration is _ actually present, the best treatment is the ^fo^r° ^iNcniowiNo removal of the affected half of the nail, giving Toenail. special attention to the extraction of the pro- jecting angle. If there is much discharge, it is also wise to cut away the overhanging fold of skin with scissors, and scrape away any granulations present. The parts are then dressed antiseptically, and in a few days the patient is able to walk about. The term Onychogryphosis is applied to a hypertrophic condition of the nails, which become distorted and bent, or twisted up, per- haps simulating a ram's horn. It is usually limited to the great toes of elderly people, and is due to neglect. The nails are very rough, and often covered with grooves or ridges, whilst beneath them is an accumulation of soft, offensive epithelium. The only treatment is removal. AfEectious of the Sebaceous Glands. Sebaceous Cysts occur on any part of the surface of the body, but, especially the scalp, and are due to obstruction of the duct of a seba- ceous gland. They are rounded swellings, firm and elastic to the touch, moveable on the deeper structures, and always attached at one spot to the skin. On careful examination, the obstructed mouth of a sebaceous follicle can usually be seen, and possibly some of the contents of the sac squeezed through this opening. The cyst wall is formed by several layers of epithelium, surrounded by dense fibro- cicatricial tissue, and if exposed to irritation or pressure, as when situated on the back or shoulder, and rubbed by the braces, becomes very firmly adherent to the surrounding parts. The material con- tained within is of a cheesy, pultaceous consistency, with a peculiar stale odour, yellowish-white in colour, and under the niicroscope is seen to be composed of fatty and granular debris, epithelial cells, and cholesterine. Left to themselves, the cysts may attain considerable dimensions, whilst the walls and contents sometimes become calci- fied. Occasionally the exudation oozes through the duct, and dries on the surface, with just sufficient cohesion to prevent it from falhng off; layer after layer of this desiccated material is deposited from below, finally giving rise to what is known as a Sebaceous Horn. 4IO A MANUAL OF SURGERY These become dark in colour from admixture with dirt, and are always more or less hbrillated in texture; the base, to which they are firmly adherent, is infiltrated and hyperitmic. Sebaceous cysts sometimes inflame and suppurate; sooner or later they burst or are opened, and then the process subsides. They are sometimes cured in this way, but more frequently the cyst fills up again, and the same series of phenomena are repeated after an interval. Should the contents only escape partially, the remainder is liable to undergo putrefactive changes, giving rise to an offensive ulcerated surface with raised edges, which may readily be mistaken for epithelioma. It is sometimes known as Cock's Peculiar Tiumnir. True malignant disease of an epitheliomatous nature is said occasionally to supervene. Diagnosis. — From a dermoid cyst it is known by the facts that the dermoid is congenital in origin, that it is limited to certain localities, whilst it is hardly ever directly attached to the skin. From a fatly tumour it is recognised by its rounded shape, its fixity to the skin, the absence of lobulation, and by its more solid character, whilst a lipoma is softer and more moveable. From a chronic abscess it is distinguished by the dilated orifice, by its firmer consistency, and by the history, but it is sometimes impossible to be certain before incising it. Treatment. — A sebaceous cyst should be entirely and completely removed if giving rise to any disfigurement, inconvenience, or pain. In the scalp all that is needed is to transfix the tumour, squeeze out the cheesy contents, and then the cyst wall can be readily removed by grasping it with dissecting forceps and pulling it away. In other situations the cyst wall may require to be dissected out ; but even then it is advisable to open it by transfixion, and to deal with the sac from within. Horns and fungating ulcers should be excised with the surrounding skin. Sometimes a true sebaceous adenoma may develop in connection with these cysts. It may be slowly-growing and of a firm, solid con- sistency; but sometimes it is much more vascular and grows rapidly. The latter has a form of semi-malignancy in that it is very liable to recurrence, and has therefore often been mistaken for a sarcoma. On microscopic section it closely resembles a rodent ulcer, but its clinical history is quite distinct. Its most frequent situation is the scalp, and it requires to be removed with a free hand, the defect in the scalp being made good by Ihiersch-grafting. Molluscum Contagiosum. — This affection shows itself in the form of a number of firm hemispherical nodules, a little larger than a split pea, usually of a yellowish-white colour, and very definitely umbili- cated. The depression in the centre may be occupied by dry debris, and from the larger ones a waxy mass can be expressed. They are usually seen on the face, but may involve any part of the surface of the body. There seems no doubt as to their contagious properties, this being perhaps best seen in the development of growths of this nature on a mother's breast, secondary to those on the face of her baby, but the cause of the contagion is by no means certain. Patho- SURGICAL DISEASES OF THE SKIN 411 logically the tumours consist of numerous wedge-shaped lobules of polygonal nucleated, epitheUal cells, supported by a fibrous stroma. The cells towards the centre undergo a waxy or hyahne degeneration, and in them are seen numerous rounded bodies, which have been supposed to resemble psorosperms. Treatment consists m cutting or pulling them away, or in cutting them across, and squeezing the contents out from the well-defined capsule. Rodent Ulcer is a special variety of glandular cancer, commencing either in the sebaceous glands or in the basal layer of the rete Malpighii. It is usually met with in elderly patients, though occa- sionally observed in those under forty, and is seen with special fre- quency on the upper two-thirds of the face, the skin below the inner Fig. 141. -Rodent Ulcer of Many Years' Standing. (From a Photograph.) and outer canthi being the chief seats of election. It commences ab a papule or flat-topped nodule in the skin, surrounded, perhaps, by an area of hyperemia. The infiltration extends gradually in all directions, but the ulceration usually keeps pace with the new growth The ulcer has a smooth but somewhat depressed surface, is perhaps covered with granulations, and bounded by a slightly raised, indurated, rolled-over edge (Fig. 141) • In most cases one can detect evidences of the new formation beneath the skm beyond the edge. If kept aseptic, there is but Httle discharge, and imperfect attempts at cicatrization are often observed, the scar, however, readily break- ing down- but when septic, the surface is covered with sloughs and an abundant offensive discharge escapes. The condition ispamless neighbouring lymphatics are not enlarged, and the general healtn does not suffer, except in the later stages. The progress of the case is slow, but continuous, and although it spreads for a time super- 412 A MANUAIJOF SURGERY ficially rather than ck'ej)ly, sooner or hiter underlying structures become involved, and then nothing hinders the destructive process, even the bones of the skull being eroded, and the dura mater exposed. Microscopically, the growth consists of interlacing columns of epithelial cells, interspersed with fibro-cellular tissue (Fig. 142). The constituent cells are small, globular, and closely packed, never of the ' prickle-cell ' type, and rarely show signs of keratinization; hence ' cell-nests ' are uncommon, although they are sometimes observed. The cells of the peripheral layer, however, are often elongated, and arranged side by side like a palisade. The deep processes spread laterally rather than deeply beneath the unaffected skin, the papillie ^,<^ Fig. 142. — Rodent Ulcer. (Photomicrograph, x 30.) of which are atrophied; their outline is clearly defined, and fre- quently angular on section. There is but little infiltration of round cells around the epithelial columns. The Treatment of rodent ulcer has been considerably modified of late. Formerly the method of choice consisted in free excision when practicable, a margin of at least half an inch being allowed all round, and the defect made good by skin-grafting or by some plastic operation. Where this could not be undertaken, the ulcer was thoroughly scraped, and the surface treated with nitric acid, chloride of zinc paste, or some other caustic, the wound being allowed to heal by granulation. The discovery of the therapeutic value of the X rays has con- siderably diminished the number of cases operated on for this dis- ease. The sore or nodule is exposed to the influence of the rays for SURGICAL DISEASES OF THE SKIN 413 about ton minutes tlail}-, and a reaction of variable intensity follows, which results in many cases in the surface of the sore cleaning up and healing. Recurrence is occasionally observed, but the recurrent nodules can be treated in the same way. Of course, surrounding parts have to be carefully protected. Radium bromide has also proved serviceable in some cases. It is best applied in a lead capsule with a mica window, and 5 or 10 milligrammes is the usual quantity employed. This capsule is enclosed in a piece of sterilized gutta-percha tissue and fixed over the diseased area with strapping. It may be applied for a short time (five or ten minutes) daily, but acts equally well if applied for half an hour once a week. The reaction varies considerably with the quality of the radium, but sometimes an inflammatory reaction of some intensity follows. Treatment by zinc ions (p. 54) has also been found useful, especially in patients who can only come for treat- ment occasionally. The process is painful, and it is well to introduce cocaine as a preliminary by moistening the positive pad with a solu- tion of the hydrochlorate. The rodent ulcer is then covered with several laj'ers of lint wet with a 2 per cent, solution of sulphate or chloride of zinc, and the positive electrode is applied over this. Our present experience seems to indicate that superficial growths are best treated by X rays, whilst the deeper ones are more amenable to the action of radium or zinc ions. The scar left after treatment by any of these agents is of a most satisfactory type, being soft, supple, and often not at all obvious, and hence this treatment is particularly indicated when the disease affects the eyelids or front of the face. In other places it may be possible to remove the greater part of the disease with the knife, and the rays may then be used with advantage to the raw surface before grafting is undertaken. When bone or cartilage is affected, operation is the only hope, as, although improvement follows the use of the rays, recurrence is almost invariably the rule. CHAPTER XVIII. AFFECTIONS OF MUSCLES, TENDONS, AND BURSiE. Injuries of Muscles and Tendons. Contusion. — Muscles are bruised as a result of blows or falls, leading to more or less extravasation, with possibly some rupture of the fibres. The part becomes tender and swollen, and any active con- traction gives rise to pain; passive movement, however, is tolerated, if the injured fibres are not thereby put on the stretch. Fomenta- tions and rest may be needed for a few days ; but regular massage, and perhaps elastic support, are subsequently necessary. Sprains and Strains, due to violent efforts or falls, result in the tearing or stretching of some of the fibres. Considerable stiffness follows, especially in rheumatic and gouty patients. Rest and either hot or cold applications may be used at first ; but elastic pressure and regular massage will be needed later. In individuals predisposed to the development of tuberculous disease, special precautions must be taken to ensure complete recovery. Rupture of the Sheath of a muscle is an accident occasionally met with, especially in the adductors and rectus abdominis. The belly of the muscle, when contracted, protrudes through the opening as a hernia, constituting a soft semi-fluctuating swelling. In treating this condition the limb must be kept at rest in such a position as to ' relax the muscular fibres and allow the rent in the fascial sheath to heal. In old-standing cases it is justifiable to cut down upon and expose the opening in the muscular sheath, the edges of which are sutured together, or if this cannot be effected a sterilized sheet of silver foil may be stitched over the defect. Displacement of Tendons rarely occurs, except in parts where these structures pass through osseo-fibrous canals, and particularly in those where the line of action is thereby changed. During some violent effort the patient feels a sudden localized pain, followed by a certain amount of limitation of mobility. This accident is popularly known as a ' rick.' In superficial parts the displaced tendon can sometimes be distinctly felt in an abnormal position, and this be- comes more evident on attempting to move it. Thus the long tendon of the biceps may be dislocated from the bicipital groove; and 414 AFFECTIONS OF MUSCLES, TENDONS, AND BURS/E 415 various tendons about the wrist or ankle, especially that of the pcroneus longus, may similarly suffer. If left alone, the parts settle down more or less comfortably, but some permanent weakness may persist ; recurrence is very likely to ensue if movement is permitted before the newly-formed connections have had time to consolidate. Treatment consists in fully relaxing the muscles and replacing the tendon, if possible, by manipulation. The parts are then im- mobilized for six or eight weeks by a plaster of Paris splint or strapping. If the displacement recurs, it is sometimes advisable to expose the tendon, and stitch it back into position, using early passive movement to prevent the formation of troublesome adhe- sions. This is required most frequently in the case of the peroneus longus tendon, which slips forwards from its groove behind the ex- ternal malleolus. The external annular ligament is thereby rup- tured, and the operation consists either in suturing the divided segments, or in more aggravated cases it may be necessary to turn down a flap of periosteum from the malleolus, and by stitching its apex to the outer side of the os calcis secure the tendon in place. Rupture of Muscles and Tendons is by no means uncommon, re- sulting from excessive violence of a sudden and unexpected nature. Most frequently the tendon gives way at its union with the muscular belly ; less often the belly itself yields, whilst occasionally the tendon may snap, or the point of bone to which it is attached may be torn off. Signs. — The patient at the moment of the accident "fexperiences a sharp and severe pain, as if he had been struck with a whip ; he may also feel or hear a snap. Loss of function follows, together with a certain amount of swelling and bniising, which' is more evident if the muscular fibres have been torn across than if the tendon alone has been lacerated. On attempting to contract the affected muscle, the belly rises up as a soft, rounded, semi-fluctuating tumour, drawn towards the uninjured attachment, if the union between the tendon and belly has given way ; whilst if the lesion has been through the muscular substance, the divided halves of the belly become similarly prominent, and a distinct gap or sulcus can be felt between them. Repair is established in the usual way by the formation of granu- lation, and finally of cicatricial tissue. Where a muscular belly is involved and the ends are much separated, a long and weak bond of union is likely to form; but when they are closely apposed, the cicatrix is short, and may be replaced subsequently by true mus- cular tissue. When a tendon has been divided or torn, the con- necting medium is at first attached to the sheath, and if this ad- hesion persists, it may lead to pain and weakness. It is an interest- ing fact to note how rapidly this tissue becomes strong; a rabbit's tendon ten days after division requires a weight of 56 lbs. to break it (Paget). Treatment. — It is essential to relax the parts tally so as to hmit the separation of the divided ends, and to maintain them in this position for two or three weeks. Any resulting stiffness is combated 4i6 A MANUAL OF SURGERY by passive movomonts and massage, whilst, if need be, adhesions arc broken down under an an;esthetir. Tendons aecidentally divided in ojx^n wonnds sliould be sutnred together by silk or eatgut, careful antiseptic j^recautions being adopted to prevent sn])puration along the tendon sheaths. Where there has been actual loss of substance in a tendon, one may be split longitudinally in such a way as to leave a thin flap attached peripherally, so that the free end can be turned down and united to the other segment (Fig. 143) ; or similar flaps may be provided from each end (Fig. I-14) ; or it is possible to remedy the defect by grafting a portion of tendon from another region or person, or from an animal, between the two ends. Care must be exercised to prevent opposing muscles from dragging on and stretching the new bond of union, as thereby considerable functional disability may result. Thus, a young man had his anterior tibial muscles divided by a stab with a knife; they were carefully sutured together, but during convalescence the foot was allowed to drop, the result being that the muscles and tendons were stretched, and hence the most vigorous contractions had no effect in raising the toes, which dragged 144- along the ground. A second Fig. 143. Fig. Loss OF Tissue. In Fig. 143 the flap is taken from one end only; in Fig. 144 from both ends. Method of Union of Tendon after operation to shorten all these structures was required. Muscular bellies which have been divided longitudinally or obhquely are easily united by sutures; but when the section is transverse, the stitches tend to cut out', unless the sheath can also be secured. In such a case it is advisable to encircle with a ligature a bundle of muscular fibres on either side of the incision, and then tie the two threads together. This must be done at several spots in the cross-section. The long tendon of the biceps is not unfrequently torn from the muscular belly, which, on attempting to bend the arm. is drawn down towards the elbow, constituting a soft tumour, somewhat resembhng a hpoma. No special treatment is needed beyond keep- ing the fore-arm flexed for a time. If the tendo AchiUis is ruptured, union may be attained by keeping the knee bent and the heel raised, as by securing a strap to the back of a slipper below, and to a dog- collar or suitable strap passed round the knee above. A better result, however, would follow an aseptic incision and suture. Simi- larly, if the ligamcntum patella' \s torn across, suture through an open wound gives the best result. 'I he inner head of the gastrocnemius is AFFECTIONS OF MUSCLES. TENDONS. AND BURS/E 417 sometimes torn in wrenches or slips, as at lawn tennis, and the piantaris is similarly affected. Cooling lotions are applied for a few days, and the parts are kept at rest until the tenderness and swell- ing have in a measure subsided, and then regular massage is under- taken. The adductor longus may be lacerated in violent attempts to maintain a seat on horseback, and constitutes one form of rider's sprain; it is treated by rest and the appUcation of a firm spica bandage, but in bad cases operation may be required. The long tendons of the fingers are not unfrequently divided acci- dentally, and unless they are effectively sutured considerable im- painnent of function will result, the finger remaining in a position of flexion or hyper-extension, according to whether the extensors or flexors are involved. Operation to secure the divided ends should be undertaken at the earliest possible moment, but not until suitable aseptic conditions are present. Owing to the existence of a sheath the flexor tendons retract considerably, and a longitudinal incision in the middle fine of the finger may be required to reach the proximal end. Its position can be indicated by the passage of a probe up the sheath, which is incised only opposite the retracted end of the tendon. A suture is introduced into the tendon and carried dowm the sheath, and thereby the retracted tendon is drawn again to the site where it was divided and secured to the distal end. By this manoeuvre an extensive incision of the sheath is avoided, and ad- hesions are minimized. The finger must subsequently be kept in a spHnt, and active movements are not permitted for ten days. The extensor tendons have no syno\dal sheath on the fingers, and hence there is but httle difficulty in securing them by suture, except when the attachment to the terminal phalanx is torn through, a not uncommon accident. The aponeurosis retracts and the thickened di\aded end can be felt opposite the centre of the second phalanx ; the terminal phalanx is bent and constitutes the condition known as a mallet finger. Fixation of the finger in a position of extension is useless in this condition, as approximation of the tendon to its point of attachment is not effected. Open operation is often un- satisfactory, since the tendon is torn completely away from the bone, and there is nothing to which to fix it. Good results are often obtained even at a comparatively late stage by putting up the finger with the metacarpo-phalangeal and first interphalangeal joints fully flexed, the second interphalangeal joint being extended — an uncomfortable position at first. The extensor aponeurosis is so attached that flexion of this type drags it downwards and relaxes its terminal segment so that satisfactory union is by this means much more likely to occur. It is sometimes important and often difficult to differentiate between a di\'ided tendon with retraction of the segments, an adherent tendon, and one which has been destroyed hy sloughing; particularly is this the case in connection with the fiexors'of the fingers. Division of a tendon involves loss of active movement alone ; the finger can be moved passively, but immediately springs back into the old position. Adhesion of a tendon to its sheath or in the palm involves more or less flexion of the finger and stiffness ; attempts 27 4i8 A MANUAL OF SURGERY to straighten it are painful, and cause the tendons above the wrist to be dragged on. Sloughing of the flexor tendon results in flexion from contraction of scar-tissue, together with wasting and impairment of nutrition of the flnger. Attempts at extension produce no result either on the flnger or on the tendons above the wrist. Sloughing of the extensor tendon also results in the finger becoming bent from unbalanced action of the flexors. The persistence of any of these conditions is followed by changes in the interphalangcal joints and their ligaments which may invalidate the success of subsequent operations. Under such circumstances it may be necessary to include a resection of the joint at the same time as the tendons are reunited. Where there is much loss of substance, tendon-grafting may be required, or the finger may be shortened by suitable excision of bone. Diseases oi Muscles. Inflammation of Muscles (Myositis) ma}' arise from a variety of circumstances, but the chief results are ahke, whatever the cause, viz., a more or less painful infiltration of the muscle, with increased discomfort on attempting movement. The part feels hard and rigid, and may be tender to the touch. If suppuration ensues, the ordinary signs of an abscess subsequently make themselves evident. A certain amount of contractile tissue is thereby destroyed, and the cicatricial changes induced will possibly lead to deformity. Varieties. — i. Simple Traumatic Myositis results from contusion or laceration of the fibres, and is merely a plastic inflammation, with or without haemorrhage, running on to resolution, with perhaps a little fibroid thickening of the part. It is liable in some cases to become chronic, the muscle substance becoming shortened and re- placed by fibrous tissue {M. fibrosa), and this fibrosis may extend beyond the limits of the onginal lesion. The induration of the sterno-mastoid muscle met with in children is of this type, and may lead to torticollis. 2. Rheumatic Myositis, or muscular rheumatism, is a condition often met with, especially in middle-aged men of rheumatic or gouty temperament who are unable or unwilling to take a sufficiency of exercise, and who live well. The condition apparently involves the fibrous tissues mainly — e.g., the fascise, aponeuroses, tendons, and sheaths of muscles, or the hgamentous tissues of joints; hence the name fibrositis is often applied to it. Some forms of neuralgia result from a similar affection of nerve sheaths (perineuritis). Any part of the body may be involved, but in particular may be noted lumbago, in which the fascia lumboRim is affected, the patient walking with a stiff back slightly flexed; the pain often starts sud- denly during some effort, and when present any unexpected move- ment eh cits a sharp spasm. Rheumatic wry-neck is a similar condition, and may be induced by exposure to a draught. Pains in many joints — shoulders, knees, tendo Achillis, etc. — are of a simi- lar nature, and sometimes are distinctly influenced by climatic conditions. Treatment. — A good dose of calomel is in many cases desirable at the start, follow^ed by suitable dietetic or medicinal remedies AFFECTIONS OF MUSCLES. TENDONS. AND BURS/E 419 directed to the rheumatic or gouty basis of the trouble. Iodide of potassium is by some authorities looked on as always desirable. In the more active stages the part must be kept at rest, and dry or moist heat apphed to reUeve pain, whilst aspirin may be given for a similar purpose. Various methods of applying radiant or other forms of heat have been already alluded to (Chapter III.). Vibro- massage is in many cases most valuable. Hydrotherapy, when it can be utihzed, is exceedingly useful, and the patient must be subsequently instructed to take more exercise and to hve more simply. 3. Acute Suppurative Myositis is the outcome of infection with pyogenic organisms, either from without, as after operation wounds, penetrating injuries, etc., the pus in such cases spreading widely up and down the muscular planes; or from within the body, as in pyaemia; or by extension from neighbouring suppurative foci, as from subperiosteal abscesses; it may also arise after a contusion or sprain by auto-infection. Great cicatricial deformity is hkely to follow. 4. Chronic Tuberculous Myositis, with the formation of a chronic abscess, is not an uncommon secondary consequence of a similar affection of neighbouring bones or joints— e.g., a psoas abscess. 5. Syphilitic Disease is usually met with in the tertiary period, and takes the form either of a diffuse sclerosis or of a localized gumma. Any muscle may be affected, but perhaps the tongue and sterno- mastoid are those most frequently involved. Care is needed in making a diagnosis, since these conditions resemble tumours in their method of onset ; but the presence of a syphihtic history, the slow growth, the hardness with subsequent central softening, and the rapid disappearance after the administrarion of iodide of potassium, should suffice to determine their nature. Occasionally gummata appear in muscles in the shape of small hard and shotty nodules, usually arranged more or less longitudin- ally, which are painless and apparently attached to the fascial sheath. They react readily to iodide of potassium. 6. Parasitic Myositis, arising from the presence either of the Trichina spiralis or of hydatids, need not be described here. 7. Myositis Ossificans is a rare disease, in which various muscles, especially those of the back, are transformed into bony plates or rods, so as to lead to extensive ankylosis. The process seems to be one of ossification of the connective tissue associated with atrophy of the muscular fibres, and is sometimes extremely painful. It is most commonly seen in young males, and is possibly rheumatic in origin. In a boy under observation the arms were immobihzed by ossifica- tion of the latissimus dorsi muscles on either side, whilst the pector- ahs major was also ossified on the right side. The erector spina was involved, the back being rigid, and the right trapezius was undergoing the same change. This disease is often associated with a congenital deformity of the great toes in which the proximal phalanx is absent or stunted. No treatment has proved of any value. 420 A MANUAL OF SURGERY Quite distinct in nature is the Traumatic M. Ossificans, of which two varieties are described: (i.) The new formation results from persistent and repeated irritation of muscles or tendons, and usually starts from the periosteal attachment . The ' rider's bone ' developed in the tendon of the adductor longus is of this description, (ii.) Less commonly the affection follows a severe injury to a muscle and is often secondary to a fracture or dislocation. Extensive haemor- rhage follows, leading to the formation of much fibrous tissue, and in about three to four weeks the presence of bone can be recognised by palpation or radio- graphy. Some painful limita- tion of movement may ensue, but if possible the condition is left alone, unless the dis- ability is great, and then re- moval must be undertaken. The muscles in which this type of inflammation has been most commonly observed are the quadriceps femoris and the brachialis anticus (Fig. 145). Tumours of Muscles are not very common. Primary growths consist of angioma, lipoma, fibroma, chondroma, myxoma, or sarcoma, and of these the majority start in the fibrous sheaths or the interfibrillar con- nective tissue. Secondary de- posits of both carcinoma and sarcoma also occur. Treatment is conducted on ordinary surgical principles. If sarcomatous, the whole thickness of the muscle should, when possible, be excised for some distance from the growth, since the lymphatics run in the direction of the fibres, but the sheath forms a hmit not early overstepped. Amputation of the limb may, however, be required. Diseases of Sheaths of Tendons. I. Acute Simple Teno-Synovitis often follows sprains and strains, and is most commonly seen in connection with the extensor muscles of the thumb. A puffy swelhng in the course of the tendons is produced, painful on movement and perhaps tender to the touch, giving a characteristic fine crepitus whenever the parts are moved. Treatment. — Immobilize the limb for a few days, and apply fomen- tations. As soon as the more acute symptoms have disappeared, Fig. 145. — Radiogram of Traumatic Myositis Ossificans involving THE Brachialis Anticus. (Lent BY Dr. Knox.) AFFECTIONS OF MUSCLES. TENDONS. AND BURSM 421 massage is employed to hasten the absorption of the fluid; whilst active and passive movements are undertaken to prevent the forma- tion of adhesions. 2. Acute Suppurative Teno-Synovitis may result from a punctured wound of the synovial sheath, or the inflammation ma}^ spread to it from neighbouring tissues. The thecal variety of whitlow (p. 253) is of this nature. Suppuration may extend both up and down the sheath, and unless promptly treated by incision, the tendon will slough, or may contract extensive adhesions to neighbouring parts; in either case considerable impairment of function is hkely to follow. When the tendon survives, active and passive movements must be started very early if the formation of serious adhesions is to be prevented. The suppuration may affect neighbouring articulations, leading to their disorganization, especially in the case of the tendon sheaths around the wrist -joint. 3. Chronic Simple Teno-Synovitis is a common affection, charac- terized by a passive effusion into the tendon sheath of glairy synovia, somewhat resembling uncooked white of e^g. An elastic fluctuating swelhng forms in the course of a tendon, usually associated with creaking. In the more limited varieties it constitutes one form of ganghon. There is no pain or tenderness, but the affected part feels weak. Treatment consists in counter-irritation and pressure, as by Scott's dressing; faihng this, the part ma}^ be freely incised, the synovia removed, and, if need be, the cavity washed out. In the more locahzed forms it may suffice to puncture the cyst-like swelling and squeeze out the contents, pressure being subsequently applied. 4. Chronic Tuberculous Teno-Synovitis is of two types, in one the sheath is lined by oedematous granulation tissue of some thick- ness, containing tuberculous foci, gi^nng rise to a soft elastic swelling along the course of a tendon, which increases slowly in size, and is but slightly painful or tender. Suppuration may follow, and sub- jacent bones or joints be involved. Treatment consists in immobihz- ing the part, pressure, passive hyperemia, and improvement of the general health. If a cure is not quickly established, a free incision should be made and the diseased tissue removed. The other form of tuberculous disease consists in a passive effu- sion into the syno\'ial space, the lining membrane of which becomes thickened by the deposit thereon of fibrinous material. This is often detached, and b}' the movements of the part the loose fragments of fibrin are moulded into various shapes. In tendon sheaths they are often elongated, and constitute the so-called melon-seed bodies ; but when they occur in joints, they remain somewhat flattened, whilst in bursae they approximate more to the spherical. On examination, the}' are found to be structureless, though sometimes laminated. \\Tien numerous, they give rise to a curious and characteristic form of crepitus. That they are of a tuberculous nature can be demon- strated by inoculation experiments; the bacilli contained therein are not, however, in a very active state, and the prognosis of this type is more favourable than of the former. 422 A MANUAL Ol- SrRGI'h'Y Treatment consists in immobilization and pressure (as by the application of Scott's dressing), together with the daily application of an elastic bandage, so as to induce hyperemia. Failing this, the part should be opened, the effusion removed, including fibrin and melon-seed bodies, iodoform gently rubbed in, and the ca\nty closed, after filling it with glycerine and iodoform emulsion. Should the trouble recur, a free incision and removal of the diseased mem- brane may be required. A Ganglion is the term given to a localized cyst-like swelling form- ing in connection with a tendon sheath or joint. It is most com- monly met with at the back of the wrist, arising from the tendons of the radial extensors of the carpus, and those of the thumb or index-finger, but it sometimes occurs on the front of the wrist or in the foot (Fig. 146). It varies in size considerably, and contains a clear, transparent gelatinous or colloid substance. A rounded firm elastic swelling is produced, usually somewhat moveable, and Fig. 146. — Ganglion of Extensor Tendon of Foot. neither painful nor tender at first, although some painful weakness of the part may be experienced as it increases in size. It is due to one of several causes: thus, it may result from a chronic localized teno-synovitis, or from a hernial protrusion of the synovial mem- brane through an opening in the tendon sheath. Others seem to originate in a colloid degeneration of the cells lining the synovial space; whilst certainly some few arise in connection with subjacent articulations, in the same way as a Baker's cyst. Little difficulty arises in the diagnosis, although, when situated deeph' and closely attached to a bone, they have been mistaken for exostoses. Treat- ment. — A ganglion may often be ruptured by manipulation and pressure with the thumbs, or by a forcible blow with a book, but it is apt to fill again. Failing this, a rapid cure is usually obtained by an aseptic puncture of the ca\nty, and the subseqvient application of firm pressure. In some cases it may be advisable to lay the part open and remove the cyst wall as completely as possible; such treat- AFFECTIONS OF MUSCJ^ES, TENDONS, AND BURSM 423 mcnt requires absolute asepsis, sinec, if infection occurs, most serious consequences iTia\' ensue. A Compound Palmar Ganglion consists in a tuberculous affection of the common synovial membrane surrounding the flexor tendons of the wrist, the cavity being distended in the early stage with a glairy fluid, usually containing many melon-seed bodies, and perhaps later on with pus. In the early stages all that is noted is a fulness about the front of the wrist and palm, the normal hollow being obliterated. Later on a more definite swelling is observed, and this is found to extend into the thenar eminence, due to the involvement of the tendon sheath of the flexor longus polhcis. The condition is painless at first, and there is but little interference with the mobility of the tendons ; but in the later stages of repair the tendons may become matted together, and the movements of the fingers hampered; or if the disease ends in suppuration, the pain and disability become more marked. In all stages fluctuation can usually be detected above and below the annular ligament, being transmitted beneath it. In the Treatment, rest and pressure, as by Scott's dressing, together with induced hypertiemia and suitable constitutional remedies, may first be tried; and failing this, an incision is made both above and below the annular ligament, the cavity being well washed out, and all melon-seed bodies and fibrinous debris removed. The cavity is then filled with the glycerine and iodoform emulsion, some of which may be gently rubbed into the pockets of the wound ; both incisions are firmly sutured, and a further period of rest main- tained. Should the skin become thin and undermined, drainage may be required, and even in a few cases division of the annular hgament, in order to deal effectively with the trouble by the sharp spoon. The results in such cases are not very good, as the tendons get matted together and adherent to the skin, and the movement of the fingers is thereby hampered. Operations on Tendons. I. By Tenotomy is meant the division of a tendon through an open or subcutaneous wound with the object either of remedying some deformity, such as talipes or torticollis, or of assisting in the reduc- tion of some displacement, as in setting a fracture. It is accom- plished in two ways, viz., by subcutaneous or open incision. The subcutaneous method is made use of where there is httle hkehhood of injuring important structures. The strictest attention tojasepsis is desirable, since the characters of the wound, viz., a puncture, and the entire absence of drainage, are most favourable to the develop- ment of organisms, if entrance is once given to them. Moreover, the s3movial tendon sheath is often, though undesignedly, wounded, and infection spreads rapidly along such a structure, and gives rise to serious consequences. The operation consists in inserting a sharp-pointed tenotome through the skin down to the tendon. This is then withdrawn, and a blunt-pointed knife passed along the 424 A MANUAL OF SURGERY track thus made, cither superficial to or beneatli tlie tendon. 'I he cutting edge is turned towards it, and the tendon divided 1)\' a sawing or rocking movement, whilst the stnicture is put on the stretch. It is undesirable to operate through the synovial sheath, since even if the wound remains aseptic, the tendon often retracts more than is desirable, and in heahng gains adhesions to the sheath which considerably limit the subsequent freedom of movement of the part. Opinions vary as to whether it is better to pass the knife above or below the tendon; in the former method there is no likeli- hood of making an unduly large wound in the skin, and there is less risk of dividing the lax subjacent structures if the knife is turned towards them. On the other hand, if the knife is at once passed beneath the tendon, and any subjacent structures are by mistake included, their division is a matter of certainty. Where, however, there is any risk of dividing important structures, .such as the ex- ternal popliteal nerve in tenotomy of the biceps cruris, it is wiser to adopt the open method. In this an incision about i inch in length is made over the tendon, which can thereby be exposed, lifted on an aneurism needle, and severed without danger. There is no haemor- rhage worth mentioning, and the wound is closed by suture, dressed antiseptically. and firmly bandaged to prevent extravasation. The malposition is at once corrected, and the part immobihzed at the time, or in the course of forty-eight hours, in plaster of Paris. Passive movements may usually commence at the end of twelve to fourteen days, and gradually be increased in vigour, until active movements are allowed. Tenotomy of the Tendo Achillis. — The foot is placed on its outer side, and the tendon relaxed by pointing the toes downwards. The tenotome is introduced at the inner margin of the tendon, about I inch above its insertion (Fig. log, F), either superficial to or be- neath it, and it is readily divided when the foot is dorsiflexed. If the surgeon cuts towards the skin, he must not divide the last few fibres too rapidly, otherwise a considerable external wound may be inflicted by the suddenly liberated knife. The Tibialis Anticus is usually divided about i inch above its insertion, as it crosses the scaphoid (Fig. iii, C). There is here no synovial sheath, and the arteria dorsalis pedis is separated from it by the tendon of the extensor proprius hallucis. It is first relaxed so as to allow of the introduction from the outer side of the sharp- pointed tenotome beneath it; this is replaced by a blunt-ended instrument, and the section is accomplished when the foot is ab- ducted. The Tibialis Posticus is usually divided together with the flexor longus digitomm just above the inner malleolus, at a spot about a finger's breadth from the tip of that process in an infant, and about i^ inches from it in an adult (Fig. 109, E). A small tubercle can usually be felt here, and the section is made just above. The knife is inserted between the tibia and the tendon, and if correctly placed, remains fixed without the support of the hand, being grasped between AFFECTIONS OF MUSCLES, TENDONS. AND BURSJE 425 the tendon and the bone. The bhmt-ended tenotome is then inti'o- duced, and the edge being turned towards the tendon, the latter structure is divided when the foot is dorsiflexed. The posterior tibial vessels may be wounded, but a httle well-adjusted pressure will suffice to prevent any serious consequences. The Peronei tendons are divided just above the base of the outer malleolus, at a spot where the synovial sheath is usually absent (Fig. no, D). The tenotome is inserted close to the fibula, between the tendons and the bone. The Biceps Cruris tendon is best divided by an open operation, on account of the close propinquit}/ of the external popliteal nerve, which has often been wounded in the subcutaneous operation. An incision is made in the direction of the tendon just above its inser- tion into the fibula. It is then lifted upon an aneurism needle and divided; muscular fibres will prob- ably be found quite close to its lower end. The Semi-membranosus and the Semi-teiidinosus tendons are dealt with just above the knee-joint, and the subcutaneous operation may be conveniently adopted when they are prominent and tense. For division of the Sterno-mastoid, see p. 433. 2. Lengthening a Tendon is some- times required, in order to over- come the deformity which results from loss of substance or con- traction, where simple tenotomy does not seem desirable. It may be possible to utilize the method suggested on p. 416 for the union of a tendon where there has been loss of substance, viz., by bridging the interval by a flap turned down from one or both ends. Perhaps a more efficient method is the so-called Z-operation (Fig. 147) . The tendon is spht longitudinally [be) into two halves, which are separ- ated one from the other by cross cuts made on opposite sides, one at each end {cib and cd) . The two flaps are then drawn apart for a distance corresponding to the increase in length required, and sutured together ; the resulting bond of union wifl be as represented in Fig. 148. 3. Shortening a Tendon is undertaken in some forms of paralytic taUpes. The Z-method may also be employed here, the two halves, after they have been separated, being shortened to the required amount, and then stitched together (Fig. 149). This operation will Fig. 147. Fig. i Fig. 149. Z-Operation for Lengthening OR Shortening of Tendons. In Fig. 147 the method of divid- ing the tendon is shown. In Fig. 148 the flaps are slipped downwards, one on the other, so as to lengthen the tendon. In Fig. 149 equal portions have been cut away from each half and the remainders sutured, so as to shorten it. 426 A MANI'AL OF SURGKRY probably give a more solid bond of union than where a transverse or an oblique seetion is removed ; in such the sutures are much more likely to cut out. 4. Tenoplasty is the term applied to any plastic operation on tendons with a view (i) to transfer the action of a healthy and strong muscle to the tendons of a weakened or paralyzed group, so as to limit the deformity or disability caused thereby; or (2) to displace the line of action of a muscle so as to counteract or obviate some deformity. Clearly, this operation finds its greatest use in paralytic affections such as talipes. It is essential to study carefully the peculiar features of each case where such a procedure is considered desirable, especially as to the electrical reaction and power of all the muscles involved and the relative importance of each possible movement. Thus, in the foot plantar-flexion is of more value to the patient than dorsi-flexion, and the latter is more useful than either adduction or abduction, whilst of the two last- mentioned movements adduction is more important than abduction. Hence, although it would be mechanically correct to transplant a healthy abductor, such as the peroneus longus, into a paralyzed plantar flexor, such as the tendo Achillis, so as to improve plantar- flexion at the expense of abduction, it would be unwise to reverse the proceeding. It is desirable that, wherever possible, the re- inforcing tendon should be derived from a synergic and not from an opposing group, although with careful education muscles of opposing function may be utilized. Two methods of tenoplasty are available: (i) Tendon Implanta- tion consists in suturing the whole or part of the proximal end of the tendon of a healthy muscle to the distal end of the divided tendon of a paralyzed muscle, and for choice the latter should be divided as near its insertion as possible. The incision should be longitudinal, or a suitable flap may be raised. The actual inethod of union of the tendons varies with circumstances, but the best results have been obtained by threading the healthy tendon through a slit in the recipient, and then suturing them firmly together. Direct end-to-end suture of two tendons is less satisfactory. Occa- sionally merely a slip from the stronger tendon is employed, which is attached to the weaker one so as to fortify the latter without destroying the power of either. (2) By Tendon Transplantation is meant the total detachment of a tendon from its point of insertion with or without the periosteum or bone to which it is attached, and its transference and fixation to the point of insertion of the tendon of a paralvzed muscle, or to some spot where it can act more advantageously. It is fixed either by sutures to the perios- teum, or by metal staples, or by drilling a hole through the bone and threading the tendon through it. The greatest care must be taken with the technique of these operations, so as to ensure complete asepsis and perfect hsemostasis. Tendon sheaths must be closed by the finest catgut or silk sutures. Deformities should be corrected before the tendons are united, so AFFECTIONS OF MUSCLES. TENDONS. AND BURSJE 427 as to ensure accurate leii,i;t]i of the new stnicture. The after- treatment is in the first place directed to the avoidance of undue tension on the bond of union for fear that it may stretch. The parts should be kept in an over-corrected position for six weeks by splints or plaster of Paris. Subsequently a supporting instrument must be worn for six months, and the affected muscles are treated by massage, electricity, and educative exercises. Diseases of Bursae. Bursas exist as normal sti"uctures in many parts of the bod}" ex- posed to pressure, their object being to diminish friction and permit of a gliding movement. Similar cavities, known as abnormal or Adventitious Bursae, are developed in regions where exceptional pressure is brought to bear on some prominent structure; they con- sist of a fibrous wall lined by a serous membrane, contain a small quantity- of serum, and are formed either by dilatation of lymphatic spaces, or as a result of a localized effusion into the tissues. Ex- amples of this are met with in men following special occupations — e.g., over the vertebra prominens of Covent Garden porters, and then known as a ' hummy ' ; Billingsgate fish-carriers occasionally have bursae under the centre of the scalp ; and deal-runners often present one on the upper part of the shoulder. They occur over bony prominences arising from malformation or displacement — e.g., over the cuboid in talipes equino-varus, and over exostoses; whilst the false joint or pseudarthrosis which occurs in unreduced dislocations or ununited fractures is of a similar nature. Wounds of bursae mav be caused by penetrating injuries, or some- times by the skin over them splitting, as, e.g., in a fall on the point of the olecranon. The escape of bursal fluid which results often pre- vents healing, and then it will be necessary either to excise the bursa, or to open it freely, so that it can be packed and allowed to heal from the bottom. Subcutaneous injuries are followed by haemorrhage constituting a hasmatoma, which may suppurate or become absorbed; in the latter case adhesions will often occur, and even potypoid fringes from the organization of the blood-clot. Treatment consists in keeping the part at rest, unless suppuration is threatening, and then an incision must be made. It is always well to make certain that no fracture is present beneath a h^ematoma of the olecranon or patellar burss. The following are the morbid conditions which arise in adven- titious as well as normal bursae: I. Acute Simple Bursitis results from moderate injury or pro- longed irritation, especially in gouty or rheumatic indi\'iduals. The part becomes swollen, painful, and tender, and if superficial the skin over it may be h\"peraemic. Effusion into the cavity quickly occurs, and is sometimes mixed with blood. Lymph is deposited on the serous surface, and in many cases results in the formation 428 A MANUAL OF SURGERY of adhesions, and possibly obliteration of the cavity. Treatment consists in keeping the part at rest, and applying fomentati(jns. If the effusion persists, aspiration, or removal with trocar and cannula under strict asepsis, may be employed, or even the whole cavity excised. 2. Acute Suppurative Bursitis arises from infection occurring either from without or within ; it not uncommonly follows a sub- cutaneous injury of a chronically inflamed bursa, leading to its distension with blood. The pus, formed at first within the bursa, may travel directly to the surface, or, bursting through the capsule, is diffused through the tissues. Where this occurs, the characteristic features suggesting a bursal origin of the abscess may be masked. Thus, in suppuration of the bursa patellae, the pus often finds its way to the lateral aspects of the hmb, allowing the patella to be distinctly felt through the skin; the case might then be mistaken for suppuration within the knee-joint, but is easil}^ distinguished by the absence of the more acute arthritic sj^mptoms. Implication of subjacent bones and joints sometimes occurs; thus, the patella or olecranon may become carious, or necrose. The Treatment of sup- purative bursitis resolves itself into an early free incision, and drainage. 3. Chronic Bursitis with Effusion is, perhaps, the most common pathological condition met with in connection with bursse. The cavity becomes distended with a serous effusion of varying amount, giving rise to a fluctuating tumour. The walls differ in thickness according to circumstances; if the condition is one of long standing with frequent recurrences, the bursal wall is usually reticulated and dense, and adhesions, papilliform processes, or fibrous cords are often produced. Subacute exacerbations are frequently grafted on the more chronic variety. Treatment consists in rest and counter-irrita- tion, as by blistering or iodine paint, and if this fails, the bursa should be dissected out. WTien the bursa communicates with a joint, such as that under the semi-membranosus tendon, the neck must be isolated, and its communication with the joint shut off by ligature. 4. Chronic Fibroid Bursitis. — In this variety the walls of the bursa are much thickened, as a result of prolonged irritation, constituting a hard fibroid tumour, in the centre of which is a small cavity. Possibty a syphilitic element is present in this condition. The only Treatment is complete removal. 5. Chronic Tuberculous Bursitis usually occurs in the form of a fibrinous deposit on the inner wall, together with effusion and the presence of loose fibrinous bodies. Less frequently the lining mem- brane is transformed into granulation tissue of a tuberculous type, perhaps leading to the formation of a chronic abscess. Either con- dition may be secondary to a tuberculous arthritis, or may give rise to it, when the bursa communicates with a joint. If total removal is impracticable, Treatment consists in laying the part freely open, scraping away all tuberculous tissue, and packing the cavity AFFECTIONS OF MUSCLES, TENDONS, AND BURS/E 429 with i;auzc impregnated with iodoform. Sometimes it is possible to filf the cavity with sterihzcd iodoform emulsion and close it entirely. 6. Syphilitic Changes may also occur in bursas, m the shape either of a symmetrical bursitis in the early stages, or later on as a gum- matous peri-svnovial development. 7. Occasionally Gouty Deposits are observed in the walls of bursae, constituting tophi, the irritation of which may predispose to abscess formation, pus mixed with urate of soda crystals being discharged. The bursa over the olecranon is said to be most frequently affected m this way. Special Bursse. The hnrsa patellce (Fig. 150), which hes over the lower half of the bone and not over its centre, is very liable, from its exposed situa- tion, to injury or any of the above-mentioned varieties of bursitis. In its simplest form it constitutes the condition known as ' house- maid's knee,' and is due to kneehng. Caries of the patella may follow acute suppuration, and the more chronic varieties may lead to osteoplastic periostitis. The knee-joint itself usually escapes. Fig. 150. — Enlarged Bursa Patella. (From a Photograph.) The bursa beneath the ligamentum patellce, between it and the head of the tibia, when distended with fluid, gives rise to a fluctuating sweUing felt on either side of the tendon, more especially when the Hmb is extended; when the leg is flexed, the swelling diminishes. Chronic enlargement of this bursa may push the hgamenta alaria backward into the joint, so that they are nipped between the bones whenever the patient attempts to stand with the leg extended; the pain thereby induced is somewhat similar to that caused by a dis- placed semilunar cartilage, or by a loose foreign body in the joint. The presence of the enlarged bursa, together with the mabihty to stand with a straight leg, should suffice to make the diagnosis clear. 430 A MANUAL OF SURGERY The hurscv in the popliteal space are often enlarged, especially that between the inner head of the gastrocnemius and the semi-mem- branosus (Fig. 151), leading to a rounded tluctuating swelling, sharply limited 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 extension and flaccid in flexion, as occurs in most of these peri- articular bursae. Owing to the proximity of the popliteal vessels, pulsation is occasionally detected, but is not expansile in character. Enlargement of this bursa is often secondary to an articular lesion, especially tuberculous disease or osteo-arthritis, and before undertaking treatment the condition of the joint should be ascertained. If the joint is healthy, the bursa may be removed by dissection, the pedicle being closed by liga- ture or suture. The bursa beneath the in- sertion of the semi-tendinosus and gracilis is sometimes in- flamed, and is very liable to cause osteoplastic periostitis of the subjacent inner surface of the tibia. The bursa beneath the tendo A chillis, if enlarged, presents a fluctuating swelling on either side of that stmcture, somewhat simulating disease of the ankle - joint, but necessarily limited to the posterior aspect of the joint. Primary tuberculous disease is sometimes present. Distension of the bursa beneath the psoas tendon gives rise to a fluid swelling which usually projects anteriorly, presenting either on the outer or inner side of Scarpa's triangle. If painful, it necessitates flexion of the thigh, and thus leads to symptoms resembling those of hip-joint disease or of a psoas abscess. It must not be forgotten that this bursa often communicates with the joint. The gluteal bursa, situated between the insertion of the gluteus maximus and the great trochanter, is not uncommonly the seat of tuberculous disease. It presents as a rounded swelling, obliterating the hollow behind the trochanter, and in its more acute manifesta- tions may be accompanied by abduction and eversion of the limb, in order to relax as far as possible the gluteus. It may thereby some- FiG. 151. — Enlarged Semi-membranosus BuRS^ IN Both Legs of a Boy. AFFECTIONS OF MUSCLES. TENDONS, AND BURS/E 431 what resemble the earUer stages of hip disease, but is recognised by the absence of flexion, and by the fact that passive movements, including even the so-called test-movement for hi]) disease, can be undertaken with but little or no pain. Should suppuration occur, the pus may burrow widely beneath the gluteus. Treatment con- sists of complete excision, if possible, or incision with scraping and disinfecting the interior, and allowing it to heal from the bottom. Necessarily part of the insertion of the gluteus maximus will require division, and must be subsequently sutured. The bursa over the tuber ischii, if inflamed, gives rise to the condi- tion known as ' weaver's bottom ' ; it causes great discomfort in sitting, and is often solid and symmetrical. If troublesome, it should be removed. Enlargement of the bursa over the olecranon constitutes the condi- tion known as ' miner's elbow ' ; suppuration within it is not un- common, leading to necrosis of the underlying bone; the elbow-joint is but rarely affected. The large multilocular subdeltoid bursa is occasionally enlarged; it leads to prominence of the deltoid, and expansion of the shoulder. (For diagnosis from effusion into the shoulder- joint, see Chapter XXIIL) CHAPTER XIX. THE SURGERY OF DEFORMITIES. It is only possible in a text-book of this character to deal with a few of the more notable defects. Torticollis. Torticollis, or wry-neck, is a deformity produced primarily by contraction of the sterno-mastoid muscle, although in old-standing cases the trapezius, splenii, scaleni, and other deep mus- cles of the neck, as well as the deep fascia, are affected. It is characterized bj' the af- fected side of the head being drawn down towards the shoulder, whilst the face is turned towards the sound side (Fig- 152). Several different types are described, in particular the acute or rheumatic, the chronic, which is usually due to cicatricial changes in the muscle, and the spasmodic. I. The Acute or Rheumatic variety is usually the result of exposure to cold or to sit- ting in a draught ; it comes on suddenly, and is extremely painful, and the muscle or muscles affected are tender to the touch. The possibility of mistaking it for other inflam- matory affections, such as acute lymphadenitis or cellu- litis, must not be overlooked ; in them the neck is often fixed so as to protect the inflamed structures. Treatment must be general as well as local; aspirin 432 Fig. 152. — Chronic Torticollis. (From a Photograph.) The left sterno-mastoid is contracted, and the corresponding half of the face atrophic. THE SURGERY OE DEEORMITIES 433 may be given to relieve pain, or salicylates to counteract the rheumatic poison, whilst a close of calomel or castor oil is always beneficial. Local fomentations should be applied in the early stages, and subse(|uently massage. 2. The Chronic form of torticollis is almost always due to cica- tricial changes in the sterno-mastoid, which result in its intrinsic shortening, [a) It is occasionally congenital, and then it is due to malformation or malposition in lUero, whereby the muscle is im- perfectly developed, {b) Most commonly it follows the congenital induration of the muscle [q.v.], due to laceration of its fibres during birth; it is therefore to be looked on as a myositis fibrosa, somewhat akin to Volkmann's ischemic contracture (p. 489). (c) At a later date contraction of the muscle may result from suppuration or gummatous formation within the sheath, but the deformity is then less marked. Most commonly the sternal portion is contracted, whilst the clavicular half may be quite relaxed; the muscle usually stands out as a hard tense band, an excess of fibrous tissue being present, or the muscular substance almost entirely absent. The deep fascia always becomes secondarily contracted and shortened, and if the deformity has lasted long the posterior cervical muscles are similarly affected, whilst changes in the shape of the cervical vertebrae may also be induced, the bodies becoming wedge-shaped and thickest towards the convexity of the curve. A secondary compensatory curve is usually present in the dorsal region of the spine, so as to maintain the horizontal position of the eyes. In children the affected side of the head and face also becomes atrophic. The measurement from the external canthus to the angle of the mouth is smaller, the eyebrow is less arched, the nose somewhat flattened, and the cheek less full than on the sound side. These phenomena are probably due to imperfect vascular supply, resulting from the limited mobility. The Diagnosis of a chronic torticollis is readily made from the fact that the sterno-mastoid muscle is evidently contracted and stands out as a tense band in the neck. It must not be confounded with cicatricial contraction of the skin of the neck following burns, or with the deformity and rigidity of the neck which result from a rheumatic inflammation of the deeper ligaments and muscles of the cervical spine (rheumatic spondylitis), or from tuberculous disease of the cervical vertebrje. Treatment. — Massage and manipulation may be first tried, or even some form of mechanical apparatus directed towards stretching the contracted muscle {ijide infra), but in the majority of cases tenotomy or myotomy will give a more satisfactory result, and is less tedious and troublesome. Two methods of dividing the sterno-mastoid have been employed: (i) The subcutaneous operation is a somewhat undesirable proceeding, on account of the important structures placed immediately beneath it. There is but httle danger or difficulty in deahng with the sternal 434 A MANUAL OF SURGERY head, a tenotome being passed down to it beneath the skin, and the incision made from before backwards; the tension to which it is exposed suffices to draw it well forwards out of harm's way. The clavicular portion, on the other hand, should always be divided through an open incision. (2) '1 he open method is far preferable, as thereby all danger is obviated. The skin, about ^ inch above the clavicle, is incised across the muscle, its anterior and posterior borders are defined, and its fibres completely divided. Tense portions of the deep cervical fascia on its deep aspect may also be carefully cut across, keeping in view the importance of the underlying structures. Ihe position of the head is then rectified, and fixed by plaster of Paris or some other suitable apparatus. A simple and satisfactory arrangement consists of a padded leather strap passed round the forehead and occiput, and another under the axillae. A chain or elastic band is secured to the forehead strap above the mastoid process of the side which is not affected, and traction made by fixing it to the front of the lower belt on the opposite side of the body. Thus, if the left sterno-mastoid is contracted and has been divided, the chain is attached above over the right mastoid process and below over the front of the left axilla, traction being thus made in the direction of the weakened right sterno-mastoid muscle. In some cases more efficient support is necessary, and may be obtained by the use of Chance's back splint (p. 441), to the upper end of wliich arms are attached, bringing pressure to bear upon each side of the head in suitable directions. WTiere, however, osseous changes are present, the deformity may persist to a great extent, in spite of combined operative and mechanical treatment. 3. Spasmodic torticollis is a condition which occurs most fre- quently in women about thirty years of age, in whom there is often a family history of insanity or nervous diseases, such as epilepsy, etc. It is characterized by clonic spasms of the various muscles of the neck, especially the sterno-mastoid and trapezius, but the deep short rotator muscles are also affected in many cases. The head is continually being twisted and jerked into a position of torticollis, but other movements are often associated. The cause is some lesion of the nervous supply of the muscles, probably in most cases cortical. In a few instances irritation of peripheral nerves, as by inflamed glands, teeth, etc., may exert some temporary influence, but the true spasmodic wry-neck persists in spite of the removal or cure of such causes. The prognosis is always very unfavourable, since, even if the localized spasm is cured by appropriate operative treatment, other parts are likely to become affected. Treatment in these cases must be of a hygienic and tonic character ; peripheral sources of irritation must be removed, and careful in- vestigation made to ascertain that all the functions of the body are satisfactorily performed. Intestinal toxaemia, disorders of men- struation, and any other possible causes of irritation, must be re- lieved. Local applications of electricity of various types may be employed, as also various hydro-therapeutic remedies. Where THE SURGERY OF DEFORMITIES 435 these have failed, the spinal accessory nerve may be exposed, and eUher stretched or excised (p. 386). Not ^^^^^^^^^'p .^''l^^^' neriist in spite of this, and then it may be well to divide the pos- F ^^rMrv^ral nerves as they he on the semi-spmalis colli (Keen) Sd «^s flil." may beVstmable to deal with the cortical ""'nSerical wry-neck is occasionally seen, and must be carefully dife nt' afed from the above varieties. It may last for a varying neriod but under suitable treatment disappears completely. ^ A Cer^cal Rib is a deformity of not uncommon occurrence, .eneralTy noticed about the age of puberty. It is usually bilateral and arises most frequently from the anterior transverse process of the seventh cervical vertebra, but a similar outgrowth sometimes nrcurs from the sixth. It is composed mainly of cartilage at first, but a age advances it becomes osseous. It may be short and have a free end in the neck, but more frequently passes down to unite with the first rib near the scalene tubercle, or to gam attachment to rhfsternum occasionally it consists of two portions, an upper A fwpr Ignited together by a synchondrosis. No symptoms are and a lower, .^"1^:^^^^^^^^^ encroaches on the subclavian LTe'y'^ndTowe^aM m^e^^ brachial plexus. The vessel IS Dushed upwards and forwards, and becomes so prominent as at tiroes to be^mistaken for an aneurism; sometimes the pulse is im- paired when the arms hang down, and this may even determine San^renTof the finger-tips Nervous symptoms are referable to the first dorsal and eighth cervical nerve-roots, and appear m the orm of neuralgra along the ulnar border of the fore-arrn and httle 1 . nr of naralvsis inainlv of the intrinsic muscles of the thumb. 4'?ervicL nb^pres^n^^^^^^ swelling above the clavicle, and can be relddy recognised by radiography. Nothing should be done to it unless pressure symptoms are present, when removal may be reauked ^ An incision is made parallel to the anterior border of he lower portion of the trapezius ; the nerves and vessels are separated l?rthe mass of cartilage and drawn aside, and the growth carefully excised by gouge, chisel, or cutting phers. Deformities o£ the Spine. Scoliosis -By scohosis is meant a lateral curvature of the spine accompamed by rotation of the vertebrae. Conditions are met with inwS^he spine becomes deflected laterally as an occasional result of Pott s dfsease. or in fractures; such, however, are not generally ronsidered to be genuine scoliosis. . , Mogy-Th? following are the chief causes of scohosis: (i) It occurs te?v rarely as a congenital deformity, owing to malformation of The veTtebrI (2) It may commence m young children as a partly to their irregular growth. It is probably of^^^^.^"^^^^ the children being always carried on the same arm. The primary 436 A MANUAL OF SURGERY curve in this type is usually one directed towards the left in the dorsi-lumbar region. A similar change, due to the so-called ' ado- lescent rickets,' may also occur in children who are able to run about. (3) Any condition of asymmetry of the body may lead to what is known as compcnsatoyy scoliosis — e.g., congenital shortness of one leg, unilateral dislocation of the hip, contractions of the knee- or hip-joint, genu valgmii, falling in of the chest wall as a result of empyema, and even old-standing torticollis. If one leg is short (Fig. 153), the pelvis is tilted down on that side in order to bring the foot to the ground, producing a lumbar curve with the con- vexity towards that side, whilst a compensatory dorsal curve in the opposite direction is subsequently added in order to maintain the general axis of the body (A^). If, however, the short leg is also persistently adducted, as in old hip disease (Fig. 154, B), the spine will be curved in the opposite direction in order to maintain the paral- lelism of the limbs (B^). \Mien due to empyema, a primary dorsal Fig. 153.- — Scoliosis due to Shortening of the Left Leg. .^ Fig. 154. — Scoliosis due to Adduction of the Left Hip. curvature is produced, with its convexity towards the sound side. In torticollis the cervical curve is primary, and a compensators- curve in the opposite direction in the dorsal region usually follows. (4) The most common type, however, is the scoliosis of adolescents, met with in young people about the age of puberty, or a little older, who are in a weak and asthenic condition, often as a result of rapid growth, combined possibly with improper or insufficient food, defective hygienic surroundings, or exposure to hard work, whereby undue muscular fatigue is induced. Young women of an anaemic type who suffer from amenorrhcea, and who as housemaids or factor}^ hands have to undertake a good deal of lifting, are especially hable to this condition. It is due to a relaxed state of the ligaments and muscles, which have not developed pari passu with the weight and length of the skeleton; it is therefore not unfrequently asso- ciated with flat foot and genu valgum. Prolonged standing in a position of ease or rest, in which the weight is mamly carried on one THE SURGERY OF DEFORMITIES 437 leg, may determine its occurrence, as also faulty positions occupied by children at school, owing to low desks and want of support to the feet. The Phenomena vary considerably according to the character and extent of the lesion. Sometimes the whole spine is inv^olved in one curve [total scoliosis) ; but more usually two curves are present, one primary, the other compensatory. It is by no means uncommon for this condition to be associated with kyphosis, but the absence of the vA ^^^-^J'y Fig. 156. — Spine in Scoliosis seen FROM IN Front. (Tillm.\nns.) Fig. 155. — Photograph of Ordin- ary Type of Adolescent Scoliosis. The apparent asymmetry of the legs is in this case a photographic error ; in reality they were both well developed. latter, in what is sometimes termed the ' fiat-backed ' type, is no criterion of the slightness of the case. The most usual variety is that in which there is a double curve, with the dorsal convexity to the right and the lumbar to the left (Fig. 155). It will be desirable to describe this carefully, whilst for the opposite condition all that is necessary is to transpose the words ' right ' and ' left,' or, as Hoffa has put it, one variety is the ' mirror picture ' of the other. 438 A MANUAL OF SURGERY In addition to the lateral displacement, the bodies of I he vertehrce (Fig. 156) are always rotated towards the convexity of the curves. This is probably a purely mechanical act, and due to the more firm support given to, and the interlocking of, the posterior parts of the vertebrae. As a result, the spinous processes are directed towards the concavity, and hence always indicate a smaller amount of dis- tortion than really exists. Occasionally there may be some back- ward projection of the spines at the junction of the two curves. The thoracic icalls necessarily participate in the process, and the amount of thoracic deformity is perhaps the best measure of the degree of rotation of the vertebra;. The ribs on the right side become to some extent separated from one another, and project posteriorly on account of this rotation (Fig. 157) ; the amount of curvature at the angle is consequently in- creased, whilst the front of the chest on this side of the body becomes flattened. On the left side the ribs are huddled together, and the curve at the angle diminished, the ribs being therebv opened out ; consequently, the thorax is flattened posteriorlv on that side, but projects in front; the left breast may thus be rendered prominent. In fact, the thorax becomes more or less rhomboidal in shape. The sternum also is somewhat displaced towards the con- cavity, and twisted so that the anterior surface looks to- wards the right. The capacity of the thorax is not as a rule affected at first, but in the later stages it is considerably diminished, and the abdominal viscera may even be displaced. The scapulce follow the thoracic wall, and hence the right shoulder is pushed upwards and outwards, and it is for this ' growing out of the shoulder ' that the majority of cases come under observation. The effect on the waist varies with the situation and extent of the curves; if the dorsal and lumbar curves are nearly equal, then the true waist on the right side becomes more marked than usual, corresponding to the lumbar concavity, and in advanced cases a distinct sulcus may be present between the lower ribs and the crest of the ilium. On the left side the hip appears to project (' growing out '), owing to the deflection of the trunk toweirds the right side (Fig. 155), whilst the dorsal concavity higher up may simulate a false waist. The erector spina muscle 'stands out unduly on the left owing to the rotation of the vertebra:. Fig. 157. — Section of Thorax in Scolio- sis. (After Holmes and Hulke.) THE SURGERY OF DEFORMITIES 439 whilst the transverse processes on this side may be unusually evident. In the early stages the characteristic deformity disappears on ex- tension of the trunk, as by hanging from a trapeze, or on bending for- wards ; but as it progresses, the spine becomes more and more fixed, and but little alteration is produced by suspension of the patient. In the worst cases, especially when associated with kyphosis, the de- formity becomes so marked as to simulate the ' hump ' formed in Pott's disease, and the patient's stature becomes dwarfed and stunted. Subjective symptoms, such as neuralgic pain and weakness, are also present, but usually they are not very prominent features. Anatomical Changes. — The structure of the spinal column is at first not manifestly altered, but as soon as the deformity becomes chronic, the individual vertebrse become mis-shapen. The bodies become wedge-like on section, being thicker on the convex than on the concave side. The intervertebral discs are similarly changed, whilst the articular processes are unduly pressed together on the con- cave side, and separated from one another on the convex. The transverse and spinous processes are also approximated to one another on the side of the concavity, and often curved. The liga- ments, which in the early stages are relaxed, becomes secondarily shortened on the concave side, and may indeed disappear, the bodies of the vertebrse being ankylosed. The muscles accommodate themselves to the altered curves of the spine, and hence are con- tracted on the concave side and stretched on the convex. It is most essential that a correct Diagnosis be made as soon as possible, since so much depends upon early treatment. A thorough examination should be made with the clothes stripped to below the waist, so that the whole back can be seen. The patient should be made to sit straight up on a stool or chair placed sideways, and the surgeon stands behind her. The general appearance is first noted, and then the spinous processes are marked out one after another with a spot of ink or with a flesh pencil. The shape of the thorax, the curvature of the ribs, and the position of the scapulae, are also ascer- tained, and the length of the legs is measured. The patient is then made to stand, to hang from a bar, and to bend forwards, and the effects of these respective movements noted; by this means some idea can be obtained of the extent and nature of the deformity. There can be but little risk of mistaking it for Pott's disease, since the rigidity, deformity, and localized pain of the latter are so charac- teristic; in those cases of scoliosis, however, where there is a pro- jection of the spinous processes backwards, a mistake might easily arise if only a careless examination were made. The Prognosis necessarily varies with the stage which the affection has reached. In early days, before the deformity has become set, and when it disappears on extension of the spine, it is almost certain to be entirely cured, if suitable precautions are taken. Later on it can be improved to some extent, but in bad cases all that can be expected is to prevent it from getting worse. 440 A MANUAL OF SURGERY In tlie Treatment oi scoliosis, the cause of the trouble must not be oveiiooked, since in many cases the deformity may be remedied, or at any rate prevented from increasing, by attending to this. Thus, inequality in the length of the limbs necessitates the wearing of a high-heeled boot, whilst contractions of the knee- or hip-joints should, if possible, be corrected. In that variety which occurs in young people from constitutional or local debility, the general health must be improved by a visit to the seaside, or the administra- tion of tonics such as iron and arsenic. Carefully-ri'gulated rest and exercise must also be recommended, so as to improve the muscular tone of the back without unduly fatiguing the patient; for a similar reason massage and cold baths are beneficial. All errors of position must be corrected, and suitable desks, forms, and chairs utilized. In the slighter cases it often suffices to order the patient to rest in the supine position on an inclined board for an hour or two daily, the head being thus raised and the spine extended. Calisthenic movements and gymnastic exercises, especially on the horizontal bar and trapeze, constitute the most important element of treatment, which may be looked on as curative in early and moderate cases, and as palliative in the advanced stage. Of these exercises, the details of whicli vary with each patient, some are arranged so as to extend and render mobile the spine, and gener- ally to improve the tone of the spinal muscles; others are devised so as to undo the abnormal curves present. Space forbids us describing them here, and we must refer readers to special text-books. A spinal support is often useful, but should not be worn continuously, except in bad cases, as it renders the muscles of the back weak from disuse. All that is needed in the early stages is the support of a firm, care- fully-fitted corset; but should the deformity increase, stronger steel instruments may be employed in which springs are incorporated, whereby it is hoj)ed that correc- tion of the curvature may be brought about. In the worst cases, where the deformity is irremediable, much can be done by a skilful mechanism to hide the deformity and prevent its increase. Kyphosis.^ — By this term is meant a condition of in- FiG. 158. creased dorsal convexity of the back (Fig. 158), which is Kypho-sis. often associated with loss of the lumbar concavity, so that the whole spine is arched backwards. Occasionally, however, a marked lumbar lordosis is present as a com]xmsatory condition. Ihe chief varieties of kyphosis are as follows: I. Kyphosis from defective growth or habit. This may occur {a) in children under the age of four, resulting from rickets; (b) in adolescents up to the age of sixteen (round shoulders), from a continuous habit of stooping, as in reading or writing, especially in those suffering from myo])ia; (c) various forms oi occupation, which involve the carrying of hea\-y weights, or stooping over work. THE SURGERY OF DEFORMEriES 441 w lead to its appt'arance in adults, as in porters and cobblers (Fig- 159); ((/) in old men it results from senile atrophy. 2. Kyphosis from general diseases of the spine is a marked feature in spondylitis deformans, osteitis deformans, osteomalacia, h3'pertrophic osteo-artlu\)pathy, and acromegaly. In the latter disease the condition is limited to the dorsal region. 3. Kyphosis from localized injury or disease of the spine is some- times described, although it is more commonly known by the con tradictory term ' angular curvature.' It results from fractures. Pott's disease, gumma, or cancer [q.v.). Treatment is impossible in the majority of cases, but the round shoulders of young people come so commonly under obser- vation that a little more notice of the con- dition is needed. Round Shoulders occur most frequently in girls who have grown rapidly, and per- haps developed precociously. The con- dition is often due to defective habits of sitting and standing, especially at school, and may be induced by faulty desks and chairs, whilst other intrinsic conditions, such as mvopia or adenoids, may also be primarily responsible. The spine becomes bent forwards in the cervico-dorsal region ; at first the deformity can be voluntarily corrected, but not so later on. Treatment. — In the first place the cause must be ascertained, and if possible, re- moved; in particular, chairs and desks must be arranged so as to ensure that the child sits in a good position, and does not stoop whilst writing, reading, or playing the piano. In particular, the back should be supported whilst reading, and the feet should not be allowed to dangle. The muscles of the back, especially the trapezii, the erectores spinae, the rhomboidei, and the serrati, must be strengthened by massage, electricity, and exercises, the latter necessarily directed towards extension of the back. The girl should never be allowed to fatigue herself unduly, and must rest on her back two or three times a day for half an hour. At night she should lie on her back, without a bolster, and with a pillow beneath the curve. The general nutrition and health must also be attended to, and a course of suitable tonics prescribed In bad cases where the deformity is marked and it is feared it may be progressive, a light support may be required; a Chance's splint* * Many modifications of Chance's original splint have appeared, but the essential features of all are the presence of a metal pelvic band, from which Fig. 159. — Acquired Oc- cupation Kyphosis in a Young Man, from Exces- sive Weight-carrying. 42 A MANUAL OF SURGERY will do as well as an}-, but of course the exercises must be persisted in. Lordosis (l^g. 160) is almcjst invariably a secondary or compensa- tory conditi(jn, and consists in an increased anterior curvature of the spine in the lumbar region. It is usually produced by continued fiexion of the hip, whether due to congenital disi)lacement, unre- duced dislocation, malunited fracture, or to hip disease, and in such cases it is irremediable unless the malposition of the femur can be corrected. It is seen as a temporary condition in pregnancy, and as a more persistent phenomenon in bad cases of uterine fibroids, owing to the increased weight of the uterus or its contents, necessitating backward displacement of the upper part of the spine in order to adjust correctly the centre of gravity of the body. The same may be noticed in persons with large, fat, and pendulous abdomens. It is occasionally present in progressive muscular atrophy where the lumbar and abdominal muscles are weakened, and usually in pseudo-hypertrophic paralysis from loss of power in the gastrocnemii and other muscles engaged in maintaining the erect posture. Spondylo-listhesis is the term applied to a curious and somewhat uncommon deformity, in which the lumbar vertebra slip forwards and downwards from the top of the sacrum. It arises from fracture of the articular processes of the lumbo-sacral syn- chondrosis, or from imperfect development of the laminae or pedicles of the lowest lumbar vertebra, as a result of which the pressure of loads carried on the shoulders or the weight of a pregnant uterus brings about the dis- placement. In the latter instance the enforced lordosis aggravates this tendency. The effects produced are shortening of the stature, together with the formation of a marked hollow above the sacrum, whilst the lumbar vertebrae are unduly prominent anteriorly. The condition is accompanied by neuralgic pain and weakness. The only treatment is prolonged rest in the recumbent posture, and possibly the application of a leather jacket, moulded to the pelvis, and supplied with crutches, so as to carry part of the weight downwards from the axillae to the pelvic support without utilizing the spine. Fig. 160. — Lor DOSIS. Deformities of the Upper Extremity. In Congenital Elevation of the Scapula (Sprengel's Shoulder) the scapula may be normal in size or a little smaller than usual, but is situated above its proper position, and rotated so that its lower rises a single or double bar of malleable iron, fitted to the back, and capable of having its curve altered. Lateral supports spring from the central bars or bar, and straps to fix it in position are also provided. THE SURGERY OF DEFORMITIES 443 angle is approximated to the middle line. The muscles attached to "its upper border are prominent; in a few instances a cartilaginous or osseous band has replaced them, passing between the upper angle of the bone and the seventh cervical vertebra. The lower third of the trapezius is often defective, as also the serratus magnus. The disability, which is usually slight, depends on the condition of these muscles, but the affected arm is sometimes smaller than its fellow. A slight degree of scoliosis develops as a compensatory phenomenon. The only active treatment consists in dealing with the affected muscles by removing the cartilaginous or osseous band ; otherwise massage and exercises are required. A Winged Scapula is a condition characterized by projection back- wards of the vertebral border and lower angle of that bone when the arm is thrust forwards (Fig. i6i). It is due to paralysis of the Fig. i6i. — Winged Scapula. serratus magnus and rhomboids, resulting from neuritis or trauma of the roots of the fifth and sixth cervical nerves, or of the special branches to these muscles; the nerve-roots are not unfrequently tender on pressure. Treatment consists in massage and faradism, whilst, if persistent, a suitable apphance may correct the deformity. Various types of Club-hand occur, in which the hand is deflected to one or the other side, or is hyper-extended or flexed. Perhaps the most frequent cause is a congenital absence of the radius, under which circumstances the hand is radially abducted to a marked degree, the ulna is shortened and curved, and its lower epiphysis expanded, so as to articulate with the carpal bones. Where the bones are normal, the hand is usually flexed and adducted towards the ulnar side. In any of these deformities radiography should be employed, so as to ascertain the exact relation of the bones to each other. 444 ■' MANUAL OF SURGF.IiY Congenital Deformities oi the Finger arc much more common, iind the account licrc given of such defects of the uj^per extremity applies with equal force to those which occur in the lower. The following \arieties may be alluded to: Polydactylism consists in the presence of supernumerary fingers and toi's. There may be from one to seven additicnial digits, and the condition is usually symmetrical. One case is on record with twelve and thirteen lingers on the hands, and twelve toes on each foot. The accessory digits are often stunted, and smaller in size than the normal, but may be of average dimensions. Usually they are separated from the true digits, but now and then may be blended with them. The correct number of metacarpal or metatarsal bones may be present, or they also may be multiplied. In one of Fig. 162. — Magrodactyly and Syndactyly. In this case a child, aged two and a half years, had the ring and niidiUc fingers united laterally into a large mass which projected far beyond the others. The middle finger was normal in size, the ring finger was hypertrophic. A fruitless attempt was made to save the middle finger, but both had finally to be amputated. our cases there were six digits and six metatarsal bones; but the last two digits were supported by an accessorv metatarsal apparently springing from the outer side of the fourth. The condition is frequently inherited. 1 he Treatment consists in removing the super- numerary digits, if useless, obtrusive, or troublesome. Sometimes the patients are proud of their abnormalitv, and refuse to part with it. Ectrodactylism, or the absence of one or more of the digits, is occasionally seen, as also partial arrests of development of fingers or toes, or intra-uterine amputation at a higher level. Macrodactyly (Fig. 162) consists in a congenital overgrowth of one or more lingers or toes. The structures are perfectly normal in character, and merely gigantic in size for the age of the individual THE SURGERY OF DEFORMITIES 445 Aniinitation or excision mav be needed in these cases, as the de- formed parts grow out of all' proportion to the neighbouring tissues. 1 hus, an infant with enormous overgrowth of the second toe of the right foot was successfully treated by excision of the digit, together with a V-shaped portion of the foot, which was by this means reiluced to normal shape and size. Syndactylism, or webbed hngers, is a condition in which two or more fingers are joined together laterally, either by a thin web con- sisting mainly of skin, or by a thick fleshy bond of union. In the foot no treatment 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- formation from above downwards, as healing proceeds, a flap of skin must be trans- planted 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, however, is thick and fleshy, a more extensive operation is needed. Iwo 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 (Fig. 163, A) and from the palmar aspect of the other (B), in such a manner that, after the web has been divided, the denuded surfaces can be covered by wrappmg the flaps round ttie lateral aspects of the fingers and suturing them m position. An additional flap of skin must also be fixed in the angle between the separated digits. j r -4. Congenital Contraction o£ the Fingers is not a very rare deformity being frequentlv inherited ; it is usually limited to the little finger and may be associated with congenital hammer-toe. It_ is due to con- traction of the central prolongation of the palmar fascia m the finger whereas Dupuytren's contraction involves the palmar fascia itselt and its lateral prolongations into the fingers. Moreover, m the congenital variety the first phalanx is hyper-extended, and the second and third flexed, whereas in the acquired form the first and second phalanges are flexed and the third is hyper-extended. Treatment.— It often suffices to use massage and apply a splint, but in bad cases division of the fascial bands may be needed. Acquired Deformities of the Hand.— After burns the hands may be contracted into a useless mass in which the fingers are drawn into the palm and united by cicatricial tissue to the palmar structures, so that all treatment is hopeless. . .^ Spring-, Jerk-, or Snap-finger is a condition m which, when the patient attempts to open his hand, one finger or the thumb remains flexed, and on extending it with the other hand it flies open with a Fig. 163. — Operation FOR Syndactyly. 446 A MANUAL OF SURGERY jerk or snap. Slight tenderness is usually felt near the metacarpo- phalangeal articulation, and the cause of the trouble is some ob- struction to the free working of the long tendons under the trans- verse ligament at the root of the fingers, or between the sesamoid bones of the thumb. In a few cases a ganglion has been present here, but in most instances the condition is due to an increase in size of the sesamoid bone which ra(li(>gra]:)hy has taught us occurs constantly in this situation. Treatment consists in an aseptic incision to remove the cause of the obstruction. A Mallet Finger is one in which the terminal phalanx is maintained in a state of flexion owing to some damage to the extensor aponeu- rosis. Its treatment in the early stage has been already alluded to (p. 417) ; should tlie deformity be persistent, an incision is made on the posterior aspect of the finger, and the weak tendon isolated and stitched down in such a way as to give it a better attachment to the bone. Fig. 164. — Dupuytren's Contraction. Contraction of the Palmar Fascia (Dupuytren's Contraction). — This condition is usually met with in middle-aged individuals of a gouty temperament, more often in men than women, and not unfrequently 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 overgrowth and contraction of the fascia, inflam- matory in nature, and cirrhotic or sclerosing in type. It commences as an indurated subcutaneous nodule in the palm of the hand, about the situation 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 it increases, are graduall}^ drawn into the palm and fixed, so that extension becomes impossible (Fig. 164). The flexion is limited to the first THE SURGERY OF DEFORMITIES 447 and second phahinges, the third remaining extended, and, indeed, sometimes assuming a position of hyper-extension, owing to the injudicious appUcation of a spUnt. The skin over the indurated masses is sooner or later incorporated with them, and may become dimpled or creased by the traction of the subcutaneous connecting bands. The Diagnosis of Dupuytren's contraction is exceedingly easy, the only condition for which it is likely to be mistaken being the con- genital contraction already noted, and the flexion of the finger due to contraction, division, or destruction of the long tendons. In the latter case there is, as a rule, no palmar induration, but there will be a history of injury or inflammation, and some scarring (see P- 417)- 'i he only satisfactory Treatment is by operation, and the following methods are those which are most successful: [a] Adams' subcu- taneous section of the fascia and its prolongations consists in dividing the indurated bands by a tenotome in several places, where they can be felt tense. Orie puncture and division must be made in the centre of the palm ; a second divides the same band as near the finger as possible, whilst the third and fourth deal with the lateral prolongations at the sides of the finger; if other bands still exist, they are treated similarly, the tenotome, if possible, in all cases being inserted between the skin and the fascia. The improvement thus produced must be maintained and increased by the subsequent use of suitable apparatus and passive movements, but the final results are not very satisfactory, {b) Kocher's method consists in the total extirpation of the thickened bands and their prolonga- tions through longitudinal incisions. The fingers are at once straightened, and subsequent contraction is prevented by mechanical appliances. Many excellent and lasting cures have resulted from the latter operation. Deformities of the Lower Extremity. Congenital Dislocation of the Hip is by no means rare, although its causation is still quite uncertain. It is frequently bilateral, though more commonly unilateral ; it occurs much more often in girls than in boys. It may pass unnoticed until the child begins to walk, and then the characteristic signs become evident. The limb is shortened and flexed on the pelvis, owing to the traction of the ilio- psoas muscle, resulting in a considerable amount of lordosis (Fig. 166) , whilst scohosis is well marked in one-sided cases. Since the head of the femur is displaced from the middle line, a gap is usually noticed between the thighs close to the perineum. Considerable adduction of the lower end of the femur is present (Fig. 165), and in bilateral cases a scissor-leg deformity may ensue. The patient's gait is of a curious 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. 448 A MANUAL OF SURGERY it can often be drawn down at first, and the leg thus lengthened to the extent of an inch or two ; moreover, it is often easy to reduce the displacement and put the head of the bone in the acetabulum in children that have not walked much. 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 consideral)ly according to whether or not the child has walked. At birth the head and neck are some- times nearh' normal in shape, and located near the acetabulum ; ^- Fig. 165. Fig. 166. Congenital Dislocation of Both Hips in a Girl of Fifteen Years, seen FROM the Front and Side. (From Photographs kindly lent by Mr. J. Jackson Clarke.) generally, however, the head is rather small and perhaps flattened at the spot where it rests against the innominate bone, and the neck is short and stunted. The ligamentum teres is long, thin, and band- like. 1 he acetabulum is smaller and more shallow than usual ; it can often receive the head of the bone, though it cannot retain it. The capsule is large and room}^ After the child has walked, sundry modi- fications make themselves evident. The head of the bone becomes more and more displaced, so that finally it may lie well above the acetabulum on the dorsum ilii (Fig. 167). The capsule becomes THE SURGERY OF DEFORMITIES 449 Stretched over the displaced head, and much thicker than usual ; the ligamentum teres is elongated. The head of the bone is consider- ably altered and often much deformed; the acetabulum 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 ver\' imperfect, acetabulum forms on that portion of the dorsum ilii where the head of the bone rests. Treatment is usually dela^-ed until the child is two or three years old, and able to walk. In the meantime, if a diagnosis is made, the head of the bone is drawn down into the socket night and morning Fig. i6: -Radiogram of Double Congenital Dislocation of the Hip-Joint. The noticeable points are the absence of the acetabular cavities and the dis- placement upwards and distortion of the heads of the femora. (a matter of no diflficulty, as a rule), and worked about therein, with massage to the surrounding muscles. Some surgeons recommend the use of prolonged traction even at this early period. At a later age (up to five or six years) Lorenz's bloodless method of treatment may be employed with some hopes of a successful issue, at any rate, 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 aucesthetic. The adductor muscles are the chief hindrance, and will require a good deal of kneading, or even possibly section with a tenotome. The anterior and posterior muscles must also be fully stretched by forcible flexion and hyper-extension of the limb. (2) The head of the bone is to be replaced in the acetabulum, and 29 450 A MANUAL OF SURGERY as this cavity is small and chink-like, and sometimes covered in by the front of the capsule, a good deal of difficulty may be here ex- perienced. The limb is fully flexed and then firmly abducted, extended and everted; upward pressure from behind, as by the fingers or the insertion behind the trochanter of a leather-covered wedge (Lorenz), may be of assistance. 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 cavity. (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 hyper-extended. It is maintained in this position for ten or twelve weeks, and it is well to ascertain by radiography 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, and then massage and exer- cises will be required. Where actual reduction has failed, benefit is often obtained by forcing the head of the bone forwards into the neighbourhood of the anterior superior spine; the gait is manifestly improved by diminish- ing the tilting of the pelvis and the lordosis. In older children (from five to ten years) treatment by open opera- tion can be undertaken. The joint is opened from the back or front, the head of the bone is shaped up, the acetabulum enlarged so that the head can be replaced in it, and any tense structures divided 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 ankylosis results, the patient's gait is considerably improved. Coxa Vara, or incurvation of the neck of the femur (Fig. 168) , is a condition in which the neck of the bone, instead of passing obliquely upwards, is horizontal, or in bad cases directed downwards, whilst shortening from interstitial absorption also occurs, and the head becomes mushroom-shaped. At first the osseous tissue is softened, but after a while sclerosis supervenes. It is met with in children as a result of rickets, or perhaps more frequently in young adults, when it is sometimes due to the adolescent form of the same disease. Certainly it is seen most frequently in those who have to do much walking or carrying of heavy weights. In some cases it results from a gradual slipping down or traumatic separation of the epiphysis, which constitutes the head of the bone, or from a fracture of the neck in a child, followed by yielding of the callus. The Symptoms commence with pain in the region of the hip, followed by a distinct limp. As the neck of the bone becomes absorbed or curved, the trochanter rises above Nelaton's line, and THE SURGERY OF DEFORMITIES 451 real sliortening of the limb occurs, even up to i\ inches. The hmb is also everted and the trochanter increasingly prominent, especially on flexing the thighs. Internal rotation and abduction of the joint are limited, the latter being practically impossible in the more severe cases, owing to the base of the trochanter hitching against the lip of the acetabulum. On flexing the limb, the thigh sometimes lies across the sound one, whilst in the later stages the adduction may be so marked as to constitute a scissor-legged condition. As distin- guishing features may be mentioned: the absence of local swelling or tenderness on pressure, as also of the up-and-down movement on traction, so well marked in congenital dislocation, whilst suppuration never follows, and thickening of the tro- chanter is not observed. Treatment. — In the early stages rest is the essential, and thereby any in- crease in the deformity already exist- ing is prevented; local massage and manipulation are also advisable, whilst in children prolonged extension with inversion may do good. In the later stages, sub-trochanteric osteotomy, in order to alter the axis of the bone, is perhaps the best measure to undertake, although a cuneiform osteotom}' of the neck is recommended by some. The subsequent shortening may be dealt with by means of a thick sole on the under surface of the boot. Coxa Valga is the term applied to the opposite deformity, in which the axis of the neck of the femur approaches more to that of the shaft, and the angle of inclination between the two is greater than the normal 125°. It is usually secondary to congenital dislo- cation or infantile paralysis, and largely due to the absence of the transmission of the body-weight. The limb is usually abducted and rotated outwards, and there is some limitation of adduction and internal rotation. The trochanter is flattened and displaced below Nelaton's line. Treatment, if necessary, is usualty directed to the cause; but if the resulting limp is seriously noticeable, a sub- trochanteric osteotomy may be desirable. Congenital Affections of the knee are mainly connected with the patella, which is sometimes absent, and then other deformities are associated with its non-development. The extensor tendon passes down the front of the knee as a thick band, and the function of the joint is not much impaired. Congenital Dislocation of the Patella may be present as a persistent lesion, the bone lying to the outer side of the joint; but more com- FiG. 168. — Coxa Vara. The dotted lines represent the normal neck of the femur. 452 A MANUAL OF SURGERY monly tlie displacement only occurs at intervals, and then produces acute pain followed by synovial effusion. Replacement is easy when the joint is extended. '1 he cause of the trouble is either an imperfect development of the external condyle of the femur or abnormal laxity of the capsule. Genu valgum may be associated with the former, and paralysis of the extensor muscles with the latter. Treatment consists either in tightening up the capsule and synovial membrane by excising a portion on the inner side of the patella, or in correct- ing the genu valgum. Some surgeons have cliiselled off the tubercle of the tibia with the attached ligamentum patellae, and refixed it on the inner surface of the tibia. Genu Valgum, or knock- knee, is a deformity in which, if the knees are allowed to touch with the patelUe look- ing forwards, the malleoli are separated one from the other — i.e., it is a condition of fixed abduction of the legs from the middle line, with some external rotation (Fig. 169). One or both limbs may be affected, but if due to general causes the double form is more common. Occasionally genu valgum Fig. 169.- -Genu Valgum of Rachitic Origin. The patient was a child aged twelve years, and the cause of the deformity was rickets. The femora were curved antero- posteriorly, but radiography demon- strated that the trouble in the right leg was as much tibial as femoral in origin. Cuneiform osteotomy of both tibia and iemur was needed on the right side, whilst simple osteotomy of the femur sufficed to correct the left side. occurs in one leg, whilst the other is in a condition of genu varum. 1 here are two main varieties of the disease, viz.: (i) The rachitic genu valgum of young children, and (2) the static form occurring in ado- lescents. The genu vaLgnm of young children arises from the ir- regular epiphyseal development induced by rickets. Increased growth occurs on the inner side of the joint, and this may involve equally the femur and tibia, although most frequently the former is mainly affected. When once the axis of the limb is altered, the weight of the trunk is transmitted chiefly through the outer portion of the joint, and development on this side is thereby hindered. In not a few cases an antero-lateral rachitic curvature of the diaphysis of the femur is an important element. THE SURGERY OF DEFORMITIES 453 The Static genu valgum of adolescents occurs most commonly in voung people of relaxed constitution, and particularly m those who have to carry heavy weights. Thus, anemic girls who act as nurse- maids, and young "bricklayers, smiths, and porters, are very hable to it The method of origin is probably as follows: In the erect posture the femur is normally set at an angle to the tibia (which is Vertical) in such a way that the weight of the trunk passes rather through the outer than the inner condyle, whilst the latter structure is lengthened in order to keep the plane of the knee-]omt horizontal. 1 his position naturally throws a certain amount of strain and tension on the internal lateral ligament, even in a healthy person (hence its insertion into the shaft and not merely into the upper epiphysis oi the tibia) ; and this strain is increased when the natural position of rest— ^ 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 hmb which tend to counterbalance this strain especially if a certain amount of additional weight has to be carried, and par- ticularly in those whose bones have rapidly increased m length and weight "without any coincident increase in power of muscles or ligaments. Hence the internal lateral ligament becomes more and more stretched, and not unfrequently a certain amount of lateral mobihty of the knee is noticed in the early stages. Subsequently the outer condyle becomes atrophied from more weight being trans- mitted through it, and the inner condyle becomes lengthened from overgrowth. Flat-foot and lateral curvature of the spme often accompany this form of genu valgum, the former being also usual y due to ligamentous relaxation, whilst the latter may be merely compensatory if the deformity in the knee is unilateral. Occasionally genu valgum is due to traumatic causes such as fracture of the tibia or femur close to the joint, or lateral dislocation of the knee; whilst, again, it may be caused by atrophy consequent on interference with the epiphysis from local injury or diseases other than rickets. It is sometimes observed, as a result of ridmg, m those with long legs, as in cavalry soldiers; short-legged individuals, such as iockevs, are more liable to develop a condition of genu varum. The Physical Condition of the parts about the knee may be sum- marized as follows: [a) The inner condyle of the femur is elongated and prominent; the increase in size is mamly m the vertical ana • transverse directions, and but very little antero-posteriorly, so that, on flexion of the joint, the deformity to a large extent disappears, (b) impaired growth and atrophy of the outer femoral condyle and tibial tuberosity are present owing to the weight of the body being transmitted more directly through these structures; (c) relaxation ot the hgamentous and muscular tissues takes place on the inner side of the joint; this, however, is not constant, especially m the later stages, or in cases which are stationary; {d) the tendons and liga- ments on the outer aspect of the joint are contracted and shortened especially the external lateral ligament, the iho-tibial band, and the tendon of the biceps; {e) the patella tends to be thrown outwards. 454 A MANUAL OF SUIiGERY and in bad cases recurring dislocation is sometimes observed; (/) in rachitic cases a localized bony outgrowth can usually be detected on the inner surface of the tibia about 2 or 3 inches from the joint, and probably due to a localized periostitis at the point of attachment of the internal lateral ligament. 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, scoliosis may result. In well-marked cases the gait of the patient is of a rolling or waddling type, and very charac- teristic. 1 he legs are partially flexed, and as tiie condyles t(juch or overlajx tliey have to be separated at each step to allow of progression. Treatment. — In rachitic cases, the infant requires the adoption of dietetic and therapeutic measures suitable to the condition present. For the local deformity absolute rest in bed is enforced; the limbs are well rubbed daily, and such manipulation and pressure employed as will help to straighten the limb. By perseverance slow but appreciable progress may be made until the deformity is corrected. In older children, splints ma\' be applied on the outer side of the limbs, reaching from the waist or axilla down to the outer malleoli, or, if they are to be kept off their feet, beyond them. These are retained in position by water-glass bandages, put on firmly enough to draw the knees outwards. Such an arrangement is often sufficient in early cases to bring about a cure in the course of a few months. In static cases the administration of tonics, such as iron and arsenic, combined with rest, massage, and possibly a change of air, will frequently suffice to determine a cure in the early stages. Suitable apparatus must be adopted when the patient is allowed to walk; that usually employed consists of an outside iron stem, jointed at the knee, fixed 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, and any increase of the deformity is prevented. When, however, the osseous deformity is fixed, and the patient of such an age as to preclude the hope of a cure by mechanical means, osteotomy will be required, and the operation devised by Macewen, or some modification of it, is that generally employed. It consists in the division of the femur transversely about a finger's breadth above the upper border of the external condyle, so as to be well away from the epiphyseal cartilage. Macewen himself uses an osteotome* for the purpose, introducing it through an incision made J inch in front of the tendon of the adductor magnus, and turning it so as to lie at right angles to the long axis of the shaft ; he divides the bone for three-quarters of its diameter, and breaks the re- mainder. A similar method maj' be employed from the outer side, * An osteotome dilters from a chisel in the fact that the former is bevelled on both sides, whilst the latter is merely bevelled on one side. T?IE SURGERY OF DEFORMITIES 455 \ the force used in breaking the inner layer of compact bone com- minuting and compressing that portion, and so diminishing the deformity. Man}^ surgeons, however, prefer to divide the bone with a saw, previously making a track for it along the front of the femur, and we certainly consider that such an operation is simpler, and equally efficacious. The limb, having been straightened, is either put up at once in plaster of Paris, or, perhaps, at first in a Gooch's splint, which allows the wound to be looked at and dressed, and subsequently in plaster. Union .. is complete in six weeks, but an immoveable apparatus should be kept on for three months. In 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 the fibula will also have to be divided. WTien these wounds have consohda- ted, the femur is dealt with, if Fig. 170. —Bilateral Genu Varum. necessary. Genu Varum is a less common con- dition, characterized by a fixed separa- tion of the knees when the ankles are in contact (Fig. 170). It arises from three chief causes: (i.) Occupa- tion, and particularly that of a jockey, the short legs being constantly apposed to the sides of the horse; (ii.) trau- matism, especially if directed to the femoral condyles; and (iii.) rickets, the lesion usually present being a well-marked excurvation of the femoral shafts, with possibly a similar curve of the tibise {bow-leg). The condition is usually bilateral and sjmimetrical, but occasionally one side only is affected, whilst the other leg is in a state of genu valgum. Treatment in the early stage is by splints, in the latter by operation, which consists either in simple osteotomy above the knee, or in cuneiform osteotomy of the shaft of the femur. Genu Recurvatum, or back-knee, is a deformity occasionally met with, in which the joint is hyper-extended, the limb describing a curve with the concavity 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 limbs The patient was a girl of thir- teen years, who had devel- oped this condition during two years, and was the sub- ject of adolescent rickets. Enlargement of the epiphyseal ends of the radius and ulna, and of the costo-chondi^al junctions, was also present. 456 A MANUAL OF SURGERY not being flexed in utero, but extended with the feet under the chin. It is sometimes the result of paralysis of the extensor muscles, and is then due to the necessity for the patient to keep his knee fully or hyper-extended if it is to be a basis of support ; in time the posterior ligaments give way, and deformity results. Genu recur- vatum may also arise from irregular growth along the epiphyseal line, possibly as a sequela of tuberculous or other disease of limited Fig. 171. — Radiogram of Rachitic Curvature of Both Femora in a Child, aged Nine Years, who had suffered in Consequence from Many Fractures. The Tibi.^ also showed Typical Rachitic Deformities. extent in that region, and sometimes as a result of the disorganization of the joint in Charcot's disease. It has also been known to occur as an acquired accomplishment in fakirs and contortionists. Treatment must be suited to the special requirements of the individual case. Rachitic Deformities of the Bones of the Leg arc not unfrequent, if in the course of an attack of rickets a child is allowed to 11m about. The trouble may involve both segments of the limb, and give rise to a general excurvation, constituting what is known as hoxv-lcgs, the THE SURGERY OF DEFORMITIES 457 knees being widely separated the one from the other, and the antero-posterior curve being exaggerated. The femora are bent antero-posteriorly with the convexity of the curve forwards and outwards; the main convexity of the curve usually occurs about the junction of the upper and middle fourths, and here it may be so marked as to be a cause of spontaneous fracture. We have had a case of this nature under our observation for some years, where both femora had been frequently broken as a result of extreme rachitic distortion (Fig. 171). The tibia and fibula participate in this deformity, or are separately affected; the antero-postenor curve is usually increased, and some amount of abduction or adduc- tion may also be present. The bones in these cases are flattened from side to side, presenting a sharp edge in front, with a buttress- hke support or strut reaching along the concavity; they become exceedingly dense and sclerosed. . . , Treatment in the early stages consists of rest and constitutional treatment, and in the application of suitable apparatus to reduce the deformity. Where the femora are seriously affected, it may be necessary to provide the patient with apparatus (somewhat like a Thomas's knee-splint), which fits closely round the pelvis, and carries the weight to the ground by lateral metal rods which also maintain continuous extension. In the worst cases operation will be required, but never uiitil all signs of active disease have passed. The bones may be divided at their most prominent part, or, if necessary, a wedge-shaped portion may be removed {cuneiform osteotomy), the sections being made at nght angles to the upper and lower segments of the bone respectively. Careful and prolonged after-treatment, including the use of suitable splints, is required, especially where the femora have been divided, in order to prevent a reappearance of the deformity. The tibia and fibula also become distorted and curved antero- posteriorly as the result of inherited syphiUs ; this usually comes under notice at a later date than the rachitic change, and is due to a deposit of new bone under the periosteum rather than to bending. The deformity is purely antero-posterior, without lateral deviation, whilst the subcutaneous margin of the tibia is rounded, and not sharp as in rickets. Moreover, the curve generally involves the centre of the bone, whilst in rickets the chief deformity occurs either near the knee or a little above the ankle. Talipes. By tahpes, or club-foot, is meant a deformity of the foot due to muscular, hgamentous, or osseous causes, the displacement occurring mainly at the ankle and mid-tarsal joints. Causes. — Tahpes may be congenital or acquired. Congenital malformation is responsible for a certain percentage of the cases resulting from imperfect formation of the bones of the foot, occasionahy from absence of the lower end of the tibia or fibula, 458 A MANUAL OF SURGERY or very rarely from intra-uterine paralysis of central origin. Other cases are due to malposition of the feet in ntcro, possibly resulting from a deficient amount of liquor amnii, as a result of which the feet are abnormally compressed and held in one position. Naturally the legs of the foetus are in a state of flexion, and the feet usually in a position corresponding to that of tahpes varus; it is easy then to understand that in an unusually small uterus this position may become fixed. Spina bifida in the lumbar region is occasionally associated with congenital tahpes, 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 family, or be transmitted through many generations. The acquired varieties arise from some derangement of the equi- librium normally maintained between opposing groups of muscles, in consequence of which the more powerful group draws the foot into an abnormal position. Thus it may be due to: {a) Paralysis of central origin, one of the commonest causes of tahpes; in young children this form is usually the result of infantile palsy (anterior poho-myelitis), whilst a similar affection is occasionally seen in adults, [h] Cicatricial contraction of muscles from diffuse suppura- tion, or arising from burns or disease of neighbouring bones; thus necrosis or caries of the tibia may lead to the formation of an abscess in the sheaths of the tibiahs anticus or posticus, and contraction of one or both of these muscles may cause tahpes varus, (c) Essential muscular shrinking, resulting from a chronic myositis fibrosa, is occasionally met with in elderly people, [d] Affections of the main peripheral nerve-trunks of the leg also lead to talipes. If the in- ternal pophteal -nerve is involved, tahpes calcaneo-valgus will ensue, whilst a lesion of the external popliteal nerve produces tahpes equino-varus, but never to any marked degree, {e) Certain diseases of the cord of a sclerosing type occasionally cause a spastic variety of tahpes. (/) Shortening of the leg from hip or knee mischief often induces a compensatory talipes equinus, whilst injuries or diseases of one of the epiphyses of the leg bones may stop its grow^th, and then the continued development of the other bone forces the foot to one side or the other, (g) It is a question whether the condition known as flat-foot, arising from prolonged standing, is to be classed as a form of tahpes ; some surgeons draw but little difference between it and talipes valgus, [h) Finally, prolonged maintenance of the foot in a bad position may lead to permanent deformity, a^^in the variety known as talipes decubitus. Four primary forms of talipes are described, viz.: T. Equinus, in which the heel is drawn up, the patient walking on the toes (plantar- flexion) ; T. Calcaneus, in which the toes are raised from the ground (dorsi-flexion) ; T. Varus, in which the anterior half of the foot is adducted and inverted, and the inner side of the foot is raised, the patient walking on the outer; and T. Valgus, due to abduction and eversion of the anterior half of the foot, or to yielding of the longi- tudinal arch on the inner side. Not unfrequently mixed forms occur, THE SURGERY OF DEFORMITIES 459 due to the association of two of the above — e.g., T. equino-varus, or T. equino-valgus, or T. calcaneo-valgus. As to the relative frequency of these different forms, there is not the shghtest question that T. equino-varus is by far the commonest. If, however, we exclude congenital cases and fiat-foot, T. equinus is in all probability the variety most frequently observed. Talipes Equinus (Fig. 172, A, B, and C) is almost always acquired ; as a congenital lesion it is very uncommon. It is usually due to paralysis of the extensor muscles, either from infantile palsy or injury to the anterior tibial nerve; secondary contraction of the calf muscles follows, the tendo Achillis being tense and rigid. It also occurs as a compensatory manifestation where the limb has been shortened, as after hip disease, and may result from prolonged A B C Fig. 172. — -Various Forms of Talipes Equinus. pressure of the bed-clothes on the dorsum of the foot of a bed- ridden patient (T. decubitus). In the slightest cases all that is noticed is that the foot cannot be dorsi-fiexed beyond a right angle (right-angled contraction of the ankle) . When more marked, the heel is drawn up, and the patient walks on the heads of the metatarsal bones and on the toes, which are usually hyper-extended. In neglected cases due to paralysis, the toes sometimes become plantar-flexed, the patient walking on their upper surface (Fig. 172, C) ; the whole dorsum of the foot may even in time be turned downwards. The astragalus is displaced forwards from under the malleolar arch, only the posterior part of the articular surface being in contact with the tibia. In the paralytic type the anterior segment of the foot drops at the mid-tarsal joint, so that the head of the astragalus and scaphoid constitute a marked prominence beneath the skin. In all cases the sole of the foot is shortened by contraction of the plantar fascia and of the short plantar muscles (pes cavus), and a certain amount of varus is frequently present. 460 A MANUAL OF SURGERY In this, as in all forms of talipes, callosities, and perhaps bursse beneath them, form over points of pressure — viz., under the heads of all the metatarsal bones. Talipes Varus, or, as it is most frequently termed, Equino-varus, is the commonest variety of congenital club-foot, and is then often Fig. 173. — Double Talipes Equixo- VARUS OF Congenital Origin. Fig. 174. — The Same, seen from Behind. bilateral, and may be accompanied by other congenital defects — e.g., hare-Hp or spina bifida. As an acquired deformity, T. varus is not a very unusual result of infantile palsy affecting the extensor and peroneal muscles; other cases are due to a primary spastic contraction of these muscles. The heel is drawn up, and the anterior half of the foot adducted and drawn inwards (Figs. 173 and 174). The inner border of the foot is concave, and a well-marked trans- verse crease crosses the sole on a level with the mid-tarsal joint ; the outer border is convex, and in adults who have walked a thick bursal formation is usually present over the cuboid. In neglected cases the patient may even stand on the dorsal aspect of the latter bone (Fig. 175). The sole of the foot is arched from secondary contraction of the plantar fascia and short muscles of the sole, and a longi- tudinal crease may run dowTi the centre of the sole, owing to doubling over of the outer metatarsal bones. The most marked anatomical changes in the congenital type are found in the astragalus, the neck of which is elongated and inclined inwards at an angle of 50° or more to the body of the bone; the bone also projects forwards from under the tibio-fibular arch, the posterior portion of the upper articular facet alone re- FiG. 175. — Neglected Case of Talipes Varus. THE SURGERY OF DEFORMITIES 461 maining in contact with it. The scaphoid is displaced to the inner side of the head of the astragalus, and its tubercle is usually in close proximity to, or may even touch, the inner malleolus. The os calcis and other tarsal bones are also modified in position and shape to correspond with these changes. The dorsal tendons are displaced inwards, usually occupying the centre of the concavity between the foot and the leg. The hgaments on the inner side of the foot are contracted, especially the anterior portion of the deltoid, the inferior calcaneo-scaphoid, and to a less extent the long and short plantar ligaments. The following table (shghtly modified from Mr. Tubby's work on Deformities*) indicates the chief diagnostic points between con- genital and paralytic T. equino-varus : Congenital. Paralytic. History Affection has existed Affection not developed from birth. till the second or third year, and ushered in by convulsions, fever, etc. Feet affected Usually bilateral. More often unilateral. Circulation Good. Feeble ; limb is sometimes cold, blue, and clammy. Muscles But little wasting. Extreme wasting. Electrical Reactions Not much impaired. Almost entirely absent in paralyzed muscles. Growth of Bones . . Much as usual. Considerably diminished. Creases in Sole .... Present. Absent. Talipes Calcaneus is an unfrequent variety of the deformity, and may be either congenital or acquired. In the congenital form (Fig. 176) the toes are draw^n upwards so that the heel alone comes Fig. 176. — Congenital Talipes Fig. 177. — Paralytic Talipes Calcaneus, Calcaneus. with Well-marked Hallux Flexus. into contact with the ground, the sole pointing forwards. The extensor tendons are contracted, but the toes may be flexed owing to the tension of the flexor longus digitorum. It is sometimes * Macmillan, 1896, p. 398. 4^2 A MANUAL or SURGERY associated with deviation of the foot inwards or outwards, consti- tuting a condition of T. calcaneo-varus or -valgus. The acquired variety (Fig. 177) is generally due to infantile palsy of the calf muscles, or occasionally to overstretching of the tendo Achillis after tenotomy. The longitudinal arch of the foot is increased (pes cavus), partly from the development of a large pad of fat over the calcaneal tuberosities, but mainly from the dropping of the anterior half of the foot from the mid-tarsal joint. Tahpes Valgus is a condition seldom met with as a congenital de- formity, except in association with T. equinus. In it the foot is abducted and everted, owing to contraction of the peronei muscles. The sole becomes flattened, and the inner border of the foot comes in contact with the ground (Fig. 178). Considerable pain is usually experienced after walking a short distance. This Fig. 178. — Talipes Valgus (Congenital), WITH a Little Tendency to Calcaneus. Fig. 179. — Paralytic Tali- pes Valgus. deformity is occasionally due to absence of the fibula. The acquired variety, which is not uncommon (Fig. 179) results from paralysis of the tibial muscles, or from spastic contraction of the peronei, the condition in these cases closely simulating fiat-foot. The Diagnosis of the different varieties of tahpes is, as a rule, easily made, although the cause of the deformity is not always so readily ascertained. In paralytic cases the limb is generally atrophied, bluish in colour, and feels cold and clammy. Trophic lesions are not uncommon in the form of recurrent ulceration, and even ulcers of the perforating type may develop, especially in cases due to nerve lesions, whether central or peripheral. The trouble is often unilateral, and the muscles are wasted and flabby. In con- genital cases the condition is usually symmetrical, and of course present from birth; considerable resistance is felt on any attempt being made to correct the deformity, and the hmbs look healthy, are well nourished, at any rate at first, and free from trophic lesions. In spastic cases (most frequently T. equinus) spasm or contraction of other parts is usually present, which renders the diagnosis THE SURGERY OF DEFORMITIES 463 obvious; one or both limbs may be affected; the reflexes are ex- aggerated; the gait is characteristic; and the muscles, at first fninly contracted, may finally atrophy. The Treatment of talipes is always tedious, demanding care and patience on the part of all concerned. In the congenital variety no time should be lost in correcting the deformity, and, in fact, treat- ment should commence as soon after birth as possible. The nurse must be instructed to manipulate the foot into a good position, holding it there for some time daily, and the medical attendant may attempt more forcible correction two or three times a week. 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 treatment by the apphcation of suitable mechanical apparatus may suffice to restore the foot to its normal position. If this is un- successful, division of the contracted tendons, liga- ments, 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 equinus, if secon- dary to hip disease, should not, as a rule, be interfered with. In other early cases it may be remedied by what is known as Sayre's apparatus (Fig. 180). 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 limb, and as the traction X)f 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 walk subsequently with a plantigrade foot. Congenital T. equino-varus may be treated in the early stages by applying to the foot a carefully-fitted malleable splint (Fig. 181), the shape 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 patience many a cure will thus be obtained. In some. cases, the Fig. 180. — Sayre's Apparatus for Talipes Equinus. The upper figure shows how the strapping is fixed to the plantar splint. 464 A MANUAL OF SURGERY tendo Achillis and plantar fascia may be divided and the equinus and cavus elements cured, thereby rendering the varus condition more amenable to pressure. In cases where such early treatment has not been undertaken, or where the deformity has not been improved thereby, forcible correc- tion may be attempted. The child is placed under an anaesthetic, and the'foot is forcibly wrenched and moulded into a good position, a Thomas's wrench being employed, if need be. It is essential that the foot should remain in good position when all force is removed from it. Possibly division of the tibial tendons may assist in this procedure, as also section of the tense ligaments on the inner side of the foot [syndesmotomy) ,h\x\. if such can be avoided, so much the better. The foot is then placed in plaster of Paris for five or six weeks, and subsequently mas- sage and suitable exercises are employed before walking is allowed. It is, however, only in the early stages that such treatment is advisable. At the age of eighteen to twenty-four months considerable growth of the limb has determined such osseous de- velopment as almost forbids one to expect benefit from it, with- out the exercise of undue force. Hence, if treatment is not com- menced till the child is two years of age, and still more if the child has walked or is older, other methods must be employed. Of these, two chief plans have been advocated, viz., tarsectomy and Phelps' operation. I. In tarsectomy, a wedge-shaped portion of bone is removed from the outer aspect of the foot. This is accomphshed through a semi- lunar incision on the outer aspect of the foot ; the thick subcutaneous structures, including the bursa, are removed, and the extensor tendons, already somewhat displaced inwards, are stripped from the bones and held aside. The tarsus is divided by a chisel in two places in such a way that a wedge of bone can be removed, the base being on the outer aspect, and the apex on the inner. The position of the joints need not be taken much into consideration, and as far as possible the sections are made at right angles to the anterior and posterior segments of the foot respectively, sufircient bone being removed to allow the foot to come into good position without difficulty. After closing the wound, the foot is kept in position, at Fig. 181. — Malleable Splint for Treatment of Congenital Talipes Equino-varus. It 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 asgood a position as possible, and the leg- piece bandaged on. Each week the foot-piece is bent a little more to- wards the normal position. THE SURGERYIOF DEFORMITIES 465 first by ordinary splints and subsequently by plaster of Paris for six or eight weeks. The results are excellent, the foot, although a little shortened, being firm and plantigrade. 2. Phelps' operation consists 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. The mid-tarsal joint is usually opened, tendons and ligaments are divided, and the foot put up in a good position with the wound gaping. HeaUng may be accelerated by skin grafting. The results are at first quite as good as those attained by tarsectomy, but the deformity is likely to recur as cicatrization advances. In successful cases the longitudinal arch of the foot is lost, and the cosmetic result is anything but perfect, whilst the patient usually requires an instep support. In our opinion tar- sectomy is much the better operation, and even when undertaken in children need not interfere with the subsequent growth bi the foot. In paralytic Talipes varus the foot will probably remain weak 'arid flail-like in spite of treatment, and a suitable boot with leg irons to steadv it will be required. The character of the treatment neces- sarilv varies with the extent of the paralysis, but occasionally help is obtained by displacing the attachment of a healthy tibialis anticus from the inner to the outer side of the foot. In very bad cases arthrodesis of the ankle {i.e., its fixation by removal of the articular cartilage and subsequent synostosis) may secure to the patient a firm basis of support. In congenital Talipes calcaneus all that may be needed is di\asion or lengthening of the extensor tendons ; but in the paralytic variety some form of apparatus must always be worn. Where the tendo AchiUis is thin and attenuated, a portion of it may be excised, and the ends united by suture; or the tubercle of the os calcis into which the latter is inserted may be sawn off and re-attached by a nail or peg to the bone at a lower level (Walsham) ; but the prognosis in all forms due to paralysis is unsatisfactory. ^ Talipes valgus, if unreKeved by the apphcation of suitable boots;- may need di\nsion 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 foot may be undertaken, but is not very successful. Flat-foot {syn. : Splay-foot or Spurious Valgus) is a condition fre-' quently seen in young adults whose occupation exposes them to ' over-fatigue, or the carrying of heavy weights — e.g., in nurse-girls or shop-boys. It occurs as a natural condition in many of the negro races, and is more often seen in long than in short feet. - Tt also results from rupture of the inferior calcaneo-scaphoid ligament, fracture of the neck of the astragalus, of the sustentaculum tab, or; of the greater process of the calcaneum {traumatic flat-foot). Mechanism. — In thfe majority of non-traumatic cases it is due t6- relaxation of the inferior calcaneo-scaphoid ligament, which sup- ports the under surface of the head of the astragalus, and thus keeps up the longitudinal arch of the foot. This in its turn is braced up by 30 466 A MANUAL OF SUIiGERY the tendon of the tibialis posticus and an expansion backwards there- from to the OS calcis, as also by the plantar fascia and ligaments, and by the short muscles of the sole. A rapid increase in the length and weight of the skeleton ai)art from an equivalent in- crease in strength of muscles and ligaments throws undue strain upon this structure, especially if the patient is suddenly exposed to long hours of standing or weight-carrying. The ligament stretches, the head of the astragalus sinks, the anterior portion of the foot becomes abducted at the mid-tarsal joint, and the typical splay- foot results. The tibialis posticus is often relaxed or even paretic, and the peronei tendons are in the later stages contracted. Occa- sionally the deformity is due to a gonorrhreal inflammation of the inferior calcaneo-scaphoid ligament, which becomes relaxed and yields under the weight of the body. However produced, the de- formity is tolerably characteristic (Figs. 182 and 114). 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 lengthened, whilst the anterior half is abducted. The head of the astragalus is felt a little in front of and below the internal mal- leolus, whilst the sus- tentaculum tali, which is normally distinguishable about I inch below the Fig. 182. — Flat-Foot. 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. In the early stages the patient complains of a sensation of fatigue or weakness along the inner side of the leg, foot, or ankle, increased by exertion. Later on, the gait becomes somewhat shuftling, and severe pain is experienced, not only in the sole, but also on the dorsum over the astragalo-scaphoid joint. Sometimes it is extremely marked in the metatarso-phalangeal joint of the great toe, which may be enlarged and inflamed, owing to an associated chronic arthritis {vide Hallux rigidus). Treatment. — In the earliest stages, when the deformity, though threatening, has not yet actually developed, all that is required in many cases is rest, so as to allow the overstrained muscles and liga- ments to recover themselves; at the same time the parts should be massaged, and tonics administered to improve the general health. Square-toed boots without high heels must be used, so as to check any tendency to a valgoid position of the foot, and the heels may sometimes be slightly thickened on the inner side. The patient THE SURGERY OF DEFORMITIES 467 must walk with the toes pointed forwards or even inwards and in some cases assistance may be obtained by ordering him to sit cross- kneed, in the tailor position, so as to ^^ercise a certain amount of constant pressure inwards upon the front of the feet. Regular exercises ought to be instituted, such as raising the body on tip oc with the feet inverted; such can only be undertaken for a short time at first, but as the muscles regain their tone a longer period can be tolerated. In a later stage elastic tension apphed to the sunken arch is sometimes useful; Golding-Bird s sling can be em- ploved for this purpose. It consists of a loop of soft webbmg passed round the ankle and then under the instep, its free end being drawn uo on the inner side and attached to an elastic accumulator which is'connected with a steel garter-piece (Figs. 183 and iS4). In worse cases a metal spring or instep pad may be required to Fig. ■The Sling applied. Fig. 183. — Mr. Golding-Bird's Sling OF Soft Webbing for Supporting THE Arch of the Foot. support the foot whilst walking, but it must be remembered that it has no curative function, and indeed by its pressure tends still further to weaken the structures on the inner side of the foot, it must fit the instep accurately and be made to pattern for each par- ticular case, extending from the root of the toes to the heel. When the affection has reached a later stage, and the deformity cannot be remedied by ordinary manipulation, forcible rectification under an aucesthetic may be employed. The foot is hrmly grasped in the two hands or in a i homas's wrench (Fig. 185) , and the anterior portion is forced mwards and backwards m such a way as to draw the scaphoid round the head of the astragalus as a fulcrum, and thus restore the arch. Probably a number of adhesions m the astragaio- scaphoid and other joints will be felt to give way during this manipu- lation Tenotomy of the peronei is sometimes required before recti- fication of the position is possible. The foot is then put up m plaster of Paris and kept at rest for some weeks. Satisfactory results have followed. 468 A MANUAL OF SURGERY In neglected cases operative proceedings may be necessary for the relief of pain. The removal of a wedge-shaped section from the inner side of the foot, and the production of bony ankylosis between the scaphoid and astragalus (as recommended by Ogston), is the only operative procedure worthy of consideration. Prolonged rest and a suitable course of exercises and massage will be required sub- sequently, whilst an instep pad may still have to be worn. Pes Cavus (Hollow or Claw Foot) is a condition characterized by increased concavity of the plantar arch, so that when the individual stands there is a greater interspace than usual, if not an absolute break, between the impressions produced by the anterior and pos- terior segments of the foot (Fig. 172, B). Corresponding to the plantar concavity, there is a marked dorsal convexity, whilst the toes are generally in a condition to be immediately described as hammer- toe; the heads of the metatarsal^ bones are unduly prominent below, and callosities often form beneath them, causing considerable pain. Fig. 185. — Thomas's Wrench. (Down Bros.) The two cro.ss-bars are protected by thick indiarubber, and can be approxi- mated or separated by rotation of the handle. The anterior portion of the foot is firmly grasped between them, one being placed on the dorsal and one on the plantar aspect, and forcible wrenching movements can then be carried out. The condition is almost always associated with a slight degree of talipes equinus (right-angled contraction), and its method of pro- duction from this cause is as follows: The weight is normally carried to the ground mainly through the heel, but also partly through the toes; in these cases it is only transmitted through the toes and front of the foot, and since the anterior extensor muscles are probably weak, the short flexors act at an advantage, and by contracting draw the heel downwards so as to reach the ground, and thus the arch is increased. It is also seen in the paralytic form of T. calcaneus. Treatment in the early stages consists in friction applied to the weakened muscles of the leg, together, possibly, with the application of a splint to the sole. In more marked cases divi- sion of the tendo Achillis is needed, together with subcutaneous section of the tense plantar fascia. The deformity of the toes usuall}' disappears when the equinus is corrected. Hallux Rigidus {syii. : H. flexus) is a painful condition of the great toe, due to a chronic arthritis of its metatarso-phalangeal articula- tion. It usually occurs in young males with fiat feet. The foot is abnormally long ; its circulation is defective; the toe itself may be in THE SURGERY OF DEFORMITIES 469 good position, but not unfrequently the first phalanx is flexed (Fig. 177) and the distal one hyper-extended. It is probably due to abnormal pr«^ssure owing to the valgoid position of the foot, and possibly to wearing too short a boot. Treatment. — In the early stages correct the flat-foot, and see that suitable boots are worn. Failing this, careful strapping with Scott's dressing may give relief, but in bad cases excision of the head of the metatarsal may be required. Hallux Valgus (Fig. 186) consists in a displacement outwards of the great toe from the median line of the body, as a result of which the other toes are huddled together, and in extreme cases the hallux is placed over or under them. It is present in the majority of people in some measure, owing to the usual shape in which boots are made; but in its severer forms it generally occurs in adult women, and is due to a chronic arthritis of the metatarso-phalangeal joint, the greater power of the adductor group of muscles explaining the de- formity. The cartilaginous surface of the head of the first metatarsal bone becomes inflamed owing to the partial p^,.^_ iS6.— Hallux Valgus dislocation of the toe and the pressure with Bunion-. of the boot; its structure and shape are thereby altered, and the joint is more or less disorganized. Two other conditions are associated with this deformity, viz., bunion and hammer-toe. A bunion consists in the formation of a bursa over the head of the first metatarsal bone, which becomes inflamed from cold or injury, and may even suppurate, the abscess often communicating with the joint, and leading to its disorganization. A marked bony out- growth 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 in the use of correctly-shaped boots, with the inner border straight from toe to heel, whilst the sock or stocking should have a separate com- partment for the great toe. The introduction of a toe-post between the great toe and its neighbour is sometimes effective in giving relief. In more severe types excision of the projecting head of the metatarsal bone gives admirable results. The operation is best conducted by turning up a flap of skin and subcutaneous tissues over the inner aspect of the head of the metatarsal with its con- vexity forwards. The bone is then divided by a chisel, and the head removed, allowing the toe to be easily replaced in a normal position. The skin is then laid down in place, and if need be shortened to meet the requirements of the case. Very rarely ought the second toe to be removed for this condition, as the lateral support of the'great toe 470 A MANUAL OF SURGERY is thus weakened, and the deformity is probably aggravated. An injlamcd bunion is treated by removing all local pressure, and apply- ing fomentations. If the joint is involved in sujipurative disease, excision of the head of the bone, or amputation of the t(je, may be required. In less serious cases it may suffice merely to remove the thickened bursa, and to chisel away the projecting portion of the bone. Hammer-Toe. — This deformity is constituted by hyper-extension of the tirst phalanx, marked flexion to an acute angle of the second, and either flexion or extension of the terminal phalanx, so that the first inter-phalangeal joint projects under the upper leather of the boot, whilst the patient walks on the extremity of the ungual phalanx, or even on the nail (Fig. 187). Callciities form upon the Fig. 187. — Hammer-Toe Deformity of All Toes of Both Feet with Marked Cal- losities OVER THE Heads of the First Phalanges. In this case the patient, a girl of seventeen years, was quite crippled. Operation was performed on all the toes, the heads of all the first phalanges being removed, and an excellent functional result followed. Fig. 188. — Hammer-Toe. (After Keen and White.) [ , Callosity over head of meta- tarsal bone in sole; 2, cal- losity- over end of toe; 3, cal- losity or corn over head of first phalanx; 4, adventitious bursa over the same bony point. points of pressure (Fig. 188, i, 2, and 3), especially on the dorsal aspect, and a subcutaneous bursa over the head of the first pha- lanx (4), giving rise to great pain and inconvenience. The second toe is that most frequently affected, with or without the others, but it is uncommon for the hallux to be thus deformed. The extensor tendons often stand out very evidently beneath the skin. The flexion of the second phalanx on the first is carried to such a degree that the former bone is semi-dislocated. The prolongations of the plantar fascia on either side are much shortened, and the lower portions of the lateral ligaments of these articulations are also contracted. Causes. — It is occasionally congenital, but more often acquired, and then [a] it may be secondary to hallux valgus; {b) it may result from wearing short and pointed boots, or very high heels; in either case the toes are crowded together and drawn up out of the way of THE SURGERY OF DEFORMITIES 471 pressure ; (c) it follows contraction of the plantar fascia, and is then associated with pes cavus and talipes cquinus. Treatment may be commenced by the use of correctly-shaped boots, but the case has usually progressed to such an extent when the patient is first seen that no palliative measures are of any avail. Operation is then necessary, and probably the second phalanx is so much displaced that nothing short of removal of the head of the first phalanx holds out any prospect of permanent relief. An in- cision is made longitudinally over the joint, the extensor tendon being split down the middle; the head of the bone is then cleared by the raspatory, and nipped off by cutting pliers. No splint is required, as the pressure of the dressings suffices to keep the toes in good position. Sometimes there is but little room between the great and third toes, so that even if one corrected the deformity of the second toe there is no space for it to lie comfortably; amputation should then be performed. Metatarsalgia, or Morton's Disease, is characterized by severe pain of a neuralgic type located primarily about the head of one or more of the metatarsal bones, usually the fourth, but also radiating thence up and down the limb. It often occurs in gouty or rheumatic subjects, and ma}^ be attributed to some injury ; a slight degree of flat-foot and the wearing of tight boots certainly predispose to it. It is probably due to compression of the digital nerves between the heads of the metatarsal bones and the ground. The foot is found to be broader than usual, and the anterior transverse arch formed by the heads of the metatarsals flattened out. Marked callosities, or corns, are observed on the under surface close to the heads of the bones, one or more of which may be unduly prominent below. In a few cases small bony enlargements have projected from the heads of the meta- tarsal bones, and in others definite fibrous growths have been found in the subcutaneous tissues; in other cases a simple peripheral neuritis may explain the manifestations. The pain is generally induced by w^alking, and comes on in characteristic paroxysms. Lateral pressure over the bases of the metatarsal bones often relieves the pain, but similar pressure over the heads usually increases it. Occasionally evidences of osteo-arthritis are manifested in one of the neighbouring joints. Treatment consists in resting the foot, W'hilst suitable diet and drugs are ordered to combat any gouty or rheumatic tendency. At the end of a few weeks the patient may be allowed to walk again with boots which are low-heeled, thick-soled, and broad anteriorly. An instep pad may be employed, if flat-foot is present, and an attempt made to relieve pressure on the heads of the metatarsals by treating the callosities on the sole of the foot, and applying a transverse strip of felt plaster (J inch thick) behind the heads. Morton's recommendation — viz., excision of the head of the project- ing metatarsal bones — may be reserved for the more aggravated and serious forms; it is best effected through a longitudinal dorsal in- cision running parallel to the extensor tendons. CHAPTER XX. INJURIES OF BONES FRACTURES. Contusion of a Bone and of its periosteum is usually a matter of no great moment, although the part becomes painful and 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 low germicidal power, acute infective periostitis or osteo-myelitis, resulting in necrosis, may supervene. The Treatment of an uncomplicated case consists merely in the use of cooling lotions or of a bandage, whilst if peri- osteal thickening results, iodide of potassium may be given, and iodine paint applied locally. Bending of Bone may or may not be associated with fracture. Bending witliout fracture occurs mainly in children, and in adults is only the result of some local disease. More commonly a partial or green-stick fracture is produced (p. 474), and in this the deformity can generally be corrected without much difficulty. Fractures. A fracture may be defined as a sudden solution of continuity in a bone, usually resulting from external violence. Predisposing Causes of Fracture — Age.- — From two to four frac- tures are not uncommon, owing to the unsteady gait and frequent falls to which little children are liable ; from four to six the bones often bend so as to cause green-stick fractures; up to the age of eighteen years injuries near joints induce separation of epiphyses; from six years onwards fractures increase in frequency, reaching their maximum between thirty and forty years of age; old people are liable to this form of accident, owning to the bones becoming atrophic or brittle. S^ex.- — As might be expected, fractures are more common in the male sex during boyhood and adult life; but up to the age of four or five they are equally frequent in the two sexes, whilst after forty- five they are more common in women, owing to their great liability to intracapsular fracture of the cervix femoris and to Colles's fracture. 472 INJURIES OF BONES— FRACTURES 473 Morbid Conditions of the Bones predispose to fracture in a marked manner, often leading to what is known as S pontaneons Fracture, in which the determining force cannot be recognised or is very slight. Under this heading may be included: (i) Atrophy of bone, which may be of the senile type, as manifested especially in the cervix femoris; or is due to want of use, as in a paralyzed limb or from an ankylosed joint. (2) Patients afflicted with certain mental or ner- vous diseases, such as general paralysis or tabes dorsalis, are unduly liable to fracture, which may result from atrophy, but may also occur in apparently healthy bones. Thus, a man suffering from tabes was sitting with his thigh abducted and everted in order that he might examine and dress a perforating ulcer on the sole of the foot, when the shaft of the femur, subsequently shown to be of normal dimensions, and apparently of normal density, snapped in two. (3) Fragilitas ossium or osteo-psathyrosis consists in an in- herited tendency to spontaneous fracture. It results in a multi- plicity of fractures, occurring even in children; thus, a girl, aged twelve and a half years, had suffered from forty-one fractures since the second year of life. No explanation of this condition is known ; the lesions often unite perfectly, though sometimes with a good deal of deformity. (4) General bone diseases, such as rickets and osteo- malacia, also predispose to fracture; in the latter affection the bones often bend considerably before breaking, and there is usually but httle attempt at repair. (5) Local bone disease may also constitute an important predisposing factor by weakening its structure. Thus, sarcoma and secondary cancer of bone are often first recognised by causing a spontaneous fracture ; the erosion of an aneurism and the destruction of the para-epiphyseal region in acute osteo-myehtis may lead to a similar result. The Exciting Causes of Fracture are threefold: (i) Direct violence, the fracture occurrmg at the spot struck, and being often transverse, not unfrequently comminuted, and sometimes complicated with injuries to the adjacent soft parts. (2) When due to indirect violence, the accident is usually produced by the compression or bending of the bone with such force as to exceed the limits of its natural elasticity, so that it yields at the weakest spot. Thus, when a person jumps from a height, the leg bones are compressed between the weight of the body and the resistance of the ground, and, if the violence is excessive, a fracture occurs at some point of mechanical ' isadvantage. If the stress falls chiefly on the shaft, an oblique fracture ensues, often with much longitudinal displacement, and possibly becoming compound; if an element of torsion is present, as by forced inversion or eversion of the foot, the fracture is likely to become spiral in type. If, on the other hand, the violence expends itself on a mass of cancellous tissue, such as the os calcis, astragalus, or upper end of the tibia, the bone may be fissured in various direc- tions, comminuted, or even ' pulped ' ; such a condition is sometimes termed a compression fracture. (3) Muscular action is most com- monly the cause of fracture of small bones or of osseous prominences. 474 A MANUAL OF SURGERY Fig. 189. — Obstetric Fracture ofHumerus IN A Baby Four Weeks Old into which powerful muscles are inserted. The patella and ole- cranon arc not unfrcquently broken in this way, the former often occurring from sudden and vigorous efforts to avert a fall. Occa- sionally one of the long bones, such as the humerus or clavicle, has been broken by violent muscular exertion, as by throwing a cricket-ball. Intra-uterine Fractures are caused by blows upon the mother's abdomen, or by abnormal or violent uterine contractions, especially if the liquor amnii is deficient in amount, or if the formation of bone is defec- tive, as in osteogenesis imperfecta (p. 586). Ihey are usually followed by considerable deformity, which must be clearly distin- guished from that due to imperfect develop- ment. Obstetric fractures also occur as a result of undue violence used by the accou- cheur during delivery, usually affecting the shaft of the femur or humerus (Fig. 189). Varieties. — A Simple Fracture is one in which the skin is unbroken or, at any rate, where the external air has no admission to the site of injury. A Com- pound Fracture is present when the skin or mucous membrane is so lacerated that there is direct or indirect communication between the fracture and the external air. In the base of the skull, a frac- ture may open up one of the deeper air-sinuses, and thus it becomes compound without any apparent external lesion. These terms, though sanctioned by the approval of centuries, are neither of them good, subcutaneous and open being prefer- able. 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 comparatively 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 or not the continuity of the bone is pj^ 190.— Green- entirely interrupted. Various forms of Incom- stick Fracture plete Fracture are described, and indeed the intro- of Radius. duction of radiography has shown that they are much more common than was formerly supposed. A green-stick fracture (Fig. 190) is one which only occurs in young children, and most often in those that are rickety; curved bones, such as the clavicle, are usually affected, and the fracture merely involves the INJURIES OF BONES—FRACTURES 475 con\-exity of the curve, whilst the concave half is bent, just as when a green bough or twig is partially broken. Depressions of the skull may be similarly incomplete when the outer table is driven in with- out fracture and the inner table alone splintered. Fissured fractures also are often only partial. A sub- periosteal fracture is one in which the periosteum remains intact, although the bone is broken; dis- placement does not occur, and therefore the injury is likely to be overlooked, apart from radiography- Complete Fractures mav be transverse, though this is not very common: oblique, arising usually from indirect violence ; spiral, when the force acts in a rotary direction as well as longitudinally; it occurs most frequently in the tibia 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 flute ; Fig. 191). Not un- commonly a second fissure runs downwards from the main line of fracture, separating off a long narrow fragment of the shaft. A longi- tudinal fracture is one due to fissur- ing or splitting of the bone in its long axis ; it is most common as the result of gunshot injuries. If it is combined with a transverse fissure, it is often termed T-shaped. Com- minuted 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 ; complicated, when important struc- tures, such as an artery or joint, are damaged as well as the bone. The Separation of an Epiphysis results in young people from vio- lence directed to the ends of the bones, but occasionally from pathological affections of the epiphysis or of the adjacent portion of the diaphysis — e.g., from inherited syphiHs, rickets, scurvy, suppurative osteo-myelitis, or tuberculous epiphysitis. The femur, humerus, or radius are the bones most often affected. The line of cleavage usually runs through the soft spongy tissue on the dia- physeal side of "the cartilage,' so that there is cartilage wdth spicules of bone on one side, and spongy bone on the other. In very young children, w^here the epiphysis is entirely or mainly cartilaginous. Fig. 191. — Fracture OF THE Tibia: ' EN Bec de Flute.' There was but little shortening in this case ; it was impossible, how- ever, to reduce the deformity even under an anaesthetic, and operation was required. 476 A MANUAL OF SURGERY the lesion is almost always a pure separation of the epiphysis from the shaft ; but at a later date it not unusually extends in part through the adjacent end of the diaphysis (Fig. 221). A marked feature is the stripping up of the periosteum, which, though loosely attached to the shaft and easily separated from it in children, is hrmly ad- herent to the epiphyseal cartilage, and hence retains its connection with it, thus frequently limiting displacement. If, however, the force is sufficient, the end of the shaft penetrates the periosteum, which may grasp it closely, and this periosteal ' sleeve ' may seriously hinder reduction. Union usually occurs by means of bone, and arrest of the longitudinal growth may follow if the parts are not replaced in exact apposition. This is a matter of importance when one of the bones of the leg or fore-arm is affected, since deformity of the hand or foot results if the injured bone ceases to grow and the uninjured one continues its development. Suppuration some- times occurs as a sequela in unhealthy children, or when the accident is compound, and may result in acute osteo-myelitis and necrosis. Partial detachment of an epiphysis (the juxta-epiphyseal strain of Oilier) often occurs, giving rise to phenomena similar to those of a sprain ; if overlooked and neglected, it is Hkely to prove a fertile source of tuberculous disease, or may interfere with the growth of the hmb. The essential feature is a more or less tender, but very distinct swelling of the bone close to the epiphysis, but the neigh- bouring joint remains unaffected. Treatment consists in immobi- lization 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 perhaps heard, some- thing give way with a snap, and experienced sharp pain which became much intensified on attempting to move the limb. On examining the injured part and contrasting it with the opposite side, the following points are usually noticed: 1. The signs of a local trauma, viz., pain, brviising, and swelling, as a result of the effusion of blood from the torn and lacerated struc- tures. The amount of this may be so great as to obliterate all the ordinary bony prominences and landmarks. Blebs and bullae sometimes form over the surface in the course of a day or two, and these should be carefully protected from infection. The dis- coloration continues for some time, and may spread to parts far removed from the original mischief. This infiltration of the parts with blood often leads to considerable subsequent thickening, and possibly to serious adhesions and limitation of movement. It is unusual for suppuration to occur after a simple fracture, unless the patient is very debilitated and with diminished germicidal powers. 2. Preter-natural mobility in tJie continuity of the bone may be demonstrated by manipulation, but never unnecessarily. Im- paction or non-separation of the fragments prevents its occurrence. 3. Partial or complete loss of function also follows. INJURIES OF BONES—FRACTURES 477 4. Crepitus* can only be felt when the fragments are moveable and can be brought into contact, but not when there is wide separa- tion or impaction. 5. Change in shape of the limb or deformity from displacemeni results from three chief factors, viz., the direction of the violence, the weight of the limb, and the contraction of muscles, whilst injudicious movement or rough handling may aggravate it. It is always more marked in oblique than in transverse fractures, and hence is usually greater in those due to indirect violence. Various types of displacement are described, viz. : Angular, generally due to the unequal action of powerful muscles; lateral, where the displacement is merely to one or the other side, and most common in transverse fractures; longitudinal, when one fragment overlaps the other or is forcibly driven into it, causing shortening of the limb ; it may also occur in the form of wide separation of the frag- ments, as from contraction of the quadriceps in fracture of the patella; rotatory, when one fragment is twisted on the other, as in fractures of the femur, where the weight of the limb causes eversion of the lower end. In flat bones — e.g., the skull — deformity may exist in the shape of depression or elevation. Radiography has proved of the greatest service both in connection with the diagnosis and the treatment of fractures. Many a case which would formerly have been called merely a sprain can now be demonstrated to be really a fracture (especially about the wrist), and the constant use of this procedure has revolutionized our ideas as to the relative frequency and also as to the nature of many such lesions. The following points must, however, be noted if the practitioner is not to be misled: In the first place, an assured diag- nosis can never be made with the screen alone: the limb must be photographed, and for choice stereoscopically ; otherwise the radio- grams should be taken in two directions, antero-posteriorly and laterally. . The importance of this latter precaution is indicated by a study of Figs. 226 and 227, or of Figs. 258 and 259. Then it must be remembered that all radiograms are more or less exaggera- tions, owing to the proximity of the tube to the limb, and that a deformity which is very obvious in the radiogram may in reality be comparatively slight. Moreover, too, the exact position of the tube and its angular relationship to the limb must not be neglected, as otherwise misleading interpretations may be given of the appearances presented. Finally, it must be remembered that callus is for a considerable time pervious to the X rays, so that, * The term Crepitus is applied to five different conditions which may pro- duce a creaking or grating sensation to the examining hand, i . Bony crepitus; results from the rubbing together of the fragments in a fracture, or of the ends of bones in a joint when denuded of their articular cartilage. 2. A softer variety of bony crepitus is obtained when an epiphysis is detached. 3. An effusion of blood into the tissues gives rise to a soft crackling sensation on handling. 4. Effusion into tendon sheaths, bursas, and joints also causes a soft crepitant sensation, varying in different cases. 5. Air in the tissues causes surgical emphysema and a characteristic form of crepitus. 478 A MANUAL OF SURGERY although the fracture is firmly united, it may ])c still visible in the radiogram. General or Constitutional Effects. — Shock is greater or less accord- ing to the amount of violence and the seat of injury. It varies from a mere passing faintness to the severest prostration. If the bones of the head or spine are injured, special symptoms due to con- cussion of the brain or injury to the spinal cord may also be pro- duced. Hcemorrhage is rarely sufficient to give rise to general effects unless the fracture is compound, and involves some important vessel. Fracture fever (aseptic traumatic fever, p. 268) is met with in the majority of cases, commencing twenty-four hours after the accident and lasting two or three days. As a rule, it is not severe, the temperature rarely rising above 100° F. in uncomplicated cases. In compound fractures where asepsis is not attained, any form of wound infection may result, and even general septicaemia or pya-mia. Delirium tremens is a not unusual complication of fractures of the leg in debilitated individuals or habitual drinkers. The general characters and treatment of the disease are dealt with elsewhere (p. 270). As regards local treatment, the limb must be fixed 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 fragment independently of the lower. Fat embolism results from the absorption of broken-up fat globules after any injury which causes contusion or laceration of fatty tissue; when this is accompanied by tension from effusion of blood, as in fractures, this process is more likely to occur. Usually the great mass of the fat is filtered off by the lungs or ehminated by the kidneys (as can be demonstrated after death by staining with osmic acid), and no harm results. The pulmonary obstruction may^ how- ever, become so great as to lead to a fatal issue from dyspnoea; whilst if the cerebral vessels are blocked, syncope, or even coma, may be induced. The symptoms are gradual in their onset, and usually commence about the third day, but may not be evident for a week. The Union of Fractures is brought about by a series of changes analogous to those which we have already seen occur in other wounds, except that they do not terminate in the formation of cicatricial tissue, but go on to the further development of bone. When a fracture has occurred, the broken ends of the bone are left rough, spiculated, and more or less separated one from the other; the periosteum is torn, but the rupture is not always com- plete, a ' periosteal bridge ' perhaps persisting and playing an important part in the reparative process, especially if the fracture is not accurately set. Ihe muscles and neighbouring tissues are lacerated, and a varying amount of blood is extravasated, occupying the interstices of the wound. In the course of a few hours after the parts have been immobilized, the process of repair is in- augurated by the blood-clot becoming invaded by leucocytes, and INJURIES OF BONES— FRACTURES 479 after a time it is absorbed, the haemoglobin passing through various stages of degeneration, and thereby staining the surrounding tissues. At the same time there is an exudation of plasma into all the injured and lacerated soft parts around, and the connective tissue cells proliferate actively. The periosteum becomes thickened and more vascular, and its connection with the bone is loosened for a short distance on each side of the fracture. The blood-clot, occupy- ing the space beneath the loosened periosteum, is gradually trans- formed into granulation tissue, which unites with that derived from surrounding torn structures and from the bone itself, and this ovoid mass binding the fractured ends together is known as the provisional or ensheathing callus (Fig. 192). The ossification of the callus is the next stage in the process. This is brought about by the activity of the cells in the deeper part of the granulation tissue, which are derived from the osteoblastic cells set loose by the injury and the resulting rarefaction. These retain their bone-producing potentialities, and hence bony spicules develop in the substance of the deeper parts of the granulation tissue, as also from the surface of the uncovered ends of the fragments, and from the under side of the periosteum. This latter membrane when it is stripped from the underlying bone draws with it certain bone cells, accompanying the small vessels which pass from the membrane into the Haversian canals, and from these the bone develops. Ossi- fication thus starts from many foci, and the callus is quickly con- verted into a mass of bone, which is at first soft and spongy, but after a time becomes firm. When a periosteal bridge has been left, bone formation commences on its under surface, and not unf requently in radiograms a fine of newly-formed bone can be seen passing from one fragment to the other, and evidently due to this cause. The medulla becomes hyperaemic for some distance from the seat of fracture and is transformed into granulation tissue, which unites with that springing up from the opposite fractured surface. Fine spicules of bone gradually permeate the granulation mass until the whole is ossified, constituting the internal callus, or, better, the medullary -plug. Naturally, the compact bony tissue is the last to engage in these changes., and the denser the bone, the longer they are in being com- pleted. The fractured ends become hyperaemic and rarefied, the bone cells prohferating, the medullary contents of the Haversian canals increasing in amount, and the actual osseous substance being absorbed, until the rough and spiculated surface becomes smooth and covered with granulations. These unite with the medullary plug, of which they may indeed be looked on as an extension, and finally give rise to the annular bond of union between the two layers of compact bone, to which was originally apphed the name definitive or permanent callus. It will thus be obvious that the continuity of a bone is restored long before repair is completed, and that it mainly depends on the ossification of the provisional callus, the amount of which is to 480 A MANUAL OF SURGERY some extent proportional to the degree of m()l)ilityof the fragments. A certain amount of cartilage is often developed in tlic process of bone-formation, especially in young people, and where there is much mobility; it is present chiefly in the early stages, and mainly in the ensheathing callus. The newly-formed osseous tissue is at first soft and spong^^ but gradually becomes denser; at first it is easily detachable from the underlying bone, but later on becomes continuous with it. As the so-called definitive callus becomes stronger, the ensheathing callus diminishes, and finally, if the ends are in good position, may vanish entirely, whilst the medullary plug may also be totally removed. Thus it is possible for the bone, under these circumstances, to be restored so absolutely as to show, no signs of its having been fractured. When the ends of the bones partially overlap (Fig. 193), the amount of ensheathing callus is considerably increased, and fills up all the spaces left by the overlapping of the fragments. The Fig. 192. Fig. Fig. 193. iitl!ir transversely ilirough tlie articular surface, or in the shaft a little above the level of an ordinary CoUes's fracture, and sometimes well-marked displacement is present. There is usually little difficulty in diagnosing a fractured radius; the chief signs are localized pain and loss of power of active rotation, whilst passive rotary movements are accompanied by crepitus, 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 situated above the inser- FiG. 226. — Fracture of Shaft of Fig. 227. — Fracture of Shaft Radius. (Antero - Posterior of Radius. (Lateral View.) View.) From the same patient as Fig. 226, and showing excellently the necessity for taking radio- grams from two points of view. tion of the pronator teres, the upper fragment is flexed and fully supinated by the action of the biceps and supinator brevis, whilst the lower fragment is drawn towards the ulna and fully pronated by the unopposed action of the two pronator muscles. Treatment. — Inasmuch as it is scarcely possible to command the small upper fragment, the lower must be brought into apposition with it by fully supinating the fore-arm and hand after flexing the elbow, and apph'ing a posterior splint, the patient being preferably kept in bed for a time and the arm laid on pillows. It may afterwards be sup- ported in a hollow leather splint carried across the bod^^ and with the pahn directed upwards. 520 A MANUAL OF SURGERY When the fracture is placed hcloiv 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 may be slightly ap- proximated to the ulna by the direct action of the pronator quad- ratus; the hand is fully pronated looking downwards. Union to the ulna by callus thrcnvn across the interosseous space is not unlikely to occur. Treatment. — The arm is placed midway between prona- tion and supination, and the hand fully adductcd. The frag- ments are manipulated into position, and splints applied back and front. It is wise to place a good pad under the palmar splint over the site of fracture so as to repress the tendency to anterior displacement of the fragments ; a Gordon's splint is useful in this direction. 4. The Lower End of the Radius is broken with extreme frequency, constituting what is known as Colles's Fracture. This injury occurs Fig. 228. — Colles's Fracture: Lateral View. Fig. 229. — Colles's Fracture: Palmar View. most commonly in women of advanced years, although it may happen at any age or to either sex. It is almost invariably due to falls upon the outstretched palm, when the hand is completely pro- nated and extended. The line of fracture is placed about i inch from the wrist, though rather under than over this. It is usually transverse from side to side, but is oblique in an antero-posterior direction, sloping from above downwards and forwards, so that the fracture is nearer the wrist-joint in front than it is behind (Fig. 231). The displacement is somewhat complicated, {a) The lower frag- ment is carried backwards and a little upwards, owing to the direction of the violence, viz., a fall on the outstretched hand, the radius being compressed between the ground and the weight of the body, and yielding at what is evidently a weak spot ; this deformity is maintained by the radial extensor muscles of the wrist, and often by impaction of the fragments. (&) From the fact that the main violence is received on the thenar eminence, the outer side of the lower fragment is displaced more than the inner, which remains fixed to the ulna by the strong inferior radio-ulnar ligaments. This posi- tion is in part kept up by the extensors of the thumb and the supinator longus, but mainly by impaction of the fragments. The INJUIilBS OF BONES—FRACTURES 521 hand and carpus al\va\s follow the lower fragnient. and hence the former is abducted, causing the st\-loid process of the ulna to become prominent (Fig. 230). and lower than that of the radms, whereas it is normallv placed on a slightly higher level. In bad cases the styloid process of the ulna is actually torn off, or the internal lateral liga- ment ruptured, allowing displacement outwards of the whole hand, (c) The lo\\er fragment is also rotated around a transverse axis, so that the lower articular surface looks backwards as well as down- wards, a displacement due to the fact that in falhng 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. Fig. 230. — CoLLEs's Fracture: a Simple Case, without Much Lateral Displacement of Hand. Fig. 231. — Lateral View of CoLLEs's Fracture, showing Displacement Backwards and Upwards of the Lower Frag- ment. The deformity produced bv the fracture is therefore very character- istic. The hand is in a position of radial abduction, and usually pronated, with the lingers somewhat flexed (dinner-fork deformity) . Three abnormal osseous projections are present: (i.) The styloid process or head of the ulna is very marked, owing to the radial abduction of the hand (Fig. 229) ; (ii.) on the back of the wrist is a prominence which terminates abruptly above, caused by the pro- jection of the lower fragment (Fig. 228) ; and (iii.) corresponding to this dorsal projection there is a well-marked depression on the palmar surface, and above it a less sharply defined swelling, which gradually shelves into the fore-arm, due to the upper fragment. Pronation and supination are lost, and, as a rule, there is neither crepitus nor preternatural mobility, owing to impaction of_ the fragments. An important diagnostic point is the relative position of the two styloid^iprocesses; normally, that of the radius is below 522 A MANUAL OF SURCIIRY that of tlu' ulna, but in cases of fractuic it is on a k'X'cl with or above it. As already stated, tlie fracture is commonly imi)acted, tlie upper fragment being firmly driven into the cancellous tissue of the lower end; excess of violence may, however, disimpact, but often at the expense of comminution of the lower fragment. Union is effected without difficulty, but the patient should always be warned at an early date to expect some deformity about the wrist, as well as con- siderable impairment in the subsequent mobility of the fingers and hand, owing partly to adhesions in the joint, partly to blood trickling down the tendon sheaths and fixing the tendons. Treatment. — It is most important completely to reduce the defor- mity, and to this end extension and manipulation are both needed. The patient, if not under an anaesthetic, should be seated on a chair, and the surgeon, standing in front, should grasp the hand firmly, using the right hand for fractures on the right side, and the left for those on that side. Counter-extension is made from the flexed i:::,i;.l,illl:UUUI[L\\illinhHHI,IHIII IIIIII!linii,'//l/l< Fig. 232. — Carr's Splint for Colles's Fracture of Left Hand. elbow, and the hand is then forcibly extended and adducted; disimpaction is thus brought about, and a little manipulation enables the fragments to be moulded into position. In old people, however, where impaction is present, it may be wiser to leave things alone and not to attempt disimpaction or correction of the deformity. When once the deformity has been corrected, there is but little tendency for it to reappear, and therefore the use of elaborate retentive apparatus or splints is quite unnecessary in the majority of cases: (i) Perhaps the simplest and most efficacious is a piece of Gooch splint, shaped so as to cover the radius front and back as far as the middle line of the arm, and extending nearly from the elbow to the front and back of the knuckles of the index and middle fingers: its lower end is hollowed out in a horseshoe manner, so as not to reach beyond the end of the metacarpal bone of the thumb. This is well padded and firmly bandaged on; it grasps the radius and steadies the hand in a position of adduction, without in any way interfering with the movements of the fingers. (2) Carr's splint (Fig. 232) may be used in some of the more severe cases, especially when the ulnar styloid process has been fractured. It consists of two portions fitting the front and back of the radial side of the fore- arm, whilst to the palmar one is attached an oblique rod to be INJURllCS Oh' HONES— FRACTURES 523 graspod l\v tlie lingers, and thus the hand and wrist are maintained in a position of adduction, whilst tlie lingers can be freely moved. (3) Gordon's splint is another excellent contrivance occasionally useful, which consists of two pieces. The palmar portion has a rur\ed projection on its radial side, to correspond to the site of the fracture and to the concavity of the lower end of the radius ; on the ulnar side it is prolonged, so as to fit the ulnar border of the hand. The dorsal splint is slightly curved at the lower end, so as to apply itself comfortably to the wrist when in a position of flexion. Union is usually firm enough in a week to permit the removal of the splints, the arm being kept in a leather or poroplastic support for some time longer. Massage and passive movements should be employed, and the fingers left free and exercised after the first two or three days. A fracture of the lower end of the radius, known as Smith's fracture, is occasionally met with, in which the displace- ment of the fragments is exactly the reverse to that seen in Colles's fracture, viz., the lower end of the radial shaft projects posteriorly, whilst the lower fragment is displaced anterior- ly. Treatment is conducted as for a Colles's fracture. 5. Separation oJ the Lower Epiphysis of the radius occurs in 3'oung people under twenty, and when it is displaced back- wards, simulates somewhat closely a Colles's fracture. The lower end of the diaphysis projects anteriorly to a much greater extent, and, indeed, may protrude through the skin of the wrist. The lower end of the ulna may be involved in the accident, either the epiphysis being separated, or the shaft broken a little above. This condition may be mistaken for a backward dislocation of the wrist, but a diagnosis can be readily made by observing the relative position of the styloid processes to the carpal bones. Lateral displacement occurs in some cases (Fig. 233). Treatment is practi- cally the same as for Colles's fracture. Should arrest of growth result from this accident, the hand retains its connection with the stunted radius, but the ulna continues to grow downwards, and its lower end is found on the inner and posterior aspect of the carpus, which is pushed en bloc towards the radial side, but without any marked abduction (Madelung's deformity) . Fig. 233. — Radiogram of Displace- ment OF Lower Epiphysis of Radius AND OF THE HAND OUTWARDS. 524 /} MANUAL or srih'cr.Rv Fracture oJ both Bones oi. the Fore-arm may result from direct violence or falls on the palm. Any part of the bones may yield, but the middle and lower thirds are most frequently affected (Fig. 234). When due to direct violence, both bones may be broken at the same level; but if due to a fall on a palm, the ulna usually gives way at a higher level than the rachus. The line of fracture may be transverse or oblique, and the displacement varies both with this and with the force employed. The upper fragments are usually ch"awn together and pronated, whilst the lower end of the radius is drawn up by the supinator longus. In young people a not uncommon result of falls in the football field or at the skating-rink is a complete fracture of the lower third of the radius, and a greenstick fracture of the ulna. The upper fragment of the radius is dis- placed forwards in front of the pronator quadratus, which prevents its replace- ment even by traction under an anes- thetic. The diagnosis of these fractures is very simple, since there is, as a rule, obvious deformity. Treatment consists in reduction by extension conjoined with manipulation, and the application of splints which will prevent cross-union of the bones. If the fracture is above the insertion of the pronator teres, the arm must be put up in full supination, as suggested for a similar fracture of the radius alone (p. 519), whilst below that spot the usual position midway be- tween pronation and supination may be allowed. Union is generally complete in five or six weeks. If the fragments are not readily manipulated into posi- tion, as indicated by radiography, opera- tion should be undertaken without delay, as the middle or lower end of these bones is a rather favourite site of election for non-union (Fig. 197). Fractures of the Carpus.— These may result from direct violence in the nature of a severe crush, and then several of the bones may be involved, and the lesion may be com- pound. The ordinary treatment of such a condition must be followed, and the parts kept at rest on a palmar splint. Radiography has demonstrated that many ' sprains of the wrist ' from indirect violence are in reality associated with fracture of a carpal bone, and of these a transverse fracture through the waist of the scaphoid (Fig. 235) is perhaps the most common. As a rule, rest and subsequent massage are alone required; but occasionally movement is impaired by a displaced fragment, or painful weakness Fig. 234. — Fracture of Both I3ones of the Fore- arm. INJUIUJ^S OF BONES—FRACTURES 525 follows Iroin non-union, and then rmiox-al of the fragment or of {\\c hone is nt'cessarw Fractures of the Metacarpal Bones and Phalanges are ncjt un- common, particukirly in the third and fourth hngers, being due to direct violence, and hence usually transverse. There is generally but little displacement, though occasionally the fragments may overlap, whilst a certain amount of localized swelling and tender- ness is alwa^^s noted. The treatment usually required is immo- FiG. 235. — Fracture of the Waist OF the Scaphoid (X) in a Patient SUPPOSED merely TO HAVE SPRAINED HIS Wrist. Fig. 236. — Radiogram of a ' Stave of the Thumb ' Fracture. bilization for a short time, and for the phalanges a small zinc splint moulded along the front of the finger acts admirably. Should the fragments overlap, operation may be necessary. Bennett, of Dublin, has described an interesting fracture of the first metacarpal [stave of the thumb), which is due to indirect violence, and not very rare. The line of fracture is oblique (Fig. 236), separating the anterior portion of the base, which remains in situ, from the rest of the shaft, which is drawn upwards and backwards by the long extensor tendons, so as to lie behind the trapezium. Should the displacement be overlooked, the bone unites in this position, and the deformity, which persists, determines weakness and disability of the thumb. Treatment.— The fracture is reduced by traction. A poroplastic sphnt is moulded to the anterior (palmar) aspect of the thumb, reaching above the wrist ; it is first fixed to the distal end by strapping, and then bandaged above, so that extension is continuously applied. 526 A MANUAL OF SURGERY Fractures of the Pelvis. Fractures of the pelvic bones are almost always the: result oi direct injury, such as falls, blows, gunshot wounds, or crushes in railway, carriage or cart accidents. For convenience they may be described undci" the following headings: I. Fractures of the False Pelvis.- — A portion of the crista ilii may be broken off, or the anterior superior spine separated, or merely a fissure in the bone produced. The displacement is rarely great, although a portion of the crest may be drawn down by the glutei muscles, or the anterior superior spine displaced by the sartorius. Considerable pain is always present, especially on any vigorous respiratory movements, but crepitus is rarely to be detected. Union occurs readily if the patient is kept quiet in bed with the shoulders raised, and the legs supported to relax the muscles. A flannel bandage round the pelvis gives comfort and support. 2. Fracture of the True Pelvis is a much more serious accident. The line of fracture in front usually runs into the obturator foramen, and in- volves both the horizontal and descending rami of the pubes or the ascending ramus of the ischium (Fig. 237). '1 his is fre- quently conjoined behind with a fracture in the neighbour- hood of the sacro-iliac syn- chondrosis either on the same or opposite side, but more frequently the latter; whilst a double fracture, front and back, may also occur at these, the weakest, points. The cause of the posterior fracture is that, when the pelvic ring has yielded anteriorly from the violence, the continued strain, whether directed from the front or from the sides, must necessarily fall on the part where the ilium is most closely connected with the sacrum, and the bones then give way rather than the unyielding and powerful sacro-iliac ligaments. Probably the fracture involves the lateral mass of the sacrum rather more frequently than the ilium. The Symptoms are those of severe shock and pain in and aromid the pelvis, especially on movements of the legs or on coughing. T here may be local ccchymosis and tender- ness over the pubic ramus, as also deeply in the iliac fossa, and the patient either cannot stand, or feels as if he were falling to pieces on attempting to do so. Usually there is but little deformity, although occasionally displacement backwards of the innominate bone is Fig. 237. — Unilateral Fracture of THE Pelvis. (Museum of the Royal College of Surgeons.) The fracture runs through the sacrum on the left side, and through the horizontal and descending rami of the pubes. INJURIES 01- nONES— FRACTURES 527 visil)l(.", and tk'j)rcssi()n ol the pvibic sym})hysis or of the ischial (jr pubic rami may be palpable. Crepitus may be elicited on grasping the iliac bones, and moving them one on the other ; but such a method of investigation must be very sparingly indulged in. The chief dangers from a fractured pelvis arise from the presence of co-existent visceral lesions, especially to the urethra, bladder, or rec- tum. The membranous portion of the urethra is torn by the dis- placement of the pubic symphysis, and this is indicated by escape of blood from the meatus. Every effort must be made to prevent extravasation of urine, and the patient loarned against passing water, however urgent the desire. Rupture of the bladder results in pelvic or intra-peritoneal extravasation, according to the site of the lesion. The rectum may be punctured by the displaced pubic rami, and on examination the ends of the bones may be felt in the rectum. The vagina and the pelvic vessels and nerves are less frequently injured. Treatment. — The patient should be moved with the greatest care, both on account of the shock, and also for fear of producing or increasing visceral complications. He is put to bed on a firm divided mattress with fracture-boards beneath it, and kept quiet until the shock has in measure passed off. A more complete examination is then made, if need be under an anfesthetic, and complications dealt with. It is rarely desirable to attempt replacement of the fragments, which gradually return to a more or less normal position. The pubes, however, may be pushed forwards by a finger in the rectum or vagina. A many-tailed bandage or broad binder is advisable to steady the parts, and the patient's knees must be tied together ; he must of course be rolled over on the sound side in order to wash the back. The visceral complications demand suitable treatment, and especially the urethra, which must be examined in all cases and the water drawn off by a sterilized catheter. If the urethra is torn, it may be possible to pass a catheter and tie it in; but failing this, a perineal incision must be made in order to prevent urinary infiltra- tion. If the pubic rami are also felt projecting into the rectum, it may be advisable to prolong the permeal incision backwards so as to lay open that viscus freely, thereby allowing free exit to faeces and discharge, and permitting of more satisfactory cleansing. Apart from complications \inion may be expected in about six weeks, but the patient should be kept in bed for at least eight, and even then only allowed to get about on crutches, wearing a padded belt. Late complications in the form of abscesses connected with necrosis of the pubic rami or pelvic extravasation may, of course, arise, and prove fatal or delay convalescence. 3. Fracture of the Acetabulum is of two types: (i) The posterior lip is broken off by the head of the femur, which is dislocated back- wards by the same accident. Reduction is effected easily and with crepitus, but the displacement usually recurs, and to prevent it pro- longed and effective extension is required. (2) A heavy fall on the trochanter may cause (a) a simple fissure extending into or across the 528 A MANUAL OF SURGERY cavity, or {b) a starred fracture, possibly resolving tiie cavity into its three constituent elements, or {c) it may even drive the head of the bone into the pelvis [central dislocation of the femur) . A mere fissure of the acetabulum produces but few symptoms beyond a little pain and impairment of movement ; but if the head of the bone is driven into the pelvic cavity, the symptoms are much more serious, on account of the associated injuries to the viscera and the greater amount of violence employed. The case will resemble one of frac- ture of the neck of the femur, but there is usually only very slight mobihty, and the head may be felt within the pelvis on rectal examination. An attempt should be made to free it by horizontal traction outwards, and manipulation through the rectum; extension is then maintained, and passive movement commenced early. 4. Fracture of the Tuber Ischii has been known to occur from falls in the sitting position. The diagnosis is often obscure, as the dis- placement is slight. 5. Fracture of the Sacrum is always due to direct violence of con- siderable severity, such as kicks, blows, or gunshot wounds. It is not unfrequently comminuted, and, from the associated injury to the lower sacral nerves, may result in loss of power of the bladder and rectum. In a transverse fracture, the lower fragment is usually displaced forwards, and may cause pressure upon the rectum ; irregu- larity in the shape of the bone may be detected from within [per rectum) or from without. Treatment. — The knver fragment should be replaced, if possible; but considerable difficulty may be experi- enced in keeping it in position. A well-fitting pelvic band, with rest in bed, is probably all that is necessary. 6. Fracture of the Coccyx occurs during parturition or results from falls or blows, although its mobility often protects it from injury. Great pain is felt on walking, or on any movement which increases the intra-abdominal pressure, such as straining, coughing, defaeca- tion, etc., since the coccygeus muscle forms part of the pelvic dia- phragm. A rectal examination reveals preternatural mobility of the lower fragment, angular deformity, and perhaps crepitus. The Treatment consists in keeping the patient at rest until union has occurred; it is impossible to apply any apparatus, and hence the bone may unite at an angle, causing pain, discomfort, and difficulty in parturition. Excision of the hone is then required. The patient lies semi-prone with the legs slightly flexed, or in the lithotomy position, and a longitudinal incision is made in the middle line. The apex and lateral margins of the bone are cleared, and the ligamentous tissues uniting it to the sacrum divided by the knife ; the bone is now laid hold of by sequestrum 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 dressing is secured in position by a T-bandage. The bowels should be confined for some days after the operation. Falls upon the coccyx, unaccompanied by fracture, sometimes give rise to a most severe and intractable type of neuralgia, known as INJURIES OF nONES— FRACTURES 529 coccydynia, which may quite prevent the patient from following his a\'ocations. It is probably due to adhesions forming between the posterior sacral nerves and the bruised periosteum. If all the usual sedatives fail in giving relief, the bone must be excised. Fractures of the Upper End of the Femur. I. Fractures of the Neck of the Femur may involve any portion of this region, but for clinical purposes are usually divided into those near the head and those affecting the base near the trochanter. Fracture of the Cervix Femoris near the Head (the so-called intra- capsular variety. Fig. 238, A) is most frequently met with in persons of advanced age, and especially in females. This is explained by the atrophic changes which take place in the cervix femoris of elderly people. The spaces between the bony cancelli are enlarged and loaded with soft fat, whilst the ensheathing compact tissue is thinned, and the ' calcar femorale ' of Merkel {i.e., the process of thick cortical substance running from the lesser trochanter to the under part of the head) is atro- phied. As a rule it requires but little violence to produce a frac- ture, the direction of which varies according to the force applied. The accident is often due to some slight stumble or fall, such as shpping off the kerb or tripping upstairs ; the bone yields in consequence, and the patient fahs to the ground. The Hne of fracture may be transverse or obHque, and is mainly intracapsular. Some of the fibres reflected from the under surface of the capsule to the head of the bone may remain untorn at first, but later on they may give way from inflammatory softening, injudicious manipula- tion, or attempts to use the limb. The fracture is not usually impacted; if, however, this condition should occur, the upper end of the neck is driven into the loose cancellous tissue of the head. The displacement is necessarily limited entirely to the lower frag- ment, which is drawn upwards by the glutei, recti, and hamstring muscles, and rotated outwards and somewhat backwards, so that the fractured surface looks almost directly forwards. The course of the case depends to a large extent upon the general condition of the individual. If he is healthy and free from chronic pulmonary affection, so that he can be kept recumbent for six or eight weeks, bony union may certainly occur. This takes place Fig. 238. — A, Fracture of the Cervix Femoris near the Head. B, Pertrochanteric Fracture. C, Subtrochanteric Fracture. 530 A MANUAL OF SURGERY mainly from tlic lower end, as the vascular suj")]:)!}' of the head is only just sufficient to maintain its vitality. I f, however, the patient is feeble and weakly, and especially if the subject of chronic bron- chitis and emphysema, the prognosis is by no means good, since hypostatic pneumonia and extensive bedsores may carry him off during the short stay in bed which is always necessary in order to relieve the more urgent symptoms of pain. Bony union is never, under these circumstances, to be expected, and a loose fibrous union, or even a false joint, is the best that can be looked for. Not unfrequently the joint undergoes changes akin to those of osteo- arthritis, and the patient henceforth suffers much pain and dis- comfort. Sometimes the neck is absorbed and the shaft slips up on the dorsum ilii, the weight of the body being carried by the outer limb of the Y-ligament of Bigelow and the obturator internus tendon. 1 he prognosis is, of course, much improved by the pre;ence of impaction, and the fear of breaking this down must ever be in the mind of the examining surgeon; whilst the integrity of bridges of periosteum and reflected fibres from the capsule also improves the outlook. Radiographic examination has shown that a similar type of fracture occurs in children and young people. It is not unfrequently incomplete, and may be associated with bending of the neck. The patient often recovers mobility of the limb, and can walk about after resting in bed for a few days; but the deformity persists, and, in fact, increases from fiu^ther yielding of the softened bone, so that in time coxa vara results. A similar deformity follows a partial or complete separation of the upper epiphysis. A mistaken diagnosis of tubercidous coxitis may be made, unless one clearly appreciates the rapid appearance of the symptoms after an injury, and the facts that the trochanter is raised, the limb shortened, and the movements limited only in particular directions or not at all. If there is complete separation, treatment is best carried out by fixation with plaster of Paris in an abducted position, and by prolonged freedom from the body-weight, so as to allow the callus to harden, as by the application of a Thomas's hip-splint. Fracture of the Cervix Femoris near the Trochanter (the so-called extracapsular Jract'Hve) always involves the hip-joint, since the cap- sule extends to the shaft of the bone along the anterior intertro- chanteric line, and leaves no portion of the neck uncovered in this situation. The line of fracture (Fig. 239) is placed in front, either along the attachment of the capsule or well within it, and is really only extracapsular behind; sometimes, however, the shaft itself is considerably encroached on. Mechanism.- — This fracture is usually the result of violence acting transversely upon the trochanter major, as from a heavy fall upon the hip. The posterior part of the neck, being weaker than the anterior, first gives way; the whole neck then 3delds, and the severed head and neck are impacted into the junction of the trochanter and shaft. The majority of these cases are thus primarily impacted, continuation of the violence producing disimpaction, coupled either with detachment of one or both trochanters, or with comminution of the great trochanter; at least three, and perhaps four, fragments INJURIES OF BONES— FRACTURES 531 arc thus produced (Fig. 240). Disimpaction may also follow at a later date from the rarefaction associated with the early stages_ of repair or from injudicious manipulation; and thus the shortening which may at first be slight often increases at the end of a few days. The upper fragment remains in the acetabulum, whilst the lower is drawn up and everted. Union of the fragments is much more certain in this variety than in the intracapsular, but it is often accompanied by a considerable Fig. 239. — Fracture of Cervix Femoris Near the Base. (Semi - diagrammatic, from THE Front.) Fig. 240. — Fracture of Neck of Femur Near the Base, seen from Behind. (College of Surgeons' Museum.) The head and neck are de- pressed, and the trochanter major drawn slightly upwards. development of callus, which may subsequently impair the move- ments of the limb, whilst secondary bending and late increase of the shortening may occur if the patient walks too soon. The Signs and Symptoms of these two fractures may well be con- sidered together, the points of similarity and contrast being in this way more effectually emphasized. {a) The signs of local trmima, viz., pain, bruising, and swelhng, may be present in both; but whilst slight in the intracapsular variety, they are often very marked in the extracapsular. (&) Crepitus is evident in the unimpacted forms of each; but it is unnecessary and, indeed, extremely unwise to ehcit it by forcible manipulation, especially in the intracapsular variety. (c) Loss of power is perhaps more marked in the extracapsular form than in the intracapsular. Cases of the latter in which the patient was able to walk into hospital some days after the accident are not unknown, and are probably due to impaction. \d) Eversion is a most characteristic feature in both varieties, the limb lying absolutely helpless on its outer side. This displacement 532 A MANUAL OF SURGERY is accredited to the natural weight of tlie limb, to the greater fragility of the back of the cervix, causing it to be more comminuted than the anterior surface, and, lastly, to the greater power of the external rotator muscles. Inversion has been met with in a few rare cases, but is probably due to the violence in the particular instance being directed from behind forwards, and to impaction of the fragments. [e) Shortening is slight in the early stage of intracapsular, and much greater in the extracapsular, fractures, even reaching to 2i or 3 inches. It is indicated by displacement of the trochanter upwards, due allowance being made for the position of the limb as regards abduction or adduction. (/) The position of the great trochanter is of the greatest importance. It is raised above its orchnary level, and displaced backwards owing Sri" Fig. 241 . — Nelaton's Line and Bryant's Measurement for ascertaining Position of Great Trochanter. to eversion of the limb ; and it is approximated to the middle line of the body. The demonstration of this position is most important, and, amongst others, the following tests are employed : Nelaton's line (Fig. 241) is one drawn from the anterior superior spine to the most prominent point of the tuber ischii (AB). The centre of this (D) corresponds to the top of the great trochanter, if the limb is placed in the axis of the body ; but if either abduction or adduction is present, the top is situated slightly above or below the line. Definite elevation of the bone above the line indicates shorten- INJURIES OF HONES— FRACTURES 533 iii!^ ol till' liiul) iluc to clisl()Cciti(jn l);ickwurds, fracture of the neck, or absori)ti()n of the head and neck from disease. Bryant's Test Line (Fig. 241). — In this the patient Ues flat on a horizontal couch, and a vertical line (AC) is drawn from the anterior superior spine; a thin wooden rod held against the side answers this purpose admirably. The perpendicular distance of the top of the great trochanter from the line (CD) is compared with a similar measurement on the opposite side; definite shortening may thus be discovered. In the normal adult this measurement is usually about 2 ^ inches. Morris's hitrochantcric test indicates the amount of inward 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, along which two pointers work outwards. Shortening in this direction will also be observed in most dislocations of the hip-joint. Moreover, in the extracapsular fracture a considerable amount of thickening of the trochanter is always produced, owing to the exces- sive development of callus. In the intracapsular variety it is rarely fissured or injured, and therefore no thickening occurs. (g) Lastly, relaxation of the fascia between the crest of the ilium and the great trochanter (that is, of the upper part of the iho-tibial band) is given as a characteristic feature of these fractures. Diagnosis. — A severe contusion of the hip, which may be associated with marked eversion, is known from a fracture by the absence of shortening and crepitus ; there is no displacement of the trochanter, which rotates in a normal manner. The shortening which some- times follows, owing to subsequent atrophy of the neck, may, how- ever, complicate matters. In a dislocation the head of the bone can be felt in an abnormal position, and hence no difficulty should be experienced in its recognition. In chronic osteo-arthritis of the hip a patient may fall and present for examination a limb with definite shortening and marked bony crepitus. It will be found, however, that there is no acute eversion, pain, or loss of power, whilst the existence of similar disease in other joints may assist the surgeon. Moreover, osteo-arthritis of the hip usually results in prominence of the trochanter, and not in flattening, as occurs after fracture; the fascia, too, above the trochanter is never relaxed in osteo-arthritis, always in fractures. It must not be forgotten that, after an intracapsular fracture, the patient may fall, not on the injured side, but on the sound thigh, and cases have been known where the surgeon's attention was directed to the wrong limb owing to the amount of bruising there manifested. The Treatment of Intracapsular Fractures must depend in great measure, as already stated, upon the individual. If old, weakly, and with a tendency to chronic bronchitis, long confinement to bed would have a most deleterious, if not fatal, effect. In such cases the limb is put at rest for a few days between sandbags, and cooling lotions applied. Some suitable appliance, such as a Thomas's splint with 534 A MANUAL OF SURGERY mechanism for extension, or a plaster ofJ^Paris spica, shoulcl^be fitted as early as possible, and the patient encouraged to get about on crutches. In a healthy individual with good physique, a determined effort must be made to secure bony union, and this will involve the patient being kept in bed for six or eight weeks. Reduction is obtained by making manual extension on the limb, a roller-towel around the perineum being employed for counter-extension. This is maintained until the limbs correspond in length, and then the leg is inverted so that the foot is at right angles to the table, and the whole hmb is slowly abducted under tension so as to bring the lower fragment into contact with the upper; only in this position can satisfactory apposition of the fractured surfaces be obtained. The patient is then placed in a suitable abduction frame (Robert Jones) WW \ \ \ A _A. Fig. 242. — Method of Cutting and Folding the Strapping in Applying Extension. ::^^^M3:>~^^3IZZ] Fig. 243. — Method of Arranging Strapping on Stirrup or ' Spreader.' The end A* is attached by a safety-pin to A, the end of the upper piece of strapping in Fig. 242, and a similar attachment is made on the other side of the limb to the other piece of strapping. - — a double Thomas's splint with the frame for one limb abducted — and extension maintained, or in a plaster of Paris spica (Royal Whitman). At the end of six weeks the leg is gently adducted, and a Thomas's knee-splint with extension, or some similar con- trivance, is fitted, and massage and passive movements of the limb are undertaken. It is a mistake to commence walking too early, and the patient should always for a time have a support, such as a walking caliper (R. Jones),* which carries the weight of the trunk from the pelvis to the ground. Walking without support should not be permitted for at least three months. Occasionally it may be justifiable to trust to weight-extension or to the use of a Liston's splint, but the results of such treatment are far inferior to those obtained by abduction. Extension by iveighl and pulley is required in so many different conditions that a de- * Robert Jones, Brit. Med. Journ., December 7, 1912. INJURIES OF BONES—FRACTURES 535 A stirrup is tlien prqxuod as ■» F'S;^;« . adh.^'v^^^P^^^^^^ ^ ,,„1^ ;;;; -tte side of theCb^nd secured to it by a woollen or boraac bandage, which should not extend m"<:h >"5lovv the knee^ IM s;lrn'p^s then attached to the stops by -fety-P - ^A 'o A' the '^USSaMMMM^ ■^ F,0 ,,,_V0LKMAN>.-S SLIDING KEST FOK FRACTDKBS OF THE FEMOR. A points to the junction ol the upper and lower pieces of strapping, as in ^ Figs. 242 and 243. IfpSi-thXtl^S^"^^^^^^^^^^^^^^ ^t T,t)'SZiX:ef^^r^^^^^^^ and secured to .t by the loose end of strapping and ^ ba^^age^ comfortable appli- Ltston's long 'Pj'''{^^'^- r^"^^^^^^^^ the axilla to about J^Siris p-eteilt^S'^^lip^n^^^^^^^^^^^ ei^f the splint nrto a 536 A MANUAL OF SUIiGIiRY slot between two ' angle-irons ' screwed to a substantial wooden base, which rests on the bed. In impacted intracapsular fractures no attempt should be made to separate the fragments. The patient is kept in bed and a long splint applied. A careful watch is maintained to ascertain if disimpaction has occurred, as tlu'n the ordinar\- treatment must be eniphjyed. Treatment of Fracture near the Trochanter is usually conducted on similar lines to that of the intracapsular variety, but inasmuch as the patient is usually healthy a determined effort to secure satis- factory union must be made. In the unimpacled form extension is the all-important element. It is usually conducted by weight and pulley; the weights must be Fig. 245.- — Method of Application of Liston's Long Splint with Weight Extension. The splint reaches from the axilla below the side of the foot, and is secured in place by sheets. heavy, and sometimes as much as 14 pounds are required; the strapping must reach well above the knee, or the ligaments of this articulation may suffer. Rotation may be prevented by fixing a broad piece of wood carefully padded transversely bcliind the knee by means of a plaster of Paris bandage. The addition of a long splint will keep the body at rest, but inasmuch as it might interfere with the extension, it may be as well to apply it to the sound side. Treatment in the abduction frame will also give good results. At the end of eight weeks the patient may be allowed to get about with a Thomas's splint and crutches, or a plaster spica. INJURIES OF HONES— FRACTURES 537 Impacted fractures should rarely be broken up, except in young and active people. In older patients the limb is kept at rest for six or eight weeks on a long splint without extension. Union occurs readily and by means of bone; but there is often a good deal of deformity and subsequent disability from the de- N'clopment of bon\' outgrowths. 2. Fracture of the Great Trochanter is rare, and always due to direct violence ; in the young it occurs as an epiphyseal lesion. The trochanter, or a portion of it, is separated from the rest of the bone without any loss of the continuity of the shaft. Independent move- ment of the fragment with crepitus is usually obtainable ; and if the displacement is at all marked, an operation to fix it should be undertaken. 3. Fracture through the Great Trochanter (the pertrochanteric fracture of Kocher) closely resembles the extracapsular fracture, the lesion running from the inner and under part of the neck obliquely upwards and forwards through the base of the trochanter (Fig. 238, B) . The lower fragment is displaced upwards and everted, and its upper edge can often be felt distinct from the top of the great trochanter, which does not move on rotation of the limb; there is also much thickening about the trochanter and pain on pressure over it. This injury needs to be carefully distinguished from the subtrochan- teric fracture, which encroaches on the upper end of the shaft. In this both trochanters are included in the upper fragment (Fig. 238, C), which is flexed by the ilio-psoas and abducted, whilst the lower fragment is drawn up on its outer aspect and behind it with con- siderable shortening and complete eversion. Both types of fracture require prolonged extension in the abduction frame or by means of Hodgen's apparatus. Hodgen's splint (Fig. 246) consists of a rigid iron frame in the form of the letter U, the outer and longer limb reaching from the anterior superior spine to 3 inches below the instep, and the inner from the adductor longus tendon to the same spot, where the two limbs unite in a crossbar 3 inches in width. The sides taper with the limb, and should be | inch further apart than the diameter of the limb at any point. At the upper end the bars are united by an arch of the same material, which should correspond to Poupart's ligament ; one or two similar arches are placed at equal points lower down. The splint is slightly bent at the knee. Before applying the splint, an ordinary extension apparatus is attached to the limb. Strips of house-flannel, about 7 inches wide, are then cut and arranged beneath the limb at right angles to its direction, each one overlapping the next; the length of the strips should be rather more than the circumference of the limb at the spot to which each is to be applied. The splint is then placed in position ; the strips of flannel are raised in succession, and, being lapped over the bar, are pinned or stitched there, so that the limb lies in a flannel trough, from which only the upper surface projects. The cord of the extension appliance is then securely tied to the lower end of the 538 A MANUAL OF SURGERY splint. Two hooks are soldered to each"side of the frame, and to them are attached cords, which are brought together over the limb; another stout cord is tied to these, and passes over a pulley attached to a vertical post at the end of the bed ; it is weighted to a sufficient extent. The limb when the weight is applied should lie free of the bed, even to its extreme upper limit. It is advisable to encircle the thigh in Gooch splinting, a narrow piece in front between the bars and a broader piece behind. These are well padded and secured by bandages which extend over the whole length of the apparatus; finally, starch is rubbed in so as to fix it more firmly. When correctly applied, the splint itself is pulled on by the extending Fig. 246. — Hodgen's Splint and its Method of Application. force (the weight), and this is transmitted to the limb through the stirrup end, which should be taut ' like a harp-string ' ; laxity of this end indicates slipping of the splint, and necessitates its readjust- ment. Fractures o£ the Shaft^of the Femur are extremely common accidents, in spite of the apparent strength of the bone. Any part may be involved, particularly the centre, whilst they occur at the lower end more frequently than at the upper. In the latter situa- tion they are usually due to indirect violence, whilst at the lower end they generally result from direct injury; either form of violence may lead to a fracture about the middle of the bone, and radiography has shown us that spiral fractures are by no means uncommon Exact diagnosis is sometimes difficult, owing to the amount of swelling from hsemorrhage, and to the muscularity of the part. In almost every case displaceme^it occurs, the direction and amount of which depend not only on the line of fracture, but also on the situation. In the tipper third (Fig. 247), the small upper INJURIES OF BONES— FRACTURES 539 fragment is usually tilted forwards by the ilio-psoas, and abducted and everted by the gluteus minimus and external rotators; whilst the lower fragment is drawn upwards and to the inner side of the upper by the hamstring 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 comphcated displacement is not always present. In the middle third, if due to indirect violence, the hue of fracture usually slants from above downwards and backwards, causing a simple overriding of the fragments or an angular deformity. The Fig. 247. — Fracture of Upper Third of Femur, showing Dis- placement OF Bone. (After Gray's ' Anatomy.') I, Ilio-psoas tendon; 2, rectus; 3, adductors; 4, biceps. Fig. 248.— Fracture of Lower Third of Femur, showing Dis- placement OF Lower Fragment Backwards. {After Gray's ' Anatomy.') I, Rectus; 2, biceps; 3, semi-mem- branosus and semi-tendinosus ; 4, gastrocnemius. 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 or less transverse, often comminuted, and any form of displacement may then occur. In the lower third the fractures which arise from direct force are transverse; the lower fragment may then be tilted backwards by the gastrocnemii muscles (Fig. 248), and compress or rupture the popliteal vessels, perhaps causing gangrene. Oblique or spiral fractures from indirect violence, sloping from above downwards and forwards, are also met with; the upper fragment is driven into tne 540 A MANUAL OF SURCFAiY substance ut the quadricej)S muscle and may become fixed in it, pro- jecting immediately^ beneath the skin, whilst the lower fragment is drawn up behind. If such a case is left unreduced, non-union is likely to ensue; the knee-joint is generally penetrated by the lower end of the upper fragment. Treatment. — In the uppcy lliiyd, where the upper fragment is often too short to be controlled by any splint, reduction of the deformity is accomplished by flexing the thigh, and making extension from the knee, the lower fragment being thus lirought into the same axis as the upper. Manipulation will usually correct any lateral displace- FiG. 249. -Bryant's Method of Extension for Treatment of Fracturk OF the Femur in Small Children. The right leg is fractured and has the weight attached to it; the lelt leg is merely tied up to keep it vertical and out of the way. ment. The limb must be confined in this position by some form of inclined plane, such as a Macintyre's splint, with a long thigh-piece, and with small straight wooden splints or a piece of Gooch's splint- ing fixed, if necessary, to the front and outer sides of the limb, over the seat of fracture. The splint is slung at the knee, the foot-piece being fixed to blocks of wood, a little lower than the level of the knee. If these precautions are not taken, an ununited fracture, with the upper fragment in front of the lower, is likely to occur. Hodgen's apparatus also answers admirably in these cases, and where there is much abduction of the upper fragment the abduction INJURIES OF BONES—FRACTURES 541 frame (p. 554) may advisably be employed; in healthy patients, however, treatment by operation is often desirable. In the middle Ihird of the thigh, where the upper fragment can be controlled by splints, shortening is prevented by weight extension or by the use of a Thomas's knee-splint, the thigh being sur- rounded by pieces of Gooch's splinting, which grasp the muscles and keep the parts at rest. A half-box splint [i.e., a long splint with a back-piece) may be successfully employed in many of these cases, the limb being firmly bandaged to the appliance. Where the fracture is oblique or spiral, and especially if there is any ten- dency to overlap, Hodgen's apparatus may be utilized, or operation undertaken. In the loioer third, when the lower fragment is tilted backwards, a Macintyre's sphnt, with a long thigh-piece and the knee well flexed, may sometimes be employed, together with a short anterior thigh-piece of Gooch's splinting; but in the oblique type, if the upper fragment has penetrated the quadriceps, operation alone holds out any prospect of bringing the parts into apposition, the muscular fibres being divided to allow the projecting end of the bone to be replaced, and fixed by screws or wire. In other cases the ordinary long splint or Hodgen's will be required. In children, Bryant's plan of treatment (Fig. 249) is excellent; it consists in slinging the limb from a crossbar at right angles to the body, with or without a back-splint, reaching from the heel to the nates, and short lateral sphnts, thus obtaining extension by utihzing the weight of the body, whilst the bandages, etc., are kept from being soiled. ' If a long spHnt is used for children, a double one [e.g., Hamilton's sphnt) with a crossbar below is the best. For the obstetric fracture which occurs in babies, the best treatment is to apply a small Thomas's knee-splint with extension. The ring which encircles the groin is well padded and covered with impervious oilskin, and the extension is carefully maintained. A fractured femur usually unites well in from six to eight weeks, but the patient must not bear his weight on it for another morith or two. Some form of retentive mechanism is employed, permitting walking, and yet maintaining sHght extension — e.g., a Thomas's knee-sphnt with a foot-piece. There is certain to be some amount of stiffness of the knee-joint, following effusion, after all fractures of the femur ; but it generally passes away in time, and that without active surgical intervention. Fractures 0! the Lower End of the Femur. I. T- or Y-shaped Fracture of the Condyles.— In this a transverse fracture is compHcated by a fissure, which runs into the joint, separating the two condyles; or a Y-shaped fissure may start from the intercondyloid notch. The condition is very painful; the joint is distended with blood ; the bone may feel broader than usual, and crepitus may be detected. Treatment is best effected by operation, 542 A MANUAL OF SURGERY in order to empty the joint of blood, hrinj^' tiie frat^mients into apposi- tion, and fix tlicni I)y screws or pegs. 2. Separation of either Condyle usually results from direct violence, but occasionallv has followed such indirect injury as catching the toe against the kerbstone. There is no shortening, but the leg may be deflected towards the side injured, and the joint cavity be full of blood. The fragment, which is tilted backwards by the gastroc- nemius, may^move separately' from the shaft, and give rise to Fig. 250. — Radiogram of Fracture of External Condyle of the Femur, with Fixation of Fragments by Screws. This fracture occurred in a healthy man, and was caused by catching his toe against 'the kerbstone whilst walking. The fragment was completely detached and drawn back into the popliteal space by the outer head of the gastrocnemius. It was treated by operation, with a good result. crepitus. Treatment.- — Reposition is effected by flexion of the limb, which is best put up in this position ; but in healthy adults treatment by operation is desirable (Fig. 250). Occasionally a small portion of the condyle may be detached and lie loose in the knee-joint; when the immediate symptoms due to the injury have subsided, the signs of a foreign body in the joint may become evident, and operation will be required for its removal. 3. Separation of the Lower Epiphysis of the Femur (Fig. 251) is not a very rare accident, and is frequently due to a child sitting behind a cab and getting a leg entangled between the INJURIES OF BONES— FRACTURES 543 Spokes of the revolving wheel. The limb is tluis forcibly hyper- extended at the knee, and the epiphysis yields, and is carried for- wards. The lower end of the diaphysis projects behind, and may compress the popliteal vessels; gangrene has been known to result. As in the humerus, the line of separation does not always correspond to the epiphyseal line, but sometimes encroaches on the shaft. Sup- puration occurs in a fair proportion of the cases. Treatment.— Reduction is effected by an assistant making traction'on the tibia^in the line of the limb so as to stretch the quadriceps ;[then the thigh is gradually 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 com- menced carefully in a fortnight. Fractures of the Patella. The patella is broken either b}- muscular force or by direct vio- lence, and the conditions produced are so different that a separate description is necessary. 1. Fractures by direct violence may traverse the bone in an}- direction, but are most often ver- tical or star-shaped, and frequently comminuted. They are usually mere fissures without displacement, owing to the aponeurosis or capsule of the bone remaining intact. There is a good deal of subcu- taneous bruising, and perhaps some effusion into the joint, whilst on careful palpation the fissure may be felt, and crepitus occasionally detected. Treatment consists in keeping the limb at rest on a back-splint, and perhaps applying evaporating lotions. Massage and passive movements are com- menced early where there has been much haemorrhage into the joint. Operative measures are rarely required. 2. Fractures due to muscular force are always transverse, usualty complete, and since they involve the fibrous aponeurosis, consider- able displacement occurs. Mechanism. — When the knee is semi-flexed, the patella is poised upon the front of the condyles of the femur, resting upon the middle Fig. 25 1 . — Radiogram of Separa- tion OF Lower Epiphysis of Femur, with Displacement Forwards. The patella was mainly cartilagin- ous, and is not visible. 544 A MANUAL OF SURGERY of its articular surface: in this position any sudden and violent con- traction of the quadriceps, as in attempting to recover one's ecjuili- brium after having slipped, takes the bone at a disadvantage, and may succeed in snapping it. Possibly in some people there is a predisposing weakness, as cases are not rare in which the other patella is broken at a later date. The fragments may be almost equal in size (Fig. 252), but the lower is often the smaller; either of them may be again divided vertically, or comminuted. The Signs of this fracture consist of loss of power in the limb, pain, distension of the joint with blood, and separation of the fragments, which can be readily felt and sometimes seen (Fig. 253). This displacement is due to unopposed muscular action, and is always associated with rupture of the lateral expansions of the vasti muscles. Union by bone is rarely obtained apart from operation. Fig. 252.- — Fracture of Patella, WITH Separation of Fragments. (After Gray's ' Anatomy.') I, Rectus; 2, vastus externus; 3, ligamentum patellae. Fig. 253. — Appearance of Knee after Fracture of Patella. owing to the separation of the fragments, and the carrying in of loose tags of the fibrous aponeurosis or capsule, which yields at a different level to the bone. Fibrous union is the usual result, and when this is short and strong, it is quite satisfactory; but more commonly the bond of union yields when the limb is used, so that the two fragments are once again separated, merely a bridge of fibrous tissue intervening, the joint being left in a weak state, and the power oi active extension of the leg lost. The Treatment of these cases may be grouped under three headings, viz., by retentive apparatus, by subcutaneous ojieration, or by the open method. I. Simple retentive apparattis may be employed in cases where the fragments are not widely separated, and can be readily brought into contact, and where the patient is not a good subject for operation. A large piece of moleskin plaster is applied over the front and INJiiRIFS OF BONES—FRACTURES 545 sides of the extensor surface of the thigh, reaching half-way up to the groin, and terminating below in two lateral elongated ends or tags, to which elastic traction is applied. The limb is placed on a back-splint, with a foot-piece, beneath which the elastic accumu- lator is firmly fixed. Removal of the effusion in the joint may be hastened by the use of the aspirator. At the end of about three weeks the patient is allowed to get about on crutches, with his knee in a rigid splint, which can be easily removed for daily massage and passive movements. At the end of five or six weeks active movements are permitted, and a special knee-splint is ordered (Fig. 254), which allows of only a small amount of mobility at first, but, by filing away a stop, this can be gradually increased, until a full range of movement is permitted. It is probable that only fibrous union is ob- tained by this method of treatment, but this is satisfactory and strong enough if the patient can give the time (6 to 12 months) to ensure its solidification. The strength of this fibrous union is best illus- trated by the fact that if the bone gives way a second time, the lesion takes place through the bony, and not through the fibrous, tissue. When, however, the patient has to work for his living, it is essential that repair should be established at as early a date as possible, and this can only be secured by operative treatment. 2. To avoid the supposed risks of laying open the joint, various subcutaneous operations have been adopted. Of these the least objectionable is that recom- mended by Mr. A. E. Barker, who ties the fragments together by silver wire (Fig. 255). An opening is made with a tenotomy knife into the joint just below the lower segment, through which any effused blood or synovia can be squeezed, and along which a curved hernia needle is passed, traversing the articulation from below upwards, and emerging through the skin above the upper fragment. A piece of sterilized silver wire is then carried back under the bone. The needle is again inserted at the same spot below, and carried in front of the bone under the skin, emerging at the same point above. The upper end of the wire is threaded through it, and by this means brought out at the lower opening. The bone is thus encircled, and by tightening and twisting * For the loan of this block we are indebted to the late Mr. T. Hawksley, 357, Oxford Street, W 35 Fig. 254. — Splint for Fractured Patella.* The steel joints at the sides are made \vith an adjustable stop, which prevents overstretch- ing or rupture of the newly-formed bond of union. 546 A MANUAL OF SURGERY the wire the fragments are brcmght into apposition. The ends are cut off and pushed back under the skin. The linil) is placed on a back-spHnt for a week or so, when passive movement is com- menced, the patient being allowed to walk about at the end of the second week, and discarding all apparatus at the end of five weeks. 3. The open plan of treatment, advocated and perfected by Lord Lister, is undoubtedly the best, in that it permits of the removal of the tags of fascia and aponeurosis, which always intervene. It may be wise to delay operation for a few days in order that the joint may recover from the immediate effects of the injury. A horseshoe-shaped flap is usually dissected up, exposing the fractured ends of the bone, which are cleared of all clot and fibrous shreds. Tracks for the wire sutures are now made by a drill, extending from the upper or lower end through the centre of the Fig. 255. — Barker's Method of Subcu- taneous Suture for Fractured Patella. Fig. 256." — Lister's Plan OF Suturing Patella BY Open Operation. Fig. 257. — -G. G. Hamil- ton's Method of Introducing Silver Wire for Fracture OF Patella. bone, so as to emerge on the fractured surface just in front of the articular cartilage (Fig. 256) ; should the drill emerge at different levels on the faces of the fragments, cartilage 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 tendinous or periosteal tissue over the upper fragment, so as to keep it from projecting under the skin and causing irritation. A second wire is sometimes needed in order to prevent rotation of the fragments. The wound is closed, and the limb kept on a baok- INJUniES OF BONES— FRACTURES 547 splint. In healtli}- adults passive movement may commence in ten days, and by the end of a fortnight the patient is allowed to walk in the simpler cases; but in complicated fractures and in elderly people it is better to keep the limb immobilized for a longer period. It is sometimes wise to pass the wire transversely through the fragments (Fig. 257), as suggested by Mr. G. G. Hamilton, of Liver- pool, a firmer and more secure hold being obtained in that way, and the wire being less likely to cut out. In old cases, where the fibrous union has stretched and the utility of the limb is seriously impaired, operation holds out the only hope of helping the patient. The fibrous tissue must be dissected away, and the surfaces of the fragments freshened, if need be, with the saw, and drilled for the passage of the wire. To obtain apposition, the upper fragment must be detached from the femur, to which it is often adherent, and the rectus muscle, which is secondarily con- tracted, may need partial division. The limb should be well raised to relax the quadriceps and thus diminish tension on the bond of union, and lowered inch by inch on succeeding days. The muscle is thus stretched to accommodate itself to the altered conditions. If the fragments cannot be brought absolutely together, the same treatment may be adopted, and the patient allowed to get about with a loop of silver wire between the fragments ; the quadriceps is stretched by this means, and a subsequent operation may prove successful in gaining bony union. Fractures of the Leg. Fractures of the Tibia alone. — Several varieties are described. [a) The n.pper end is usually broken as a result of direct violence, the fracture being often comminuted. The characteristic 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-shaped 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. ih) 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 oblique below. 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, but the lower end of the upper fragment, which is usually pointed, is tilted forwards by the action of the quadriceps and may pierce the skin. The Treatment consists in the application of back or side splints (Cline's) for a few days until the swelling has gone 548 A MANUAL OF SURGEnV down, and tlicn the limb may be put up in plaster. If the bone has been comminuted, treatment will be more protracted. In some few cases reposition may be difficult owing to the character of the lesion, and operation may then be needed. Thus, in the patient whose fracture is represented in Fig. 191, although the limb had been immobilized in plaster of Paris, the fragments were not in apposi- tion, and operativ'e treatment was required, (c) The iiitenial malleolus is occasionally separated as the result of direct injur3^ apart from any other osseous lesions, constituting what is known as ' Wagstaffe's fracture.' There is comparatively little displace- ment, but the malleolus is loose, and crepitus can usually be obtained on moving it backwards and forwards. Union by fibrous or osseous tissue ensues, but usually in a more or less abnormal position, in consequence of which the integrity of the ankle-joint is disturbed, and weakness or lameness may follow. Treatment consists in securing the fragment into position by screw or nail; otherwise massage and the application of lateral splints must be relied on. Schlatter's Disease. — This term is applied to an affection of the upper end of the tibia in young people, the nature of which is a little doubtful. Probably it is due to a partial separation of the lower tongue-shaped prolongation of the upper epiphysis, which forms the tubercle of the tibia, and this is followed by a subacute inflammation. The child complains of a tender swelling in this region without any affection of the joint, and walks with a limp. The part requires to be kept at rest, and will in time get well. Radiography suggests a displacement forwards of the epiphysis, but operative treatment is not desirable. Fractures of the Fibula alone are by no means uncommon, usually occurring as a result of direct violence. There is no displacement or deformity; but the patient complains of pain localized to some particular spot, and this can usually be elicited by grasping the bones above and below, and compressing them laterally (' springing ' the fibula). Radiography will make the diagnosis clear. Treatment consists in immobilizing the limb in a plaster case. Fracture of both Tibia and Fibula is a very common accident, due to both direct and indirect violence ; if to direct violence, any part may be injured, both bones yielding at the same level ; but if in consequence of an indirect injury, the tibia usually gives way at its weakest part, viz., at the junction of its middle and lower thirds, and the fibula at a slightly higher level. The fractures are often oblique, running in any direction, although the obliquity is most frequently directed downwards, forwards, and inwards. The lower fragment is generally drawn upwards on account of the contraction of the powerful calf muscles, and often rotated outwards from the weight of the foot; hence there is well-marked shortening. The ordinary characteristics of a fracture are very evident, 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 upper fragment of the tibia piercing the skin. The fracture of the tibia has been proved by radiography to be frequently of a spiral character, and is then probably always due as IN J UNI HS OF BONES— FRACTURES 549 much to iurciblc torsion of the hmb as to vertical strain. The rotation is an important element, and the shortening is sometimes less marked than in simple obUque fractures; there is frequently some diffi,culty in getting satisfactory approximation of the frag- ments, even on operation, owing to the broken ends becoming en- gaged in the fibro-muscular tissues around. Treatment. — In the simpler cases reduction is accomplished by flexing and fixing the knee, so as to relax the muscles of the calf, and then making traction on the foot and manipulating the parts Fig. 258. — Fracture of Both Bones of the Leg, seen from IN Front. Fig. 259. — The Same Fracture AS IN Fig. 258, SEEN from the Inner Side. From a study of the two radiograms it will be noticed that both lower fragments have been displaced outwards, with but little alteration in their antero-posterior axes. into position. The tendo Achillis may, if necessaiy, be di\dded. It will usually suffice to put up the limb in side-splints, such as Cline's, the longer one with the foot-piece being intended for the outer side. In other cases it may be better to applj' a broad posterior splint with a rectangular foot-piece, e.g., Macintyre's or Neville's, and two lateral splints; or the old-fashioned half-box splint may be employed. \\'hatever treatment is adopted, it is necessary to see that the length of the limb is as far as possible maintained, and that no rotation of the lower fragment is present. To ensure absence of rotation, all that is needed is to note that the inner aspect of the great toe, the 550 A MANUAL OF SURGERY subcutaneous surface of the internal malleolus, and the inner border of the patella, are in the same Hne, and correspond with the opposite limb. Union will be sufficiently advanced in two or three weeks at the latest to allow of the limb being put up in a removeable plaster casing, which must be taken off daily for purposes of massage, but in spite of this much subsequent lameness is the usual result. In oblique and spiral fractures there is often very great difficulty in getting the fragments together, and even more in maintaining them in good position. Taking into consideration the degree of permanent depreciation that a man (especially if of the labouring classes) suffers from vicious union of these bones, surgeons need now have no hesitation in cutting down on and fixing any fracture of the tibia and fibula which is determined by radiography to be obhque or spiral in nature and with well-marked displacement. Fractures in the neighbourhood of the Ankle-joint are usually pro- duced by indirect violence, the foot sUpping, and leading primarily to a displacement of the ankle, the fracture being a secondary result. They would therefore be better described as Fracture-dislocations at the Ankle-joint. I. Displacement of the Foot oiitn^ards is by far the most common variety, resulting usually from the patient shpping on the inside of the foot, as from off a kerbstone. Several distinct varieties of lesion are now recognised. {a) In Pott's Fracture (Fig. 260) sudden abduction, usually com- bined with eversion, of the foot results in severe strain upon the internal lateral ligament, which gives way, or the base of the internal malleolus is torn off. The astragalus is at the same time driven outwards against the external malleolus, and the force is thence transferred up the fibula, which bends and breaks at some weak spot. Generally the line of fracture runs obliquely from above downwards and forwards through the malleolus; less frequently it is situated in the position originally described by Pott, viz., about three inches above the tip of the malleolus, and is transverse, the upper end of the lower fragment being displaced inwards towards the tibia. The inferior interosseous tibio-fibvilar ligament remains intact, and hence the foot itself is merely rotated outwards and abducted, and the heel is drawn upwards, whilst the toes point downwards. If the internal lateral ligament alone is torn, the malleolus projects beneath the skin, and may, indeed, protrude; if the malleolus is broken, a distinct sulcus can usually be felt between it and the lower end of the tibial shaft. In both these types the ankle-joint is necessarily laid open, and there is probably much haemorrhage on the inner side of the ankle and into neighbouring tendon sheaths. {h) In Dupuytren's Fracture (Fig. 261) a much more serious lesion is produced. The interosseous tibio-fibular ligament yields more or less completely, or the flake of the tibia to which it is attached is torn off; the foot, carrying with it the lower portion of the fibula and the superficial flake of the tibia, which has been detached, is INJURIES OF BONES—FRACTURES 551 displaced firstly outwards, and so long as the upper surface of the astragahis does not clear the lower eirticular surface of the tibia, there is merely lateral displacement with marked abduction of the foot and increased breadth of the ankle. Should the force continue to act, the astragalus may be carried sufficiently outwards to clear the lower end of the tibia, and then an upward and to a less degree a Fig. 260. — Pott's Fracture, show- ing Separation of Internal Malleolus and Fracture of Fibula. (For the loan of the negative from which this plate was prepared, we are indebted to Mr. Caldwell, of Mandeville Place, W.) Fig. 261. — Dupuytren's Fracture, WITH Well-Marked Displace- ment Outwards of the Foot, as well as of the Lower Frag- ment OF THE Fibula and the Internal Malleolus. (Radio- gram TAKEN from IN FrONT.) backward displacement is added, causing great eversion of the foot and deformity of the ankle. On the inner side either the ligament or the malleolus may yield. (c) In another variety the injury consists in the usual type of fracture of the fibula, associated with an almost transverse fracture of the tibia, just above the base of the inner malleolus. In this form the lower end of the shaft of the tibia projects beneath the skin, and is likely to be mistaken for the tip of the malleolus ; if this error is committed, and the fracture allowed to unite without proper rectifi- cation, considerable deformity results. [d) A similar injury in children may-produce a separation of the 552 A MANUAL OF SURGERY lower epiphysis of the tibia, whilst the fibula yields in the usual situation. The line of separation in the tibia is uKire or less trans- verse, but may extend into the diaphysis on the outer side. In almost all of these varieties the ankle-joint itself is involved, and this, combined with the amount of bleeding that occurs into tendon sheaths and muscles around, and the difficulties sometimes experi- enced in complete reduction of the fracture, explains why the results of these cases are frequently so unsatisfactory. Sometimes after union has occurred, pain and deformity become increased, owing to the patient being allowed to walk too early, the result being that the callus yields to the weight of the body. 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. Displacement of the Foot inwards. — When the patient shps on the outer aspect of the foot, the astragalus is forcibly driven against the inner malleolus, which may be broken off or impacted into it. The outer malleolus is dragged inwards with the foot, and owing to the integrity of the inferior tibio-fibular hgament, which acts as a fulcrum, the fibula }aelds at the same spot as in Pott's fracture. The foot is displaced inwards, and perhaps shghtly backwards. 3. Displacement of the Foot backwards, by catching the heel and tripping forwards, is usually associated with fractures of the tibia and fibula in the same position as in Pott's fracture, but eversion of the foot is absent (see dislocation of the ankle backwards, p. 625). Treatment. — In reducing these fractures, traction should be made upon the foot after the tension of the calf muscles has been reUeved by flexing the knee under an anaesthetic, or by tenotomy of the tendo AchilHs; the position of the internal malleolus must be accurately defined. Before applying the splints, careful attention must be given to the following points: {a) The foot must be maintained at right angles to the leg; [h) the heel must not project unduly back- wards ; and (c) the foot must not be rotated on the leg — i.e., the inner surfaces of the great toe, internal malleolus, and patella must be in the same line. A pair of Cline's spHnts is often sufficient to steady the parts in simple cases, and must be applied with sufficient firm- ness to keep the malleoli together and prevent subsequent lateral play in the ankle-joint. Some patients are better treated, however, by a Dupuytren's spHnt (Fig. 262), which is really a Liston's sphnt 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 lying on the sound side during its application. A firm pad extends down as far as the base of the internal malleolus, and over 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 to the limb. Marked tendency to backward displacement of the heel may be counteracted by the application of a Syme's anterior horseshoe splint, which can be used in combination with a Dupuytren. It consists of a flat piece of wood, well padded, extending from the knee INJURIES OF BONES— FRACTURES 553 to the ankle along the crest of the tibia; the lower end is shaped like a horseshoe, the two limbs passing one on either side of the loot. A handkerchief or piece of bandage is applied, with its centre over the point of the heel ; it passes up on either side between the splint and the foot, winds over the former structure, and is tied behind the heel which is thus hfted forwards. A similar end may be obtained by the use of a Macint^Tc's back-splint combined with a pair of Chne's splints. . At the end of ten days or a fortnight, when all tendency to dis- placement has ceased, these spHnts mav be discontinued and lateral poroplastic or plaster of Paris sphnts applied, so that they may be removed dailv for massage and suitable movements. Even when fit to walk, considerable after-care is needed to prevent harm ansmg from the weight of the body. In many cases it suffices to thicken the sole of the boot on the inner side so as to maintain the loot m Fig. 262.— Dupuvtren's Splint applied for Pott's Fracture. (Till- MANNS.) a position of shght varus; in worse cases an outside iron should be worn, passing down from a circular band below the knee to be hxed in a slot in the sole of the boot. In the simpler forms, early massage may be employed, and then all the retentive apparatus necessary is a hght removeable plaster case In the more serious cases, where there is considerable dis- placement and much difficulty in keeping the fragments together, operation to fix them is quite justifiable. In cases of vicious union after Pott's fracture, it is usually necessary to re-di\ide the fibula, and to excise a V-shaped portion of bone from the tibia, perhaps extending into the ankle-joint, so as to enable the maUeolus to be brought in contact with the shaft. Fracture of the Os Calcis may result from direct ^^olence, such as a blow or fall on the heel, or possibly from muscular action the epiphysis being then separated, or the sheU of bone into which the tendo AcliilUs is inserted being torn oft". The fragment thus separated is displaced upwards by the contraction of the call muscles and the resulting deformity is very evident. If the hne of fracture pa^^es through the body of the bone, there may be no dis- placement owing to the attachment of the interosseous and lateral ligaments; but should the sustentaculum tah or greater process be broken, the arch of the foot may be more or less flattened W Hen due to a fall from a height, the bone is often comnunuted and the loot 554 A MANUAL OF SURGERY much bruised and swollen {compression fracture). Treatment con- sists in immobilizing the foot in a plaster case if there is no displace- ment ; but where the posterior part of the bone is drawn upwards, it must be approximated to the rest of the bone after flexing the leg, 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. In fractures which are likely to be followed by traumatic flat foot, the patient must not be allowed to walk without an effective support, and the foot must be maintained in a slight varus position. Fracture of the Astragalus is usually due to falls on the foot from a height, or from direct violence appHed to the foot, as by a weight falling upon it. The lesion is often a severe comminuted one, and portions of the bone may be displaced forwards or backwards, making a marked projection beneath the skin. Such accidents are often associated with lesions of the tibia or fibula, and possibly even of the femur. The whole region of the ankle becomes infiltrated with blood, and an exact diagnosis is sometimes difficult. Treat- ment 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 projecting fragments. Occasionally in less severe accidents the bone merely sphts across, the lesion being usually situated about the neck. Such is due eithei to the weight of the body flattening out the arch of the bone beyond the hmits of elasticity, or, if the foot is dorsi-flexed, to penetration of the bone by the anterior edge of the tibia, impaction being sometimes produced in this way. Massage and early mobilization shoiild be employed in such cases. Other bones of the foot are occasionally fractured, but these lesions require no detailed description. CHAPTER XXI. DISEASES OF BONE. Inflammation of Bone. General Considerations.— Bones are divided into the long, the short, and the flat, each of these consisting of compact and cancellous tissue. In the short bones there is but a thin layer of compact tissue sur^ rounding a cancellous central mass, the meshes of which are filled with medullary fat and connective tissue. In the flat bones the compact tissue forms two hmiting plates, separated by a layer ot cancellous tissue (known in the skull as the diploe). In long bones the ^haft consists of a tube of compact structure, surrounding a space which is 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 extend into the Haversian canals, and are thence continuous with the peri- osteum, so that the mineral skeleton has incorporated withm it a vascular fibro-cellular mass which permeates its whole structure. The vascular supply of a bone is derived [a) from the nutrient artery which passes into the medullary space, and there breaks up into branches which ramify through the whole of the medullary tissue, and thence extend into the Haversian canals; and (5) from the peri- osteum, an exceedingly vascular ensheathing membrane, froni which small vessels pass perpendicularly into the Haversian canals, and estabhsh a communication between the two systems. These latter vessels are especially numerous and large close to the epiphyses. Large veins occur in the medullary and cancellous interior, and are frequently thrombosed in inflammatory mischief; if the thrombus becomes infected, and so disintegrated, pysemia is very hkely to ensue. The growth of bone manifests itself in three different directions: (i.) It increases in length from the shaft side of the epiphyseal carti- age, the epiphysis itself growing but little. In the upper imb the chief increase in length occurs at the shoulder and wnst, whilst m tne leg it is mainly evident on either side of the knee-iomt, and this in 555 SSG A MANUAL OF SURGERY spite of the fact tliat the so-called nutrient arteries are directed away from these points, (ii.) Increase in breadth is produced by new formation under the periosteum. 1'herc has been much difference of opinion as to whether this membrane has any true bone-forming power. That bone is often formed from it when stripped up is undoubted; but it is probable that the angular nucleated osteoblasts found on its under surface have been derived from the bone itself by the process of detachment, which necessarily tears through or drags out the vessels which pass from the periosteum into the bone, (iii.) A bone increases in density by a new deposit of osseous tissue around the Haversian canals and cancellous spaces. In considering the inflammatory affections of bones, it must always be kept in mind that the essential pathological phenomena (viz., hypenemia, exudation, and tissue changes) are similar to those manifested in any other vascular structure, but tfiat the effects are modified by the Hmited space in which the vessels he, and the resist- ing character of the surrounding osseous tissue. Hence any actiie inflammation, associated with rapid vasculor engorgement and considerable exudation quickly poured out, leads to necrosis from thrombosis, due to increased pressure within the unyielding bony canals. If, however, the process is subacute, so that the tissue- liquefying properties of the exudation and the tissue-absorbing activity of the leucocytes can come into play, then osteo-porosis or rarefaction of the bone follows, a condition sometimes termed caries. On the other hand, if the inflammation is chronic, and due to causes other than tubercle or the pressure of tumours, then new formation occurs, and osteosclerosis, or condensation, is most likely to result. Tubercle in bones, as elsewhere, causes primary rarefaction of the tissue attacked, though sclerosis may be associated with or follow it, and the chronic pressure of tumours or aneurisms lea.ds to local rare- faction and atrophy, although a certain amount of sclerosis may be induced around. Much needless confusion has arisen in connection with the termi- nology of inflammatory affections of bone. To all of them, whatever their nature or position, the term ' osteitis ' might rightl}' be applied ; but when the medullary cavity of a long bone is particularly affected, the term ' osteo-myelitis ' is substituted, as also sometimes when masses of cancellous tissue, as in the os calcis, or sheets of it, as in the diploe of the cranial bones, become the seat of an acute inflamma- tion. The vascular continuity between the periosteum and medulla through the Haversian canals will explain why periostitis is always associated with osteitis of the underlying bone, and why osteo- myelitis is never strictly limited to the medullary cavity. It is also important to realize that necrosis, caries, and sclerosis are results of inflammation, and must neither be confounded with the pathological processes leading to them, nor described as distinct diseases. Necrosis, or death of bone, may occur in a variety of forms, and from many different causes, e.g. : {a) From acute localized suppura- DISEASES OE BONE 557 tivc periostitis, the sequestrum or dead mass being then simply a superlicial plate or flake of the compact exterior (Fig. 263), the process by which it is cast off being then known as ' exfoliation ' ; (/;) from acute infective osteo-myelitis, the sequestrum then often involving the whole thickness of the bone, and invading more or less of the length of the diaphysis, if the condition is not early and efJiciently treated (Figs. 265 and 266) ; (c) from acute or subacute infective osteitis of cancellous bone, the sequestra being small spiculated fragments of the bony canceUi which have escaped ab- sorption by the granulation tissue always forming in such a process; {(i) from tuberculous disease of cancellous tissue, the sequestrum being light and porous, often infiltrated with curdy material, and rarely separated completely from surrounding parts (Fig. 273); {c) from syphilitic disease of cancellous or compact tissue, usually resulting from excessive sclerosis, or gummatous disease of the peri- osteum which has become septic (Fig. 276); (/) from the action of local irritants, e.g., mercury, or phosphorus fumes gaining access to the interior of the teeth; (g) occasionally as a simple senile loss of nutrition, as in senile gangrene; and [h) a variety, described by Sir James Paget under the name of ' quiet necrosis,' occurs as a result of direct injury, the sequestrum separating without suppuration; it is one of the causes of loose bodies in joints, and especially the knee, following a blow on one of the condyles. The presence of dead bone in a hmb may be suspected when one or more sinuses are present, discharging pus or serum according to circumstances, with puffy granulations pouting round the opening, and the underlying bone thick and enlarged. A probe passed down the sinus can usually be made to strike against the sequestrum, perhaps after passing through a casing of new bone, and its fixity or freedom may be demonstrated in this manner. Caries, or, as it is sometimes called, osteo-porosis or rarefaction of bone, is characterized by a soft and spongy state of the bone, which, if it can be reached, readily breaks down on pressure with a probe. It may result from the following conditions : (a) A simple subacute inflammatory process, e.g., during the early stage of repair in a fracture ; (6) from acute or subacute infective inflammation of can- cellous tissue; (c) from tuberculous affections of the cancellous tissue or periosteum ; {d) from syphihtic disease of the medulla or of the under surface of the periosteum. PathologicaUy, it is characterized by the replacement of the meduha by granulation tissue, which usually contains some large multi-nucleated cehs, or osteoclasts, and these seem to be closely con- nected with the removal of the bone. The cancellous tissue be- comes hollowed out to accommodate these granulatioris, and the osteoclasts are usually found occupying shallow depressions known as ' Howship's lacunae.' In tuberculous and syphihtic lesions the bone corpuscles often undergo fatty degeneration. Caries may occur with or without suppuration (C. sicca or supp'ura- tiva) ; sometimes the development of granulation tissue is excessive, 55S A MANUAL OF SURGERY as when it fungatcs into a joint (C. fungosa). Not unfrequently it is associated with necrosis, constituting a condition of ccirio-necrosis (or C. necrotica), as in infective infiammation of cancellous bone, minute spiculated sequestra being found in the discharge, whilst in tuberculous osteitis dead portions of larger size often occur. In fact, caries and necrosis bear much the same relation to one another as ulceration and gangrene of the soft tissues. If caries is recovered from, a subsequent condition of sclerosis usually follows, with loss of substance and often deformity. Sclerosis of bone (osteo-sclerosis) is invariably the result of some chronic inflammatory affection, e.g., [a] chronic periostitis, whether simple or syphilitic; {b) chronic osteo-myelitis, simple, tuberculous, or s}'philitic; or (c) chronic osteitis of the compact bone, which is always secondary to one of the former. In all cases the condition is due to a slow formation of new bone within the Haversian canals or cancellous spaces, thus diminishing their lumen; in syphilis this may progress to such an extent as to lead to their total occlusion, and even to localized necrosis from lack of blood-supply, especially when sepsis has occurred. In tuberculous 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 or bone-scar in the process of repair in those cases where a cure has been obtained by natural or surgical means. Classification of Inflammatory Affections of Bone. I. Periostitis : {a) Acute localized, with or without suppuration. [h] Acute diffuse, always associated with or secondary' to acute infective osteo-myelitis. (c) Chronic simple, or hyperplastic. [d) Chronic tuberculous. [c) Chronic syphilitic. II. Osteitis of compact bone, which is always associated with and secondary to either periostitis or osteo-myelitis, and so need not be described separately. The acute form results in necrosis, the subacute in osteo-porosis, and the chronic in sclerosis, except in tuberculous disease. III. Osteo-myelitis, or inflammation of the medulla of long bones: (a) Acute infective. (b) Subacute simple or infective, e.g., during the separation of sequestra, resulting primarily in rarefaction, but finally in sclerosis. (c) Chronic simple, tuberculous or syphilitic, usually caus- ing general enlargement and sclerosis of the bone, even if locally some rarefaction is present. IV. Osteitis of Cancellous Tissue may similarly be: [a) Acute infective. [b) Subacute simple or infective. [c) Chronic simple, syphilitic, or tuberculous. DISEASES OE BONE 559 Wlu'ii liniiteil to the artirular end of a bone in a young person, this is sometimes termed Epiphysitis; this title is also sometimes appHed erroneously to an acute osteomyelitis, which commences in the vascular tissue on the shaft side of the epiphyseal line. It is unnecessary to describe in detail all these conditions, since many of the divisions overlap, and hence we shall group together the various acute and chronic affections. Acute Inflammations of Bone. I. Acute Localized Periostitis usually arises as a result of trauma- tism applied directly to the bone, with or without an open wound; it may also be determined by rheumatism, or by an extension of in- flammatory mischief, as in an alveolar abscess. Pathologically, the process consists of hyperemia of and exudation into the periosteum, which becomes swollen, turgid, and thickened. 1 his may be followed in due course by resolution, or may leave the bone thickened and in a condition of chronic inflammation ; or sup- puration may ensue, and with it usually a limited superficial necrosis. In the last event pyogenic organisms of no great virulence find an entrance to the area of mischief, and probably in cases due to trauma through the abraded or injured skin; in other instances they may come from neighbouring foci of inflammation, or possibly from the blood. The inflammatory process extends to the small vessels entering the bone from the under surface of the periosteum; these become dilated, next thrombosed and strangled by the pressure of the exudation around them, and finally pulled out from the osseous canals by the tension of the subperiosteal effusion. Consequently, the vitality of the superficial layer of bone is destroyed for an area corresponding almost exactly to that from which the periosteum has been stripped (Fig. 263, A). As soon as tension has been relieved by the escape of the pus, repair commences. Where the mischief is shght and superficial, the involved bone may entirely recover, necrotic portions being absorbed, if the surrounding parts are sufficiently vascular. If the dead portion of bone is compact and more extensive, it will be separated from the subjacent living tissues by one of the processes alread}'' described (p. 109), whilst from the under surface of the stripped-up periosteum a casing of new bone is developed, constitu- ting an involucrum or sheath, at first spongy and cancellous in texture, but finally hard and sclerosed. In the centre of this new formation are found one or more openings or cloacce through which the discharge passes, and corresponding in position to the apertures in the periosteum and skin made for the escape of the pus (Fig. 263, B). Clinically, the symptoms of acute localized periostitis consist in the ordinary phenomena of acute inflammation, the pain being of an intense aching character, worse at night, and increased by lowering the limb or by any kind of pressure. If a subcutaneous portion of bone is involved, a painful swelling develops, at first brawny in character, but when suppuration has occurred the centre softens. 56o A MANUAL OF SURGERY whilst the skin over it becomes red and (edematous. When an abscess has burst or been opened, bare bone is felt beneath the periosteum, and the greater part of this denuded structure usually dies, and must then be either absorbed or separated; in either case a sinus remains for a time, leading down thnjugh a cloaca in the involucrum to the sequestral cavity. From this either pus or serum will be discharged, according to whether the wound has become septic or not. In about five or six weeks' time the sequestrum is loose, and this may be ascertained by moving it with a probe within the osseous cavity, which is now lined on the inner aspect with granu- hition tissue. Treatment. — Rest, eleva- tion of the limb, and fomen- FiG. 363.— Superficial Necrosis RESULT- tations are usually rehed on iNG FROM A Localized Periostitis locally in the early stages, and (Diagrammatic). favourable reports have been A represents the necrosed tissue lying in given as to the value of Bier's continuity with the surrounding living induced hyperemia. If, how- bone; the periosteum is stripped up ^.v, rr ,• • j. from it, and has an opening through ^^er, tUe attection IS not which the pus has been discharged, readily checked, and suppura- B shows a later stage, in which the tion threatens or develops, a sequestrum is being separated by a pro- fj-ge aseptic incision down to cess of rarefying o.steitis in the immedi- ,, hnnp i Fig. 273- -Lower End of Tibia affected with Tuberculous Disease. (King's College Hospital Museum.) In A, a subperiosteal deposit of new bone is seen surrounding an opening (cl), which leads into the interior of the bone; in B, the interior of the same bone is seen, and shows a sequestrum (S) just above the epiphyseal line. The ankle-joint is healthy. of any chronic inflammation of bone, viz., a deep aching or boring pain, worse at night, together with enlargement of the affected bone, whilst one spot is often very tender on palpation. If it has existed for any length of time, the whole shaft may become en- larged as a result of chronic osteo-periostitis. (iii.) The disease may burrow along the epiphyseal line, and find its way into the neigh- bouring joint, if the epiphysis is intra-articular, as in the hip; but if the epiphyseal cartilage is placed beyond the limits of the caj^sule, a subperiosteal extra-articular abscess will develop (Fig. 273). Should the disease spread equally in all directions, the epiphysis may actually be separated, (iv.) A more common result is for the DISEASES OF BONE 577 whole or part of the CLincellous tissue of the epiphysis to become in- volved, and the joint to be secondarily affected with tuberculous arthritis, either by perforation, erosion, or necrosis of the articular cartilage, or by extension to the synovial membrane around its margins.' (v.) The process may sometimes extend upwards along the medulla into the shaft, causing a diffuse osteo-peri- ostitis, with or without a medul- lary abscess (Fig. 274). The Treatment of tuberculous epiphysitis is conducted in the first place by absolute immobili- zation and hygienic measures; but the surgeon must not be tempted to trust too long to such a regime, for fear of the joint becoming also affected. If considered necessary, an opening is made into the interior of the epiphysis, and all the pulpy granulation tis- sue, caseous debris, or diseased bone removed , - with a sharp spoon, the cavity being subse- quently disinfected, and packed with gauze in- filtrated with iodoform. Of course, the utmost care must be taken not to open the joint by scraping through the articular cartilage. Where a chronic ab- scess exists in the end of a bone, a trephine should be applied over „ the tender spot, and, if the cavity is not at first opened, the bone may be drilled in different directions to ascertain whether or not pus exists. {d) The medullary canal of the shaft of a long bone sometimes becomes the seat of tuberculous disease; this, as also the abscess of bone described above, is more common in adults than in children. The part thus affected becomes carious, with or v,^ithout the forma- tion of sequestra or pus; but the most marked feature of this deep- seated central trouble is that the whole bone passes into a state of chronic inflammation, which we have described, as well as the treatment necessary for it, under the title of chronic diffuse osteo- periostitis (p. 569). Pjg 274.— Localized Abscess in the Lower End of the Femur, extending from the Epiphyseal Line Upwards into the Me- dulla. (From Specimen in the College of Surgeons' Museum.) 578 A MANUAL Of SURGERY Syphilitic Diseases of Bone. In the Secondary Stage ll>ing pains about the bones (sometimes termed vstcocopic) arc otten c()nii)lained of; they are, however, of but Httle importanee, and cUsappear rapidly as the patient gets under the influence of mercury. In the late secondary or early tertiary periods, a periosteal node is often met with, as a result of chronic periostitis. It usually affects only one bone, and most commonly the tibia, and consists of an infiltration and thickening of the peri- osteum, which may entirely disappear, but later on is accompanied by a formation of new bone. This is at first spongy and soft in character, but after a while becomes hard and sclerosed. When such has once occurred, absorption of the newly-formed bone does not readily follow, even under treatment, the part perhaps remaining permanently thickened. It is recognised clinically as a fusiform swelling, a little tender on pressure, and the seat of deep aching pain, usually worse at night. It must be understood that the pain is not so much associated with the onset of night as with the in- creased warmth of the limbs when in bed; indeed, patients with syphilitic tibiai frequently sleep with their legs exposecl Night- watchmen and others, on the contrary, complain of pain during the day, when they take their rest. Suppuration does not often occur, and constitutional rather than local treatment is required. In the Tertiary Period the bones may participate in the changes which involve any and every tissue of the body. The following lesions are described: {a) The formation of subperiosteal gummata, either localized or diffuse, probably resulting in caries of the subjacent bone; if the afiection is limited, only a small portion may be thus involved ; but where it is widely diffused, an extensive surface of the bone may become eroded and irregular. This process is sometimes accorn- panied by a development of new bone under the adjacent peri- osteum, and is very often complicated by sclerosis and necrosis. Xhe calvarium is the part most frequently involved, and as but little new bone forms in this situation the skull often presents a curiously pitted or worm-eaten appearance (Fig. 275). Frequently the overlying scalp is invaded and destroyed by the gummatous process, permitting the entrance of pyogenic organisms, and giving rise to deep and sometimes extensive wounds, discharging an abun- dance of foul pus, at the bottom of which bare and even dead bone may be felt. (&) At the same time a condition of sclerosis may he produced in the underlying or surrounding parts, and this may progress to such a degree as seriously to compress and constrict the vessels in the Haversian canals. Moreover, an obliterative endarteritis is almost ahvays present, and these factors, combined with the separation of the periosteum by the above-mentioned gummatous changes, so DISEASES Of BONE 579 interfere with the vitaHty of the bone that, should pyococci be atlniitted, necrosis is ahnost certain to ensue. Tlie effects produced vary considerably in different cases, and esi)ecially with the situation. When the calvanum is attacked, pyogenic infection often supervenes, owing to the thinness of the scalp and the depth to which the hair follicles penetrate, and consequently necrosis is common. The process in such a case, as is represented in Fig. 276, is probably as follows : The pericranium corresponchng to the necrotic area becomes gummatous, and at the same time the subjacent bone undergoes sclerosis. Sooner or later the gummata burst or are opened; pyogenic infection occurs, and the scalp tissues are stripped off the calvarium to the limits of the disease, necrosis resulting in the sclerosed area of bone. A line of rarefaction subsequently forms around the sequestrum in consequence of Nature's attempts to separate it. The later stages of the disease are marked by extreme chronicity, the sequestrum Fig. 275. — Syphilitic Caries of Skull from Diffuse Gummatous Disease. (From King's College Hospital Museum.) 1 ying bare in the wound perhaps for years without being separated, owing to the slight degree of vascularity and the extreme conden- sation of the surrounding parts. Moreover, as explained above, there is an entire absence of an involucrum. In the shafts of long bones, where the compact tissue is thick and resistant, there may be extensive periosteal disease, with but little affection of the under- lying parts; but if this compact layer is thin, and especially when the cancellous ends are involved, a considerable amount of destruc- tion from caries may result, though if pyococci are not admitted there will be an entire absence of necrosis. The sternum is not uncommonly affected by syphilitic disease, which manifests itself as a gumma, which breaks down and sup- purates, but does not often cause much bone destruction. The nasal bones and hard palate are frequently the site of subperiosteal gummatous formation, resulting in suppuration and necrosis; a foul discharge from the nose results in the former case, which may be followed by destruction of the septum nasi and permanent deformity. The palatal trouble often results in perforation. 58o A MANUAL OF SURGERY In the Treatment constitutional remedies must be emi)Ioyed, and will be valuable if su])puration and necrosis have not occurred. They may have but little effect, however, if i)yogenic infection has supervened apart from measures directed t(j providing effective drain- age and removal of the dead bone. In the calvarium, however, no attempt should be made to take away the dead bone unless it is loose, (c) Occasionally a gummatous osteo-myelitis is met with, in which a gumma forms in the interior of a bone. It results in the so-called expansion of bone and secondary thickening and enlargement of its whole structure — i.e., a diffuse chronic osteo - peri- ostitis. Ihe symptoms are the same as those described for the latter affection, and if it resists the administration of anti-syphilitic remedies, it must be treated in the same way, viz., by separation of the periosteum, freely open- ing the medullary cavity, and removing all diseased tissue. 'Ihese cases when affecting the long bones have often been mistaken for malig- nant growths; necessarily, it is a matter of the greatest importance to come to a right conclusion as to their nature. Ihe greater rapidity of growth in the syphilitic cases, and the evidences of tertiary lesions elsewhere, or of a syphilitic history, and the existence of a positive Was- sermann reaction, will often guide the surgeon to a right conclusion, whilst radiography is also helpful; but if there is any doubt an exploratory incision and a microscopic examination of the diseased tissues should always be made before amputation is undertaken. In Inherited Syphilis any of the above manifestations may be seen, but with more or less special features added, and, in addition to these, certain forms which do not occur in the acquired type of the disease have been described. I. A new formation of bone beneath the periosteum is perhaps the most frequent result, and this occurs with but little pain. Perhaps the most common situation of this lesion in infants is the calvarium, where bony masses known as Parrot's nodes form around the 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 spongy, and on post-mortem examination is dark red or maroon in Fig. 276. — Syphilitic Necrosis of the Skull. (King's College Hospital Museum.) The sequestrum is becoming separated, and a ring of caries is forming around it. DISriASES OF BONE 581 colour. If the process is not checked by suitable antisypliilitic treatment, the newly-formed osseous tissue becomes dense and sclerosed, and the deformity may then persist through life (Fig. 39, p. 173). Any part of the calvarium may, however, be affected, and the change is not necessarily limited to the first years of life. 2. A somewhat similar condition is met with in the shafts of long bones, due to the deposition of alternating lamella of soft and hard bone outside the ordinary compact tissue and beneath the peri- osteum. 3. Syphilitic epiphysitis (or, as it is termed, syphilitic osteo-chon- liritis) is a lesion characterized by enlargement of the ends of the bones, as in rickets, but coming on within the first year after birth. The enlargement is mainly situated in the epiphysis, but also extends some way along the shaft, thus contrasting forcibly with rickets. Occasionally only one side of the epiphysis is affected. The change commences in the zone of calcified cartilage nearest the diaplwsis, which becomes friable, opaque, and irregular, and as the condition progresses it may be transformed into granulation tissue, so that separation of the epiphysis follows. Pyogenic infection may follow, resulting in suppuration and necrosis of the epiphysis or acute arthritis, or the limb hangs powerless in a condition known as syphilitic pseudo-paralysis. The disease is usually symmetrical, and often multiple, and situated in much the same positions as rachitic affections, the knees, elbows, and wrists being perhaps most often affected. It may terminate in the early stages, and be followed by organization of the granulation tissue, the ultimate result being cessation of growth in the bone. 4 . A symmetrical overgrowth of the tibia, perhaps combined with an anterior curvature, also occurs in syphilitic children, resulting in permanent elongation of the legs (p. 457)- 5. Craniotahes consists of a locahzed absorption of the osseous tissue of the cranium, leaving small areas where the bone is thinned or absent, so that on pressure a sensation of crackling, like that of parchment, is imparted to the finger. It occurs most frequently in the parietal bone (in 60 per cent, alone; in 95 per cent, with other bones — Carpenter*), and in the majority of cases within the first six months of life, a fact that throws considerable doubt on the idea that it is due to rickets. The Treatment of syphilitic lesions in children must be carried out in accordance with general principles, and mainly by the administra- tion of suitable drugs. Rickets. Rickets is a general disease of malnutrition, occurring in children and manifesting itself mainly in lesions connected with the bones It usually commences within the first three years of life, but some- times appears later. ♦Carpenter, 'Syphilis of Children in Everyday Practice.' Biilliore Tindall and Cox. 1901. 582 A MANUAL OF SURGERY Causes. — Rickets is induced chiefly by giving to the child in- sufficient or improper food, especially by the too early administration of starchy materials and the want of suitable fats, whilst uncleanli- ness 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 amongst poor patients this habit is frequently responsible for its appearance, although in Japan, where the children are suckled for two or three years, the disease is unknown. Syphilis has no causative connection with rickets, except by inducing marasmus and digestive and assimilative chsorders. The Symptoms may be divided into the early or general, and the later or osseous. The general symptoms are mainly referable to a state of irritability of the gastro-intestinal mucous membrane. The child may be fat and flabby, or thin and ennciated; the mucous membranes are pale, and vomiting and diarrhrea are constantly present, the motions being often green, slimy, and very offensive. The spleen is enlarged, the abdomen tumid, and profuse sweating of the head is very characteristic. Fig. 277. — Section of Costal Cartilage and of End of Rib in Rickets, SHOWING Depression at the Junction on Anterior Surface and Projection on Inner Surface. The commencement of the osseoiis changes is usually indicated bv increasing irritability and restlessness, the child tossing off his 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 various 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 to new formation of bone under the periosteum; it is a question, however, whether these are not syphilitic rather than rachitic in origin. The fontanelles remain open much longer than usual, and craniotabes is said to occur. The teeth do not erupt till late, and are 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 of a large circle, whilst the typical notch of syphilis is a large segment of a small circle. The spine may be affected by kyphosis (p. 440), or less frequently by scoliosis (p. 435) ; the kyphotic curve results when the patient DISEASES OF HONE 583 is allowed to lie too much in bed with the head on a high pillow, or if the child is carried about with a curved back; scoliosis more often occurs when the patient is able to walk. Occasionally a kypho-scoliosis is produced as a result of the child being carried about sitting on a nurse's arm with the j^elvis tilted. ('.hanges in the thorax are produced by enlargement of the costo- chondral junctions [beaded ribs), which, when present on either side Fig. 278. — Pelvis and Leg-Bones in Rickets. (From College of Surgeons' Museum.) The photograph on the left is taken from the side, in order to show the extent of the antero-posterior curvature of the bones. of the sternum, produce what is known as the rickety rosary. The swelling is more marked on the pleural aspect than on the outer side of the bone (Fig. 277). If there is any obstruction to the entrance of air into the lungs, as from tracheitis or bronchitis, the atmospheric pressure may cause the softened bone and cartilage to sink inwards, and as a result of this the sternum may be pushed forwards [pigeon 584 A MANUAL OF SURGERY breast), wliilst the curvature of the ribs nt the anpjle is increased. A very characteristic feature, of the rickety change consists in the lateral groove thus produced on each side of the sternum, which may meet with a transverse depression below, caused by the projection of the lower floating ribs by the tumid abdomen. The pelvis is flattened antero-posteriorly, or more rarely tri- radiate, tlie former condition being produced when the patient lies hal itually on his back, the latter only occurring when walking is permitted, the acetabula being then pressed inwards and backwards by the heads of the femora. The deformity of the long hones (Fig. 278) usually consists in an in- crease in their natural curves, especially at points where powerful muscles are attached. The femora are curved antero-posteriorly, and the tibiae in a similar direction, although there is often some lateral displacement super- added. Most commonly the lower end of the tibia is bent inwards — i.e., in a direction opposite to that represented in Fig. 278. Genu valgum or varum may also result from these changes (pp. 452, 455, and 456). When the acute stage of rickets has passed away, any deformities present become fixed by the complete ossifica- tion of the softened bony tissues. As a rule the density of such deformed bones is increased, whilst their natural shape is altered by deposits of new subperiosteal bone or struts in the concavities, so that on section they are usually more or less flattened from side to side, and the medullary canal appears to be displaced towards the convexity. Growth is often checked by this disease, and thus the individual becomes stunted and dwarf-like. Pathologically, the chief changes in rickets are found in the neighbourliood of the epiphyses. Ordinarily, the epiphyseal car- tilage is a lamella about a line in thickness, bounded on either side by a zone of calcified tissue, containing regular alveolar spaces filled with vascular medulla, and lined by osteoblasts, passing gradually into normal cancellous bone. Tn rickets the epiphyseal cartilage is not only circumferentially enlarged, but also thickened and irregular (Fig. 279), outgrowths of cartilage projecting on either side into the calcified tissue, which is more abundant and more open in texture than usual, whilst it passes irregularly into the Fig. 279. — Section through Lower End of Rickety Radius, showing Exagger- ated Depth and Irregular Borders of the Prolifer- ating Epiphyseal Carti- lage. (From Ashby and Wright's ' Diseases of Children.') DISEASES OF BONE 5S5 cancellous bone. Thus, there is an increased preparation f(jr the formation of bone, but the ossifying process is inefficiently carried out. In addition to this, the Haversian canal systems and the nirtlullary spaces in the diaphyses are enlarged, so that the bones become weaker and less rigid from the insufficient amount of lime salts present, and thus readily bend under the weight of the body or from muscular action. Less frequently the subperiosteal com- pact bone becomes similarly rarefied. When the disease comes to an end, the deformities may persist, but the bone, now effectively ossified, becomes harder and stronger than usual. In the Treatment of rickets the most essential feature in the early stages is the correction of all errors in the personal hygiene. The diet should consist of good cow's milk, diluted if need be, and with lime-water added; whilst the juice expressed from raw beef, or one of the many meat juices now sold, may also be administered. The condition of the bowels must be attended to, and the child placed in as good surroundings as possible. Cod-liver oil must be adminis- tered, together with Parrish's food (syr. ferri phos. co.) . Deformities must, if possible, be prevented by keeping the child in the recumbent posture and not allowing it to crawl or run about. The early stages of deformity in young children can often be corrected by daily manipulation of the affected bones; for the legs, it may suffice to keep them off their feet, as by a splint which extends from the thighs 6 inches below the soles; a certain amount of pressure can also be exercised by this appliance. Osteotomy, or even resection of portions of bone, is required in the severer cases where the deformity persists, and the bony changes have become consolidated (seep. 457). Adolescent Rickets comes on about puberty, and is usually independent of an early rachitic history, although in a few cases it may be looked on as a recrudescence of the infantile ailment. Imperfect nutrition is probably a less important aetiological factor than in infancy; but strain, mental or ph^'sical, combined with defective hygiene, has been present in most instances. Ihe chief changes are to be found in the shafts of the long bones of the legs, which become bent from the superjacent weight of the body. Deformities in the upper extremities are less frequent. Enlargement of the epiphyses is also observed. There is usually no sweating of the head, but the patient is pale, and complains of fatigue and languor, but not of pain. The softened bones bend, and no buttresses or struts are formed in the concavities; hence the deformities produced are often serious, and the course of the case is slow. (See Fig. 170, which occurred in a girl of thirteen years, the subject of this affection.) Treatment must be directed towards an improvement of the general health and of the conditions of life; undue mechanical strain must be avoided, and, if need be, the patient kept at rest. Deformities are dealt with by the use of orthopaedic appliances or by osteotomy. Infantile Scurvy [syn. : Barlow's Disease^ Scurvy Rickets, Hsemorrhagic Rickets). — This condition, first accurately described by Sir Thomas Barlow, presents the symptoms of scurvy in a rachitic child, and in its manifestations either one or the other set of phenomena may predominate. It is usually seen in the children of well-to-do people from four to eighteen months old, and apparentlv arises from defective nutrition, especially from the prolonged administration of peptonized or prepared foods, or even possibly of sterilized milk. In the slighter cases there may be but little evidence of the scorbutic 586 A MANUAL OF SURGERY condition, beyond the fact that in a rickety child there is some tendency for the glims to bleed, or a little hematuria; but in those that are more marked the rickety signs are of little importance compared with those due to haemor- rhagic extravasations. The disease often comes on suddenly with some amount of pyrexia, rarely exceeding 102° F., but the child is evidently ill, and perhaps complains of tenderness of the limbs, which mav l)e kejit so (juiet as to suggest that they are paralyzed. This is followed by the appearance of swellings of some size, due to sub-periosteal extravasations, the skin over the affected parts being at first shiny and (Edematous, but subsequently becoming stained by the blood-pigment. The femur and tibia are most often affected in this way, and the epiphyses may occasionally become detached, or evxn spontaneous fractures occur. Bleeding may also take place beneath the conjunctiva or in the orbit, leading to protrusion of the eyeball, whilst there may be blood-stained diarrhoea, haematuria, or epistaxis. The disease, when recognised, is readily amenable to treatment, but should its nature be overlooked, the child is likely to become emaciated and die. Attention to the diet is the main point to be attended to, for when fresh milk, lime-juice, or vegetables are given, the symptoms soon disappear. The affected limbs must be kept at rest, and cooling lotions applied, whilst splints^ aie required when epiphyses are separated or fractuies have occurred. Achondroplasia (Chondrodystrophia foetalis) is a curious congenital con- dition, somewhat rescmV)ling rickets, in which the growth of osseous tissue on the shaft side of the epiphyses of the long bones of both arms and legs is defective, so that the limbs are short and stunted, and the stature corre- spondingly diminished, although the epiphyses are normal. The bones generally are not bent or curved abnormally, though there is probably some change of the neck or shaft of the femur, resulting in lordosis, which is very marked when the patient stands. The fingers taper to their tips, and are separated one from another in ' spoke-like ' fashion. The bones at the base of the skull, being of cartilaginous origin, undergo premature synostosis, whilst the upper half of the skull, being derived from membrane, and therefore developing naturally, looks unusually large; the face is small, and the bridge of the nose depressed as in congenital syphilis. The children, if they live, are usually efficient in their mental development, and the thyroid body normal. Xo known treatment is of anv value. Osteo-genesis imperfecta (or idiopathic psathyrosis) is a rare congenital con- dition, characterized by a defective development of osseous tissue from cartilage, so that the bones are brittle or soft, and thus are easily bent or broken, constituting a condition of fragilitas ossium. Nothing is known as to aetiology, except that there is a strong hereditary tendency. Not a few of the subjects are stillborn, with broken or deformed limbs, whilst many die within the first year of life. Cases in which fractures occur more or less spontaneously and frequently in older life are probably due to some other condition, such as osteo-malacia. If the child lives, one fracture occurs after another, and the limbs may become terriblv deformed, although with care they sometimes unite very well. In addition to the deformities due to the malunion of fractures, the JDones are usually bent and distorted, and thus the case may be confused with rickets or osteo-malacia. The cranial bones sometimes participate in the process, and the basi-occiput may be driven upwards into the cranial cavity by the thrust of the spine; this condition is demonstrable by radiography. The actual anatomical changes in the bones consist in the persistence of cartilage cells in their capsules and calcification of the trabeculae between, very little f)one being formed and that of a defective type. No known remedies are of any avail, and all that can l)c done is to protect the patient from mechanical injuries and treat the fractures as they occur. Mollities Ossium (m ». .• Osteo-malacia) is an acquired disease of somewhat unusual occurrence, characterized by the absorption of the osseous substance of the bones, as a result of which softening and rarefaction are produced, followed by bending or spontaneous fracture. The complaint is almost limited to the female sex (only ^hotic (Fig. 280), the dorsal curve being increased, and the lumbar concavity ob- literated ; it is nearly rigid from ankylosis of the vertebrae, and may be very painful. In the later stages the head is carried forwards by the bent spine, the height is diminished, the shoulders are round, and the chest sunken towards 588 A MANUAL OF SURGERY the pelvis; the gait is slow and awkward. The disease usually attacks middle- aged men; its progress is exceedingly slow, the patient often living to an advanced age, or dying from some intercurrent malady. Some cases have terminated in multiple sarcomata of the bones. The structure of the os.seous tissue is suggestive of intlammatory rather than degenerative changes. It is softer and more uniform in structure than usual, the difference between the cancellous and compact tissue being less defined; the Haversian canals are large and arranged irregularlv, whilst the bonv substance looks chalky. Fig. 280. — Early Stage of Osteitis Deformans. (From Photographs Differential Diagnosis. — From arthritis deformans, which it resembles by the attitude and gait of the patient, it is known by the absence of articular lesions, especially in the fingers, and the enlargement of the bones, notably of the cranium. From acromegaly it is distinguished by the absence of enlarge- ment of the hands, feet, and lower jaw. Treatment is most unsatisfactory, no remedy at present known having any control over the disease. Acromegaly. Acromegaly is a rare condition, the characteristics of which were first de- scribed by Dr. Pierre Marie in 1885. It is a general affection involving mainly the osseous system, commencing usually in young adults, and, after lasting for a long time, killing the patient by syncope or cerebral compression, if some intercurrent malady does not destroy him. It is characterized by a very definite enlargement of the hands and feet, which are, however, not lengthened, so that the hands have been compared to battledores, and the fingers to .sausages. The bones themselves are enlarged, and the soft structures on the palmar aspects project as pads. The nails and DISEASES OF BONE 589 skin arc unchanged, whilst the other segments, both of the upper and lower limbs, arc usually unaffected, though sometimes considerable overgrowth in length occurs; in fact, many of the so-called giants who have been exhibited are typical illustrations of acromegaly. Both the upper and lower jaws are thickened and prominent, whilst the lower lip is enlarged and overhanging. The orbital ridges project, and the forehead is usually low; the nose and tip of the tongue are also more or less enlarged. The spine is kyphotic in the dorsal region, with a slight lumbar lordosis. The ribs and sternum project anteriorly. The patient usually suffers from headache, lassitude, and great fatigue, wandering pains about the body, and excessive appetite and thirst; amenor- rhcva is a marked symptom in women, whilst men suffer from a loss of virile power. The urine is abundant, but of a low specific gravity. Vision is usuallv diminished, and optic neuritis has been observed in some cases. Fig. 281.- -Head of Woman with Acromegaly. AND FROM THE SiDE.* Seen from the Front Morbid Anatomy. — The cause of acromegaly appears to be overgrowth of the anterior half of the pituitary body, and excessive absorption of its secre- tion (hvperpituitarism) . The sella turcica is expanded, and this can be recognised by X rays. The changes in the bones are merely those of over- growth. Diagnosis. — The disease has been mistaken for myxcedema, but there is not much difficulty in distinguishing the two if it be remembered that, in the latter condition, the skin is not mobile over the thickened subcutaneous tissue, that the face is broad, pasty, and puffy, and that masses of gelatinous tissue are found above the clavicle, whilst in acromegaly the face is elongated and the skin and subcutaneous tissues normal. The mental condition and speech of a patient suffering from myxoedema are widely different from those in acromegaly; whilst in the former the thyroid body is either absent or diseased, and in the latter skeletal changes are present. From chronic osteo-arthritis affecting the hands, the diagnosis is easy, in that there are usually no signs of articular disease, and much less pain. From osteitis defoymans, the dis- tinguishing features have already been indicated. Medical Treatment is merely symptomatic, antipyrine being useful in re- lieving the headache, as also valerianate of caffeine. Possibly thyroid extract * Reproduced from the Edinburgh Medical Journal, by kind permission of the late Dr. G. A. Gibson. 590 A MANUAL OF SURGERY may be of some use in combating tlie functional phenomena, though it will not influence the skeletal changes. Attempts have lieen made to remove the growth by operation tlnough the nose anil base of the skull, and with some degree of success, though naturally the mortality is high (p. 77'^). Hypertrophic Osteo- Arthropathy.* It has long been known that clubbing of the ternnnal jihalanges is associated with chronic j)ulmonary and cardiac disease; and it is probal)le that such is the earliest stage of this more generalized affection, liist described by Pierre Marie. In it the ends of the lingers and toes are enlarged and bulbous, with the nails curved over towards the jialm or sole; in tlie early stages the change may be limited to the soft tissues, but radiography has demonstrated that in the later there is a well-marked new formation of bone along the shafts of the phalanges and also of the metatarsal and metacarpal bones. There is a considerable swelling of the bones just above the wrists and ankles, extending some way along the shafts, and similar bony enlargements sometimes occur elsewhere; they aic due to a diffuse osteo-pcriostitis. The spine is kyphotic in the upper dorsal region, but with well-marked lordosis below. It is thus seen that the changes are somewhat like those of acromegaly, from which they are distinguished by (a) the implication chiefly of the lingers and toes, and particularly of the terminal phalanges, whilst in acromegaly the enlarge- ment of the different portions of the hands and feet is general; {b) the nails are not affected in acromegaly; [c] the joints are but little involved in acro- megaly; and [d) the enlargements of face, tongue, jaw, etc., so marked in acro- megaly, are absent in osteoarthropathy. These phenomena probably result from chronic toxic absorption, since the condition arises in such diseases as chronic bronchitis, bronchiectasis, and chronic empyema, where suppuration has existed for some time. It is, however, sometimes associated with lesions other than pulmonary — e.g., chronic jaundice, syphilis, and even influenza, and has even been found in otherwise apparently healthy individuals. Little can be done in the way of treatment, except to deal with the cause, if obvious. Tumours oJ Bone. The characters of the osteomata, chonckomata, and fibromata of bone have been described in Chapter IX., and various stjlid and cystic tumours connected with the teeth are dealt with elsewhere. " Myeloma (Fig. 283) is practically a benign tumour, rarely giving rise to secondary deposits either in lymphatic glands or viscera, and its growth within the bone is strictly limited, with no tendency to diffusion along the medulla; occasionally a layer of condensed bone demonstrable by radiography forms an effective barrier in this direction. For its pathological features, see p. 211. The sites of election for myeloid tumours are the growing ends of the long bones, especially the lower ends of the femur and radius, and the upper ends of the humerus, tibia and fibula, whilst they also occur in the diploe and lower jaw, and constitute one form of epulis. The development of the tumour leads to the so-called expansion of the bone, in which the osseous tis.sue is absorbed from the inner aspect, and new bone is laid down externally; the outer layers, however, gradually become thinned, so that after a time the osseous lamina can be pressed inwards, giving rise to a feeling known as ' egg-shell * See Janeway, Amer. Jonrn. of Med. Sci., October, 1903. DISEASES OE BONE 591 crackling '; and Unally tlic tumour projects through the bony wall, i his expansion may be central, and the bone end thus becomes more or less globular, or it may be eccentric, and then the growth projects merely on one side. vSooner or later spontaneous fracture is likely to occur. Neighbouring joints usually escape, but in old- standing cases the growth may project arcjund the articular cartilage and somewhat impair the movements; there may, however, be some serous effusion in the cavity. The Symptoms may be so slight at the commencement that nothing is noted until fracture has taken place; but sometimes pain similar to that of a chronic osteo- periostitis draws attention to the enlargement of the bone. Radio- graphic examination reveals a well-defined area of bone which is unduly translucent, but with a characteristic ' stippling,' due to the presence of calcareous foci scattered through the growth (Fig. 282). The accurate limita- tion of the growth, and its de- marcation from the medullary cavity, are important diagnostic signs. Treatment is governed by the assurance that a myeloma is non- malignant, and hence may be dealt with in a conservative manner by a localized removal of the growth, amputation being reserved for the more advanced cases and for those where a local removal would leave a more or less useless limb. In quite the early stages it suffices to incise the growth and scrape it away with a sharp spoon, disinfecting the cavity with liquefied carbolic acid, and packing it with gauze to ensure healing by granulation. or X rays is desirable in order to ensure total destruction of any remaining portions of the growth. In a later stage the affected portion of the bone must be completely removed, and if necessary the gap thus produced bridged by bone grafting. Thus a myeloid tumour of the upper end of the fibula can be treated by excision, care being taken of the external popliteal nerve and its branches; but if the upper end of the tibia or lower end of the femur is involved, amputation will usualh' be required, although bone grafting may be sufficient to make good the defect. When affecting the lower end of the radius or upper end of the humerus, and not in too advanced a stage, an attempt may be made to save the limb by excising the diseased portion of bone. In the wrist the lower part of the ulna is taken away, as well as the growth in the radius; by this plan there is less chance of the hand being drawn up and abducted, and hence r 1 1 *; 1 ^ j n ■ 1 \_- i^H^H Bi Fig. 282. — Radiograph of Mye- loma OF Outer End of Clavi- cle. (By Favour of Dr. Salmond.) Exposure of the part to radium 592 A MANUAL OP SUliGERY it is Diurc likely to be of use subsequently, especi;illy it' ;i leather yauntlet is worn. Sarcoma is the most important primary tumour of bones, and eilmo'^t any variety may occur. The microscopical characters have been detailed in the chapter on tumours, and we shall here chiefly refer to their clinical characteristics. They may be divided into two main groups — the endosteal or central, and the periosteal. Central Round- or Spindle-celled Sarcoma is of an extremely malignant nature. There is usually more pain in its development, which is much more rapid than with a myeloid growth, but the Fig. 283. — Myeloma of Head of Tibia. (King's College Hospital Museum.) Fig. 284. — Round-celled Endos- teal Sarcoma, disseminating Itself in the Medullary Cavity. (King's College Hospital Museum.) bone may be but little expanded (Fig. 284), since the growth tends rather to diffuse itself along the medullary cavity, and encroaches more closely upon the neighbouring joint. The outer wall is likely to be absorbed earlier than in a myeloid, and invasion of the sur- rounding tissues or spontaneous fracture results. Lymjihatic glands and viscera are soon involved by dissemination of the disease. The tumour substance itself is usually of a soft nature, not containing much newly-formed bone; cartilaginous and myxomatous foci are often associated with it. The growth is highly vascular, and cysts may form therein, but not so frequently as in the myeloid tumours J)lSJ;ASIiS OJ: BONE 593 l\;uli()grai)hy shows an irregular removal of bony tissue, and there is no sharj)ly defined limiting zone of thickened bone (Fig. 287). The rapidit\' of growth and the radiographic characters are the features on \\ hich a diagnosis of a malignant endosteal sarcoma must be based. Periosteal Sarcomata are round- or spindle-celled in nature, and occur less frequently than the endosteal variety. They often develop rapidly without giving rise to much pain, unless causing erosion of the bone. They usually start on one side, but may surround the whole circumference later on, and spread for some distance along the shaft. A high degree of malignancy is attained 4f^ t' Fig. 285. — Soft Periosteal Sarcoma OF Lower End of Femur, eroding Bone and leading to Spontaneous Fracture. (King's College Hospital Museum.) Fig. 286. — Ossifying Periosteal Sarcoma of Fibula. (King's College Hospital Museum.) by them, secondary growths forming in lymphatic glands or the viscera. Ossification often occurs in their substance with or with- out the previous development of cartilage, and in such cases the subjacent bone may become sclerosed and thickened, so that spon- taneous fracture is not common in this variety. The bony skeleton of such a growth is very characteristic, consisting of fine spiculated trabecule , radiating more or less regularly from the surface, and looking in the dried state somewhat hke asbestos (Fig. 286) . These ossifying sarcomata have a very characteristic appearance on radio- graphy (Fig. 288). When a periosteal sarcoma does not become 38 594 A MANUAL OF SURGERY ossified, the growth often erodes the underlying bone (Fig. 285), and ma}' lead to spontaneous fracture; the tumour in such cases is softer and more elastic than in the fomier variety, and usually attacks the bone from one side and not equally all round. Osseous sarcomata are always exceedingl}' vascular, and may even pulsate, whilst the superficial veins are obviously chlated beneath the stretched integument, giving rise to a blue network. The Diagnosis of osteo-sarcoma in the early stages is often a matter of the greatest difficulty. The endosteal form may easily Fig. 2S7. — Radio(.,kam of En- dosteal Sarcoma of Upper End of Humerus, burrow- ing ALONG THE ShAFT AND CAUSING Spontaneous Frac- ture. Fig. 2S8. — Radiogram of Periosteal Sarcoma of Lower End of the Femur. The irregular outgrowths of ossific material arc very characteristic, as also the limitation of the growth to the diaphysis. be mistaken for chronic osteo-periostitis, medullar}^ gumma, or a deep abscess of the bone, and can sometimes only be distinguished from them by an exploratory incision and microscopic examination of a portion of the growth; this should always be undertaken in doubtful cases prior to radical operations, such as amputation. In the later stages, the presence of ' egg-shell crackling ' or cystic changes \\\\\ help to make evident the nature of the disease. The periosteal form may at first be looked upon as a periosteal node, or a deeply- placed abscess. The rounded and definite edge of the growth, its DISEASES OF BONE 595 iricgular consistency, and the history of the case, will assist in the determination of its nature; but in the early stages an exploratory operation is not unfrequently necessary. For the diagnosis of a pulsating sarcoma from an aneurism, see p. 312. When either form involves the articular end of a bone, especially the lower end of the femur, it may simulate tuberculous disease of the adjacent bone. It will, however, be noted that the centre of the swelling corresponds to a point well above or below the joint, that a certain amount of movement is possible and even painless, whilst the starting pains at night characteristic of joint mischief are absent. The age of the patient, and the presence or not of cachexia, are also important features which have to be taken into consideration. Radiographic examination serves in most cases as an important diagnostic adjuvant. It is of the greatest importance that a clear opinion as to the diagnosis be made at the earliest possible moment, as thereby both prognosis and treatment are immensely influenced. Periosteal sar- comata have a bad prognosis, as general dissemination occurs early; the small spindle-celled are the worst. Secondary deposits often contain ossific material — e.g., in the lungs. Central sarcomata are not quite so malignant, althougli the round-celled variet}' is decidedly unfavoural:)le. The Treatment of osteo-sarcoma is eminentl}' unsatisfactory, as., even though the most radical measures are taken, recurrence is only too frequently observed, or death from secondary deposits occurs in spite of a successful issue locally; hence the importance of a thorough investigation, and, if need be, of an early exploratory incision in doubtful cases, cannot be over-estimated. Formerly, the rule that governed surgical practice was to amputate the limb well above the growth in all cases, and to ascertain by microscopic examination of the medulla at the time that it was free from disease. Ihus, for a tumour of the lower end of the tibia, amputation through the knee would be practised; if the upper end of the tibia is in- volved, amputation through the middle of the thigh; and for a growth of the lower end of the femur, disarticulation at the hip-joint would be required for a periosteal growth, though for an endosteal one just below the trochanters might suffice. For a sarcoma of the upper end of the humerus, disarticulation of the shoulder was thought to be scarcely sufficient ; it was usually considered wiser to remove the scapula in addition (interscapulo-thoracic amputation). The results of such treatment have been so bad, and dissemination of the growth to the lungs so constant, that surgeons are now doubting the desirability of such mutilating procedures, and trusting rather to the effects of local excision, where feasible, followed by treatment with radium, X rays, or Coley's fluid. In some cases disappearance or diminution of the primar\^ growth have been re- ported after burying radium in its substance for twenty-four or fortj'-eight hours, but, of course, this does not in any way touch the question of secondary deposits. From an early diagnosis, and that 596 A MANUAL OF SURGERY alone, can any improvement be expected in the terrible statistics of the results of treatment of this dreadful disease. Secondary Sarcoma of bone is by no means imcommon. It is almost always endosteal in character, and, except in the most un- usual circumstances, will not demand treatment, owing to the general infection of the system. Possibly where it has led to spontaneous fracture, and there is much pain owing to the dilftculty of fixation, it would be justifiable to remove the limb. Carcinoma of bone is always secondary in nature, although it may be inN"o]\'ed by direct extension in a primary growth. Secondary growths are endosteal in char- acter, and often extremely painful; they may occasion- rdly lead to spontaneous fracture (Fig. 289), but the bone may consolidate again satisfactorily. After scirrhus mammpe, the upper end of the femur and vertebra are the bones most often affected, apart from those of the chest wall. For the so-called Thyroid Cancer of bone, see ]). 894. Pulsating Tumours of Bone, or Osteo-Aneurism. — Apart from pulsating sarcoma, two other conditions are met with, in which distinct pulsation is also noticeable. In the first of these the medullary cavity is occupied by a non-malig- nant vascular tissue, prac- tically identical with what has been already described as an aneurism by aiiasfoiiiosis (P- 353)- Such tumours are situated most frequently in the cranial bones, and may be multiple, the medullary tissue being in consequence atrophied, and the compact tissue thinned, so that ' egg-shell crackling ' may be obtained. The second form is found most commonly in the upper end of the tibia, or some such cancellous mass. It consists of a hollow cavity, filled with blood. Several distinct arterial twigs may open into it, and the overlying bone is thinned and absorbed. It is probable that the majority of such cases are in reality due to the breaking down of a sarcoma of extreme teniiity, or possiblv of a myeloma. Treatment." — If it seems probable that the condition is not asso- FiG. 289. — Radiogram of Secondary Carcinoma of Upper End of Femur, resulting in spontaneous fracture. The primary disease was in the breast. DISEASES OF BONE 597 ciatcd with nuilignant disease, the cavity slu)uld be incised, scraped, swabbed out with pure carbolic acid, and then hrmly packed with gauze, so as to obtain healing by granuhition from the bottom. If the bleeding persists, amputation is the only treatment, as also in the malignant cases. Hydatid Disease of Bone.— The cancellous tissue of bones occa- sionally becomes the site of hydatid development, any part either of the medullary cavity or of the ends being involved. The bone becomes expanded, with all the symptoms of an endosteal growth. Considerable deformity may occur, and when the compact layer lias been sufticiently absorbed, spontaneous fracture may follow. In this affection there is no limiting wall, the small daughter cysts being diffused through the affected area. A diagnosis is little likely to be made (at any rate in countries where hydatid disease is rare) prior to an exploratory incision. Treatment.— If all the cysts can be removed without interfering with the integrity of the shaft, a recovery, with good subsequent utility of the limb, should follow. Where, however, the disease has encroached widely on the bony tissue whether spontaneous fracture has occurred or not, amputa- tion holds out the only prospect of cure, unless bone-grafting is feasible. . . . Simple Cysts o! Bone are observed most frequently m the tibia or upper end of the humerus. The condition develops insidiously, probably without pain, and may be mistaken for a sarcoma, the true state of affairs not being recognised until after amputation ot the limb • or attention may be drawn to the part by the occurrence of a spontaneous fracture. The cyst is found to be lined with a thin layer of fibrous tissue, with no endothelial covering. The actual pathology is not clear, but it is thought possible that it is akin to osteitis deformans or osteo-malacia, since in all three conditions the true bony tissue disappears and the medullary tissue increases, in ■ osteo-malacia it remains fatty; in osteitis deformans new irregular bone is deposited in its place; and, in this condition there is a new formation of fibrous tissue, which, however, subsequently becomes cystic. This osteitis fibrosa, as it has been termed, may be more or less generalized through a bone, or may be locahzed, and then a simple cyst may develop. The only available means of diagnosis, apart from incision, is radiography. The thinning of the bone is more regular than in any sarcomatous condition, and there is a com- plete absence of motthng or detail such as is usually seen in cases ot myeloid disease. Treatment consists in laying open the cavity, scraping it out, and packing, so as to determine healing by granula- tion; or by excising the affected portion of bone, and replacing it by a bone graft. Bone-grafting is sometimes required to replace the normal bone in cases of comminuted fractures where much destruction of tissue has occurred, or after resection of portions of the shaft of a bone tor tumours, cysts, or caries. Formerly fragments of dead bone, or rods of ivory or bone, were 598 A MANUAL OF SURGERY used for the purpose, but it has been abundantly proved that they are merely passive actors in the process of regeneration, being absorbed or replaced. Living bone, on the contrary, is capable of retaining its vitality and uniting with the surn^unding parts, even if totally separated from its former osseous connections. Much discussion has arisen as to whether the bone graft sliould be covered by periosteum or not. Some claim that a graft with its periosteum intact lias a greater chance of living and uniting with the adjoining bones than one devoid of periosteal covering, because, although it is believed that the periosteum itself takes no active share in new bone formation, it conveys nutrition to the graft and obtains a fresh blood-supply from its new surroundings more rapidly than does uncovered bone, and thus secures the vitality of the graft. This idea, however, is quite open to question, since it is possible that naked bone is more porous and permeable to newly- formed vessels than periosteum. As a matter of fact, excellent results have been gained in both ways. The graft may be obtained from the patient himself [anlogcnous) , or from another patient {Iioiiwgeneous), or from a freshly killed animal {heierogeneous). Of these, the first method is usually adopted, and at present it gives the best results. The bone is usually taken from the surface of the tibia, or a portion of the whole thickness of the fibula. It is generally employed in a long strip, and the prac- tice of breaking it up into small fragments has no obvious advan- tages except in special circumstances, as after trephining. The graft is, if possible, fixed firmly to the two bony ends, between which a bond of union is required, either by implantation into the suitably prepared medullary cavities, or by means of catgut or silk sutures. Metal plates, wires, or screws are undesirable means of fixation. New bone can also live when implanted in the midst of soft tissues, as is evident from grafts surviving which have been utilized in the re-formation of a nose. Of course, in all cases abso- lute asepsis, both of the graft and oi the cavit}^ in which it is placed, must be present, and therefore it is useless at once to attemi)t bone- grafting in the cavity left by the removal of the diaphysis after an attack of acute osteomyelitis which has caused necrosis of the whole shaft. When once the cavity is free from infection, a bone graft may be introduced with some prospect of its survival. CHAPTER XXII. INJURIES OF JOINTS- DISLOCATIONS. Sprains and Strains result from sudden violence applied to a joint either directly or indirectly, as in the football field or in many laborious occupations. They consist in a tearing or stretching of the synovial membrane, partially detached portions of which may be tucked inwards, or of ligaments, which in bad cases may be torn from their attachments to the bones. The accident itself is associated with severe pain, and is immediately followed by more or less haemorrhage into the surrounding tissues, or into the articular cavity. Inflammatory effusion follows, and unless suitably treated, persistent weakness and pain may result, either from the formation of adhesions, or from imperfect repair. A neglected sprain may originate tuberculous disease in those who are so predisposed, whilst osteo-arthritis is by no means an uncommon sequela. If the patient is in a bad state of health at the time of the injury, an attack of acute infective arthritis may be determined. Treatment. — The joint should be firmly supported by a wet bandage as soon after the accident as possible, in order to limit the amount of effusion. The part is raised and kept quiet, and the bandage dabbed over with evaporating lotion from time to time. In the slighter cases the patient may be allowed to use the limb in a few days, the part being supported by strapping or an elastic bandage; but in severe sprains it may be necessary to keep the part absolutely at rest for a much longer period, before the pain and tenderness disappear. Friction with stimulating liniments, douching the joint alternately with hot and cold water, massage, passive and active movements, and finally exercises against resistance, are useful in restoring the limb to full functional activity. Penetrating Wounds of Joints are often accompanied by an escape of synovia, which is recognised as a glairy, oily fluid, floating perhaps on the surface of the blood; if, however, the aperture is small, this may not occur. It is always followed by a certain amount of reaction, the character of which depends on whether or not the joint is infected. If no infection has taken place, a simple synovitis ensues, but soon passes; if, however, infection has occurred, 599 6oo A MANUAL OF SURGERY acute arthritis proljably supervenes, leading to disorganizati(jn of the joint. (For symptoms and treatment, see p. 634.) A pene- trating wound, even if untreated, does not necessarily become infected; thus, if the lesion is produced by a small, clean instrument, and especially if this is inserted in a slanting direction, so that the wound is valvular, or if the incision is a large one, allowing free vent t(j all discharges, recovery without infection is possible. Treatment. — If the wound is small, and there is reason to believe that the instrument inflicting it was aseptic, the external skin should be thoroughly purified, and an antiseptic dressing applied. A careful watch must be kept upon the condition of the joint and upon the temperature of the patient; as soon 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 dirty, and probably involves the joint, it should be enlarged so that its depths may be purified, and then carefully examined. If it is found that the cavity has been opened, the aperture should be increased in size so as to allow it to be washed out and a drainage-tube inserted. Bier's treatment may assist in preventing infection, but if it supervenes, the condition must be treated in the usual way. Dislocations. Congenital Dislocation. — This term is applied generally to any irregularity of location of the bony constituents of a joint present at birth, but is rather due to an error of development than to any forcible displacement. The hip-joint is most frequently affected; but similar malformations have occurred in the shoulder, wrist, and jaw, whilst the patella may be congenitally absent or displaced. For congenital dislocation of the hip, see p. 447. 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. — The Causes are divided into predisposing and exciting. Under the former head may be included anatomical peculiarities, such as the shallow socket of the glenoid cavity, or some muscular or ligamentous weakness. 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 latter 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 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 pro- duce dislocation in certain joints; the head of the humerus, the patella and condyle of the jaw, are the bones most often affected in INJURIES OF JOINTS— DISLOCATIONS 6oi this way. If, however, the Hgaments of a joint have been stretched by previous disease or disphicement, recurrent dislocations from muscular action are not unusual. The term complete dislocation, or luxation, is applied to that con- dition in wliich the articular surfaces of the bones are completely sej^arated from one another. An incomplete dislocation, or sitbliixa- 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- f^licated dislocation is one in which there has been some associated injury of vessels, nerves, or viscera. The term fracttive-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) The evidences of a local trauma, e.g., pain, bruising, and swelhng of the soft tissues, due to their laceration and the effusion of blood into them: 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 ab- normal 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 latter phenomenon obtains is necessarily variable, but as a rule it is very marked; if, however, fracture is also present, passive movements may be possible, though associated with pain and crepitus. The Effects produced by a dislocation extend to all the structures entering into and surrounding the site of injury. The ligaments 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 dis- placed; adjacent vessels and nerves are often contused or com- pressed. 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 arrangement of the joint and its ligaments, resulting 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 tendons in such a way as to render its replacement a matter of the greatest diffi- culty, {b) Muscular contraction also constitutes an obstacle, which, though it can be counteracted by suitable traction, is more effectively overcome by the use of an aucesthetic. Not only does the patient maintain the limb in a condition of rest by a voluntary tonic con- traction, but it becomes fixed by the involuntary passive tension of the displaced muscles. When once reduced, there is usually but little tendency for a dis- location to recur. Reparative changes quickly manifest them- 6o2 A MANUAL OF SURGERY selves; hlood-rlot is absorlK'd, the rent in the capsule closes by cicatrization, and in many cases no permanent lesion remains; in some, however, the joint is left in a weak and relaxed state, and liable to a recurrence of the displacement, while intra-articular adhesions, or the cicatricial contraction of the injured ligaments and muscles, may cause some loss of mobility. If a dislocation is allowed 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 adiierent to the structures amongst which it lies; as the result of a })lastic inflammation, eitlier dense fibrous adhesions are V A Fig. 290. — Old-Standing Subcoracoid Dislocation of the Shoulder, SHOWING Atrophy of True Glenoid Cavity, together with Forma- tion OF New Joint and Alteration in Shape of Head of Bone. (From College of Surgeons' Museum.) formed, or a new false joint {pseudarihroi^is). 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 the disi)laced head rests undergoes changes, partly atrophic (from pressure), partly hypertrophic (as a result of chronic periostitis), whereby a new socket is produced (Fig. 290). Neighbouring muscles are second- arily 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. Serious pain is not unfrequently caused by pressure on neighbouring nerves. INJURIES OF JOINTS— DISLOCATIONS 603 Treatment. — ^The treatment of dislocations consists in tlie reduc- tion of the displaced bone with as little delay as possible. There are two chief methods of gaining this end, viz., manipulation and extension. iMdnipiUation is always the best means to employ where practicable, 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 already taken, through the rent in the capsule to its normal position. The shoulder and hip joints are more amenable to this method of treatment than hinge joints. Anaesthesia will be required in chfficult cases, and especially in dislocations of the shoulder and hip joints. Chloro- form is generally preferred, as inducing deeper muscular relaxation but where 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 right to draw attention to the fact that a large number of fatal cases of chloroform administration have been reported as occurring in the treatment of shoulder dislocations ; this is due mainly to two causes, viz., the deep anaesthesia required, and the want of prepara- tion of the patient. The greatest care must therefore be exercised in giving the anaesthetic, and for the hip-joint spinal analgesia might be preferable. Extension is employed to overcome muscular and other forms of resistance, so as to allow the bone to slip back or be manipulated into its original position. In order to make this effectual, the parts above the dislocation are steadied by some counter-extending force apphed 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 applying a bandage or towel to the limb. 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 attached to the limb. When any such contrivance is employed, precautions must be taken to prevent the soft tissues from being injured. A useful plan consists in applying a damp bandage at 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 continuously; no jolting or jerking action is allowable, or considerable mischief may ensue. Since the introduction of anaesthetics, however, pulleys have been very rarely required. 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, but massage may be started in a day or two, and passive movements after a week. The treatment of an unreduced dislocation is often a matter of con- siderable difficulty. Attempts at reduction may be undertaken up 6o4 A MANUAL OF SURGERY tu two or three months, but the greatest caution must be employed for fear of rupturing adhesions and endangering the main v(!ssels or nerves. Extension by pulleys has given rise to so many accidents, varying in severity from laceration of the skin to actual avulsion of the limb, that it is wise to discontinue such treatment if it has failed on its first application. The amount of mobility possible in an unreduced dislocation varies a good deal in different cases, and the character of the treatment is mainly governed by this. If movement is tolerably free, and not particularly painful, massage and manipulation may be undertaken, and a very useful limb result. Where, however, movement is both ])ainful and limited, one or other of the following plans of operative treatment should be undertaken: (i.) Reduction 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 maniimlation 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 scarcely com- mensurate with the risks and difficulties of the operation, especially if a considerable interval has elapsed since the accident, (ii.) Ex- cision of the displaced head of the bone will give the best results in most cases. In the elbow-joint it is often the only practicable treat- ment, and in the shoulder and hip it is usually better than attempt- ing open reduction. Compound dislocations are always serious lesions, for not only are adjacent vessels and nerves liable to injury, but unless efficient treatment is adopted, suppurative arthritis ensues, leading to dis- organization of the articulation, with subsequent ankylosis, or, in the case of larger joints, possibly to death from pyaemia and toxic poisoning. The treatment consists in rigid antisejisis to the wound, together with reduction of the dislocation and temporary drainage. If necessary, the opening 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. Special Dislocations. Dislocation of the Lower Jaw forwards is not a very common accident, and usually results either from muscular action, or from a blow on the chin when the mouth is widely open, as in gaping, laugh- ing, 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 nwts with an elevator. In some persons the accident ha])pens with the greatest ease, and constantly recurs, owing probably to laxity of the capsule or insufficient development of the eminentia articularis. The mechanism of the dislocation is as follows: When the mouth INJURIES OF JOINTS— DISLOCATIONS 605 Fig. 291. — Dislocation of Jaw. 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. 291). The inter-articular cartilage follows the condyle, and the attachment of the external pterj-goid muscle to that structure and to the 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 in- terval of about an inch. The lower jaw projects unduly, and is fixed, saliva dribbling over the lip; speech and deglutition are impaired, 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 hollow the condyle can be felt, being recognised by the slight amount of passive movement still possible. A finger in the mouth may define the coi onoid 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. — Reduction is usually easy. 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 glenoid cavity. The patient is seated in a chair; the surgeon standing in front protects his thumbs with thick napkins, and introduces them into the mouth, pressing 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 a week or ten days by means of a four-tailed bandage. Anaesthesia is occasionally necessary. A few cases are on record of displacement of the cond\de oi the jaw hackitmrds, associated with fracture of the tympanic plate and tearing or separation of the cartilage of the auricle, leading to bleed- ing from the ear. Displacement upwards into the cranial cavity through the roof of the glenoid fossa has also been described. Subluxation of the Temporo-maxillary Joint is due to displacement of a relaxed interarticular cartilage, which becomes folded or nipped on opening the mouth, the result being a painful temporary fixation of the jaw with a snap or crack on freeing it. The condition is associated with a passive synovial effusion into the joint, and may Go6 A MANUAL OF SURGERY be dealt with by the external application of blisters; should this fail, it is justihable to open the joint and fix the cartilage by sutures or rcmox'c it i]). 81JK Dislocation of the Sternal End of the Clavicle. In spite of the apparent weakness of this joint and the great strains to which it is subjected, dislocation is uncommon, owing to the strength of the ligaments surrounding it, particularly of the rhomboid, the clavicle being more easily broken than displaced. The cause of these dis- locations is always violence directed to the outer end of the bone, and since that usually acts from in front, the inner end of the bone is generally thrown forwards. Two other varieties are described, however, in which the displacement is backwards or upwards. In the forward dislocation the end of the bone lies on the anterior surface of the manubrium, where it can be easily detected; all the ligaments of the joint are torn, except, perhaps, the interclavicular. The point of the shoulder is approximated to the middle line. Treat- menf.^ Reduction is effected by placing the knee against the spine between the scapula, and drawing the shoulders backwards, the elbow on the affected side being kept in front of the mid-axillary line. To prevent recurrence, the shoulders are kept back by hand- kerchiefs passed round the axilla and knotted together in the middle line behind, as for a fractured clavicle (p. 501). The elbow is then drawn forwards in front of the mid-axillary line, and supported by a sling or bandage. It is advisable to keep the patient in bed for a few days, so as to give the ligaments a better chance of re-uniting, 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 seen. The end of the bone lies behind the upper part of the sternum, and pressure upon the trachea, oesophagus, and vessels of the neck, result, giving rise to difficulty in breathing and swallowing, and to congestion of the head. Reduction and after-treatment are similar to that suggested for the former variety. If the condition cannot be reduced, and serious symptoms of pressure are present, the end of the bone should be excised. The upward dislocation is one of extreme rarity, the end of the bone lying in the episternal notch behind the sterno-mastoid, and compressing both trachea and oesophagus. To effect reduction, the shoulders are drawn forcibly backward^, and direct pressure applied to the end of the bone. Dislocation of the Acromio-clavicular Joint consists in the acromion being forced either above or below the outer end of the clavicle, more commonly the latter. Ihe displacement is easily recognised by the abnormal prominence of one or other of the bones. It usually results from violence directed to the scapula. No difficulty is experienced in reduction, but the displacement is ver\- liable to recur, especially in the more common form. Ihe elbow is then flexed to a right angle, and pads of lint or small towels placed over the acromion and beneath the elbow; a bandage or strap, applied INJURIES OF JOINTS— DISLOCATIONS 607 over the slinuldor and under the elbow, suffices to maintain the bone in position. The strap is kept from shpping by passing a bandage under it round the opposite side of the chest. Should the displace- ment persist, the bones may be wired together after bringing the cartilaginous surfaces into contact. Care must be taken to prevent subsequent ankylosis by passing the wires in such a way as not to encroach on the joint surfaces. Either they may be passed through the bones vertically, or as a mattress suture from before backwards. Dislocation of the Shoulder occurs almost as frequently as all the other dislncations of the body put together. The shallowness of the glenoid cavity, the size of the head of the humerus, the laxity of the capsule, the extent and force of the movements possible, and the exposed position of the shoulder, explain the great frequency of the accident. It usually results from falls upon the hand or elbow, the arm at the time oi the accident being widely outstretched. The weak lower and inner part of the capsule first yields, the head of Fig. 292. — Subglenoid Dislocation OF Shoulder. (Tillmanns.) Fig. 293. — SuBcoRACoiD Disloca TioN OF Shoulder. (Tillmanns.) the bone being primarily displaced downwards into the axilla (subglenoid variety), and then, according to the direction of the force, or the character of the subsequent manipulations, the head travels either forwards (subcoracoid or subclavicular dislocation) or backwards (subspinous). Falls on the elbow or shoulder may, however, cause a direct forward or backward displacement. The Signs of a dislocation of the shoulder are sufficiently ob\'ious, and certain characteristic features are present in almost all varieties, (i) The shoulder looks flattened, owing to displacement of the head inwards (Figs. 212, B, and 294), and as a result of this the acromion process is unduly prominent, and a hollow is felt below it, occupied by the tense deltoid. (2) The head of the bone lies in some abnormal position, and the glenoid cavity is empty. (3) The elbow is displaced awa\- from the side, and it is impossible to make it touch the chest wall at the same time that the hand is placed on the opposite shoulder (Dugas' test) ; this does not always obtain in the subcoracoid tj'pe. 6o8 A MANUAL OF SURGERY (4) The vertical measurement round the axilla is increased in all the varieties (Callaway's test) ; whilst inspection reveals a lowering of the anterior or posterior axillary fold (Bryant's test). (5) A ruler or straight-edge can be made to touch both the acromif)n process and the outer condyle of the elbow in most cases of dislocation (Hamil- ton's ruler test) ; this is impossible when the head of the bone is in its normal position, but can also occur in fractures of the anatomical neck. At the same time, the usual signs of a dislocation, viz., rigidity and local bruising, are also present. Stereoscopic radio- graphy is, of course, invaluable for diagnostic purposes. Subglenoid Dislocation (Fig. 292) is always the primary condition when due to a fall upon tlie outstretched arm, but is not often seen, since further dis- placement usually occurs before the case comes under observation. The head of the bone passes down into the axilla, resting against the outer border of the scapula below the glenoid cavity, be- tween thesubscapu- laris above and the teres minor below, with the long head of the triceps be- liind. The capsu- V " lar ligament and ^^^^ - muscles passing to the tuberosities are torn, whilst the ax- illary vessels and nerves may be seriously compressed, leading to numbness of the fingers. The head of the bone is felt in the axilla, and the anterior axillary fold is much lowered; the elbow is directed away from the side and slightly backwards; the arm is lengthened, perhaps to the extent of i inch, whilst the fore-arm is usually flexed. A few cases have been recorded in which the arm was alxlucted and displaced vertically upwards, although the head of the bone was in the usual position of a subglenoid dislocation. This variety is known as the luxatio erecta. Subcoracoid Dislocation (Figs. 293 and 294) is, without doubt, the most common form. The head of the bone lies under the coracoid process on the anterior part of the neck of the scapula, immediately in front of the glenoid cavity, the anatomical neck impinging on its anterior border. In this position it is above the tendon of the sub- FiG. 294. — Subcoracoid Dislocation of the Right Shoulder. INJURIES OF JOINTS— DISLOCATIONS 609 scapularis, which is cither torn or stretched over the neck as a tense band, and may considerably impede reduction. The muscles attached to the great tuberosity may be stretched, resulting in marked external rotation of the limb (subcoracoid variety), or they are torn, or even the great tuberosity itself pulled off, the humerus being then rotated inwards (intracoracoid variety). The elbow is displaced backwards and outwards, and the head of the bone can be usually felt on rotation of the arm under the outer third of the clavicle. Comparatively little alteration is produced in the length of the arm. The Subclavicular variety is uncommon, and merely an exaggera- tion of the subcoracoid. The head of the humerus passes further inwards, and lies deeply under the pectoralis minor, on the second and third ribs. The elbow is markedly separated from the side and directed a little backwards, whilst distinct shorten- ing is present. The Subspinous Dislocation (Fig. 295) is unusual. The head of the bone hes in the infraspinous fossa, immediately behind the glenoid cavity, between the infraspinatus and teres minor muscles, the subscapularis being generally torn. The elbow is displaced considerably for- wards, biat can be made to touch the chest wall ; the arm is rotated inwards, so that the hand is thrown across the fig. 295 .^Subspinous Dis- front of the body. There is usually a location of Shoulder. marked hollow in front of the shoulder, (Tillmanns.) whilst a prominence is caused behind by the head of the bone in its false position. The length of the Hmb is frequently unaffected, or if any change is present, the arm is slightly lengthened. A few cases have been described of what is known as a Supra- coracoid Dislocation. The head of the bone is displaced upwards, and either the coracoid or acromion process is broken, more com- monly the former. Replacement with crepitus is easily obtained, but the dislocation is Hable to recur. The Treatment of Dislocation o£ the Shoulder consists in reduction by manipulation or extension. I. For reduction by manipulation an angesthetic is always ad- visable, but must be given with caution. Many different niethods of manipulation have been suggested, of which the following are the more important. Not unfrequently, however, when the muscles are relaxed, any slight rotary movement suffices to "' put the bone in.' Kocher's Method for Subcoracoid Dislocations. — The surgeon stand- ing in front of his patient, who is seated or recHning, and supported by an assistant, grasps the elbow after flexion of the fore-arm, and 39 Cio .1 MANUAL OF SURGERY Figs. 296, 297, 29S. — Kocher's Method OF Reduction of a Subcokacoid Dislocation of the Shoulder. l)resses it to tlie side and slightly backwards. With one hand hold- ing the wrist and the other the elbow, the arm is now rotated iirmly and steadily outwards as far as it will go, the elbow still being pressed to the side (Fig. 296) . Distinct resistance will be felt during this move- ment, which causes the head of the humerus to roll out beneath the acromion, and may suffice to effect reduction. If the limb is still displaced, the elbow should be drawn forwards and upwards as far as it will go, with the hu- merus still fully everted (Fig. 297), whilst "finally the arm is rotated inwards so as to carry the hand towards the opposite shoulder, and the elbow drawn across the chest and lowered (Fig. 298). All these movements should be carried out steadily and evenly, and without undue force for fear of fracturing the surgical neck of the bone. The value of this plan, according to Kocher, 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 outwards re- laxes these structures and removes them from the fossa, whilst the rent in the capsule gapes; but owing to the fact that the upper and lower luargins of the opening are stiir 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. INJURIES OF JOINTS— DISLOCATIONS 6ii and the lower part, which remains tense, guides the head of the bone into the joint.' Siiii/h's Method varies somewhat in its appHcation, according to whether the head of the bone is displaced anteriorly or posteriorly. 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 cir- cumducted 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 disloca- tion, 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 circum- ducted outwards, and finally brought to the side. 2. Extension may be applied in different ways, the object being to overcome the tension of surrounding ligaments 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. Occasionally the foot has been placed against the thoracic wall, and extension made directly outwards at right angles to the body, as recommended by Sir Astley Cooper. \Vhite of Manchester suggested vertical traction, the arm being pulled directty 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 when other plans fail, is that the axillar\^ 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 direct or 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. 510), and of the degree of mobility of the difterent 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 radiogram should be taken. I. Dislocation of Both Bones may occur either hacki&afds, for- wards, or laterally. The backward variet}' (Fig. 216, 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 6l2 A MANUAL OF SURGERY brokt-n, considerable mobility of both bones occurs, with crepitus. The fore-arm is semi-flexed, the hand held midway between prona- tion and supination, and the displaced bones form a considerable swelling at the back ot the joint, above which is a marked hollow, crossed by the triceps. The lower end of the humerus projects in front, and the artery and the soft parts are displaced forwards. The measurement from the acromion process to the external condyle remains unaltered, but that from the condyle to the styloid process of the radius is distinctly shortened, and the distance between the condyles and the olecranon process is increased. Dislocation forwards of both bones rarely occurs without frac- ture of the olecranon process, although a few cases of this unusual accident are on record. The dis- placement is readily detected, the fore-arm being lengthened perhaps to the extent of an inch. The arm is in a condition of flexion, and, indeed, the accident can only take place from falling backwards on the point of the elbow when in this position. The triceps muscle may be con- siderably torn. Lateral dislocations of the fore-arm are almost always in- complete, and are not very frequent ; the bones may be dis- placed either inwards or out- wards, the latter being the more common. They are recognised by a careful examination of the relative position of the bony prominences and by stereoscopic radiography. 2. Dislocation of the Ulna alone occurs only in a backicard direction. It is very rare owing to the position and strength of the orbicular and oblique ligaments and of the interosseous membrane. If, however, the bones of the fore-arm are rotated backwards upon the head of the radius as a fulcrum, and then the fore-arm adducted, this displacement can occur without extensive ligamentous lacerations, which, indeed, have not been noted in any of the cases observed. In the Treatment of the above dislocations, all that is necessary is to unhitch the interlocking bony prominences, so as to allow the bones to return to their normal positions by muscular contraction. This is usually accom])lish(?d by the method described by Sir Astley Cooper. The patient being in a sitting position, the surgeon presses backwards, with his knee in the bend of the elbow, against the Fig. 299. — Reduction of Backward Dislocation at the Elbow. INJURIES OF JOINTS—DISLOCATIONS 316 lower cMid of tlu> humerus; at tlie same time he grasps the patient's wrist, and slowly and forcibly bends the fore-arm (Fig. 299). 3. Dislocation of the Radius alone may occur either forwards, hackwards, or outwai'ds. The forward dislocation (Fig. 300) is that usually seen, and results from falls on the hand when the fore-arm is in a state of extreme pronation, or from forcible traction upon the hand, or from chrect injurv applied to the back and outer side of the elbov/. The head of the radius rests against the lower end of the humerus in the hoHow above the capitellum, and the most characteristic feature consists in the inability of the patient to flex his fore-arm, owing to the bone impinging against the lower end of the humerus. Tt can be readily detected in this situation, rotating with the movements of the fore- arm, whilst a deep hollow is felt behind, immediately below the external condjde. The fore-arm is somewhat flexed, and midway between pronation and supination ; the former act can be satisfac- torily accomplished, but supina- tion cannot be carried further 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 pro- duced by direct violence. If this luxation is not reduced, great Fig. 300. — Dislocation of the impairment of the mobility of the Radius Forwards. (Pick.) limb results, flexion beyond an obtuse angle becoming impossible. Treatment. — Reduction is accomplished by traction from the wrist, with the fore-arm 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 de- formity is likely to recur, unless the limb is kept completely flexed in order to relax the biceps. Active movements of the limb must be interdicted for three or four weeks. In old-standing cases excision of the head of the bone is desirable. Dislocation backwards is less common. The head lies behind the external condyle on the outer side of the olecranon, where it can be detected on rotating the limb. The fore-arm 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 bone being dis- placed to the outer side of the external condyle, where it can be felt, causing considerable impairment of movement. Reduction is accomplished without difficulty, or, if necessary, the head may be excised. Occasionally a rare form of dislocation is met with in which the ulna passes backwards and the radius forwards, resulting in great deformity. 6i4 A MANUAL OF SURGERY A very common arrident in children under four years of aj^c consists of a subluxation of the head of the radius downwards within tlie orhiruhir Hganient, so that a f(jld (jf syn(jvial incmbrane shps up and becomes nipped between the head and capitellum. It results from forcible traction of the hand, as from pulling up a child roughly after it has fallen, and is a common nursery accident, popularly known as pulled elbow. The limb becomes fixed in a position of slight flexion, and witli the hand pronated. and the child cries out with the pain; it is readily treated by completely flexing the limb, and subsequently extending and fully supinating it, and leaves no bad results. It must not be forgotten that here merely the pure dislocations have been described. In actual practice complications of a serious nature are frequently present in the shape of fracture (jf one or both condyles, which add to the difficulty of diagnosis, apart from radiography, and even then the results of treatment may be un- satisfactory. Abundant callus is formed, and fibrous adhesions of such strength are developed, that considerable impairment of func- tion is liable to ensue. Dislocation of the Wrist is a very uncommon accident, and may occur fontHirds or backwards. The lower ends of the radius and ulna project under the skin, and the styloid processes retain their relative positions; it is thereby easily distinguished from a Colles's fracture. Occasionally the radius, carrying with it the hand, is dislocated from the lower end of the ulna, as a result of forcible pronation, which results in laceration of the inferior radio-ulnar ligaments, and probably of the lowest portion of the interosseous membrane. The triangular fibro-cartilage is in some of these cases loosened, and its mobility may subsequently give rise to a painful weakness of the wrist. The ulna projects backwards, and its reduction' is eas}^; but some laxity of the inferior radio-ulnar joint may persist, unless the bones are kept firmly together by suitable bandaging. Dislocations of Various Carpal Bones have been described, and radiography has demonstrated that they are by no means uncommon. That which is best known is a displacement of the os magnum back- wards. 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. If troublesome, the bone may be excised. Dislocations of the Metacarpal Bones and Phalanges are not un- frequent, but need no special mention, except in the case of Disloca- tion Backwards of the First Phalanx of the Thumb. The chief interest here lies in the difficulty experienced in reduction, which was formerly attributed to the head slipping between the two portions of the flexor brevis pollicis and being grasped by them, as a button in a button-hole. It has now been shown that there are two much more important factors, viz., the tension of the long flexor tendon, which INJURIES^OF JOINTS— DISLOCA TIONS 615 hitches round the neck (Fig. 301), and the arrangement of the glenoid hgament. This libro-cartilaginous structure passes between the two heads of insertion of the short flexor, and is thus incorporated between the two sesamoid bones ; whilst tirmlv attached to the base of the phalanx, it is but loosely connected with the head of the metacarpal bone, so that it accompanies the phalanx in its disloca- tion, and will then be situated immediateh' behind the head of the metacarpal, so as to prevent any attempts at reduction. Treatment. — Trac- tion and manipulation are alwa\-s attempted in the first instance. The thumb is grasped by a suitable ap- paratus and M'per-extended to a right angle, thus making the head of the metacarpal project still further through the muscular interspace, and, as it w^ere, enlarging the buttonhole. Still maintaining the traction, the thumb is rapidly flexed into the palm, the metacarpal bone being at the same time pressed inwards. Should this fail, as it often \vi\\, a sterilized teno- tome should be inserted in the middle line of the thumb behind, immediately above the base of the phalanx, and should be pushed on till it reaches and divides the glenoid fibro-cartilage between the sesamoid bones ; this little manoeu\T"e will at once render replacement simple. Dislocation of the Hip, though not ver}- 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 surrounding the articulation, explain the comparative unfrequency of the accident. It always results from violence applied to the feet or knees, or, if the legs be fixed, to the back. It is rarel}' met ^^dth 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. Four chief varieties of dislocation are described, in two of which the head of the bone is displaced posteriorh^ and in two anteriorly. The two former are known as the Dorsal and the Sciatic varieties, in which the head of the bone occupies some situation on the dorsum ilii, determined by the integrity or not of the obturator internus tendon. The two anterior dislocations are known as the Ohtiirator or Thyroid, and the Pubic; in the former the head of the bone is located Fig. 301. — -Dislocation of Thumb, SHOWING Head of the Metacarpal Bone protruding Forwards between the Heads of the Short Flexor Muscle. (Pick.) 6i6 A MANUAL OF SURGERY in the obturator notch, and in the latter upon the i)ul)ii; ramus. The relative frequency of these dislocations is as follows: About 50 to 55 per cent, of the cases are of the dorsal type, 20 to 23 per cent, sciatic, 10 to 15 per cent, obturator, and 5 to 10 per cent, pubic. In addition to these four varieties, many other slight modifications Tiave been described, which it will be unnecessary^ further to particularize. Mechanism. — In considering these dislocations, the relative strength or weakness of the different parts of the capsule and its surrounding structures must be remembered. The weakest part of the capsule is placed below and behind, and it is through a rent in this position that the head of the bone most frequentl}' escapes. In front, the ilio-femoral or Y-shaped ligament of Bigelow is a structure of much strength, on the integrity of which depends the fact whether the displaced head of the bone shall occup}- some definite position or be freely moveable. Bigelow, to whom we owe so much in the elucidation of the mechanism of these dislocations has divided them into two classes — the regular and the irregular — according to whether this ligament is intact or completely lacerated. Posteriorly, the plicated tendon of the obturator internus is the most important structure, and the position and level of the bone on the dorsum ilii depend in some measure on whether it remains intact or is ruptiired. It must also be remembered that the ligamentum teres is relaxed when the thigh is forcibly abducted, and is made tense by adduction. The limb is usually in a position of abduction at the moment of dislocation, the head of the bone escaping through a rent in the lower and back part of the capsule. The type of accident responsible for this is a fall 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 direction 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 will be subsequently produced. If the limb is externally rotated and extended, or the trunk is hyper-extended and the limb remains fixed, the head travels forwards, and either the pubic or obturator 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 displacement of the bone, thus giving rise to the so-called sciatic variety, or as Sir Astley Cooper called it, the dorsal below the tendon : 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 displace- ment on the dorsum ilii. Dislocation may also result when the limb is in a position of adduction, a direct dorsal dislocation being thus produced, the head of the bone escaping from the capsule above the tendon of the INJURIES OF JOINTS—DISLOCATIONS 617 obturator internus; such an accident is sometimes associated with fracture of the posterior Hp of the acetabuhun. The type of violence leading to this occurrence is when a heavy weight falls on the back of a person whilst kneeling, or when, the knee being flexed, the^body is thrust forwards, so that the limb is forcibly inverted. If, however, the thigh is in a position of extreme flexion, the head may be dis- placed below the tendon of the obturator internus, and the sciatic variety will then result. 1 . Dorsal Dislocation (Fig. 302) .—The head of the bone lies on the dorsum ilii, a variable distance above and behind the acetabulum, and always above the obturator internus tendon. It may be detected on manipula- tion of the hmb, although in muscular sub- jects this is difficult. The ligamentum teres is necessarily ruptured, as also the capsule, the rent being situated either below or above the obturator tendon, according to whether the dislocation is due to forcible abduction or adduction. The small external rotator muscles are often lacerated, and perhaps even the glutei and the pectineus. The ilio- femoral ligament usually remains intact. The great sciatic nerve is sometimes com- pressed or contused. The trochanter is raised above Nelaton's line (p. 532) and approxi- mated to the anterior superior spine; the ilio- tibial band of fascia is therefore relaxed, and there is considerable shortening of the limb, amounting sometimes to 2 or 3 inches. The leg is in a position of flexion, adduction, and inversion, 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. The Diagnosis should be easy, the only difficulty being experienced in distinguishing it from an impacted extra-capsular fracture. The character of the accident, the presence of adduction and inversion, the increased breadth of the trochanter in the case of fracture, and the abnormally placed head of the bone in dislocation, are the points to which attention must be directed. 2. Sciatic Dislocation, or dorsal below the tendon, is one in which the head of the bone is prevented from travelling upwards to the dorsum ilii by the integrity of the obturator internus tendon. It may occur either from forced abduction of the limb, or from extreme Fig. 302. — Dorsal Dis- location OF THE Hip. (TiLLMANNS.) 6i8 A MANUAL OF SURGERY flexion in the addueted position. Tlie lesions of muscles and liga- ments are practieally the same as for the dorsal variety. The ilio- femoral ligament is uninjured. The Signs resemble those of a dorsal dislocation, but are less marked. There is less shortening, often not more than | to i inch; the limb is fiexed, addueted, and inverted, but the axis of the femur 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 thickness of the glutei muscles at the lower level. Treatment of the Two Backward Dislocations is effected in much the same way, whether the dorsal or sciatic variety is present. The most usual method is that of manipulation and rotation, so accurately worked out by Bigelow. The patient is anaesthetized, preferably on a mattress placed on the floor. The leg is first flexed on the thigh, and the thigh on the abdo- men, the position of adduction being still maintained, so that the knee extends beyond the middle line of the body (Fig. 303). This position is maintained for some moments, and then the limb is freely circumducted outwards, and brought rapidly down into a position of extension parallel with the othei. By this man- oeuvre 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 traction may be employed. The patient, lying on his back, is firmly fixed 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 grasp his own elbows, and the front of the leg is steadied against the operator's perineum. Direct and forcible traction upwards can now be made, and this is often sufficient in itself to lift the head of the bone into the acetabu- lum. If this is unsuccessful, the movements described above can be energetically repeated in this position. The above plans, combined with the use of an anaesthetic, rarely fail in reducing a backward dislocation of the hip, and hence extension by means of pulleys is rarely required. If, however, it is needed, traction should always be made in the direction of the displaced limb, i.e., across the other thigh, counter-extension being obtained by a towel passed between the Fig. 303. — Reduction of Dorsal Dislocation of Hip. (Bryant.) INJURIES OF JOINTS— DISLOCATIONS 619 injured tliii;li and the perineum. When suiiieient force has been a})pHed, the surgeon rotates the Hmb outwards so as to allow th e head of the bone once more to slip into its socket. 3. Thyroid or Obturator Dislocation fFig. 304). — ^The head of the bone in this case passes downwards through a rent in the lower part of the capsule, and its position is subsequently but little altered, a slight forward and upward movement being alone superadded. The ilio-femoral ligament is untorn, but the pectineus and adductors are very tense, or may even be lacerated; the ligamentum teres is, Fig. 304. — Dislocation of the Hip : Obturator Variety. (TiLLMANNS.) Fig. 305. — Dislocation of the Hip Forwards: Pubic Variety. (Tillmanns.) of course, ruptured. The head Hes on the obturator externus muscle, and can be detected in the perineum. The trochanter is less prominent than usual, and, indeed, its normal position may be represented bj^ a depression. The limb is slighth^ 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 interesting to note that if the disloca- tion remains unreduced the patient may be able to walk without 620 A MANUAL OF SURGERY miuii pain or inconvenience, though in a more or less stooping position. 4. Pubic Dislocation (Fig. 305).— In this variety the head of the bone either escapes from the joint below, or may be forced out in front and to the inner side of the ilio-femoral ligament as a result of hyper-extension of the trunk. The head 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 move- ment of the limb. The vessels are pushed inwards, and considerable pain may be felt down the limb from pressure on the anterior crural nerve. The ilio-fcmoral ligament is untorn, whilst the ligamentum 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 being approximated to the middle line and raised. Tfie limb is shortened to the extent of i inch, and there is considerable abduction and eversion, so that the inner aspect of the limb looks forwards. The thigh is slightly flexed 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 anesthetized; the knee is flexed, as also the thigh upon the abdomen, but in a position of abduction; circumduction inwards follows (Fig. 306), and on ex- tension of the limb the head again enters the acetabulum. The thyroid variety may sometimes be reduced by upward and outward traction when the limb has been flexed to a right angle in the ab- ducted position, the unbooted foot being placed against the pelvis to steadv it. If extension by pulleys is required in the thyroid dislocation, it is made trans- FiG. 306. — Reduction of versely outwards across the upper part Anterior Dislocation OF of the thigh, counter-extension being THE Hip. (Bryant.) 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 b}^ 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 fort- night, and then passive movement may be commenced, but with considerable caution; voluntary movements should not be under- taken for another week or two. Should the dislocation recur, it may be due to fracture of the INJURIES OF JOINTS—DISLOCATIONS 621 posterior lip of the acetabulum, or to some involuntary movements 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 the limb subsequently kept immobilized for a longer period than usual with a weight-extension and a Liston's splint. Dislocation of the Patella may occur onhvanis, im&ards, or edgeways. A dislocation upwards resulting from rupture of the ligamentum patellae is sometimes described, but it is scarcely to be included in the same category as the others. The displacement may be com- plete or incomplete; in the former the capsule is always lacerated; in the latter, not necessarily so. The outward variety is much the commonest on account of the obliquity of the limb, and may result from muscular action, especially in people suffering from genu valgum; it also arises from direct violence. In either case it occurs most frequently when the limb is extended, since during flexion the bone is firmly lodged in the inter- condyloid notch. When completely displaced, it lies upon the outer surface of the condyle, with its 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 dis- tinguishable in the position usually occupied by the patella. It is not unfrequently, however, incomplete, and then the inner half of the articular surface of the patella lies in contact with the cartilaginous surface of the outer condyle, with its outer border projecting for- wards. Reduction may take place spontaneously, but is usually effected by manipulation. The thigh is flexed on the abdomen, and the knee extended, so as to relax the quadriceps, and then a little pressure on its outer margin causes the bone to slip back into place. In the incomplete form, where one of the borders of the bone is odged in the intercondyloid notch, reduction is sometimes very difficult, and to effect it an open operation may be required. The inward dislocation is rare, being always due to direct violence. In characters and 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 completely 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. Recurrent dislocation of the patella may be associated with genu valgum, or with laxity of the extensor muscles from paralysis. In the former case it may be cured by correcting the deformity by means of osteotomy of the femur ; but sometimes the synovial mem- brane of the knee-joint on the inner side will require to be braced up by excision of a portion and suture of the margins of the defect. In the paralytic variety, when the extensor muscle is slack, it may suffice to pleat up the rectus or to shorten it by a plastic operation. 622 A MANUAL OF SURG 11 RY Dislocations of the Knee may occur laterally, as also fonoanls or hackivards. When due to disease of the joint, the backward disloca- tion is commonest; but when arising from traumatic causes, the lateral is the most frequent. The lateral displacements arc rarely complete, and are usually associated with a certain amount of rotation; the leg is partially flexed. Reduction is effected without difficult}^ Dislocation of the tibia forwards is more common than displace- ment backwards. It is generally complete, the lower end of the femur projecting into the popliteal space, and compressing the vessels, so that gangrene not unfrequently follows. The upper end of the tibia, carrying with it the patella, lies in front, forming a well- marked swelling with a hollow above it. There is usually consider- able shortening of the limb if the articular surfaces overlap. Dislocation of the tibia backwards is a much rarer accident, and is also as a rule complete (forty out of fifty-five cases were complete).* The signs are exceedingly characteristic, the pressure effects upon the popliteal vessels and nerves often resulting in gangrene (ten cases out of fifty-five). Reduction of either of these conditions is easily accomplished 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 on a splint for two or three weeks. Displacement or Rupture of a Semilunar Cartilage [svn. : Subluxa- tion of the Knee, Internal Derangement of the Knee-Joint) is a condi- tion frequently met with, resulting from sprains and strains associated with torsion. In an}' rotary movement of the knee, which is only possible when the limb is flexed, the pressure of the condyles always tends to modify the position of the cartilages, which, moreover, are relaxed and more freely moveable on the upper surface of the tibia in flexion than in extension. Displacement of a cartilage is almost always due to a sudden strain or wrench of a rotary type, e.g., turning quickly round in such games as tennis or football, or slipping off the kerb with the knee bent. The inner cartilage is much more frequently affected than the outer, and the character and extent of the lesion varies much in difterent cases. Sometimes its anterior or posterior tibial attachment is torn through, thereby permitting considerable lateral mobility (Fig. 307) ; but more frequently the cartilage is broken across the middle (Fig. 30S) or split longitudinally (Fig. 309), thereby detaching a hinged portion from its free border, which slips in or out of position, and not un- commonl}' gets nipped between the bones, or may even be doubled over. It subsequently becomes inflamed and swollen, and unless properly treated the displacement is likely to be repeated. Ihe Symptoms produced by this accident are a sudden sickening pain of much severity, located in the knee, which becomes partially locked in a position of flexion, with inability to extend it. The patient * Sheldon, Annals of Surgery, January, 1903. INJURIES OF JOINTS— DISLOCATIONS 623 Fig. .307. Fio. 308. inuy be able to ' wriggle ' his joint free, or the limb nuiy remain stiff for some hours, or even a day or two, wlien movement suddenly re- turns more or less spontaneously, a snap being at the same time felt within the joint. An attack of subacute synovitis usually fol- lows. In other cases tfie cartilage remains out of place, until reduced by the surgeon, with or without an anesthetic. If the case is not correctly treated, the displacement is liable to recur, the cartilage constantly slipping in and out, and getting nipped between the bones; as times goes on, this becomes more and more easy, owing to the ligaments of the joint being re- laxed from the recurrent attacks of synovitis. In fact, the limb may pass into such a state of chronic weakness as to interfere seriously with the patient's comfort. Ihere is usually a spot of localized pain in the front of the joint, corre- sponding to the upper surface of the tibia; possibly there may be some amount of lateral mobility of the leg, and movement of the cartilage ma,y be detected on flexing and extending the knee. The Diagnosis is not always easy, as the symptoms may be simulated by other conditions, such as a loose foreign body in the joint (p. 664), or a fringe of syn- ovial membrane thickened and swollen protruding backwards and getting caught between the bones, or perhaps pushed backwards by enlargement of the bursa beneath the ligamentum patellae. The definite history of a traumatic onset is an important element in the diag- nosis of a torn or loose meniscus. Inflammation of a semilunar carti- lage [meniscitis) also needs to be considered; it usually results from a heavy fall on the foot or heel, whereby the cartilage is bruised; painful limitation of movement results, and especially pain on standing, or straightening the knee. Fig 309. Figs. 307, 308, 309. — Diagrams of Various Types of Injury sus- tained BY THE Internal Semi- lunar Cartilage. In Fig. 307 the anterior attach- ment has been stretched and torn, and the cartilage is conse- quently loose. In Fig. 308 the cartilage has been torn trans- versely across, and a weak cica- trix has formed. In Fig. 309 the cartilage is split longitudin- ally, and it has a loose tag, which causes trouble. 624 A MANUAL OF SURGERY which is kept semiflexed; there are usually no sudden attacks of painful locking of the joint, but the cartilage is tender, and can perhaps be f<]t, though it is not moveable. 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 neighbourhood of the displaced cartilage, which often returns into position with a distinct snap. The limb is subsequently kept at rest on a back-splint, and cooling lotions are applied until the inflamma- tion has subsided; it is then further immobilized for s(jme weeks in removeable plaster of Paris or w^ater-glass, so as to allow the lacerated ligaments to reunite and consolidate. During this period massage is employed, passive movements are permitted, followed by active move- ments, and movements against resistance, and finally the patient is again allowed to walk. When the cartilage has become loose and is constantly slipping out of place, im- mobilization of the limb, with pressure by an elastic knee-clip, or by a knee-truss (Fig. 310), may be useful. Should this not prove satisfactory, operative proceedings must be undertaken. The knee-joint is opened by a curved incision on the appropriate side of the j7j(..,jQ Knee-Truss patella, and the condition of the cartilage FOR Dislocated In- ascertained. If of normal shape and merely loose and moveable, it may perhaps be stitched to the periosteum over the head of the tibia, so as to keep it from again slipping between the bones; this is sometimes best accomplished by splitting the cartilage diagonally into two portions, and securing each of these by two or three stitches. If, however, the cartilage is very loose or much torn, it is better to remove it. The joint is carefully closed, and kept quiet for ten days, when massage and suitable exercises are commenced, so as to consolidate and strengthen the divided tissues. For general considerations concerning intra-articular operations, see p. 629. Rupture of the Crucial Ligaments is another form of internal derangement, resulting from great violence. The integrity and strength of the joint are much impaired, and abnormal lateral and antero-posterior movements are possible. The only Treatment is to open the joint and suture the ligaments.* Dislocations of the Ankle-joint may occur in the following direc- tions: onhvards, inwards, hackicards, fonvards, and upwards, this being the order of their frequency. Owing to the fact that the * Mayo Robson, Annals of Surgery, May, 1903. ternal or external Semilunar Cartil- ages, OR FOR Chronic Dislocations of the Patella. INJURIES OF JOINTS— DISLOCATIONS 625 astragalus is wedged like a l)lock into the mortice formed by the lower ends of the tibia and fibula, it is obvious that fractures of these bones are frequently met with as complications. The lateral dislocations are in reality fracture-dislocations, and have been already described in the chapter on fractures (p. 550). Although the upper articular surface of the astragalus is broader in front than behind, dislocation of the foot backwards is a more com- mon accident than displacement forwards. It results from falls on the feet while running or jumping, or by sudden violence applied to the limb when the foot is fixed. Usually both malleoli are fractured, and the articular surface of the astragalus is thrown behind the lower end of the tibia. The heel projects unduly backwards, and the articular surface of the tibia usually rests upon the neck of the astra- galus, the scaphoid, or even the cuneiform bones. Dislocation forwards is ver}' uncommon, and may occur without any associated fracture of the bones of the leg. The foot is appar- ently lengthened, and the tibia rests upon the posterior part of the upper surface of the os calcis, behind the astragalus, the prominence of the heel and of the tendo Achillis being lost. The treatment of antero-posterior dislocations consists in reduction by traction. The leg is flexed upon the thigh, so as to relax the tendo Achillis, or, if necessary, this structure is divided. The ankle is subsequently commanded by a pair of Cline's side-splints, care being taken to keep the foot at right angles to the leg, and the articular surfaces of the astragalus and tibia exactly in apposition. A dislocation upwards has been described in which the astragalus, together with the foot, is carried up between the tibia and fibula,- owing to a rupture of the inferior tibio-fibular ligament and the lower end of the interosseous membrane. The displacement is very marked. Dislocation of the Astragalus alone is by no means common. It consists in a partial or complete detachment of the bone from all its normal connections, both to the bones of the leg and of the foot, and its displacement from under the tibio-fibular arch. It may travel backwards or forwards with or without lateral rotation, and be complete or incomplete. It is frequently more or less compound. Dislocation forwards is much the more common variety, and is usually associated with partial rotation, the displacement occurring more frequently outw^ards than inwards. When complete, the bone is entirely detached from its connections, and lies upon the upper surface of the external cuneiform and cuboid bones, the skin of the dorsum being tightly stretched over it, or even torn. In the incomplete variety, the head of the astragalus impinges 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 may or may not be associated with rotation of the bone, which can easily be felt between the tendo Achillis and the malleoh. 40 626 A MANUAL OF SURGERY Treatment. — Reduction is only possible in the incomplete forms of dislocation. The patient is anaistlietized, 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 pressure upon the displaced bone in a suitable direction. In the complete variety re- duction is impracticable, owing to the fact that the os calcis is drawn up into contact with the malleolar arch. In such cases manipulation is useless, and excision of the bone is necessary. Comparatively little impairment in the function of the foot results from this operation. Subastragaloid Dislocation. — By this term is meant a displacement of all the bones of the foot from below the astragalus, which retains its normal position between the malleoli. It is due to some violent strain or wrench of the foot. Displacement may occur either for- wards or backwards, but in the great majority of cases it is either backwards and inwards or backwards and outwards. The luxation is rarely complete as regards the calcaneo-astragaloid joint, but the articular surfaces of the head of the astragalus and scaphoid are completely separated, the former structure lying on the dorsal surface of the latter bone. The foot is greatly deformed, the anterior portion being shortened, the heel projecting, and the toes pointing down- wards. The head of the astragalus forms a rounded globular swelling under the tense skin. In a compound dislocation of this nature examined post-mortem, the inner edge of the under surface of the astragalus had burst through the skin; the vessels and nerves were torn or stretched, and even when the wound in the skin had been enlarged, reduction was impossible owing to the tendons which were caught around the neck of the astragalus. In such a case removal of the astragalus would have been the only practicable treatment. In the inward displacements, the foot is somewhat inverted, so that the outer malleolus is unduly prominent, and the inner malleolus is lost in a deep depression caused by the lateral displacement of the OS calcis; the foot is thus in a position somewhat simulating talipes equino-varus. In the outward dislocations the foot is everted, the inner malleolus prominent, and tlie 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. Treatment consists in reduction by manipulation, which is sometimes readily accomplished, but may be a matter of the greatest difficulty, pro- bably from the tibial tendons becoming hitched aroimd the neck of the astragalus. Section of the tendo Achillis is occasionally needed. In difficult cases excision of the astragalus may be required, and when there is much associated injury to the soft parts amputation. CHAPTER XXIII. DISEASES OF JOINTS. General Considerations— A careful study of the anatomy and physiology of ioints IS requh-ed in order to appreciate the many problems, mechanical and pathological, which confront the surgeon in the treatment of their diseases Limitations of space prevent us from discussing these, but we would remind students that the exposed ends of the bones entering into a joint are covered with articular cartilage, and in young people are separated Irom the shafts bv the intervention of epiphvses, which protect the joint m many cases froni the spread of disease from the diaphyses, but in some cases are a source of danger in that the junction cartilages are mtra-articular. Holding the bones together is a complicated series of ligaments, of varying strength and density, usually inserted into the epiphyses in young people, and arranged so as to resist the various forms of strain to which the particular joint is exposed. Lining the under side of the ligaments, and more or less closely attached to them is the synovial membrane, a thick, smooth structure which secretes a glairy fluid for lubricating purposes; it extends as far as the margins of the articular cartilages. \\Tiere it is not in close proximity to the ligaments, as in the knee-joint, the interspaces are padded with fat, which niay occa- sionally prove a source of trouble. On the inner aspect of the niembrane are a number of small villi, which sometimes develop to a considerable size. Inflammatory affections of joints are of the most diverse character, and are brought about bv injury, infection, or general constitutional conditions, such as gout The trouble may be limited mainly to the s^movial membrane, con- stituting merely a synovitis, or may spread to or involve the other articular structures, such as ligaments, cartilages, ends of the bones, etc., thereby con- stituting an arthritis. Effusion into a joint occurs in most of the various manifestations, the exudate varying with the cause. The phenomena, however, are similar in all the diverse conditions, and it would be ^^•ell to note them here. Shoulder : The curvature of the shoulder is mcreased, and the deltoid expanded by a fluid swelling beneath it, which is especially noticeable at its anterior border along the bicipital groove, and sometimes posteriorly ; in the axilla a painful intumescence may also be felt. These s>miptoms may be somewhat simulated by inflammation of the multilocular 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 bv the'fact that, although when the patient voluntarily moves his arm pain is produced, yet when the surgeon gently mani- 627 628 A MANUAL OF SURGERY pulates it, so as to press the head of the bone against the glenoid cavity, there may be none. Elboip : 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 pufftness 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 the bony projection. Uyisi : There is a general fulness around the joint, most marked (jn the anterior and posterior aspects, but also noticeable behnv the styloid processes. The tendons in their sheaths are lifted up back and front, and deep fluctuation ma}^ be detected beneath them. It is distinguished from a teno-synovitis by the facts that the swelling is limited more or less to the joint line, and does not extend up and down in the direction of the tendons; there is also no limitation of movement of the fingers, and the characteristic crepitus of teno- synovitis is absent. Effusion into the Hip-joint cannot be easily detected b}' 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, abduction, and eversion taken by the hmb, whilst limitation of movement is equally marked. The Knee, when dis- tended with fluid, presents a rounded outline, in which all the normal hollows, especially those on either side of the patella and ligamentum patellcC, have disappeared. There is also a swelling corresponding to the subcrural pouch, more marked on the inner than the outer side, and extending for 3 or 4 inches above the patella. Fluctuation can be readily detected when one hand is placed above the patella, and the fingers of the other hand compress the tissues on either side of the ligamentum patellae below, or by alternate pressure on either side of the rectus tendon. When the eft'usion is considerable, the patella is felt to float, and on pressing it sharply backwards can be made to tap against the intercondyloid notch of the femur {patellar tap). A smaller effusion is recognised by pressing the fluid downwards from the subcrural pouch with the knee fully extended, when the patellar tap can usually be demonstrated. Enlargement of the bursa patelke is recognised by the swelling being central and in front of the patella, so that its outline is obscured. Ankle: The hollows between the tendo AchiUis and the malleoli are replaced by fluctuating swellings, whilst the dorsal tendons are displaced forwards, and a fluid swelling appears in front of eacn 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. Finally, it must be noted that joints are peculiarly liable to bac- terial invasion, especially from without. Any breach of strict aseptic precautions is only too likely to be followed by an infection which will have disastrous results, endangering both the utility of the limb and also the life of the patient. Hence the most minute DISEASES OF JOINTS 629 cair must be taken in all operations which involve the opening of joints. Prolonged sterilization of the skin must be insisted on when possible, and all needless introduction of fingers into the wound should be avoided. No antiseptics are allowed to enter the joint, as they are always somewhat irritating, and may cause a considerable synovial effusion which becomes a suitable nidus for the develop- ment of bacteria, if such happen to be present. At the conclusion of the intra-articular manipulation, the joint must be carefully closed by buried sutures, which involve seriatim the synovial membrane, the ligaments, the overl^'ing muscular or aponeurotic structures, and finallv the superficial parts; exact co-aptation of each of these struc- tures" is necessary if good functional repair is to be obtained, free from weakness. Drainage is not as a rule necessary ; but if there has been much bleeding the patient's comfort is increased by introducing a drainage-tube for twenty-four hours. The joint is usually kept at rest for a week or ten days, perhaps on a splint, and then movements are cautiously permitted, at first passive, then active, and finally active against resistance, and all these advisably before the patient strains the joint (if a knee) by bearing upon it the weight of the body. Massage to the surrounding muscles will of course be employed as soon as the wound is securely healed. Acute Synovitis. In this affection the inflammation is limited almost entirely to the synovial membrane, the ligaments and other structures of the joint being but little affected. The Causes are local and general. Local conditions include cold and injury; general or constitutional comprise rheumatism, gout, syphilis, and gonorrhcea. It is probable that in all cases apart from trauma there is some mild infection, but it is limited in its action and results. Pathological Anatomy.— Acute synovitis is characterized by hyper- emia, of the synovial membrane, and exudation of plasma and leucocytes, firstly into the substance of the membrane, causing it to be 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 sometimes spontaneously coagulable; after a time the plasma may coagulate, depositing hmiph upon the articular surface, whilst serum remains. This hmiph 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 some varieties, especially if repair is not quickly established, a certain amount of peri-synovial inflammation follows, resulting in the ligaments becoming corgesti^d, infiltrated, and perhaps somewhat relaxed. The Clinical Signs of acute synovitis consist in the joint becoming painful and distended, whilst if the articulation is superfixial, as m 630 A MANUAL OF SURGERY the knee, a sense of heat may be imjxirted to the hand, and the surface may even be red and liypenennc The hmb is maintained by muscular spasm in that position whicli gives the most ease- — viz., that in wliich its capacity is the greatest, and this is usually one of slight flexion. If the condition is neglected, the flexion may increase considerably, and the limb become more or less fixed in an undesir- able position, whilst the muscles governing the movements of the joint undergo rapid atrophy. The phenomena resulting from effusion into various joints have been already noted (p. 627). When the acute stage has passed, the joint is usually left in a somewhat weak and relaxed condition, with a little passive effusion, or perhaps some adhesions. The adhesions which follow acute syno- vitis are usually slight in character, if the case has been properly treated; they result from the union of patches of lymph on opposing surfaces of synovial membrane or bone, which become organized into loose libro-cicatricial tissue, containing a few delicate bloodvessels, and covered by endothelium extending over them from the adjacent serous membrane. The characteristic signs of such a condition are painful limitation of movement in some particular direction, and possibly a little soft crepitus. The Treatment of acute synovitis consists in so immobilizing the joint as to give the patient the greatest amount of ease, whilst, should ankylosis result, the limb is left in as favourable a position as possible for subsequent utilitv. Thus, the shoiihier should be bandaged to the side, and the hand kept in a sling; the elhoiv 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 icri^.t all that is needed is to apply a palmar splint to the fore-arm; the hip is immobilized by the application either of a Thomas's splint or of a Liston's long splint, or by placing the limb between sand- bags and adjusting an extension apparatus; 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 ex- ternal splint with a foot-piece. Necessarily, in all severe cases of acute synovitis the patient should be confined to bed and the limb elevated. In the early stages cold should be applied to the joint by means of evaporating lotion, an icebag or Leiter's tubes, but this is not advisable in old people. In the later stages fomentations 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 ptirified aspirator, or trocar and cannula, may diminish pain and hasten recovery. Such fluid should always be examined bacteriologically, and if organisms are found a vaccine should be prepared. In not a few cases of acute synovitis the induction of passive hyperemia by the application of an elastic bandage will give relief and hasten repair. In the subacute stage, when the joint is weak and relaxed, massage or friction with stimulating liniments should be employed, whilst in the later stages elastic pressure is often of the greatest value. If the DfSEASES OF JOINTS 631 case has been neglected and tlie limb has assumed a vicious position, the patient should be amesthetizcd and the deformity forcibly cor- rected ; or gradual extension is made by means of a weight and pulley until the correct position is attained. If adhesions are present, they should be carefully broken down under chloroform ; the limb is subsequently kept at rest for a few da>-s upon a splint, whilst passive movements and massage are after- wards adopted. In bad cases it mav be desirable not to do too much at a time, as a good deal of inflammatory reaction is thereby lighted up; the manipulation may be repeated more than once with a few days' interval. Chronic Synovitis. This affection follows an acute attack, or may be lighted up by some injury or condition in- sufficient to determine a more violent form of inflammation. The synovial membrane becomes thick and infiltrated, whilst the effusion is sometimes relatively less than in the acute form, sometimes excessive. Three varieties have been de- scribed : (a) Chronic Serous Synovitis (Fig. 311) is a con- dition in which effusion is the most prominent factor. It results from many causes, which throw strain upon the joint, or is sometimes inexphcable» It ^^^ 3ii.__Chronic Serous Synovitis is not unfrequently associated ^^ Knee, with Distension of the with some condition such as Subcrural Pouch. (From Col- a loose cartilage, osteo-arthritis, lege of Surgeons' Museum.) etc., and in its most aggravated j j . , ^,.\ form constitutes a condition of hydrarthrosis or hydrop^_ (p. b3o)- It is not unfrequently seen affecting the knees after rising from a prolonged stay in bed. The fluid is often clear and limpid, and the changes in the structure of the membrane are but slight. The pain is usually not severe, being replaced by a sense ot uselessness and weakness. It is interesting to note that, m cases where the effusion is well marked, the burs^e commumcatmg with the joint frequently become distended; they are prevented from partici- pating in the acute forms of inflammation by the fact that the apertures of communication with the interior of the joint are narrow and slit-like, and thus readily become occluded by the swelling of the membrane. 632 A MANUAL OF SURGERY (b) Chronic Synovitis with Thickening of the Synovial Membrane is always a suspicious condition, as it may be a precursor ol tuberculous disease, if it lasts, or an outcome of a syphilitic infection. There is but little effusion, and the membrane may even be pal])able. Crepitus is sometimes met with in this condition, possibly from a roughening of the articular surfaces on which lymph has been deposited, or between which fibrous adhesions have formed. (c) Chronic Papillary Synovitis. — Occasionally the synovial fringes and the villi of the sjnovial membrane become hypertrophied, giving rise to a conchtion somewhat similar to that described under osteo-arthritis (p. 654). The overgrown villi usually spring from the reflections of the synovial membrane close to the bone, and may be loaded with fat, constituting a condition known as ' Lipoma arbo- rescens.' In the knee- joint the fringes may be felt rolling under the fingers, and painful symp- toms may be caused by the loose ends being caught and nipped be- tween the bones. Treatment varies some- what in the different varieties, but in all com- mences by keeping the joint at rest in a suitable position, and applying counter - irritation and pressure; Scott's dressing and blisters are especially useful in this affection. At a somewhat later stage Bier's hyperemia may be helpful, or elastic pressure by a Martin's bandage over the affected joint may be employed, together with friction with stimulating liniments, or even hot-air baths. When effusion is marked and resists these methods of treatment, removal of some of the fluid b}- aspiration and subsequent compression may do good ; but if the effusion re-appears, the best procedure consists in opening the joint, washing it out with sterile saline solution, and draining it for a few days. In the chronic fibroid form iodide of potassium, or iodolysin* may be useful in addition to the above-mentioned nu'thods, but as a rule one has to rely on prolonged massage, radiant-heat baths, the intro- duction of iodine by ionic medication, or spa treatment. Should enlarged villi be present and give rise to trouble, the joint * Iodolysin is a 5 per cent, solution of the ethyl-iodide of thiosinamin (p. 263) ; 20 to 60 minims may be given by the mouth three times a day. Fig. 312. — Baker's Cysts from Back of Knee. (Howard Marsh.) DISEASES OF JOINTS 633 Should be opened, and if they arc limited in their distribution they mav be clipped away, or the synovial membrane from which they ^row dissected out. When very extensive, so that removal would involve total excision of the synovial membrane and consequent stiffness it may be wise to wash out and dram, in the hope that tliey may become fixed, before undertaking complete extirpation of the membrane. Hydrarthrosis (Hydrops Articuli) is the term appHed to any '^°f^*['^\°|^^ chrome nature in which the joint is much distended with fluid It ^ay anse from at least five different affections: («) Chronic serous synovitis (^)mosteo-- artliritis, a very common cause; (c) in Charcots disease; (d) ^^ secondary syphilitic synovitis; and {e) occasionally in tuberculous disease. I* must be remembered that it is but a symptom, and not a disease sui generis, aad tieat- mcnt necessarily varies with the cause. .,_,,,.., +^ ivr^ Mr,rrant Baker's Cysts.-This condition, first described by ^he Jate Mr. Morrant Baker, consists in a hernial protrusion o the synovial membrane of ajomt through an aperture in its fibrous capsule (Fig. 3 1 2) ■ It is usually due to some chronic affection of the articulation, especially osteo-arthi itis or tuber culous disease, whereby the intra-articular pressure is i^^^^^^f^^' ^"\J°^ uncommonly several such sacs are connected ^^i^hthe same joint^l hey vary much in size, contain synovial fluid, and, though at ^.^-^^ ':ommim^catm with the joint cavity, have a tendency to travel away from it burr°wing alon muscular and fascial planes, and coming, perhaps, to the surface at a distance from their origin, the aperture of communication with the lo^nt Imping m some instances been shut off. If causing no troublesome ^yniptoms^ there is no necessity to interfere; but if they become mconyenient or pamtui _it IS best to dissect them out, closing where necessary by If^^f ^,°fJ^J,^'™ narrow neck which leads into the joint. Of course, the strictest asepss must be maintained in all such proceedings, and the causative affection must not be forgotten. Acute Arthritis. Causation.- Acute arthritis is nearly always due to infection of the joint cavity with pyogenic bacteria, which reach it either from withm or without the bSdy. (i.) It may be due to the entrance of cocci through a punctured or valvular wound of the joint, or during opera- tions The micro-organisms most commonly present are the Fneto- mococcus and the Streptococcus pyogenes, but staphylococci and other pathogenic organisms have also been found, (u.) It rnay arise in a manner exactly analogous to that in which acute infective osteo- myelitis is produced, viz., by auto-infection. A slight injury (g.g., a sprain or strain occurring in a weakly child, convalescent from rneasles or scarlet fever) may result in this affection which is then commonly due to the pneumococcus. (iii.) It may be produced by the lodgment of a pyemic emhohts, and in a similar way it not un- frequently follows as a sequela of fevers, such as enteric or pneu- monia by direct transmission of some infective material, (iv.) it is sometimes met with as a result of gonorrhoea, and may then run its course with or without suppuration, (v.) It may be hghted up a.s a result of the extension of inflammation from the end of a neighbouring bone, or from the bursting of a subcutaneous or bursal abscess into the joint. Acute arthritis of the hip-joint is sometimes due to the former of these conditions, being consecutive to an acute mtective 634 A MANUAL OF SURGERY ostco-myc'litis of tlic upper end of the femur, (vi.) It is occasionally observed as a result of vhcmnaiisin, the inllanunation running a very acute course, and leading to disorganization of the joint, though without suppuration. Such attacks are undoubtedly bacterial in origin. Course of the Case. — In the early stages acute arthritis manifests itself as a hyperacute synovitis, combined with severe pain and fever. The pain is often so intense that the patient cannot bear the part to be touched or the bed shaken, and indeed the slightest jar of the limb is so exquisitely painful that the patient may scream with agony. The joint itself is distended with a turbid effusion, which rapidly bcconles purulent, and the tissues around are hypertemic 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 by muscular contraction. As the disease progresses, pus is formed within the capsule, but in time bursts through it, and either travels directly to the surface, or burrows deeply into the substance of the limb, and spreads along the muscular planes; thus, in the knee an enormous abscess may collect beneath the vasti 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 waked by a painful start just as he has fallen asleep. This condition usually indicates that the articular cartilages are becoming affected, and is explained by the fact that just as the patient loses consciousness, the muscles which fix the joint are re- laxed, and allow the inflamed surfaces to shift their position slightly, exciting severe pain and a sudden spasmodic contraction of the muscles. Gradually the deformity becomes more and more obvious, whilst the infiltration and relaxation of the ligaments sometimes allow of abnormal movements — e.u,., of lateral mobility in the knee- joint ; the ends of the bones become carious, and absolute displace- ment or dislocation may follow. Sinuses may open in all directions, and the patient suffer from recurrent rigors, caused by toxaemia or the onset of pyeemia. The constitutional effects are always severe, consisting of high fever, and rapid exhaustion from the pain, sleep- lessness, and absorption of toxins. The terminations of this affection are as follow: [a) Recovery, rarely with a moveable joint, and then only after active interference; in most cases ankylosis in a good or bad position, according to the treatment, is the best result that can be expected, [h] During the acute stage the patient may die of pysemia, or acute toxaemia and exhaustion, (c) If he survive the acute stage, chronic suppuration may ensue, and symptoms of hectic and amyloid degeneration of the viscera may supervene. In such cases sinuses leading down to carious bones exist, and, unless efficient measures are taken to obtain asepsis, or to remove the diseased structures, perhaps bv amputation, the patient is likely to die from exhaustion or chronic toxaemia. DISEASES OF JOINTS 635 Pathological Anatomy. — The synovial inoiibrane, at first merely infiltrated and hypenemic, soon becomes converted into granulation tissue, exuding an abundance of pus. The ligaments in turn are sodden and relaxed by the presence of a plastic exudation between the fibres, rendering them soft and edematous, so that the tonic contraction of the muscles easily stretches them and brings about displacement. The articular cartilages are disintegrated and destroyed in various ways according to the acuteness of the inflamma- tion and the amount of pressure to which they are exposed. In acute cases the}^ early lose their normal l)luish-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 overgrown granulation tissue developing from the synovial membrane. When once the cartilage has been perforated at any one spot, the suppurative inflammation 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. The inter -articular cartilages are affected in a very similar manner, and quickly disappear. The ends of the bone pass into a condition of acute osteitis, re- sulting in the transformation of the medulla into granulation tissue, absorption of the bony cancelli with or without suppuration, and sometimes necrosis of small portions of the cancellous tissue [caries necrotica) . The veins within the cancelli become thrombosed, and hence p^^aemia may result. The periosteum covering the ends of the bones is also inflamed and hypergemic, in consequence of which spicii- lated or stalactitiform osteophytes are pro- duced (Fig. 313). The muscles in the neigh- bourhood of the joint undergo rapid atrophy and fatty degeneration. Treatment. — In the early stages the limb must be elevated, absolute^ immobilized, and put into such a position that, if ankylosis subsequently obtains, it may be of some use to the patient. \Veight extension is usually desirable in order to keep the inflamed articular ends from rubbing ; but as light a weight as possible must be used, or the inflamed and softened ligaments may be stretched. Bier's treatment by induced hyperemia is sometimes of the greatest value in checking the inflammation and relieving pain, which may also be helped by applying fomentations or an icebag. Increasing effusion. Fig. 313. — Ends of THE Bones after Acute Arthritis OF Elbow, show- ing THE Carious Surfaces Devoid OF Cartilage, and the Devel- opment OF Stal- actitiform Os- teophytes. (From King's Col- lege Hospital Museum.) 636 A MANUAL OF SURGERY espeiially if supi)ur;iti<)n is })r()l)al)lc, necessitates an incision into the joint, and the demonstration of the existence of pus indicates the free opening of the joint in as many situations as may be necessary to ensure perfect drainage. The cavity is frequently washed out with some sterile or mild antiseptic solution, and to assist this the openings are made for choice on opposite sides of the joint. A vaccine is, of course, grown from the pus as quickly as possible and administered. It may be wise to discontinue the use of the elastic bandage during the stage of free suppuration, but as soon as it is checked the hypenemic treatment may be continued. The fixation of the limb is carefully maintained, and the general health attended to. Irrigation should be continued until all signs of inflammation, pain, heat, and startings of the limb have passed away. Should this not occur, it may be desirable to lay the joint even more freely open, and to maintain continuous irrigation with salt solution, to which peroxide of hydrogen has been added. Under such a r'^ime it is sometimes possible to obtain a moveable joint, but more frequently ankylosis must be expected. Excision may be required in order to secure effective drainage in some joints, such as the shoulder; to prevent or remedy faulty 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 or displacement, but, as a rule, not until all acute symptoms have passed away. If the patient is suffering from severe toxsemic or pysemic symptoms threatening life, amputation may be required, as also for exhaustion from long-stand- ing suppuration and hectic fever. Acute Arthritis 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 penetrating injury. Severe pain is caused by any movement of the arm affecting the joint, and if abscesses form, they will come 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 behind by cutting down on a pair of dressing- forceps pushed backwards 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 of the arm are, on the whole, very satisfactory. 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 rect- angular 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 DISEASES OF JOINTS 637 acute stage has passed, in order to obtain a moveable elbow; but hi .iuldren. where the growth is incomplete, it is better to allow ankxiosis to occur, and excise, if need be, at a later date. The Wrist may be inlected secondaril\- to septic conditions follow- ing operations on ganglia in the neighbourhood or through direct injury. The essential treatment consists in free incisions parallel with '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 infec- tive osteo-myelitis attacking the upper end of the shaft of the femur, and involving the joint, owing to the epiphyseal cartilage being intra- capsular ; 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. 670), but much more acute. Ihere is high fever, together with intense pain, marked flexion and e version of the limb, early suppuration, and rapid disorganization if not properly treated; indeed, where nothing is done, and the patient lives long enough, the head of the bone may be entirely absorbed, or is detached, and remains as a sequestrum in the disorganized articular cavity. As soon as the capsule gives way, the pus may come to the surface in any of the usual locahties for hip-jomt ab_scesses._ In treating these cases, the joint should be freely laid open in the situa- tion which appears most favourable. The anterior incision is more suitable for the early, and the posterior for the later, stages, when the head of the bone is either dislocated, or remains m sifu and separated from the shaft. A double opening may sometimes be utilized with advantage. . The Knee-joint is more frequently involved by this disease than any other, and is usually infected from mthout. The symptoms are exceedingly tj-pical: 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, giving rise to large abscesses, which ultimately find their way to the surface. The de- formity gradually increases, until in the worst forms the tibia shps behind the cond\-les of the femur, the leg is flexed to a right angle and rotated outwards, and if the limb has long rested on its outer side, considerable lateral displacement may also occur. Early and efficient treatment will usually prevent such a disaster. The joint should be freely incised on each side of the patella, so as to open up the subcrural pouch, and the whole articular cavity well washed out. In some cases a counter-opening may be made with advantage and a drainage-tube 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 external popliteal nerve. By this means more efflcient drainage of the articular cavity is obtained. r ^. -u When the Ankle-joint is involved, amputation has often to be 638 A MANUAL OF SURGERY resorted to, in consequence of the difficulty of securing good drain- age, although excision of the astragalus will sometinK^s cut short the disease and lead to a good result. Special Forms of Synwitis and Arthritis. Rheumatic Synovitis is met with in the course of acute rheuma- tism, or as a chronic affection from the commencement. In the former one joint after another is involved; complete resolution usu- ally follows, but there may be some thickening of ligaments and con- sequent impairment of mobility. If the disease is limited to one joint, absolute disorganization, though without suppuration, may ensue (acute rheumatic arthritis). There can now be little question that this disease is of bacterial origin and due to a diplococcus (Poynton, Paine). The chronic variety is characterized by swelling of the joints, due partly to effusion, partly to thickening of the synovial membrane, and of the capsular and other ligaments. If neglected, it may pro- duce fixity of the joint, due mainly to ligamentous changes, but also resulting from the development of intra-articular adhesions; but there is never any lipping of the cartilages or new formation of bone, as in osteo-arthritis. Not unfrequently other evidences of rheuma- tism may be present, such as chorea, erythema, etc., whilst rheu- matic nodules* [i.e., new growths of fibrous tissue beneath the skin, perhaps attaining the size of a walnut, but more often much smaller) may also develop. The Treatment of the acute form is medical rathei than surgical, and general rather than local. The affected joints must be kept at rest in good position, and wrapped in warm cotton-wool, or, perhaps better, soda fomentations may be applied. Should the inflammation resist such measures, it is quite justifiable to open and wash out the joint, which is found to be occupied by a greenish, semi-puriform effusion. In the more chronic forms anti-rheumatic drugs have less power., and more attention must be paid to diet. Butcher's meat, sweets, and rich dishes should be avoided, and as far as possible a ' white diet ' obtained. Alkaline mineral waters are valuable, and a visit to a suitable home or Continental spa may be desirable. Locally, massage and stimulating embrocations do good, but in bad cases counter-irritation by repeated blisters, or even bv applying the actual cautery, may be required. Malposition should be corrected under an anaesthetic or by weight extension. Localized or general hot-air baths do good in most cases, as also diathermy (p. 49) and ionic medication (p. 54) with iodine. * Dr. Bannatyne's opinion as to the diagnostic value of fibrous or bonj' subcutaneous nodules connected with articular lesions is as follows: ' Muscular swellings are most often due to rheiimatism, small subcutaneous nodules also to rheumatism, larger ones to rheumatoid arthritis, bursal enlargements to chronic gout, rheumatoid arthritis, or rheumatism, and bony nodes (of the Heberden type) to chronic gout or chronic rheumatoid arthritis.' DISEASES OF JOINTS G39 Gouty Arthritis is characterized by certain well-marked features. It often attacks the metatarso-phalangeal articulation of the great toe (podagra) , or the metacarpo-phalangeal joint of the thumb (cheir- agra). Its onset is usually sudden, and it frequently commences in the middle of the night. The tissues around the joint become swollen, red, shiny, and oedematous, whilst the superficial veins are prominent. The attack is exceedingly painful, and the skin ex- quisitely tender. These symptoms pass off in the course of a few days, leaving the articulation swollen and sensitive. Even a single attack results in a slight deposit of bi-urate of soda in acicular crystals in the matrix of the articular cartilage close to the surface; but when the joint has been several times inflamed, the whole thickness of the cartilage may be invaded by this chalky de- posit, whilst the hgaments and ends of the bones are also infiltrated. In the smaller joints it may increase to such an extent as to form well-marked swellings, or ' tophi,' similar in character to those so commonly seen in the external ear; the skin sometimes gives way over them, and a chalky discharge results. In some cases the carti- lages are eroded, and eburnation of the exposed bone may follow, as in osteo-arthritis. The treatment of acute gout consists in foment- ing the parts or applying glycerine of belladonna, whilst colchicum, citrate of lithia, and alkaline purgatives are administered. In the more chronic forms iodides may be given, and the diet and drink are carefully regulated. Probably some form of hydro-therapeutic treatment will be required, and if the patient cannot go to a suitable spa much may be done at home by getting him to drink a large cup of hot water an hour before each meal. Pysemic Synovitis is due to embolic infection from some suppurat- ing focus. The joint becomes rapidly distended with pus, and often without pain. If the joint is promptly opened, washed out and drained, its disorganization may be in many cases prevented (vide Pyaemia, p. 97) ; otherwise destructive changes ^vill quickty follow. Typhoid Disease of Joints. — i. A simple synovitis occurs in one or more joints, with but slight effusion and little inflammatory disturb- ance. It is somewhat resistant to treatment, and hence may cause limitation of movement. Possibly it is due to the action of toxins rather than of the living organism. 2. The true typhoid avthritis, due to the B. typhosus, is characterized by a marked inflammatory effu- sion into one or more joints, and is liable to end in spontaneous dis- location, especially in the hip-joint. Suppuration, however, is rare, and the prognosis favourable, provided the limb is kept in a good position. The presence of a large effusion indicates aspiration, 3. A mixed pyogenic and typhoid infection results in active suppura- tion within the joints, the B. typhosus playing quite a subsidiary part. 4. A ptire pyogenic infection. In these latter two varieties the ordinar}'- symptoms of acute suppurative arthritis occur, and the treatment for that aft'ection must be instituted. ^ Pneumococcal Arthritis. — In the course of an acute pneumonia the pneumococcus is occasionally disseminated through the body, and is 640 A MANUAL OF SURGERY then ver}' likely to attack a joint which has been already damaged, giving rise to a suppurativ^e arthritis with an effusion of thick creamy pus, or sometimes to a milder form of syno\itis. Males are more often affected than females, and the upper rather than the lower extremity. Occasionally more than one joint is involved, and, with the exception of the hip, the larger joints are attacked rather than the smaller. 1 here are no special peculiarities in the disease, but since it is merely part of a general infection, a high mortality is asso- ciated with it. Suppuration usually occurs, and its onset is always an indication for incising, washing out, and draining the joint. It may also occur primarily and apart from any other obvious pneumococcal lesion. The symptoms are then those of a subacute arthritis with effusion, which may be so resistant to treatment as to require arthrotomy. Some limitation of movement is likely to follow. Gonorrhceal Disease oi Joints is always due to infection with the gonococcus, transmitted by the blood from the primary focus of mischief. It is sometimes associated with pyogenic organisms, and then the prognosis is decidedly worse. In the later stages the pus or serum from the joint is sometimes found to be sterile, the gonococci having died after causing the inflammation. Such an occurrence is always suggestive, as sterile pus is rarely found in an acute abscess due to ordinary pyococci. Whilst usually seen in connection with gonorrhceal urethritis in males, it has been known to follow ophthal- mia neonatorum, and has been lighted up by passing a full-sized bougie on a patient with gleet. It generally commences after the third week of the gonorrhfeal attack, when the discharge is becoming subacute, but may sometimes appear at a much later period. It may involve one or many joints, the knee, ankle, and wrist being most frequently affected, and perhaps on both sides of the body. Many distinct types of trouble manifest themselves, and they are not unfrequently combined. In one, the synovial membrane is mainly affected, and the effusion is chiefly intra-articular, so that the con- dition closely resembles an ordinary attack of acute traumatic syno- vitis, except that it is more severe, more painful, and more persistent. Occasionally a synovial effusion occurs with but little reaction, and then the gonorrhceal origin is likely to be overlooked. A more frequent form is that in which the peri-articular structures bear the brunt of the mischief ; and there is at first but little effusion in the joint, but much around it, the parts even becoming (edematous and reddened; the ligaments are infiltrated and softened, so that dis- placement readily occurs; surrounding muscles atrophy rapidly; the patient suffers from severe pain and fever, so that he becomes thin and worn. In the worst cases the intra-articular effusion increases, and is sero-purulent, yellfjwish-green in colour, and contains flakes of lymph; sometimes it becomes frankly purulent. All the forms are very chronic and resistant to treatment, and hence ankylosis, with or without disorganization, is very liable to follow. Treatment is not very satisfactory. The urethral discharge must be arrested as soon DISEASES OF JOINTS 641 as possible, whilst the affected joints are kept at rest; moderate pressure and counter-irritation, as by Scott's dressing, are useful appliances, but Bier's treatment is perhaps of more value, or in the more chronic stages ionic medication with iodine preparations or hot-air baths. Iodide of potassium, mercury, and quinine may be administered internally. Should the local phenomena be at all severe, the joint must'be opened and irrigated, and if undertaken sufficiently early, ankylosis may be prevented. Anti-streptococcic, and even anti-diphtheritic, serum, given per rectum, has proved of value in some of these cases, probably by increasing the general resisting power of the body. In most cases a gonococcal vaccine (p. 146) may be employed with advantage, even as an intra-articular injection. Tuberculous Disease o£ Joints. Tuberculous Arthritis [Syn. : Pulpy Degeneration of the Synovial Membrane, White Swelling, etc.) may commence either in the syno- vial membrane or in the articular end of the adjacent bone (tuber- culous epiphysitis, p. 575) ; or it may spread to the synovial mem- brane from the periosteum, as a result of a tuberculous periostitis, or from a neighbouring bursa. In children the disease commences most frequently in the epiphyses, whilst in adults it may start either in membrane or bone with about equal frequency, but considerable variation occurs according to the particular joint affected. The Causes may be summed up as follows: The individual is pre- disposed to the development of tuberculous disease, often as the result of an inherited tendency; the general health of the patient may also be at fault. Some slight injury, of which but little notice is taken, may lead to the actual deposit of the B. tuberculosis, which has probably been lying latent in the bronchial or mesenteric glands, or is present in an active state in the lungs. Severe articular lesions, such as dislocations, are less likely to induce tuberculous disease, partly because their gravity demands efficient treatment, partly because the activity of the reparative process is capable of dealing with the organisms, even if they are brought to the spot. Pathological Anatomy.- — The synovial membrane becomes thickened, pulpy, and oedematous, and in the early stages is found to be studded with small gelatinous nodules, about the size of a pin's head, situated immediately beneath the serous lining; later on, these may amalgamate into caseous masses, which burst and dis- charge into the joint, leaving ulcerated surfaces. Occasionally these masses are of considerable size; more often they are only small. Finally, the synovial membrane is changed into a so-called pyogenic membrane, consisting of granulation tissue similar to that lining the cavity of a chronic abscess, and more or less closely attached to the surrounding structures, which are transformed into oedematous fibro-cicatricial tissue, whilst the superficial parts undergo fatty or necrotic changes. Fringes of the sjmovial membrane, swollen and succulent, spread over the margins of the articular cartilage, and as 41 642 A MANUAL OF SURGERY they increase in size become adlierent to it, just as, according to Rillroth's classical description, ivy creeps along a wall. C)n 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 end of the hone becomes invaded by the tuberculous disease, and the granulations spread along under the cartilage, cutting it off from its nutritive supply, and thus large flakes of necrosed cartilage may be shelled oft (Fig- 314)- As a result of the hypersemic condition of the end of the bone, especially when pyogenic infection is super- added, a new formation of subperi- osteal osteophytes, stalactitiform in character, sometimes takes place, but not to such an extent as in a true pyococcal arthritis. Occa- sionally the periosteum itself is in- volved in the tuberculous process, and the disease may then extend some distance from the joint. The joint itself usually contains but little fluid, being fully occupied by the swollen synovial membrane ; but occasionally in the early stages there is much effusion, constituting a condition known as tuberculous hydrops, and in it there may be a considerable amount of fibrin, which is moulded by the movements of the joint into the so-called melon- seed bodies. The chief cytological element in the effusion is the lym- phocyte. The peri-synovial tissues are fre- quently affected in these cases, especially where there is much loose fatty tissue, as around the knee. The parts are infiltrated and gela- tinous, and muscles and tendons are incorporated in the swelling and modified similarly in texture. This change constitutes a large element in what is known as the white SKeiling of a joint. When the disease originates in the bone in adults, the tissue directly contiguous to the articular cartilage is often that primarily attacked; but in children it more frequently starts in connection with the epiphyseal cartilage. The joint is usually infected by extension of the disease through the articular cartilage; but when the synovial membrane extends along the bone beyond the cartilage, as in the hip-joint, it may become involved without any cartilaginous lesion. In the early stages a simple synovial effusion may occur, Fig. 314. — Tuberculous Dis- ease OF Head and Neck of , THE Femur. The disease evidently started on the under side of the nerk, which has been eroded, and spread into the head; the articular cartilage is loose, and necrotic fragments of it have been stripped up off the bone. DISEASES OF JOINTS 643 and should the osseous trouble quiet down and be cured, this may be absorbed, and merely a few adhesions be left. More frequently, however, infection follows, and the type of trouble varies. Some- times a tuberculous abscess of the bone or surrounding parts bursts into a joint; acute symptoms supervene, but gradually quiet down, and the usual chronic phe- nomena subsequently develop. More commonly the infection is due to the gradual erosion of the cartilage towards its peri- phery, and the onset of the ar- ticular symptoms is then of a chronic type. At any period of the disease a natural cure may supervene, and is characterized by the ab- sorption of the tuberculous tissue and its replacement by healthy cicatricial tissue. The result of this is the production of adhe- sions, slight or dense, as the case may be, and which may remain fibrous or osseous; ankylosis is naturally a common termination. If, however, the condition does not improve, abscesses develop, and when opened are liable to pyococcal infection ; the liga- ments soften and yield; deformity is produced, and even if at length a cure is established, it is at the expense of usefulness and perhaps growth, and may be associated with deformity. Clinical History. — The disease usually commences in a most in- sidious manner. It may be dated back to some injury, but as often as not no such occurrence has been noted. Slight impairment of movement, together with some pain, especially when the limb is jarred or twisted, is perhaps the first sign, causing the patient to limp if one of the lower extremities is involved. This limitation of movement is usualh^ manifested in all directions, and this will often assist in diagnosing it from the fixity due to the presence of adhe- sions in a simple chronic synovitis. The amount of rigidity varies Fig. 315. — Bones entering into Formation of Knee- Joint, which HAS BEEN Disorganized by Tu- berculous Disease. (From Col- lege of Surgeons' Museum.) The cartilage is almost entirely de- stroyed, and the exposed bone is carious and eroded. 644 A MANUAL OF SURGERY much; in a purely synovial lesion the movements may at first be painless and but little impaired, although the whole region of the joint may be puffy and swollen ; when, however, the bone is affected, either primarily or secondarily, the limitation of movement is con- siderably increased. The position of the limb is that which will give the greatest amount of comfort, and varies in different joints {- ■ST^x^a--^^ in over the frontal sinus without iniury to its inner wall, or the mastoid may be similarly affected. The inner table has also been broken, and fragments even separated, as a result of a simple depression without fracture of the outer table; this rarely oc- curs in adults, but '<, is not uncommon in children. Amongst the latter, it is also possible for a con- siderable depression to exist without any fracture of the inner table. More usually both inner and outer tables are involved, and when such is due to force reaching it from without, the inner table is always more damaged than the outer, especialty in the punctured variety (Fig. 361 , A and B). When, however, the force is applied from within, as by a bullet which has traversed the brain, the outer table suffers more than the inner. The causes of this condi- tion are similar, from whichever side the force comes, but need only be considered when the violence acts from without. [a] The inner table is less supported than Fig. 361.— Depressed Fracture of Skull seen *^^ outer, having FROM Without and from Within. (King's merely the soft bram College Hospital Museum.) and dura mater with- in, and hence is exten- sively splintered, just as a nail driven through an unsupported piece of wood causes ripping up of its under surface, ib) The loss of momentum of the fracturing body will assist this; the greater the AFFECTIONS OF THE SCALP AND CRANIUM 737 momentum of a bullet, the more cleanly it cuts, a smaller momentum breaking or splintering rather than cutting; of course, a considerable amount of force is expended in penetrating the outer table, (c) The debris caused by the injury to the outer table will add to the bulk of the penetrating body, and its wedge-like action still further increases the injury to the inner table, {d) All force tends to radiate and diffuse itself from the spot struck, and hence, if the outer table is first injured, the force will be disseminated over a more extensive area of the inner. The Symptoms and Signs arising from a depressed fracture vary widely in their nature, and are partly due to the injury inflicted on the bone, partly to that sustained by the brain, whilst the infection or not of the wound is of the gravest significance. Locally, when an external wound is present, one sees blood or cerebro-spinal fluid escaping, or even brain substance protruding. The damage to the bone may be seen or felt, and the extent of the depression or comminution thus ascertained. When there is no ex- ternal wound, a haematoma of variable size forms under the scalp, 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 pond or saucer 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 g^liter fracture, and the prognosis is increasingly grave. The two forms are, however, often associated. Necessarily, considerable variations are met with in this type of fracture, accord- ing to the nature of the injury and the means by which it was in- flicted. Thus, if it is due to a fall on the vertex, there 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 opening 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 bevelled, which may or may not pene- trate 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 injuries of the skull manifest any degree of severity, according to the velocity and angle of incidence of the projectile. A non-penetrating wound produces either a severe localized contusion or a depression with or without comminution. If a modern conical bullet, travelling at a high rate of speed, strikes the skull, it will probably penetrate, and possibly may traverse both sides and thus escape, doing comparatively little harm, except along its immediate track. If, however, the bullet is of an expanding type, or if it is travelling slowly, it may cause a much more serious lesion. 47 738 A MANUAL OF SURGERY In a simple depressed fracture the patient usually suffers from con- cussion, followed almost immediately by compression, the latter due in part to the depressed bone, but mainly to exudation of blood and bruising of the brain; if this is at all extensive and remains unrelieved, a fatal result quickly follows. Where, however, the depression is but slight, the symptoms of compression may be absent or not marked, and the patient recovers, perhaps to become the subject of traumatic epilepsy or insanity at a later date, induced by the irritation of the dura mater and of the subjacent cortex. If the depressed fragments irritate the motor area, convulsions, spasms, or paralysis may be thereby induced. In a compound depressed or punctured fracture the immediate effects are not necessarily severe, the patient perhaps not even suffering from concussion, though brain substance presents in the wound ; the more limited the spot injured, the less the concussion. The ex- planation of this fact is that the blow has expended its force in fracturing the cranium, and hence does little harm to the brain, in the same way that a watch may receive but slight damage from a fall if the glass is broken, whilst if the latter remains intact the works are liable to suffer. Left to itself, such a fracture is sure to become infected, and inflammation of the bone, brain, or membranes will follow. Septic osteitis leads to necrosis of the fragments, which may be seen King dead and yellow at the bottom of the wound, whilst the infiamimation may either spread along the diploe to the surrounding bone, causing extensive necrosis with pyaemia, or between the bone and the dura mater, leading to a subcranial abscess. When once the dura mater has been penetrated, inflammation is liable to spread to the meninges, and then a diffuse oi localized suppurative meningitis, accompanied or not with a localized sup- puration of the brain, will ensue. Even if the dura mater has not been opened b}^ the injury, the irritation of depressed spicules of bone and the presence of a purulent exudation often lead to its ulceration at a later date. If there is a free external opening, allow- ing a ready exit to the discharge, and thus preventing tension, the process may be quite limited, and compression of the brain or diffuse septic meningitis is avoided; but if the bones are locked together as well as depressed, and the external wound is small, retention of inflammatory products may lead to their diffusion, and the symp- toms of compression will soon become evident. A hernia cerebri may also form subsequently. When the fragments of depressed bone are early removed, even if perfect asepsis is not attained, the patient has a good chance of recovery; whilst laceration of the dura need not result in menin- gitis, since the opening in the subdur-al space can be shut off by adhesions of the arachnoid in a very short time. \Mien an aseptic condition of the wound is obtained by early inter- ference, and depressed fragments of bone are successfully elevated or removed, the prognosis becomes much better, and the case may AFFECTIONS OF THE SCALP AND CRANIUM 739 run an uncomplicated course towards recovery, unless some deeper cerebral lesion co-exists. 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 bv making even what may prove to be an unnecessary explora- tion. The object of the operation in all cases is to elevate depressed bone and to remove sharp edges of fragments which might injure the dura mater. The indications for operation may be epitomized 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-shapep, wait for symptoms, unless the fracture is a bad one. The most debatable of these propositions is that relating to the simple depressed fracture in an adult. It may be objected that many such cases have recovered without operation, and that there- fore in shallow depressions one should wait for symptoms; but, whilst the existence of such cases must be admitted, the fact remains that serious after-effects, such as traumatic epilepsy and insanity, are not uncommon sequelse of an unrelieved depression. The operation in itself is slight, and the risk insignificant when asepsis is maintained, so that one cannot but insist that the patient should be given the benefit of an exploration, especially 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 shaved and thoroughly purified. An anesthetic may or may not be given, according to the condition of the patient. In a simple depressed fracture the surgeon should ne\'er incise the skin directly over the wound, but should turn down a flap to avoid the presence of a cicatrix over the lesion in the bone. Having cleared away blood-clot and exposed the fracture, some loose fragments may be exposed, and the removal of these maj^ permit of the introduction of an elevator ; if more room is required, Hoffmann's bone rongeur will suffice to enlarge the opening. If there are no loose fragments, it is sometimes possible to make an opening by sawing off a corner of bone with a Hey's saw. If neither of these plans is feasible, an opening must be made with a trephine. The centre-pin is placed upon some firm undepressed bone as near the margin as possible (Fig. 362), and a circle of bone removed. An elevator can now be introduced, the fragments prised up into posi- tion, and the condition of the inner table investigated. Care must be taken in removing loose fragments not to tear the dura mater by injudicious violence, especially is this the case when the fracture lies over one of the venous sinuses. Sufficient bone must be taken away to allow the whole of the damaged area to be examined. The bony tissue removed during the operation should be kept in warm 740 A MANUAL OF SURGERY saline solution, or may be tucked in under the flap and thereby protected. When the loss of substance is small, there is no need to replace the fragments; but when it is of considerable size, it is wise to attempt this, wedging them accurately together, so that none lie loose in the wound. An opening for drainage may be left between them, if need be. In other cases they may be chipped up into small pieces and powdered over the wound. If the dura mater has been injured, brain substance mixed with blood may escape as soon as the flap is raised. When the bone has been dealt with, any protruding portion of cerebral material is removed, and the dura mater lightly stitched across the gap. In the majority of cases no attempt should be made to replace the bony frag- ments, as they would certainly interfere with free drainage; but occasionally it may be possible to replace them as indicated above, with a small opening for drainage between them. If the dura mater cannot be closed, an attempt must be made to prevent the formation of adhesions between the brain sub- stance and the superjacent tissues by introducing a piece of sterile gold-foil (or some similar substance) between the brain and the dura mater. In a compound depressed fracture the conditions var}^ so much that it is only possible to give general indications for treatment. The scalp is first shaved and purified; a flap is then turned down so as to expose the bony lesion. Loose Fig. 362.— Punctured Fracture fragments of bone are removed, and OF Skull, showing Spot for depressed portions elevated. It is Application of Trephine. often unwise to replace bone in . these cases, as thev are probabh' mfected, and any attempt to purify them by antiseptics would destroy their vitality. The margins of the defect are carefully cleansed, and fragments of living uncontaminated bone may be sown over the surface of the dura mater. The scalp flap is replaced, and, if possible, the original wound sutured after trimming up or excising its edges. An opening for drainage may be made through the lower part of the flap. Exposed or protuberant brain substance is dealt with as in simple fractures, except that it is necessary to purify it by washing with some efficient antiseptic, such as 5 per cent." carbolic lotion, or a I in 2,000 sublimate solution; of course, drainage is essential in ^ *^^ Hi "— " AFFECTIONS OF THE SCALP AND CRANIUM 741 these cases, but the drainage-tube should be removed, if possible, in forty-eight hours, so as to minimize the chances of hernia cerebri. In a punctured fracture, although the opening in the bone may be small, a large circle is removed, since the inner table is almost always extensively damaged. The centre-pin should rest on sound bone, as near the opening as possible (Fig. 362), and care must be taken to include all depressed fissures in the field of operation. If need be, the dura mater must be opened up and the brain explored. In all cases the patient should be confined to bed with the head shghtly raised on a single pillow, and the general rules suitable to head injuries followed. It is b}^ no means certain that elevation of the depressed bone will relieve the symptoms, as they may be due to haemorrhagic effusion into the brain which cannot be reached. For treatment of gunshot injuries of the skull, see pp. 249 and 760. The symptoms and treatment of the intracranial compHcations of head injuries are dealt with in the next chapter. Affections o£ the Frontal Sinuses. These sinuses are cavities in the frontal bones fined with a mucous membrane continuous with that of the nose. They can hardly be said to exist in children, not developing much before the age of puberty. In adults they vary much in size and shape, and are often very asymmetrical; the prominence of the superciliary ridges is no guide to their extent. A good deal of information as to these points may be gained by radiography, the rays being directed from behind, and the plates placed in front. The presence of pus and of tumours ma\^ sometimes be determined in this way, whilst transillumination (p. 801) is also useful. Fracture of the anterior wall is not uncommon as the result of a direct blow, depression of the fragments being produced, but with- out cerebral compfications. If the mucous membrane is torn, surgical emphysema of the scalp and face ma}' follow, and is naturally increased on blowing the nose. In compound fractures, suppuration usually occurs, leading to septic osteitis and necrosis of the frontal bone, and, if the posterior wall is involved, to a subcranial or even a cerebral abscess. In rare cases, when the anterior wall has been destroyed, a localized collection of air may form under the skin, and remain as a permanent tumour, constituting what is known as a pneumatoceh capitis ; it rises and faUs with forced respirations. A similar condition may also result from a fracture into the mastoid cells; in either situation it should be treated by compression, or, faifing this, incision. Inflammation of the frontal sinus is caused by extension of catarrh from the nose, by penetrating wounds or fractures, by foreign bodies, or it may be secondary to disease of neighbouring bones. Acute Inflammation is usually of a catarrhal type, and produces frontal headache, tenderness and pain on pressure, both above and below the eyebrow, and a feeling of dulness or apathy. Constitutional 742 A MANUAL OF SURGERY conditions, pyrexia, etc., may also be present. In such cases the forehead should be constantly fomented, and the patient inhales steam from hot water to which eucalyptus and menthol have been added; rest in bed and suitable purgatives are also necessary. Acute Suppuration of the sinus is generally traumatic, and then is liable to extend into the frontal bone, giving rise to an acute osteo-myelitis, which may spread rapidly. The posterior wall of the sinuses is extremely thin, so that the membranes of the brain are easily invaded, and an abscess may develop in the frontal lobe. Occasionally extension of mischief to the cavernous or other venous sinuses may follow. The case must be treated by laying the cavity open and draining it. For this purpose a curved incision is made along or immediately below the e^^ebrow, and the soft parts stripped from the bone, through which a sufficient opening is made with a gouge 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 occasionally remains. A median vertical incision is useful if there is any doubt as to which sinus is involved, or if both are affected. Should acute osteo-myelitis develop, vigorous measures are necessary. In a case of this type under treatment, incisions were made along each eyebrow from the middle line, and a vertical one extending from the hair to the root of the nose. The flaps thus formed were thrown back, the sinuses freely opened, and their anterior walls entirely removed: a large amount of the frontal bone was also taken away until healthy diploe free from purulent infiltra- tion was reached. During the process the posterior wall of the right sinus was removed, and a large cerebral abscess opened. The patient made a good recoverv, although a considerable amount of dead bone had subsequently to be taken away. Chronic Empyema of the frontal sinus may be the outcome of an acute catarrhal inflammation, or may be chronic from the first, extending upwards from the nose. Pus is constantly found in the anterior portion of the middle meatus, and its discharge is not much influenced by the position of the head. Frontal headache is often complained of, and there may be some localized tenderness on pressure. If the infundibulum becomes blocked, the pus may collect and lead to distension of the cavity, the bony walls gradually thinning and yielding before the pressure. A similar condition occasionally results from distension of the cavity with mucus [hydrops). When the walls are sufficiently thinned, ' eggshell crackling ' may be noticed. Owing to its anatomical relations to the lower orifice of the infundibulum, the maxillary antrum is often involved second- arily, if it has not been already infected. In the Treatment of chronic empyema external operation must, if possible, be avoided, since experience has shown that it is associated with a definite mortality, due to acute osteo-myelitis. The intra- AFFECTIONS OF THE SCALP AND CRANIUM 743 nasal condition is carefully treated ; the anterior portion of the middle turbinal is removed so as to give a better exit to the discharge, and a skilled rhinologist is usually able to pass a tube up the infundib- ulum and wash out the cavity. Should these measures fail to give relief, and should urgent symptoms appear, then the cavity must be opened as described above, and a tube passed through into the nose, the external wound either being closed at once (Luc), or left open for a few days and packed with gauze. The chief Tumours growing from the frontal sinuses are mucous cysts or polypi, and ivory osteomata; they may also be involved in diffuse sarcoma or carcinoma, but the disease is then not limited to the sinus. The main symptoms and signs result from distension of the walls of the cavity, which may yield anteriorly, causing a large frontal swelling; or the posterior wall is absorbed, leading to cerebral compression ; or the upper wall of the orbit may be depressed, causing dislocation of the eyeball, and possibly blindness (Fig. 57, p. 210). Tumours which have attained considerable dimensions can rarely be removed, death then resulting from cerebral compression; but occasionally bony masses may necrose, and become loosened by suppuration around them, and in a few cases they have been taken awav successfully. CHAPTER XXVII. AFFECTIONS OF THE BRAIN AND ITS MEMBRANES. Cranio-cerebral Topography. It is scarcely necessary or desirable in a students' manual to deal exhaustively with this subject. 1 he main facts can alone be referred to, and larger text-books of operative surgery or surgical anatomy referred to for further details.* The Fissure of Rolando may be found topographically by the fol- lowing methods : (a) The upper extremity of the fissure corresponds to a point i centimetre (or | inch) behind the centre of the line extending from the fronto-nasal suture to the external occipital protuberance. The direction of the sulcus is downwards and for- wards at an angle of about 67° to the middle line. This' may be 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 obliquely from this point, leaving an angle of 45° between the front of the paper and the middle line of the skull; and then the same process is again repeated, bisecting the angle and leaving one of about 67°, so that the anterior hmit of the folded paper corresponds to the line of the fissure, which is about 3f inches in length. A ' Rolandometer,' consisting of two strips of flexible metal united at the appropriate angle, is now sold by many instrument-makers. As a general rule this ' Rolandic line ' crosses the fissure about its centre, being in front of the fissure above and a little behind it below; but it is sufficiently accurate for practical purposes, [h] A less exact method is that defined 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. 363). From it are drawn upwards two perpendiculars, one (CD) corre- sponding to the small depression in front of the external auditory meatus, the other (EF) to the posterior border of the mastoid * For a review of the relative accuracy of various methods, see a paper by Berry and Shepherd, Brit. Med. Journ., p. 1382, November 19, 1904. 744 AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 745 process. The fissure of Rolando extends from the upper Hmit of the posterior vertical line to the point where the anterior line inter- sects the fissure of Sylvius. To map out the Fissure of Sylvius, (i) Reid utilizes a line drawn from a point ij inches directly behind the external angular process of the frontal bone (Fig. 363, A), and about the same distance above the zygoma, to a spot | inch below the most prominent part of the parietal eminence. The undivided portion of the fissure is repre- sented by the first _ f inch, and from here 'ff.,....-.,T the anterior limb (Sy. A. Fiss.) rises verti- cally upwards .for about an inch, whilst the posterior limb ex- tends backwards for the rest of the line. If prolonged to the middle line behind, it indicates with toler- able accuracy the situation of the parieto-occipital fis- sure (P. O. Fiss.). Careful investigation, however, has shown that no great relia- bility can be placed on this method. (2) Hare and Thane suggest the following measurements, which in the majority of adult skulls may be looked on as substan- tially accurate: To find the Sylvian point {i.e., the point of bifur- cation of the fissure), a line is drawn hori- zontally backwards Fig. 363. — Diagram of Head to indicate Method of finding the Fissures of Rolando AND Sylvius by Reid's Method. Sy. A. Fiss., Anterior branch of Sylvian fissure; P. O. Fiss.,parieto-occipitaV fissure; Trans. Fiss., transverse fissure along line of tentorium; A, ex ternal angular process of frontal bone ; B, occipi- tal protuberance; CD, anterior perpendicular in front of tragus; EF, posterior perpendicular through back of mastoid process. from the fronto-malar suture for a distance of 35 millimetres, and from the posterior end of this a vertical Hne upwards for 12 milli- metres; the upper extremity of this line is the Sylvian point. The posterior limb of the Sylvian fissure is indicated by a line drawn backwards from the fronto-malar suture through the Sylvian point to the lower part of the parietal eminence. The external limb of the parieto-occipital fissure corresponds almost exactly to the lambda. 746 A MANUAL OF SURGERY (3) Kronlein's method (Fig. 364) of locating the Kolandic and Sylvian hssures is useful, and not so complicated as many others. Two horizontal lines arc drawn round the skull, one, the lower (AB), through the infra-orbital border and upper margin of the external auditory meatus; the other (CD) above it and passing through the supra-orbital margin. Perpendiculars are carried upwards from the lower of these (i) through the centre of the zygoma, (2) through the condyle of the lower jaw, and (3) at the posterior border of the mastoid process. The posterior of these is prolonged to the vertex at R; the anterior cuts the upper horizontal line at S ; and the middle perpen- dicular intersects the line joining S and R at R'. The angle RSD is finally bisected by a line fJ SS' which represents the posterior limb of the Sylvian fissure, whilst RR' corresponds to the fissure of Rolando. Methods of Opening the Cranium. In the old days but one instrument was em- plo^'ed for this purpose, viz., the trephine; but our increasing know- ledge of cerebral lesions and the security given by aseptic methods have necessitated a consider- able elaboration in the methods of operating on the cranium. I. Simple trephining is still employed in dealing with many traumatic lesions where an extensive exposure of the brain is not required. The modern trephine is often fitted with a solid metal handle to render sterilization easy, and the crown is usually bevelled and not straight, so as to check the liability to slip inwards and wound the dura. The scalp is incised and turned aside by raising a flap which has its base downwards, so as to ensure its vitality. Bleeding is abundant, and it may save time to prevent this by encircling the base of the scalp with rubber tubing drawn tight and fixed by a pair of Spenser-Wells forceps. The pericranium is stripped from the bone, and the trephine applied with the centre-pin projecting. As soon as a well-marked groove has been made, the centre-pin is withdrawn or removed, and the instrument carried through the cranium. An increased flow of blood will often indicate when the diploe is reached, and care must be taken not to injure the dura. Fig. 364. — Kronlein's Method of locating THE Fissure of Rolando (RR'). and the Posterior Limb of the Fissure of Syl- vius (SS'). AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 747 To this end tlic groove in the bone is carefully examined from time to time by a flattened probe or the blunt end of a needle, and the more so when the operation is undertaken in a region where the bone is known to be of irregular thickness. The disc is removed by an elevator. Considerable bleeding sometimes takes place from the section of the bone, but can usually be controlled by crushing the spot with powerful forceps, or by rubbing in Horsley's wax (carbohc acid, I part; oil, 2 parts; wax, 7 parts). If the opening is not sufificiently large, it may be increased by the bone rongeur. Key's saw or cutting pliers, or even by the trephine. 2. In many cases of cerebralabscess the trephine is unnecessary, as the causative focus (e.g., mastoid disease or frontal sinus empyema) can be opened up, and the cranial cavity reached by removing por- tions of bone with a gouge. When well inside the skull, a bone rongeur or de Vilbiss' punch will suffice to enlarge the opening. Even when the cranium is intact, the gouge is used by some in preference to the trephine to make the first opening. 3. When a considerable area of the brain needs exposure, as in the case of cerebral tumours, various plans are adopted: (a) Some surgeons utihze a large 2-inch trephine, but this is obviously undesirable owing to the irregular thickness of the skull, and the difdculty which attends the equal deepening of the groove in all directions over such a large circumference. (b) When there is no hkehhood of being able to replace the bones, a small trephine hole and enlargement by the rongeur should be adopted. (c) Of late, however, some form of Wagner's osteoplastic method has been chiefly used. In this a flap of scalp tissues is turned down together with the underlying bone, laying bare the dura mater. Some surgeons divide the bone along the hne of incision with a chisel and wooden mallet ; this requires great care and skill, as the dangers of concussion of the brain from such a plan are not to be overlooked. Others use a circular saw ; but probably the simplest way is to make four small trephine openings at the corners of the flap, and connect these either by the use of a Key's saw, or by a Gigh saw (i.e., a piano-wire with a screw-thread turned on it, and with handles at- tached at each end), passed by means of a probe under the bone from one opening to another, or by the use of a rongeur on two sides, whilst the upper end is sawn through by a Key's saw set on the slant, so that the incision is bevelled, thereby preventing the bone from slipping in when replaced, and the base is divided by a Gigh saw. This procedure is a serious one, attended by considerable shock and haemorrhage, and therefore is often undertaken as a preliminary measure a week or ten days before the lesion in the brain is attacked. Lumbar Puncture in Cerebral Lesions. The removal of cerebro - spinal fluid from the lumbar region has been much employed, since Quincke first suggested it in 1891, in connection with affections of the cranium and its 748 A MANUAL OF SURGERY contents, and both diagnostically and therapeutically it is of the greatest value. ' The method of withdrawal is quite simple. A stout antitoxin or exploring needle should be selected and sterilized by boiling, and the skin in the region of the third and fourth lumbar interspaces (the spinous process of the fourth vertebra is on a line joining the iliac crests) is to be carefully purified. The patient sits or lies with the body well flexed. The needle is then inserted in the fourth inter- space, either in the middle line, or a third of an inch from it ; it must be pointed forwards, with a very slight inclination upwards. In most cases the needle will go straight into the spinal canal below the termination of the cord, and the fluid will escape. If bone is encountered, it is advisable to withdraw the needle and re-insert it at a slightly different angle. In cases of repeated failure the third interspace ma\' be tried. Under ordinary circumstances the fluid escapes quietly, drop by drop; but in cases of increased tension it may gush out freely. Normal cerebro-spinal fluid* is slightly alkaline and as clear as water, with a specific gravity of 1006 to 1008; it contains a trace of globulin and of a copper-reducing substance, and perhaps a few lymphocytes. It is calculated that from 100 to 130 c.c. are present in the normal adult, but the amount is readily increased where free exit is possible, as in fractures of the skull, when quantities of the fluid escape. It is probably secreted by the choroid plexuses, and removed by absorption into the venous sinuses. It not only sur- rounds the brain and spinal cord, but occupies the ventricles, and passes into direct communication with the lymphatics of the cortex and of the peripheral nerves. In acute meningitis, due to organisms other than the tubercle bacillus, the fluid is turbid and contains much albumen. Many cells are present, most of which are polynuclear leucocytes. Bac- teria ma}' be detected by suitable methods of staining or by cultures. In tuberculous meningitis the fluid is almost clear, and contains a slight excess of albumen and of lymphoc\^tes. Tubercle bacilli are rarely found. In all varieties of meningitis the fluid is secreted under pressure, and usually issues from the needle in a stream. In cerebral abscess and lateral sinus thrombosis the fluid is normal, but may be under excessive pressure. In fracture of the base of the skull or of the spinal column, and in injuries of the surface of the brain, blood usually appears in the cerebro-spinal fluid within a few hours of the accident and is inti- mately mixed with it. The Therapeutic value of this procedure has not been so fully recognised as its use in diagnosis. In many cases of meningitis the coma is due mainly to excessive cerebro-spinal fluid, and if the amount of this can be diminished the symptoms often abate. The value of lumbar puncture will, therefore, depend on whether or not it * For further details, see Sir David Ferrier : ' The Cerebro-Spinal Fluid in Health and Disease,' Lancet, October 18, 1913. AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 749 is possible to influence the intracranial tension thereby and that, in turn is dependent on the situation and character of the adhesions present The puncture must, therefore, be obviously experimental, as one can never be certain as to the adhesions; but it is a simple proceeding, and may well be employed in all cases of memngitis, in the hope that some good may follow. In traumatic conditions it mav be useful when the lesion is not very serious, and the pressure on the brain not hopelessly exaggerated. In cerebral tunriours it must be emploved with the greatest caution if at all, as fatal results have followed the removal of a comparatively smaU amount of fluid owing to undue pressure on the base thereby induced. It ?s also possible to introduce drugs within the spinal theca after lumbar puncture, e.g., antitetanic serum in tetanus solutions of magnesium sulphate in tetanus, or of sodium bromide in dehrium tremens. Attempts have also been made to influence by this means parasvphihtic ner^•ous affections where the cerebro-spmal flmd remains positive to the Wassermann reaction m spite of general medication; such treatment has not yet met with much success. General Conditions of the Brain after Head Injuries. Concussion of the Brain, or stunning, is a clinical condition characterized bv a more or less complete suspension of its functions as a result of injurv to the head, which leads to some commotion of the cerebral substance, and may or may not be associated with hEemorrhage. It varies with the severity of the cause from a slight momentarv giddiness and confusion of thought to the most complete insensibilitv, and is closely allied to shock, from which it is often distinguished with difficult v. . . In fatal cases, one finds on post-mortem examination mere y the same conditions as obtain in shock, viz., engorgement of the lungs, viscera, and the right side of the heart, whilst the bram presents some lesion of varving severitv, from mere punctiform ecchymoses to actual disintegration and disorganization. The symptoms can scarcelv be attributed to the injury itself or to a reflex stimulation of the vagus, as thev often bear so little proportion to the degree ot mischief. Buret's theorv is probably correct which attributes the phenomena to stimulation of the restiform bodies m the medulla by the sudden displacement of cerebro-spinal fluid o^^•lng to the tem- porar^• driving in of the skull by the injury Apparently the fluid is forcibly expeUed from the lateral ventricles along the iter to the fourth ventricle, the roof of which has been ruptured the floor bruised, or the iter torn in experiments confarmmg the theorv. The grouping of the vital centres about the floor of the fourth ventricle wiU explain the gravity of the symptoms often present. The Symptoms varv considerablv in degree, but m a well-marked case the stage of concussion is evidenced by unconsciousness, niore or less complete, although the patient can sometimes be roused by shouting- he hes on his back, with the muscles relaxed and flaccid; 750 A MANUAL OF SURGERY the eyelids are closed, and the conjunctivae may be insensitive; the pupils vary, but are equal and often contracted, usually reacting to light; but in bad cases they are dilated, and do not contract when light is admitted. The surface of the body is pale, cold, and clammy. The respirations are slow, shallow, and sighing, whilst the pulse is rapid, weak, fluttering, and scarcely sensible to the fingers; the temperature is at first subnormal; 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 they 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 irrita- tion. In the simpler cases, however, reaction soon begins to manifest itself. The patient is presumably put to bed, and warmth carefully applied to the extremities. 'Ihe first sign of reaction is probably a slightly increased rate of both breathing and pulse, whilst he may be able to tell his name and address; sometimes 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 established by the occur- rence of vomiting, due to a condition of cerebral hypersemia follow- ing 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 quite well, or with a somewhat irritable brain requiring prolonged rest. Subsequent events may, however, prove that more mischief has been done than appears at first. Thus, some special function of the brain may be permanently lost or impaired, such as memory, hearing, or vision; a patient may forget the names of places or persons, or may lose all memory of time; speech may become defective or stammering, or a certain amount of asthenopia (weakness of vision) may supervene. Such individuals are very liable to develop signs of mental instability, and even delusional insanity or melancholia, if placed in positions of responsi- bility or strain. Others seem to suffer from a general loss of nerve tone (neurasthenia), rendering them incapable of fulfilling their ordinary duties in life. In all the more severe cases there is a complete lapse of memory as to the accident, and even as to the events which preceded and followed it, extending sometimes to a fortnight or more, and perhaps including a period during which the patient was apparently quite rational. 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 apphed near the extremities, and friction to the surface. Any needless stimulation must be avoided for fear of exciting hctmorrhage; an enema of hot coffee may be given, or, if in extremis, brandy, or a hypodermic injec- tion of strychnine. A good purge, such as 5 grains of calomel, or a AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 751 drop or two of croton oil on sugar, should be administered after reaction in the milder cases, but whilst still unconscious m the graver forms. It is most important that the patient be kept quietly in bed for at least ten days or a fortnight after a moderately bad concussion and free from all sources of worry and irritation, even though he 'feels quite well. The diet must be restricted, and the bowels kept open. ' Make haste slowly ' is here a golden rule. When the unconsciousness is prolonged, and no signs of fracture of the cranium exist, lumbar puncture should be employed, and may be most beneficial. Thus, a lady who had attempted suicide by throwing herself from a window lay for two or three days on the borderland of unconsciousness, frequently relapsing into a comatose state. Lumbar puncture resulted in the drawing off of some drachms of blood-stained fluid, and at once restored her to complete consciousness, which was not again lost. Should this treatment fail, the head should be shaved, and an icebag or Leiter's tubes apphed; the bowels are opened regularly, and the state of the bladder attended to; the room must be kept dark and quiet, the attendants making as Httle noise in walking 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 or a nasal tube. Cerebral Irritation.— By cerebral irritation is meant a clinical con- dition which sometimes follows concussion, characterized by great irritability of both mind and body. It usually results from blows or falls on the temple, forehead, or occiput, and is probably due to a superficial laceration of the brain, possibly in the frontal region, and to the hyperemia caused by its subsequent repair. The Symptoms are very characteristic, and usually manifest them- selves two or three days after the injury, though sometimes earlier. The patient lies on his side in a condition of general flexion, the back arched, the legs 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 extends himself fully or lies supine. The eyes are closely shut, and he resists all attempts to open them; the pupils are con- tracted" the temperature is usually a little raised, but the surface of the body and head are both cool; the pulse is quiet but weak; the sphincters are usually in a normal condition, and the excreta are often passed in the bed, but the bladder may occasionally need to be emptied by catheter. In some mild instances the patient may get up to empty his bladder and then return to bed. He is by no means unconscious, but takes no heed of what is passing around, and is intensely and morbidly irritable. When disturbed, he will gnash his teeth, frown, swear, and resent the intrusion m the most expres- sive 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 himself out, and with this is conjoined an improvement in both pulse and temperature. Sometimes he becomes childish, and needs to be taught the names of persons and things; at other times he is garrulous, perhaps giving a 752 A MAl^UAL OF SURGERY fresh story of his accident every day, but generally there is an absolute lapse of memory in this direction. Usually the brain recovers in time, but serious after-effects in the direction of chronic meningitis or mental aberration are likely to ensue. Treatment.- — The patient is kept quiet and free from noise or excitement ; his diet must be light and nourishing. The head should not be too low, and Leiter's tubes may be fitted on if the patient will permit it; but it is better to omit this entirely than to apply cold intermittently. The bowels are kept well open, and possibly small doses of bromide, or even opium, may be useful. If any signs of meningeal inflamjnation follow, such as rise of temperature and pulse, heat of head, and great sleeplessness, blisters or leeches may be applied locally, and mercury administered internally. Compression of the Brain. — Compression is the term given to a clinical condition due to some abnormal and excessive intracranial pressure which disturbs the functions of the brain. In the earlier stages a displacement of cerebro-spinal fluid from the cranium to the vertebral canal, and increased absorption in various directions, may relieve the symptoms ; but as the pressure increases, the brain sub- stance itself suffers, the cortical centres being involved first, and the medulla last. The effect of such increased pressure is to paralyze after temporarily stimulating. When of traumatic origin, it may arise from the following causes: [a) Depressed bone or the presence of a foreign body, in which case the symptoms of concussion merge directly into those of compression, and usually without any interval of consciousness. It is probable, however, that in these cases the symptoms are due more to the associated haemorrhage than to the actual cranial lesion. (&) 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 prob- ably be a short interval of consciousness between the concussion and the compression; if the bleeding is cerebral, the symptoms of com- pression may manifest themselves at once without any interval being noticed, (c) It may be due to an acute spreading oedema, the explanation of which is subsequently given (p. 755). (d) It may arise from the pressure of inflammatory exudation or pus, in which case the symptoms are preceded by those of inflammation, and at the earliest will not manifest themselves before the third day, whilst they may be deferred for a week or two. Compression also arises as a result of idiopathic hsemorrhage, tumours, gummata, or abscesses — e.g., of middle-ear origin. The Symptoms of compression are essentially those of coma. When the condition is well established, the patient lies on his back abso- lutely unconscious, and cannot be roused either by shouting or shaking. His breathing is slow, laboured, and stertorous, the lips and cheeks being puffed in and out. The stertor arises from paralysis of the soft palate, and the pufftng of the cheeks from paralysis of the facial muscles. In the later stages the respirations become irregular, and take on the Cheyne-Stokes type. Gradually breathing becomes AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 753 more shallow and difficult, and death finally arises from cessation of the respiratory act. The pulse is full and slow at first from irrita- tion of the vagus and vasomotor centres, but later on becomes rapid and irregular, owing to increased pressure upon and exhaustion of these medullary centres. The surface of the body may either be cool, hot, or perspiring; the temperature similarly varies, often being low in the early stages and higher at a later date. Not unfrequently the fatal end is associated with marked hyperpyrexia. In some cases where the compressing force is unilateral, there may be some differ- ence of temperature 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 diffused, both pupils first contract, and then gradually dilate and 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 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, if 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 cerebral stimuli. A localized compression involving the motor area may lead to convulsions in the corresponding group of muscles. The bladder is paralyzed, and hence retention ensues, whilst the sphincter ani is relaxed, and fseces pass involuntarily, although marked constipation is usually present. The symptoms in some cases are ushered in by severe pain or headache, which is partly due to pressure upon and tearing of the dura mater, and partly to the altered vascular conditions of the brain ; the brain substance itself is not sensitive, and hence the pain is not directly referable to any lesion of or pressure upon it. Natur- ally, the clinical picture is modified according to the cause of the compression, even as the course of the case varies widely according to whether or not the compressing agent can be removed by the surgeon, or absorbed by natural processes. 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, and no history either of the patient or of an accident is obtainable, and no serious lesion of the skull is present, the diagnosis is often extremely obscure, since coma may be due to many other causes, e.g. : {a) Cerebral lesions, such as apoplexy, whether the result of haemorrhage, embolus, or thrombosis; or it may be the consequence of a preceding epileptic fit, or due to a rapidly spreading oedema in cases of cerebral tumour or abscess. [b) Various toxic agents may induce coma; they may be introduced 754 A MANUAL OF SURGERY into the system from without, as in the case of alcohol, opium, or other narcotics, or may be developed within the body, as in ureemia or diabetic coma, (c) Heatstroke or exposure to cold may also lead to 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 severe prostration; in the former the diagnosis may for a time be 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 may lead to an erroneous diagnosis. It is therefore evident that a very careful examination of the patient is required before any conclusion can be arrived at as to the cause of the coma, and it is often impossible to make an immediate diagnosis. In such cases the patient should be carefully tended and watched, and not shut up for the night in a police-cell without attendance. The following points should always be observed in the examina- tion: (i) A rapid note should be made as to the surroundings of the patient — whether there is blood or vomit near him, how the bod}' is lying, and the nature of the ground. (2) The depth of the coma should be ascertained, and, if possible, the man should be roused, and asked to give an account of himself. (3) A most thorough and complete investigation should be made as to his con- dition. His skull must be first examined, to settle if possible whether or not a fracture is present ; the surface temperature of the body is noted, as also the character of the pulse and respirations. The tongue should be looked at, as it is often bitten in an epileptic fit, and the smell of the breath should also be noted. Be it remem- bered that the smell of alcohol in the breath is not sufficient warrant in itself to diagnose merely drunkenness, as the alcohol may have been given after the accident to revive the patient. The condition of the pupils may throw some light on the case; in opium-poisoning they are small and equal, a condition also seen in haemorrhage into the pons; in alcoholism they are often dilated and fixed, but vary considerabty in different cases. The amount of power and the state of the reflexes are then observed, any inequality probablv 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, the stomach should be emptied and washed out. (5) Finally, if the cause is still uncertain, the patient should be put to bed and carefully watched. The Treatment of compression must be, where possible, directed to removing the cause. When it is due to depressed bone or a foreign body, immediate operation is required; collections of pus should be opened, and blood-clots removed. Failing such measures, and if lumbar puncture gives no relief, the treatment of the con- dition resolves itself into keeping the patient quiet, with the head low ar.d cool, the room dark and noiseless, the bowels open (using croton AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 755 oil on sugar, or encmata, for this purpose), and tlie bladder empty. Tlie patient may have to be fed by the rectum, and if the breath- ing 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 ansesthesia during surgical operations, and if due to this cause the head mav be rolled over to one side, or the tongue pulled forwards. Laceration of the Brain. — ^Injuries to the brain and its membranes are frequent complications of head injuries, and all the most serious results of these accidents arise from this source. They are produced in many different ways, and cause varied symptoms ; but the most important distinction to draw is between those wounds which com- municate with the exterior and those which do not. I. Non-penetrating Wounds of the Brain result from blows and falls, which may or may not produce simple fissured or depressed fractures of the skull, but not unfrequently the most serious cerebral symptoms follow injuries in which the bones do not participate. In depressed fractures the brain is usually most contused or torn imme diately below the injured spot; but in cases where there is no depression, the greatest mischief is frequently found at a point exactly opposite to that struck (point of contrecoup), whilst the local bruise may be much slighter. Thus, in the case of one of our students who, in an epileptic fit, fell, striking the left occipital region on a stone pavement, we found post-mortem a fissured fracture at the spot struck and a bruise on the left occipital convolution, whilst the anterior portion of the right frontal lobe was severely contused, and, indeed, disintegrated. The explanation of this fact is that the force of the injury is transmitted to the brain substance in a wave which concentrates its violence against the opposite side of the skull. In very sharp sudden locaHzed blows, as from a spent bullet, local bruising of the subjacent brain may be alone produced. Pathological Anatomy.- — The immediate effects of such an injury vary considerably. There may be a mere bruise, evidenced by a few points of extravasation, on the surface or in the gray matter; or the more superficial parts of the brain may be totally disintegrated and mixed with clots ; or, if laceration has occurred, clots may be found adhering to the injured spot, or extending from it widely into the subarachnoid space, or even, under rare circumstances, into the lateral ventricle. The later effects in cases where the wound does not communicate with the exterior are mainly those of inflammation or degeneration. Soon after the accident considerable exudation follows, causing the ecchymosed brain substance to swell and become oedematous; this may speedily subside, but in the more serious cases a spreading oedema may be caused, owing to the pressure of the swollen tissues upon the superficial veins in the pia mater; the circulation in these is hindered, and increased exudation follows, leading to general cerebral pressure and even death, a consequence hastened by the excess of cerebro-spinal fluid usually induced by the 756 A MANUAL OF SURGERY process. Under such circumstances the greater part of the brain IS oedematous and ghstening, the injured area being yellowish-red in colour, with evident points of extravasation scattered through it. Still later, degeneration of the brain substance may follow owing to the disturbance of its circulation, and is indicated by the presence of a pulpy yellowish mass, soft enough to be washed away by a stream of water, and containing fat globules and granular cells, with debris of nerve fibres {yellow softening) . If the area involved is small and unimportant, the patient may recover, the softened tissue being absorbed, and replaced by a scar; if large or implicating important centres, death or paralysis must ensue. In cases of laceration of the brain which recover, a tough depressed cicatrix is formed, usually adherent to the membranes, and containing hsematoidin crystals, whilst extravasated blood may be organized into a dirty brownish lamina, adherent to the pia mater, 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 patient recovers slowly from it, the surgeon will rightly suspect contusion or laceration of the brain. In the slighter cases recovery is often inaugurated by an attack of vomiting, and this is followed by a rise of temperature to about ioo° F. for a few days, whilst the patient complains of fixed pain and headache, which under suitable treat- ment may entirely disappear. Some impairment of sense or function may, however, persist. More serious lesions give rise to various symptoms resulting from haemorrhagic effusion, and these will manifest themselves either at once or within twenty-four to forty-eight hours of the injury. Thus, if the phenomena of compression supervene at once, without any interval of consciousness, a diagnosis of depressed bone or a serious haemorrhage into the cerebral substance may be safely made. If, on the other hand, the patient rallies for a time before the incidence of compression phenomena, an extradural haemorrhage from the meningeal vessels or venous sinuses may be suspected, or a rapidly spreading cedema. Haemorrhage into the cortex is characterized by irritative or paralytic phenomena, which vary with the cortical area involved. The degree of unconsciousness depends on the amount of the hsemorrhagic effusion. In the Upper and Middle Frontal Convolutions neither motor nor sensory symptoms are noted, but cerebral irritation and subsequent weak-mindedness are likely to follow, especially if the left side is involved; lesions to the right frontal lobe do but little harm to a right-handed individual. Apparently, the intellectual faculties are limited to one side of the brain, in the same wa}- as the power of speech. Wounds of the Third Left Frontal Convolution lead to motor aphasia — i.e., the inability to produce or articulate words, in right- AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 757 handed individuals; in left-handed people wounds of the right side have a similar result. Injury to the opposite convolution has no effect. If onl}^ one side is damaged, the other convolution can after a time be educated so as to take on the function of the damaged region. Hemorrhage into the Motor Area (Fig. 365) results in locahzed convulsions or paralysis, according to the degree of mischief. If the bleeding is progressive, a regular extension of the convulsions may be witnessed, the movements commencing, perhaps, in some region which is at the time incapable of voluntary movement, and spreading to other parts of the body. Thus, if bleeding is occurring into the' cortical centres for the face on the left side of the brain, paralysis of POT. AtfCrVLAT-. CYRUS. CEKEBELLUM Fig. 365.— Diagram representing the Functions of the Cerebral Cortex. F. R., fissure of Rolando; P. O F., Parieto-occipital fissure the right side of the face may be present, and it is here that the convulsions will start, spreading regularly to the right side of the neck, arm, and leg, and then involving the left leg, arm, and side of the head in order, finally becoming general, as in an epileptic fit. After each convulsion the paralysis is found to have spread. It is sometimes very difficult to diagnose between a true cortical hsemorrhage and one which extends diffusely over thecortex in the subarachnoid space from the rupture of a vein in the pia mater. In the latter, however, the symptoms develop earher, the paralysis is less marked, and the convulsions are less regular, though perhaps more generalized. An irritative lesion of the motor area for the head and eyes causes 758 A MANUAL OF SURGERY a conjugate deviation of the eyes towards the other side; a destruc- tive lesion causes both eyes to be deflected towards the injured side. 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 associated with permanent disturbances of vision. The Upper T emporo-sphenoidal Lobe contains the cortical auditory centre, and lesions in this region cause deafness. The sense of smell is located in the anterior portion of the lower temporo- sphenoidal lobe which constitutes the uncinate process. Injury to the Corona Radiata leads to paralysis of the regions repre- sented by the overlying cortex, but without convulsions or other irritative phenomena. If the corpus striatum or internal capsule is torn or involved in a haemorrhage, coma rapidly supervenes, accom- panied by hemiplegia and perhaps hemiansesthesia. Occasionally the effused blood bursts into the lateral ventricle, and causes a rapid rise of temperature, increasing until the patient's death, together with a very rapid weak pulse and increased respiratory rate (40 to 60 per minute). Wounds of the Cerebellum cause giddiness, vertigo, and ataxy, the patient reeling about in characteristic cases, as if drunk. A wound of the Crus Cerebri occasions more or less complete hemiplegia of the opposite side of the body, associated with some amount of hemiansesthesia, and total paralysis of the 3rd (oculo- motor) nerve on the side of the injury. 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 9th nerves, on the same side as the lesion, constituting the so-called ' crossed paralysis.' Marked contraction of the pupils (myosis) may also be present. Wounds of the Medulla are usually fatal . If, however, the patient should escape, he is liable to suffer from disturbed functions of the circulatory and respiratory centres, with perhaps Cheyne-Stokes respiration and glycosuria. The later results of a cerebral laceration vary much. The patient may recover perfectly after a more or less prolonged period of un- consciousness, but not unfrequently some loss of power persists, which will seriously impair the patient's subsequent usefulness. The febrile phenomena already mentioned as characteristic of the first few days of convalescence after an attack of concussion may pass into a condition of subacute or chronic localized inflammation of the injured area, as indicated by pain and headache. In such cases the inflammator}/ effusion may be so abundant as to determine the onset of unconsciousness in four or five days. Occasionally an abscess forms deeply in the white substance, and this will be indicated by the usual phenomena of such a condition, coming on ten or fourteen days after the injury. The formation of cicatrices between the brain and membranes may AFFECTIONS OF THE BRAF"^ .l.VD ITS MEMBRAMES 759 determine the development of traumatic epilepsy or insanity at a later jx^riod (p. 780). The Treatment of these cases is always an exceedingly anxioai matter for the surgeon. In the majority of instances it is merely symptomatic, following the usual course adopted in concussion, com- pression, cerebral irritation, etc., as indicated elsewhere. Depressed bone, if present, will, of course^ be dealt with by operation. Early convulsions and paralysis are carefully watched to see if any indica- tion as to the site of the bleeding can be obtained, since it is possible that trephining over the injured spot and removing blood-clots or securing bleeding-points might be advisable; but the clinical records as to such treatment are not very encouraging. Late convulsions and paralysis due to inflammation are best treated by shaving the head and applying an ice-cap, and by lumbar puncture. If the pulse is full and hard, and the patient otherwise young and healthy, general venesection may be adopted ; the bowels must be moved by a smart purgative, such as croton oil, whilst bromide in full doses may be administered. If the convulsions continue in spite of such treatment, and become more severe and extensive, the patient will almost certainly die of coma; trephining over the injured area is then distinctly indicated, the surgeon hoping to find and remove some clot, or, at any rate, to relieve tension by decompression. II. Penetrating Wounds of the Brain result from blows or falls, as in compound depressed fractures; or from the entrance of foreign bodies, such as bullets; or from stabs or punctures, which most commonly occur in the weaker parts of the cranium — e.g., the temple or upper wall of the orbit; or from sabre-cuts or axe-wounds, in which an oblique or almost valvular incision is made through the scalp and cranium, laying bare and wounding the brain and its mem- branes. In these cases the general disturbance is often slight, compared with the extent of the local injury, so that, although brain substance may protrude from the wound, there is sometimes but little con- cussion. Any of the conditions due to haemorrhage detailed below may follow, but they may be slight, since the blood can escape from the wound. The inflammatory phenomena due to infection of the wound may be locahzed or diffuse. In the latter instance general meningo-encephahtis manifests itself in the course of two or three days, and is rapidly fatal; in the former case adliesions prevent the extension of the trouble beyond the neighbourhood of the wound. Hernia cerebri is very likely to follow, and possibly a deep cerebral abscess may complicate matters at a later date. In cases that have been successfully rendered aseptic, the course is similar to that run by a non-penetrating wound, except that, if anything, the immediate prognosis is better, since the opening in the skull diminishes the likelihood of compression from simple or spreading oedema. Where the lesion has involved the motor area, permanent monoplegia may persist, and traumatic epilepsy is always liable to result owing to the formation of cori"ical adhesions. 76o A MANUAL OF SURGERY Treatment. — In all cases of punctured or compound depressed fracture, a thorough exploration of the wound should be made, and all depressed or injured bone removed. Foreign bodies should be taken away, if found close to the wound; but it is doubtful whether a bullet should be sought for, if it has penetrated deeply into the brain, or if it has traversed the brain and fractured the bone on the other side. Probably an aseptic incision, with removal of the spHntered fragments and a limited search for the bullet, is the best treatment to adopt, and, even if unsuccessful, will do but little harm, if the patient's general state warrants an operation. Protruding brain tissue is gently removed, and the whole wound thoroughly purified with carbolic lotion ; even the i in 20 solution may be used without fear. The dura mater should, if possible, be drawn together by one or two sutures, and a small drain-tube or a gauze wick inserted wathin it. It is often advisable to introduce a portion of sterilized gold or silver foil between the cortex and the dura, so as to prevent the formation of adhesions. The scalp-wound is closed, except at the drain opening ; the gauze or tube should be removed, if all is going well, in about tw'o days' time. If the temperature rises as a result of infection, the wound must be reopened, and every effort made to relieve tension, and thus localize the mischief. Should diffusion occur, as indicated by an increasing severity of the symptoms, the patient must be treated in accordance with the general principles laid down for dealing with acute meningitis. In this description of lacerations of the brain the fact that symptoms may arise from inflammatory conditions affecting the bones (p. 728) has been purposely omitted. In actual practice the course of events is often considerably modified by such complications. Injuries to the Intracranial Bloodvessels. I. Wounds of the Venous Sinuses are by no means uncommon, being torn across in fractures, or punctured either by some sharp instrument, or by spicules of bone. The superior longitudinal, petrosal, lateral, and cavernous sinuses are those most frequently in- volved, especially the first, because it is more intimately connected with the bones than any of the others. Not unfrequently a depressed fragment of bone is driven into a sinus, and no bleeding occurs until the fragment is displaced with a view to elevating it, when a serious gush of dark venous blood will follow. When there is no external wound, and the outer wall of the sinus has been torn, the hsemorrhage may strip up the dura mater and compress the brain, producing effects resembling those due to a wound of a meningeal artery; but generally the bleeding is not great, since comparatively little pressure suffices to arrest it by determining thrombosis. If, how- ever, the inner wall of the sinus is torn across, the blood finds its way between the meninges, and gives rise to the symptoms of diffuse intrameningeal haemorrhage. When an external wound exists, there is the usual evidence of venous bleeding, but it is readily AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 761 checked and rarely fatal. Infective thrombosis and pyaemia are the chief dangers, but entrance of air has also led to a fatal issue in a few cases. Treatment, when practicable, consists in plugging the sinus with aseptic gauze, and applying an antiseptic compress, pos- sibly removing fragments of bone in order to expose it. Where the outer wall alone has been torn, it may be possible to suture it with- out interfering with its continuity. For symptoms and treatment of infective thrombosis, see p. 768. 2. Wounds of the Middle Meningeal Artery. — This vessel enters the skull at the foramen spinosum, and subsequently divides into two branches which ramify between the skull and the dura mater. The anterior branch is most frequently torn as it crosses the antero-inferior angle of the parietal bone, as the result of any type of frac- ture in that locality. The artery is, however, some- times ruptured by a blow on the side of the head, sufficiently severe to detach the dura mater, but without causing any injury to the bone ; this membrane always carries the vessel with it, and if it emerges from a bony canal just at that spot, as so often happens, the artery is torn across by the projecting inner lip of the canal. Whether or not the dura is primarily de- tached, the blood soon col- lects between it and the bone, pressing the brain inwards, and burrowing down towards the base of the skull (Fig. 366). This is due mainly to the force-pump-like action of the arterial pressure, for when fluid is driven into a closed cavity, the power of the jet is multiplied by the area occupied. The clot rarely measures more than 4 inches in diameter. The posterior division is only wounded in about 5 to 10 per cent, of the cases. The Symptoms are, unfortunately, often obscured by some co- existent cerebral lesion or complication ; but in a typical case three stages should be present, viz. : (a) A primary concussion, as the result of the blow; (b) a temporary return to consciousness; and (c) the gradual supervention of coma within twenty-four hours, and that usually without any considerable rise of temperature, though it may be associated with severe pain in the head and vomiting. The Fig. 366. — Meningeal Hemorrhage. (From Specimen in College of Sur- geons' Museum.) 762 A MANUAL OF SURGERY interval of consciousness varies widely, but it is not often longer than an hour or two, whilst in many cases it is scarcely recognisable. On the other hand, cases are known where symptoms were delayed for days or even weeks after an injury. As accessory signs, the follow- ing may be mentioned: (i) Since the blood-clot is situated close to the motor area of the cortex, and especially over the centres of the head and arm, twitching of these parts, followed perhaps by paralysis, may be a well-marked feature, and usually supervenes before the onset of coma; (2) when the clot extends to the base of the skull, it presses on the cavernous sinus, and may induce passive congestion of the eyeball, paresis of some of the ocular muscles, and proptosis, with possibly a dilated pupil and high temperature; and (3) 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 that out of ninety-nine cases only sixteen recovered. The Diagnosis of extra-dural as distinct from intra-dural haemor- rhage is by no means simple. The latter is usually more rapid in its onset, and if involving the motor area may be associated with definite cortical phenomena ; it is hkely to be associated with blood- staining of the cerebro-spinal fluid. Unfortunately, the two con- ditions not unfrequently co-exist, and even if an extra-dural haemor- rhage is diagnosed it is difficult to be certain whether it is arterial or venous in origin. The Treatment consists in trephining in order to remove the blood-clot and secure the artery, if still bleeding. The spot selected for dealing with the anterior division of the artery is i| inches behind the external angular process of the frontal bone, and I J inches above the zygoma (Fig. 370, F), and this point may be marked on the bone w4th a bradawl through the scalp before commencing the operation. The scalp is shaved and thoroughly purified, and a flap turned down, including everything as far as the pericranium (Fig. 105, A). A crucial incision is then made over the selected spot, and the pericranium reflected sufficiently to allow a i-inch trephine to be applied. On removing the disc of bone, a mass of blood-clot presents, which should be broken up with the finger and washed or scraped away. If the artery is seen bleeding on the dura mater, it may be possible to pick it up, and tie or twist it, or a fine curved needle threaded with catgut may be passed under it, and thus a ligature applied. If, however, the blood comes from a canal in the bone, the outer table must be clipped away sufficiently to enable the canal to be seen and plugged by a small piece of aseptic wax, sponge, or gauze, which may be left without danger. The flap is then replaced, and stitched down, a drain-tube being inserted for a time. The posterior branch of the artery can be reached by trephining immediately below the parietal eminence at the same level as for the anterior branch — i.e., i| inches above Reid's base-line; or, again, it can be exposed nearer its origin at a spot i| inches behind the AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 763 external angular process of the frontal bone, and I inch above the upper margin of the zygoma (Fig. 370, G). 3. Wounds of the Internal Carotid Artery, in its intracranial portion, are rare, but if complete are necessarily fatal. They usually result from penetrating wounds of the orbit, or from a gunshot wound, or the vessel may be torn by a splinter of bone in a fracture of the base of the skull. Mere fissures through the carotid canal do little harm, since there is plenty of room within it around the artery. Occasionally, however, the artery is slightly torn, and an aneurismal varix develops between it and the cavernous sinus. Treatment.— The injury is fatal in the majority of cases before help can be obtained; if not, compression of the carotid trunk or ligature of the internal carotid in the neck is the only hope. See also on orbital aneurism (p. 323). 4. Intrameningeal Hsemorrhage arises from wounds of the cerebral cortex or membranes in cases of fractured skull, or from concussion without fracture. The blood may be derived from the veins and capillaries so abundantly present in the pia mater, or from lesions of the inner wall of venous sinuses, or even from the middle meningeal artery, if the dura mater is also opened. It may be widely diffused over the surface of the hemispheres, or be more locahzed. It is often but slowly absorbed, and may become encapsuled, constituting what is known as an arachnoid cyst- — i.e., a closed cavity containing serum, the walls of which are formed of fibrous tissue stained brown with haematin. The Symptoms are those of concussion or compression, and need not be discussed further. The Treatment is symptomatic, the patient being kept absolutely quiet, and all excitement and noise which might induce cerebral congestion excluded. Should there be any focal symptoms indicating the position of greatest pressure, or should there be some concurrent lesion of the skull, the trephine may be apphed at this spot. It must not be forgotten, however, that the chief hsemorrhage often occurs, not at the point to which the injury was directed, but at an exactly opposite spot on the other side of the cranium, and hence considerable uncertainty may arise both as to the advisabiHty of an operation and as to its site. Should the right locality have been exposed, the dura mater will probably bulge into the wound, after the circle of bone has been removed; it is blackish-blue in colour, owing to the clot lying beneath it, and the cerebral pulsations will not be detected. It is carefully incised, and the blood-clot removed ; any bleeding-points should be tied or compressed, and it may be necessary to insert a small wick of aseptic gauze for a day or two, in order to drain off serum and blood. 5. Cerebral Haemorrhage occurs more frequently from idiopathic causes than from trauma, except in the case of severe lacerations. In the more aggravated forms, death is almost certain to follow in a short time from coma. 764 A MANUAL OF SURGERY Intracranial Inflammation. Inflammation of the cranial contents is almost always bacterial in origin, and may follow a great variety of lesions, e.g. : (i) Injuries of all types, but especially compound or punctured fractures. (2) Middle-ear disease is perhaps the most frequent origin of these affections, the infection reaching the brain through an opening in the tegmen tympani, or spreading from the mastoid process along the sigmoid groove in which lies the lateral sinus. (3) It may extend inwards from scalp, face, nose, or neck by way of the emissary veins, or even along the sheaths of nerves. (4) It may accompany simple contusion of the cranial bones (p. 730), as a result of an auto- infective inflammation in these structures. (5) It may develop as a complication of pyaemia, septicsemia, pneumonia, scarlet fever, small-pox, and other general infective diseases. The causative bacteria are generally of the usual pyogenic type, viz., staphylococci and streptococci, when the inflammation is due to traumatism; but the pneumococcus is present, as a rule, when the mischief extends from the middle ear or accessory nasal sinuses. In the so-called idiopathic form of diffuse meningitis the Diplococcus intracellulans of Weichselbaum is generally the causative organism. It must be remembered that in actual practice the different forms of inflammation described below run into one another, and that the resulting symptoms are often a complex mixture of several types. For descriptive purposes the following groups may be differentiated: (i.) Subcranial Inflammation manifests itself either as a simple thickening of the dura {pachymeningitis) , or as an effusion of pus between the dura and the bone {subcranial abscess). Simple Pachymeningitis results either from a slight simple depressed fracture, or from a contusion with or without a fissured fracture, or from the gradual spread of a mild infective inflammation from the overlying bone. I he process is really protective in character, the dura becoming thickened. It may extend to the under surface of the dura, and lead to a localized lepto-meningitis, characterized by adhesions between the cortex and the dura. If the process extends no further, the clinical manifestations are slight, consisting merely of pain and localized headache. For treatment, see chronic meningitis (p. 768). Subcranial (or Extradural) Abscess results from either a compound depressed or a punctured fracture, in which the dura mater is only separated from the bone and not lacerated, especially when the external wound is small and efficient drainage is not obtained. It sometimes occurs, however, in consequence of a simple contusion or fracture of the skull, leading to a detachment of the membranes and a collection primarily of blood and later of inflammatory fluids in the cavity thus produced. Microbic invasion is here due to auto-infec- tion, or to the passage of organisms through the bone (Fig. 367). Any form of osteo-myelitis of the cranial bones may determine its AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 765 onset, but apart from injury, its most common cause is, without doubt, extension of intiammation from the middle ear. A perforation of the tegmen tympani (Fig. 369, B) allows of the invasion of the cranial cavity, and an abscess forms above the attic, which perhaps discharges through the ear; in other cases the sup- puration extends along the groove for the lateral sinus. In the fomier instance, a locahzed subdural abscess may subsequently develop, Hmited bv meningeal adhesions, and the intervening dura mater may slough; in the latter, thrombosis of the lateral sinus mav follow. . . the Symptoms produced are (i) those generally characteristic ot suppuration, viz., a high temperature, with perhaps rigors. (2) The signs of intracranial pressure in the form of fixed headaches followed by coma are also present, if the abscess is large, or if it affects the cerebral membranes sufficiently to cause a serous meningeal Collection Inflamed CEdematous of pus. bone. scalp tissue. "*^ ^.''t^. ■*^'" J^'S^^ /Subdural space Fig 367 —Subcranial Suppuration, involving Overlying Bone and CA.USING an CEdematous Condition of the Scalp— Pott's Puffy Swelling (Semi-diagrammatic) . (Frojm Treves' ' System of Surgery. ) effusion. (3) If there is no open wound, an oedematous swelling of the scalp, known as Pott's puffy tumour, may develop over the site of the abscess (Fig. 367). When there is a compound fracture of the skull, the margins of the wound look unhealthy, and at its base may be seen bare bone, yellow and dry, from which the pericranium has separated, ^^dth perhaps pus oozing out between the fragments. If the pus burrows towards the base of the skull, optic neuritis may develop. (4) Focal s\Tnptoms of spasm or paralj^sis may complicate the case if the dura over the motor area is involved. The Treatment of such a condition consists in evacuating the abscess cavity through a sufacient opening made bv trephining, or by remo\dng loose or diseased portions of bone, and providing for drainage. Sometimes more than one opening is required for this purpose. When the affection follows middle-ear mischief, the mastoid antrum is usually opened up, as also the attic, and a sufacient amount of bone gouged or cut away to give effective drainage. 766 A MANUAL OF SURGERY (ii.) Acute Diffuse Meningitis (lepto-meningitis) is always infective in nature. 1 1r- symptoms vary consi(UTal)ly in their intensity according to the site and method of inoculation and the activity of the organisms, but the whole pio-arachnal space is quickly involved. The superficial part of the brain is also invaded in the inflammation as well as the meninges, and the term ' meningo-encephalitis ' would perhaps be the better appellation. The Symptoms appear about forty-eight hours after an injury, although sometimes infection may be delayed beyond this period. In the early stages the patient complains of severe, constant, and in- creasing headache, associated with heat of head, a forcible pulsation of the carotids, a quick pulse, and general irritability of the brain, as indicated by vomiting, intolerance of light and sound, delirium, and perhaps convulsive twitchings of the muscles, not only of the head and back, but also of the extremities. The vomiting is of the usual cerebral type^ — i.e., it occurs apart from nausea, and has no relation to the ingestion of food. High fever is generally present, and possibly a rigor may occur at the onset. As the disease pro- gresses, the patient gradually becomes comatose, the pulse slow and full, the respirations laboured, and death usually ensues in three or four days. 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 dis- tinguished, viz., meningitis of the convexity and meningitis of the base. The general symptoms are alike in both forms, but 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 some 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 congested, and the subjacent veins are manifestly distended; the cerebro-spinal fluid is increased in amount, and turbid from admixture with lymph or pus; the arachnoid is thick and opaque; the surface of the con- volutions is flattened and (edematous, and l\TTiph occupies all the sulci, matting them together; the cortical gray matter is usually red and congested ; the underlying white substance of the centrum ovale is injected, numerous puncta cruenta being evident; the ventricles are distended with cerebro-spinal fluid, and the choroid plexuses are engorged with blood. The Treatment consists in shaving the head and applying cold by means of an icebag or Leiter's tubes, care being taken that the application is continuous, and not intermittent. In the robust general venesection is useful, but in weaker mdividuals cupping or leeching may replace it. The bowels are freely opened and a bland diet ordered. The patient should be kept absolutely quiet in a dark- ened room, and every source of irritation and excitement removed. AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 767 Even if recovery ensues, it is somewhat delayed, and similar pre- cautions as to quiet, etc.. must be maintained for some time. In the later stages, blistering of the scalp, or neck, and the admmistration of mercury, are advisable. If the condition is due to a localized infective lesion, this must, of course, be dealt with by suitable means— e.g., the middle ear must be opened up and diseased bone removed, depressed fractures must be operated on, and locahzed drainage effected, etc. Apart from this attempts have been frequently made to reUeve 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 successfully em- ployed lumbar puncture, repeating it frequently (p. 748). 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, and especially when it is remembered that the bram sub- Collection of pus beneath Inflamed dura mater. bone. I <^^^^^^^^->.^_ Scalp. I^»K' V:J^'"i-— Cranium. Subdural space, Fig :!68 —Superficial Abscess of Brain, spreading from Subdural Space "(Semi-diagrammatic). (From Treves' ' System of Surgery. ) Stance is itself swollen, and that the important fourth ventricle has only a small communication with the subarachnoid space— all these considerations suggest that it is unhkely that much success will follow such treatment. ,••-,• n x 1+ Acute Meningo-encephalitis is sometimes hmited m character, it can only occur in the absence of tension, diffusion along the meninges being prevented by the formation of adhesions. It usually results from a locahzed inflammation of bone (Fig. 368), due to a contusion, a penetrating wound, or possibly to middle-ear mischief. The pro- cess ends in the formation of adhesions between the bram and its membranes, preceded or not by suppuration. Of course, where pus forms, a cure can only be established by operation. (iii) A Subacute form of meningitis is occasionally met with, coming on at a somewhat later date. The patient may have ap- parently recovered from his injury, with the exception of a fixed pain m the head. The onset of the symptoms is often due to some in- discretion, and may be gradual or sudden. In all probabihty this 768 A MANUAL OF SURGERY 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 possibly they have been latent for a time, and are aroused into activity by secondary causes; or, again, they may have gradually worked their way inwards along h-mphatics 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 treatment of this form, no active antiphlogistic measures should be adopted, since the patient's condition is somewhat asthenic. Absolute rest and quiet are essential; counter-irritation should be applied to the scalp and neck, and possibly mercury administered, or some absorbent organic salt of iodine. (iv.) Chronic Lepto- meningitis arises from very similar causes to the pachymeningitis already described (p. 764), but in addition may be associated with deep lesions, and may serve to limit the spread of infection ; it is usually of a protective character. Syphilitic patients are perhaps more liable to its development than others. It is 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 treatment consists in attention to the general health, free action of the bowels, abstinence from excitement or stimulants, the local application of counter-irritants, and the administration of mercury or iodolysin (p. 632). For the question of operating for traumatic epilepsy, see p. 780. (v.) Tuberculous Meningitis is a condition usually seen in children, due to an invasion of the meninges with tubercle. The pial vessels are chiefly affected, and the base of the brain is mainly involved. Inflammatory adhesions follow, and the free circulation of the cerebro-spinal fluid is checked by the blocking of the foramina of Magendie and Luschka, so that the ventricles are often distended. For symptoms and clinical history, medical text-books must be consulted. Many attempts have been made to deal with this affection by surgical means, especially by trephining through the occipital region and draining away the cerebro-spinal fluid, so as to relieve pressure on the fourth ventricle, or by lumbar puncture. One or two cases have recovered post hoc, but the prospects of success are poor. (vi.) Infective Thrombosis of the Sinuses, though occasionally seen after injuries, is more commonly associated with suppurative diseases of the bone apart from trauma, and one variety, viz., that affecting the lateral sinus, is almost exclusively caused by disease of the middle ear. It is also induced by extension from scalp injuries as a complication of subaponeurotic cellulitis, or may spread inwards from erysipelatous or pyogenic lesions of the face, or suppurative conditions of the nose. Putting aside the results of chronic otorrhoea, AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 769 the cavernous sinus is much more frequently involved than any other, and the affection is often secondary to suppuration in the sphenoidal sinus. Pathologically, the same manifestations are observed as in any case of infective phlebitis. The sinus becomes impervious owing to thrombosis, and the clot becomes disintegrated and gives rise to multiple emboli, whilst various inflammatory conditions of the sur- rounding tissues necessarily result — e.g., necrosis or caries of bones; subcranial abscess; meningitis, simple and localized, or infective and diffuse; or even cerebral or cerebellar abscess. The symptoms are mainly of a pysemic nature. The temperature is high, but wdth remissions, and often with repeated rigors; fixed headache and early and continuous vomiting are also marked features of the case. With these may be associated evidences of meningeal mischief, or of pulmonary trouble in the shape of dyspnoea, but sometimes diarrhoea and septicaemic manifestations may be the more prominent. If the cavernous sinus is involved, marked exophthalmos, with congestion of the orbit, and even of the eyelids and face, may result, and ptosis or squint may also be set up by implication of the nerves which lie in the walls of the sinus. If the superior longitudinal sinus is affected, there may be turgescence of the veins of the scalp and forehead, together with tenderness along the line of the sinus and epistaxis, whilst convul- sions may be induced by irritation of the neighbouring motor area. For local results and treatment of thrombosis of the lateral sinus, see p. 882. Treatment, except for the lateral sinus, is but rarely possible, and hence the importance of preventing this disease by a most careful attention to asepsis in the surgery of the face and of the nasal cavity. For the lateral sinus much can be done, but for the other sinuses all that is feasible is attention to general measures. Abscess of the Brain. Causes. — -Pyogenic infection is, of course, the ultimate cause of all cerebral suppuration, but the manner in which the organisms find their way to the brain varies considerably. (i.) It ma}' be due to traumatism, either in the early or late stages of head injuries. In the early, it is usually superficial, and connected with some infective lesion of the scalp, cranium, or membranes, wdth or without a penetrating wound (Fig. 368). In the later stages the pus forms deeply in the white substance. It may be due to a pene- trating wound, whether a foreign body is present or not, the microbes finding their wav into the interior of the brain either through the track of the missile, or along bloodvessels or l3Tnphatics. Some- times it occurs apart from penetration, and then one can only suppose that it is due to auto-infection of a contused or lacerated area. Chronic abscess of this type is most frequently seen on the same 49 770 A MANUAL' OF SURGERY side of the brain as the lesion, and the parietal and frontal lobes are most often affected; occasionally, however, it may occur on the opposite side in the same way as a contusion. (ii.) It'arises by extension of an infective lesion from without, the organisms reaching the brain by direct continuity of tissue, or by way of the bloodvessels or lymphatics. The commonest cause of all abscesses in the brain is chronic otorrhcea (Fig. 369), and the cerebellum is nearly as fre- quently involved as the cere- brum. In the former the ab- scess is usually in the anterior portion of the lateral lobe (D), close to the back of the petrous bone, whilst in the latter the posterior portion of the temporo-sphenoidal lobe is most frequently affected (C). The inflammation may spread directly from the tympanic cavity or inner aspect of the mastoid process through the bone to the membranes, which become adherent to the brain, and then into the cerebral substance. Occasionally a sub- cranial abscess is first developed (Fig. 369, B), and the cerebral affection follows ; sometimes a direct opening has been found through the tegmen tympani into an abscess cavity, and the abscess has even discharged itself and been drained in this direction. More commonly a layer of brain tissue intervenes between the membranes and the pus, and then infection must have been carried along vessels and lymphatic sheaths running between the meninges and the brain. Abscesses of a similar type occur in connection with suppuration in the frontal sinus, the abscess being usually acute and secondary to a frontal osteo-myeHtis, and occupying the anterior portion of the frontal lobe ; it may also follow purulent infection of the sphenoidal and ethmoidal sinuses, or thrombosis of the cavernous sinus. (iii.) The infective material may be brought to the brain by the blood in pyaemia, or after some of the exanthemata, such as scarla- FiG. 369. — Diagram to represent THE Course of Inflammatory Trouble from Suppurative Dis- ease OF THE Middle Ear. A, dilated and infected mastoid antrum ; B, subcranial (extradural) abscess from infection through the roof of middle ear or mastoid; C, abscess in temporo-sphenoidal lobe; D, cere- bellar abscess; E, lateral sinus; F, Eezold's abscess through perfora- tion of tip of mastoid process. AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 771 tina, typhoid, etc. Abscess of the occipital lobe is almost always of P3^aemic origin. (iv.) A chronic abscess of tuberculous origin may also occur. A cerebral abscess is usually single; occasionally more than one is present, e.g., a cerebral and cerebellar may co-exist in connection with middle-ear mischief. The course taken by the case is generally chronic, and then the pus is encapsuled; in acute cases there is usually no limiting membrane. A chronic case not uncommonly terminates in an outbreak of acute symptoms, due either to the abscess bursting into one of the lateral ventricles, or to the super- vention ot spreading oedema. The Symptoms vary somewhat with the method of onset and the characters of the abscess. If traumatic and due to infection from \\-ithout, the case runs an acute course, associated ^vith intense pain in the head, recurrent rigors, and rapid development of coma. Diffuse meningitis is often present, and the two conditions can scarcely be distinguished. In not a few of the cases of chronic abscess, all that the patient complains of is headache, until suddenly the temperature rises with a bound; he becomes unconscious and dies within a day or two. Such a course of events is probably due to the bursting of the abscess into the lateral ventricle or meningeal cavit}-, or to the onset of an acute spreading oedema. When the s\-mptoms are more characteristic. Sir W. Macewen describes them in three well-marked stages, (i.) In the Initiatory Stage, which lasts from twelve hours to two or three days, the patient is suddenly seized with severe pain in the region of theear, radiating perhaps throughout the head, and accompanied by a rigor of some severity. The temperature and pulse are both raised, and vomiting of a cerebral type is present ; the tongue is foul, whilst anorexia and constipation are w^ell marked. During this period the otorrhcea diminishes, or ceases entirely. (ii.) In the Fully -developed Stage the patient lies quietly in bed in a duU, apathetic condition, able to answer questions but slowly, and with his brain evidently in a torpid state. The headache has to a great extent ceased, but tenderness over the temporo-mastoid region stiU remains. The temperature gradually faUs and becomes sub- normal; the pulse is slow and full; and respiration is usually slow. The vomiting and constipation continue, and the patient's mouth and breath become very offensive. Loss of muscular power scarcely amounting to paralysis occurs in many cases where the motor track is involved, and the order in which this paresis appears is of localizing value. Thus, if a temporo-sphenoidal abscess is not far from the cortex, the face is first affected, then the arm, and finally the leg; but if the abscess is deeper and presses on the motor fibres in the internal capsule, the order in which these parts are involved is reversed. Motor aphasia is sometimes well marked when the abscess is on the left side. If the abscess is placed posteriorly, it may press on the cerebellum through the tentorium, and cause symptoms of a cerebellar type. Optic neuritis (p. 776) is a somewhat unrehable 772 A MANUAL OF SURGERY sign, but if present is more marked on the affected side, whilst the corresponding pupil is dilated and fixed. (iii.) The Terminal Singe is marked by a gradually increasing unconsciousness and death; or the abscess may burst into the lateral ventricle, causing sudden coma, a rapid rise of temperature and pulse, irregular respirations (often of a Cheyne-Stokes type), and death ; or it may burst into the subarachnoid space, and then death is preceded by symptoms of diffuse lepto-meningitis. The signs connected with a small Cerebellar Abscess (Fig. 369, D) are often very indefinite and vague, but if the abscess increases in size, the symptoms may become very characteristic. The patient complains of giddiness, and staggers when attempting to walk, falling towards the opposite side. The head and neck are retracted ; respiration is irregular and feeble; the pulse is often slow and weak; paralysis may be noted on one or both sides of the body, and may only affect the upper extremity ; of course, vomiting, optic neuritis, and a low temperature are present. Diagnosis. — From meningitis, a cerebral abscess is usually recog- nised by the fact that in the former condition irritative phenomena, such as acute and active delirium, contraction of the pupil, photo- phobia, rigidity and spasm of muscles, especially in the back of the neck, and severe pain, are more evident and are produced earlier. The temperature is usually high, and mental dulness comes on mthin three or four days of an injury, whereas an abscess rarely forms before the end of the first week. Extradural abscess (sub- cranial) is associated with a high temperature, earlier onset after an injury in traumatic cases, and more rapid compression symptoms; optic neuritis is unusual, and the vomiting is less troublesome. There is also likely to be some localized oedema or tenderness on deep pressure. In thrombosis of the lateral sinus the temperature is high and oscillating, optic neuritis may be absent, and there may be the characteristic tenderness in the neck along the course of the internal jugular; in abscess symptoms of compression are associated with a low temperature and marked optic neuritis. It must not be forgotten that the two conditions may co-exist. It is often impos- sible to diagnose between a chronic abscess and a tumour of the brain ; the symptoms in the latter usually come on more slowly than in the former, but the progress is steady and unrelenting ; the temperature remains near the normal, and there is less gastric disturbance. The history of the case may throw some light upon its nature, since in cases of cerebral abscess there is generally some causative focus of infection. Tumour is more common in the frontal and parietal regions, abscess in the temporo-sphenoidal lobe. Optic neuritis is more marked and more common in tumour than in abscess. Treatment necessarily follows the usual rule, viz., to give an exit to the pus as soon as possible ; no delay is permissible when once the diagnosis is certain. The patient is prepared in the same way as for operation on a cerebral tumour (p. yyj)- A flap of scalp tissue is raised, and in such a manner as will most effectually serve for subse- AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 773 quent drainage purposes. The trephine is apphed according to the rules given below, or in accordance with the special indications given by the symptoms of the case. Sir W. Macewen recommends that, when the circle of bone has been removed, the exposed surface and cut edge should be well rubbed over with powdered iodoform and boric acid, so as to guard them from infection. The dura mater, which bulges into the wound and does not pulsate, is then carefully incised. A mere slit often suffices, and this may open the abscess; but more usually the brain substance protrudes. It is carefully explored with a pair of sinus forceps, which is passed directly into it in various directions, or with a fine trocar and cannula. In a temporo-sphenoidal abscess the most likely direction to explore is downwards and inwards towards the tegmen tympani. Pus, when discovered, is allowed to escape by opening the blades of the sinus forceps. Sloughs are not uncommonly present in the cavity, and are removed by the gentle introduction of a curette, whilst it is wise to wash out the interior by gentle irrigation with sterilized salt solution, A drainage-tube is advisably inserted, and may be kept in position by stitching it to the margins of the incision in the dura, which is closed except for the passage of the tube. Sometimes it is wiser not to close the flaps around the tube, but to pack gauze round it, thereby determining the formation of adhesions, which will serve to shut off and guard from infection the meningeal cavity. The scalp flap is replaced in position, the tube being brought out through its centre, if need be. The tube is retained in position for two or three days, and is then removed. Symptoms of re-accumulation or of extension of the mischief to the meninges will, of course, necessitate a re-open- ing of the wound, and the institution of free and effective drainage. Occasional!}^ a hernia cerebri develops as the result of opening a cerebral abscess. For an abscess in the temporo-sphenoidal lobe, the centre-pin of the trephine may be placed i^ inches above Reid's base-line, and directly above the external auditory meatus; but a better situation is a spot I inch above the posterior root of the zygoma, and directly above the posterior border of the osseous meatus (Macewen; Fig. 370, D). For an abscess in the cerebellum the point selected is 1 1 inches behind the centre of the external auditory meatus, and 1 inch below the base-line (Fig. 370, E) . In the latter case the soft parts, including the muscles and periosteum, should be stripped off the occipital bone, and turned downwards, and it is usually inadvis- able to apply a trephine, as the bone is very thin, and may be broken through with a gouge. It is often necessary to carry through the cerebellar operation rapidly, as the respirations sometimes stop under an ansesthetic, though the heart continues to beat forcibly; as soon as the dura is opened, the respirations recommence. In middle-ear disease the diagnosis, both as to the presence of an abscess and its situation, is often doubtful. The antrum and attic are then opened and explored thoroughly, and according to whether the disease is more marked in the former or latter, the further steps V- O i > -^ pH O --" 2 5 ^-^ ^5 .2 X ^ o • "! o - c "^ «i S Ri _ ^ I = I " a -3 „. fi:2^ 1-5 5;; o o -J c tJC^ ^iSo rt 1- 'J • '^ Si f^ ^ r^^+-> C^ CJ O -C • - — -_= ^ f^ ^ M-* 4) 4) '^■^ CL, 3 ^ "pi o __ ^ o -2 O o -H -r o "^ ° > '*'.S ^ " c- > r ^ ^j ^ '^ ,i-*N^ ^ ■" CD P ^ •- -^ ^ O :i T c: S Ts O ■%> 3 -S.S ST-- -i H ^ > P O :j ,- N] ^ ^ c o o a O ^ fi o 5 c^-s >rUo f- i;.s E V- >- .*j .^j +j O tn cS O --^ g'2 ^C - -3 i^ = C- 2 .2 • - >- _3 ^ rg^ v- "; u X =^ -. C5 ^ . ° O g N ^^ o C S -t^ ° ..JJfc O X 4-> -r "^ > •r; o > N c lU X V- <£ « b 2 ^ fa H AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 775 of the operation are directed towards the cerebellum or cerebrum. By carefully removing bone behind and above the antrum, the lateral sinus is exposed; and by working above or below it, the cerebrurn or cerebellum can be examined, and, if need be, incised. A sirnilar result can be obtained by applying a |-inch trephine to a spot i inch behind the meatus and h iii^h above the base-hne (H. P. Dean). The lateral sinus lies in the lower portion of the opening, and the dura over the temporo-sphenoidal lobe in the upper ; by enlarging the opening downwards by Hoffman's rongeur, the cerebellum can also be explored. Cerebral Tumours. The chief Varieties of new growth met with in the brain are as follows: (i.) Glioma, which consists of a small round-celled neoplasm with a verv^ dehcate intercellular substance, similar in character to the neuroglia (p. 214) ; it may occur in any part of the brain. It is alwavs continuous with the surrounding cerebral tissue, and is scarcelv ever encapsuled, so that to the naked eye it may be indis- tinguishable from brain substance, although rather harder, and hence its limits can seldom be accurately defined, or its removal completelv effected, (ii.) Sarcomata and secondary_ carcinomata also occur, and are as unfavourable as the gliomata in their char- acters, (hi.) Endotheliomata are not uncommon tumours of the brain, growing usuaUv from the membranes, and may attain con- siderable dimensions before causing symptoms. They press upon and excavate by pressure rather than infiltrate the brain, and their situation at the' base of the skull and their size are often such as to preclude removal. In some cases they present the characteristic features of a psammoma (p. 228). (iv.) Tuberculous fod are met with either associated with or apart from any meningeal infiltration, varving in size considerably, and may be either firm and caseous, or \\-ith a diffluent centre, (v.) Gummafa of the brain usually spring from the meninges, and are more irregular in shape than tuberculous masses. They are frequently multiple, and are seldom seen in children, (vi.) Occasionally 'hydatid cysts are found, as also other less common conditions. Cerebral tumours are more often observed in males than in females, and the different forms occur at varying periods of hfe. Thus, ghoma and sarcoma are most common at puberty or in middle hfe; tuberculous foci, in children; gummata, in the fourth or fifth decade; carcinomata, in middle or late hfe; and parasitic tumours in the second and third decades. The local effects of a cerebral tumour may be to cause some amount of sclerosis of the surrounding brain substance, whilst, il superficial, the membranes may become adherent and the overlying bone thickened or eroded. Erosion and enlargement of the sella turcica can be shown by the X rays in cases of tumour of the pituitarv bodv. The Symptoms of a cerebral tumour in the early stages are com- 776 A MANUAL OF SURGERY paratively seldom brought under the notice of the surgeon, but it is of the greatest importance that their significance should be recog- nised by the general practitioner, who ought in case of doubt at once to obtain the assistance of a skilled neurologist, as it is only through improved and earlier diagnosis that we may hope for better surgical results. When the later phenomena, which are almost entirely the result of intracranial tension, are observed, the time has often gone for successful interference. ' The old classical s^TTiptoms of tumour of the brain which are given in most of our text-books, although often found, are not always present, and if one waits for such symptoms we may wait too long ' [Macewen at International Medical Congress, 1913). The early s^miptoms consist in some localized modification of the cerebral function, probably combined with headache and per- haps vomiting. The character of the localizing phenomena varies, of course, with the part of the brain involved; thus, if the cortex of the motor area is affected, Jacksonian epilepsy is likely to result, in which a definite aura associated with a particular group of muscles precedes the fit, which develops in an orderly fashion; in the later stages the fits are replaced by paralysis, and a localized monoplegia may be an important sign of a cerebral tumour. A sub- cortical lesion produces localized paralysis \\-ithout convulsions. Motor aphasia would suggest an affection of Broca's lobe; word- deafness, an implication of the hinder end of the temporal lobe; and hemianopsia of the occipital region. Interference with co- ordination, vertigo, and nystagmus point to mischief in the cere- bellum, and the association of these phenomena with localized lesions of cranial nerves, especially of the seventh or eighth, points to the cerebello-pontine angle, a rather favourite site for tumours. The headache varies much in character, but is usually localized, occurs in paroxysmal attacks, and may be associated with local tenderness on deep pressure. It is increased by anything that causes passive congestion of the brain, such as coughing, and it is important to note that the sites of maximum pain and of the tumour often correspond. Vomiting, if present, is of the usual cerebral type — i.e., it bears no relation to the ingestion of food, and is not preceded by nausea. The later phenomena are purely those due to intracranial tension, which may aggravate or to some extent mask the locahzing signs. Headache becomes more severe and persistent; vomiting and con- stipation are well marked; the patient becomes drowsy and apa- thetic, wasting rapidly, and the temperature is subnormal. Optic neiiriiis (choked disc or papilloedema) is generally present, and at first more marked on the side of the tumour. It is due to increased tension of cerebro - spinal fluid, which is thereby forced into the sheath of the optic nerve, and produces a condition of oedema, which extends to the lamina cribrosa, and causes serious inter- ference with the return of blood and lymph from the retina. There is in reality no inflammatory element about it. In the earlier stages AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 777 the margin of the disc becomes blurred and indistinct, and the retinal veins congested and tortuous; the neighbouring retina is cedematous, and the vessels are only seen at intervals ; linear ecchy- moses mav also occur. The vision ma\' at first be but little affected ; but if the case persists, atrophy of the disc and blindness follow, even in cases of gummata which have progressed to cure by means of medicine, if that cure has not been attained quickly. The terminal phenomena of a cerebral tumour are gradually increasing coma, and the supervention of sj-mptoms similar to those of compression (p. 752), whilst the temperature may be subnormal or occasionally very high. Treatment. — In every case, the possibility of the symptoms being due to gummatous disease must not be forgotten, and a test for the Wassermann reaction should alwa^'s be undertaken; if positive, an intravenous injection of salvarsan may be given, or large and increasing doses of iodide of potassium (even up to 40 or 60 grains three or four times a day) should be administered, together with the inunction of mercury, before undertaking operative proceedings. S^Tnptoms of gastric irritation must be prevented by giving some alkaline carbonate (especialty the ammonium or soda salts) , whilst the dose should be freely diluted with water. Operation should be undertaken as early as possible, since, even if no tumour exists, the patient runs but little serious risk, whilst delay may prevent the removal of the gro\\i;h. The scalp should be entirely shaved a day or two previously, and very thoroughly purified. A quarter of a grain of morphia is injected about half an hour before the operation, with the idea both of reducing the vascularity of the brain and of dulling the patient's sensations, so that a smaller amount of anaesthetic is subsequently needed. Chloroform should be employed rather than ether, as it produces less congestion of the head. The surgeon marks the supposed site of the growth on the skull with a bradawl through the scalp. A large semicircular flap is then turned down, exposing a considerable area of the calvarium, so that, if a larger amount of bone than is expected needs to be removed, no fresh scalp incisions are required; moreover, the cicatrix will in this way be prevented from forming over the defect. One of the methods of opening the cranium already described (p. 746) is then employed; the further proceedings on the brain are carried out at once, or the intracranial portion of the procedure is delayed for a week or so. Under such circumstances the wound is re-opened, and the dura mater exposed. The dura mater when laid bare under normal conditions is firm, but yields slightly to the finger, and allows the pulsation of the sub- jacent brain to be felt, if the latter is healthy and no undue pressure is present within; but if the intracranial tension is markedly in- creased, the dura mater bulges into the wound, feels firm and unresisting, and the cerebral pulsations are diminished or absent. The dura mater is next incised crucially, or a flap turned down, care being taken to avoid, if possible, the main meningeal vessels; 778 A MANUAL OF SURGERY the brain substance protrudes if the intracranial pressure is ex- cessive. The region is gently explored by the finger, and any areas of abnormal hardness or softening noticed; failing this, a grooved needle is inserted in different directions, or a fine trocar and cannula. In introducing such instruments, care must be taken to make direct stabs, and never any lateral movements, which necessarily lead to laceration of the brain. The opening of the skull may be enlarged, if need be, either by the use of the bone rongeur or by additional small trephine holes. It is but rarely that a cerebral tumour is so placed that enucleation is possible; it is estimated that not more than lo per cent, of all cerebral tumours are removeable. If, however, a cortical neoplasm is found, it is isolated from the surrounding brain substance by blunt instru- ments — e.g., the handle of a scalpel or a flexible knife made of platinum, as suggested by Horsley- — ^and the mass freely removed. Haemorrhage is controlled by the application of fine ligatures, or by pressure with a hot sponge for a few minutes. The dura mater is then loosely stitched together, and a drainage-tube inserted, reaching to the bottom of the wound, and brought out at one angle of the incision in the skin, which may be closed by a continuous suture, or through the centre of the flap. After the operation, the patient must be kept absolutely quiet, with the head slightly raised. The drainage-tube is removed in twenty-four or forty- eight hours, and the scalp wound is usually healed in six or seven days. When the tumour is inaccessible or irremoveable, or its situation doubtful, temporary benefit often results from decompression — an operation which consists in removing large areas of the cranium, and incising the dura mater, so as to allow a hernia cerebri to form. The decompression is best undertaken over the supposed site of the tumour, but has sometimes been subtentorial, with a view to influencing beneficially the vital centres. A considerable measure of benefit follows such operations, as evidenced by an improved mental condition, loss of pain, retrogression of the optic neuritis, and the preservation of sight. Of course, sooner or later the continued growth of the tumour results in the patient's death. In dealing with cerebellar tumours, or those in the neighbour- hood, either by removal or decompression, Cushing's cross-bow incision may be employed. It consists of a curved incision, with its concavity downwards, passing along the superior curved line of the occipital bone, and from its centre passes down a vertical incision as far as is necessary in order to reflect the muscles from the posterior aspect of the atlas. A considerable mortality is associated with this operation owing to the close proximity of the vital centres; rapid relief of tension produces serious shock, and it is well sometimes to delay the opening of the dura. Tumours of the Hypophysis Cerebri or Pituitary Body may affect tlie anterior or posterior portion. Most frequently the affection is an adenoma with cystic degeneration (resembling somewhat a AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 779 goitre), but malignant disease is not unknown. Increased func- tional activity of the anterior lobe results in hyperpituitarism or acromegaly (p. 588); defective activity causes hypopituitarism, as manifested by an increased deposit of fat in the body, together with loss of function or an infantile condition of the genital organs. In women amenorrhea is usually present. These conditions may follow extrinsic pressure on the hypophysis, as well as mtrmsic growths. The close proximity of the optic chiasma explains the association of these phenomena with varying forms of visual dis- turbance, most commonly with bilateral temporal hemianopsia. Operative Treatment has been successfully undertaken in a number of cases. Von Eiselsberg* reports sixteen operations with four deaths, and certainly one cure of seven years' duration. The growth is approached through the nose by chiselUng away the pos- terior wall of the sphenoidal sinus. The Surgical Treatment o£ Epilepsy. It would be waste of time to discuss the many surgical procedures which have been suggested in this connection, mainly with the idea of modifying the cerebral circulation. The only operation now seriously considered is that deahng directly with the cerebral cortex, a proceeding dependent on the supposition that the epileptic convulsion is a syrnptom, and not in itself a disease, and that it results from an irritable condition of the cortex, which niay be excited into convulsive activity by various stimuH, originating either in the brain or elsewhere. Sir Victor Horsleyt classifies epilepsy as follows: (i) Idiopathic (with no gross lesion) . (a) Onset localized (focal). (&) Onset generalized. (2) Jacksonian (always some gross lesion or traumatism). (a) Traumatic (with local or general convulsion). (&) Congenital. (c) Neoplastic (tumour, abscess, aneurism). (3) Reflex (injury of spine, nerves, etc.). (4) Hystero-epilepsy. As regards the characteristic symptoms and pathological pheno- mena found in many of these conditions, students must refer to medical text -books. Before discussing the individual groups from the surgical stand- point, one or two general considerations must be noted. In the first place, the prognosis is gravely modified by the length of time that the epileptic habit has persisted, and if traumatic cases have lasted two years the outlook is very unsatisfactory. A careful study should also be made of the family history as to the existence or not * Von Eiselsberg: Report of the International Medical Congress, London, 1913. Section VII., Pt. II. t Trans. Medical Society of London, February 9, 1903. 78o A MANUAL OF SURGERY of a neurotic predisposition; in many cases of traumatic epilepsy this is well marked, and then the outlook is correspondingly bad. It is now generally recognised that operation is useless in the idiopathic variety, even when the onset is accompanied by focal symptoms. Congenital epilepsy is often more or less of the Jacksonian type, and usually depends on some injury sustained during birth. It is frequently associated with other evidences of cerebral mischief (spasm, paralysis, etc.) and with defective growth. If taken early, and if the convulsions still remain localized, some good may follow operation ; but if allowed to persist too long, the disease is irremedi- able by surgical means. When due to tumours, abscess, etc., epilepsy is accompanied by other manifestations, which should guide the surgeon to a correct opinion as to the nature of the case and the operative outlook. Reflex epilepsy is rare, and may perhaps be cured by dealing with the causative focus. As regards hystero-epilepsy, the surgeon must never be tempted to undertake such a measure as double oophorec- tomy, which has been tried again and again, and found wanting. Traumatic Epilepsy is the term applied to an epileptic condition resulting from injuries. It may arise from any of the following con- ditions: (i) A neuralgic and irritable cicatrix in the scalp; (2) a slight unrelieved depression of the skull; (3) excessive formation of callus after a fissured fracture, or chronic thickening of the bone from osteitis after a contusion, whereby the dura mater is pressed upon and irritated; (4) chronic meningitis, usually associated with an adherent cicatrix in the brain, and particularly liable to occur in syphilitic patients; (5) a single depressed spicule of bone projecting into the cerebral substance. The Symptoms produced are epileptic seizures of the Jacksonian type, the exact manifestations varying with the portion of cerebral cortex which is involved. Localization of the lesion depends partly on the character of the aura, partly on the associated symptoms, such as a fixed headache or the presence of a cicatrix. The convul- sions are localized to begin with, but often become general. Operative Treatment is only applicable in those cases in which the convulsions remain localized; general convulsions place the patient in the category of idiopathic epileptics with a focal onset. The skull is opened over the site of the supposed injury, and it may be that some depressed fragment or spicule of bone is found; it will, of course, be removed. If, however, nothing is found but an adherent cicatrix between the membranes and the underlying brain, it is still an open question as to whether the surgeon should proceed further. In a considerable number of cases the cicatrix and underlying brain substance have been removed; the fits ceased for a time, but in most instances recurrence followed sooner or later from the formation of a fresh adherent cicatrix. Possibly the introduction of a sheet of sterilized gold or silver foil between the brain substance and the membranes might suffice to prevent this occurrence. The locality of AFFECTIONS OF THE BRAIN AND ITS MEMBRANES 78 r the lesion has a considerable influence, according to Horsley, on the result, since the prognosis is good in the motor area, middling in the sensory (parieto-occipital) region, and bad in the frontal. The obvious difficulty of dealing with epileptic conditions emphasizes the statements already made (p. 739) as to the importance of dealing with all depressed fractures of the skull, simple or com- pound, slight or severe, by immediate operation, so as to prevent, as far as possible, the development of the mischief. When there is a history of tubercle or syphilis, or of both, medicinal treatment directed to the absorption of cicatricial tissue should certainly precede operation. Traumatic Insanity is sometimes produced by slight depressions or lesions, similar in nature to those causing epilepsy, and can occa- sionally be relieved by operation. Certainly, when a distinct history of injury precedes the mental aberration, and when there is any localizing lesion or symptom, an exploratory operation is justifiable, and in a number of cases excellent results have followed. The type of insanity is not constant, but varies with the condition and environment of the individual. Hernia Cerebri. By hernia cerebri is meant a protrusion of the brain substance through an acquired opening in the skull. It thus differs from an encephalocele, which consists in the protrusion of brain substance through some congenital defect. It is always an evidence of increased intracranial pressure, and may be looked upon as Nature's safety-valve for the relief of com pression. It is met with in two distinct forms: 1. When a decompression operation has been performed for a cerebral tumour. The brain substance protrudes through the open- ing under the scalp, and by this means a temporary relief of intra- cranial tension is brought about, the patient's life prolonged, and possibly consciousness for a time restored. The tumour, however, continues growing, and sooner or later the patient dies comatose, unless the tumour is inflammatory and disappears. 2. The other variety, due to a compound depressed or punctured fracture, is the result of infection in the underlying brain substance, and the increased pressure within the skull thereby induced leads to a protrusion of inflamed and oedematous cerebral tissue 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 of the patient is unimpaired, but sooner or later coma follows, if the hernia progresses, ending in the patient's death. To begin with, the mass consists mainly of oedematous granulation tissue covered by blood-clot, without much brain substance, but later on cerebral tissue itself may protrude. The condition is usually fatal, though 782 A MANUAL OF SURGERY recovery is occasionally seen Treatment. — Prevention of this affection must always be aimed at by endeavouring to render any wound involving the meninges aseptic and providing for drainage. Punctured wounds and depressed fractures of the skull, even when giving rise to no urgent symptoms, should always be operated upon, since free relief of tension may prevent the formation of a hernia cerebri, even should absolute asepsis not be attained. If, however, protrusion occurs, it may be possible in a few cases to apply a dry dress- ing and elastic pressure, and thus prevent it increasing in size; this, however, must not be attempted when the inflammatory 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 suggested is to paint the projecting mass once or twice a day with absolute alcohol, which is an efficient antiseptic, and also tends b}' its dehydrating power to diminish the size of the hernia. If such treatment is successful, the tumour slowly granulates over and cicatrizes. Traumatic epilepsy may, however, ensue. CHAPTER XXVITT. AFFECTIONS OF THE LIPS AND JAWS. Affections of the Lips. Hare-Lip. — By hare-lip is meant a congenital fissure of the upper lip, which may extend for a variable distance through the soft tissues alone, or may also impHcate the bony alveolus and the floor of the Fig. 371. — Single Incomplete Hare- Lip, INVOLVING MERELY THE TIS- SUES OF THE Lip, and not ex- tending INTO THE Nose. Fig. 372. — Double Hare-Lip: Complete on the Left Side, Incomplete on the Right. A B Fig. 373. — Double Complete Hare-Lip, with Displacement Forwards OF the Central Portion of the Intermaxilla (Os Incisivum). A, Front view; B, seen in profile. nose, and extend backwards through the palate. The name is not a good one, since a hare's lip is cleft in a Y-shaped manner, the fissure being central below, and bifurcating above into each nostril. 783 784 A MANUAL OF SURGERY Varieties. — A hare-lip is complete or incomplete, according to whether or not it extends into the nostril. It is termed simple if limited to the soft parts; alveolar, if the bony alveolus is also in- volved; complicated, if associated with a cleft palate. The defect may exist on one or both sides of the middle line; if unilateral or single, it is most common on the left side, in the proportion of two to one; if double or bilateral, it is usually, but not invariably, alveo- lar, and accompanied by a complete cleft of the palate. The central portions of the lip and alveolus (os incisivum) may retain either their normal position, or, as is more frequently the case in Fig. 374. — Head of Fcetus of ABOUT Five Weeks, from Ven- tral Aspect (after His), show- ing THE Primitive Stomod^um Bounded Above by (A) the Un- divided Fronto-nasal Process, Laterally by (B) the Maxil- lary, and Below by[(C) the still Separate Mandibular Pro- cesses. The quinque-radiate appearance is well represented. Fig. 375. — Head OF Fcetus of Six TO Seven Weeks, from the Ventral Aspect. (After His.) The mandibular processes (E) have now united ; the ocular vesicle (C) is seen on either side towards the upper end of the orbito-nasal fissure, and the fronto-nasal process has developed (A) internal and (B) ex- ternal nasal processes on either side of (F) the still unclosed anterior nares; (D) maxillary process. the bilateral type, project forwards at the end of the nose, forming a proboscis-like appendage (Fig. 373, A and B) ; its base of support is often thin and elongated, so that lateral mobihty may be ob- tained. Even in simple cases the nose is deformed, being broad and flattened, a condition which becomes much more marked when the alveolus and floor of the nose are widely fissured. Hare-lip is not uncommonly associated with other deformities — e.g., spina bifida and tahpes — and it is frequently transmitted from one generation to another. Occasionally a thin red line, as of a cicatrix, is seen occupying the position of a hare-lip cleft, and is probably due to a persistence of the raphe of union of the labial segments; a AFFECTIONS OF THE LIPS AND JAWS 785 slight groove in the alveolus may also be observed at a corresponding point. Development- — The bony and fleshy parts of the face originate from the outgrowth of processes around the cavity formed by the bending forward of the primitive cerebral vesicle over the end of the notochord. At about five weeks after conception the primitive buccal cavity or stomodaeum has a c|uinque-radiate appearance, due to the manner in which these processes are formed (Fig. 374). A broad median lappet (fronto-nasal process, A) descends from above ; this is separated by a fissure on each side from the symmetri- cally placed maxillary processes (B), and these again below from the more prominent mandibular processes (C), which early unite across the middle line, to form the lower jaw. The fronto-nasal process soon, however, changes. On either side of a slight depression in the median line is placed the internal nasal process or globular process (Fig. 375, A), from which are produced superficially the central portion of the upper lip, and from its deeper aspect the intermaxilla, which divides into the two incisive segments, each carrying the germ of an incisor tooth. Separated from this by a hollow (F), which subsequently forms the anterior nares, is the rounded external nasal process (B), from which develop the side of the cheek and the ala nasi. External to this a fissure (naso-orbital) runs up to, and even beyond, the primi- tive eye (C), and this is later on closed by amalgamation of the internal and external nasal processes on the inner side with the adjacent maxillary process on the outer (D), except in the deepest part, which constitutes the nasal duct. The integrity of the upper lip is obtained by the union of the lower parts of the internal nasal and maxillary processes, which thus exclude the external nasal from participation in its free border. It is doubtless owing to this arrangement that the sulcus or depression around the ala nasi constitutes such a distinct and characteristic feature of the face. At the same time the deeper parts of these nasal processes are uniting with one another and with the palatal plates, which grow horizontally inwards from the under side of the maxillary processes, uniting in a Y-shaped suture, the point of junction of the limbs being situated at the anterior palatine canal. The union of all these elements is taking place from the sixth to the tenth week, and by that date even theuvula, the last part to unite, should be complete. Ordinary hare-hp is due to a failure of union of the internal nasal process with the structures in external relation with it; if limited to the soft parts (simple hare-lip), the cleft runs between the internal nasal and maxillary processes; if complete or alveolar, between the same two below and super- ficially, but in addition between the internal and external nasal processes above and on the deep side. The cleft in the alveolus passes between the intermaxilla and the maxilla (Fig. 376) . The relation of the cleft to the teeth varies somewhat, since the germ of the lateral incisor may be developed on one or other side of the suture between the maxilla and intermaxilla, or may even lie between the segments. Hence the lateral incisor is sometimes found, on the outer side of the cleft, sometimes on the inner; moreover, an accessory incisor is occasionally developed on the inner side of the cleft. 50 Fig. 376. — Diagram to Repre- sent THE Situation of the Cleft in Alveolar Hare-Lip. II, 12, Incisors; C, canine tooth; Ml-, M^, first and second molars. 786 A MANUAL OF SURGERY The OS incisivum, or projecting portion of the intermaxilla, usually consists of two segments of bone, united in the median line, and in a child most fre- quently contains only the two milk central incisors and the rudiments of the two permanent ones; occasionally, as we have just stated, there may be an extra tooth developed on one or both sides of the process. A simple hare-lip does not interfere seriously with the infant's nutrition, but when double, and especially if associated with a cleft palate, considerable trouble may arise, thus necessitating surgical treatment as a life-saving measure at a very early date. It must also be remembered that all movements of the face — e.g., in crying or laughing — exaggerate the deformity from the unbalanced action of the divided orbicularis oris and other muscles. As to the period at which to operate, it is better to allow the infant to get over the shock of its entrance into the world and become acclimatized to an independent existence, whilst at the same time the operation should be performed before the troubles of dentition begin. From six weeks to three months is perhaps the best age for operation — in well-nourished and healthy children at the earlier date, in poorly-fed and weakly children at the later, unless the inanition is due to the difficulty of feeding the infant owing to the deformity. Under such circumstances the operation may have to be undertaken within the first three weeks. Operation for Single Hare-Lip. — The child should be laid on an operating-table with its arms bound to the body. The surgeon stands behind it, the ansesthetist and assistant one on each side. The operation may be described in three stages : 1. The lip is thoroughly dissected up from the maxillce and alveoli b}' cutting through the reflections of mucous membrane and the attachment of the muscles and other soft parts. This is mainly needed on the outer side, and where there is much flattening of the nose the ala nasi will also require to be separated. This may cause some amount of bleeding, but sponge pressure easily controls it. 2. The edges of the cleft are then pared. Many dii^erent methods have been employed to accomplish this, but it is only necessary to mention two. The object to be attained is the union of the cleft lip by means of a cicatrix, which shall be as unobtrusive as possible, whilst the red margin must be continuous, and the section such that the raw surfaces are larger than are absolutely 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 from within the nostril, in a crescentic manner (Fig. 377), so that a slight angular projection is formed to constitute a prolabium. This is done on each side, and where the nose is much flattened, more tissue is removed on the outer than on the inner side, so that when the parts are sutured together the nostrils become as nearly as possible sym- metrical. By this means the depth of the lip is increased to allow of subsequent contraction, wh'ist the red margin can be made continuous. AFFECTIONS OF THE LIPS AND JAWS 787 (b) Miranlt's Operation (Fig. 378). — The inner margin and apex of the cleft are pared, so as to leave a raw surface; a flap of red mar- ginal tissue, as thick as possible, is then cut from the outer side, and implanted on the bevelled raw surface of the red margin on the inner side, the upper portions of the cleft being also apposed. Fig. 377. — Rose's Operation for Single Hare-Lip. On the left side the semilunar incisions are seen extending as far as the free borders of the lip. The right-hand figure shows the parts drawn into position; the wide cross lines represent the wire sutures, the narrow ones the catgut or horsehair stitches. 3. Sutures are now inserted to maintain the lip in the position into which it can be drawn by the fingers without tension. Two deep silver-wire sutures should be introduced, one just above the red margin, and one close to the nose, to draw into position and steady the nostril, which should be left smaller than that on the other side. Fig. 378. — 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. SO as to allow for subsequent dilatation, which is certain to occur. Horsehair or catgut stitches are used to bring the exact margins together, the continuity of the muco-cutaneous line being accu- rately preserved, and the cut edges of the mucous membrane upon the deeper aspect being sutured, each stitch, after it is tightened, being used to elevate and evert the lip, and thus assist the insertion 788 A MANUAL OF SURGERY 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 butterfly, 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 tlie fourth day, and the superficial ones about the eighth or tenth. Careful feeding by spoon is necessary, the mother's milk being drawn off and given in this way if possible. In simple cases the child may be returned to the breast about the fifth day. In order to prevent the child from picking at the Hp or disturbing the dressing, it is well to put a sphnt on the flexor side of each arm to control the elbow-joint. The Treatment of Double Hare-lip may be discussed under two eadings, viz., the treatment of the os incisivum, and that of the soft parts. The OS incisivnim need not be touched if it retains its normal position, and the labial clefts are then alone dealt with; but if it Fig. 379. — Rose's Operation for Double Hare-Lip. 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 long cross lines represent the position of the wire stitches, the shorter ones of the catgut sutures. projects forwards, as is often the case, it must be either removed, replaced, or reduced in size, [a) In bad cases where there is much projection the process must be removed. The central portion of the upper lip is freed from it by dissection, and the base of the process divided with cutting-pliers; a small artery in the bone will spurt vigorously, and may need an application of the cautery to stop it. The operation on the lip is deferred till ten days later. A certain amount of deformity from dropping back of the upper hp is certain to result, but can be in measure obviated by adding a projecting cheek-plate to that which carries the artificial incisors, {b) Reposi- tion may be effected by several methods, the best of which is Bardeleben's, who incises the lower border of the septum, strips off the muco-periosteum from either side, and then bends or breaks the bone back into position, fixing it by silver wires, and uniting the lip at once to form a sphnt to maintain it in situ. The advantages AFFECTIONS OF THE LIPS AND JAWS 789 claimed for reposition are that the patient retains his own central incisor teeth, and that the normal contour of the jaw and face is not interfered with. Against this plan, however, must be placed the facts that the bone rarely becomes firmly united, that the teeth are stunted and erupt obliquely backwards from rotation of the process, and that its presence prevents the maxillse from falling together and increases the difficulties of subsequently closing the palatal cleft. By dividing the septum parallel to the plane of the palate, the process can be slid back, and its rotation is thereby avoided, (c) Where, however, the projection is not 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 as in single hare-lip. They are freely detached from the maxillae, and the edges pared, as shown in Fig. 379, 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 latter are now drawn to- gether and united in the middle line below the central portion, so that a Y-shaped cicatrix results. One of the deep silver stitches should fix the apex of the V; the other should be inserted just above the red margin. The dressing and after-treatment are as in the single operation. For a time the child may have difficulty in breath- ing owing to the diminution in the size of the oral aperture, but this is obviated by the nurse drawing down the lower lip with the fingers, or by painting it in a vertical direction with collodion. Median Hare-lip may occur in one of two forms ; eittier a simple cleft exists in the middle line (Fig. 380), or there may be an absence of the intermaxilla and nasal septum, causing flattening of the bridge of the nose, and a broad median defect, flanked by the maxillary portions of the lip. Oblictue Facial Cleft is an uncommon deformity, characterized by a cleft or sulcus in the face, starting from the usual situation of a hare-Up below, but running up outside the nostril to the inner side of the lower Hd (Fig. 381). Coloboma of the iris or choroid is sometimes associated with this rare defect. The deformity is due to non-closure of the naso-orbital fissure, and runs along the line of the nasal duct. It may be limited to the soft parts, or may involve the bones, even lajdng open the antrum. Macrostoma (Fig. 382) is characterized by an abnormal width of the mouth, and is due to non-union of the maxillary and mandibular processes. It may be uni- or bi-lateral, and is usually associated with anomalies of development of the ear, accessory auricles being often present. As a rule, a small papilla on the upper and lower margins will indicate the true limits of the mouth, being constituted by the points of attachment of the orbicularis. The existence of these is of great importance as indicating the extent to which the cleft must be pared in order to restore the mouth to its normal size. Fig. 380. — Median Hare-Lip. 79° A MANUAL OF SURGERY Mandibular Clefts are exceedingly rare. They are due to non-union of the mandibular processes in the middle line, and involve either the soft tissues of the lower lip alone, or may extend to the bone, and even the tongue. Treat- ment is as for ordinary hare-lip. Microstoma is the term applied to a condition in which the fusion of the parts entering into the formation of the lips progresses to a greater extent than usual, so that the oral orifice is contracted. It may be associated with defective development of the lower jaw. In the more severe cases, where the mouth is extremely narrowed, a transverse cut should be made outwards on each side, and the mucous membrane stitched to the skin. Macrocheilia, or hypertrophy of the lip, occurs in three forms: I. The congenital variety, a condition analogous to macroglossia, and due to a congenital distension of the tymphatic spaces, or chronic Fig. 382. — Macrostoma Auricular Appendages. GUSSON.) WITH (Fer- FiG. 381. — Oblique Facial Cleft, OR, RATHER, CICATRICIAL DE- FORMITY ALONG THE LiNE USUALLY TRAVERSED BY SUCH A Cleft. (Kraske's Case.) lymphangiectasis, accompanied by overgrowth of the connective tissue. The lower lip is most often involved, and is firm, thickened, and everted, causing considerable deformity. The treatment con- sists in the removal of a V-shaped portion from the centre. 2. An acquired form occurs in children and young people with a tuber- culous inheritance, constituting the so-called ' strumous lip. ' Either lip may be affected, but perhaps more'Jrequently the upper; the thickening is due to a chronic lymphangitis, resulting from the absorption of toxic material from persistent cracks and fissures. If these can be healed, and the general health improved, diminution in the size of the lip soon follows. 3. In adults, macrocheiha 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 AFFECTIONS OF THE LIPS AND JAWS 791 sclerosis characteristic of tertiary mischief. General treatment, and not local, is needed. Syphilitic Affections of the lip are not uncommon. A primary chancre may be caused by kissing, or by smoking an infected pipe, or drinking from a glass with an infected rim. It usually presents a smooth ulcerated surface, dischaiging a small amount of sero-pus, resting on a mass of infiltrated tissue which may extend over the whole lip (Fig. 383). The induration is not so great as in chancres upon the genital organs, but the infiltration is much more extensive. Enlargement of the submaxillary lymphatic glands occurs very early, and the disease usually runs an active course. The treatment is as for syphilis elsewhere (p. 166). A labial chancre may closely resemble epithelioma, but is dis- tinguished from it by its rapid development up to a certain point, by the early implication of the glands, which soon become very large, by the absence of typical cachexia, by the age of the patient, and the course taken by the case, as well as by the local ap- pearances. The surface is usually flattened, and less warty and irregular than in epithelioma, whilst the skin is more involved than the mucous membrane. Moreover, it is more common on the upper lip, whilst epithelioma is usually seen on the lower (com- pare Figs. 383 and 384). In the secondary stage mucous tubercles are frequently met with, involving the inner side of the lip and the angle of the mouth. In the tertiary period serpiginous ulceration and gummata may occur, or the diffuse induration described above. In inherited syphilis, cracks and mucous tubercles are constantly present, and may be so extensive as to leave cicatrices radiating from the mouth, which are very characteristic (Fig. 173). Cracked Lips (or, as they are often called, chapped lips) are usually the result of cold weather, a central crack or fissure forming which is extremely painful, and liable to bleed very readily on everting or stretching the part. The lower lip is that generally affected. In tuberculous children more than one may occur, and by their per- sistence they give rise to a considerable degree of induration and infiltration, and perhaps lead to glandular trouble. All that is needed in the shape of treatment is the application of a little lanoline or cold cream, but if they persist, it may be advisable to touch them with nitrate of silver. Fig. 383. — Chancre of Upper Lip. (From a Photograph.) The enlargement of the submaxil- lary lymphatic glands is very evident. 792 A MANUAL OF SURGERY 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 hypersemic 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. Xo special treatment is required. If the inner aspect of the lip is affected, the epithelium early becomes sodden and is shed, so that the vesicular stage is much shorter. Mucous Cysts occur on the inner side of the lip in the form of small rounded swellings, which are translucent and contain a glairy fluid. They are often due to trauma, whereby the opening of a mucous gland is blocked. The whole cyst wall should be dis- sected out, and the wound closed by stitches. Naevi are frequently met with in the lip. If confined to the inner aspect they may be dis- sected out, but when large and involving the whole thickness, they should be dealt with by elec- troh^sis. Warty Growths are often seen on the lower lip, especially near the angle, and may then simu- late epithelioma. They are dis- tinguished, however, by the fact that ulceration is not often present, that the lymphatic glands are not involved, and that there is but little infiltration of the base. They should, how- ever, be removed 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 commonly due to the irritation produced by smoking a short clay pipe, which is allowed to rest on one or the other side near the angle. A semicircular notch will frequently 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 friction of the pipe-stem. It may also start opposite the site of some projecting, rough, or carious tooth. It is but rarely met with in women, occurring in England in not more than 5 to 6 per cent, of the cases, and probably most of these are clay-pipe smokers. It is certainly more common amongst country folk, who use the short clay pipe, than amongst the cigarette and cigar smokers in towns. Fig. 384.— Chronic Epithelioma of Lower Lip. (From a Photo- graph.) AFFECTIONS OF THE LIPS AND JAWS 793 The disease may start as an induration around a crack or fissure, \\'hich gradually extends, forming a typical malignant ulcer ; or as a wart-like growth, which fungates and ulcerates; or as a chronic infiltration leading to an irregular nodulated thickening of the lip, which sometimes looks shrunken and feels sclerosed (Fig. 384). If allowed to run its course unchecked by treatment, the disease steadily progresses, forming an ulcerated mass of greater or less size, and even involves the jaw. The submental and submaxillary glands are early implicated, and secondary deposits are also found in the glands which accompany the carotid vessels. Beyond this, however, the disease rarely extends, visceral complications being uncommon. Death is generally caused by the secondary growths in the neck, which attain considerable dimensions and then ulcerate, this stage being possibly preceded by one of cystic degeneration. From these ulcerating surfaces a quantity of discharge escapes, the amount varying with the septicity or not of the wounds. Intense pain is caused by implication of nerves, and haemorrhage is also likely to follow from erosion of the vessels in the neck. The Diagnosis of epithelioma is rarely doubtful, but occasion- ally warty growths, or even a primary chancre (p. 791), may be mistaken for it. The clinical history generally suffices to de- termine 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 small portion of the edge under cocaine, and its microscopic examination, are required to set doubts at rest. Treatment. — The primary growth must be excised completely, if such be possible, together with its lymphatic connections, including the submental and submaxillary glands and the deep carotid glands, whether they can be felt enlarged or not. When once the deeper glands in the neck have become palpably enlarged, they often contract such adhesions as to render their extirpation im- practicable. If the growth is limited to one part of the lip, a V-shaped wedge extending half an inch beyond it in all directions may be taken away (Fig. 385), and the wound closed, as in a case of hare-lip, without much deformity resulting. When it is more extensive, considerable ingenuity 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 labial fissure transversely to one or the other side, or to both, dissecting up these segments from the bone; the flaps can then Fig. 385. — V-SHAPED Incision for Re- moval OF Epithelioma of Lip. 794 A MANUAL OF SURGERY 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, Syme's operation may be 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 extending down- wards under the chin, to terminate below the angles of the jaw, an inverted V-shaped portion of skin between them remaining fixed to the symphysis menti to form a base of support for the new lip. The lateral flaps are now dissected up, raised, and united one to the other in the middle line, so as to constitute the new lip, an inverted Y-shaped cicatrix resulting. The elasticity of the skin in this region allows this to be accomplished, and the whole wound closed, without leaving any part to granulate. The mucous membrane should 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 be restored in a variety of ways. Perhaps one of the best consists in making incisions which skirt the alse nasi on each side, and then extend outwards into the cheeks sufficiently to allow the tissues, when they have been freed from the maxillae by undercutting, to be drawn together in the middle line. In such cases care must be taken not to encroach on Stenson's duct. The Extraction of Teeth. Although this operation is usually undertaken by dentists, yet surgeons and medical practitioners have not unfrequently to perform it, and not a little skill and judgement are sometimes needed in its execution. An anaesthetic may or may not be employed. If merely one or two teeth are to be drawn, gas or chloride of ethyl will suffice; but when a large number require extraction at one sitting, it is better to give ether or the x\.C.E. mixture; chloroform should never be administered when the patient is in the sitting position. The posterior teeth are, of course, dealt with first, and subsequently those in front. Suitable forceps are required for the various teeth, and the number of fangs belonging to each must be kept in mind. Incisor and canine teeth are removed by a com- bination of traction and rotation; the bicuspids and molars by traction combined with lateral movement, especially inwards. The forceps, after being sterilized, should be pushed well up under the gum, and no traction made until a firm grasp has been taken of the neck of the tooth, and the tooth itself loosened by lateral swaying. Accidents of various types happen from time to time. The crown may break away, leaving the fangs in situ, and then each of these must be sought with root forceps and accounted for. In dealing with the first or second upper molar, it is quite possible to drive a fang upwards into the antral cavity, setting up thereby AFFECTIONS OF THE LIPS AND JAWS 795 acute suppuration within the cavity. Laceration of the gum is often unavoidable, and injury to the alveolar margin may follow; but such accidents as fracture or dislocation of the lower jaw are certainly avoidable. The use of an elevator is sometimes desirable in order to remove old roots, but it is an instrument that must be used with great care. After extraction the mouth is washed out with sterilized or car- bolized water, and the bleeding usually ceases without delay. If the gum has been much torn, it should be pressed back into position by the fingers, and when the mouth is dirty, it may be desirable to touch the socket over with tincture of iodine. A mouth-wash of boric acid or sanitas is subsequently employed. Should the hcsmorrhage continue, as in patients suffering from purpura, scurvy, and haemophilia, the socket must be carefully plugged with a strip of gauze soaked in a styptic, such as adrenalin or antipyrin ; the use of perchloride of iron in this connection is un- desirable. Occasionally the bleeding re-starts after two or three days as a result of infection of the socket ; it is then necessary to open up the cavity freely from the outer side, cutting away gum and, if need be, bone, so as to allow free exit to discharges and a more ready access for strips of gauze soaked in styptics or antiseptics. AfEections o£ the Gums and Alveolar Processes. Spongy or Inflamed Gums (gingivitis) are not unfrequently caused by a dirty and uncared-for condition of the teeth, the ad- ministration of mercury, or scurvy. They are characterized by being soft and congested, bleeding readily on pressure, and perhaps showing signs of ulceration. The teeth are often loose, and may fall out. All that is necessary is the correction of the determining cause and the use of an alum mouth- wash. Alveolar Abscess (Fig. 386) is almost always associated with sup- puration around the fang of a carious tooth, the bacteria finding their way out of the pulp chamber through the apical foramen. The alveolar walls become expanded, and the pus either finds its way over the edge of the bone (C, D), or even through the osseous tissue (A), under the external periosteum. If limited in extent, it per- forates the gum directly, and is then known as a gum-boil; but occasionally it burrows beneath the periosteum, which is stripped from the bone, and may thus lead to an abscess of larger size, pos- sibly resulting in necrosis of the jaw. The formation of an alveolar abscess is almost always associated with considerable oedema of the face, pain of a serious character, and when extensive may give rise to marked constitutional disturbance. Sometimes graver comphcations ensue; thus, iri 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 796 A MANUAL OF SURGERY 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. When suppuration occurs beneath the periosteum, the pain can at first be relieved in measure by fomentations, but as soon as fluctuation is detected a free incision should be made, if possible, through the gum, 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 enough opening has been made, all that is subsequently needed is repeated and frequent Fig. 386. — Diagram of Alveolar Abscess, resulting from Disease of Molar Tooth. (After the American System of Dentistry.) Abscess arising from escape of septic material from B, the pulp chamber, through the foramen at apex of the fang; it has burrowed directly through the alveolar process and burst through the gum; C, similar abscess, which has tracked down between the tooth and the alveolus, and spread out beneath the alveolar periosteum at D, constituting the typical alveolar abscess; E, cheek; F, antrum; G, nasal cavity. irrigation, preferably with peroxide of hydrogen. When the skin is thinned and the cheek red, an external incision is usually re- quired, and sometimes this may have to be undertaken as a pre- liminary, the extraction of the tooth being left until the swelling has somewhat subsided. If a small sinus persists after removal of the tooth, it must be opened up, and any carious or necrosed bone taken away. Not unfrequently the masseter becomes infiltrated and sclerosed when the lower jaw is affected, and this may result in fixed closure of the mouth, demanding operative treatment for its cure. Pyorrhoea Alveolaris (or Riggs' Disease) consists in an inflam- matory condition of the margins of the gums, accompanied by a AFFECTIONS OF THE LIPS AND JAWS 797 purulent discharge, which arises from pockets or pouches which may extend a greater or less distance along the roots of the teeth. In the early stages the gums are swollen and cedematous to such an extent that they often hide or partially cover the stumps of decayed teeth, and they bleed readily. The tongue is coated, and the breath exceedingly offensive. In less severe cases and in the later stages the tissues of the gums shrink, and, together with the alveolar border, become atrophic ; the fangs are thereby uncovered and the teeth loosened, so that after a while a natural cure may be estab- lished by the patient becoming edentulous. The process is limited to a few teeth, or may involve many. It is generally preceded by an excessive deposit of tartar, beneath which bacterial infection occurs, the inflammation spreading down along the periodontal membrane, and perhaps extending to surrounding parts — -s.g., the maxillary antrum. In most cases, on making pressure along the alveolar margins, a greater or less quantity of pus can be squeezed out. For the constitutional results of this oral sepsis, see p. 84. Treatment must, in the first place, be directed to the teeth, and consists in the removal of tartar and the application of astringents and antiseptics, preferably peroxide of hydrogen, not only to the exposed mucous membiane, but also into the pouches and pockets where pus collects. In some cases it is wise to destroy the granu- lation tissue forming the outer wall of these pouches by means of the electric cautery, or even to remove the teeth. Too much must not be done at a time, as the general symptoms may be aggravated by an increased absorption of toxins, and the reparative activities of the patient may be very deficient. Goadby* has pointed out that in many of the worst cases the resisting power of the individual, as estimated by the opsonic index, is very low to particular organisms isolated from the mouth, and recommends the employment of a suitable vaccine prepared from these particular bacteria. Hypertrophy of the Gums is met with in the form of a sessile over- growth, sometimes almost cauliflower-like, around and between the teeth, which are usually carious; it occurs most frequently in children. In slight cases the overgrowth may be destroyed by the application of a crystal of trichloracetic acid; but in the more exaggerated types excision is required. Dental Cysts are by no means uncommon, resulting from the irritative effects 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 the bony wall is absorbed, parchment -like crackling can be felt; finally, the con- dition presents as a rounded tense elastic swelling, around the margins of which the remains of the expanded bone can be detected. * Goadby: Erasmus Wilson Lecture on ' Pj^orrhoea Alveolaris ' (Lancet, March 9, 1907). 798 A MANUAL OF SURGERY In the upper jaw they often encroach on and project into the bony antral cavity, pushing the mucous membrane in front of it. The tooth which is the cause of the trouble is always dead, and fre- quently merely a septic root is present. The catise of these cysts is probably the proHferation of certain embryonic remains of the enamel organ, brought about by the irritation of toxic matter which has escaped from the pulp cavity. These foetal residues are lighted up into activity, developing into masses or columns of epithelial tissue, which undergo cystic de- generation. Their pathogenesis is practically identical with that of the epithelial odontome, but merely one cyst develops here in- stead of many. The fluid contained therein is thick and mucoid in character, and broken- down epithelial cells and cholesterine are seen in it on micro- scopical examination. Treatment. — The cyst must be laid freely open into the mouth, the septic tooth or stump removed, and the anterior wall of its alveolus cut away. The alveolus and cyst thus laid into one cavity are scraped so as to remove all the epithelial lining, and packed with gauze so as to ensure healing by granulation. In the upper jaw the utmost gentleness is required in dealing with the deeper wall of the cyst, as the septum between it and the antral cavity may be extremely thin and entirely devoid of bony tissue. Epulis. — By this term is meant a tumour growing from the alveolar periosteum. Two varieties are described, viz., the simple and the myeloid. A Simple Epulis is usually of a fibromatous nature, and may grow from either jaw, though more commonly from the lower. It is generally due to the irritation 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. 387), of an elastic consistency, and possibly 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 away and scrape the bone from which it arises; but if large, or if it recurs after such treatment, the portion of the alveolus from which it springs must also be excised. This is best Fig. 3S7. — Simple Epulis. AFFECTIONS OF THE LIPS AND JAWS 799 accomplished by extracting a tooth on either side of the tumour, and cutting vertically through each socket with a saw, the two in- cisions being united below by a chisel, so as to remove a quad- rangular portion of bone without interfering with the continuity of the jaw. Myeloid Epulis. — This title is applied to a myeloma developing from the interior of the alveolar process. It forms a soft, rapidly increasing mass of a dusky purple colour, which runs on to ulcera- tion or fungation ; the deeper portions may contain an ossific deposit. As with all forms of myeloid growth, it is only locally malignant. Treatment consists in free removal of the tumour and of the portion of alveolus from which it arises. In the upper jaw this sometimes necessitates excision of the complete palatal segment of the maxilla, but in the lower jaw it is generally possible to maintain the con- tinuity of the mandible by removing merely a quadrilateral portion in the same way as for a simple epulis. Epithelioma and Sarcoma (round or spindle-celled), arising from the gum, are both met with. Epithelioma in this situation occa- sionally fungates, but more often invades the bony tissues, and in the upper jaw extends upwards to the antrum; hence it is sometimes termed a ' creeping or burrowing epithehoma.' The ordinary signs of this disease become evident, lymphatic glands are enlarged, and typical ulceration of the gum follows. The only possible treatment consists in free excision of the growth, together with the portion of bone affected and the lymphatic area involved. Necrosis of the Jaw. — Causes: (i) Subperiosteal alveolar abscess, connected with dental caries. (2) Traumatism, such as blows on the jaw, with or without fracture, in the latter instance being due to infective periostitis or osteo-myelitis, owing to the lesion becoming compound. The use of dirty forceps or elevators in extracting a tooth may similarly light up an infective inflammation, resulting in necrosis. (3) In tertiary syphihs necrosis also occurs, affecting most frequently the palate or alveolar borders. (4) It results from mercurial poisoning, but rarely at the present day. (5) Phos- phorus necrosis is met with amongst those who work in lucifer- match factories, but only when ordinary phosphorus is used; the amorphous form is harmless. The fumes 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 seques- trum, which is curiously gray and porous, like dirty pumice-stone, is always slow in separating. Either jaw may be affected, but perhaps the lower a little more commonly than the upper. (6) Ne- crosis may follow one of the exanthemata or any condition of mal- nutrition or anaemia, arising as an infective idiopathic or embolic osteo-myelitis, and then probably affecting a considerable extent of bony tissue, possibly the whole mandible. (7) Tubercle is occasionally responsible for this condition. The symphysis menti in children is occasionally the seat of a 8oo A MANUAL OF SURGERY pyogenic or tuberculous infection, previous to the eruption of the permanent incisors. An abscess forms, and caries or a hmited necrosis results. In a case of this type an opening is required in the submental region, through which the diseased tissue can be thoroughly scraped away. Ihe teeth are of course lost, but a good result, and with but little scarring, may be anticipated. The Clinical Phenomena associated with necrosis of the jaw are necessarily much the same whatever the cause. The acute form commences with severe pain in and around the jaw, followed by great swelling of the face and difficulty in opening the mouth or taking food. Ihe temperature is raised, and even rigors may be present; the breath is usually foul. Sooner or later an abscess forms, which may point either in the mouth or on the face, or the pus may burrow downwards for some distance into the neck. Sinuses persist, discharging the most offensive pus; a new covering of bone sometimes forms in the lower jaw, enclosing a sequestrum, but in the upper this is rarely noticed, and even in the lower it is not unusual to see a considerable amount of bare or dead bone absorbed without the formation of an involucrum. Treatment.^ — In the early stage the cheek should be fomented, but as soon as there is any suspicion of pus a free incision is made down to the bone inside the mouth and along the line of reflection of the mucous membrane. When necrosis is present, it must be treated in the ordinary way, the sinuses being flushed out with an antiseptic solution three or four times a day until the sequestrum is loose; it is then removed, if possible, from within the mouth. Drainage by means of an external opening is often absolutely necessary. In the worst cases necrosis may extend from the middle line of the mandible to the temporo-maxillary articulation; it is then wise to make an external incision, and remove the bone in toto after detaching it by saw from the other ramus. Af¥eetions of the Antrum. Suppuration within the Antrum {empyema of maxillary sinus) fre- quently arises from disease connected with the fangs of the first or second molar or bicuspid teeth ; it not uncommonly results from an acute inflammation of the nasal cavities as in influenza, and may then be associated with trouble in the other accessory nasal sinuses, such as the frontal and ethmoidal (p. 821) ; it is occasionally lighted up by injury. In chronic cases it is not unusual to find the antrum filled with soft polypoid granulations. The Symptoms produced are often extremely equivocal, and the condition may be present for some time without being recognised. In the chronic forms all that is noticed may be an intermittent dis- charge of pus into and from one side of the nose, associated perhaps with some pain in the infra-orbital region, a chronic cough, and an irritable throat. The pus varies considerably in amount and character, being sometimes extremely offensive. On holding the PLATE V. Transillumination of the face. [ To face page 800. AFFECTIONS OF THE LIPS AND JAWS 8oi patient's head forwards, it can be demonstrated that there is an overflow of pus into the nostril, and sometimes when the patient rechnes it flows back into the pharynx. Should the opening into the nose become blocked, all the symptoms are aggravated, the pain becoming more marked and the swelling increasing. Signs of distension of the antrum may also be produced in this way, and are manifested in four directions: (a) Inwards, causing obstruction to nasal respiration, and possibly epiphora, from compression of the nasal duct; {b) upwards, leading to protrusion of the eye- ball or exophthalmos; (c) downwards, resulting in depression of the side of the palate, and possibly irregularity in the line of the teeth; and {d) outwards, giving rise to a somewhat charac- teristic projection of the cheek beneath the malar eminence. Under these circumstances, a finger inserted into the mouth, between the cheek and the bone, will detect a loss of resistance in the anterior wall of the antrum, and if the distension has lasted long, eggshell crackling may be noticed, or the whole anterior wall may be absorbed and an elastic swelling take its place. Infra-orbital neuralgia is often a marked feature in these cases. In acute cases all the above phenomena may be present in an accentuated degree, accompanied by severe tensive pain and some amount of febrile disturbance. Necrosis of the lining bony walls may also be induced, owing to the fact that the mucous membrane is closely adherent to the periosteum. The Diagnosis of suppuration within the antrum is not always easy. The periodic discharge of pus from the nose is suggestive, as also the presence of a dead or painful molar or bicuspid tooth. If a flow of pus can be induced by change of position of the head, it is pathognomonic of suppuration within one of the accessory sinuses connected with the nose, probably of the antrum. If, after the nose has been cleared and the head hung down, pus is seen welling up from under the middle turbinal, the diagnosis is almost certain. Transillumination of the antrum may confirm this opinion. A suitable electric lamp is placed within the mouth, and if the patient is in a dark room, or if he and the surgeon are under a photographer's cloth, and his antra are normal, the cheeks, lips, and lower margins of the orbits become of a rosy-red colour (Plate V.). If, how- ever, the cavities are occupied by pus, blood, or a growth, the parts remain dark. Transillumination does not answer in every individual, and hence the value of the test is much dimin- ished. The presence of illumination excludes intra-antral growths or abscess, but its absence, unless unilateral, is not of much significance. Finally, the antrum may be punctured with trocar and cannula through the canine fossa, or through the inferior nasal meatus, and an absolute diagnosis obtained by washing it out. The Treatment necessarily varies with the type of the disease. It must always be remembered that the orifice of the antrum into the 5^ 8o2 A MANUAL OF SURGERY middle meatus is an inch above the antral floor, and hence the natural drainage is very defective (Fig. 396). In the early active form that sometimes follows the extraction of a tooth, and may even be associated with the pushing up of a broken fang into the cavity, it will probably suffice to enlarge the opening in the alveolus with a suitable antrum drill. A solid rubber plug is introduced, and the cavity washed out into the nose with sterile salt solution two or three times a day, until the purulent discharge ceases, when the opening may be allowed to granulate. The sohd plug is better than a hollow tube, which permits discharge to get into the mouth, and food or septic material to pass up into the antrum. In the acute post-influenzal cases the cavity may be washed out from the nose, the inner wall being punctured, after efficient cocaini- zation, through the inferior meatus; this lavage may be required at first daily, but subsequently less frequently, and in the intervals the patients must be guarded from cold. Sometimes a change of air will clear up the trouble. In the more chronic cases, intranasal treatment will usually suffice, but to be effective the greater part of the inner (nasal) wall of the antrum must be removed so as to leave a large communica- tion through which the cavity can be cleansed. Sometimes there is a large accumulation of polypoid granulation tissue within the antrum., and to remove it the surgeon must make an additional opening by dividing the mucous membrane above the first molar tooth and take away the anterior bony wall. Effective curet- ting can then be performed, and it is usually possible to close the buccal opening. Only in very old-standing neglected cases is it necessary to utilize the old-fashioned method of packing the antrum from the buccal aspect and making it heal by granulation. It is important in these cases to make certain that the trouble is limited to the antrum, and not dependent on the overflow into it of pus from other accessory sinuses. Hydrops Antri is the terni applied to a chronic distension of the antrum with a glairy mucoid fluid, somewhat similar in character to that contained in a ranula. The condition is painless, and free from inflammatory phenomena, and as the expansion increases, eggshell crackling of the anterior wall, or even distinct fluctuation, may be observed. It was formerly supposed to arise from obstruction to the aperture into the nose and retention of secretion, but is in reality due to a cystic tumour forming from the glands of the mucous membrane, or more often to a dental cyst (p. 797) which has en- croached on the antral cavity; rarely is it due to the presence of a dentigerous cyst (p. 808). The treatment required is to open thoroughly the cyst from the mouth after dividing the mucous membrane, subsequently removing a sufficient portion of the anterior wall to enable it to be washed out and drained. It is sometimes possible to remove the whole lining membrane without wounding the mucous membrane of the antrum. AFFECTIONS OF THE LIPS AND JAWS 803 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 symptoms, except when large enough to cause expansion of its walls. Malignant growths, however, generally pass beyond the limits of the antrum, and lead to the usual signs of malignant disease of the upper jaw. Treatment consists in removing simple growths, if possible, with- out interfering with the integrity of the maxilla. This may be accomplished by reflecting the overlying cheek, as in excision of the upper jaw. For malignant tumours, removal of the complete upper jaw on the affected side is probably the only remedy. Tumours of the Upper Jaw. Many of the Simple Tumours springing from the upper jaw have been already described amongst those involving the alveolar border and antrum. Only a few remain to be dealt with. Osteoma occurs either in the form of a tumour composed of compact tissue, then usually growing within the antrum; or occa- sionally as a diffuse symmetrical overgrowth, constituting the con- dition known as leontiasis ossea. A few cases of Chondroma have also been reported. Leontiasis ossea is a disease, fortunately very rare, which, com- mencing in young adult life, progresses slowly, but relentlessly, and may at length destroy the patient after causing a great amount of suffering. Nothing is known as to its origin. It affects either the cranial or facial bones, or both, and consists in a development therefrom of nodular masses of soft spongy bone, embedded in which are areas of fibrous tissue. When affecting the facial bones, the projections may become very marked, and give the patient a hideously repulsive appearance, with a more or less leonine aspect. As growth progresses, the new bone encroaches on the cavities of the skull, the antrum, the orbits, or even the cranial cavity, and thus exophthalmos, neuralgia, and finally coma may be produced. No satisfactory treatment is known, although attempts to chisel away the masses have been made. Malignant Disease of the Upper Jaw occurs in the form of sarcoma or cancer. Sarcoma is perhaps the more common, and originates either from the anterior wall, from the cavity of the antrum, from the spheno-maxillary fossa behind the bone, or may extend into the maxilla from the naso-pharynx. Not unfrequenily these growths have a considerable ossific basis, and this is sometimes so extensive as to obhterate the antral cavity, and convert the bone into a solid mass. Cancer develops in the form of a squamous burrowing epithe- lioma, springing from the gums ; or as a columnar or acinous cancer starting in the glandular tissue, found both in the nasal and antral cavities. It is probable that not a few of these growths, both sar- coma and carcinoma, are derived from embryonic rests, associated 8o4 A MANUAL OF SURGERY with the enamel organs and teeth, and, as Sir F. S. Eve* points out, are in reality malignant odontomata. The Clinical Features of both forms of malignant disease are practically identical. If arising/ro;;/ the anterior aspect of the bone, a tumour is produced which projects under the cheek, the tissues of which are invaded by it; it extends down towards the mouth, and is readily detected through the mucous membrane. It may, however, spread deeply, and involve the cavity of the antrum. It causes no obstruction to nasal respiration, and no epiphora except in the later stages. 1 . If it originates ivithin the antrum, the usual signs of distension of that cavity (p. 80 1) are produced, associated with a foul, and often blood- stained, discharge from the nose, within which the ulcerated surface of the growth may be seen. Epiphora is caused by pres- sure on the nasal duct, whilst the growth has been known to burrow upwards along this passage and project near the inner canthus. The passage of air through the nose on that side is also impeded, and the palate may be depressed. If the growth commences behind the maxilla, it usually springs from one of the walls of the spheno - maxillary fossa, or from the base of the skull, and is then characterized by a great tendency to spread in all directions. It may push the whole bone bodily for- wards without encroaching upon the antrum; sometimes it finds its way outwards to the pterygoid fossa through the pterygo-maxillary fissure, or inwards to^the nose through the palatine foramen, or even up into the orbit; whilst more rarely it spreads down along the posterior palatine canal, so as to appear at the postero-external corner of the palate; in the later stages the antral cavity is also involved, and even the base of the skull eroded. The General Signs of a malignant growth of the superior maxilla consist in the appearance of a tumour which, in its earlier stages, may produce various effects, but finally is likely to destroy the bone and occupy the whole of the maxillary region (Fig. 388). It is usually accompanied by nasal obstruction, epiphora, and a dis- charge of blood or pus from the nares. Severe pain sometimes * Sir F. S. Eve, Brit. Med. Journ., June 29, 1907, Fig. 388. — Osteo-Sarcoma of^[the Upper Jaw. AFFECTIONS OF THE LIPS AND JAWS 805 accompanies the process, especially affecting the second division of the trigeminal. Neighbouring lymphatic 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 viscera may also occur somewhat later. The tumour follows a typical malignant course, and, owing to the great vascularity of the parts, its onward progress is very rapid. The Diagnosis of malignant disease of the upper jaw from a simple tumour or cyst should be readily made; the rapidity of its growth, the greater pain and more abundant discharge from the nose, the associated enlargement of the lymphatic glands, and the tendency to spread to and encroach upon surrounding structures, all point to malignant disease. In some cases, however, an exploratory incision is required to make certain of the diagnosis. More fre- quently the existence of a tumour at all is for some time entirely overlooked, some one prominent symptom, such as neuralgia or epiphora, being treated without ascertaining the cause. Trans- illumination (p. 801) may assist in clearing up the diagnosis, as also radiography, which would indicate the presence of an unerupted tooth in a dentigerous cyst. Treatment consists in free removal of the growth with a good margin of healthy tissue around it, together with the lymphatic area involved. This not unfrequently involves excision of the superior maxilla, but if the disease has spread beyond the limits of that bone- — e.g., into the cheek^ — or has invaded either primarily or by extension the retro-maxillary tissues, the advisability of attempting removal is very doubtful, since it involves a terrible mutilation, and complete eradication is always a matter of uncer- tainty. In these cases, as in so many others, early diagnosis is all-important ; and inasmuch as this is now practicable, thanks to improving knowledge and experience of intranasal work, the more severe types of operation are less frequently required. Wherever practicable, the alveolus and floor of the orbit ought to be spared, and if the case is recognised sufficiently early, this can often be accomplished. ife Lateral Rhinotomy (Moure's operation) is the most effective and satisfactory method of removing growths of the maxilla or neigh- bouring portions of the nasal cavity which do not encroach on the mouth or orbit. The interior of the nose is treated with cocaine and adrenalin; the patient is then ansesthetized, and the choana plugged. Two incisions are made from the inner end of the eyebrow, one down to the nasal orifice, the other along the infra-orbital border. The triangular flap between these is dissected down and outwards, including, if possible, the periosteum, and the bone is thereby exposed. Incisions are then made through the bones with hammer and chisel as follows: One between the nasal bones, or slightly to one side; a second from the upper end of this hori- zontally out to the orbital margin; and a third from the lower border 8o6 A MANUAL OF SURGERY of the nasal aperture upwards and outwards to the infra-orbital border close to the infra-orbital foramen. The portion of bone thus marked out, including a small section of the floor of the orbit, can be easily twisted out of its bed by forceps, laying bare the lachrymal sac and canal. The amount of bone removed varies necessarily with the case, but a considerable opening into the antrum and nasal cavity results, and growths of this region can be readily removed, if need be piecemeal, without grave haemorrhage or serious mutilation. The incisions are subsequently closed by stitches, and the resulting deformity is very slight. Excision of Superior Maxilla varies somewhat in different cases according to the character and extent of the disease. The patient's head and shoulders are well raised, and anaesthesia is maintained b}^ means of chloroform given by Junker's apparatus. Prehminary tracheotomy is scarcely necessary or desirable if good assist- ance is available. The proceeding may be described in stages as follows: Stage I. : Incision and Reflection of the Soft Structures of the Cheek. — The central incisor tooth of the affected side having been extracted, the upper lip is divided in the middle line; the incision is carried round the ala and along the side of the nose, to a point half an inch below the inner canthus; it thence extends along the lower orbital margin to a point below its outer border, or even to the zygoma (Fig. 389, A). The flap thus marked SAT °^^ ^^ raised from the bone, and re- 'removIZ ' of'''''^Super^or fleeted outwards so as to clear the Maxilla; B, for Removal zygomatic eminence, and the more im- oF Lower Jaw. portant vessels secured, as they are divided, by Spencer Wells' forceps. Stage II. : Divison of the Bony Attachments. — The side of the nose is then freed from its bony attachments, and the periosteum stripped up from the floor of the orbit. The nasal process of the superior maxilla is now cut through with a saw (Fig. 390), and also the malar bone divided so as to open into the spheno-maxillary fissure. A key- hole saw is next parsed into the nose, and the alveolus and hard palate divided from before backwards through the empty socket of the central incisor tooth. The surgeon then takes a pair of long- handled cutting-pliers, and completes the division of each of these bony attachments. The cutting-pliers must always be applied with the smooth surface towards the tissues which are to be left, and the bevelled surface towards the part which is to be removed. The section of the palate is completed last, and then the cutting- pliers are used as a lever to prise the bone out of its bed, the sound AFFECTIONS OF THE LIPS AND JAWS 807 bone acting as a fulcrum, the posterior attachments being thus fractured. The pterygoid processes are broken through close to their origin from the sphenoid, and the lateral mass of the ethmoid yields along the inner orbital margin. Stage III. : Removal of the Bone and Tumour. — The bone is now seized by lion forceps, one blade holding the alveolus and the other the infra-orbital border; 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 when all other connections to the soft tissues have been severed, the bone is removed. Considerable hsemorrhage occurs at this stage from the infra-orbital and posterior palatine vessels ; it / ""i \ is checked temporarily by plug- / J / Jk ging the wound firmly with a sponge, and subsequently the chief vessels are secured by liga- ture. Any outlying portions of the tumour are now dealt with, and the cavity is packed with strips of sterile gauze. The wound in the cheek is closed, the greatest care being taken to obtain ac- curate apposition of the flap, especially at the lip margin, and fig. 390.— Skull showing Lines of dressed with gauze secured with Section of the Bone in Excision collodion. °^ ^^^ Superior Maxilla. In the majority of cases there On the right side of the skull the malar is comparatively little shock, and bone is divided into the spheno- thenatientsdoremarkablvwell— maxillary fissure, as would be re- tne patients ao remarKaoiy wen aniv&d for disease limited to the at any rate, for a time — although, body of the bone. If the tumour unfortunately, recurrence is only invades the malar bone, incisions too likely to follow. The plug in as on the left side must be made— the nose is left in situ for twenty- ^^ '^f Sf mSa^ bole tt7?he four hours and then removed fissure, and behind through the through the mouth, and the wound zygoma, irrigated with some antiseptic solution. The plug may be replaced, but can usually be dispensed with if the cavity is washed out several times a day. Healing is effected by granulation, and of course a large gap communicating with the mouth remains. This can be subsequently remedied by an obturator, to the upper surface of which is attached a plug or cheek- plate to prevent falling in of the cheek, and to diminish the cavity of the nose. The patient is fed for the first few days by the rectum, or by a tube passed into the pharynx, but soon acquires the knack of swallowing fluids, especially when the soft palate has been left intact. The chief dangers are shock, recurrent haemorrhage, and septic pneumonia. 8o8 A MANUAL OF SURGERY After the wound has healed to a certain extent, the lymphatic area of the neck should be dealt with as for cancer of the tongue (P-843). Tumours of the Lower Jaw. These are similar in character to those met with in the upper jaw. Thus, Chondroma, Osteoma, Fibroma, and the simple and malignant forms of Epuhs, have been already described. ^," .Dentigerous Cysts form around teeth which are misplaced so 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 alread}^ described under the title of follicular odontomas at p. 215. They are met with in young people, and give rise to expansion of the jaw (Fig. 391) ; the tumour thus formed is at first hard and solid to the touch, but later on eggshell crackling and even true fluctuation are observed when the encasing wall has become thin or absorbed. Absence of one of the permanent teeth may sometimes be noted, but not necessarily, since the corresponding milk tooth is not always shed, owing to the want of pressure from below. Occasionally suppuration within the cavity may be caused by an extension of inflamma- tion from the fang of a neighbouring tooth, or by the cyst being opened during its extraction, and a sinus dis- charging offensive pus will then form. The diagnosis from a myeloid tumour or from a dental cyst is not always easy. The long history and the dental irregularity would point to a dentigerous cyst ; whilst dental caries would suggest a dental cyst ; but the actual diagnosis is perhaps best made by radiography, when the misplaced tooth can be seen. Treatment consists in freely opening the cyst through the mucous membrane, and removing a sufficient portion of the bony wall to permit of the removal of the misplaced tooth. The cavity is left open and allowed to heal by granulation, during which process strict attention to cleanliness must be observed. Fibro-cystic Disease of the Jaw {epithelial odontome, p. 215) has been already mentioned as characterized by the formation of a tumour, often of great size, which consists of spaces lined with cuboidal epithelium, and supposed to originate from the enamel Fig. 391. — Dentigerous Cyst, SHOWING Expanded Condi- tion OF THE Lower Jaw, and Unerupted Tooth lying Horizontally WITHIN IT. (College of Surgeons' Museum.) AFFECTIONS OF THE LIPS AND JAWS 809 organ (Fig. 392). It occurs most frequently in young people, and, as a rule, runs a perfectly benign course, although when of large size it may encroach on surrounding parts and even destroy life. The only Treatment consists in complete removal of the affected portion of the jaw. Actinomycosis sometimes develops in connection with the jaws, but more frequently in the lower. It produces a large swelling due to its growth within the bone, which may closely simulate a sarcoma; the constant tendency of this disease to suppurate and discharge the mycelial elements is a characteristic feature. For the general clinical signs and treatment, see p. 192. Myeloma is met with in the lower jaw, not only in the form of an epulis, but also occasionally as an endosteal growth, usually attacking the central portion of the bone, which becomes expanded by it. It presents but slight evidences of malignancy, and may be treated in the first place by opening the outer shell of Fig. 392. — FiBRO-cYSTic Disease of the Lower Jaw. (By kind permission of the Council of the Royal College of Surgeons.) bone through the mouth and scraping away the soft contents, the cavity thus formed being swabbed out with pure carbolic acid and plugged with gauze. Should it recur, the affected portion of the bone must be removed, although, whenever possible, a bridge of osseous tissue is left so as to connect the two segments of the jaw; if this is not attended to, they are likely to fall together, and lead to considerable deformity and discomfort. If the whole thickness of the bone is excised, a wire frame or splint should at once be intro- duced between the fragments with the same object. It is replaced later on by a suitable plate carrying artificial teeth. Round or Spindle-Celled Sarcoma also occurs, usually springing from the periosteum, the deeper parts undergoing ossification (Fig. 393). The course is typically malignant, and free removal of the affected portion of the bone must be undertaken. Epithelioma invades the lower jaw as an extension of a similar affection arising either from the gum, lips, or tongue. Excision 8io A MANUAL OF SURGERY of a portion of the bone together with the primary disease is always required, unless it has extended so far as to render extirpation impracticable. Removal of the lymphatic glands of the neck is required at a later date. Excision of the Lower Jaw is employed in the treatment of various tumours arising from that bone, as also sometimes for extensive necrosis. In the latter case it may be possible to deal with it from the mouth, but when required for the treatment of malignant disease an external incision is absolutely essential. If the whole of one side is to be removed, an incision is made reaching from just below the red margin of the lip downwards to a point immediatelv below the symphysis, and thence along the under surface of^the body of the jaw as far as the angle; it is then pro- longed upwards along the posterior border of the vertical ramus, not ex- tending further than the attachment of the lobule of the ear, so as to avoid the facial nerve (Fig. 389, B) . When a large tumour is being dealt with, the whole thickness of the lip should be divided, and the flap thus marked out dis- sected off the bone, and turned outwards. Where, however, the upper portion of the lip is left, the in- cisions 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 incisor tooth is drawn, and the jaw divided through the empty socket with a saw and cutting-pliers a httle to the side of the middle hne By this means the genial tubercles and their attached muscles are not encroached on, or the movements of the tongue impaired. The bone is seized and drawn outwards, and its internal connections as far as the angle divided. It is then firmly depressed, and the muscular attachments of the masseter on the outer side, and of the internal pterygoid on the inner, cut through, as also the inferior dental nerve and artery. By still further depressing the bone, the temporal tendon is exposed, and should be divided by successive touches of the knife, which is kept close to the bone. Finally, the condyle is freed after division of the external pterygoid muscle and Fig. 393. -Osteo-Sarcoma of the Lower Jaw. AFFECTIONS OF THE LIPS AND JAWS 8ii of the ligaments of the temporo-maxillary articulation. The prox- imity of the internal maxillary artery to the inner aspect of the neck of the bone must be remembered. After h?emorrhage has been arrested, the wound is stitched together and dressed with collodion and gauze; possibly a drainage-tube may be inserted with ad- vantage for a few days through the floor of the mouth. Consider- able deformity usually results from this operation, owing to the remaining 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 of rheumatic fever, and is evidenced by pain on movement of the jaw, and by tenderness and swelling immediately beneath the root of the zygoma, due to effusion into and around the joint. Resolution generally follows, but fibroid thickening of the ligaments and im- pairment of movement may result. Acute Arthritis arises from pyaemic infection after the exanthe- mata, or from gonorrhoea, but may be caused by direct extension of inflammation from the middle ear, as in scarlatina. It occurs in children, and is due ' to the persistence of a hiatus in that part of the tympanic plate which forms the floor of the meatus and the roof of the articulation ' (Barker). It is characterized by the usual signs of a severe locahzed inflammation, with the formation of abscesses, and results commonly in ankylosis. Fomentations and the antiseptic opening of abscesses constitute the only early treat- ment, whilst excision of the condyle is sometimes required at a later date. Osteo- Arthritis is by no means a rare affection of this joint. It is often sjonmetrical, and characterized by an enlargement of the condyle, which can be felt distinctly in front of the tragus, especially on opening the mouth, when crepitus is also noticed. The pain is worse at night and in wet weather, and the jaw becomes deflected to the sound side if the disease is unilateral; when both sides are affected, the jaw is pushed forwards, and the chin projects. The articular cartilage undergoes the usual changes, the inter-articular cartilage disappears, and the glenoid cavity becomes enlarged and flattened, so that the eminentia articularis is relatively less marked, thus permitting the external pterygoid muscle to draw the condyle forwards. After a time, considerable difficulty is experienced in opening the mouth, even amounting to ankylosis. Ordinary medical treatment may be used in the early stages, but in the later the condyle of the jaw should be excised, a proceeding followed by excellent results. Tuberculous Disease may arise either in the bone or synovial membrane, perhaps spreading to it from neighbouring lymphatic glands. It runs the usual course of the disease, terminating in caries of the condyle, and ankylosis after protracted suppuration; to prevent this, excision of the condyle is indicated. 8i2 A MANUAL OF SURGERY Immobility or Closure of the Jaw may be caused by a variety of conditions: 1. True ankylosis of tlie temporo-maxillary joint, fibrous or osseous, as the result of any of the diseases mentioned above. 2. Cicatricial contraction of the soft structures either within or without the mouth, as from burns, lupus, or extensive operations in the pterygoid region upon the roots of the fifth nerve, from cancrum oris, or very rarely from myositis ossificans. 3. Spasm of the muscles of the jaw {trismus), due to reflex irrita- tion, as from carious teeth or an unerupted wisdom-tooth, or some other local lesion. It is occasionally hysterical, and is one of the early symptoms of tetanus. 4. Local inflammatory conditions often render opening of the mouth impossible, both from the pain and swelling — e.g., in mumps, parotid abscess, acute alveolar periostitis — whilst in epithelioma of the jaw, tongue, or fauces, and various forms of tumour, the size and position of the growth may seriously impair the mobility of the jaw. The term ankylosis can only be applied to the conditions men- tioned in the first two groups. In the others appropriate treatment must be instituted according to the character of the affection. Where the closure of the jaw is permanent, it may be due to osseous ankylosis, the bony masses extending not only between the articular surfaces, but also between the alveoli ; or to fibrous adhesions within the joint; or to extra-articular contraction of the soft parts, not only the skin and mucous membrane being involved, but also frequently the muscles and deeper structures. Division of the neck of the bone or excision of the head may thus be impracticable, or, even if possible, is useless, since the muscles of the jaw hold the surfaces in such good apposition as to bring about a recurrence of bony union, unless obviated by implanting a flap of the temporal muscle or a vulcanite plate between the bony surfaces. Division of the intra- or extra-buccal cicatrices is usually unsatis- factory, owing to their rapid re-formation. The best treatment in most cases is either removal of the vertical ramus of the jaw down to the level of the alveolus, or the plan suggested by Esmarch, viz., excision of a wedge of bone, with its apex towards the alveolar border, from the neighbourhood of the angle, and the establishment of an artificial joint at that spot. The incision should be made below and behind the angle down to the bone, from which the periosteum is stripped up, and division is accomplished by means of the saw. Excision of the Condyle of the Jaw is not always a simple opera- tion, since the space at the surgeon's disposal is limited by the zygoma above, the facial nerve below, the parotid gland in front, and the external ear behind. The best incision is a curvilinear one, commencing over the middle of the zygoma, and passing downwards in front of the tragus. It should merely divide the skin and sub- cutaneous tissue, and the flap thus marked out is turned forwards. AFFECTIONS OF THE LIPS AND JAWS 813 A transverse incision is now made through the deep fascia im- mediately below the posterior extremity of the zygoma, extending down to the neck of the bone, which is cleared by a raspatory and divided by cutting-pliers; the condyle is then grasped by necrosis forceps, and twisted out. But little bleeding occurs, and the wound heals by first intention, except along the track of the drainage-tube, which should always be employed. Internal Derangement of the temporo-maxillary joint (locking or clicking jaw) is not a very uncommon affection, resulting from laxity of the interarticular cartilage, which gets folded up and caught between the condyle and the eminentia articularis when the mouth is opened. The effect is a temporary painful fixation or locking of the jaw, which is usually set free by lateral movements. At other times there is marked clicking or creaking of the jaw when the mouth is opened. In bad cases treatment consists in ex- cising or stitching down the loose cartilage^ — preferably the former — through an incision made as for excision ; in the milder cases nothing can be done except to assist the removal by blistering of the synovial effusion which may be present. CHAPTER XXIX. AFFECTIONS OF THE NOSE AND NASO-PHARYNX. Depression or Flattening of the Bridge of the Nose is either a result of traumatism, such as a fracture of the nasal bones (p. 493), or may follow defective growth of the ethmo-vomerine septum, due to disease either of syphilitic or tuberculous origin early in life, whilst it may also be due to tertiary syphihs. If caused by injury, and dealt with promptly, it may be remedied; but when once acquired, and especially if the consequence of disease, treatment is much less satisfactory. Several cases have been recorded, however, in which bone-grafting 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-graft is in- troduced, and kept in position partly by sutures, but mainly by closing up the wound in the soft tissues. In one case the patient's own fourth metatarsal bone was utilized with success, whilst platinum, gold, or celluloid frames have also been employed in the same way. The subcutaneous injection of paraffin has been utilized in many of the worst cases with advantage. At first a paraffin was employed which melts at 110° F. ; this, however, caused a good deal of irrita- tion, and its exact limitation to the desired area was difficult. At the present time a cold paraffin is utilized, being expressed little by little from a powerful syringe (Mahu's), and the tissues are built up into shape exactly as is desired. The paraffin is supposed to remain permanently as an infiltration of the tissues, but further experience is required to make sure that this is the case. Expansion of the Bridge of the Nose is always the outcome of some long-continued intranasal pressure, especially from the growth of polypi. It rarely follows the development of mucous polypi, except when they are very large and chronic, but it is not an uncommon accompaniment of the fibrous or fibro-sarcomatous variety. The bridge is flattened and bulged out on either side, giving the face an appearance justifying the name ' frog-nose ' which has been applied to it. Congenital swellings at the root of the nose are not very un- 814 AFFECTIONS OF THE NOSE AND NASO-PHARYNX 815 common, and may be either a meningocele (p. 725), or a dermoid cyst which may have a deep connection between the nasal bones with the cerebral membranes. It is often advisable to leave them alone until adult life, since their intracranial connections may be shut off as the child grows up. It is impossible to discuss all the different affections of the skin ot the nose. Many of them are associated with the sebaceous glands, which in this region are very large and abundant. Thus, acne is commonly met with, arising from an inflammation of the glands after obstruction to their ducts. It is especially frequent in drinkers and dyspeptics, women addicted to tea-drinking often suffermg 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 attached to it, whilst if acne pustules are also present, it is known as acne rosacea. Sometimes the spots become much en- larged, and there is a considerable amount of infiltration of the base, a condition described as acne hypertrophi- cum. In the most exaggerated stage the sebaceous glands become over- grown and form large protuberant 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 coursing freely over them. This condition is generally known as lipoma nasi, rhinophyma, or hammer-nose (Fig. 394) . The Treat- pj(,_ ment of simple acne consists in cor- recting 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 appHcations should be used locally, such as a lotion consisting of calamine, oxide of zinc, and precipitated sulphur, held in suspension with glycerine and lime water. Dilated and unsightly capillaries may be dealt with by puncturing them with the galvano-cautery or an electrolytic needle. Rhinophyma requires operative proceedings; the protuberant mass should be freely dissected away from the cartilages, and the raw^ surface covered by Thiersch grafts or allowed to granulate. Partial or Total Destruction of the Nose may result from trau- matism, but usually from some chronic inflammatory or malignant growth, such as lupus, tertiary syphilis, or rodent ulcer. Epithe- lioma sometimes attacks it, and requires total removal of the nose for its cure. In any of these conditions the resulting deformity is so repulsive that the surgeon is certain to be asked to undertake some proceeding to remedy it. Indian surgeons have had a good 394. — Rhinophyma.^or Hammer-Nose, 8i6 A MANUAL OF SURGERY deal of experience in this direction, since in that country cutting off the nose is often resorted to as a means of avenging some real or fancied wrong. Various plastic operations have been devised, wliich, however, we can only indicate briefly here, referring students to larger works of operative surgery for fuller details. The chief methods of Rhinoplasty are as follows : 1. The so-called Indian method * consists in the formation of a nose from a fiap of skin obtained from the forehead. The ffap (Fig. 395) is more or less pyriform, with the pedicle so placed as to contain one of the frontal arteries and the supratrochlear nerve. Necessarily its exact shape and size vary with the character of the defect and with the type of nose desired. Keegan, who has done some excellent work in this direction, advises that the skin covering the nasal bones, as high as the level where the bridge of spectacles would rest, should first be turned down in two flaps, using their attach- ment to the nasal mucosa as a hinge, so that the cutaneous surface shall look inwards and the raw surface outwards. Over these the forehead flap is placed, and there should be sufficient tissue in the nasal flaps to enable their free ends to be stitched below to the forehead flap on either side of the columna, thus com- pleting the anterior nares. The columna itself IS formed by the free end of the forehead flap. Drainage-tubes are inserted through the an- terior nares and kept in position for ten to fourteen days. The lateral margins of the flap are carefully sutured to the freshened edges of the defect. When the union of the lower por- tion is sufficiently firm, the nose is made more shapely by partially dividing the twisted pedicle, but if possible the integrity of the fron- tal artery should still be retamed. The wound in the forehead is drawn together as far as possible b}' sutures, and healing promoted later by skin-grafting. 2. In the Tagliacozzian or Italian operation (so called from Tagliacozzi, the surgeon who first proposed it) a flap of skin is taken from the arm. The pedicle must always be broad, and is left attached to the upper part of the inner aspect of the arm; it must be so placed that it can be brought into apposition with the nasal defect without tension, the fore-arm and hand being fixed by a suitable apparatus above the head, and retained there until good union has been accomplished, when the pedicle is gradually divided. Abso- lute fixation of the arm is an essential, and as this may need to be maintained for two or three weeks, the patient needs a considerable amount of pluck and perseverance. When the pedicle has been detached, subsequent plastic measures are required to mould the new tissue to the shape of the nose. 3. The cheeks have also been made use of in what is known as the French method to supply material for the nose, flaps being dissected up from either side, and united in the middle line. 4. The above operations have the great objection that the new nose only consists of soft tissues, and hence it is very likely to shrivel up and contract, so that all that is finally obtained is a covering for the defect, which is often quite flush with the surface. To obviate this, and to secure a bony basis for the * For full details of this plan we would refer to Keegan's ' Rhinoplastic Operations.' Bailliere, Tindall and Cox, 1900. Fig. 395. — Indian Method OF Rhinoplasty, show- ing THE Shape and Posi- tion OF THE Forehead Flap. The points A and B are brought down to A' and B' when the flap is twisted into position. AFFECTIONS OF THE NOSE AND NASO-PHARYNX 817 nose, attempts have been made to utilize a fmger for the purpose, and Mr. Astley Bloxam has had one or more successful cases. The terminal phalanx is removed, the soft parts split down the middle line on the palmar aspect, and the divided segments united by suture to the margins of the nasal defect. When union is secured, the amputation of the finger is completed. Naturally, where only a portion of the nose is destroyed, partial operations can be devised to meet the requirements of the case. It must be admitted, however, that the nose produced artificially by any of these methods is rarely satisfactory, and has a consider- able tendency to shrink. Indeed, it is probable that in the majority of cases patients are better off with an artificial nose made of vul- canite or some such material and suitably coloured, and held on by a spectacle frame or some adhesive substance. Examination of the Nasal Fossae and Naso-Pharynx.— In order to under- stand fully the diseases of the nose, it is essential that the mterior of the organ be efficiently examined, and to do this three chief methods are employed. I. Anterior 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. Per- haps Thudichum's speculum is one of the best ; it consists of two unf enestrated blades, connected by a U-shaped spring, which is held in the hand whilst the blades are inserted into the nostril, the nasal vibrissas being 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 turbinal and the erectile tissue at its anterior extremity. The amount of distension of the latter limits the view of other structures ; if greatly swollen, it feels soft and even fluctuating, but collapses entirely on the apphcation of a 5 per cent, solution of cocaine, allowing the free convex border of the middle turbinal to come into view, as also the cleft or olfactory fissure between it and the septum. The septum can also be examined, frequently showing deviations from the middle hne, and thickenings or spurs of bone or cartilage which run in an antero-posterior or vertical direction. A certain amount of erectile tissue is also present on the septum. The introduction of a sterihzed probe under the guidance of the eye is of the greatest value in examining the nose. It not only serves to distinguish the different qualities of growth that can be seen, but will also give information concerning regions beyond the surgeon's eye. 2 By posterior rhinoscopy is meant an examination of the posterior nares by a mirror placed behind the uvula and soft palate. It is by no means easy to accomplish, and requires some dexterity and practice. The tongue should be depressed and a small 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 and position a view should be obtained of the structures exposed posteriorly. If not successful, and it is absolutely necessary to obtain a view, the fauces should be cocainized and the velum held up by some form of palate retractor, such as White s. The posterior nares (or choanse) are seen, separated by the vertical posterior free margin of the septum, and within each cavity the rounded ends of the turbinals with the meatuses intervening. The inferior meatus often looks very small owing to the prominence of the velum palati, whilst the middle meatus may be encroached on by tumefaction of the erectile tissue at the back of the inferior spongy bone. Outside the choanse are seen the yellowish openings of the Eustachian tubes, and above and between them Luschka s tonsil, a raised collection of lymphoid tissue in the roof of the pharynx is occasionally observed. " • 1 j- 3. Palpation of the Posterior Nares with the index finger, previously dis- 8i8 A MANUAL OF SURGERY infected, 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 j)asscd behind the uvula and velum, and the narcs can then be well explored, and the existence of adenoids or other growths determined. Spurs and Deviations of the Nasal Septum. — By the term spur is meant a cartilaginous or bony ridge or thickening of the septum, which runs in a more or less transverse direction, and is of congenital origin. A deviation is a bending of the septum from the middle line, leading to inequality of the nasal fosscC ; the cartilaginous septum is mainly involved, and the condition is sometimes of traumatic origin. The two conditions are not unfrequently combined, and when they are not the outcome of an injury, a high-arched palate is usually present. They give rise to unilateral nasal obstruction, associated with a chronic rhinitis on the patulous side. Attacks of paroxysmal sneezing of the hay-fever type, and possibly asthma, may result from these defects. External deformity in the shape of nasal as3-mmetry is visible in most of the cases of deviated septum. Spurs may be removed by a special knife or spokeshave, if cartilaginous, and by a suitable saw- — e.g., Bosworth's — if bony. Most of these operations, however, have been displaced b}' stibmucous resection of the septum. It is performed under a local or general ansesthetic, and the results are excellent. The mucous membrane is stripped up on the convex side, and the w^hole thickness of the cartilage removed; the two layers of mucous membrane are placed in contact, and by their union constitute a median septum. Foreign Bodies are rarely impacted in the nasal passages except in children, in whom the condition is not uncommon. Any unilateral 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 thereb}-, 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 best effected by thoroughly cocainizing the affected side so as to reduce the con- gestion and swelling of the mucous membrane, and then seizing the foreign body by suitable forceps, a hook, or a snare. This should never be attempted without the assistance of frontal illumination and a rhinoscope. Necessarily, all instruments used for this pur- pose should be thoroughly sterilized. After the removal, the nostrils are carefully washed out for a few days with a weak alkaline anti- septic lotion, such as salt and water to which a little sanitas has been added. 1 he old-fashioned plan of attempting removal by syringing is most unsatisfactory, and, indeed, dangerous, and should be totally discaided. Acute Rhinitis.— Several distinct varieties of this affection are described. I. The Catarrhal form is extremely common, constituting what is popularly kno\\n as a ' cold in the head.' It is not only due to ex- AFFECTIONS OF THE NOSE AND NASO-PHARYNX 819 posure to cold, but may be caused by irritating gases, dust, and the pollen of plants (hay-fever) . Not only is the nasal mucosa involved, but the inliammation often extends to the frontal or maxillary sinuses, causing brow-ache and face-ache, 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 ex- treme 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 increasing the action of the bowels, kidneys, and skin, considerable rehef can often be obtained by washing out the nasal cavities three or four times a day with a weak warm alkaHne lotion containing borax, or by spraying the interior of the nose with menthol dissolved in paroleine by means of a suit- able atomizer. 2. A Suppurative form arises not unfrequently as a result of acute suppuration in one of the accessory sinuses (acute empyema), and then treatment must be directed mainly to the sinus. Occasionally it is due to gonorrhoeal 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 i 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 (p. 134)- Chronic Rhinitis occurs in many distinct types, of which we can merelv give a bare outline. I. Chronic Hypertrophic Rhinitis, one of the most common forms, is characterized by engorgement of the erectile tissue cover- ing the inferior turbinated bone, causing obstruction to nasal respiration and an abundant discharge of muco-pus. It usually occurs in patients with prominent noses, where the passages are narrow, and may be lighted up by some slight local irritant, suchas a sudden change of temperature. The anterior end of the inferior turbinal is swollen, red, and rounded, the mucous covering being oedematous, and the mass feehng, on touching it with a probe, like a sac full of fluid. The local application of a 5 per cent, solution of cocaine causes its complete, though temporary, collapse in a few moments. If it is allowed to persist, hypertrophy of the mucous membrane follows, and in the most marked types a projecting papillomatous-like mass, almost resembling a polypus, results. It is, however, merely an inflammatory hyperplasia, arid not a new gro^vth; true papillomata are extremely rare in this situation. The posterior end of the bone may be similarly affected, and the mucous covering of the middle turbinal may participate in the same process. A certain amount of pharymgitis or laryngo-tracheitis may also be present. Treatment.— In the early stages aU that is 820 A MANUAL OF SURGERY required is to wash out the nasal cavity night and morning with some simple nose lotion, such as borax or bicarbonate of soda (5 grains to i ounce). This may be accomplished either by sniffing the solution from the palm of the hand, or by using some form of nasal irrigator or douche; Basdon's douche is perhaps the best for this purpose. If such is insufficient to give relief, or if collapse is not produced by cocaine, the surface may be swabbed over with some diluted caustic {e.g., chromic acid, 5 grains to i ounce), or, better still, a point of galvano-cautery at a red heat may be run along the length of the bone. In the later stages removal of the hypertrophied excrescences by the cold-wire snare, or by the galvano-ecraseur, is required. 2. Chronic Rhinitis Sicca is associated with collapse of the erectile tissue, and 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. 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 spurs on, the septum, and then is unilateral, the discharge coming from that side which is most patulous, whilst the narrowed side remains healthy. When symmetrical, the disease is rather due to constitu- tional than to local causes, occurring in weakly, anaemic women, and is to be treated by general rather than local measures. In the unilateral form, the deviation or spur must be remedied. In this way the inspired air is made to pass more freely along the narrowed healthy side, and the other nostril is dealt with by the use of weak alkaline lotions. It may also be 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 pro- longed, and it is possible that a daily alkaline nose lotion may be needed permanently. Stimulating applications are never borne well, and hence should rarely be ordered. 3. Chronic Atrophic Rhinitis (Ozaena) is characterized by an ex- ceedingly offensive muco-purulent discharge from the nostrils. It must be carefully distinguished from such conditions as tuber- culous or syphilitic disease of the turbinated bones or of the septum, suppuration in the accessory sinuses, the impaction of foreign bodies, or the ulceration of malignant growths, in which an offensive dis- charge also occurs. True ozsena is usually met with in young females, and may some- times originate from traumatism, or after one of the exanthemata. The nose is almost always wide and roomy ; the lips are often thick and everted, and the mouth is usually held open owing to the im- pediment to nasal respiration caused by inspissated mucus. The foetor of the breath due to the decomposition of this discharge is the special feature that calls attention to the complaint; it is peculiarly searching and objectionable, but the patient fortunately is not cognizant of it. There is not much discharge, but at varying AFFECTIONS OF THE NOSE AND NASO-PHARYNX 821 periods large crusts come away, giving relief both to the nasal respiration and to the f re tor. Both nostrils are usually involved. The disease lasts for many years, but in time tends to improve, and gradually to disappear. On examination, the narcs are found to be unusually patulous, and the vibrissae are scanty. The mucous membrane over the turbinated bones is dry, collapsed, and pale, so that 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 pharyngeal wall is also dry, and may be coated with a film of inspissated mucus. No ulceration is present, although the removal of the crusts may be associated with a slight amount of bleeding owing to their close attachment to the mucous membrane. The examination of a case of suspected ozsena should also include the accessory cavities of the nose, since many cases in which crust- formation is a prominent symptom are really due to an empyema of one or more of the sinuses. Treatment.- — The first essential is to keep the nose clean and free from putrefying masses of dried secretion. This must be accom- plished by irrigating the cavity once or twice daily with a warm weak solution of common salt to which a little sanitas has been added. At first it is well for the surgeon to see to this himself, but after a while the patient or her friends can be entrusted with the task. Every portion of scab ought to be removed daily, and the surface lubricated with some such application as a spray of menthol and paroleine (10 grains to i ounce). The nose should then be partially plugged with a tampon of cotton-wool, especially along the lower meatus, and if thought desirable the wool may be medi- cated with some antiseptic. By this means a flow of mucus from the membrane is determined, and the discharge is thus rendered more fluid, and inspissation prevented. A similar end may also be obtained by plugging the nostril partially with a rubber tube, so as to diminish its size. The general health must be attended to, and patience and perseverance will generally be crowned with success. Operative measures are scarcely ever required in this disease, although they have frequently been resorted to most unnecessarily. Disease of the Accessory Sinuses of the Nose is a frequent accom- paniment of either the acute or chronic nasal affections just passed under review, or it may arise from more localized lesions — e.g., antral trouble from affections of the teeth, or frontal sinus mischief from traumatism. Perhaps the most common cause is a sharp influenzal attack, which may lead to an involvement of the nasal fossae and all the sinuses (the so-called pan-sinusitis) ; this is toler- ably amenable to treatment in the early stages, but if neglected, may become chronic, and then serious trouble may result. Pyogenic infection of the nasal fossae from the introduction of dirty instru- ments by careless or meddlesome surgeons may also be responsible for this condition. The obvious outcome is the persistent discharge of offensive purulent material from the nose, which is often wrongly 822 A MANUAL OF SURGERY termed ozsena; to this may be added special features according to the particular sinuses which arc mainly affected. It must be remembered tliat the outlet of most of the sinuses (Fig. 396) is badly placed for drainage purposes, especially the maxillary antrum, the opening to wliich is near the roof rather than the floor. Even in the case of the frontal sinus, the outlet, which is well situated for drainage, is a long narrow passage easily blocked by oedematous swelling of the mucous lining. When once su])pura- tion has commenced among the sinuses, it is likely to spread from one to another owing to the close proximity of the various orifices; thus, pus escaping from the infundibuhmi is almost certain to find its way into the antrum or ethmoidal sinuses, especially' if the escape of the discharge is hindered by the presence of granulation tissue. In the more acute cases which follow influenza or cold, the antrum and frontal sinus are most frequently involved. Readers are referred back to what has already been written on these subjects (pp. 742 and 801), with the emphatic reminder that careful treatment during the early stages may prevent the affection becoming chronic and save the patient from much suffering and danger. The nose should be carefully irrigated with warm saline solution night and morning, and the antrum washed out after puncturing its inner wall. In chronic cases the discharge will be found to come from one or both sides of the nose, and the patient will complain of feeling stuffed up; breathing will be mainly oral, and the breath is likely to become offensive. On examining the interior of the nose, even after cleans- ing it, the cavity is not found to be patent as in ozaena, but is blocked up with polypoid masses of granulation tissue, which project mainl}^ from the middle meatus; they are often covered with a half-dried scab, and pus can be seen to exude from it when pressed upon; this usually comes from the antrum or frontal sinus, a mass of granula- tion tissue developing both above and below the entrance. A probe passed into the mass always impinges on dead or carious bone, which is probably a part of the middle turbinal. The special features of diseases of the frontal sinus and antrum of Highmore have been already indicated, and their peculiar dangers and methods of treatment discussed. The ethmoidal cells lie along the inner wall of the orbit, and should they become distended with mucus or pus, may bulge into the orbital cavity on the inner side and even displace the eyeball outwards. The sphenoidal sinus lies at the back of the nose (Fig. 396, S), and the discharge escapes downwards into the naso- pharynx. Suppuration therein causes deep-seated pain in the back of the orbit and nose, and, unless relieved, may determine infective comphcations about the base of the skull — e.g., basal meningitis, thrombosis of the cavernous sinus, or affections of the nerves to the eye and orbit in the neighbourhood of the sphenoidal fissure. Treatment, except in the simpler cases, should always be handed over to a rhinological expert, as operative measures of a serious haracter may have to be undertaken. The essential element is AFFECTIONS OF THE NOSE AND NASO-PHARYNX 823 drainage of the affected cavities, together with removal of the pro- tuberant granulation tissue and diseased bone which hinder the exit of the discharge. It may be desirable for a few days to treat the patient merely by irrigation of the nasal fossae, and of such sinuses as are readily accessible, e.g., the antrum and frontal sinus; but further and more effective treatment must not be long delayed. In many cases the Hning membranes of these cavities will be thickened and transformed into polypoid masses, and hence the more extensive of the procedures mentioned at pp. 743 and 813 are hkely to be required for the frontal sinus and antrum. For suppuration m-/ -ET PiG_ 396.— Outer Wall of Nasal Fossa, indicating the Position of the Accessory Sinuses and of their Orifices. F Probe passed from frontal sinus down the infundibulum to middle meatus; ' AE, anterior ethmoidal cells ; PE, orifices of posterior ethmoidal m superior meatus shown by removal of a portion of the superior turbmal; S, sphe- noidal sinus with probe in its orifice; MA, orifice of maxillary antrum shown by cutting away part of the middle turbinal; ND, orifice of nasal duct under cover of the inferior turbinal, part of which has been removed ; ET, pharyngeal opening of Eustachian tube. of the ethmoidal sinuses it may sufdce to remove the anterior por- tion of the middle turbinal and to break down the inner wall of the - cells, so as to lay the cavities into the nose ; but when the surrounding bone has become diseased, it may be desirable to open into them from the orbit by prolonging backwards the incision for exposing the frontal sinus. The sphenoidal sinus can, of course, only be dealt with from its nasal aspect, and an opening has to be carefully made into its anterior wall, which is picked away by punch forceps. Syphilitic Disease of the nasal fossae is generally tertiary m type, and consists in a diffuse gumniatous affection of the septum and 824 A MANUAL OF SURGERY tiirbinals, with resultant suppuration, and either caries or necrosis. Ihc condition is usually a very offensive one, but the accessory sinuses are not specially liable to involvement. Treatment is of the usual antisyphilitic type, including the injection of salvarsan, and perhaps the use of iodides and mercury. Locally, the nose niust be ke]:)t clean by irrigation, and diseased bone removed. It is probable that if the septum is seriously affected, the bridge of the nose will become depressed. Nasal Polypi.- — Two fomis of nasal polypus are described, viz., the simple or mucous polyp, and the fibrous or fibro-sarcomatous. Other malignant tumours occur in the nasal fossae, to which, how- ever, the term polypus can scarcely be extended; they mainly originate from the superior maxilla. The Mucous Polypus consists of a soft gelatinous mass, which on microscopic examination much resembles myxomatous tissue, covered by cihated columnar epithehum, and supplied freely with bloodvessels. Polypi are inflammatory in origin, con- sisting merely of oedematous hypertrophic tissue, mainly dependent on a chronic osteitis of the underlying turbinated bone. They are often associ- ated with suppuration of the adjacent sinuses, especially the ethmoidal, but the pus production may be secondary and not causative. Polypi are usually situated on the middle and superior turbinals; they rarely start from the roof of the nasal fossas, occasionally in the sinuses, or at the orifices leading into them; they hardly ever involve the septum or inferior turbinal. Polypi are generally multiple (Fig. 397), a large one projecting downwards and forwards towards the anterior nares, and covering or hiding a series of smaller ones, which readily spring into prominence when that in front is removed. They are usually attached by a small pedicle, and when developing in the nasal fossa are pyriform and laterally compressed. When of large size, they may protrude through the nostrils, and then the epithelium covering the anterior portion becomes squamous, and the mass firmer in texture and papillomatous in appearance. Sometimes they project backwards into the pharynx, and are more distinctly globular and usually single. The main Symptom arising from nasal polypi is obstruction to the passage of air along one or both sides of the nose. This is always of gradual onset, and invariably worse in wet weather, on 'V Fig. 397.^Mucous Polypi of Nose, SPRINGING FROM THE BaCK AND FrONT ' OF THE Middle Turbinated Bone. AFFECTIONS OF THE NOSE AND NASO-PHARYNX 825 account 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 is unable to blow the nose, and his articulation becomes nasal in quality. On rhinoscopic examination one finds a grayish semi-translucent glistening mass occupying the nostril, and attempts to blow the nose render this more obvious. Its pedunculated nature can be easily demonstrated by passing a probe around it. When of large 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 a deviation of the septum, though causing unilateral obstruction, can be recog- nised by the exercise of a very small amount of intelhgence. (Edematous masses of granulation tissue, associated with tuber- culous or syphihtic disease of the bones, are recognised by involving usually the septum as well as the turbinals, by the absence of super- ficial epithelium, and by not being distinctly pedunculated ; carious bone can often be felt by a probe through the granulation tissue. From hypertrophy of the mucous membrane over the inferior turbinated bone, a polypus is known by the fact that it scarcely ever springs from this region, whilst the former condition is sessile and red, and shrinks considerably on the application of cocaine. The Treatment of mucous polypi consists in their removal either by the snare or the curette. The snare is specially indicated if there is a single polypus hanging down the naso-pharynx, or if the polypi are few in number. The patient is seated in a chair, and the surgeon sits or stands m front of him. The nasal cavities are well sprayed with a solution of eucaine or cocaine (5 per cent.) and adrenalin (5 per cent.), and the situation of the pedicle ascertained by inspection and by the use of a probe. The snare is then introduced, and the loop passed round the base of the pedicle and gradually tightened until it has cut through. The same process is repeated to the smaller tumours until the nostril is clear. A certain amount of hemorrhage may result, and to check this the nostrils should be plugged with a strip of sterilized gauze, but this should never be left unchanged longer than twenty-four hours. The plug is then removed, and the base of the growth carefully examined and cauterized with the galvano- cautery by the aid of a nasal speculum so as to prevent recurrence. The patient should be again examined after a short interval, so that any smaller polypi which^have commenced to develop may be suitably treated. Where many polypi exist, or if recurrence has occurred after the removal by the snare, the nostril must be effectively curetted, a.nd the polypi and underlying bone removed as a stage in the operation for the cure of the underlying sinus trouble. A Fibrous Polypus is the term applied to a fibroma, which sooner 826 A MANUAL OF SURGERY or later becomes sarcomatous, springing from the base 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 lobulated. The early symptoms are almost limited to those of obstruction to nasal respiration, but to this is not unfrequently added severe epistaxis, owing to the vascularity of the capsule and of the overlying mucous membrane. As it increases in size, ulceration occurs, leading to a foetid 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-pharyngeal tumour. In other cases it may force its way into the orbit or any of the other surrounding cavities, or may even erode the base of the skull, or encroach upon the cranium. It is rare for any of these latter manifestations to occur until after the tumour has taken on a distinctly sarcomatous type. The disease usually attacks young people, and mainly those in the second decade of life. It progresses with considerable rapidity, and the fatal issue may be due to haemorrhage, asphyxia, or cerebral complications. Treatment. — When the gro\\i;h is small and polypoid, it can some- times be dealt with from the anterior nares by means of a galvano- ecraseur. The wire loop is inserted from the front, and hitched over the tumour, so as to encircle its base, by the assistance of the right index finger passed behind the velum. The pedicle must be divided as near the skull as possible, and even then recurrence is almost certain to follow. Nelaton's operation, or one of the other methods described below (p. 827), will in some instances assist the surgeon to reach the base of the skull and deal with the tumour. In the more severe cases, where the growth has become diffuse, it is very doubtful whether much good can be done by operation, since the base of the skull is sure to be gravely affected. Other forms of Malignant Disease of the Nose are met with, and may originate in any part of the nasal fossae. Squamous epithelioma is that which occurs most frequently; the S3-mptoms 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 vascu- larity of the part. It is sometimes possible to deal with these patients by operative measures, which must be varied accord- ing to the requirements of the case. Radium may perhaps be of service. 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 intranasal growth, and may occasionally be dealt with in a satisfactory manner by local means, such as curetting and AFFECTIONS OF THE NOSE AND NASO-PHARYNX 827 the application of caustics. Not a few cases are on record in which such treatment has proved efficacious in curing the disease, although one would now raise the question as to whether these tumours were sarcomatous at all, and not endotheliomata. The operations which have been devised Joy dealing with disease of the nose and naso-pharynx are so numerous and comphcated that it is impossible for us to mention more than a few of the most useful and important. (rt) In many cases of intranasal disease considerable assistance can be derived by opening up the anterior nares, especially when one is operating for caries or necrosis of the turbinated bones. It may suffice merely to divide one ala nasi and the attachments of the cartilages to the maxilla; but where both sides are involved Rouge's operation is advisable. This consists in the detachment of the mask of the face from the maxilla by everting the upper Up and incising the mucous membrane and subjacent tissues until the nasal cavities are opened. The septum nasi is divided by cutting-pUers, and the nasal cartilages are completely separated. The soft tissues of the face can then be retracted upwards, and the nasal fossae fully exposed. The bleedmg is always considerable, and the space gained in children is but slight. When the operation is completed, the mask of the face is allowed to fall back again into position, union occurring without difficulty, although no sutures are employed. When the upper and anterior portion of the nasal cavity is to be dealt with, lateral rhinotomy, as described above (p. 805), or some modification of it, may be employed with advantage. , When the septum alone is involved in malignant disease, it is possible to deal with it by an operation, which consists in sphtting the upper lip m the middle line, and carrying the incision round the ala nasi on each side so that the lower portion of the nose can be turned upwards after dividing the septum. A wedge-shaped portion is then removed from the front of the palate after detaching the muco-periosteum from its buccal aspect. An excellent approach is thus obtained into the nasal cavity, and the entire septum can m this way be removed without difficulty. The parts can be afterwards brought together quite naturally, and the deformity is very shght. A patient on whom this operation was performed for undoubted epithelioma of the septum reported himself at hospital eight years later ; he was quite free from recurrence, and apart from a sunken bridge to his nose, there was no deformity. [b) When the disease is located further back, originating rather m the naso- pharynx than in the nose itself, the palatine route may be used with advantage. Perhaps the best of the several suggested operations is that of NSlaton. Ihis consists in a median section of the velum and of the mucous membrane cover- ing the posterior half of the hard palate. A transverse incision is then made on either side of the anterior extremity of this, and two muco-penosteal flaps are reflected, exposing a quadilateral area of bone which 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 the removal of the polypus or growth. The reflected segments of the palate are subsequently sutured together. Adenoids.— It has been already mentioned that the naso-pharynx is the seat of a large amount of lymphoid tissue, similar to that met with in the tonsil, which may either be distributed widely over the whole mucous membrane, or be gathered into a special mass on the roof, known as the pharyngeal or Luschka's tonsil. Adenoids consist in a hyperplasia of this tissue, exactly analogous to the chronic hypertrophic form of tonsillitis, with which, indeed, it is often associated. They usually occur in the form of broad, cushion- like masses springing mainly from the roof or posterior walls, or 828 A MANUAL OF SURGERY occasionally as pedunculated tumours hanging down into the posterior nares. The tumours are extremely soft and vascular, bleeding very readily. The surface is often plicated, and in the recesses or folds between the different portions of the mass bacteria lodge and give rise to various inflammatory troubles, both locally and in neighbouring lymphatic glands. Not uncommonly isolated masses similar in structure to the above are also to be seen on the posterior wall of the pharynx, and a certain amount of chronic rhinitis and laryngitis may be associated. The condition is rarely seen in others than children, and especially those living in the smoky atmosphere of large towns. If untreated, they usually atrophy in time, but not before much harm may have been done to the individual. The Symptoms are mainly due to obstruction to nasal respira- tion. The mouth is generally held half open, so as to allow the child to breathe through it, thereby exposing the upper central incisors (Fig. 398) ; from a similar cause he snores during sleep, and usually wakes with the mouth and tongue dry. The nostrils are drawn in, and the nose is thin and pinched, the whole facies being very charac- teristic; the children often look sleepy and half silly, and, in- deed, 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. Acute or chronic otitis media often results from extension of the catarrhal condition to the mucous lining of the Eustachian tubes, and deafness may be thereby induced; both taste and smell are sometimes im- paired. The palate 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 expression to the face. The cervical glands are sympathetically enlarged, and often the seat of tuberculous disease. In bad cases which have been allowed to persist throughout adolescence the thorax becomes flattened owing to the inability'of the child to take a really deep in- spiration, the ribs are drawn in, and the spine is kyphotic (Fig. 399)- Fig. 398. — Adenoid Facies. (From A Photograph kindly lent by Sir St. Clair Thomson.) This illustration shows well the sleepy look, the pinched, nostrils, the open mouth and projecting upper central incisors, so characteristic of this condition. AFFECTIONS OF THE NOSE AND NASO-PHARYNX 829 Physical Examination consists in posterior rhinoscopy, by means of wliich the growths can be seen, or in palpation of the posterior nares, a process more suitable to children, who rarely have sufihcient control to permit of the former. On passing the finger behind the velum, the naso-pharynx is found to be occupied by a soft mass of tissue which readily bleeds, and more or less obstructs the openings of the posterior nares. Treatment consists in the great majority of cases in removal of the adenoids by operation. In mild cases, however, much may be done by enforcing respiratory exercises with the mouth shut; and in young adults attention to the general health, combined with irri- gation of the nose with salt and water, and perhaps the local application of a weak solution of nitrate of silver (5 grains to I ounce) to the naso-pharynx, may suffice to bring about improvement. Operation. — As a general rule the child should be anaesthetized with gas, chloroform, or chloride of ethyl, and the head may be allowed to hang backwards over the end of the table. If enlarged tonsils co-exist, these should be dealt with in the first place. Gottstein's curette, or some modification of it, is then intro- duced behind the soft palate, the velum being drawn forwards by the left index finger. It is pressed upwards so that its free convex edge impinges on the upper part of the posterior border of the nasal septum. It is then swept backwards and downwards over the pharyngeal wall, so as to shave away the chief por- tion of the projecting mass of adenoids. Possibly the application of a second smaller curette may be required to deal with outlying lateral portions of the mass ; and finally the adenoid tissue about the orifices of the Eustachian tubes and any remaining tags are removed by the use of Lowenberg's forceps or the finger-nail. Of course, there is considerable bleeding, but this quickly stops of itself ; as soon as the operation is over, the child should be turned over and held face downwards, so as to allow the blood to run out of the mouth and nose, whilst the face and fore- head are sponged with ice-cold water to check the hcemorrhage. The patient is kept indoors for a few days, and only fluid food allowed. No local after-treatment is required as a rule, but the Fig. 399. — -Lateral View OF A Child with Neg- lected Adenoids. (From A Photograph lent by Sir St. Clair Thomson.) This is the same child whose face appears in Fig. 398. It will be seen that the chest is shallow and re- tracted, and the spine kjrphotic. The arms are small, but the legs are well developed. 830 A MANUAL OF SURGERY tliroat may be gargled or the nose washed out with weak salt and water. Nose-breathing exercises should be subsequently instituted. Epistaxis, or bleeding from the nose, may arise from a variety of causes, including traumatism, directed either to the mucous mem- branes or the bones, or from the presence of ulceration or tumours. Some of these local causes are very evident, if only they are care- fully 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 linger 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 frequent 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 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 parts; again, cerebral congestion may induce it, owing to the communication by means of emissary veins between the interior of the skull and the venous plexuses in the nose ; excessive changes in the atmospheric pressure, as in mountaineering, may lead to epis- taxis, whilst in abnormal states of the blood it may be associated with haemorrhage elsewhere, as in haemophilia, purpura, and scurvy. It is sometimes an evidence of chronic Bright's disease, and may be one of the first symptoms to call attention to its existence; it may follow cardiac or pulmonary disease, resulting in cerebral congestion, and may be a prominent symptom in enteric fever. One or both nostrils may be the seat of the bleeding, and it may be so excessive as even to threaten life. Treatment.' — It must not be forgotten that, in the majority of cases, there is some local cause of epistaxis which can be found and treated directly- — a fact which once more emphasizes the necessity for gaining a mastery over the use of the rhinoscope. The bleeding is generally unilateral, and in nine out of ten cases the source is within easy reach of the anterior nares, and hence in many instances all that is required is to grasp the nostrils hrmly, and thus allow the blood to collect within, and give it an opportunity of clotting. At the same time, the patient should sit up, and cold be applied to the root of the nose, or to the nape of the neck. If on examination the bleeding-point is detected, whether it be a varicose vein or an ulcer- ated surface, the haemorrhage can almost at once be stayed by applying a pointed galvano-cautery, or by sealing the spot with a swab soaked in a solution of chromic acid (5 per cent.) or adrenalin. Faihng these measures, the nostrils may need to be plugged, but such a proceeding ought to be seldom required. It may suffice merely to pack the anterior nares with long strips of sterile lint or gauze soaked in adrenalin, or a sterilized rubber finger-stall may be introduced and filled with wool. If this does not suffice, the posterior nares must also be plugged. For this purpose Bellocq's sound is usually AFFECTIONS OF THE NOSE AND NASO-PHARYNX 831 employed in order to pass a thread round the base 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 rubber catheter may be used instead. To the lower end of this thread a pledget of sterilized lint or gauze about i-| inches by i inch in size is attached, and this, guided by the finger round the soft palate, is drawn tightly forwards into the posterior nares. It is a good plan to have two threads coming forwards out of the nose, and these may be tied firmly around a pad of lint placed over the side of the nostril, thereby occluding the anterior nares and completely blocking the nasal cavity, back and front. The loose end of the thread emerging from the mouth is fixed to the cheek by a strip of adhesive plaster. The plug is retained for twelve hours, and then removed, and the nasal fossse irrigated with a weak warm alkaline antiseptic lotion in order to prevent infection. CHAPTER XXX. AFFECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS. Stomatitis, or inflammation of the mucous membrane of the mouth, is by no means uncommon, especiahy in children. 1. Catarrhal Stomatitis results from mechanical irritants, such as roughened teeth, from irritating chemicals, or from septic inflamma- tion following operations which involve the mouth. It also arises in the course of fevers, and in conditions of debility such as follow measles and other exanthemata in children; or is associated with disturbances in the alimentary canal, as from improper feeding, dyspepsia, etc. The mucous membrane becomes hyperaemic and swollen, usually in small localized patches, which may gradually spread and become confluent, involving nearly the whole of the oral cavity. 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. Ihe treatment consists in the removal of all sources of irritation, and the administration of drugs to correct intestinal derangements. Antiseptic mouth-washes should also be employed, such as sanitas (i in 20), boro-glyceride (i in 20), chlorate of potash, Condy's fluid, or peroxide of hydrogen. 2. Aphthous Stomatitis occurs in badly-fed children in the form of small whitish spots on a hypersemic base, which run together and produce ulceration. Attention must be directed to the general con- dition, and a little borax and honey or a solution of boro-glyceride (i in 20) applied locally. Thrush is due to the presence of a para- sitic fungus, the Oidinm albicans, and occurs in patches somewhat resembhng curdled milk in appearance. In history and treatment it resembles the aphthous variety. In both these types there is often considerable enlargement of the lymphatic glands, which, however, frequently subside without suppuration when the cause is cured. 3. Gangrenous Stomatitis, or cancrum oris, has been already described (p. 123). A similar condition occurs in elderly debili- tated people, especially if suffering from albuminuria or diabetes, and the possessors of foul teeth. Treatment must be of a similar character. 832 AFFECTIONS OF THE MOUTH, THRO A T, AND (ESOPHAGUS 833 4. Mercurial Stomatitis may arise during the administration of a course of mercury, or occasionally from a single dose in persons who are sensitive to its action. It is increased in severity if the mouth and teeth are dirty, or if the patient smokes to excess. The gums are swollen and tender, bleed on pressure, and are very painful, especially when biting, or drinking hot fluids. The teeth may become loose and fall out, whilst the alveolar borders may be laid bare and necrose. The tongue is sometimes swollen and inflamed; salivation is a marked symptom, and the breath becomes very offensive. Treatment. — Either leave off the mercury, or at any rate reduce the dose considerably, and administer saline purgatives. Chlorate of potash, combined with alum, dilute hydrochloric acid, or tincture of myrrh, may be useful locally. 5. For Syphilitic Stomatitis, see p. 159. The buccal mucous membrane is also involved in the course of other diseases, e.g., diphtheria, scarlet fever, and erysipelas, but special descriptions are not needed here. Affections of the Tongue. Congenital Abnormalities. — {a) The tongue has been completely or partially absent. (6) One half of the tongue is defective in size [hemiatrophy) . (c) Tongue-tie is said to be present when the f raenum is shorter than usual, causing the tip to be depressed and fixed in the floor of the mouth so that it cannot be protruded. Sucking becomes difficult in such a condition, and when it is allowed to per- sist, there is often a lisp in the speech. Treatment is only needed in the severer forms, and consists in raising the tongue with the index and middle fingers placed one on either side, and snipping the frsenum, thus put on the stretch, across its centre with a pair of blunt-pointed scissors directed downwards, [d) The tongue may be adherent to the floor of the mouth, being hound down by folds of mucous membrane [ankyloglossia) . This may also exist as an acquired condition due to cicatricial contraction after ulceration. In congenital cases the adhesions are but slight, and the organ can be readily freed; in the acquired condition this cannot always be accomplished, (e) The frsenum and tongue are occasionally too long, allowing of increased mobility, and even fatal results have occurred from the organ rolling backwards and impeding respira- 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, (g) Macro- glossia (or large tongue), although sometimes acquired, is usually a congenital deformity. The organ is enlarged in all directions, and 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 mem- brane looking almost like skin, although saliva dribbles freely from beneath it. In old-standing cases the teeth are displaced outwards 5j 834 A MANUAL OF SURGERY and the jaws defomicd, so that, even if the tongue is reduced to its normal size by treatment, it may be impossible to close the mouth. Pathologically, it is due to diffuse overgrowth of the connective tissue, secondary to lymphatic obstruction and dilatation. Re- current attacks of lymphangitis add to the trouble, the tongue gradually increasing in size, and the disease has been known to terminate in the development of a lympho-sarcoma. 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 the teeth, especially during an epileptic seizure, or in children as a result of falls with the tongue out. There is often brisk haemorrhage for a few moments, which soon ceases, though blood may be extravasated into its sub- stance, and cause considerable swelling. In simple cases the wound should be examined and purified, and the mouth constantly cleansed with mild antiseptic lotions; a few points of suture may also be inserted if necessary, but the wound must not be entirely closed, or tension from infection will result. When smart arterial bleeding is present, the mouth must be opened, the tongue pulled forwards, and the wounded vessel sought for and tied. Failing this, the lingual artery may be tied in the neck, or even the external carotid. Acute Superficial Glossitis occurs as part of a general stomatitis, and needs no special notice. Acute Parenchymatous Glossitis, or acute inflammation of the tongue, may arise from penetrating and, of necessity, infected wounds, or from the bites or stings of insects, or may be associated with acute stomatitis in the course of fevers, but is most commonly due to the injudicious administration of mercury. The condition may be limited to one half of the organ, but when arising from general causes is bilateral. The tongue becomes painful, swells up rapidly so as to fill the mouth, and even protrudes beyond the teeth, the pressure of which leads to superficial ulceration. The salivary glands are enlarged and painful, and salivation is a marked feature in the case. Speech, swallowing, and even respiration are much interfered with, and there may be considerable febrile disturbance. The case, if treated with care, usually ends in resolution ; but diffuse or localized suppuration may ensue, as well as the most urgent dyspnoea, arising either from oedema glottidis or from the pressure of the enlarged organ. Treatment 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 be- neath the angles of the jaw, but in bad cases a free incision 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 symp- toms is thereby obtained, although the organ may remain enlarged for some time. If asphyxia is threatening, high tracheotomy or laryngotomy 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 A FFECTIONS OF THE MO U TH. THRO A T. A ND CESOPHA G US 835 anterior part of the organ. It is generally due to the admission of micro-organisms through some superficial lesion which has quickly healed. It presents as a tense swelling, fluctuation in which may be masked by the amount of inflammator\- thickening which surrounds it. A free incision both settles the diagnosis and cures the case. Sublingual Abscess, when acute, is due to infection of the sub- mucous tissue, as bv puncture with a fishbone, or starts in a folhcle of the sublingual or in a submucous gland. A puffy sweUing forms beneath the tongue, which, if not opened early, may lead to an extension downwards of the mischief into the submental region. The tongue becomes swollen and turgid from pressure upon the veins, whilst (Edematous laryngitis mav also be induced. Considerable constitutional disturbance generally accompanie.- this process. _ A median incision through the mucous membrane, and the insertion and opening of a pair of dressing forceps, is the safest and best method of treatment, the ca\-itv being subsequently washed out and drained. The more diffuse form of subUngual abscess is usually associated \\-ith submaxillary cellulitis (p. 89). Chronic Superficial Glossitis is an interesting and important disease, which may be associated with a similar condition of the mucous membrane lining the interior of the cheeks and hps. It is most commonly due to syphiHs, occurring as a tertiary phenomenon, but may arise from excessive smoking, ragged and rough teeth, or spirit- drinking, chronic d\-spepsia, perhaps of a gouty nature, being also present in many cases. It is very liable to be followed by epithe- lioma. Barker stating that out of no cases he carefully investigated cancer occurred in 43. . . For purposes of description it is useful to divide the disease into the f ollo\nng five stages, although it must be clearly understood that they are artificial, and several of them mav be present m different parts of the same tongue, (i.) The papiUs become enlarged and sw^oUen, leading to the appearance of red hypersemic patches, which cannot be recognised for certain unless the tongue is thoroughly dried \nth a handkerchief, towel, or piece of clean blotting-paper, which must not be carelessly dabbed over the organ, but should be firmly pressed down so as to absorb aU the moisture. (11.) Over- gro\\-th of epithelium follows, and as it increases m thickness, it becomes opaque and hornv (Plate VI., Fig. i), so that the red patches are replaced bv white ones, leading to the appearance which has been designated Leucoplakia. Sometimes the papiUffi become much en- larged, and stand out definitely and separately from the organ ; or the whole surface may be covered \nth dense white patches. To this condition the term IcJithvosis has been appHed. (ni.) Later on, the excess of epithelium is shed, leaving red smooth patches m which the papillce are atrophied, or have entirely disappeared. If this occurs over the greater part of the organ, the glazed red tongue so characteristic of tertiary syphilis is produced. If, however, this process only occurs in smaUer areas intermixed with portions covered \ritii white epithehum, a patchy appearance of the tongue 836 A MANUAL OF SURGERY results, wrongly termed Psoriasis linguce. (iv.) At varying periods of the disease, sometimes earlier, sometimes later, the organ be- comes ulcerated, cracked, or fissured in a somewhat characteristic manner. A median fissure is usually seen running down the middle, and from this furrows extend transversely, dividing the surface into rectangular compartments. These fissures are not always due to the cicatrization of cracks, as when opened out healthy papillae are seen at the base, and no sign of superficial scarring. They are, then, evidently the result of the contraction of deep sclerosed tissue in the substance of the organ. Superficial ulceration often occurs, apart from these fissures, being probably due to some local irritation, or to smoking; the atrophic condition of the mucous membrane explains the great liability to this occurrence, (v.) Still later, epithelioma may develop, and usually in connection with one of the cracks, or of the cicatrices arising therefrom. It is often somewhat slow in its progress, owing to the amount of sclerosis induced by the preceding inflammation. The typical smoker's patch is a red irritable area on the front of the tongue, from which papillae are often absent, and perhaps covered . with a yellowish-white crust. Sometimes the epithelium is heaped up here into a well-marked leucoplakic spot. All these stages of the disease are accompanied with much dis- comfort, the tongue being sometimes so tender that the patient can- not drink hot fluids or take condiments or stimulants without pain. The speech, too, is interfered with, becoming thick and indistinct. The course of the case varies considerably, and the affection may settle down after a time, and cause but little discomfort, so long as the patient conforms to the restrictions as to diet, etc., which are essential. If, however, he is careless or refuses to obey orders, the trouble may progress, and epithelioma develop. The Treatment of the case is usually a matter of some difficulty. All sources of irritation are excluded from the mouth as a first pre- caution. Thus, smoking or chewing tobacco must be rigidly pro- hibited. Spirit-drinking and all acid wines which cause pain should be forbidden, dilute whisky and water being perhaps the best stimulant. The teeth must be well brushed night and morning, and all stumps and rough excrescences removed; definite pyorrhoea must be carefully treated. Gaps between the teeth should be filled by artificial teeth fitted to a smooth plate. Condiments, such as mustard, spices, curry, and cheese, are excluded from the dietary, and only simple unirritating ingesta allowed. The mouth is washed out frequently with an alkaline lotion — e.g., bicarbonate of soda {20 grains to I ounce), or borax (10 grains to i ounce) — especially after meals, so as to exclude all risk of acid fermentation in the debris of food. Cracks and sores may be treated by painting the surface with a solution of chromic acid (grs. v. ad ,5i.) or of perchloride of mercury (grs. ii. ad ,3i.), but it is better to excise them completely, as also any wart-like formations. Solid nitrate of silver should parti- cularly be avoided, as its use is likely to predispose to epithelioma. AFFECTIONS OF THE MOUTH. THROAT. AND (ESOPHAGUS 837 General antisyphilitic remedies are employed where necessary, even including salvarsan; the digestion is attended to, and if the new formation of epithelium is excessive, arsenic may be adminis- tered. On the appearance of definite epithelioma suitable operative measures must be instituted. Ulceration of the tongue arises from a variety of causes, and occurs in many different forms. Ihus, dental or traumatic ulcers, due to the irritation of rough and carious teeth, are generally seen at the margins of the organ. Dyspeptic ulcers are associated with gastric disturbances ; they are usually located on the middle of the dorsum, and are often very painful. It is sufficient to touch them with lunar caustic after dealing with the cause. Tuberculous ulcers are not common, and are nearly always secondary to pulmonary or laryngeal phthisis, the organ being infected by the sputum. They commence in the form of a submucous abscess, which bursts and leaves a small painful sore, rarely situated on the posterior part of the organ, but chiefly at the sides or on the dorsum near the tip. Secondary abscesses form around and coalesce with the original ulcer. Treat- ment is chiefly needed on account of the pain and discomfort caused by them; it consists in their complete excision, or in cocainizing and scraping the sores, touching the base with pure carbolic acid, and dressing with iodoform. Applications of cocaine may also be made before meals, as a palliative measure where radical treatment is not undertaken on account of the extent of the piilmonary mischief. 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 under our care it appeared in the form of an irregular granulating surface surrounded by nodulated cicatricial tissue of an exceedingly dense character. The progress was very slow, owing to the amount of sclerosis present. Treatment consists in the appli- cation of the X rays or of radium; but in some cases it may be advisable to undertake a preliminary course of treatment by scrap- ing and cauterization. Syphilitic and cancerous ulcerations are described below. Syphilitic Disease of the tongue occurs in a variety of different forms. A primary sore presents a characteristic indolent and inac- tive surface, usually near the tip, with subjacent infiltration, and much chronic enlargement of the submental lymphatic glands, which, however, do not generally suppurate. In the secondary stage mucous tubercles, fissures, and ulcers form, and usually on the sides or near the tip. Occasionally one meets with a broad wart-like condyloma on the dorsum, which may be associated with longitudinal fissures; it is sometimes termed ' Hutchinson's wart.' In the tertiary period chronic superficial glossitis may develop, as also diffuse infiltration of the organ, or gummata. Gumma of the tongue is not uncommon, occurring usually in patients under forty years of age, as a late tertiary phenomenon. It starts as a localized submucous or intramuscular infiltration near 838 A MANUAL OF SURGERY the median line, and generally towards the middle or posterior part (Fig. 400). The swelling is at first hard and firm, but later on becomes soft and fluctuating, and in time the overlying mucous membrane, which was unaffected, yields, and gives exit to the characteristic contents. The ulcer thus produced is oval or round in shape, and deeply excavated, the base being constituted by a slough. There is but httle induration either of the base or edges, and neither the floor of the mouth nor the base of the tongue is involved, so that the organ can be freely protruded, whilst degluti- tion and articulation are scarcely interfered with. The patient complains of little pain, and the submaxillary glands are only affected either as part of a general enlargement throughout the body, or from the local irritation. The progress is slow, and the effect of antisyphilitic treatment very decided, the gumma being absorbed, or the ulcer, if present, healing readily, but leaving a localized area of sclerosis or a deep cicatrix, from which malignant disease may subsequently originate. In some cases a diffuse infiltration of the organ occurs, leading to a generalized sclerosis rather than to a localized gumma. The treatment consists in the administration of iodides with or without mercury, whilst t\x > '' -^^^Z ^^^ mouth is kept clean with a simple 1 ^-.--^ "^1;^^^* mouth-wash. Innocent Tumours are not frequent in -^ ^ ^ the tongue, papilloma, cysts, lipoma, and Fig. 400.— Gumma of Right • , °- \^J , • r • i.: „„^ ^^ Side of Tongue. (From "^^i being the chief varieties, and re- Wax Model in College quiring no special description. OF Surgeons' Museum.) Dermoid Cysts also form within or under the tongue, occupying the middle line, projecting either into the floor of the mouth or beneath the chin. They are due to non-obliteration of the upper end of the thyro-glossal duct (p. 886). The contents are of the usual sebaceous type. Such tumours should rarely be dealt with from the mouth, as they extend deeply, and need to be carefully dissected out. A free incision should be made beneath the chin, and the whole cyst removed unopened. Cancer of the Tongue occurs in the form of squamous epithelioma, and is both a frequent and a very fatal variety of this disease. It is usually met with in men, and may arise as a result of the irritation caused by excessive smoking, especially when neglected, rough, and carious teeth are present. An underlying strain of syphilis is also frequently present in these cases. Its mode of onset varies somewhat according to the situation: [a] It arises most commonly as an ulcer at the margin of the organ, towards the junction of the middle and posterior thirds, and is then generally due to the irritation caused by ragged and irregular bicus- pid or molar teeth (Plate \T., Fig. i) ; [h) it may start in a crack, PLATE VT. Fig. I. — Epithelioma of Tongue, secondary to chronic superficial^ glossitis. The tongue was a characteristic one, showing heaping up of the epithelium, which was white and sodden (ichthyosis), as well as cracks and fissures in the middle line, due partly to chronic interstitial glossitis ; the epithelioma developed late in the case on the left side opposite a diseased and dirty tooth. />•,.-. 5.— Epithelioma of Tongue of a hypertrophic papillomatous type. \To face page 'i>l%. AFFECTIONS OF THE MOUTH, THROAT. AND (ESOPHAGUS 839 fissure, or cicatrix on the dorsum, as a result of chronic superficial glossitis, or of a preceding gumma; (c) it may commence as a wart- like growth (Fig. 2), the base of which becomes infiltrated, the tumour invading the muscular substance, and spreading to the root of the tongue; [d) it may originate as a submucous infiltration, starting as an ingrowth from the mucous membrane, without much external manifestation of its presence; {e) it may first be noticed as an irregular ulcer in the floor of the mouth; or (/) it may spread into the tongue from surrounding parts, such as the tonsil or larynx. In whatever way it starts, the same features are soon manifested, viz., a new growth is noticed, hard in consistence, indefinite in its extent, which ma}- or may not be painful from the first, and which ulcerates superficially, exposing a more or less crateriform cavity, with a gray, sloughy, foul surface, readily bleeding when touched, and discharging a foul secretion, which causes extreme foetor of the breath. The ulcer is surrounded by an indurated' mass, which gradually shelves off into the neighbouring healthy structures, or may be abruptly limited. Profuse salivation is produced by the irritation of the branches of the third division of the trigeminal, and all the movements of the tongue are painful and limited on account of the infiltration of the base, so that both swallowing and speech are difficult, the patient allowing the saliva to dribble out of his mouth. The pain is often severe, and usually extends along many of the branches of the fifth nerve, especially to the ear, so that sleep be- comes impossible, and the patient's condition steadily and rapidly deteriorates. The submental, submaxillary and subparotid glands early become involved in the disease according to the position of the primary growth; thus, cancer of the tip of the tongue usually affects the submental glands ; if situated further back, the submaxillary glands are involved ; whilst in the region of the pillars of the fauces the sub- parotid glands are first attacked. Ultimately the disease spreads to the deep glands lying along the main vessels, a gland lying over the bifurcation of the common carotid artery being early enlarged. These glands, if not removed, soon attain considerable dimensions, and become stony hard and fixed to surrounding structures, especi- ally the carotid sheath. If the disease is strictly limited to one half of the tongue, the lymphatic glands on the other side of the neck are seldom affected except in the last stages ; but if the disease extends towards the centre of the organ, the glands on both sides are often equally involved. These secondary growths are very frequently cystic in character, from the degeneration of the masses of epithe- lium fonned within them; after a time they approach the surface and burst, leaving ragged malignant ulcers in the neck. The lower jaw itself is often invaded in the later stages of the disease. The occurrence of the typical cachexia is determined not only by the pain and consequent sleeplessness, but also by the inability to take sufficient nourishment, the absorption of products of putre- faction swallowed with the saliva, the excessive salivation, the S4'5 A MAl^UAL OF SUliGERY occasional lucmorrliages, and the extent of the secondary growths. The patient rarely lives, apart from treatment, for more than twelve months after the disease has been first noticed. Death is due to exhaustion, haemorrhage, or septic pneumonia. Diagnosis. — When a case is met with where the ulcer is situated at the side or base of the tongue in a patient over forty-live years of age, with the typical enlargement of the glands, profuse salivation, and impaired movements, there can be little doubt as to the diag- nosis. But when it is seen in the early stage, as an inliltration of a syphilitic fissure or cicatrix, or as a small wart, it may be difficult to determine whether or not malignant disease is present. The early enlargement of the glands, the amount and character of pain, the fixity of the organ, and the inliltration of the base of the ulcer, are important guiding marks; but in doubtful cases a small portion of the edge of the growth and of the adjacent parts should be excised under cocaine, and subjected to careful microscopic examination, and thus its nature ascertained. Moreover, the fact of improvement after the administration of steadily increasing doses of iodide of potassium, does not absolutely disprove the existence of cancer, as the two conditions so often co-exist. Treatment.- — The only hope of curing the patient lies in thorough . and earh' removal of the growth, which it sliould be remembered has probably extended much further than one expects. The excision must include not only the tumour, but also a wide area of tissue around it, so as to get well beyond the zone of infiltration; not only the lymphatic glands, which are obviously enlarged, but also the whole lymphatic area, extending practically from the base of the skull to the episternal notch. It is obviously desirable to undertake such extensive operative proceedings in two stages, if possible, deal- ing first with the tumour in the mouth, and subsequently with the glands. When the base of the organ is free from infiltration, and the disease appears to be separated from the glandular area by a sufficient margin of healthy tissue, the operation in two stages may be undertaken ; and the fact that recurrence is rarely noted in the portion of the organ that intervenes between the two operative areas indicates that such a practice, though not ideal, is justifiable. The mouth is often in a very dirty state, and the danger of infection after making an extensive dissection of the main vessels of the neck is not slight. On the other hand, when there is considerable infiltration of the deeper parts of the tongue with extensive glandular mischief, it may be impossible to find a sufficient margin of healthy tissue to justify the division into two stages; and then the patient must run the risks associated with the removal of tongue and glands at one time. In all cases great care must be taken in the preparation of the patient so as to minimize the risk of infective mischief. Suitable antiseptic mouth-washes are employed for some days; dirty roots and stumps are removed, and the remaining teeth carefully cleansed. ' Possibly, if time permit, a culture might be made of the chief AFFECTIONS OF THE MOUTH. THROA T. AND (ESOPHAGUS 841 organisms in the mouth, and a vaccine procured, which may help to guard the patient from post-operative infection. It is wise also to keep him indoors for a few days beforehand so as to protect him from risks of cold and bronchitis. The actual operative details differ somewhat according to the extent and situation of the disease, but most of the operations for removing the growth are a modification of the intrabuccal method suggested by Whitehead. If the tip only is involved, it can be removed by a V-shaped incision, made after steadying the tongue with a deep suture. The small ranine artery will spurt on each side, but is easily secured, and the gap closed by sutures. When the disease involves one side of the tongae and is not very extensive, and does not spread deeply into the base, it will suffice to remove the anterior half or two-thirds of the affected side as a first stage without touching the glands. The patient having been anesthetized, the mouth is opened with an efficient gag, and anaes- thesia is maintained by giving chloroform through a Junker's apparatus, or ether by intratracheal insufflation. A good assis- tant is necessary in order to prevent blood entering the larynx, small swabs or pieces of sponge held in smooth-nosed, long-handled forceps or suitable sponge-holders being used to clear the pharynx. A coarse silk thread is passed through each half of the tongue to draw it forwards and steady it. The tongue, being drawn out of the mouth by these loops of silk, is carefully divided by blunt-ended straight scissors down the middle line into two segments, which are readilv separated from one another by the finger, the scissors merely dividing the mucous membrane. The base of the organ is freed by cutting through the mucous membrane close to the alveolus, and then along the middle line of the floor of the mouth, so that the subhngual salivary gland can be also taken away — a most necessary step. The mucous fining of the dorsum is now divided transversely behind the growth, and the muscular structure of the organ slowly snipped through with scissors. During this process, by the aid of the finger or a director, the vessels can be seen and secured before division. Removal of the diseased half with the subhngual gland is thus easily accomphshed by making the incisions meet, and dividing the "^ intervening tissues. Bleeding-points are picked up and secured as they appear. It is often possible and advisable to expedite heahng by closing the wound in the tongue partially or entirelv, either bv stitching the mucous membrane of the dorsum to that of the base, or, better, by twisting the half tongue on itself and stitching the tip to the back of the organ. The patient will probably be sufficiently recovered from this operation to enable the surgeon'to deal with the glands in a week or ten days (p. 843). If both sides of the tongue are involved, but the disease has not extended deeply into the base, it is not difficult to effect removal by a modification of the same procedure. The mouth is gagged open, and two silk sHngs are inserted, one through the anterior portion, and 842 A MANUAL OF SURGERY the other just in front of the epiglottis. The mucous membrane of the floor of the mouth is then incised on either side, and the muscles attached to the genial tubercles divided. By this means the tongue is considerably loosened and can be drawn well up out of tlie mouth, so as to enable the section to be made across it with scissors at the desired level. The main vessels can generally be seen and secured before division, and the amount of bleeding is not excessive. It is often possible to draw forward the stump of the tongue and secure the mucous membrane anteriorly, so as to diminish the size of the raw area in the mouth. If the disease extends more deeply into the substance of the tongue, so that the whole organ has to be removed, it is wise to employ a preliminary division of the lower jaw, as originally sug- gested by Syme, and more lately recommended and practised by Kocher.* An incision is made in the middle line dividing the lower lip, extending downwards to the hyoid bone. The mandible is sawn through in the middle, and the two halves separated widely. As much of the tongue as is considered necessary can be easily removed by the scissors. After affecting hccmostasis, a silk thread or silver wire is passed through the stump of the tongue and epi- glottis in order to control it and prevent interference with respiration ; the halves of the jaw are wired together and the superficial wound closed. It is possible that a preliminary tracheotomy may be useful in these cases, but it is not essential. When the tongue, or a portion of it, has to be removed with the glands en bloc, the lateral extrabuccal method, known as Kocher's operation, is perhaps the best. A preliminary tracheotomy is usually associated with it. An incision is made, commencing close to the lobule of the ear, running down along the anterior border of the sterno-mastoid to the great cornu of the hyoid bone, and thence forwards nearly to the middle line, and upwards to the symphysis. This flap of skin and subcutaneous tissue is dissected up, and stitched to the cheek out of harm's way. All the lymphatic glands in the region — the submental, submaxillary, and those lying over the carotid — are now removed, as well as the submaxillary salivary gland, the lingual and facial arteries being tied close to the carotid. If necessary, the incision is enlarged downwards along the anterior border of the sterno-mastoid in order to permit of more thorough removal of the glands. Any diseased portion of the jaw is isolated by saw-cuts in front and behind, and removed. Where only half the tongue is to be removed, it is now split down the middle line with scissors, and the mucous 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. If the whole organ is to be removed, it is unnecessary to divide it in the middle hue. By detaching the mylo-hyoid from the bone a communication is made between the * ' Kocher's Textbook of Operative Surgery.' Translated from the fourth German edition by Harold J. Stiles, M.B., F.R.C.S. London: Adam and Charles Black, 191 1 5 AFFECTIONS OF THE MOUTH. THROAT, AND (ESOPHAGUS 843 outside wound and the mouth, and the tongue is then drawn through this Literal opening, and can be removed as far back as the epiglottis behind and the hj^oid bone below, the whole floor of the mouth being effectually dealt with in this way. The wound in the neck is closed by buried and superficial sutures, a drainage-tube being inserted for a few days. The After-Treatment is much the same in all cases. The raw surface may be painted with Whitehead's varnish (which consists of Friar's balsam, but with the rectified spirit replaced by a saturated solution of iodoform in ether) ; the all-essential thing, however, is to keep the cavity well irrigated with antiseptic lotions, such as weak solutions of boric acid, boroglyceride (i in 20), sanitas or lysoform. The patient must be closely watched for the first forty-eight hours, to see that his respiration is not obstructed by the stump of the tongue falling backwards; but at the end of that time this danger will be at an end, and the silk or silver wire may be removed. It is not desirable to keep him in bed more than two or three days. The patient is fed per rectum for twenty-four hours, but afterwards a tube attached to the spout of a feeder is introduced into the pharynx or oesophagus. In the simpler cases he is able to swallow freely and without difficulty in the course of a day or two, and even in the worst cases he can feed himself with a long tube passed into the pharynx in five or six days. The chief dangers of the operation arise from septic contamination, resulting in secondary haemorrhage or septic pneumonia; and these are best avoided by careful and thorough preparation of the patient. The removal of a part, or even the whole, of the tongue is not such a mutilation physiologically as one might expect at first. Degluti- tion is interfered with for a time, but the power is soon regained, and even articulation may be in great measure restored. The operation for removing the glandular area in connection with cancer of the tongue is a formidable proceeding, as its scope must extend from the mastoid process to the episternal notch. If the disease has involved both sides of the tongue, both sides of the neck must be cleared, and even when the disease has only apparently affected one side of the tongue, the glands on both sides of the neck may be involved. The incision should extend along the anterior border of the sterno-mastoid throughout its whole length, and a second incision meets it extending from the chin to just below the great cornu of the hyoid bone. The flaps thus marked out are dis- sected up and turned forwards, the platysma being included in them. The submental and submaxillary regions are cleared of their loose cellular tissue, including all lymphatic glands and the submaxillary salivary gland (except the deep process and duct) , which are turned back towards the main vessels. The internal jugular vein is then laid bare and all the lymphatic glands lying upon it are dissected upwards from below or downwards from above. All the cellular tissue of the anterior triangle is cleared away in one piece with the glands, extending from that which lies under cover of the omohyoid 844 A MANUAL OF SURGERY below to those which are phiced beneath the posterior belly oi the digastric and lower edge of the parotid above. The facial and lingual arteries will have to be secured back and front ; the external jugular vein will be sacrificed, and if need be the interned should also be taken away; but the facial and spinal accessory nerves must be spared. Careful deep suturing will minimize the deformity, but it will be necessary to drain the lower part of the wound, and if the parotid has been encroached on a tube must also be inserted above. Affections of Salivary Glands. Inflammation of the Parotid Gland is met with in several different forms. 1. Epidemic Parotitis (Mumps) is an acute specific disease usually seen in children, and highly infectious or contagious in character. The period of incubation is about three weeks, and the attack itself consists in a slight febrile disturbance, associated with swelling of one or both parotid glands; one gland is attacked first, becoming enlarged and tender, whilst the other side is similarly affected in a day or two. Mastication becomes difficult, owing to the tension of the parts. The swelling, which lasts for about a week and then gradually subsides, extends below and in front of the ear, and the socia parotidis can be distinctly felt lying over the masseter ; the submaxillary, sublingual, and neighbouring lymphatic glands are sometimes, but not frequently, enlarged. Suppuration is rare, but in adults metastatic inflammation of the testis, mamma, or ovary 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 quiet, 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 or from injury, whilst the presence of a calculus in the duct leads to a chronic sclerosing inflammation. The s>Tnptoms consist of pain and swelling, together with a certain amount of constitutional dis- turbance. An extremely interesting phenomenon is the parotitis which follows injuries or diseases of the abdominal or pelvic viscera. This condition is not very unusual, and was fomierly attributed to pyaemia, but is now considered to be due to infection spreading up from the mouth, owing to a dirty 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 been 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 — e.g., A FFECTIONS OF THE MO UTII. THRO A T, A ND OISOPHA G US 845 scarlet or typhoid fevers. The gland becomes much enlarged, with congestion and oedema of the overlying skin, and, owing to the ten- sion 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 con- stitutional symptoms from toxic absorption are usually very severe. Owing to the fact that large veins and arteries pass through the parotid gland, pysemic symptoms are not unhkely to supervene, and the prognosis is therefore somewhat serious. Diagnosis. — Inflammation of the lymphatic glands lying on the outer surface of the parotid closely simulates 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 precaution 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 used freely, regard- less of anatomical considerations. Inflammation of the submaxillary and sublingual glands may arise in an exactly similar way, but no special description is called for. _ Occasionally, however, the process extends beyond the sub- maxillary glands to the neighbouring tissues, giving rise to what has already been described as submaxillary cellulitis, or Ludwig's an- gina (p. 89). Ranula is a cystic swelHng of the floor of the mouth, containing a glairy mucoid fluid, and sometimes due to obstruction and disten- sion of one of the sublingual ducts (or ducts of Rivini) . A similar condition has been caused in rare cases by a blocking of Wharton's duct, but this has generally been found to run along the outer surface of the cyst. The tumour may be as large as a walnut or pigeon's egg, and is unilateral. The Treatment consists in removing a good- sized piece of the wall, so that the cavity may be obliterated by a process of granulation, or if that should fail, the whole cavity must be dissected out. Obstruction to the Flow of Saliva results from various causes, such as cicatricial contraction in the neighbourhood of the entrance of the duct into the mouth, or from the presence in the duct of a salivary calculus, consisting of phosphate and carbonate of lime, and usually fusiform in shape. Calculus formation only occurs in connection with the submaxillary and sublingual glands, since the saliva secreted by them is thick and mucoid, whereas parotid saliva is limpid in character. The chief Symptom of such obstruction is a painful enlargement 846 A MANUAL OF SURGERY 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 in- creased 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 fistula results. 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 project- ing from the entrance of the duct ; in such a case the duct must be incised from the mouth, and the stone removed. Where, however, it is located in the substance of the submaxillary, total removal of the gland ma\- be necessary. 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 neigh- bourhood. 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 being, of course, increased at meal-times. Stenson's duct extends forsvards 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 midwa^^ between the ala nasi and the angle of the mouth. The diameter of the duct is about | 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. The following plan is often 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 pro- ceeding sometimes facilitated by slightly enlarging the wound. A double thread of silk is now tied to the end of the probe, and drawn through the thickness of the cheek, along the buccal portion of the duct, and out of the external wound. A fine drainage-tube is then carried along the same track, and left so as to project both externally and internally. 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 it 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 AFFECTIONS OF THE MOUTH, THROAT. AND (ESOPHAGUS 847 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 be passed, a trocar and cannula are inserted through the external wound and cheek into the mouth; a silk thread is insinuated through the cannula, and a tube drawn into position, as in the former case. The subsequent treatment is the same as that indicated above. Tumours of the Parotid Gland are of considerable interest, and may be simple or malignant. {a) The Simple parotid tumour is usually an endothelioma, in which, however, fibrous and adenoid tissue may occur. It usually commences near the surface in the endothelium lining the blood- vessels and lymph spaces, and, owing to a colloid or mucoid degeneration of the interstitial tissue, may simu- late a chondroma or myxoma. The tumour feels hard, firm, and nodular, but areas of softening may be in- terspersed amongst the harder por- tions. The mass is situated between the jaw and the sterno-mastoid, accessory processes 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. 401). In the early stages the tumour is freely moveable on the deeper parts, as is also the skin over it, but subse- quently the mass becomes fixed and adherent. The growth is usually slow, and at first quite pain- less, and there is no tendency to invade lymphatic glands or produce cachexia. Mastication is impaired in the later stages, but otherwise the subjective symptoms are of but slight importance, owing to the fact that the growth is superficial to the gland, and to the more important vessels and nerves. If allowed to persist, the growth will finally take on malignant characters. True adenoma or fibroma of the parotid gland is occasionally observed. [h) Malignant tumours of the parotid (Fig. 402) occur in the form of endothelioma, sarcoma, or carcinoma, and are 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 of pressure upon the vessels and nerves develop; the facial nerve is very likely to be imphcated, leading to paralysis of the face. Moreover, the skin becomes hyperaemic and often adherent to the tumour, and finally ulceration 9,nd even Fig. 401. — Parotid Tumour. (Fergusson.) A MANUAL OF SURGERY fungation may obtain. Secondary deposits occur in the neigh- bouring lymphatic glands or in the viscera, and the patient soon passes into a state of malignant cachexia. Carcinomatous tumours are less common than the sarcomata, but run a similar course. The growth is an adenoid cancer, not unfrequently of the soft or encephaloid type, and neighbouring lymphatic glands are early invaded. The Diagnosis of simple parotid tumours from malignant growths is a matter of the greatest importance from a prognostic point of view, since simple tumours are usually encapsuled, and their removal, except when large or deeply placed, is not a matter of special diffi- culty; malignant disease is more diffuse, rendering extirpation of the "mass almost impracticable. The distinction between the two forms is made by a consideration of the signs and symptoms con- sidered above, attention being 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 recognised by their more superficial position. The Treatment is often a matter of some difficulty, owing to the important character of the surrounding tissues. Removal 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 tumours become irremoveable after a time on account of their deep connections and change of type, whilst it is seldom justifiable to touch malignant growths on account of their early and wide local dissemination. Simple parotid tumours are dealt with by turning forwards or upwards a flap of skin and subcu- taneous tissue, so as to expose completely the capsule and enable the dissection of the growth to be made with as little danger to the facial nerve as possible. It is generally placed beneath the growth, but occasionally runs superficial to it, or in its substance. The tumour is often enucleated without much difficulty, but the surgeon must make certain that no deeper processes are left, or re- currence will inevitably follow. The haemorrhage from the trans- FlG. 402. — Malignant Tumour of THE Parotid Gland. AFFECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS 849 verse facial and other arteries is free, but easily restrained. There is no need to remove redundant skin in these cases, as it quickly contracts. In dealing with early malignant disease excision of the whole parotid gland may be occasionally required. 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, securing with double ligatures the external carotid artery and temporo-facial vein. The mass is then drawn up- wards and forwards, and its deep connections severed. The facial nerve is, of course, divided, and the patient must be warned before the operation of the necessarily result- ing facial palsy. Recurrence is almost certain to follow. Removal of the angle of the jaw as a pre- liminary step has been recommended, since considerable space is gained thereby, and a better access to the field of operation. Tumours o£ the Submaxillary Gland are very similar in nature to those of the parotid. Simple tumours are represented by endo- theliomata, resembling cartilaginous or myxomatous growths, according to whether they are hard or soft (Fig. 403). Sarcoma and car- cinoma are also met with; if seen in the early stages they are easily removed. Fig. 403.— MOUR. -Submaxillary Tu- (TlLLMANNS.) Affections 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 formation do not unite in the middle line, thus allowing an abnormal com- munication to exist between the nose and mouth. The term does not include losses of substance, resulting from injury, syphilis, or lupus. The mildest cases consist merely of a bifid uvula, perhaps not involving the palate at all ; the next degree of severity affects the velum alone (Fig. 404, A) ; 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 (B) ; whilst the severest type of the deformity extends in addition through the alveolus and upper lip on one or both sides, the os incisivum being in the latter case displaced forwards, perhaps on the tip of the nose (C). The union of the palatal segments takes place from before back- 54 850 A MANUAL OF SURGERY wards, so that it is very unusual to find the alveolar portion of the palate affected apart from the rest. On looking carefully at a cleft palate, the defect usually appears to be mesial, but occasionally it seems as if a unilateral or bilateral fissure existed. To understand such an occurrence it must be remembered that three anatomical elements unite in the middle line of the roof of the mouth, viz., the two palatal processes growing in horizontally from the maxillai, one on each side, and tlic ethmo- vcmerine septum projecting vertically downwards from the under surface of the fronto-nasal process and base of the skull. All these should join together about the ninth or tenth week of intra-uterine life. If, however, the palatal processes fail to reach the middle line, a median defect appears (Fig. 405, A), unless the ethmo-vomerine septum is so hypertrophied as to project between them, when Fig. 404. — Various Forms of Cleft Palate: A, Involving merely the Velum; B, traversing the Hard Palate as Far Forwards as the Anterior Palatine Canal; and C, being complicated with a Double Hare-Lip. the appearance of a double cleft is produced (B). When only one division of the palate unites with the septum, an apparently unilateral cleft results; most commonly the defect is on the left side, the vomer being attached to the right free edge, a left-sided alveolar hare-lip also complicating the case (C). In these cases the septum often slopes off so as to appear to be continuous with the palatal segment. The width of the cleft and the slope of the segments varies greatly in different cases. The wider the cleft, the more unfavourable it is for treatment by operative means ; and this is one of the arguments used in favour of the removal of the intermaxilla in cases of double hare-lip, so as to allow of the approximation of the two maxillae. As to the slope of the segments, the more vertical they are, the more favourable for operation, since the flaps of muco-periosteum AFFECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS 851 easily meet in the middle line. When the palate is more horizontal, and like a Norman rather than a Gothic arch, the flaps are shorter, and greater lateral displacement is necessary to bring their edges into a])position; this involves much more traction on the stitches, and hence less satisfactory results. 1 he effect of such a deformity upon the infant, from a physiological point of view, is very serious. The process of nutrition is consider- ably impaired, owing to the fact that the power of suction is lost, and fluids taken into the mouth are apt to escape through the nostrils instead of being swallowed. Consequently these children must be carefully spoon-fed with the head thrown well back. Articulation becomes very indistinct, so that it is often impossible to understand what is said, the voice having a peculiar and characteristic intona- tion. All the letters known as explosives, whether dentals, labials, or gutturals, requiring a certain amount of air pressure within the ABC Fig. 405. — Diagram to Show the Modifications of Cleft Palate. a, Ethmo- vomerine septum; b, palatal segments; c, tongue; d, cavity of the I nose; e, buccal cavity. mouth for their due pronunciation, are difficult to produce, par- ticularly b, d, p, t, g, f, etc. Moreover, the exposure of the nasal mucous membrane to the air is so much greater than usual that it is liable to chronic rhinitis sicca (p. 820). 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 tiiturated by the tongue. Treatment.- — Considerable divergence of opinion exists as to the period at which operation should be undertaken for dealing with this defect, and also as to the best method to be employed. Some surgeons advocate its performance at as early a date as possible, even within a few weeks of birth; but, whilst admitting that in some hands this seems to have met with a certain degree of success, the plan does not seem generally applicable. The parts are very small; the tissues are very delicate and friable. The operation is therefore increasingly difficult, and the child is incapable of standing much shock or loss of blood. On the other hand, operation should not 852 A MANUAL OF SURGERY be deferred too long; bad habits of articulation will be contracted, and subsequent physiological success, as gauged by the quality of the speech, is much less likely to follow. On the whole, we see no reason to modify the opinion expressed from the start in this text- book, that the best period for operation is between the second and third years, when a child can be easily kept under control. It is most important that the general health be good, and the mouth and throat free from local disease or inflammation. To guard against accidents, it is well to make a routine practice of keeping a child indoors under observ-ation for a few days before operating, and for choice the spring or summer should be selected. Enlarged tonsils are usually removed before operation, but a pad of pharyngeal adenoids may sometimes be left with advantage, as they assist subsequently in closing the nasal cavity. The object of operative treatment is to close the gap in the hard palate by the union of flaps of muco-periosteum or by compressing the maxillae; it is also desirable that the velum palati should not only be continuous, but mobile. Of the various methods that have been suggested to attain these ends, only three need be noted. Brophy's operation is one which aims at closing the palate by draw- ing together the bony maxillse. The child is anaesthetized; the margins of the cleft are pared, even down to the bone, and stout silver sutures, two or three in number, are carried through the maxillae from side to side, just above the palate. The ends of the silver wire are passed through holes in lead plates, and drawn tightly together by twisting. The maxillae are forced together by digital pressure so as to approximate the margins of the palate, and the wires are tightened as much as necessary. The soft palate is subsequently closed by sutures. The wires are kept in place for three or four weeks and then removed This operation is not desirable after the age of six months, and should be performed before the treatment of the associated hare-lip. It has been but little used in this country, and its advantages are doubtful. Lane's method of treatment is applicable to young children within a few weeks of birth. It is in reality an elaboration of the method suggested by the late Mr. Davies CoUey. It consists in raising suitably shaped flaps of muco-periosteum from either side of the palate, in such a manner that when turned over they can be sutured one to the other, and form a complete barrier between the mouth and the nose. Text-books on operative surgery must be consulted for exact details of this procedure, which will have to be modified according to the requirements of each particular case, but the accompanying diagrams (Figs. 406 to 410) will sufficiently suggest the character of the operation. It will be noted that the muco- periosteum is detached on one side from the bony palate, and allowed to hang down, whilst a small flap consisting only of mucous mem- brane is raised from the back of the soft palate. On the other side a similar, but rather more extensive flap, encroaching on the alveolus, is raised from without inwards, and turned over, the free margin Fig. 406 indicates the treatment of the left side of the palate. At A and B small incisions are made, through which the com- plete muco-periosteum of the hard palate is separated from the bone. The dotted hnes from CD indicate the outlines of a flap of mucous membrane to be raised from the upper nasal surface of the velum; a smaller flap is raised from the margin of the hard palate. Fig. 407 shows the incision (EF GH) needed on the right side, and shows the muco- periosteal flap in process of being raised. * exposed Figs. 408 and 409. — Palatal Flaps Dissected up and Ready FOR Suturing. Fig. ^10. — Palatal Flaps Over- lapped AND Sutured Together The lower figure shows the completed palate in section, M representing the flap from the right side, over- lapped by and united to L, the muco-periosteum of the left side. Figs. 406-410. LANE'S OPERATION FOR CLEFT PALATE. 853 854 A MANUAL OF SURGERY of the cleft acting as a hinge. The raw surfaces of these two flaps are approximated by a double row of suitable stitches, and if they unite an effective barrier is produced, constituting a new palate. It will be noted that a considerable area has to be left bare, to be healed by granulation, and some amount of interference with the subsequent development of the teeth may be anticipated. It is very doubtful whether the final results are any more satisfactory than those gained by Langenbeck's operation, and certainly a good many failures and a certain percentage of deaths have been re- corded. Langenheck' $ operation of uranoplasty is usually undertaken be- tween the age of two and three years, and in practised hands gives admirable results. It consists in the detachment of muco-periosteal flaps from either side, and the careful approximation of their pared Fig. 411. — Diagrams to indicate Extent of Incisions in Urano PLASTY. The thick black lines show the primary incision; the thick dotted lines, the extension backwards of the same to relieve lateral tension ; the thin dotted lines indicate approximately the position of the free border of the bony palate. The right-hand figure shows the position of the sutures, and the condition of the parts at the close of the operation. edges one to the other. In a case involving both the hard and soft palates there is no reason why the whole cleft should not be dealt with at one sitting ; and there are but few cases where the gap is so wide that it cannot be closed by this means, at any rate posteriorly. Occasionally the anterior portion of the cleft has to be left open, especially if the premaxilla has been removed; but this really is not an important matter, as an obturator, carrying the necessary artificial teeth, can always be applied. Where the soft palate, with or without the posterior part of the hard palate, is alone in- volved, Langenbeck's operation gives admirable results. Operation. — Anaesthesia is induced in the ordinary way by chloroform dropped upon a suitable mask or given by Junker's apparatus. The greatest care must be taken not to drop chloro- form into the mouth nor to direct the stream of chloroform vapour against the edges of the cleft. The mouth is efficiently gagged AFFECTIONS OF THE MOUTH, THROAT, AND (ESOPHAGUS 855 open, and preferably by a unilateral instrument which can easily be slipped in and out of place. Stacc I. : 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 behind the lateral in- cisor to preserve the vascular supply of theiront of the flap (Fig. 411) . The muco-periosteum is divided down to the bone, and by the use of a suitable raspatory the soft structures of the palate are stripped up towards the middle line, until the point of the instrument is seen protruding into the cleft. Great care is needed to ensure its total detachment from the back of the bony palate, and yet not to damage it at this, its weakest part. This must be thoroughly carried out on both sides. Copious bleeding always accompanies this stage of the Fig. 412. Fig. 413. Fig. 414. Figs. 412-414. — Diagrams to illustrate the Loop Method of Passing Stitches in the Operation for Cleft Palate. The needles and silk thread are, for purposes of illustration, represented much thicker than would be really employed. operation, and the head should be turned on one side and lowered, and the pharynx kept clear by careful sponging. Stage II. : Paring the Edges of the Cleft.— This is accomplished by grasping the base of the uvula with a suitable pair of angular catch- forceps. Thus steadied and held, a thin paring can be removed, m one piece, if possible, on the side seized, and the same process repeated on the other. The paring of the edges is purposely deferred until after the muco-periosteal flaps have been detached, because the freshened edges do not thus get bruised by the frequent use of the sponge ; moreover, the bevel at which the edges should be pared can be more accurately estimated when the flaps have been loosened. Stage III. : Passage and Tightening of Sutures.— The simplest plan to adopt is that known as the ' loop method ' of Sir W. Fergusson, and it is carried out as follows : A long-handled palate needle with a suitable curve, and threaded with about 18 inches of fine white silk, is passed through the muco-periosteal flap from below upwards, and at a spot about 2 or 3 mm. from the margin (Fig. 412, A). This loop projecting from the cleft (Fig. 412, B) is now grasped with 856 A MANUAL OF SURGERY smooth-nosed forceps, and drawn out of the mouth, whilst the needle is withdrawn. A similar loop is inserted through the opposite side of the cleft at an exactly corresponding point, so that there are now two loops emerging from behind through the cleft (Fig. 412, C, D). One of these is loosely threaded through the other (Fig. 413, E), and the latter gently withdrawn, carrying with it the loop-end of the former (Fig. 413, F), through which a suitable length of fine well-annealed silver wire can be drawn into position (Fig. 414, G, H), and tightened to the requisite degree by a wire-twister, so that the pared edges are exactly apposed. Ihis process is commenced anteriorly and carried backwards until the base of the uvula is reached, the stitches being inserted about half a centimetre apart. Finalh', the uvula is stitched with silk inserted by means of a double- curved needle ; silver wire would irritate the back of the tongue too much and cause vomiting. Some surgeons prefer to introduce the wire by means of a specially constructed hollow needle with a double curve, through which the wire is protruded by unwinding a drum in the handle. This is passed through both flaps, commencing at the uvula, and working forwards, tying each stitch as it is inserted. Stage IV.- — It is now only necessary to take steps for the relief of all lateral tension, a most important and essential proceeding. The best way to accomplish this is to prolong backwards through the soft palate the lateral incisions already made so as thoroughly to divide the levator palati (see the thick dotted lines in Fig. 411). Occa- sionally the anterior and posterior pillars of the fauces, containing respectively the palato-glossi and palato -pharyngei muscles, will also need to be snipped across. The child should be put to bed with the head low, so that any accumulation of blood or mucus may gravitate easily into the pharynx. The mouth can be washed out with a weak solution of sanitas, although some surgeons prefer not to disturb the parts for three or four days. No nourishment should be given for the first four or five hours, and but very sparingly for the first twenty-four. Milk and water, given by a spoon or from a feeder, will form the staple article of diet. By about the fifth day soft food, such as soaked bread and custard pudding, may be safely permitted. The patients are generally allowed up on the sixth day. The silver stitches may be left in for ten days or a fortnight without doing any harm. Should an}' signs of inflammation occur, the palate should be sprayed over with a solution of peroxide of hydrogen. In dealing with clefts of the soft palate alone, a modification of the above operation may be performed called staphylorrhaphy. The edges are first pared, lateral incisions are then made to divide the levatores palati. and the stitches finally passed and tied. Results.— It is possible that in most cases articulation will be, if anything, impaired as the immediate result of the operation, since the mechanism which the patient ordinarily employs is thrown out of gear; subsequent education at the hands of a voice-trainer is abso- A FFECTIONS OF THE MO UTH, THRO A T, A ND CESOPHA GUS 857 lutely essential in order to correct this. Even then the unpleasant articulation occasionally persists, owing to the patient being unable to draw up the velum so as to close the posterior nares ; this is due to a reduction of the depth of the soft palate owing to the traction required to close the cleft. In spite of this, however, the operation is most beneficial in that it shuts off the nose from the mouth, prevents the dropping of mucus, improves the sense of taste, and adds greatly to the general comfort of the patient. Mechanical Treatment of clefts in the palate by means of obturators or artificial vela is still advocated by some surgeons and dentists in preference to any operative interference. An obturator consists of an adjustable plate or plug fitted to and closing an aperture in the hard palate. It may be used with advantage in perforations due to traumatism or syphilis, and in aper- tures left after operations in which portions of the palate are removed, such as excision of the superior maxilla. In cases of double hare-lip and cleft palate, where the os incisivum has been extirpated, an aperture is often left anteriorly which cannot be satisfactorily closed except by an obturator, which also serves to carry the necessary artificial incisors, and may have cheek- plates attached to push forwards the upper lip. For whatever purpose an obturator is needed, it should never take the form of a closely-fitting plug, which, by its constant pressure and irritation, causes the aperture to become enlarged, but always that of a plate, either of thin vulcanite or gold, which can be fixed to the teeth, and maintained in position by suction. It is some- times found, however, that the addition of an intranasal projection to the upper surface of the plate improves the articulation by diminishing the size of the nasal cavity. An artificial velum consists of a plate obturator, to which is attached posteriorly a moveable segment to take the place of the normal velum. Such consists either of a hinged metal plate, resting on the nasal side of the segments of the soft palate, and moved by them, or of a thin india- rubber bag filled with air, sewn to the back of the obturator. They are complicated and difficult to keep in order, and as a general rule the results of operative interference are superior. Ulceration of the Palate occurs in a variety of forms, e.g., [a) simple, as an accompaniment of general stomatitis : (6) syphilitic, which may involve either the hard or soft palate; if superficial, it is usually a late secondary phenomenon ; if deep, it involves the bones, and often leads to necrosis, and is then due to tertiary mischief: (c) lupoid, a somewhat uncommon condition, which may result in great destruc- tion 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) tuberculous, due to the breaking down of a tuberculous abscess under the periosteum, and then complicated with caries of the bony palate: {e) malignant, usually resulting from the growth of epithe- lioma, either starting primarily in the palatal mucous membrane, or extending to it from the tongue, tonsil, or upper jaw. Acquired Perforations of the Palate, though occasionally caused by traumatism or lupus, are in almost all cases due to tertiary syphilis. The ethmo-vomerine septum is often involved in the destructive process, giving rise to a most offensive discharge from the nose. If . the soft palate is alone affected, the velum may become fixed by cicatricial adhesions to the back of the pharynx, and pharyngeal stenosis, or considerable loss of substance of the velum, results. A nasal intonation of the voice is always caused by any condition which 858 A MANUAL OF SURGERY interferes with the closure of the naso-pharynx by the vehim during articulation. The treatment of these conditions sliould foUow the usual antisyphilitic course. Perforations arc best remedied by the use of plate obturators. We have seen out-patients make efificient obturators out of a piece of sheet indiarubber maintained in situ by suction, or of two pieces stitched together in the middle, one piece passing above and the other below the opening. Occasionally when the aperture is small, the local disease soundly cured, and the general health good, an attempt may be made to close it by stripping up muco-pcriosteal flaps, paring the edges and suturing them together. The results are, however, seldom satisfactory. Any of the ordinary forms of inflammation of bone may be met with in the hard palate. Necrosis is usually due to tertiary syphilis, or may accompany acute subperiosteal suppuration, extending from an alveolar abscess. In either case the surgeon must wait till the sequestrum 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. 798) may extend from the alveolus, or an identical condition may start in the middle line. An adenoma of the palatal glands is occa- sionally met with. It presents as a smooth or papillated tumour, somewhat resembling epithelioma, but distinguished from it by its slower rate of growth, and the absence of ulceration, pain, or glandular enlargement. An operation limited to the soft parts is probably all that is necessary. Sarcoma may be primary, and is then often myxo-sarcomatous in type, or secondary. In the former case it simulates rather closely a diffuse alveolar abscess, but is recognised by its slower growth, less pain, absence of inflammation, and, if need be, by the results of an exploratory puncture. Epithelioma also occurs, but is uncommon. Treatment for the two latter conditions, if limited to the palate, would consist in partial removal of the affected superior maxilla. Elongation of the Uvula is frequently the result of a chronic re- laxed throat. At first it merely lasts for a time, and by the use of astringents disappears; but later on the elongation becomes chronic, and causes great irritation of the back of the tongue and fauces, re- sulting in a troublesome throat-cough and even vomiting. Under such circumstances it should be removed. After well cocainizing the part, it is grasped by a pair of hook-forceps, which seize not only the mucous membrane, but also the muscular structures beneath, and a sufficient amount is then removed by snipping it across near the base with a pair of blunt-ended 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 inhalation of impure air, or of sewer-gas. It is often seen amongst the residents in hospitals (hospital throat), and may precede an attack of acute rheumatism. Three varieties are described: AFFECTIONS OF THE MOUTH. THROAT. AND (ESOPHAGUS 859 (a) Acute superficial tonsillitis, which consists of a shght superficial inflammation/the result of cold, etc., in which the tonsil participates with the pharynx and velum. There is but little swelhng of the part, which however, becomes red and painful, rendering swallowing difficult. Ordinary anti-catarrhal remedies are necessary, and a chlorate of potash gargle. (h) Acute follicular tonsillitis is characterized by a general enlarge- ment of the organ, which is dusky red in colour and pam ul, causing obstruction to both breathing and swallowing, the tonsils, perhaps, almost meeting in the middle line. There is a good deal of yellow patchy exudation from the foUicles. which may coagulate on the surface and form a false membrane, somewhat hke that of diph- theria. The temperature is high ; the glands below the angle of the iaw become enlarged and tender, and may suppurate; the tongue is covered with a thick, whitish fur, and the bowels are confined. Such a condition is often due to streptococci, and may herald m an attack of septicaemia. . . x • a +i^v, (c) Acute suppurative tonsillitis, or quinsy, is an acute inflammation of the tonsil, with suppuration within and around it {peritonsillar abscess) . Both sides are affected, but the suppuration is often uni- lateral or if bilateral, one tonsil is affected before the other, pus usually takes three to seven days to form, /he swelling is great, so that breathing and swallowing are ahke difficult, the tempera- ture is high, pain is severe, and the cervical glands are consider ably enlarged (Edema of the glottis ^^V 'ff''}^:, J^^^Z symptoms are much the same as in the above. Left to. itself the abscess sooner or later bursts and gives the patient immediate "^^^The Diagnosis must be made from scarlet fever by the absence of the characteristic rash and red tongue of the latter condition, and by the redness being more dusky and less diffuse in tonsihitis. From erysipelas of the fauces, it is known by the redness Jemg more con- centrated, the oedema less marked and more hmited, by the glands at the angle of the jaw being less enlarged, and bj the absence of any external manifestation of the disease. From diphtheria the folhc- ular variety is recognised by the want of adhesion of the false mem- branl to the subjacent parts, it being readily detached by a camel s- hair brush, and by the absence of the Klebs-Loffler bacillus on '""TieatmenUholM always be commenced by a good calomel purge which may be followed by the administration either of sahcy ate of Toda (20 grains, thrice daily), or of chlorate of potash and sulphate of magnelia, to which a few drops of tincture of aconite may be added if the constitutional symptoms are severe^ The patient wi 1 experiencemuch relief by inhahng the steam from hot water (150 F, in which a little creasote or carbolic acid is dissolved, or the tonsils mav be scarified. Suppuration is dealt with by a free incision, the S enterTng at a spot on the line drawn from the base of the uvula to the last molar tooth, and nearer the inner than the outer end 86o A MANUAL OF SURGERY (Fig. 415, X), as recommended by Sir St. Clair Thomson. Hot flannels 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. The fact that quinsy is very liable to recur suggests that during the quiescent interval after an attack the tonsils should be removed. '. Chronic Tonsillitis appears in two distinct forms: ' J {a) Chronic inflammatory tonsillitis occurs in children whose tonsils, after one acute attack, remain enlarged, painful, congested, and very liable to recurrence, which often runs on to suppuration and ulcera- s , tion. After a time the tonsils shrink back and atrophy, becoming hard and fibroid. (b) Chronic hyper- trophic tonsillitis is met with in weakly chil- dren predisposed to tubercle, and is usually associated with the presence of adenoids in the naso-pharynx. The tonsils are en- larged, pale in colour, and firm in consist- ence; the orifices of the crypts are often patent, and in them are seen plugs of mu- cous secretion, which may become infiltrated with lime salts, form- ing concretions (ton- silloliths), or may de- velopinto cysts. Some- times the tonsils pro- ject inwards, and may meet in the middle line beneath the uvula, causing obstruction both to swallowing and respiration; sometimes they are buried and lie under cover of the anterior pillar of the fauces, but their enlargement may be recognised by pressing inwards from the neck. The patient usually breathes with the mouth open, owing to the concurrent naso-pharyngeal obstruction, and from the same cause speaks thickly, as if he had some loose body in the mouth, and necessarily snores during sleep. Hearing is often interfered with from the mucous lining of the Eustachian tube becoming thickened and inflamed. Recurrent attacks of inflammation occur from time to time, with or without suppuration. Fig. 415. — Diagram to indicate the Situation TO Open a Peritonsillar Abscess — viz., on A Line drawn from the Base of the Uvula to the Last Molar Tooth, but Nearer the Uvula. (After Sir St. Clair Thomson.) AFFECTIONS OF THE MOUTH, THROAT. AND CESOPHAGUS 861 The Treatment of these cases consists in first attending to con- stitutional weakness by removal of the patient to fresh or seaside air, and by the administration of iron and cod-liver oil; at the same time the throat should be painted twice a day with glycerine of tannic acid, or with equal parts of glycerine and tinct. fern perchloridi. i^aihng this, the tonsils should be removed, and for choice by enucleation. Tonsillotomy may be undertaken in the following ways: (a) By the guillotine. The fauces having been carefully and re- peatedly brushed or sprayed with a 5 per cent, solution of cocaine, the mouth is opened and one of the many forms of tonsil guillotine introduced; Mackenzie's spade guillotine is as good as any. ine ring of the instrument is passed over the projecting organ, external pressure behind the angle of the jaw assisting in this manauvre. By the pressure of the thumb the projecting mass is cut off by tne sharp blade. In dealing with the right side, unless the surgeon is ambidextrous, he had better stand behind the patient s head, look- ing over into the mouth. . , , (h) By the bistoury. The tonsil is seized at its lowest point and drawn well inwards by means of hooked forceps, and the projecting mass removed by a straight blunt-ended bistoury, the base of the blade being guarded, if preferred, by a piece of plaster wrapped round it The incision should be made from below upwards, and the edge of the knife kept rather in than out, so as to avoid all nsk ot wounding the internal carotid, which is in close contiguity to the outer surface of the gland. Care must be taken to include the lowest portion of the tonsil, which often hangs down into the pharynx, and is liable to be left behind. This method is not frequently em- ployed at the present day. n ^ -i t.^ (c) In children the hypertrophic type of enlarged tonsil may be enucleated without much difficulty by dividing the mucous rnenibrane in front of it, and shelling it out of its bed, the posterior reflection ot mucous membrane being subsequently divided by bistoury, scissors or guillotine. -f „„^„ The h£emorrhage, though brisk for the moment, soon ceases if care is taken not to cut too deeply, or encroach upon the surrounding mucous membrane. Should the bleeding continue, it can generally be arrested by douching the face with iced water, or by the local pressure of wool pledgets soaked in iced boric acid lotion, or in adrenahn. Occasionally a bleeding vessel can be seen and secured by ligature ; but in bad cases of persistent or recurrent bleeding it may be necessary to stitch the anterior and posterior pillars of the fauces together over a gauze plug which is retained for twenty-four hours. Serious bleeding is more hkely to occur in adults than m children. Syphilitic Disease of the Tonsil is met with m various stages, i ne l^rimayy chancre is seen occasionally, arising in one case we know ot through infection from a stick of caustic which had been previously used to cauterize a syphilitic ulcer and insufficiently cleaned before being apphed to the tonsil, the surface of which was abraded, i he glandular enlargement in the neck is very marked m such cases, and 862 A MANUAL OF SURGERY the course of the disease as a rule severe. Secondary ulcers of the ' snail-track ' type [plaques muqueuses) are common in this region, being usually symmetrical. In the tertiary period a diffuse gumma- tous infiltration occurs, involving also the palate and fauces (p. 864) and leading to phar^-ngeal stenosis. Tumours of the Tonsil are almost always malignant in type, but are not very common. Epithelioma occurs as a firm indurated infiltra- tion, rapidly spreading to adjacent parts, and involving the lym- phatic glands. It generally starts either in the root of the tongue or in the pillars of the fauces, and presents a ragged ulcerated surface with a hard margin and sloughing base. It is not always very painful, and notice may first be called to it by the enlargement of the glands in the neck. It runs a rapidly fatal course, if left to itself. Lymphosarcoma of the tonsil arises in the organ itself; it presents a smooth, dusky red appearance, the mucous membrane being stretched over it, and feels soft and almost fluctuating. In the early stages it may be freely moveable, but ere long it infil- trates surrounding structures, and affects the neighbouring lymphatic glands. Round-celled sarcoma also attacks the tonsil as a primary growth, and is less limited and defined than the former. In all these varieties the growth extends into the pharynx, impeding deglutition and respiration, and ulceration with or without serious haemorrhages may ensue; indeed, the latter complication is a frequent cause of the fatal result. Extirpation of Malignant Tumours of the tonsil is often imprac- ticable from the extent of the disease and the early implication of 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 and freely moveable lympho-sarcomata. The capsule is divided preferably by a galvano- cautery, and the growth shelled out sometimes with the utmost ease, and with very little haemorrhage. Recurrence in the lym- phatic glands is, however, almost certain to follow, [h) From the neck. This is the only plan of any value in dealing with an epithe- lioma, and it is seldom available, owing to the extent of the mis- chief when the patient is first seen. An incision is made along the anterior border of the sterno-mastoid, and a careful dissection con- ducted down to the pharyngeal wall, removing all lymphatic glands which are enlarged or suspicious, and securing the external carotid or its anterior branches. The mass is then isolated from the sur- rounding structures and removed. It is sometimes necessary to make an incision from the angle of the mouth backwards through the cheek, or to remove a portion of the mandible. It is very questionable whether extensive proceedings such as these are ever justifiable. The immediate mortality is high, and the ultimate freedom from recurrence very small. The majority of cases demand merely palliative treatment, including gastrostomy to permit of the administration of food, and tracheotomy. AFFECTIONS OF THE MOUTH. THROAT, AND (ESOPHAGUS 863 Affections of the Pharynx. Acute Pharyngitis is usually associated with a similar inflamma- tory condition of the velum palati, nasal mucous membrane, and tonsils, and results from exposure to cold, from absorption of sewer- gas, and from general diseases of the exanthematous type — e.g., scarlet fever and diphtheria. It is characterized by redness, pain, and swelling of the mucous membrane, which becomes covered with mucus or muco-pus. An irritable cough, with perhaps sneez- ing, interference with nasal respiration, and great pain on swallow- ing, are produced by this condition, and if it spreads to the Eusta- chian tube temporary deafness is induced. Ulceration of the velum 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, sudorifics, and diuretics) and soothing local applications {e.g., ice to suck, chlorate of potash gargle, etc.). Great rehef is often given by inhahng steam from water at 150° F. to which a httle Friar's balsam has been added. Chronic Pharyngitis is commonly met with in clergymen and 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 chronic inflammation, or may follow an acute attack. The mucous membrane is more or less red and infiltrated, with vessels coursing over it, and there is often a good deal of muco-purulent discharge. If the buccal side of the velum palati is affected, there is usually much less secretion than from the pharyngeal aspect, where a 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 somewhat offensive. Two main varieties are described: 1. Chronic follicular pharyngitis, in which the lymphoid follicles scattered throughout the mucous membrane become enlarged. This is specially evident upon the soft palate, but is often greater in amount upon the upper wall and sides of the pharynx, where there is a mass of lymphoid tissue, sometimes known as the pharyngeal or Luschka's tonsil (vide Adenoids, p. 827) . The uvula may be also elongated and hypertrophic in this condition. 2. Chronic atrophic pharyngitis is generally associated with the atrophic form of rhinitis sicca (p. 820), and possibly with chronic laryngitis. The mucous membrane is smooth, dry, and glazed, and the exudation forms adherent scabs. The throat feels dry and irri- table, and the voice is often husky. The Treatment of chronic pharyngitis varies with the condition and character of the affection. In many cases the nasal trouble is the more urgent, and if it is treated effectively the pharynx improves rapidly. In simple relaxed throats all sources of irritation — such as sm.oking, spirits and condiments — must be avoided, the bowels and 864 ^ MANUAL OF SURGERY digestion attended to, and astringent sprays, gargles, or applications made use of. The most useful reagents are the glycerine of tannic acid, and equal parts of glycerine and tinct. ferri perchloridi, whilst chloride of ammonium inhalations are sometimes valuable, as also sprays of menthol dissolved in paroleine, or lozenges containing menthol and liquorice. When the inflammation is of the follicular type, it may be further necessary to destroy the follicles with the galvano-cautery after cocainizing the surface ; enlarged and varicose vessels may be divided in the same way. Syphilitic Affections of the Pharynx may be met with in the secondary or tertiary stages. In the former they are of a superficial character, such as mucous tubercles, snail-track ulcers, etc.; in the latter they appear in the shape of a diffuse gummatoiis infiltration, which is often of considerable consequence, both at the time and subsequently. It manifests itself as a widespread nodular thicken- ing of the mucous membrane, especially in the neighbourhood of the fauces and soft palate, which rapidly runs on to ulceration, and may impede both respiration and deglutition. The administration of salvarsan, or of mercury and iodide of potassium usually causes a rapid improvement, but the subsequent cicatrization may bind down the velum, and lead to pharyngeal stenosis of such a character as to constitute a fibro-cicatricial septmn, with an opening through it perhaps only large enough to allow a small bougie to pass. For such a condition much may be done; the opening may be more or less dilated by careful division of some of the bands and the passage of bougies; and the soft palate can be set free from the dorsum of the tongue. Of course, there is a great tendency for the opening to contract again, and treatment by bougies must be persisted in. A localized gumma may form in the submucous tissue, not unfre- quently involving the posterior pharyngeal wall, and running its ordinary course with or without ulceration. Tumours of the pharynx are rarely primary. They may extend into it, however, from surrounding parts — e.g., naso-pharyngeal polypi arising from the base of the skull, or retro -pharyngeal growths from the spine. Epithelioma either involves the pharynx primarily, or spreads to it from adjacent parts, such as the tongue or tonsil. The usual type of tumour develops with some amount of ulceration; lymphatic glands become secondarily affected, and the tumour gradually in- vades surrounding tissues, although it is interesting to note that for some time it is limited to the mucous membrane, extending super- ficially over it, but not involving the underlying pharyngeal muscles. Death results from haemorrhage due to ulceration into large vessels, from interference with swallowing or breathing, from 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 ; even now the mortality is very high, and statistics prove that if the operation involves removal of portions of the upper or lower jaw, a fatal issue is likely to follow. AFFECTIONS OF THE MOUTH. THROAT. AND (ESOPHAGUS 865 The same precautions as to cleansing the teeth, etc., must be taken as in dealing with naso-pharyngeal or buccal growths. As a general rule, an incision along the anterior border of the sterno -mastoid is the best to employ, although occasionally a second may be required, split- ting the cheek towards the angle of the jaw. The external carotid is tied, all glands are removed, and then the growth is extirpated, partly from without, partly from within. It is always advisable to perform a preliminary tracheotomy, and feeding must be undertaken for some days by means of a stomach-tube. Transhyoid pharyn- gotomy is a useful means of approach in some of these cases (p. 907). Betro-pharyngeal Abscess is acute or chronic in its course. The acute form results from infection through the mucous membrane, as by fishbones, etc. ; or arises from an inflammation of the lymphatic glands which are found in this situation in children, but atrophy in adults, and derive their lymph from the interior of the nose and naso- pharynx. The pus is situated between the pharyngeal wall and the pre- vertebral fascia, and is therefore tolerably superficial. The chronic variety generally follows tuberculous caries of the spine, or disease of the bones at the base of the skull, and the pus is placed behind the pre-vertebral fascia. Whether acute or chronic, the abscess forms a tense elastic swelling, situated behind the posterior pharyngeal wall ; in the former case it is associated with high fever, and locally much redness and inflammatory oedema, which may even extend to the glottis, and cause dyspnoea ; in the latter, where the affection is chronic, there is less local inflammatory reaction, but signs of cervical spinal disease are present. The abscess may burst into the pharynx, or may burrow outwards on either side, being guided by the pre-vertebral fascia, and point either in front of or behind the sterno -mastoid. Treatment should never be delayed, from fear of the supervention of oedema of the glottis. The chronic abscess should always be opened from the neck, as then an aseptic course can be maintained, and there is no fear that the pus will enter the air-passages. If pointing in front of the sterno -mastoid, the abscess is opened in that situation ; but otherwise an incision should be made along the pos- terior border of the muscle, which must be drawn forwards, and the transverse processes of the cervical vertebrae defined. Possibly the abscess will be opened by the necessary manipulation of the wound ; if not, the index finger of the left hand should be placed against the abscess wall in the mouth to guard it from injury, and a pair of sinus forceps thrust into it in front of the vertebrse by the right hand. A drainage-tube is then inserted, and the case runs an ordinary aseptic course. The great majority of cases of acute abscess, however, may be opened from the mouth without much fear. The child is placwi on its back with its head hanging far back ; a gag is introduced, and a guarded knife inserted through the mucous membrane into the swelling at its most prominent point. Careful swabbing should avoid any danger of pulmonary trouble. 55 866 A MANUAL OF SURGERY Affections of the (Esophagus. The cesophagns reaches from the lower extremity of the pharynx to the cardiac orifice of the stomach, a distance of about lo inches; it corresponds above to the lower border of the cricoid cartilage, and below approximately to the lower end of the sternum. The distance from the central incisor teeth to the stomach is about i6 inches. The tube is not quite in the middle line, but inclines to the left as it passes through the posterior medias- tinum. The pericardium is in relationship with the oesophagus in front, and the pleura on each side. Its narrowest portions are its upper end, in the centre about 12 inches from the teeth where the left bronchus crosses it, and at the cardiac extremity. The pneumogastric nerves are also in immediate relationship with it. The Methods of Examination of the oesophagus are threefold : 1. By the introduction of a bougie it is possible to detect the existence of a stricture and its situation. Before undertaking this, it is essential to make sure that there is no aneurism of the aorta by the use of radiography or by auscultating the left vertebral curve. To pass an oesophageal bougie, the surgeon stands in front and slightly to the right of the patient, who is seated with the head held forward; if thrown backwards, the larynx is pressed against the spine, and the difficulty of introducing the instrument is increased. The bougie, which bj^ preference should have a conical end, is warmed and smeared with glycerine or melted butter, and, having been suitably curved, it is guided by the surgeon's left index finger over the base of the tongue and epiglottis into the oesophagus. This stage usually causes a certain amount of discomfort and retching on the part of the patient. Once past the entrance to the larynx, the bougie is pushed steadily onwards, and if there is no stricture, the point enters the stomach about 16 inches from the teeth. Formerly this was the only method of examination available for the lower part of the tube. It was possible to palpate in an indefinite way the upper part of the tube, and auscultation of the vertebral curve whilst the patient swallowed, was sometimes resorted to; but obviously these methods are very inexact. 2. The use of the oesophagoscope has transformed the surgery of this organ. The instrument is practically the same as that introduced by Killian for examination of the bronchi (p. 900), and its method of use is very similar. It is advisable to administer a preliminary injection of morphia and atropin not only to dull the patient's sensitiveness, but also to check the salivary secretion. The mouth and pharjmx are thoroughly cocainized, and then, with the patient either sitting or lying on his back, it is possible to introduce the instrument and gently to insinuate it down the tube. By this means foreign bodies, growths, strictures, etc., can be seen, and direct treatment controlled by vision can then be adopted. 3. Radiography is also of assistance in the examination of the oesophagus. Metallic foreign bodies can be seen and accurately located; and by the use of a bismuth meal it is possible to determine the situation of a stricture, and the amount of distension of the oesophagus above it. Malformations of the oesophagus are congenital or acquired. A Congenital communication may exist between the oesophagus and trachea, either in the form of a small 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 con- ditions, and the children die shortly after birth. Congenital stricture may also be met with near the cardiac orifice, resulting in general distension and dilatation of the oesophagus [cesophagoccele). The Acquired malformations consist in the dev^elopment of the so-called Diverticula. Two forms have been described by Zenker ; [a) Pressure AFFECTIONS OF THE MOUTH. THROAT, AND CESOPHAGUS 867 Diverticula, which are the more common, and seem to be associated with some congenital weakness of the wall, probably connected with the branchial clefts. They vary much in size, perhaps becoming as large as a child's head, and rarely come under observation before the age of thirty. They usually spring from the posterior wall, close to the junction of the pharynx and oesophagus, constituting what is sometimes known as a * pharyngocoele ' ; the cavity extends down- wards between the oesophagus and vertebral column. The symp- toms are due to distension of the cavity with food which stagnates and putrehes, 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 careful manipulation it may be kept on the sound wall, and so slipped past the orifice into the stomach. The administration of a small bismuth meal and subsequent radiography will probably make clear the diagnosis. Treatment, where possible, consists in exposing the diverticulum in the neck, through a lateral incision in front of the sterno-mastoid, removing it, and stitching up the opening in the pharyngeal or oesophageal wall. (6) Traction Diverticula are much 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 inflamed bronchial gland. They are always of small size, often multiple, and cause no symptoms, unless a foreign body lodges in them, when ulceration and perforation may lead to suppurative mediastinitis and death. They cannot be recognised ante mortem, except, perhaps, by direct oesophagoscopy. Foreign Bodies not unfrequently lodge in the oesophagus, especi- ally in children and lunatics. Portions of food, coins, fishbones, pins, plates of false teeth, etc., are the substances usually met with. The patient complains that something has lodged in the gullet, causing a feeling of pain and distension, whilst swallowing is painful or impossible, and respiration may be more or less hampered. Large bodies are often impacted at the entrance to the gullet, and then cause sudden death from dyspnoea ; if the obstruction is not so great and remains unrelieved, oedema of the glottis may supervene. Im- paction lower down is likely to be followed by ulceration, perfora- tion, and death, either from haemorrhage owing to one of the large vessels being opened, or from suppurative cellulitis. In the case of a metallic body, diagnosis both as to its presence and situation can be made by radiography, and attempts at removal undertaken with the assistance of the radiographic screen. By means of the oeso- phagoscope it is possible to see the foreign body and sometimes to remove it. The Treatment varies much according to the nature, size, and situation of the obstructing body. If small and incapable of being detected by a sound — e.g., a fishbone — it is best removed by an expanding probang (Fig. 416), being caught in the loops of thick horsehair forming part of the apparatus. If a coin or smaU hard 868 A MANUAL OF SURGERY substance is impacted, it may be removed by oesophageal forceps, or by a coin-catcher. If it is impossible to draw it up, it may some- times be pushed down into the stomach. A large bolus of food may be removed by forceps from the upper part of the (esophagus, and large foreign bodies- — e.g., plates of teeth- — may be similarly ex- tracted, perhaps with the help of the resophagoscope, though great care must be taken not to tear the mucous membrane. If firmly impacted in the upper part, cesophagotomy may be per- formed. An incision, 4 inches long, is made along the anterior border of the sterno-mastoid, preferably on the left side, because the oesophagus naturally curves that way. The surgeon carefully finds his way between the carotid sheath on the outer side and the larynx and trachea on the inner, avoiding the thyroid vessels and nerves. The projection of the foreign body will indicate the situa- tion of the tube, and this is incised and the obstruction dealt with. The oesophageal wound may then be closed by sutures which do not include the mucous membrane, whilst the external wound is either packed with gauze plugs or drained. When the foreign body is located in the upper part of the thoracic portion of the cesophagus, the tube is opened as low as possible by cutting down on the point of a bougie passed from the ^ ^ „ T^ mouth, and then it is often Fig. 416. — Expanding Probang for the ., ' .^ ■ ^ -^ Removal of Foreign Bodies from the possiDle to extricate it. CEsopHAGus. When impacted in the It is introduced closed as at A, and opened thorax and removal by one as at B on withdrawal. of the suggested methods IS impossible, it has been pro- posed to open the oesophagus from behind in the posterior medias- tinum, after excising the necks of one or more ribs ; but a successful case has not }'et been published. When the foreign body is fixed near the cardiac orifice, and cannot be moved either up or down, the stomach may be opened, the fingers or even the hand inserted into it, the cardiac orifice dilated, and the obstruction removed. When once the foreign body has passed into the stomach, purga- tives and emetics should be avoided, and if not of large size and irregular shape, the case is left to Nature, the treatment being merely expectant. The patient is kept quiet, and fed on pultaceous food — such as brown bread, porridge, etc. — and the course of the foreign body watched by radiography. Should it be large and its course be arrested at any particular point, and especially if inflammatory symptoms occur, a laparotomy for its removal must be promptly undertaken. Jlnflammation oi the oesophagus, with or without ulceration, is caused by swallowing corrosives or irritants, and, in a more localized form, by the impaction of foreign bodies. The symptoms are pain B AFFECTIONS OF THE MOUTH, THROAT, AND OESOPHAGUS 869 and difficulty in deglutition, and the treatment consists in the re- striction of the diet to liquids, whilst in bad cases rectal feeding may be necessary. Chronic catarrh, followed by stenosis, may result from the continual drinking of raw spirits. Varix of the veins in the lower portion of the oesophagus is occa- sionally met with as the result of pressure on the portal vein, or from cirrhosis of the liver. This is due to the fact that these branches open into the gastric division of the portal system, passing through the oesophageal opening in the diaphragm. Haematemesis may result, and has even proved fatal. Spasm of the (Esophagus, or hysterical stricture, arises in neurotic young women, usually under twenty-five years of age, and, although sometimes independent of organic lesion, is often associated with some shght abrasion or ulceration of the mucous membrane, perhaps originated by the impaction at an earher date of a fishbone. The symptoms complained of are difficulty in swallowing, and a sensation as of a ball arising in the throat {globus hystericus), due to a spas- modic action of the pharyngeal constrictor muscles. At times, when the patient's attention is diverted, deglutition occurs quite normally. The best course of treatment is anti-neurotic in character {e.g., cold douches to the spine, massage, the administration of purgatives, valerian, etc.), whilst the passage of a full-sized oesophageal bougie is useful. Organic Stricture of the (Esophagus occurs in two forms — the fibrous and the malignant : 1. Fibrous Stricture of the (Esophagus is usually located near its commencement, just behind the cricoid cartilage, and is most fre- quently caused by the swallowing of corrosives, and the cicatrization of the wounds caused thereby; it also results from syphilitic disease. At the cardiac orifice it may arise from the healing and contraction of a gastric ulcer. The main symptom produced is a gradually in- creasing difficulty in the swallowing, firstly of solids, but finally even of fluids. If the obstruction is placed at the upper end of the tube, food is returned immediately; but if lower down, the oesophagus may become dilated, and in this pouch or oesophagocoele the food collects for a time, and then returns unchanged. There is but little pain in this form of stricture, although the patient is usually able to indicate the level of the obstruction. As the case progresses, he becomes steadily emaciated from sheer starvation, and may even die from this cause. 2. Malignant Stricture of the (Esophagus is usually epitheliomatous in type, occurring in subjects over forty years of age, and situated either at the junction of the pharynx and oesophagus, i.e., behind the cricoid cartilage (Fig. 417), or in the middle of the tube, where it is crossed by the left bronchus, or at the cardiac orifice of the stomach; in the latter site, columnar carcinoma is the form usually found. The growth involves the whole circumference of the tube, and sooner or later ulcerates, perhaps perforating the trachea, pleural cavity, or one of the large vessels. Secondary deposits occur in the lymphatic Syo A"! MANUAL OF SURGE RY glands, either of the neck or posterior mediastinum, visceral compH- cations being uncommon. The symptoms are similar in character to those of fibrous stenosis detailed above, but in addition the vomited materials may contain blood, and there is a good deal of cough and pain, referred usuaUy to the site of the disease. Should the growth be at the upper end of the tube, a tumour may be distinctly felt, placed deeply in the neck and more marked on the left side ; in the earlier stages nothing can be felt externally, al- though the side-to-side movements of the larynx may be impeded. Perforation of the trachea leads to the entrance of food into the air- passages, and rapidly results in septic pneumonia and death. When the upper part of the gullet is affected, the growth may spread to the back of the larynx, and cause hoarseness and even aphonia. Occasionally the pneumogastric nerves may ba in- volved in the mass, leading to inter- ference with the action of the heart, whilst implication of the recurrent laryngeal nerves causes constant cough and uni- or bilateral paralysis of the larynx. The Diagnosis of (esophageal stricture can be made by the ad- ministration of a bismuth meal and radiography, or by examining the condition of the tube with an oesophageal bougie. The greatest care must be taken, especially in suspected malignant disease, as it is not difficult to perforate the walls and open up the medias- tinal tissues, causing thereby a fatal cellulitis. A cancerous stricture sometimes feels rough and is painful ; a simple stricture is smooth, regular, and almost painless. It is by no means easy to distinguish the two forms by the bougie alone, and the history of the case and the general condition of the patient will need to be investigated thoroughly; a hacking cough with no special pulmonary symptoms is always a bad and suggestive sign. The use of the oesophagoscope in skilful hands will enable the upper surface of the stricture to be seen, and an absolute diagnosis effected. Treatment of Fibrous Stricture of the CEsophagus.^ — [a) Dilatation of the stricture by means of gradually increasing bougies; for this purpose it is better to use conical rather than blunt-ended instru- ments. The use of the oesophagoscope facilitates this procedure. An interval of some days should elapse between the attempts at Fig. 417. — Cancerous OF THE QiSOPHAGUS. ' Surgery.') Growth (Treves' AFFECTIONS OF THE MOUTH. THROAT. AND (ESOPHAGUS 871 dilatation, and during this period the patient should be given as much food as he can take in the shape of strong broths, minced meat, raw eggs, etc., or, if need be, rectal alimentation must be resorted to. {b) If it is impossible to dilate, or if the stricture recurs, a tine rubber tube can usually be passed through the stric- ture by the assistance of the cesophagoscope, and is maintained there for a time. The upper end is drawn out of the mouth and fixed to the ear. Feeding is thereby rendered easy, and the presence of the tube for a time gradually determines dilatation of the stricture, (c) When the contraction is at the pharyngeal extremity, it may be possible to divide, and subsequently dilate, the stricture by the aid of the cesophagoscope. {d) If the cardiac orifice of the stomach is contracted, the stomach may be opened as in gastrotomy, and the fingers used to dilate the stricture (retrograde dilatation) . [e) Where these proceedings are not possible, or, if tried, have failed, the stomach may be opened and division of the stricture by Abbe's stnng sai& attempted. The patient is made to swallow one end of a piece of string, or a small shot may be clamped on a piece of fine silk, and allowed to find its way into the stomach. When this viscus is opened, the free end is secured and by this means a coarse silk thread is carried through the obstruction; by up-and-down sawing movements the stricture can be thereby divided, enabling the surgeon to introduce bougies. Excellent results have been reported from such practice. (/) Gastrostomy (p. 1005) is the final resource. Occasionally when the oesophagus has by this means been kept at rest for some time, the stricture will yield, and dilatation by bougies becomes practicable. In such a case the opening in the stomach may be allowed to close. Treatment of Malignant Disease of the (Esophagus.— Dilatation by bougies even with the assistance of the cesophagoscope, should not be employed as a routine practice, for fear of increasing the ulceration, causing severe haemorrhage, or perforating the walls of the tube. It may, however, be used very carefully so as to enable a tube to be passed through the stricture for feeding purposes. Symond's method of ttibage may be utilized in malignant disease, the patients often bearing the inserted tube well, even when the cardiac orifice is involved, the lower end then projecting into the cavity of the stomach. Radium has been employed, but is of little real value, for although the primary growth may be improved, the patient dies of secondary deposits which cannot be affected by its influence. Hence, gastrostomy is likely to be required sooner or later in not a few of the cases. By the term Dysphagia is meant a condition in which swallowing is painful or difficult. The Causes are very numerous, and may be arranged as follows: 1. Pharyngeal — e.g., acute or 'chronic inflammation, whether simple, scar- latinal, diphtheritic, etc.; ulceration of syphihtic or malignant origin; stenosis as a result of ulceration; paralysis {e.g., labio-glosso-laryngeal or bulbar) or spasm; impaction of foreign bodies; naso-pharyngeal pol}^)! projectmg behind the velu m; retro-pharyngeal abscess or tumour, etc. 2. Laryngeal — e.g., acute or chronic laryngitis; tiiberculous, syphilitic, or malignant disease. 872 A MANUAL OF SURGERY 3. (Esophageal — e.g., acute or chronic inflammation, impaction oi foreign bodies, the presence of diverticula, cesophagospasm, and simple or maUgnant stricture. 4. Extrinsic. — In the neck : goitre, enlarged glands, aneurisms, etc. In the thorax : mediastinal growths or glands, aneurisms of the aorta and large vessels, tumours growing from the vertebral bodies, pericardial effusion, and displacement backwards of the sternal end of the clavicle. To investigate a case of dysphagia, note: (i) The method of onset, whether acute or chronic — if the former, it is probably due to a foreign body; (2) the condition of the phar^Tix as seen from the mouth and on digital exploration ; (3) the condition of the neck as seen and felt from without, whether or not a tumour is to be felt behind the cricoid, or whether a goitre or aneurism exists ; (4) the character of the voice, as indicative or not of laryngeal mischief — if the voice is husky, a laryngoscopic examination must be made; (5) the chest must be carefully examined for aneurisms, etc.; (6) the oesophagus is examined by bougies or the oesophagoscope. If the obstruction is in the oesophagus, the patient's age and general condition will give prima facie evidence as to whether or not it is due to malignant disease; but it must not be forgotten that the stenosis per se causes some of the loss of flesh and of weight. The presence of blood and offensive mucus on the bougie or on the material vomited, and the existence of enlarged glands in the neck, will also assist in establishing a diagnosis. CHAPTER XXXI. AFFECTIONS OF THE EAR. The Examination of the Ear is carried out by inspecting the membrana Lmpfm tTrouTa speculum by means of light reflected from a frontal mirror ; bv testin- the%ower of hearing; and by ascertaining whether or not the Eustachran tubers permeable, and the effect on the hearing of inflation through ^^'i ""vrsuaf inspection by means of a speculum and frontal mirror In in- trodudnrthe speculum the auricle is held between the third and fourth Inters oi the operator (the left hand being used for the right ear, and vice ...?: and draw^n backwards, upwards, and outwards so as to ^ J--ght«n t^^^^ rartilaeinous portion of the meatus. The speculum held by the operator . Sumrandfi?sT finger is then gently .inserted and held m position. The reflected light illuminates the tympanic membrane, unless the presence ot wax epitheUal debris, or pus obstructs the view, when they must be removed brcot?on-wool mops or by syringing. The following points are to be noted Fig. 418. — Eustachian Catheter. in the normal membrana tympani (Fig. 419): The projection of the short process and handle of the malleus which runs from the centre upwards and Forwards; behind this the processus gracilis of the .incus and the tendon of the stapedius- and at the upper border Shrapnell s membrane (i-ig. 421 j • The motility of tSe membrane should be considered, as also its colour, whilst pathSoScaliy the presence of perforations, polypi, or adhesions, should be ''°?'The Investigation of the Hearing is usually carried out by testing the greati^dSce ft wh^^^^^ patient can hear the ordinary conversational foice or the tick of a watch; the whispered voice is also ^^„^°iP°X*. ^^f^J^^^ The cause and location of deafness is ascertained by Rinnes Tuning-* OfK Test To perform it a tuning-fork of about five hundred and twelve vibra- fions is placed in contact with the mastoid process, and retamed there until the natient can hear it no longer. If now it is placed opposite the external auditorv meatus Se sound shSuld again be heard if the middle ear is normal, but Snofbrnoted if disease is pfesent. Weber's Test consists m p acing a vibrating tuning-fork in the middle line of the forehead. In cases 01 pure L^dL e?r^iseasf , the sound will be noticed more in the affected ear than on the healthy side. 873 874 A MANUAL OF SURGERY 3. Inflation of the Tympanic Cavity is required both as a test of the permc- abihty ol the Iv.islai hum tube and also as a means of treatment in various conditions. 1 lie methods of eftecting it are as follows: Valsalva's Method consists in closing the lips, holding the nose, and expiring forcibly; the air is thereby driven up the Eustachian tubes if they are patent. In Politzer's Method an indiarubber bag with a teat-like end is introduced into one nostril so as to occupy it completely. The other nostril is closed by the surgeon's linger. The patient is instructed to take a sip of water and to Fig. 419. Fig. 420. Fig. 421. Fig. 422. Figs. 419-422. — Appearance of the Membrane in Various Circumstances ON Examination through a Speculum. By permission, from Mr. Albert A. Gray's ' Diseases of the Ear.' London: Baillidre, Tindall and Cox.) Fig. 419. — Normal membrane (right side). Fig. 420. — Perforation below and in front of head of malleus (left ear) m acute otitis suppurativa. Fig. 421. — Perforation through Shrapnell's membrane in chronic otor- rhoea. Fig. 422. — Polypi protruding through perforation in membrane. hold it in the mouth with closed lips until told to swallow. As he swallows, the bag is forcibly compressed, and air is thereby driven up the tubes. An auscultating tube may pass from the patient's meatus to the surgeon's ear, and various sounds, whistling, bubbling, etc., may be detected, according to the character of the lesion. AFFECTIONS OF THE EAR 875 The Eustachian Catheter (Fig. 4x8) can be Passed mto tl.c E-^tachian^ube and the degree o£ inflation more ^f urate ycont^lled. ine carelnlly steriHzed, is passed with the beak downwards along tne meatus of the nose until the.postenor pharyngeal wains le^ ^^ l-Si:^ - SySS,^S^iS^S;StL ^Srl^S S.e Eustachian tube ' (Lambert Lack). The External Ear is the site of various affections ^^^^^^^^ ^^^^ under the observation of the general surgeon. 1 ^^f'^^h^ Pmna may be congenitally absent, and even the external meatus c.osed^a mal formation often associated with macrostoma. Nothing can be done for this want of development, and the surgeon must nevei be tempted to try and dig out the concealed membrana tympam. More tre quently accessory auricles are present con- — sisting merely of fibro-cartilage covered with fat and skin. Large and prominent ears constitute a very unsightly deformity, tor which operative interference is occasionally required. The size may be diminished by removing a V-shaped portion from the upper part • the prominence, by excising a portion of skin and cartilage through an incision on the posterior aspect. The wounds thus produced are accurately sutured together, and considerable improvement in the appear- ance results. Hsematoma of the ear is usually due to injury, but is occasionally idiopathic in origin, especially amongst the insane. The auricle becomes swollen and enlarged, and of a bluish-red colour in trau- matic cases (Fig. 423) ; unless Ihe swelling is punctured and the blood let out, consider- ^,,,^^ l^oUs able deformity will result from its org^^^^^^^^^^-^.^^ff.'^^^^As^^are and other inflammatory affections, as also sebaceous cysts, are met with in the external ear and pmna, but call for no special "'plugs o£ wax (cerumen), which become dark and indurated not unfrequently block the rneatus leading to more or less compMe deafness; this may come on suddenly after b^^hing owing to the Dluff rapidly swelling up. If they encroach on the membrana rJ^'paTsubjective fym^toms of giddiness, vomiting and rush.ng noises in the ear may also be caused. On examination with an ear spTcuC th^pres J^ is readily detected, ^re^^^jl^^^^^^^^ washing them away, after previously so tenmg w^th oil or glycenne^ A laree svringe with a fine nozzle should be used, and a stream 01 warXX^^iected along the roof of the --t-' ^ 1^^^^^^^^^^^^ softened masses of wax are washed away, ^o^^^^^n bodies in the meatus, such as buttons or beads, are similarly removed, if possible, Fig. 423. HiEMATOMA AURIS. 876 A MANUAL OF SURGERY by syringing; if this fails, a fine pair of forceps is employed for the purpose, but it must be remembered that behind the foreign body lie delicate structures, which can readily be harmed by the exhibition of impatience or force. Where all other plans fail, the auricle may be turned forwards and the meatus opened from behind. Exostoses are occasionally met with springing from the bony walls of the meatus; they give rise to deafness by obstructing the passage, and may be removed by the dental drill. AfEections of the Middle Ear. Traumatic Rupture of the Tympanic Membrane is due to direct or indirect violence; the former includes the introduction of foreign bodies, or the ill - advised efforts of friends or even of medical practitioners to remove the same; the latter causes rupture of the membrane by the sudden compression of the air in the external meatus — e.g., by boxing the ear, loud noises as from explosions or big-gun practice, or from diving. The lesion also occurs not uncommonly in fractures of the middle fossa of the skull. The patient complains of pain and deafness, and blood escapes from the meatus, but not to any great extent. On inflating the drum- chamber, as by Valsalva's or Politzer's methods, air can be heard to escape tlirough the opening, perhaps with a whistling sound. As a general rule, these cases do well, the wound cicatrizing, and the hearing being fully restored; but the surgeon must at first give a guarded opinion, as there may be some deeper lesion which does not immediately become apparent. The greatest care must be taken to sterilize the meatus, although it is not wise to use a syringe for the purpose; the meatus is filled with i in 20 carbolic lotion, which is allowed to soak m ; by this means infection of the tympanic cavity with pyogenic organisms may be prevented A strip of gauze is then gently inserted into the meatus, and an external dressing applied. Otitis Media.- — Inflammation of the middle ear is an exceedingly common affection, and constitutes the great bulk of all ear diseases. It must be remembered that the tympanic cavity is lined by a mucous membrane which is in direct communication through the Eustachian tube with that of the naso-pharynx ; and hence the cause is almost invariably an extension of inflammation along the Eustachian tube, and the organisms usually present are the pneu- mococcus or ordinary pyogenic cocci. The inflammation may be catarrhal or suppurative, acute or chronic. We can here only refer very briefly to that most commonly associated with surgical lesions. Acute Inflammation of the Middle Ear is very common in children, being secondary to lesions of the naso-pharynx, such as an ordinary cold, adenoids, scarlatina, measles, etc. It is ushered in by severe pain in the ear (earache) of a boring, persistent character, together with deafness and perhaps some degree of fever. The pain increases as the secretion accumulates, and if the Eustachian tube becomes closed in consequence of the inflammatory hypersemia of its lining AFFECTIONS OF THE EAR 877 wall, the tympanic membrane bulges outwards into the meatus and finally ruptures (Fig. 420), the pain being at once reheved. The discharge is mucous, or purulent fromthe first ; in the former mstance, if infection from the meatus is guarded against, the inflammation may subside, the perforation heal, and no ill result follow. In many instances, however, especially when the child is suffermg from measles, or if his resisting powers to microbic invasion are low, pyogenic infection follows, and the catarrhal otitis media is trans- formed into a suppurative lesion, which may persist as a chronic otorrhcea for a lengthy period, and may lead to the most serious results. . , It is therefore obvious that the greatest care should be taken m the Treatment of all cases of acute otitis media. In the first place, the possibility of infection from the external meatus must be guarded against by thoroughly purifying it ; the external ear is well washed with soap and water, and the meatus is filled with i m 20 carbolic lotion, which is aUowed to soak in and act for some minutes. An antiseptic dressing is then placed within and over it. The child is kept in a warm room, and his general condition attended to by suit- able diet, diaphoretic medicine, and a smart purge. In mild cases a blister behind the ear will often act beneficially, whilst m more acute ones leeches may be applied. Solution of cocaine or drops of lauda- num instilled into the meatus may relieve pain, and in adults it may be possible to cocainize the orifice of the Eustachian tube in the pharynx, thereby relieving the hypersemia and opening up the tube, and thus giving an exit to the retained discharge. Pain is often relieved by fomenting the ear or by the appHcation of dry heat, as in the form of a hot-water bottle or a baked bran-bag. _ When the membrane is seen (by speculum) to be bulging, it is wise to incise it, as a clean cut often heals better than the ragged perfora- tion made by Nature. Local or general ansesthcsia is required, and the incision is usually made just behind and slightly above the handle of the malleus downwards and backwards. An antiseptic dressing is left in and over the meatus until healing has occurred. Chronic Otorrhcea, as already explained, is a common sequence ot an acute attack, which may have been purulent from the first, or may have been the result of a pyogenic infection from without of a simple catarrhal otitis media. The membrane is perforated, and the discharge varies in amount and character. In uncomplicated cases, treatment consists in: (i) Improvement of the general health, as by the administration of tonics, residence in fresh country air, and avoidance of chills. (2) The naso-pharyngeal condition must be attended to, so as to ensure a patulous condition of the Eustachian tube, by which discharges may escape. Gargles may be ordered and adenoids and enlarged tonsils may require removal. (3) ine middle ear must be kept free from any accumulation of discharge which might undergo decomposition. When the discharge is abun- dant, external syringing with sterilized salt solution or weak boric acid solution is needed, and the tympanic cavity is inflated from tne Eustachian tube by Valsalva's method, PoHtzer's bag, or even the 878 A MANUAL OF SURGERY Eustachian catheter, once or twice a day. If the discharge is offen- sive, or difficult to dislodge, peroxide of hydrogen (10 volume strength) will be found useful. If the discharge is slight, the meatus may be packed with boric acid powder, and syringing avoided. Not unfrequently, however, a persistent discharge from the ear is due to some of the complications mentioned below, and further operative treatment may be required. The Surgical Complications of Chronic Otorrhoea are often serious, and call for prompt treatment ; they may be classified under three headings- — the extracranial, the cranial, and the intracranial. The extracranial complications of otorrhoea are comparatively unimportant. ((/) Eczema of the meatus is frequently seen, and merely needs the parts to be kept dry and clean, and possibly a Httle boric acid powder insufflated: it readily disappears when the dis- charge ceases, but is not unfrequently associated with enlargement of the cervical glands, which may suppurate or become tuberculous. (h) Boils arise from infection of the sebaceous glands in the meatus with pyogenic cocci from the discharge, and are exceedingly painful owing to the denseness of the tissues involved. They should be fomented, and opened when pus has formed, (c) Inflammation may occasionally spread from the meatus to the tympanic plate of the temporal bone, leading to subperiosteal abscess and necrosis; or it may extend into the temporo-maxillary articulation, giving rise to suppurative arthritis anddisorganizationof that joint (p. 811). The cranial complications of otitis media are often of a grave nature, and may produce deafness, or even endanger life. {a) The ossicles become ankylosed, or may die and be cast off in the discharge, the hearing being impaired in either case, but not necessarily destroyed. {b) The inflammation may extend from the lining membrane of the tympanum to the bony walls surrounding it, giving rise to a limited caries or necrosis of the temporal bone. This may be as- sociated with suppuration within the skull, and any of the intra- cranial complications mentioned below. The roof of the tympanic cavity {iegmen tympani), which is very thin, is especially liable to be affected in this way. If diseased bone can be felt through the external auditory meatus with a probe, an attempt should be made to remove it ; if this is impossible, the part must be kept clean by the injection of mild antiseptics, retention of discharges being pre- vented by the regular use of Politzer's bag. (c) Polypi may also develop, consisting essentially of granulation tissue protruding through the opening in the membrane (Fig. 422) thereby hindering the escape of the discharge. Ihey should be removed by the snare or curette, and the base touched with a satu- rated solution of chromic acid; the part is subsequently syringed with a weak carbolic solution and dressed antiseptically. [d] Facial Paralysis not uncommonly arises from sclerosis and thickening of the bony tissue surrounding the aqueductus Fallopii, causing pressure on the facial nerve in the canal. It must be re- membered that the bony canal lies immediately behind the tympanic AFFECTIONS OF THE EAR 879 cavity, and to the inner side of the passage from the attic to the mastoid antrum [aditus ad antrum). For symptoms and treatment, see p. 384. [e) Involvement of the Internal Ear or Labyrinthitis results from the spread of the infection inwards, either through the wall of the ex- ternal semicircular canal, or through the fenestrum rotundum or ovale; in the former case the posterior or vestibular portion is involved, in the latter the cochlea. Invasion of the semicircular canals is usually evidenced by vertigo, a tendency to fall towards the affected side, nystagmus and vomiting; pain and fever are present in the more acute forms. Involvement of the cochlea is generally a later manifestation, and results in tinnitus and absolute deafness. Infection of the meninges sometimes arises by spread of inflammation along the internal auditory meatus. (/) Inflammation may also extend into the mastoid cells, giving rise to the condition known as mastoiditis. The mastoid process is a triangular mass of bone, which is practically undeveloped until the age of puberty. Before that period a single cell relatively of large size communicates with the posterior portion of the tympanic cavity and represents the antrum; it is comparatively superficial, being immediately under cover of the squamous flake of bone, and is in reality petro-squamosal rather than mastoid in origin. After puberty the whole bone may become hollowed out into a series of spongy cells, lined with mucous membrane, which open into the floor of the antrum; or it may develop but few cells, and remain more or less solid. These cells lie below and superficial to the antrum, which is therefore more deeply placed in the adult than in the child. The communication with the tympanic cavity, which in a child is widely open, becomes encroached on in the adult, and narrowed to the small track known as the aditus ad antrum. When the inflammation in otitis media becomes purulent and extends into the antrum, severe local and general symptoms are likely to result. The patient com- plains of intense pain in the ear, with tenderness on pressure, and perhaps redness and oedema over the mastoid process. The dis- charge 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 intermittent type, and even rigors, may supervene, whilst the patient becomes drowsy, or may be irritable and restless. An abscess may form under the periosteum covering the mastoid process, with or without caries or necrosis of the outer table of the bone; in children, where this bony lamella is thin, it is not unfrequently absorbed, and on incising the abscess protuberant masses of granulations, springing from the interior of the bone, may be seen. When such an abscess has developed, the auricle is characteristically displaced downwards and outwards. Not unfre- quently the suppuration extends through the bone cells and may encroach on the inner aspect rather than the outer, and hence is likely to lay bare the dura mater and expose the lateral sinus ; in such circumstances intracranial complications are probable (Fig. 369). Occasionally a few thin-walled cells occupy the tip of the mastoid; 88o A MANUAL OF SURGERY and these, if involved, may perforate downwards, and thus an ab- scess may form under cover of the sterno-mastoid, and track into the neck; this is known as Bezold's perforation (Fig. 369, F). At times the trouble is of a more chronic type, and is then associated with the more solid form of mastoid process. Sometimes it is 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 is the seat of a good deal of deep-seated pain of an aching character, and worse at night. When the discharge is inspissated and mixed with epithelial cells and cholesterine, so as to form flaky masses like the layers of an onion, the condition is known as cholesteatoma. It k often the cause of great distension of the antrum, which in one case operated on measured quite i| inches across. The symptoms, at first of a Fig. 424. — Incision for [ Mastoid Operations. Fig. 425. — Site for Drilling Bone in Order to Open the Mastoid Antrum. It is often well to apply a chisel over the desired area so as to include a triangle, the centre of which corresponds to the apex of the so-called supra-meatal triangle. As soon as the outer layers of the bone have been removed by the chisel, the gouge is used to reach the deeper parts. chronic type, are likely to be followed sooner or later by an acute attack of suppurative inflammation. Treatment. — In the early acute stage belladonna fomentations may be employed, and the patient kept quietly in bed, whilst the diet is regulated and a suitable purgative administered; accumulated dis- charge is removed from the tympanum by the use of Politzer's bag. Two or three leeches may also be applied over the mastoid process, and relief to the pain thus obtained, though it is often only of a temporary character. It is most important not to rely upon such palhative measures for too long, but if the symptoms are well marked, the mastoid antrum must he laid open and its contents evacuated without interfering with the tympanic structures which in acute cases are capable of effective repair [Schwartzes operation). A curved incision is made immediately behind the ear, which is drawn well forwards (Fig. 424), and a gouge or burr worked by a surgical engine, applied on a level with the roof of the external AFFECTIONS OF THE EAR 881 auditory meatus, and about h inch behind its centre (Fig. 425). A small dmiple in the bone can often be felt at the required spot, which can also be found by taking the point of junction of two hues drawn as tangents to the roof and posterior wall of the bony meatus respectively (Fig. 370, C) . The direction taken by the gouge should be slightly downwards, forwards, and inwards, and a useful guide will be found in a probe , passed down the external auditory meatus, the bor- ing being made exactly parallel to this. In an adult the mastoid antrum is reached about three- fifths of an inch from the surface of the bone. The surgeon recognises that he has opened the cavity by the probe, or by the loss of resistance and escape of offensive pus. The opening is enlarged by the use of the gouge and spoons, so as to ex- pose all the affected bj.ie cells and remove all diseased bone, and the cavity is then syringed out. The wound is packed with sterile gauze and should be syringed daily. A Bezold's perforation must be enlarged, and possibly an incision in the neck may be prevented, if the case is treated early. In the more chronic cases, where tympanic complications are present, a more extensive proceeding known as Stacke's operation is usually required. In it the auricle is detached posteriorly from the bony margins of the meatus, and then the antrum is opened and the whole of the osseous tissue intervening between it and the meatus and tympanic cavity in front is gouged away. A metal guide is passed from the opening in the antrum into the attic along the aditus, and all the bone superficial to the guide may be safely removed. The facial nerve and superior semicircular canal lie behind, and are protected by the guide. The remains of the mem- brane and the ossicles are then removed, and the cavity curetted (Fig. 426) . The deep portion of the posterior wall of the cartilagin- ous meatus is incised longitudinally and the margins of the aperture stitched to the posterior edge of the wound, the meatus thus leading to the whole of the opening in the bone, which can in this way be syringed out and cleansed more effi,ciently. The intracranial complications of otorrhcea are subcranial abscess, 56 Fig. 426.^Stacke's Operation completed. The antrum (A) has been thoroughly opened up, and the bridge of bone covering the aditus removed, thus bringing the antrum into free communication with the tympanic cavity (B), which is curetted and the ossicles removed . 882 A MANUAL OF SURGERY localized or diffuse meningitis, thrombosis of the lateral sinus, and abscess in the cerebrum or cerebellum. {a) Subcranial Abscess.^ — For general phenomena connected with this condition, see p. 764. Accumulations of pus occur most com- monly along the summit of the petrous portion of the temporal bone (Fig. 369, B), and in the sulcus in which the lateral sinus is lodged. The patient complains of pain and headache, which increase for a time and are then followed by drowsiness, which may pass into coma. The temperature is raised, but rigors, even if present at first, are b}- no means a constant feature of the case. The pulse is of the usual febrile type, viz., quick, full, and bounding. There is no pain in the neck along the course of the jugular vein, but retraction of the head occurs if basal meningitis is present, and vomiting is a marked S3-mptom. Optic neuritis ma}' be observed in consequence of the inflammation extending to the membranes at the base of the brain. There may be some tenderness on pressure over the temporal region, and possibly oedema. In some cases the pus finds its way outwards along the mastoid emissary vein, or through the suture between the occipital and temporal bones. The Diagnosis from cerebral abscess is sometimes a matter of con- siderable difficulty. 1 he sj^mptoms, however, set in somewhat more acutely, whilst the temperature is raised, and the signs of irritation of the membranes, such as retraction of the neck, all suggest that the lesion is extradural, and not cerebral in origin. The pulse is fast, and not slow, and focal symptoms are less likely to develop. Ihe Treatment consists in trephining above and behind the meatus, so as to escape the lateral sinus, and in much the same situation as for a temporo-sphenoidal abscess {q.v.). The pus is washed out, and a drainage-tube inserted for a few daj-s. [b) Meningitis ma}' be localized or diffuse. The former often accompanies some other condition, and is in itself of little moment. It may produce fixed headache, but, if non-suppurative, usually dis- appears when the originating disease has been cured. The diffuse variety is generalh' infective in nature, and secondary to some sup- purative affection in the neighbourhood, or to thrombosis of the lateral sinus. (For symptoms, see p. 766) . Occasionally a simple serous effu- sion occurs within the meninges, leading to increased pressure and consequent drowsiness, but disappearing entirely when the cause has been removed, or the excess of fluid withdrawn by lumbar puncture. (c) Thrombosis of the Lateral Sinus arises from direct extension of the inflammatory process from the middle ear through the mastoid bone (Fig. 369, E), or it may be set up by an infective thrombosis of the mastoid emissary vein spreading to the sinus. A clot forms within it, which, gradually increasing in size, leads finally to occlu- sion of its lumen. Infection with pyogenic organisms determines disintegration of the clot; infected emboli are detached, and thus pysemic symptoms originated. In well-marked cases the thronibus extends as far back as the Torcular Herophili, and downwards along the jugular vein. Ihe most marked Symptom of the case is the sudden appearance AFFECTIONS OF THE EAR 883 of a high temperature, which is usually remittent, and associated with rigors, vomiting, and localized pain in the head, perhaps most marked over the point of emergence of the emissary vein at the posterior border of the mastoid process. The pulse is rapid, feeble, 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 thrombus 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. The cervical lymphatic glands become enlarged, and stiffness of the muscles at the back of the neck is an evidence of associated basal meningitis, as is also the optic neuritis. Suppuration may occur outside the sinus, or around the vein in the neck, which becomes swollen, red, and oedematous. In well-marked cases the Diagnosis is easily made, but m the early stages, and especially in children, it is often a matter of some difficulty. The abrupt onset, the oscillating temperature, the re- current 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.— A radical mastoid operation is usually undertaken first, and by extending its scope backwards the sinus can be exposed. Apart from this, the sinus is laid bare by applying a trephine at a spot about 1 inch above Reid's base-Hne, and about i inch behind the centre of the external auditory meatus (Fig. 370, A or B). A puncture with a fine needle readily determines whether the smus contains fluid blood or thrombus. If it is thrombosed, there is often some evidence of inflammation or pus around it, between the dura mater and the bone. Having thus verified the diagnosis, an incision is made along the anterior border of the sterno-mastoid, through which the jugular vein is tied at a spot below the lowest point of the thrombus, so as to prevent the escape of any more emboli into the general circulation. In old-standing cases this may involve exposing the vein in the lowest part of the neck, and placing the ligature close to the innominate. Ihe lateral sinus is now freely incised, and the infected thrombus partly scraped, partly washed away, the opening in the bone being increased in size, if necessary. It is desirable, but not essential in the simpler cases, to remove completely the lower part of the thrombus; if such is attempted, the jugular must be opened above the ligature, and the clot syringed or scraped away. Bleeding occurs from the posterior part of the upper opening as soon as all the coagulum is removed, but is easily controlled by plugging the sinus with a small piece of aseptic gauze. The wound in the neck should be lightly packed and not closed, since infection and suppura- tion are almost certain to follow. The upper wound is also packed in the same way, and allowed to granulate. [d] Abscess in the cerebrum or cerebellum, a comphcation not unfrequently met with, has been already discussed (p. 769). CHAPTER XXXII. SURGERY OF THE NECK. Affections connected with the Branchial Clefts. — In the second or third week of intra-uterine life a series of branchial arches 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 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 of the hyoid bone from 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 Fistulse are due to imperfect closure of the branchial clefts. They consist of narrow sinuous tracks extending inwards from the skin, and perhaps communicating, but not necessarily so, with the pharynx. The external 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. SURGERY OF THE NECK 885 Branchial Cysts arise from incomplete closure of a branchial cleft, the unoblitcratcd portion becoming 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 structures which would otherwise have remained passive. They grow slowly and painlessly, fornimg rounded swellings, often rather soft, with more or less distinct fluctuation, according to the depth at which they are situated; their contents, if near the cutaneous end of the cleft, are sebaceous in character, similar to, but more fluid than, that found in dermoid cysts (viz., flattened epithelial cells, cholesterine plates, and fatty granules) . If placed nearer to the pharynx they are occupied by a glairy mucoid fluid. They are usually lined with squamous epithe- lium, but a few cases have been recorded in which the cells were columnar, and even ciliated, 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 outwards. More rarely a cyst arises from the second cleft, being then located in the upper third of the neck, and spreading 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 extirpa- tion 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 un- obliterated 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 malignant cyst of the neck. It is characterized by the formation of a tumour placed deeply beneath the sterno-mastoid, indefinite in outline, and of firm consistence. Considerable pain is experienced, 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 in- duced. Pathologically, the condition is an epithelioma. Treatment is usually impracticable owing to the deep connections of the growth. Various other congenital conditions may be met with in the neck. Congenital induration of the sterno-mastoid in all probability arises from injury during parturition, and usually occurs in head presenta- tions, probably from bruising of the side of the neck against the under surface of the symphysis ; it is said to be more common on the left side than on the right. In cases that have been examined micro- 886 A MANUAL OF SURGERY scopically, 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. 432), cysts in connection with the thyro-glossal duct, and cystic hygroma, may also be mentioned. Cysts of the Neck. I. Cysts o£ Congenital Origin. — {a) Dermoids occur here as in any other region where congenital remains are found. As already mentioned, they may develop later- ally 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. 427) consists of a tubular outgrowth from the em- bryonic pharynx passing down- wards behind the body of the hyoid bone in front of the larynx and trachea as far as the isthmus of the thyroid gland, which is sub- sequently 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 hyoid bone ; the lower end is repre- Median Section of rented by the pyramid of the thy- roid 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 substance of the tongue or immediately below it (p. 838). If the lower portion A small dermoid cyst in the centre remains patent, a cyst develops of the tongue is also represented. containing mucoid or glairy fluid, which, however, is not present at birth. If 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 adenom- atous nature mayjdevelop from^any part of the duct, but especially from the lower end; they are quite innocent in nature, and unless Fig. 427 Tongue, Larynx, and Trachea, SHOWING Thyro-glossal Duct Extending from the Foramen C^cuM OF the Tongue Down- wards Behind the Hyoid Bone, and in Front of the Trachea TO the Isthmus of the Thyroid Body (Semi - diagrammatic, FROM College of Surgeons' Museum.) SURGERY OF THE NECK 887 troublesome may be left alone, (c) Cystic hygroma is sometimes congenital, but may also be acquired. It consists of a multilocular swelling, the spaces composing it being due to dilatation of lymphatic spaces, and filled with lymph. The tumour is often of considerable size, with a sinuous, irregular outline, and may produce great deformity and marked pressure effects. The skin over it may be occupied by dilated capillaries or lymphatics. Unless extending to inaccessible parts, such as the superior mediastinum, it should be dealt with by excision (p. 359). 2. Acquired Cysts of the Neck are of the following types: {a) Sebaceous cysts develop in the skin as elsewhere, but need no separate notice, [b] Bursal 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 is also stated to exist 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 ex- amination of the lining wall will quickly settle the diagnosis, since if it is bursal in origin it is lined with endothelium, 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 re- moved, (c) Unilocular serous cysts 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 (p. 233) . [e] Blood cysts have been found in close connection with 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. If .their vascular origin is recognised, they should be left alone unless causing urgent symp- toms. If, however, a blood cyst is opened by mistake, the supplying vessels must be secured, if possible, and, failing that, the cavity must be packed with gauze soaked in adrenalin. (/) Cysts are also occa- sionally met with in connection with the salivary glands and the thyroid body, (g) Malignant cysts arise, as already mentioned, from the remains of the branchial clefts, or from a degeneration of epithe- liomatous 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 extent and position of the wound. A right-handed suicide usually 888 A MANUAL OF SURGERY cuts his throat 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 homi- cidal cut throat varies in its direction according to whether it is done from behind or in front, and also with the hand employed. If the front of the neck is mainly involved, the air-passages 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 hemorrhage is very liable to ensue, 'f he 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 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, en- croaching 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, hsemor- rhage, asphyxia, or the entrance of air into veins. When above the hyoid bone, the root of the tongue and submaxillary region are in- volved, 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 impair- ment of the movements of the tongue. When the thyro-hyoid space is opened, 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 extensive, owing to the resistance offered to the knife by the cartilage. The thyroid body may be wounded and bleed freely, otherwise there is iDut little haemorrhage. Blood may find its way into the trachea or lungs, and asphyxiate the patient. When the trachea is involved, the common carotid and inferior thyroid vessels are 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 veins. The recurrent laryngeal nerve may be divided, causing paralysis of the larynx. The secondary effects following cut throat are mainly inflammatory in origin, (a) The wound is likely to become infected, giving rise to a cellulitis which may spread down to the mediastinum, or to oedema SURGERY OF THE NECK 889 of the glottis. Secondary haemorrhage also arises from this cause, and even general pyaemia, [h) Inflammation of the air-passages, tracheitis, bronchitis, or broncho-pneumonia, frequently follows, partly as a result of the entrance of cold air, partly from the admis- sion of septic material, such as food, decomposing blood-clot, or discharges. The patient may become cyanosed from these causes, and in consequence of the 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 with- out injury to the main vessels, (c) Surgical emphysema, or the entrance of the atmospheric air into the cellular tissue, may also follow a wound of 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 a few days. The Treatment consists in securing all bleeding-points, if possible, but occasionally they are placed so deeply that it is necessary to tie the external carotid; general oozing from the surface must be attended to, for fear of blood being sucked into the air-passages. Every effort should be made to render the wound aseptic, and if 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 together, the central portion being left open. The treatment of the air-passages varies with the site of the lesion. If the trachea has been roughly divided, the portions should be steadied by a stitch on either side, and a tracheotomy-tube inserted — at any rate, for a few days ; when cleanly cut, total closure without the use of a tube can be safely permitted. 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 necessary, it is better to perform a high tracheotomy. When the wound in- volves the thyro-hyoid space, or is situated above the hyoid bone, it is quite safe in many cases to close the wound layer by layer after carefully disinfecting it. The mucous membrane is first dealt with by stitches which do not penetrate its whole thickness, and then a more thorough purification can be undertaken; if the epiglottis is divided, it must be accurately sutured. If there is any doubt as to the advisability of this proceeding, a high tracheotomy is first per- formed, 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. Loss of blood is dealt with by the infusion of saline solution, and the patient's general condition attended to. Feeding should always be undertaken through a tube passed into the oesophagus, whether that structure is wounded or not, and this Sgo A MANUAL OF SURGERY should be continued until the patient's natural powers of swallowing are restored. The following Sequelae occasionally result from a cut throat: {a) An aerial fistula is a persistent abnormal communication between the air-passages and the external air, and occurs most often in the thyro-hyoid space, the skin and mucous membrane becoming con- tinuous one with the other around the margins of the opening. In some cases it may be closed ; but if laryngeal stenosis or adhesions are present, it must be left alone for a time until these conditions have been treated. The operation consists in separating the skin from the mucous membrane, and in order to accomplish this, the external wound must be enlarged vertically. The edges of the mucous mem- brane are then pared, and stitched together horizontcdly. The external wound is either closed vertically, or left partially open and packed, [h] Laryngeal or tracheal stenosis, due to the cicatrization of wounds in these regions, may be remedied by wearing an O'Dwyer's tube (p. 916) for a time, or may necessitate the constant use of a tracheotomy-tube, (c) A phonia may arise from division of the recur- rent laryngeal nerve, and is then usually persistent, {d) (Esophageal or pharyngeal fistulcB may also in rare instances complicate the heal- ing of an extensive wound in the throat, but tend to close of them- selves, and require no special treatment. Diseases of the Thyroid Body. Goitre. — Enlargement of the thyroid body, or, as it is termed, bronchocele or goitre, is a condition frequently seen in this country, and is of general, and not merely local, importance, since the thyroid body exercises considerable influence over metabolism and nutrition. Total absence or removal of the gland or its complete degeneration leads to accumulation of mucin in the body, producing myxoedema in adults, and cretinism in children ; whilst the excessive absorption of normal or vitiated thyroid secretion is probably responsible for Graves' disease, and possibly to some forms of skeletal trouble. The Causes of bronchocele are still enshrouded in a good deal of uncertainty. It occurs endemically in this and many other countries , being especially frequent in mountainous districts. At home the favourite sites are the hilly parts of Derbyshire and Gloucestershire (where it is known, in fact, as Derbyshire neck) ; it is exceedingly common in Switzerland and the valleys of Northern Italy, but also occurs frequently in relation with the Himalayas, Pyrenees, Andes, etc. Epidemics have also been known to occur, but rarely except in goitrous regions. There can be little doubt that the disease is due to the presence in the drinking-water of some living contagion, which probably develops in the intestinal canal and produces a peculiar toxaemia. Major McCarrison in his Milroy Lectures* has elaborated this thesis in a most convincing manner, and related at length his observations and experiments in connection therewith. Working with the goitrogenous waters of certain springs, he was able to pro- * Lancet, 1913, January 18 et seq. SURGERY OF THE NECK 891 duce the affection in animals (rats and goats) and in healthy men ; if filtered effectively, the water had no result ; the scrapings of the filter, however, if administered, produced goitre. These results coincide with the experimental findings of other workers in this field in Switzerland and elsewhere. Thus Wilms and Sazuli (Heidelberg) found that rats fed on cooked rice mixed with rat fseces, or injected subcutaneously with rat fasces, developed moderate goitres, whereas all other t\'pes of abnormal and vitiated feeding had no result. jMixing the contaminated food with KI or th^'roidin gave a negative result. The goitre itself is probably alwa\-s sterile and free from micro-organisms; the intestinal habitat of the germs is rather pre- smned than proven from the results of the emplo\'ment of intestinal antiseptics and of vaccines of intestinal bacteria, but there can be little doubt as to the value of these suggestions. Other contributory causes may assist in this development — -e.g., want of sunshine and air, as in the case of those who live in valleys into which the air does not readil}' penetrate, or in the underground kitchens and cellars of large towns, defective sanitary conditions, and the habit of carrying weights upon the head. The ordinar}- t\'pe of goitre seen in this country is much more common in women than in men ; it is not hereditary to an}- great extent, and is not influenced by intermarriage; but it maj^ be congenital, and then is associated mth skeletal changes, defective gro^\i;h, and intellectual weakness, con- stituting the condition known as cretinism. Varieties and Clinical Features. — Four chief forms of goitre are described, \-iz. : The parenchymatous or simple, the cystic, the fibro- adenomatous, and the exophthalmic; but the th\Toid body may become enlarged in other ways, giving rise to the conditions known as malignant goitre and acute goitre, whilst acute inflammation 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 of its lobes, or possibh* the isthmus alone. Its consistence varies with the nature of the gro\\-th, but it always moves with the larynx on deglu- tition. 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 cases, possibly from the excessive absorption of thyroid secretion. Pressure on surrounding structures leads to dyspnoea or d\'sphagia, and cerebral symptoms may arise from interference with the main vessels, which are dis- placed outwards. The trachea is especiaUy liable to changes of situation and shape from its compression ; it is usually flattened from side to side [scabbard trachea), and is sometimes pushed an inch or more from the middle line. Atrophy of the cartilaginous rings may also be induced, and if this results from the pressure of a cyst or adenoma of the isthmus, severe dyspnoea may be caused thereby. If, as sometimes happens, the goitre develops downwards, pushing behind the sternum (^retrosternal goitre), the trachea is likel}' to be compressed from before backwards, and respiration may then be 892 A MANUAL OF SURGERY accompanied by stridor, but with no aphonia. Pressure on the recurrent lar^^ngeal nerve Jeads to harshness or loss of voice, and to spasmodic attacks of dyspnoea, which may even prove fatal. It must be clearly understood, however, that the effects produced by a goitre are not necessarily proportionate to its size; some of the smaller growths at times produce severe symptoms. Simple or Parenchymatous Goitre (Fig. 428) consists of a diffuse overgrowth of the whole thyroid body, the parts retaining to a great extent their usual proportions. The enlargement is due partly to an overgrowth of the glandular tissue, but also to an accumulation of colloid material within the vesicles; a normal amount of fibrous stroma is usually present. The whole gland is generally involved, Fig. 428. — Front and Lateral \ie\v ok a Parenchymatous Goitre. The right lobe had been removed by a former operation. but possibly one lobe is larger than the other. It is soft and elastic to the touch, quite painless, and there may be some amount of lobu- lation. Not uncommonly it is associated with a cystic development or new formation of an adenomatous type. When the interstitial tissue is abnormally abundant, as often occurs in the later stages, the tumour feels harder than usual, and is more definitely lobulated. It ii then termed a. fibrous goitre, and if the sclerosis is very marked, myxoedema may supervene. The Fibro-adenomatous Goitre (Figs. 429 and 430) consists in the development of one or more encapsuled adenomatous nodules in the substance of the thyroid body, which is itself often concurrently enlarged. These nodules may occupy one or other lobe, or, when multiple, be scattered through the substance of the organ ; occasion- ally they develop in the isthmus alone. If situated near the surface SURGERY OF THE NECK 893 their limitation and free mobility in the gland can be easily detected; but when placed deeply, their special features cannot be recogmsecL Two varieties have been described: [a) The foetal m which the growth is solid and homogeneous, consisting of closely apposed ah-eoli in which there is no coUoid development, and identical in structure with embryonic thyroid tissue. Such growths are usually seen in young people; they are seldom very large, but frequently rather vascular, ih) The more ordinary type of adenoma resembles ordinary adult thyroid tissue more closely, and shows a considerable tendency to cyst "formation. It is impossible to draw an exact line Fig 429.— Fcetal Adenoma of Right Lobe of Thyroid Body in a Woman AGED Twenty-five Years. (From photograph kindly lent by Mr. James Berry.) of separation between this latter condition and the simple hyper- trophy, which is often of a diffuse adenomatous nature. Cystic Goitre (Cysto-adenoma) arises from the dilatation into cysts of alveolar spaces in the normal gland tissue or m a localized adenoma, the interalveolar w^alls being absorbed. They may be single or multiple, and contain either a thin fluid or a thick grumous colloid material, somewhat like furniture pohsh. Intracystic growths of a papillary nature are not unfrequent. The hnmg mem- brane of these cysts is epithehal in nature, the individual cells being cuboidal when the cyst is small, and flattened out or even squamous when large. It is sometimes intensely vascular, and haemorrhage into the cyst is by no means uncommon, causing the contents to be brown or blood-stained. . . Secondary changes occur in any of these varieties, chiefly affecting the interstitial tissue, which may develop into cartilage or bone, or 894 A MANUAL OF SURGERY may calcify, but only in very chronic cases. Haemorrhage into the alveolar spaces or cysts is not uncommon ; acute infective inflamma- tion may also involve the mass, and malignant disease, usually of a cancerous nature, sometimes supervenes. As a rare complication may be mentioned general dissemination,* gi\-ing rise to secondary growths, which are usually found in the short and flat bones, especially the cranium and vertebrie, but occasionally in the viscera. Their texture is usually identical with normal thyroid tissue, but may be more cellular and of a cancerous type, and may be sufficiently vascular to pulsate. They produce local symptoms of Fig. 430- -Multiple Fibro-adenomatous Goitre. (King's College Hospital Museum.) varying gravity. The thyroid may be apparently normal or the site of a simple goitre. The Treatment of the three preceding forms of goitre may be con- sidered together, as they are very different in nature to those which follow. In the early stages palliative measures can be employed, consisting in the use of soft or distilled water, the improvement of the general health, and the correction of errors in the personal and sanitary hygiene. Change of air to the seaside is often advisable, whilst iron and iodides may be administered internally, and iodine paint applied locally, or driven in by cataphoresis (p. 54). In India cures are often produced by inunction of iodide of mercury ointment, the part being subsequently exposed to the rays of the midday sun ; such treatment is generally impracticable in this country. The * Patel, ' Tumeurs benignes du corps thjToide donnant des metastases,. Rev. de Chirurgie, 1904. SURGERY OF THE NECK 895 exhibition of thyroid extract or of the active principle of the gland isolated by Baumann and called ' thyro-iodine ' is sometimes followed by a diminution of a simple goitre. In cases where, in spite of such treatment, the growth persists or increases in size, operative treatment sliould be undertaken in order to remove the tumour or a part of the gland. Total extirpation, as already mentioned, results in myxoedema ; but as long as a suffi- cient portion of the secreting substance is left, whether it is derived from the isthmus or from one of the lobes, no such sequela need be feared. In fact goitres should be treated much in the same way as other new growths, viz., by removal when small; there is still, un- fortunately, a considerable tendency amongst practitioners and patients to leave them untouched until they are of large size, thus greatly increasing the risk of the operation. Partial thyi'oideciorny is conducted as follows : An incision is made over the most prominent part of the tumour, either along the lower third of the anterior border of the sterno-mastoid, or transversely across the neck in order that the scar may be less visible. The plat3'sma and deep fascia are divided, and the sterno-mastoid, sterno- hyoid, sterno-thyroid, and omo-h5'-oid drawn aside, or, if need be, divided. The lobe to be removed is thus exposed within its capsule, which should not be opened. The limits of the mass are defined by the finger or a blunt 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 to avoid the inferior or recurrent laryngeal nerve by tying the vessels as near to the gland as possible. The lobe is now freed from the underlying structures, as also, if need be, the isthmus from the trachea. In detaching the latter, the surgeon must not forget that the cartila- ginous rings may have been absorbed, and that the walls of the trachea, being then merely fibrous in nature, are easily wounded. The isthmus is divided, and any bleeding vessels secured; or if necessary, it may be ligatured before division. The wound is closed by buried sutures for muscles and fascise, and a Halstead's intra- dermic stitch for the skin. A drainage-tube may be required for twenty-four hours, as it is difficult to employ much pressure on the neck. Healing by first intention should be the invariable result, and the scar almost invisible. The question as to the desirability or not of employing a general anaesthetic in these operations has been much discussed. Some surgeons, and notably Kocher, advise that local anaesthesia (Schleich's infiltration method) should be always employed; many others reserve that procedure for the worst cases, and trust to a skilled anaesthetist to administer safely a general anaesthetic to the maj ority of the patients. With this latter view we personally concur. When the growth is retro-sternal or the trachea much compressed, the intra-tracheal administration of ether is desirable. 896 A MANUAL OF SURGERY Fihro-adenomata, or Cysts, when multiple or deeply placed, are treated by extirpation of the affected lobe ; but if the new growth is single and superficial, it may be safely enucleated by dividing the skin and muscles as before, incising the gland substance and capsule down to the growth, which is readily shelled out. Exophthalmic Goitre, or, as it is often termed. Graves' or Base- dow's disease (Fig. 431), is a condition characterized by a diffuse enlargement 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 disease is probably due to some derangement of the sympathetic or central nervous system, asso- ciated with definite changes in the thyroid body which result in the excessive absorption of thyroid secre- tion, either normal or vitiated in character. The enlargement of the thyroid body is not always marked, and indeed may be scarcely notice- able, but microscopic changes will always be found. The gland is more solid in texture than usual; the alveoli are small and crowded together, and often contain no colloid ; papillary proliferation of the columnar epithelium lining the walls is present. The gland is always extremely vascular. 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 responsible 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 most cases, and is sometimes due to an increase of the orbital fat. Contraction of the so-called muscle of Miiller (unstriped muscular fibres stretched across the spheno-maxillary fissure) has also 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 hd and the cornea (von Graefe's sign). A fine fibrillary tremor of the hmbs is also commonly 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 may induce considerable respiratory distress. The blood shows an increase in the lymphocytes, although the leucocytes generally are Fig. 431 . — Exophthalmic Goitre. (From a Photograph.) SURGERY OF THE NECK 897 diminished in number. 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 irritation and worry by absolute rest in bed, whilst bro- mides, iron, and perhaps iodide of potassium, are administered in- ternally, attention being also directed to correcting menstrual derangements, or any other abnormalities of function or structure ; thus, the cure of a nasal catarrh by cauterizing the nasal mucosa has several times led to a rapid amelioration of the symptoms. Phos- phate of soda has been found useful in some cases, and Kocher speaks favourably of it when conjoined with suitable hygienic measures. 1 hymus and suprarenal extracts have sometimes proved beneficial, as also the blood-serum or dried blood of animals after thyroidectomy (antithyroidin) . Surgical treatment by removal of a portion of the gland is often followed by excellent results, although the proceeding is not devoid of serious risk, and should not be hghtly undertaken. Half of the gland has usually been removed, but some surgeons have been satisfied with tying three of the thyroid arteries in order to starve the growth. General anaesthesia is decidedly dangerous in these cases, and it is better to rely on local anaesthesia, either of the Schleich type, or by cocainization of the superficial cervical nerve, which can be exposed at the posterior border of the sterno -mastoid at the level of the thyroid cartilage; 2 or 3 drops of a 2 per cent, solution should be introduced within its sheath. Patients are also very liable to syncope after the operation, and occasionally to a curious train of symptoms probably due to excessive absorption of thyroid secretion. Ihe temperature a few hours after operation rises suddenly to 104° or 105°, the pulse-rate is greatly accelerated, and the patient becomes delirious and finally comatose, dying in that state in about forty-eight hours. The wound should be at once opened up, and probably a considerable quantity of a thin glairy fluid will be found within it ; this should be soaked up by repeatedly packing the wound with dry sterile wool, or a drainage-tube may be inserted. In the cases that recover, a gradual improvement usually shows itself, but the full benefit of the operation is rarely gained under six or twelve months, and even then the exophthalmos often persists. Malignant Disease of the Thyroid Body is more frequently can- cerous in nature than sarcomatous, usually taking the forrn of an adenoid cancer, and almost always preceded by some variety of simple goitre. The tumour grows rapidly, infiltrating the surround- ing parts, and causing enlargement of the lymphatic glands, and secondary deposits in the viscera and elsewhere. The trachea is severely compressed, and in some cases perforated ; the main vessels are frequently surrounded by the growth, and not merely displaced as in the simple variety. Myxoedema may ensue as a late comph- cation, owing to the total destruction of the glandular substance. 57 898 A MANUAL OF SURGERY Treatment by extirpation can only be undertaken in the early stages. Acute Goitre is but rarely met with, consisting of a rapid enlarge- ment of the thyroid body, which attains a considerable size in the course of a few days or weeks. It affects young subjects, and is generally fatal from asphyxia due to pressure on the trachea or spasm of the glottis. Removal of one lobe under local ansesthesia is the only treatment that holds out any prospect of cure. Inflammation oi the Thyroid Body, or acute thyroiditis, occasion- ally supervenes as a complication of an ordinary goitre. It is almost always infective in nature, the cocci reaching it from without, as from tappmg cysts or from a punctured wound, or from within the body in a pyaemic embolus, suppuration being usually induced; it some- times occurs as a sequela of the acute specific fevers, or may follow a blow. The gland becomes enlarged, hot, and tender; fever and rigors follow, and the presence of pus is indicated by superficial cedema and fluctuation. 1 he early treatment consists in the applica- tion of fomentations and perhaps leeches, or in the use of an ice compress. Ihe patient is kept in bed, purged, and carefully dieted. Under such a regime, resolution may occur ; but if, as happens more frequently, pus forms, free incisions should be made. Accessory Thyroids sometimes develop above or below the isthmus, or are closely attached to one of the lateral lobes. They ma}- be connected with the thyroid body, moving up and down with it on deglutition ; or they may be independent of it, occurring in any part of the thyro-glossal duct, and even in the base of the tongue, in that situation resembling a dermoid cyst. If troublesome, they should be removed and subjected to microscopic examination, as their structure varies, and there is a possibility of recurrence. Myxcedema (or cachexia strumipriva) is a curious condition, which, as already mentioned, supervenes when the thyroid body is totally removed, or so absolutely disorganized or infiltrated by a new growth as to be functionless. Although it is possible that we have still much to learn of the duties of this organ, yet it is known that the elimination, if not the development, of mucin in the body is controlled by it, and that its absence leads to an accumulation of this substance in the blood and tissues. The condition and appearance of 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 in 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 thyroid gland or extract (half a gland, raw or lightly cooked, twice a week, or a 5-grain tabloid once or twice a day), the SAinptoms soon disappear, and the change from the dull, heavy condition of mj-xoedema to one of normal health of mind and body is almost miraculous. Similar treatment should be employed for myxcedematous cretins, who often start growing rapidly as soon as treatment commences. The Parathyroid Glands are small ovoid bodies, usually four in number; situated behind the thyroid gland, and generally near the SURGERY OF THE NECK 899 termination of the inferior thyroid artery. Microscopically they consist of columns of epithelial cells with large nuclei, embedded in a rich capillary stroma. Spaces are often found in them containing a colloid material, which is not considered identical with that found in the thyroid vesicles. Their function is not definitely known, but their complete removal in animals causes acute convulsive attacks, together with the condition known as tetany, and death in a few days from coma. The tetany formerly ascribed to removal of the thyroid body is in reality due to disease, absence or removal of the para- thyroids. It is also considered possible that the changes in the thyroid body in Graves' disease are in some way due to lesions in the parathyroids, but the exact relationship is not yet certain. The Thymus Gland is an occasional source of trouble in that it persists and becomes enlarged instead of disappearing. Normally it reaches its greatest dimensions about the age of two years, and then gradually wastes so that by puberty it is represented by a mass of fatty tissue, with perhaps a few remnants of the original organ. Its persistence, and still more its enlargement, are indicated by fulness of the root of the neck, dulness over the sternum, perhaps by evidences of mediastinal pressure on the large veins, and certainly by increasing dyspnoea. A thymic asthma, partaking of the nature of laryngismus stridulus, has been described; but more important is the association of an enlarged thymus with generalized lymphatic hyperplasia, and a large spleen in the condition known as status lymphaticus [q.v.), which may be the cause of sudden death under anaesthetics. The thymus is also enlarged in some cases of Graves' disease. Tracheotomy is useless in the treatment of the somewhat severe dyspnoea sometimes present, and operative interference for the removal of the enlarged gland has been undertaken with success in some cases. Lymphadenoma and lymphosarcoma have also been known to affect this organ. CHAPTER XXXIII. SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST. Examination of the Upper Air-Passages.— Before the student can understand aflEections of this region, it is absolutely essential for him to master the use of the laryngoscope. This consists of a circular mirror set at an angle on the end of a metal stem, which is inserted into the patient's widely-opened mouth in such a way that it rests against, and slightly elevates, the soft palate. A beam of light is thrown into the mouth, either from an electric head-lamp on the surgeon's forehead, or reflected by a frontal mirror from a suitable source 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 seen in the mirror. Considerable 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 structures. The use of cocaine to anaesthetize the fauces is in man}' cases indispensable. It must be remembered that the image is always inverted, so that the anterior portion of the larynx appears behind, but there is no reversal of the sides. A new appliance has been recently employed to see the interior of the air-passages in the form of Killian's bronchoscope (Fig. 432). This consists of a straight tube, which can be introduced through the upper air-passages thoroughly cocainized (upper bronchoscopy), or through a tracheotomy incision (lower bronchoscopy), and can then be carried down to the bifurcation of the trachea. Smaller tubes slipped down inside the outer allow the bronchi to be examined. The interior is illuminated either directly or by reflection from a mirror. By this means foreign bodies have been extracted from a bronchus on many occasions. Foreign Bodies in the Air-Passages.^ — Any part of the respiratory tract may be partially or completely obstructed by the presence of some foreign body, the effect of which may be of greater or less gravity according to the situation, character, and size of the in- truding substance. 1. In the Nasal Passages, see p. 818. 2. Obstruction occurring at the pharyngeal entrance to the larynx is usually due to attempts to bolt large masses of food, which, be- coming (mpacted, 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 act as attempting to swallow a billiard ball. If the obstruction is not complete, as when a plate of false teeth becomes impacted, great dyspnoea is caused, and absolute inability to'-'swallow, the symptoms rapidly increasing owing to oedema of the submucous tissue of the glottis. 900 SURGERY OF THE AIR-PASSAGES. LUNGS. AND CHEST 901 Accidents of a similar nature may occur during chloroform narcosis, an epileptic fit, or drunkenness, some such substance as a plate of teeth being dislodged from the mouth, or a mass of food being vomited, and blocl^ing 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, laryngo- tomy must be performed at once, and artificial respiration, if neces- sary, instituted. In less urgent cases there is time to remove the Fig. 432. — Killian's Bronchoscope in Position. The patient is generally anaesthetized, and lies on his back with the head thrown over the end of the table. After introduction of the main tube down the trachea, extension tubes can be inserted to explore the bronchi; one of the latter is shown in the above sketch reaching down to the bifurcation of the trachea. substance from the mouth with the assistance of a frontal mirror and suitable forceps. 3. In the Larynx. — A foreign body enters the larynx by inhalation during a deep inspiratory effort, when the glottis is widely open. Anything large is likely to be stopped above the larynx, and hence the type of foreign body found in this region consists of small coins, buttons, nutshells, or a small tooth-plate. It may cause total obstruction and immediate death, or may enter one of the ventricles, and only produce partial obstruction, as evidenced by a sudden sense of suffocation, urgent dyspnoea, and a violent attack of coughing, attended, perhaps, by vomiting, such as occurs when anything is said 902 A MANUAL OF SURGERY to have ' gone down the wrong way.' The voice becomes croupy and hoarse, respirations are stridulous, and any movement of the patient may for some time bring on a spasmodic fit of dyspncea. 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 examina- tion should reveal the situation of the intruding body. The Treat- ment consists in attempting to remove it through the mouth with suitably curved forceps guided by 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. 908) must be undertaken. 4. In the Trachea. — To lodge in this situation a foreign body must be small enough to pass through the rima glottidis, 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, irritation, and inflammation. During the passage of the body through the larynx, the patient suffers from a severe attack of spasmodic dyspnoea 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 the introduction of a Killian's bronchoscope so that the foreign body may be seen, and by suitable forceps secured and removed. If such appliances are not available, a low tracheotomy must be performed, with a good-sized opening, and it may be possible to reach and remove the foreign body; 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 impacted in a Bronchus the foreign body must be sufficiently small to pass through the rima glottidis, and heavy and smooth enough to allow of its dropping down the trachea ; the most common articles met with are buttons, pebbles, slate pencils, a pin, an O'Dwyer's tube, or the inner cannula of a tracheotomy-tube. Ihe right bronchus usually becomes obstructed, the reason for this being that although the left bronchus is more in a direct line with the trachea, yet the right is the larger, the septum between them lying to the left of the middle line. A series of sjonptoms similar to those SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 903 already described manifests itself, viz., obstruction, irritation, and in- flammation. The obstruction is twofold: immediate, as a result of the passage of the intruder through the glottis, a condition due more to spasm than to mechanical causes; and late, as a sequence of its lodgment in the bronchus. Even if the obstruction is at first partial, it soon becomes complete from swelling of the mucous membrane; for a time it is more or less valvular in character, 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 dulness and the absence of breath-sounds. Irritation and inflammation soon follow, resulting in bronchitis, the formation of a bronchiectasis, and peri-bronchial pneumonia; sup- puration ensues, and the foreign body may be expelled sooner or later with a sudden gush of pus during a fit of coughing. Thus, in one case* a beech-mast was inhaled in November, 1812, and was not extruded till May, 1822, the patient having in the meantime de- veloped all the symptoms of a bronchiectasis. Sometimes the abscess may extend through the lung substance to the pleura, setting up a localized empyema, through which, when opened, the article i? 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 radiography may also be useful, and Killian's bronchoscope may permit it to be seen. A skilled laryngologist will probably be required to introduce this instrument through the mouth, but in his absence any surgeon could pass it through an incision in the trachea. The patient is advisably anaesthetized, and lies on the back with his head hanging over the end of the table. Fine tubes can be passed through the main cannula so as to enter the smaller bronchi. f In the absence of this appliance a low and extensive tracheotomy is performed, and the bronchi are examined by a long bullet probe, suitably curved. The foreign body may thus be felt, and its removal accomplished by a delicate pair of forceps, a loop of wire, or a coin- catcher. Should it be impossible to remove it, the tracheotomy wound is left open for a time in the hope that inflammatory disturb- ance may loosen it, and it may be coughed up. Abscess of the lung, and localized empyema, are dealt with by incision, and it is possible that the foreign body may be removed by this means through the thoracic parietes. In several instances tlie chest has been opened successfully in the early stages, and a foreign body removed by direct incision into the bronchus. Injuries of the Larynx. — Several conditions arising from trau- matism of the upper air-passages have been already described — e.g., * Mr. William Rose, senior, Lancet, August, 1843. \ For the employment of this method in the removal of a pin, see Sir St, Clair Thomson, Lancet, May 7, 1910. 504 A MANUAL OF SURGERY fracture of the hyoid bone (p. 497), and incised wounds, as in cut throat (p. 888). Occasionally the thyroid or other cartilages may be injured or fractured by direct violence, as in garrotting, causing local pain and hsemorrhage, and possibly some obstruction to the respiration. As a rule, no treatment is required beyond keeping the patient quiet, but should symptoms of dyspnoea arise, intubation or tracheotomy must be undertaken. Diseases of the Larynx. The study of laryngeal diseases can only be briefly referred to here, since it is now so extensive as to require special text-books. Acute and Chronic Laryngitis are conditions of but slight surgical interest. The acute affection arises from cold or over-exertion of the vocal apparatus, and is characterized by aphonia (loss of voice) and cough. Locally, the vocal cords are seen to be hyperaemic and swollen. The Treatment is rather medical than surgical, although in children intubation or tracheotomy mav be sometimes required. Diphtheritic Inflammation of the Larynx (p. 133) is usually met with as an extension of a similar afEection of the fauces. It gives rise to severe dyspnoea from obstruction, and, if the condition does not yield to the injec- tion of the diphtheritic antitoxin, will probably require intubation or tracheotomy. Acute (Edematous Laryngitis, or oedema of the glottis, is a condition of considerable surgical importance. Causes. — {a) It is secondary either to some other laryngeal afEection, such as acute catarrhal laryngitis or acute perichondritis, or more rarely to some chronic affection, such as syphilis or carcinoma; or (b) it may extend from inflammatory conditions of neighbouring tissues, such as the root of the tongue, or the submaxillary region — e.g., in cellulitis or Ludwig's angina; or it may be secondary to a retropharyngeal abscess, (c) It is also not unfrequently seen in children from drinking scalding water, as from the spout of a kettle, or sometimes in adults from swallowing corrosives. {d) It may result from the presence of a foreign body, {e) It has also been known to occur as part of the general anasarca of chronic Bright's disease. Characters. — The folds of mucous membrane extending on either side of the epiglottis both to the root of the tongue and backwards to the arytenoid cartilages become swollen and cedem- atous from a serous effusion into the submucous tissue (Fig. 433). The Fig. 433. — CEdema of Glottis from Behind. (College of Surgeons' Museum.) The base of the tongue is seen to be en- larged and swollen, and the aryteno- epiglottidean folds are oedematous, so that the entrance to the larynx is represented by a mere chink. SURGERY OF THE AIR-PASSAGES. LUNGS, AND CHEST 905 same condition also involves the interarylenoid fold and the false vocal cords (superior thyro-arytenoid folds) , extending down as far as the true cords. The process is checked at this level owing to the absence of submucous tissue, the vocal cords consisting of elastic fibres covered merely with a layer or two of squamous epithelium. The epiglottis becomes folded laterally upon itself as a leaf, leaving only a valve-like chink, which permits of expiration although con- siderably checking inspiration. The Symptoms produced by this condition are those of mechanical dyspnoea, to which not unfrequently spasm of the glottis is superadded, and this is sometimes of sufficient intensity to destroy the patient's life. There may be also some difficulty in swallowing, owing to associated oedema of the pharynx and oesophagus, and some degree of febrile disturbance. The diagnosis is made, either by passing the finger into the pharynx, when the rigid, swollen epiglottis can be felt, or by laryngoscopic ex- amination, when the slit-like opening of the glottis, bounded below and behind by thickened oedematous folds of mucous membrane, can be seen. Treatment consists in scarification of the swollen tissues below and behind the epiglottis, which can be effected after spraying the parts with cocaine by means of a suit- able knife guided by a laryngoscope. The usual result is a rapid diminution of the oedema, and additional relief may be gained by inhaling steam arising from hot water, to which some tinct. benzoini co. has been added. Fomen- / Fig. 434. — -Gummatous Disease of Fig. 435. — Tuberculous Disease THE Larynx. (Tillmanns.) of the Larynx, with Exten- Small gummata are seen invading ^^^^ Ulceration in Front the mucous membrane of the ^^° Behind. (Tillmanns.) epiglottis and front of the larynx. a, b, c, Remains of the epiglottis. tations or ice compresses applied externally are also useful, especially the latter. In more severe cases, and especially in children, intubation may be necessary, or the air-passages may be opened below the obstruction, laryn- gotomy sufficing in adults, but a high tracheotomy being needed in children. Syphilitic Diseases of the Larynx. — In the secondary stage, mucous tubercles or superficial ulcers occasionally form in the neighbourhood of the vocal cords, concurrently with the rash on the skin, and the formation of condylomata and mucous tubercles elsewhere. These are most likely to occur in costermongers or those who have to speak loudly, and may then lead to a good deal of thickening of the cords. Apart from such cases, it rarely causes much trouble beyond a little hoarseness. No special treatment is required, although possibly the parts, if ulcerated, may be brushed over with a solution of perchloride of mercury. In the tertiary period, diffuse gum- matous infiltration or localized gummata may develop, giving rise to destructive ulceration, which especially affects the epiglottis and aryteno- epiglottidean folds, and may spread backwards and involve the whole glottis (Fig. 434) . Inflammation of the perichondrium is likely to follow, leading to necrosis of the cartilagej. Hoarseness and dyspnoea are the chief s^rmptoms of this affection, whilst considerable obstruction may be caused subsequently by cicatrization and laryngeal stenosis. Treatment consists in the adminis- tration of iodide of potassium and mercury, whilst ulcers may be sprayed ■with perchloride of mercury solution, or dusted over with calomel or iodoform. Should urgent dyspnoea arise, tracheotomy must be undertaken. 906 A MANUAL Of SURGERY Tuberculous Laryngitis (Fig. 435) is occasionally a primary manifestation, but is much more Ircquently secondary to phthisis, arising from infection of the mucous membrane owing to the constant passage over it ot the sputum. It usually commences at the posterior part of the larynx in the neighbourhood of the arytenoid cartilages, as a submucous infiltration, which breaks down, and leads to typical tuberculous ulcers, similar to those occurring in other viscera (p. 182). Considerable destruction of tissue ensues, involving the whole circumference of the larynx, and even leading to perichondritis and necrosis of the cartilages. Hoarseness, cough, pain on swallowing, and perhaps a certain amount of dyspnoea, in a patient suffering from phthisis, are the chief symptoms arising from this affection, the prognosis of which is always of a grave nature. The anaemic condition of the mucous membrane is an important diagnostic sign in the early stages. Treatment. — As for other tuberculous affections, constitutional treatment is now mainly relied on, and for choice in a sanatorium, whilst absolute silence is insisted on. Occasionally local treatment is undertaken by the laryngologist in the form of topical a]jplica- tions of lactic acid, and the removal of papillary outgrowths or of the epiglottis. The earlier recognition of pulmonary tuberculosis and its more effective treat- ment is, however, reducing the number of cases of the laryngeal affection. Paralysis 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, Fig. 436. — Papillomata of the Larynx, springing from the Right Vocal Cord. (Till- MANNS.) Fig. 437. — Epithelioma of the Larynx, involving the Right Vocal Cord and Base of the Epiglottis. (Tillmanns.) the recurrent laryngeal nerve. It may follow the removal of a goitrous tumour or of tuberculous glands, but is most commonly seen in connection with aneurisms of the innominate or aorta, or tumours in the same neighbour- hood — e.g., cancer of the oesophagus, the actual pressure in the latter case being probably exercised by secondarily enlarged lymphatic glands. Paralysis from the above causes is generally unilateral, but if due to cancer both sides may be involved. The effect of complete paralj-sis of one recurrent laryngeal is to produce total immobility on the affected 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 uncom- monly the paralysis is incomplete, and then merely affects the abductor muscle (the crico-arytenoideus posticus). The Symptoms arising from uni- lateral recurrent paralysis are often slight, the voice being usually but little modified, owing to the healthy cord being capable of passing across the middle line. If, however, both sides arc completely paralyzed, absolute aphonia, without dyspnoea, results; but if only the abductors are involved, the voice may be unimpaired, although severe dyspnoea is often present, and this may prove fatal unless tracheotomy is promptly performed. Papilloma of the Larynx (Fig. 436) occurs in the form of wart-like masses, usually growing from the true vocal cords, and giving rise to considerable hoarseness and perhaps some dyspnoea. They are recognised on laryngoscopic examination, and may be removed successfully by laryngeal forceps, after the SURGERY OF THE AIR-PASSAGES. LUNGS, AND CHEST 907 parts have been efficiently cocainized. It is recommended by some authorities to destroy the growth with a galvano-cautery, but there is always a certain liability to recur, and thyrotomy may be required in a few cases to establish a radical cure. Epithelioma Laryngis occurs in patients over forty, originating as a papil- lary ONcrgrowth, usually near the base of the epiglottis, or from the true or false cords (Fig. 437). The tumour gradually spreads, both superficially and deeply, and may invade the cartilages, giving rise to necrosis. At a later stage it extends beyond the limits of the larynx, attacking the base of the tongue, oesophagus, and even the lateral walls of the pharynx. As long as the disease is strictly limited to the larynx (intrinsic), the growth is often unilateral, causing hoarseness and aphonia, together with an irritable cough and the expectoration of blood-stained muco-pus, which may be horribly offensive; it is associated with but little tendency to affection of lymphatic glands. When, however, the growth has extended to surrounding structures (extrinsic), lymphatic enlargement follows, and the disease runs its usual course, destroying life by dyspnoea and exhaustion. Pain is often a most distressing sj^mptom, being referred either to the larynx or phar\Tix, or, according to Ziemssen, not unfrequently to the ear. Treatment. — In the early stages thyrotomy and efficient curetting and cauterization will probably bring about a cure. Later on, removal of one or both halves of the larjnax, together with the affected glands, will be required, and the operation may even include parts of the tongue and pharyngeal wall. WTiere, however, the disease has spread extensively, its total extirpation is rarely practicable, and all that can be done is to treat symptoms as they arise, and perform tracheo- tomy when necessary. Acute and Chronic Perichondritis are affections of the perichondrium, usually ending in the formation of an abscess and in necrosis of the cartilage involved. The acute variety is pyogenic, and due to traumatism or to auto-infection, following acute fevers, such as typhoid. The patient complains of severe pain and tenderness over the larynx, with fever, dysphagia, and hoarseness. Dyspnoea results from swelling of the mucous membrane, and oedema of the glottis may follow. An abscess may point internally or externally, and on opening it the cartilage will usually be felt bare and perhaps necrosed. Treat- ment in the early stages consists in fomentations; but when the affection is producing dyspnoea, and an external swelling is present, it is well to cut do%vn on the cartilages from outside. Should this fail to relieve the dyspnoea, a tracheotomy will be required. The chronic variety is more often due to tubercle, sj'philis, or carcinoma: in it an abscess forms more slowly and with less constitutional disturbance, but necrosis ensues none the less. When the abscess points externally, it should be opened from outside, but sometimes in these cases it is possible to deal with it from within. When a well-marked sequestrum is present, it must be removed by an external incision, and if need be thyrotomy must be undertaken. Distortion or stenosis of the larjmx is not an unusual sequela, possibly necessitating the perpetual use of a tracheotomy- tube. Operations upon the Air-Passages. I. Subhyoid Pharyngotomy was devised by Malgaigne, in order to provide access to the upper parts of the larynx in the treatment of foreign bodies or tuberculous disease. A transverse incision is made through the thyro-hyoid space, the pharynx is opened, and the epi- glottis detached from the base of the tongue (Fig. 438, I.). It is a proceeding that is seldom undertaken, and scarcely necessary. A much more satisfactory procedure is Trans-hyoid Pharyn- gotomy,* in which the hyoid bone is divided in the middle line * See Revue de Chirurgie, May, 1900. 9o8 A MANUAL OF SURGERY through a vertical incision extending from the symphysis menti to the thyroid cartilage. The pharynx can then be opened either above or below the level of the hyoid bone, and the back, of the tongue, the posterior wall of the pharynx, or the upper part of the larynx freely exposed. A preliminary tracheotomy is, of course, necessary. We have utilized this operation both for the removal of an epithelioma of the epiglottis and back of the tongue, and for enucleating a sar- coma of the posterior pharyngeal wall, and were much pleased with the ap- proach given to these parts. 2. Thyrotomy (Fig. 438, II.) con- sists in a vertical section of the thy- roid cartilage, and may be required for the removal of foreign bodies or tumours, or for the radical treatment of laryngeal tuberculosis or cancer. Tracheotomy is performed as a pre- liminary measure, and the trachea plugged around the tube. An incision is then made in the middle line of the neck, extending from the hyoid bone to the cricoid cartilage. The crico- thyroid ligament is clearly defined and severed transversely, and the thyroid cartilage accurately divided by a knife, cutting-pliers, or fine saw. The lateral halves are separated, and the intralaryngeal portion of the operation proceeded with. When closing the wound, the greatest care must be taken to bring the sides together in such a way that the vocal cords are exactly opposite each other, or phona- tion will be considerably impaired. This is best ensured by making a hori- zontal nick across the front of the cartilage before dividing it. 3. Extirpation of the Larynx (Laryn- gectomy) is always a serious operation, which is never undertaken except for malignant disease. According to the site of the tumour, the removal may be partial or complete; for a growth strictly limited to one side, extirpation of that half will suffice, and admirable results have followed such treatment, distinct speech remaining ; but if the whole larynx is removed, although the patient is subsequently able to whisper, phonation is impossible with- out mechanical assistance, whilst if the disease has extended beyond the limits of the lar5mx, operative interference is rarely successful. Operation for Complete Extirpation. — An incision is made in the middle hue of the neck from the hyoid bone to below the cricoid Fig. 438. — Operations on the Air-Passages. I., Subhyoid pharyngotomy; II., thyrotomy; III., laryn- gotomy: IV., cricotomy; V., high tracheotomy; VI., low tracheotomy; H., hyoid bone; Thy., thyroid cartil- age; Cr., cricoid; G.Th., thy- roid body. SURGERY OF THE AIR-PASSAGES. LUNGS. AND CHEST 909 cartilage The soft parts are stripped from the lateral aspects of the thyroid cartilage with raspatories, the sterno-hyoid, sterno-thyroid, and thyro-hyoid muscles being divided at their msertions, and the isthmus of the thyroid body being divided between ligatures it necessary. The crico-tracheal membrane is then cut through, or the trachea itself is divided on the slant, and either fixed m the lower angle of the wound, or a fresh incision is made a little lower down, and through this it is drawn and stitched flush to the skin. At this stage it is often wise to divide the thyroid cartilage longitudinally so as to ascertain exactly the extent of the disease. If it is limited to the larynx, removal is perhaps best effected from below upwards, a transverse incision at the level of the hyoid bone, and extending between the two sterno-mastoid muscles, being required to facilitate this proceeding. The connections of the constrictor muscles to the cricoid and thyroid cartilages are severed by scissors, and the larynx can now be drawn forwards and separated from the anterior pharyn- geal wall, which must be left intact if possible. The thyro-hyoid membrane and base of the epiglottis are cut through, and the final steps of the operation consist in clearing the superior cornua of the thyroid and dividing the lateral thyro-hyoid hgaments. The opera- tion is not particularly difficult or dangerous, provided that the surgeon keeps close to the larynx, and that the disease does not extend beyond its limits. When other structures such as the base ot the tongue have been invaded, these steps must be modified so as to secure if possible, complete removal of the disease. The upper portion of the oesophagus has even been included m the scope of the operation.* Finally, the rent in the mucous membrane of the pharynx is closed by sutures, the divided muscles are drawn together, and the incisions in the skin closed; if this be practicable, healing by first intention may follow, the air-passages being thereby entirely separated from the pharynx. Of course, phonation is lost completely, but the patient can whisper, and by means of suitable apparatus this can be magnified and utihzed so as to be of service. In not a few cases, however, it is impossible to close the wound completely, and then 'it must be packed and allowed to heal by granulation. If the oesophagus is encroached on in the operation, it is some- times feasible to restore continuity between the pharynx and the lower end by means of a flap of skin turned m, or the wound is allowed to granulate, and a rubber funnel passed so as to prevent cicatricial contraction, and to allow the passage of food, in other cases a communication can be estabhshed between a pharyngeal fistula above and a gastrostomy wound below, and food can be carried into the stomach through an external rubber oesophagus worn under the clothes. ^ j.-l. -a If the disease is hmited to one half of the larynx, the thyroid cartilage is cleft in the middle line, and the operation confined to the affected side. * Arthur Evans, Transactions of the Royal Society of Medicine. Clinical Section, vol. iii.. p. 44, and vol. iv., p. 142. 910 A MANUAL OF SURGERY 4. Laryngotomy is rarely undertaken except for the relief of dyspncea 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 (Fig. 438, III.), the sterno- hyoid muscles being, if necessary, drawn aside, and a tube inserted. Possibly the small crico-thyroid artery arising from the superior thyroid may require a ligature. In cases of great urgency, a simple transverse incision may be made with a penknife, and the larynx opened, the margins of the wound being held aside by a hairpin, or by the handle of a scalpel turned edgeways, whilst a toothpick will serve temporarily as a cannula . Whenever there is time to operate deliberately, a high tracheotomy is the better practice, since a tube inserted through the crico-thyroid space gives rise to conriderable irritation, and the voice may be subsequently impaired by the con- traction of the cicatrix. A special laryngotomy-tube is required, the lumen of which is not circular, but oval and flattened from above downwards. In children, where there is but little space, the proceeding may be modified by division of the cricoid cartilage, and even of the first ring of the trachea, constituting what is known as cricotomy or laryngo-tracheotomy (Fig. 438, IV.). 5. Tracheotomy. — The trachea usually consists of from sixteen to twenty rings, of which six or seven are situated above the sternum. 1 he isthmuf of the thyroid body generally covers the third and fourth rings, and the trachea may be opened either above or below it, or even sometimes behind, the isthmus being, if necessary, divided. Tracheotomy is required in any condition in which there 's serious obstruction to the respiration — e.g., various forms of laryngitis, and especially for oedema of the larynx or diphtheria; for stenosi?, tumours, and some forms of paralysis of the larynx; occasionally for the removal of foreign bodies, either in the larynx, trachea, or one of the bronchi ; or for compression of the larynx or trachea by external tumours, such as a malignant thyroid body. It is also undertaken as a preliminary measure in operations on the mouth, tongue, pharynx, or larynx, in which there is any likelihood 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 opera- tion (that is, above the isthmus of the thyroid body) is to be pre- ferred, but under special circumstances 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. SURGERY OF THE AIR-PASSAGES, LUNGS. AND CHEST 911 'Ihc high operation (Fig. 438, 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 structures on the stretch, and with the shoulders somewhat raised. Ansesthesia may be induced by chloroform, but it is unnecessary, and indeed unwise, to push the anesthetic, since it is only needed for the division of the skin; where the dyspnoea is considerable, it is better to employ local anaesthesia by the infiltration method (q.v.). The head is held exactly in the middle line, and the surgeon feels tor, 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 edges of the wound are drawn aside by blunt hooks, which should both be held by one assistant, so as to ensure equable traction. Ihe 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 dissecting forceps and should be fixed and steadied by inserting a sharp hook into the lower border of the cricoid cartilage. The wound is freed from blood as far as possible, and the trachea opened by inserting the point of the scalpel and dividing two of the rings from below up- wards. A deep inspiration is usually taken at once, followed by a severe fit of coughing, and if the operation is undertaken for diph- theria the surgeon must be careful not to let any membrane which may then be expelled enter his eyes, nose, or mou^h. The insertion of the tube is in many cases easy, in others a matter of some difficulty ; a good deal depend: 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— e.g., 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 beneath the plate. Low tracheotomy (Fig. 438, VT) is performed in almost precisely the same way, except that the incision extends further 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 cau'^e trouble if they are distended with blood, as is so frequently the cas-^ in patients suffering from dyspnoea. They must be held aside by hooks or divided between ligatures, and the deep layer of fascia 912 A MANUAL OF SURGERY behind them incised so as to expose the trachea, which is cleared, fixed, and opened in the same way as described above. Many different forms of tracheotomy-tube have been used from time to time, but the essential elements of which it consists are a double cannula, the inner portion of which can be readily removed and cleansed; it should always be longer than the outer, in order to prevent any plug ot 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 Parker's tube (Fig. 439), which has a handy introducer, anO 's perhaps of a better shape than most of the others, following more closely the direc- tion of the trachea. The bivalve tube is another useful instrument ; the outer sheath consists of two lateral portions, attached to a single face-plate, and these can be pressed together, and hence with care easily inserted through the incision in the trachea. The sur- geon must see that both limbs enter the trachea, as trouble has arisen from one limb passing out- side, and the other inside, thus hindering the introduction of the inner tube. Whatever variety of tube is preferred by the surgeon, it is essential to have several sizes to hand, as the calibre of the trachea varies much in different patients. In cases of preliminary tracheotomy, undertaken to pre- vent the entrance of blood during operations, Hahn's tube may be used with advantage ; in this the outer cannula is covered with a layer of compressed sponge which swells up from the absorption of moisture, and thus occludes the lumen of the trachea. Trendelen- burg's tampon is recommended by some for the same object; the outer tube is here ensheathed with a thin indiarubber casing, which 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 an 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 Fig. 439. — Parker's Tracheotomy- Tube AND Introducer. (Down Brothers.) SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 913 following arc the chief conditions which may lead to mistakes and (i) 'Ihe administration of any general anaesthetic is often in- advisable in semi-asphyxiated patients, since complete cessation oj respinilion may be caused thereby, possibly from spasm of the glottis, Local ancT2sthesia by the infiltration method should be re bed on m such cases, and the employment of /3-eucaine and adrenalin has been most satisfactory. (2) It is not always easy to find the trachea, especially in the necks ot fat children, or where 'it is hidden by an unduly large thyroid isthmus, or possibly by the projection of the thymus gland into 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 hne by some external growth, and can then only be found by careful exploration with the finger. (3) Hcemorrhage 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 by pressure-forceps before opening the trachea; but this is not abso- lutely necessary in urgent cases, since it usually ceases as soon as easy respiration through the tube has been established. The presence of the left innominate vein in front of the trachea must not be for- gotten, although it but rarely reaches above the sternum. In about 8 per cent, of all subjects an arterial twig (the thyroidea ima) courses upwards from the innominate artery along the trachea, to reach the isthmus of the thyroid body; if divided, it can be easily secured and tied. Should much blood be inspired, it may determine the occur- rence of septic pneumonia at a later date. {4) The possibility of the entrance of air into veins must not be over- looked, although it is an uncommon accident, since the intravenous pressure is usually increased. (5) Not unfrequently considerable mischief has been done by an incautious use of the knife, especially if the operator forgets to fix the trachea with a sharp hook before opening it. The knife should always be entered with its back towards the episternal notch, and the incision made from below upwards. In a child the trachea 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 anesthetic, the difdculty is manifestly increased. Many accidents have happened from this cause— g.g., wounds of the large veins or arteries of the neck, or even of the oesophagus or bodies of the vertebrse ! . (6) As soon as the trachea is opened or an attempt made to intro- duce the tube, 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 with a tracheal dilator, or by a pair of sinus forceps, and a few drops of cocaine swabbed over the mucous membrane. (7) The introduction of the tube is a matter of no difficulty if the ^^' 58 914 A MANUAL OF SURGERY surgeon takes the precaution of not removing the hook until this is satisfactorily accomplished. Many mistakes have followed the non- observance of this rule; thus, the tube has missed the trachea alto- gether 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 membrane has also been a cause of difficult}', 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 breathing. 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, some surgeons have recommended that the lower portion of the larynx should be carefully stuffed with antiseptic gauze above the tube. After-Treatment.^ — The patient is placed in bed, in a room kept at a uniformly wann 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. 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 diphtheria to the lungs, or of septic pneumonia, is the re-inspiration of material which has been coughed out upon a portion of muslin or gauze, placed with excellent intentions over the mouth of the tube. A nurse should be in con- stant 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 being readily removed by the use of a solution of bicarbonate of soda (20 grains to I ounce) . The outer tube is also removed once a day for cleansing purposes, but only by the medical attendant. Should the respira- tion 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 contingency special suction-tubes have been devised. Attempts have been made to clear the passages by applying the hps to the tube, and removing the block by suction; such is, however, quite unjusti liable, and several promising house- surgeons have in this way 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 impairment 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 may pass through the larynx. If the patient can then breathe comfortably when the finger is placed over the entrance to the tube, its presence is no longer necessary. SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 915 After-Complications of Tracheotomy. — {a) The tube may give 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 is advisable to make use of indiarubber tubes. L: {b) Various forms of septic trouble may arise in the wound, lead- ing to cellulitis and even secondary haemorrhage; this is especially Fig. 440. — O'Dwyer's Intubation Apparatus. (Down Brothers.) The cannulse are seen below on the right; a hinged inner tube passes through- out the length of each, and the upper end of this is screwed to the ex- tremity 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 extract the tube, the rectangular forceps represented 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. 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) Difi&culty is sometimes experienced in leaving off the tube, owing to the presence of granulations obstructing the lumen of the 9i6 A MANUAL OF SURGERY trachea, or to stenosis of the trachea or larynx, or even to paralysis of the abductor muscles, especially in diphtheritic cases. The trachea ma\' also be kinked, and its calibre thus diminished, b}' cicatricial union of the skin and mucous membrane. Ihe 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 anaes- thetic or destroyed by caustics; stenosis of the larynx is overcome by dilatation with an O'Dwyer's tube; stenosis of the trachea may require excision of the affected segment, whilst laryngeal paralysis must be treated by the use of electricity. [e) Finally, it should be remembered that if a patient (and especi- ally a boy) is condemned to the perpetual use of a tracheotomy-tube, he must be warned of the possibility and danger of w^ater getting into the trachea and his being drowned thereby. Certainly one death has occurred from a boy bathing under these circumstances ! 6. Intubation of the Larynx is a means of treating laryngeal obstruction which has been introduced in order to obviate the risks 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 emplo}' for the purpose are those known as O'Dwyer's tubes (Fig. 440). The lower end of the cannula is oval, and not circular, and passes between the cords into the larynx, whilst the upper enlarged end lies over the entrance ; it requires changing frequently in order to prevent erosion of the mucous membrane. It has been used with considerable suc- cess in cases of oedema of the glottis and laryngeal stenosis, but is scarcely to be recommended for diphtheria, owing to the risk of carrying the false membrane down with it. The actual mortality in a large series of cases of diphtheria has been proved to be much the same as for tracheotomy — viz., about 30 per cent. Affections of the Ribs and Sternum. Several forms of Fracture have been already described (pp. 498 and 499). Acute Suppurative Inflammation of these bones is very unusual. Occasionally an acute osteo-myelitis, running its usual course to necrosis, occurs in children ; but the most common cause is typhoid fever (p. 568). The affection is generally of a subacute type, and a more or less extensive carlo-necrosis results. Ihe special feature of the disease is the tendency of the bacihi to remain in a latent condi- tion in the tissues, so that it is difficult to ensure a perfect cure apart from complete extirpation of the affected portion of bone. Mere scraping is rarel}' sufficient. Syphilitic Disease is more common in the sternum than in the rib?. The upper part of the sternum is that usually involved, and the affection is characterized by a formation of gummata in and upon the bone, which erode it, usually in a pitted fcishion, and may cause SURGERY OF THE AIR-PASSAGES. LUNGS. AND CHEST 9x7 necrosis The usual treatment with iodide of potassium and mer- ■°ru^elCf re^aSkTribs n.uch more ..^ mmmmm sever^ ribs may be involved at the f "« t'f^^,,, ^h?^f^<=i^=4«lf J^^^^ f nToiitsSe the chest Treatment in these cases must be of a radical "totrfpSg and disinfection are often meffiaent and th complete removal of an extensive portion of the rib and ^''?rS::S:f^^™n:S^S?course, andmay^esent^n -To-'^sfrZteS-b-^^^^^^^^^ of it by gouge or cuttmg-pbers, m order to gam access 10 u p the ribs, the latter in the sternum. The Pf *^^,^/°^^P^^^^^^^ unless special precautions are taken (p. 923) ■ Surgical Afiections o£ the Lungs and Pleural Cavities. yi8 A MANUAL OF SURGERY and of the pleura, as indicated by loss of resonance and possibly fric- tion sounds. The treatment consists in keeping the patient quiet in a warm room, at the same time carefully regulating the bodily func- tions. Pain is often relieved by strapping the side of the chest. Laceration of the Lung is usually secondary to fracture of the ribs, especially if due to direct violence. 'Ihe severity of the symptoms necessarily varies with the character and extent of the injury. The patient suffers from marked shock in bad cases, associated with pain in the side and dyspnoea. Evidences of hcsmorrhage soon follow, either in the form of haemoptysis or hsemothorax. 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. HcBmothorax may also be so excessive as to cause the patient's death from compression of the lung. It results in a gradu- ally increasing area of dulness extending from below upwards, together with loss of breath-sounds and vocal fremitus, coming on soon after the injury without signs of inflammation, but with the constitutional signs of haemorrhage. Owing to the laceration of the pulmonary vesicles, air tends to escape either into the pleural cavity, giving rise to the condition known as pneumothorax, or into the cellular tissue of the body, con- stituting surgical emphysema. Pneumothorax is always associated with more or less collapse of the lung, and, if complete or produced suddenh', is almost certain to lead to considerable interference with respiration, and possibly to severe dyspnoea, or even orthopnoea. A slight degree of pneumothorax, or a complete one, if produced slowly, and if the other lung is healthy and no strain is thrown upon it, has but little functional result. The air which finds its way into the pleura in connection with a ruptured lung, having been filtered through the pulmonary alveoli, 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 previously. The physical signs of pneumothorax consist in a high- pitched tympanitic note on percussion, and on auscultation amphoric breathing and possibly metaUic tinkling. As soon as the wound in the lung commences to heal, the amphoric sounds disappear, the effused air is absorbed, and the lung gradually expands — a process which may take four or five days. If blood is also present in the thorax, a condition of hsemo-pneumothorax is produced, recognised by a splashing or succussion sound heard on shaking the patient. Surgical Emphysema almost always indicates a wound of both pulmonary and parietal layers of the pleura, which are slightly separated by air, constituting a localized pneumothorax. At each inspiration a fresh amount of air enters this cavity, and is expelled into the areolar tissues through the parietal wound at each expira- tion, being forced perhaps to a considerable distance from the spot SURGERY OF THE AIR-PASSAGES. LUNGS. AND CHEST 919 where it commences, or even spreading over the whole body. It is of no serious signihcance, unless extensive, disappearing rapidly after the wound in the lung has commenced to heal, thus occluding the opened pulmonary ah-eoh. It is recognised by the parts be- coming swollen and puff}', and gi^'ing a sensation of fine crackling crepitus when the hand is pressed over them. Occasionally emphy- sema ma\' arise as an interstitial condition, when the parietal pleura has not been injured, the air escaping from the alveoli along the interalveolar connective tissue into the root of the lung, and then appearing first at the lower part of the neck. This is often a con- dition of grave import. Such are the ordinary phenomena observed in the early stages of a ruptured lung. The effects subsequently produced consist in a localized traumatic pleuro-pnemnonia, associated with slight eleva- tion of the temperature, possibly rusty sputum, and often severe dyspnoea. In the worst cases death may result from asphyxia. Penetrating Wounds of the Lung, due to direct injury and often associated with fracture of the ribs, are followed by very similar effects. The story is modified, however, by the fact that the ex- ternal wound in the chest wall allows of the exit of blood, arising either from an intercostal artery, the internal mammary, or from the wounded lung, whilst it also permits the entrance of bacteria with the air into the pleural cavity, and thus may change the re- sulting pleuro-pneumonia from a simple to an infective inflamma- tion. Empvema is consequently a frequent sequela, whilst the inflammation of the lung may be of a spreading nature, possibly terminating 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 fabling together. This condition may ensue even when the lung itself has not been damaged. Treatment. — When the rupture of the lung is due to a subcuta- neous injury, the patient should be kept quiet in a warm room, and the side strapped. The compression of the chest wall must some- times 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 hsemoptysis must be treated by keeping the patient absolutely quiet, and allowing him to suck ice continually. _ Ergotin may be injected hypodermically, or a mixture of ergot, opium, and sulphuric acid administered; the opium is especially needed when great restlessness and irritability are present. Lactate of calcium mav also be given by the rectum. Stimulants are necessarily contra- indicated, for fear' of again starting the bleeding. Haemothorax rarely needs special treatment, since the blood soon clots and is readily absorbed; but occasionally it may be so abundant as to com- press the lung and lead to d^'spncea, and under these circumstances it may be necessary to aspirate the chest, or if that fail (as is not unlikely) to open up the pleural cavity and remove it. This must 920 A MANUAL OF SURGERY never be undertaken until sufficient time has elapsed to permit of thrombosis in the wounded vessels. Decomposition of the blood in the pleural cavity occasionally happens even in non-penetrating injuries, the bacteria reaching it either from the blood or from the torn bronchi ; the suppuration and fever thereby induced necessitate the opening and drainage oi the pleural sac. Simple pneumothorax seldom requires surgical treatment, since the imprisoned a'r is quickly absorbed, and the lung re-expands; should this not occur, and if severe dyspnoea is present, it may be ad- visable to remove the air by aspiration. Ihis may sometimes fail, or the air may re-collect, and then the chest wall must be opened so as to give exit to the air. It is impossible for the lung to re-expand against the pressure of air confined in the chest; when an opening is made, the aii can be driven out by a vigorous expiratory movement, such as coughing, which also forces air from the healthy lung into the wounded one when the glottis is closed. Temporary dyspnoea may be overcome by the inhalation 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-pref;-ure, and thus decrease the amount of blood cariied to the uninjured lung, so as to enable it to cope with the work of blood-aeration. This may be accomplished by administer- ing antimonial wine (lo to 15 minims every four or six hours) com- bined with full doses of liquor ammonia 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 penetrating wounds of the thorax, involving 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 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 readily accessible. The greatest gentleness must, however, be employed, and no attempt made to pass a probe into the pleural cavity, since it is easy to dislodge clots lying in the pulmonary tissues, and thereby restart the bleeding. If the wound itself needs sterilizing, it is perhaps best to touch it over with pure carbolic acid or tincture of iodine rather than to irrigate it, and then a dry antiseptic dressing is applied without drainage. Immediate operative interference is only required under two con- ditions, viz., for haemorrhage and for hernia of the lung. Hemorrhage after a penetrating wound of the" chest wall may be derived either from a vessel in the parietes (intercostal or internal mammary), or from the lung itself. The recognition of the source of the bleeding is not always easy, but it is probably of parietal origin SURGERY OF THE AIR-PASSAGES, LUNGS, AND CHEST 921 (a) if it is unaccompanied by haemoptysis ; ib) if it increases obviously at each systole; and (c) if it can be controlled by digital compression. The treatment of bleeding from the internal mammary and intercostal vessels has been already indicated (p. 297). Pulmonary hemorrhage is not so readily controlled, and various plans have been recommended. Probably the best method consists in keeping the patient absolutely quiet in the horizontal position, applying cold to the side, and giving haemostatics, as indicated above for non-penetrating wounds. The effect of this will be to cause the blood in the pleural cavity to clot, and this acts as a tampon to the affected viscus; firmly plugging the external wound may limit the loss of blood and determine coagulation more quickly. In bad cases the haemorrhage may cease only when the patient is in a condition of profound collapse ; intravenous or hypodermic infusion of hot saline solution may then suffice to tide over the period of danger and lead to a successful result. 1 he question of opening the thorax by turning up a large flap of the chest wall (including portions of several ribs) so as to deal directly with the injured lung has been raised of recent years, and cases in which it has been undertaken have been recorded. Further ex- perience will probably decide that such a procedure is quite unjustifi- able except in very unusual circumstances. 1 he later treatment of these cases is much the same as for simple non-penetrating injuries. Should symptoms of suppurating pleurisy follow, the wound must be freely opened, a portion of rib being ex- cised, if necessary, and the cavity drained, as for empyema. Hernia o£ the Lung, or pneumocele, is a rare condition in which a portion of the lung protrudes through an opening in the thoracic 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 neck from a lesion in the dome of the pleura. It is recognised by the appearance of a rounded swelling, increasing in size on coughing or making expiratory efforts, and possibly disappearing entirely on holding the breath. It imparts a crepitant feeling to the fingers when compressed, and on ausculta- tion a loud vesicular murmur is heard. As a rule, no treatment is advisable in this condition beyond the application of a pad or truss. A similar condition, arising as a complication of an open wound, is termed a Prolapse of the lung. An attempt should always be made to return the protruded viscus, and to prevent its recurrence by suturing the aperture through which it has escaped. It left unre- duced, it is very likely to become gangrenous from strangulation, and should then be removed by the application of a ligature, the wound being subsequently closed. Empyema, or suppuration within the pleural cavity, occurs most frequently as a sequela of an acute pneumonia, being perhaps pre- ceded by a simple pleurisy, but is also an occasional result of trau- 922 A MANUAL OF SURGERY matism. It is not unfrequently associated with tuberculous disease of the lung. 1 he whole pleural cavity may be involv'cd, or it may be limited to a portion of it. Thus, a basal empyema is not an uncom- mon result of intra-abdominal suppuration, whilst inter-lobular collections of pus also occur, and cause sometimes much difficulty in diagnosis. Bacteriological research has demonstrated that in children more than half of the cases are due to the pneumococcus, either alone or less often in conjunction with streptococci, whilst in adults the streptococcus is the commonest organism. A description of the physical signs and symptoms belongs rather to the physician than to the surgeon. It will suffice to mention here that in a total empyema the affected side of the chest does not move on respiration, whilst the intercostal spaces may bulge; on percussion the side is dull, except perhaps immediately below the clavicle, where tym- panitic resonance (Skodaic) may 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 amount of fever and d3'spnoea is usually present in cases of empyema; leucocytosis is well marked, and the heart and other viscera may be displaced. Left to itself, an empyema slowly finds its way to the surface, and perhaps miost commonly bursts through the fifth or sixth costal interspace in front, though sometimes through the second, owing to the perforating vessels being larger here than elsewhere. An extrathoracic abscess of some size may develop, and the opening in the skin may not correspond to that in the chest wall. A localized empyema gives rise to similar effects, but on a smaller scale. When situated on the left side in close proximitj' to the pericardium, the movements of the heart may be transmitted through the fluid to the surface, causing a pulsation which can be seen or felt {pulsating empyema) . In the early stages the pleura is but little altered in structure, although a certain amount of lymph may be deposited on it; in old- standing chronic cases it becomes very dense and firm, owing to a development of fibro-cicatricial tissue, whilst the surface is converted into a layer of granulation tissue, similar to that found in all chronic abscesses. The lung collapses and retreats backwards towards the spine; at first its alveolar texture remains unaltered, and the early removal of the exudation enables it to re-expand, as a result of the atmospheric pressure. In chronic cases, however, there are two hindrances to this expansion, viz., the density of the thickened visceral pleura, which 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, and Nature then attempts in several ways to remedy the mischief and obliterate the pleural cavity; {a) Ihe opposite lung undergoes expansion and hypertrophy, and together with the heart projects over to the opposite side; {b) the abdominal viscera and diaphragm are displaced upwards; (c) the chest wall falls in, and the spine becomes laterally curved, with its SURGERY OF THE AIR-PASSAGES, LUNGS. AND CHEST 923 convexity to the sound side ; and {d) there is an exuberant growth of granulation tissue from the surface of the pleura. In a certain pro- portion 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 a mixed infection is present. Under these circumstance? extensive operative interference is necessary. The Diagnosis of empyema is readily made b)' attention to the ph3'sical signs, and confirmation of such an opinion can be obtained by puncture with a sterilized exploring 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 valvular puncture results. The character of the organisms contained in the sample of pus thus withdrawal 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, usually runs a mild course, and is sometimes cured 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 a mixed infection to any of the above aggra- vates the process and much impedes a cure. The chronicity or not of the affection is also a most important element, since the later the treatment commences, the denser are the adhesions which bind down the lung, and the less the chance of its re-expansion. The character of the pus varies with the organisms present ; with pneumococci, the pus is usually yellow, creamy, and laudable, whilst there is c ft en an abundant production of fibrinous false-membranes ; when of strepto- coccal origin, the pus is generally thin and oily. 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 rather to be regarded as of an exploratory nature, though a cure will occasionally follow when the empyema is of pneumonic origin. It is, however, sometimes of value in very extensive effusions with dis- placement of the heart, so as to allow the latter organ more gradu- ally to return to its proper position; by this means, too, it becomes possible to administer a general anesthetic for the more serious subsequent operation. In double empyema (usually seen in children) aspiration also is desirable as a preliminary measure so as to relieve the urgent symptoms. Both sides are aspirated in the first instance, and then one side is opened and drained first, and after a few days the other is similarly treated. Drainage of the pleural cavity through an external incision is the treatment almost invariably necessary, and as a matter of mechanical convenience it is usually ad\isable to resect a portion of a rib in order that the drainage-tube may not suffer compression ; especially is this the case in children. The best site for opening a complete 924 A MANUAL OF SURGERY empyema has been much discussed, and it is probable that subse- quent drainage is facihtated by making the opening well back — e.g., in the ninth space just external to the scapular line. Possibly in children with a pneumococcal empyema, which is not likely to need lengthy drainage, a more convenient site may be selected in the fifth or sixth interspace, just behind the mid-axillary line; apart from these cases, an opening here is usually ineffective, and will require a subsequent counter-opening further back. An incision is made along the course of a rib about i| inches in length, and the periosteum stripped up from both the superficial and deep aspects of the bone, so as to enable a cur\-ed raspatory to be passed beneath it ; at least i inch of the rib is then cut aw-ay with bone pliers. Ihe parietal pleura is opened sufficiently to enable the finger to be introduced and the cavity explored, as also to allow of the removal of flaky masses of fibrin. A large drainage-tube is inserted, just long enough to enter the pleural cavity, but not to project into it; the tube is carefully stitched in, and the wound immediately covered, so as to prevent as far as possible the entrance of unfiltered air. Care must be taken both at the operation and at the subsequent dressings, to prevent the tube being sucked into the thorax, a well-known but easily prevent- able accident. Irrigation of the chest is unnecessary and occasionally dangerous ; several cases of sudden death have followed this practice, probably due to reflex irritation of the vagus. In chronic cases, however, where a mixed infection is present, irrigation is often beneficial, but the following points must be attended to: (i.) The fluid employed must be sterile and unirritating ; (ii.) it must be at the temperature of the body, neithei 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 early, the lung may be expected to expand quickly, the discharge steadily diminishing, and the wound healing without delay; but this 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 Estlander's operation, which is character- ized by the excision of portions of ribs comprising the outer wall of the cavity. It is usually carried out through a vertical 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 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 tlie intervening SURGERY OF THE AIR-PASSAGES. LUNGS, AND CHEST 925 tissues, SO that the subcutaneous or muscular structures in the flaps are laid down upon the prepared surface of the deeper layer of the pleura. Necessarily, either of these methods of treatment is associated with considerable deformity, and also with a terrible weakening of the 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 practised with occasional success is the stripping of the thickened pleura away from the collapsed lung, so as to enable it to expand once more (pulmonary decortication). Obviously such a procedure could only be of value when the compression of the lung has not been followed by sclerosis ; whilst infection of the pulmonary tissue has resulted in grave inflammatory disturbance and even death. It is more than doubtful whether this proceeding is ever justifiable. Considerable assistance in gaining re-expansion of a collapsed lung may be obtained by making the patient undertake forced ex- piratory efforts against resistance — e.g., by learning to play some wind instrument. Intrathoracic Surgery has been much hindered in its progress owing to the frequent development of pneumothorax, which fohows open- ing the pleural cavity. The teaching of physiologists would lead us to anticipate this catastrophe in every case of pleural puncture ; that it does not occur so frequently is due to the power of cohesion of the two moist smooth surfaces of the parietal and pulmonary pleura; over this atmospheric pressure has Httle effect. In spite of this a large opening into the pleural cavity, especially if conjoined with digital exploration of the lung, will almost certainly result in a pneumothorax which may injuriously or even fatally affect the patient. To avoid this catastrophe, all that is needed is to arrange that the intra-alveolar pressure shall be slightly greater than the intra-pleural pressure when the chest is open, and this desideratum may be obtained in one of two ways : 1. By mea.nsoiSmierbruch's Chamber. This is an air-tight cabinet in which the surgeon and his assistant are placed for the operation together with the patient's trunk ; the patient's head projects through an air-tight window, the neck being surrounded by an india-rubber collar. The chamber is suitably lighted, and ah requirements for the operation are previously placed in it. The doors and windows are carefully closed, and by a suitable suction-pump the air pressure in the chamber is reduced to such an extent as not to trouble the operators, and yet to exercise a negative pressure on the exposed pulmonary tissue, and thereby to prevent its collapse. 2. By raising the pressure in the pulmonary alveoli by intra- tracheal insufflation (p. 1350) . This is easily and readily accomplished by any of the modern contrivances for the administration of ether vapour by this route— e.g., the Elsberg apparatus; the increase of 926 A MANUAL OF SURGERY pressure required does not exceed that represented by lo or 12 milli- metres of mercury. This latter method is far the simpler, and seems to be equally effective. 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 tuberculous 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 for a cavity located in the lower half of the lung, which drains badly, and the difficulty of diagnosing such a condition is considerable. 2. For bronchiectases pneumotomy, though prima facie desirable, has given but httle 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 fcetid secre- tion, which is with difficulty expelled, it may be useful. 3. Gangrene of the lung and pulmonary abscess usually follows acute septic pneumonia in debilitated individuals. The expectoration is abun- dant and extremely offensive. The localization is made partly with the stethoscope, but mainly with the exploring needle. The gangrenous area is often near the base of the lung. Operation is frequently successful. Of course, the pulmonary abscesses of pyaemia, being multiple, are not suited to operative treatment. 4. In hydatid disease of the lung, incision and drainage have so considerably reduced the mortality that this method of treatment should alone be adopted. As to the technique of the operation, the first thing is to locate the mischief, and this is effected 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 removed. If the lung is adherent to the thoracic walls, and shows no sign of retracting, the operation may be continued; but if no adhesions are present, and positive intratracheal pressure is not inavailable, it may be well to pack the wound with gauze for a day or two, so as to determine their formation and thus shut off the pleural cavity. It may, however, be possible to stitch the pulmonary to the parietal pleura, and thus prevent collapse. The lung itself may be punctured with sinus forceps introduced along an exploring needle, and then opened, or may be incised with a cautery. The abscess or other cavity is thus emptied of its secretion, and a drainage-tube inserted. As a general rule it is unwise to scrape or irrigate it, for fear of a communication existing with any of the larger bronchi. Pneumectomy, 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 hygienic measures, whilst if it is more diffuse it cannot be extirpated. Primary malig- nant tumours of the lung, moreover, are usually central, and the diagnosis can rarely be made early enough to warrant an attempt at SURGERY OF THE AIR-PASSAGES. LUNGS. AND CHEST 927 removal. The only conditions under which it is justifiable to excise portions of lungs 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 being cut away; in the latter the disease is snipped away with scissors, and bleeding stayed by cautery, ligature, or plugging. The creation of an Artificial Pneumothorax has occasionally been employed in the treatment of phthisis. Mitrogen is employed for the purpose, and must be washed and filtered before admission to the pleural sac. It is doubtful whether the procedure has any real therapeutic value. Wounds o£ the Heart. Wounds of the Heart and great vessels are so generally fatal, either immediately or within a few hours, that it is unnecessary to discuss them in any great detail. They may be divided into two classes, the non-penetrating and the penetrating. The former are due to crushes of the chest wall, and fragments of the overlying bones may be driven into the heart substance; it is unusual for any surgical treat- ment to be practicable in such cases. Penetrating wounds (90 per cent, of the whole) have of late years been brought within the range of surgical art, and a number of successful cases of cardiac suture have been reported. The right ventricle is most often injured; the left auricle least frequently. Wounds of the auricles are more dangerous than those of the ventricles, as the thicker and more muscular walls of the latter may suffice to check the bleeding. The outlook depends largely on the nature of the wound, those due to small penetrating bodies, such as stilettos, etc., being the most favourable. The patient may die from immediate cessation of the heart's action; or from intra-pericardial pressure of blood; or from haemorrhage, internal or external, according to whether or not the blood can escape. If the patient does not die at once, he suffers from intense shock and prostration, combined with a weak and turbu- lent action of the heart, great pain in the chest, and dyspnoea, whilst the pulse is scarcely to be felt. Purulent pericarditis is likely to ensue. Treatment. — The patient must be kept absolutely quiet and with the head low until it is decided whether or not operative inter- ference is justifiable. If the case is to be left, the external wound is purified, but no attempt made to explore it with finger or probe for fear of dislodging clots. If operation is attempted, an anaesthetic is carefully administered so as to avoid struggling, and a suitable incision made in the chest wall ; possibly the best plan is to turn up a trap-door flap consisting of parts of the fourth and fifth ribs or their cartilages. The pericardium is freely opened, and the cardiac wound gently explored. It has been found possible to stay a sudden gush of blood by introducing one or more fingers into the ventricle. Deep sutures are then inserted through the muscular substance, for choice 928 A MANUAL OF SURGERY during the diastole, and tied ; branches of the coronary artery may require ligature. It must not be forgotten that cases have been reported in \vhicli a wound of the heart has healed spontaneously, and the patient sur\i\ cd for years. Effusion into the Pericardium, whether serous or purulent, may require surgical treatment in order to relieve symptoms of cardiac failure, due to the pressure of the exudate. The sac when distended pushes aside the pleurae and lungs, and also is enlarged upwards, carrying up the base of the heart and rotating the apex forwards to a slight degree. The bare interpleural area of the pericardium is therefore increased, and the cavity may be tapped by trocar and cannula, or by aspirator either close to the left 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 internal mammary trunk, which courses down about half an inch from the border. It may also be reached with safety from the right side of the sternum in certain cases. For suppurative pericarditis incision and drainage are necessary. This may be readily accomplished by removing the fourth or fifth costal cartilage, thereby exposing the pericardium, which is opened, washed out, and 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. Possibly better drainage is provided by operating through the costo-sternal angle (Allingham). An incision is made through the left rectus abdominis, reaching up between the xiphoid and the seventh costal cartilages, the latter being, if necessary, removed. The peritoneum is depressed; the interval between the sternal and costal attachments of the diaphragm is opened up ; and the lowest part of the pericardium is thereby exposed, and can be easily drained, i he patient is propped up in bed. Cardiolysis is an operation for the removal of a portion of the chest wall, tying in front of the heart, with the object of replacing the comparatively unyielding thoracic wall by a soft, pliable cover- ing. It has been performed in cases of adherent mediastino-peri- carditis to relieve the fixation of the heart to the chest wall, with its consequent mechanical disadvantage; and also for cases of valvular disease with great hypertrophy. The parts usually removed have been the third, fourth, and fifth left costal cartilages, wath or without a piece of the sternum, and the ends of the corresponding ribs. It is desirable to remove the peri- chondrium, but in cases of adhesive inflammation this may be almost impossible without wounding the underlying structures. Asphyxia. Asphyxia, or Apnoea, is the term applied to indicate the condition arising from interference with or stoppage of the respiratory act. If this has not proceeded to any great extent it is termed Dyspnoea ; when, however, the SURGERY OF THE AIR-PASSAGES. LUNGS. AND CHEST 929 obstruction is so marked that the patient is obliged to maintain the upright sitting position, the term Orthopnoea is applied to it. The Causes of asphyxia may be classified as follows: I. Conditions arising frona the presence of abnormal contents withm the air-passages — e.g., foreign bodies; blood-clot or pus from the bursting of an aneurism or abscess; serum, as in oedema of the lung; mucus or muco-pus, as in bronchitis; the consolidated exudation in pneumonia; diphtheritic mem- brane; or irrespirable gases— e.^., nitrogen, hydrogen, carbonic acid gas, etc., as in suffocation. Death by drowning usually arises from a similar cause, viz. the replacement of air by water in the respiratoiy passages. 2.' Causes arising in the walls of the air-passages, such as diminution of their lumen from inflammatory congestion, as in oedema of the glottis; cicatricial stenosis ; the presence of new growths, or the displacement of parts, as m cut throat ; or the falling back of the root of the tongue after partial excision of that organ . . 3 Extrinsic causes, or those arising outside the air-passages— e.^., m the neck : strangling, hanging, garrotting, etc.; the presence of tumours, such as goitres or aneurisms; a retropharyngeal abscess or tumour; and, under ex- ceptional circumstances, displacement backwards of the sternal end of the clavicle. Within the thorax gradually increasing obstruction to the respira- tion 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 m 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 asphyxia, owing to the increasing difficulty in eliminating the excessive accumulation of carbonic acid. The Treatment of the different conditions giving rise to asphyxia cannot here be dealt with in extenso, but merely the general plan of treatment in- dicated. A rapid examination is at once made, to ascertain, if possible, the cause of the mischief, and whether its onset has been gradual or sudden. If it has been graduallv developing, it is not uncommonly due to some thoracic condition which cannot be relieved; if, however, its onset has been sudden, and not the result of anv evident lesion, the neck and chest should be bared, and examined for signs of traumatism, the mouth opened, the tongue drawn forwards, and the glottis examined with the finger to see that the passages are clear. The patient should, if necessary, be removed into fresh air, and artificial respiration at once commenced. Breathing can sometimes be excited by alternately dashing hot and cold water over the thorax, whilst electric stimulation of the phrenic nerve may also be undertaken, one electiode being placed over the neck and the other on the epigastrium. The administration of oxygen instead of air is useful during the earlier stages, whilst if the con- dition is due to cardiac disease with distension of the right side of the heart, venesection holds out the best hope of rehef. Obstruction withm the larynx needs tracheotomy or intubation, as also other conditions associated with pressure on the trachea. Artificial Respiration is required in a variety of surgical conditions, and can be undertaken by what is known as Sylvester's method. In this the patient lies 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. This position is maintained 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. At the end of about two seconds more the arms are again elevated, and the 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 hurry over it unnecessarilv, as harm rather than good thereby results. 59 930 A MANUAL OF SURGERY Another 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 expansion of the chest walls draws in a fresh su])i)ly. In the Treatment of the Apparently Drowned the air-passages must be cleared as quickly as possible. During the struggles of the drowning man water enters the trachea and is churned up with mucus, saliva, and perhaps blood into a froth which does not easily escape, but must be slowly squeezed out by the application of pressure to the back, whilst the patient is lying face down. At the same time artificial respiration must be maintained, and it is obvious that Sylvester's method is not an ideal plan under these circum- stances. The late Dr. R. L. Bowles elaborated a procedure for these cases which admirably suits their requirements, and we have much Fig. 441. — Treatment of the Apparently Drowned — •Movement No. i pleasure in quoting his instructions verbatim, and introducing the illustrations which he kindly placed at our disposal: ' Treat the patient at once and on the spot. Undo any tight clothing. Kneel and place the patient on the right side and quickly wipe out the mouth and throat. ' If there are no signs of breathing, spread a handkerchief on the ground where the patient's mouth will come, and carry out ' Movement No. i.— Turn the patient flat on the stomach, and at once with widespread hands press gently but firmly for three or four seconds on the back of the ribs on both sides to squeeze out the froth, fluid, or foul air (Fig. 441). Then suddenly remove the hands to allow the entrance of air by the natural recoil of the ribs, and pro- ceed to ' Movement No. 2. — With the right hand grasp the patient's left shoulder; with the left hand take his left wrist, place it against his SURGERY OF THE AIR-PASSAGES. LUNGS. AND CHEST 931 hip, and roll him towards you on to his right side (Fig. 442). This movement should take about two seconds ' Repeat first and second movements in succession for ten mmutes Fig. 442.— Treatment of the Apparently Drowned— Movement No. 2. Fig. 443. Treatment of the Apparently Drowned — Movement No. 3. or more (if necessary), when some of the froth or fluid will have drained away from the lungs, and then proceed to ' Movement No. 3.— Each time the patient is rolled from the 932 A MANUAL OF SURGERY stomach on to the right side, take hold of the left or uppermost arm and raise it above the head in a line with the body. This movement expands the chest still more and allows air to enter the upper left lung (Fig. 443)- Then bring the arm down to the side, roil the patient on to the stomach, and begin again at movement No. i, and continue each movement in succession as before, for an hour or until signs of natural breathing begin. ' Always turn the patient on to the right side, never on the left, and under no circumstances on the back. From time to time wipe away froth from the mouth and nose. ' The neck should be kept fairly straight and the chin away from the breast-bone ; the head may then be left to take care of itself, and the face will take no harm, as it will remain chiefly on its side, and yet perfect drainage will be ensured.' CHAPTER XXXIV. DISEASES OF THE BREAST. Congenital Malformations of the breast are much more common than is generally supposed. One or more accessor}' breasts {polymastia) or nipples are found either below the normal one or just above it ; sometimes they have been found in the axilla, on the outer side of the thigh, or other unusual situations. They are often of a most rudi- mentary nature, but in a few- cases have secreted milk. Very rarely the breasts are entirely absent [amazia). Oc- casionally the male breast becomes enlarged to the or- dinar\' size of a \-irgin's breast (gynecomastia) ; the organ is usuallv functionless, since the overgrowth mainl\' affects the stroma, although lactation has been known to occur. The condition may be asso- ciated with imperfect or irreg- ular development of the sexual organs . Diffuse Hypertrophy of the breast (Fig. 444) consists of a p^^ general enlargement of the organ, both gland substance and interstitial tissue partici- pating in the process, and hence the breast becomes lirm 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 mav become enormous, hanging down by their weight, and perhaps to such an extent as to rest on the knees of the patient when sitting. 93.S 444- Diffuse Hypertrophy of THE Breasts. It occurred in a girl aged sixteen and a half years, and both organs had to be removed. The left breast weighed 9^ lbs., the right breast 9 lbs. 934 A MANUAL OF SURGERY They are usually painless, although sometimes neuralgia is noticed. Functionally they are useless, as even if the patient becomes preg- nant, secretion of milk but rarely occurs. No cause can be assigned for the overgrowth, and the only treatment is amputation, when the increased size is causing discomfort. 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 cleanliness 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 preg- nancy with spirit, so as to harden them. The actual lesion is brought about by leaving the nipples wet after nursing. The super- ficial layers of epithelium become macerated, and are easily rubbed off, thus ex- posing the more delicate and sensitive deeper parts, which are irritated and in- flamed by the repeated acts of suction. As a result, nursing becomes painful, and if persisted in, the wound may be infected, the inflammation spread- ing to the breast substance along the ducts or lym- phatics, or extending along the superficial 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 acid lotion, immediately after nursing, and then to dry them thoroughly. If at all tender, a little powdered boric acid and starch may be dusted over them in the intervals. When a fissure has i cmed, it should be dressed with cooling or antiseptic lotions — e.g., lotio plumbi or lotio acidi borici. Sometimes more stimulating applications are required, such as a solution of sulphate of copper, or even of nitrate of silver. It is also recommended to paint the sore with 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 really b'lG. 445. — Chanckk tU' UN': XipVLii. (From Photograph and Sketch lent by Pro- fessor RusHTON Parker, of Liverpool. DISEASES OF THE BREAST 935 due to a carcinomatous development in the skin. It is seen, but very rarely, in parts other than the breast. It presents a smooth, red, raw surface, discharging a yellowish viscid fluid, and may occasionally spread widely beyond the areola. The progress is very slow, but the condition is almost invariably followed by a cancerous tumour in the breast, which may resemble either a' duct cancer or an ordinary scirrhus. No local treatment is of' any avail, and the disease, when once recognised_^witli certainty, is best treated by removal 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 (Fig. 445) is rarely seen in the mothers of syphilitic children (CoUes's law, p. 171), but much more commonly in wet-nurses. It usually presents as a shallow ulcerated surface with a well-marked, raised, and indurated border. Not uncom- monly the condition is symmetrical. Primary Tumours of the Nipple are met with, such as papilloma, sebaceous cysts, and occasionally epithelioma. Inflammatory Affections of the Breast. Acute Mastitis is most often observed in puerperal women, owing to the sudden establishment of function in the breast after the birth of a child, and to its maintained activity during lactation. It usually results from a sore or cracked nipple, through which pyogenic organisms find their way into the lymphatics or acini of the breast substance. In the former case the inflammation is mainly interstitial in character, the pus diffusing itself widely between the lobules; in the latter the pus is primarily intra-alveolar. Simple obstruction to one or more of the ducts from inflammation of the nipple, without any external wound, also determines an attack of mastitis, which is frequently non-suppurative in character. In non-puerperal women acute mastitis may result from injury, or may be pysemic 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 in- flammation, involving both the breast and areola, and even ter- minating in suppuration, has been observed. In newly -born infants a similar inflammation, sometimes running on to suppura- tion, has been seen, possibly resulting from an 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 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. — x\n inflamed breast is characterized by the organ becoming swollen, acutely painful, and tender. The gland lobules are felt to be enlarged and indurated, whilst if lactation is 936 A MANUAL OF SURGERY progressing, the secretion is to some extent impaired ; but owing to the inability of the mother to allow the child to relieve the organ, on account of the pain produced thereby, considerable tension results from accumulation of milk. If suppuration follows, the skin over the breast becomes red and oedcmatous, and, according to the situation of the pus, three different forms of acute abscess of the breast are described: {a) Supramammary abscess is the term applied to a collection of pus in the subcutaneous tissues or beneath the nipple; it is often unconnected with the organ, or may originate in the superficial lobules. It does not burrow deeply, and comes readily to the surface, {b) An intramanimary abscess is the most common variety, the pus developing within^ and distending the lobules, or infiltrating the cellular tissue around them ; it is usually diffused widely throughout 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 forms in the cellular tissue beneath the breast. It may spread from the deep lobules, but more frequently results from disease of some of the adjacent ribs or cartilages, or starts 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 commonly at the lower and outer quadrant. Inflammation of the breast occurs in women who are anaemic and weakly. Even the simple forms are associated with fever and malaise, and these become exaggerated if suppuration ensues, owing partly to the pain, 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 at rest the pectoral muscle, on which it hes. Fomentations are then apphed, 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 nourish- ing diet, whilst stimulants and tonics, such as iron and quinine, may be judiciously administered. As soon as the acute stage has passed, friction with wann oil, or the inunction of a belladonna ointment, is 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 supramammary variety it matters Httle 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 DISEASES OF THE BREAST 937 with a free hand, so as to allow of the insertion of the finger, and the opening up of any pockets or lobules which are distended with matter. A large drainage-tube is inserted for a time, and gradually shortened da}' 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 efhcient drainage. With such treatment the best of results may be attained, and it is interesting to note how quickl}^ the contour of the breast is restored, and how slight is the permanent injury inflicted on the parts. The sub- mammary abscess is best opened towards the lower and outer side, but also at any spot where pus points. If discharging sinuses persist after an abscess has burst, their orifices should be enlarged, and their walls thoroughly scraped and disinfected; deep cavities should be efficiently drained and packed with gauze, so as to ensure the wounds healing by granulation ; the arm must also be kept to the side. 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). 1. Chronic Lobar Mastitis is by no means unfrequent as a result of imperfect involution of the organ 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 exces- sively painful, the pain being of a neuralgic character, and increased during menstruation. The condition is of comparatively little importance, but may give rise to a great deal of anxiety and worry. x\ll that is necessary in the shape of Treatment is to support the part and keep the arm at rest in a sling, whilst an ointment containing belladonna, or a belladonna plaster, may be applied. 2. Chronic Lobular or Interstitial Mastitis is an affection which occurs not unfrequently in women with small or atrophic breasts, who have passed, or are near to, the climacteric. It is also met with at an earlier age in unmarried women, involving the whole of one or both breasts, or limited in its development to a portion of one breast, and then being sometimes mistaken for a mahgnant tumour. Pathologically, it is characterized by diffuse overgrowth of the connective tissue, which becomes thickened and perhaps sclerosed, This is associated with well-marked epithelial proliferation, so that sometimes in the earlier stages the acini are filled with a thick cheesy or grumous material which can be squeezed out in thread- like masses, often of a dirty brown or greenish-yellow colour. Cysts are formed in the gland tissue, partly b}^ liquefaction of this pro- liferated epithelium, partl}^ by exudation into the acini of serous fluid, which is unable to find an exit owing to the pressure of the interstitial growth. Such are known as ' involution cysts,' and the 938 A MANUAL OF SURGERY fluid contained therein is usually clear and limpid; but may be brown and turbid, from admixture of blood ; intracystic growths are not present. As a rule, many of these cysts are scattered widely through the breast substance, but they are small and insignificant ; occasionally one or more of them become notably enlarged, and simulate a tumour, especially when covered in by a mass of thickened glandular tissue. Clinical History.— The condition often passes unnoticed in the early stages, until a distinct lump has formed, which is nodular and indurated to the touch, and often very painful. The breast may be somewhat enlarged, and there is, perhaps, some retraction of the nipple, owing to contraction of the interstitial tissue; but this is by no means an essential feature. A scanty serous discharge from the nipple is sometimes noticed. The skin seldom becomes adherent to the swelhng, whilst the lymphatic glands in the axilla may be enlarged and tender, but they are never hard. On careful examination of the breast, the affection is rarely found to be limited to one particular region, for although a distinct enlargement of one portion may be present, yet the whole organ feels more or less ' lumpy,' and not unfrequently the other breast participates in the same change. Small, rounded, elastic spots can often be detected, and indicate the presence of cysts. 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 the menstrual periods. If left to run its course, the disease may remain much in the same condition for many years, and even in time disappears ; but more iNG FROM Chronic frequently it slowly progresses, and then results Interstitial Mas- jj^ q^q q^ three conditions : [a) General atrophy, the breast becoming shrunken, hard, and nodular, [b) More frequently general cystic disease (Fig. 446) follows, a condition in which the organ becomes transformed into a number of cysts held together by dense connective tissue, (c) There is some question as to whether or not cancer is a sequela of this disease; there is abundant evidence to prove that any continued source of irritation in an organ like the breast renders an individual with a cancerous inheritance more liable to its develop- ment, especially if it commences at or about the climacteric. The Diagnosis is sometimes easy, but the condition often simulates somewhat closely a scirrhous tumour. The chief points of distinc- FiG. 446. — General Cystic Disease of THE Breast, result- titis. In this case both breasts were equally affected , and were removed at the same time. DISEASES OF THE BREAST 939 tion, however, lie in the facts (i.) that the whole 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 enlarged they are not hard, as in the latter disease; (iv.) that the skin is usually free from the mass; (v.) that the tumour is never adherent to the pectoral fascia, nor is it of the stony hardness of a scirrhus; and (vi.) that it is often more disseminated and less defined than a cancerous growth, (vii.) More- over, on careful palpation with the fiat of the hand, it is often impossible to make out any distinct lump, the so-called tumour merging into the surrounding tissues; this never occurs in scirrhus, the growth always being easily detected with the flat of the hand. Small cysts can also be felt as localized elastic spots in the inflam- matory mass. Of course it is possible for the two conditions to co-exist, and in doubtful cases an exploratory incision, and micro- scopic examination of a portion of the tissue, can alone be depended on. Treatment. — In the early stages, and especially in the younger patients, friction with some sedative application containing bella- donna may be used at the same time that the breast is supported, and freed from the irritation of badly-fitting stays. Firm and equable pressure, as by strapping, is also useful in some cases whilst iodides may be administered. If a definite tumour is present, or if many C5^sts can be detected, and especially if the patient is anxious and worried about herself, it is wise to remove the affected portion or even better to excise the whole breast, especially when there is a family history of malignant 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, giving rise to a sense of fluctuation, although when the abscess walls are very thick ., as is often the case, it maybe exceedingly difficult to detect this. Retraction of the nipple is not uncommonly present, and the axillary glands may be enlarged. The condition has frequently been mis- taken for a tumour, but is recognised from it by its incorporation with the breast substance, by its lack of definition, and by the fact that on careful examination elasticity can be felt at its centre, which is almost always less resistant than the margin, whereas the opposite is the case with a tumour. In cases of doubt the insertion of a grooved needle or an exploratory incision will settle the diagnosis. Sometimes chronic abscesses of the breast are of a tuberculous nature. Treatment consists in opening the abscess cavity, scraping out its interior, disinfecting with pure carbolic acid, if tuberculous, and draining or packing it. Diffuse Tuberculous Disease of the breast is not very uncommon. Scattered nodules of caseous material are developed in the inter- acinous tissue, which break down into pus, and come to the surface at various spots. The breast may thus become riddled with sinuses 940 A MANUAL OF SURGERY discharging caseous pus. It may be associated with tuberculous disease of the lungs, whilst a like affection may arise secondarily in the axillary glands; possibly in some cases the primary trouble lies in the glands, the breast being subsequently involved. Treatment should be carried out, if possible, by incision, scraping, and purification of the cavities; but if the tuberculous foci are 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 recog- nised, although the causative lesion can only be ascertained by exploration. It must be opened thoroughly, and its wall scraped 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 or beneath 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 difierent forms of cystic change are asso- ciated 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 of the organ is unable to escape. They are met with most fre- quently in women during or after the puerperal period, a milk cyst, or galactocele, being then produced. It usually results from compression 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 epithelium and surrounded by a fibro-cicatricial layer, the thickness of which increases with the chronicity of the case. In very old-standing cases the fibrous wall becomes very dense, and may cause retraction of the nipple and puckering of the skin, closely simulating a scirrhus. The condition is treated by excising or draining the cavity. Similar glandular cysts form, as already described, in the course of chronic interstitial mastitis, and are then known as involution cysts ; in long-standing cases, general cystic disease of the breast may follow. Retention cysts have also been described as resulting from irrita- tion of the nipple, as, for instance, when a young, non-pregnant woman constantly puts a baby to her breast ; it may also occur apart from such irritation in young and vigorous unmarried women, as an expression of the inherent capacity of the gland for functional development. The organ becomes enlarged, the epithelium pro- DISEASES OF THE BREAST 941 liferates, and a thin serous fluid is secreted, wliich does not entirely escape, and by its distension of the lobules gives rise to what may be termed iryitation cysts. They may in time undergo spontaneous absorption, but Erichsen describes a case of this nature in which the swellings did not disappear until the patient subsequently became pregnant. Chronic interstitial mastitis may sometimes supervene. Again, one frequently 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 blood-stained discharge from the nipple. A scirrhous growth also occasionally starts from the wall of an acinous cyst. In most of these retention cysts, discharge from the nipple occurs on squeezing the organ. . 2. Interacinous Cysts develop in the interstitial tissue of the breast. [a) Serous Cysts originate 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 intracystic growths are unknown. They are usually surrounded by a wall of connective tissue which may become exceedingly thick and dense. Occasion- ally, however, they project under the skin, and if the walls remain thin, fluctuation, and even translucency, 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 occurring near its under surface; that on careful examination an elastic resistance is transmitted to the fingers, quite distinct from the stony hardness of a scirrhus ; that there is no retraction of the nipple and no enlarge- ment of the axillary glands, whilst, as a rule, the patient complains of but little pain. The diagnosis in cases of doubt may be readily determined bj^ inserting a grooved needle, or by an exploratory incision, which should be made of sufficient depth to ensure the thorough division of the mass, for fear that a small cyst surrounded by walls of fibrous tissue, half an inch, or even an inch, in thickness, should be mistaken for a solid tumour. Treatment. — Although it may suffice to lay the cavity open and drain it, it is decidedly wiser to remove it completely. (&) True Hydatid Cysts are occasionally met with, manifesting the general characteristics described at p. 233. 3. Cysts may also arise in connection with cancerous or sar- comatous tumours, from degeneration of tissue in the former case, and from haemorrhage into the substance of the latter. 4. Dermoid Cysts are described; but it is a little doubtful whether old galactoceles have not been mistaken for them. 942 A MANUAL OF SURGERY 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 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 be little doubt, more- over, as to the occasional tendency of tumours to run in families. The length of time for which the swelhng has been observed should be ascertained, and whether or not it varies in size at the menstrual periods. The general appearance of the patient should be noted, as also the fact whether or not pain, local or neuralgic, is experienced. It is not unusual for pain to be referred to that part of the shoulder supplied by the posterior division of the second intercostal nerve, the anterior branch of which goes to the breast. A careful inspection of the organ 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 the 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 fibres is always possible, unless the growth is fixed to the thoracic wall; movement in the direction of the fibres is at once hmited if the tumour has invaded the muscle, or even if the overlying fascia is seriously involved. Finally, the lymphatic glands in the axilla must be carefully examined, as also, in suspicious cases, the supra- clavicular glands and the opposite breast and armpit. The chief types of tumour met with in the breast may be arranged in three groups: the adenomata, the sarcomata, and the cancers. A few other conditions have been observed, but are so rare that they need no special description — e.g., lipoma, fibroma, chondroma, and osteoma. Adenoid Tumours of the Breast. — ^This group includes the two forms of fibro-adenoma (the hard and the soft) and the cysto- adenoma. All are characterized by the existence of spaces lined with epithelium, which does not extend beyond the basement membrane. The spaces may contain a variable quantity of fluid, and in some cases intracystic growths are a prominent feature. The interstitial tissue is sometimes of a very embryonic type. DISEASES OF THE BREAST 9-13 A pure Adenoma is said to occur, but is very uncommon. Its texture would be identical with ordinary mammary tissue, and its characters with those of a fibro-adenoma, except that it is a httle softer. The Hard Fibro-adenoma (or Adeno-fibroma) is the most common mammary 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, may be described as floating in it (Fig. 447) ; if situated deeply, it still appears quite moveable, but its definition is less evident. Some- FiG. 447.— Fibro-Adenoma Maumje^ (From Museum of Royal College OF Surgeons.) times several such growths are found in the same breast. A fibro- adenoma is usually firm and more or less elastic in consistency, of slow growth, and it may be either painless, or in antemic and neurotic women exceedingly painful, the pain often increasing at the men- strual periods. There is no concurrent enlargement of the axillary glands, unless arising from other causes, and no retraction of the nipple, with which it is entirely unconnected; the skin over it does not dimple. The general health is unimpaired unless the patient is suffering from an associated anaemia. On section the tumour is of a grayish-white colour, becoming pink on exposure to the air. It is more or lessHoHated in texture, being compared by Virchow to the section of a^cabbage ; no juice can be obtained on scraping the 944 A MANUAL OF SURGERY cut surface with a scalpel, although on pressure some fluid of a thick glutinous or mucoid nature may escape. ]\licroscopically, the tumour consists of imperfectly developed glandular elements, sur- rounded by a considerable amount of firm interstitial tissue (Fig. 6i). but ducts are never present. The tumour is distinctly encapsuled, except at the one spot, through which vessels enter, and at which it is connected with the neighbouring mammary tissue. It is stated that fibro-adenomata are occasionally converted into sarcomata, thus changing their type from simple to malignant; the evidence, however, as to this is not conclusive. The Diagnosis is readily made if the above signs are considered. An adenoma differs from chronic interstitial mastitis or a serous cyst by its exact definition and free mobility, whilst from malignant Fig. 448. — Cysto-Adenoma Mamm^. (Museum^of Royal College of Surgeons.) The intra-cystic growths are seen projecting from a large cyst, into which a bristle, passed down the nipple, enters. A glass rod has also been passed into the cyst through a perforation in the skin. tumours it is distinguished by its slow rate of growth, and its freedom from adhesions either to the skin or to surrounding parts. The Treatment consists in its removal, which is easily affected by cutting down upon the tumour in a direction radiating from the nipple, until the capsule is reached, when the mass is enucleated from its surroundings with a few touches of the knife. When the growth is situated deeply in the upper half of the breast, a crescentic incision may be made along the lower and outer border of the organ, and by iDurrowing upwards, the breast can be turned over sufficiently to permit the tumour to be removed from the deep aspect; the scar will be subsequently hidden (Thomas's operation). The Soft Fibro-adenoma differs from the above mainly in the increased rate of growth, in its soft consistency, and in the fact that DISEASES OF THE BREAST 945 the interstitial tissue is of a more embryonic character, and, indeed, is often of a mucoid nature; it is sometimes incorrectly termed an adeno-sarcoma. It usually occurs in women at a somewhat earher period of life than cancer — viz., between the ages of twenty-five and thirty-five. It may consist from the first of a localized tumour, increasing rapidly in size, or it may possibly commence as a hard ftbro-adenoma, which, after remaining quiet for a time, 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 con- sistency, 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; thej nipple|shows u.A^ ^IC Fig. 449. — Cysto-Adenoma Mamm^. (From a Photograph.) 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 resembUng sago. It can be readily removed in its entirety, and does not tend to recur. Cysto- adenoma [Syn. : Cysto-sarcoma, Adenocele, Intracanalicular Adenoma, etc.) is a" condition characterized by a marked develop- ment of intracystic growths, consisting of newly - formed fibrous tissue covered with epithelium, within the dilated acini of a newly- formed mass of adenomatous tissue, or within the smaller ducts (Fig. 448). It usually 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 be of great size, the intrac3-'stic growths also varving in amount. Sometimes there is only one large 60 946 A MANUAL OF SURGERY cauliflower-like mass in a cyst ; sometimes there are several smaller pedunculated growths. The epithelium covering them is cuboidal or columnar; they are exceedingly vascular, and haemorrhage 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 duct or acinus before it. The tumour produced is irregular or lobulated in outline, owing to the projection of the cysts (Fig. 449) ; it is usually painless, 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 adlierent to the integument, and finally, owing to the pressure of the tumour, the skin may give way, allowing the growth to protnide. This will be followed by the development of a f ungating mass, which bleeds readily, and becomes extremely offensive. With care a probe can be passed between the intracystic portion of the growth and the thinned and stretched skin, which has merely given way, and is not incorporated with it; this fact is a ready means of distinguishing this condition from a fungating encephaloid cancer. The tumour is essentially benign in nature: it is never disseminated generally, 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 con- sequence becomes dilated. A discharge of blood-stained serum results, and there is usually but little tumour to be felt, although 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, but it may be feasible in some to deal with the tumour alone. Sarcoma Oi the Breast is not a common disease (2 to 8 per cent, of all mammary tumours). 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-celled sarcoma forms a soft, somewhat elastic swelling, which grows rapidly, and although often limited at first by a fibrous membrane, the capsule sooner or later yields, 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 blood- vessels. Cysts often occur in its substance, resulting either from haemorrhage or occasionally from the dilatation of an incorporated glandular alveolus; in the latter case the cavity will be lined with epithelium. iMyxomatous changes are also not unfrequently ob- served, and in the more rapidly growing recurrent tumours the mass DISEASES OF THE BREAST ^47 is often a true myxo-sarcoma. It usually occurs in women between the ages of thirty and forty — i.e., somewhat earher 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 ahnost impossible to distinguish it from encephaloid cancer, except on microscopic examination. {h) A spindle-celled sarcoma, or fibro-sarcoma, is also met with, forming a rounded or oval tumour, more limited than the abovei and growing less rapidly. It somewhat simulates an adenoma,' but IS more closely connected with the breast substance. The axdlary glands are but rarely involved, and the sarcomatous nature IS recognised by the microscope and by the great tendency of the growth to recur even 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 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. .ffitiology.— Cancer of the breast is usually met with after the age of forty, although the disease may occur at a much earher date. It equally affects women who have borne children and nulhpar^, 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- fittmg stays are responsible for a certain percentage of the cases. It not uncommonly follows eczema of 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 difhcult to decide, and, although it may be a marked feature of some cases, it is somewhat doubtful whether, as a general rule, it has any considerable in- fluence. Two distinct types of cancer are met with in the breast— viz., the spheroidal-celled acinous cancer (including the acute form, and the more chronic type known as scirrhus) and duct cancer. Colloid degeneration of either of the former varieties has been observed, but is very uncommon. 948 A MANUAL OF SURGERY I. Spheroidal-celled Acinous Cancer includes the great majority of cases; the division into scirrhus and acute cancer depends clinically on the rate of growth and degree of hardness, pathologically on the greater or less amount of fibrous stroma present in any particular case. Scirrhus usually commences as a hard circumscribed mass, situated most commonly in the upper and outer quadrant of the Fig. 450. — Section of Scikkhls of the Breast, showing Retraction OF THE Nipple, Infiltration of the Fat, and Secondary Nodules IN the Underlying Muscles. (King's College Hospital Museum.) organ. It is closely united to, if not absolutely incorporated with, the breast substance, and on careful digital examination its margin is quite indefinite (Fig. 450). In the early stages it is entirely dis- tinct from the skin, which moves freely over its surface; but as growth proceeds, the stroma contracts, and, by dragging on the suspensory ligaments of Cooper passing from the glandular sub- stance to the skin, the latter structure becomes more or less fixed, and hence, on attempting to move it upon the tumour, an appear- DISEASES OF THE BREAST 949 ance of dimpling results. At the same time, the whole breast is acted upon in a similar manner, so that the affected organ some- times seems to be sn.aller than the other; and, since the upper half of the gland 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 drag of the growth on the galactophorous ducts (Fig. 451J. The tumour itself is rarely of great size, so long as it retains its scirrhous nature; it is sometimes extremely painful and tender, but not uncommonly the pain is intermittent, and of a neuralgic t\'pe, extending to the shoulder, and perhaps only elicited on manipulation. As the growth increases in size, it becomes adherent to the pectoral fascia, and may even infiltrate the underlying Fig. 451. — SciRRHUs of the Left Breast. (From a Photograph.) The retraction of the nipple and its elevation above the level of the other are well seen. muscular substance, so that on examination, with the arm extended and abducted, it is found that, although moveable across the fibres of the muscles, the breast cannot be moved \^dth 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 pectoraHs major are first involved, and, as the case progresses, the remaining axillary and subscapular sets become similar!}' affected, and even after a time the supracla\'icular. \'\'hen the inner or deeper part of the breast is attacked, the disease may spread to the medi- astinal glands along the lymphatics, which accompany the nutrient vessels arising from the internal mammary trunk; and thus intra- thoracic deposits develop, which even extend along the subpleural 95° A MANUAL OF SURGERY 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 lymphatic anastomosis across the mitidle hne 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, {a) Ihe dimphng which is met with over the tumour in the early stages has already been mentioned. As the case proceeds, the cancer extends out- wards along the suspensorv 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 Fig. ^^2. — Diffuse Cancer of the Breast, showing Retraction of the Nipple, Infiltration of the Lymphatics of the Skin, and Swelling OF the Arm due to Lymphatic Obstruction from Involvement of the Axillary and Supraclavicular Glands. 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 consider- able dimensions. A typical scirrhous ulcer is hollowed out and excavated; its surface, if kept clean, is covered with smooth granu- lations, discharging 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. (6) Less commonly the disease becomes disseminated through the lymphatics of the skin, giving rise to a series of firm cord-like thickenings radiating from the nipple (Fig. 452). The skin itself is thickened and firmer than DISEASES OF THE BREAST 951 usual, so that it is impossible to pinch it up; the mouths of the sebaceous glands are enlarged and very evident, giving it a coarse appearance like ' pig-skin,' or the rind of an orange {peati d' orange of French authors). Later the colour becomes dusky, and numerous button-like nodules of cancer develop here and there ; the sebaceous glands 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 (cancer en cuirasse) ; in its most typical form it is slow in develop- ment, the patient perhaps living for many years, (c) Occasionally one meets with a much more rapid form of cancerous lymphangitis, in which the skin becomes affected with what is supposed to be a ' weeping ' eczema ; the sur - face is red, hot, and infil- trated, and on examining it with a lens the dilated 13/mphatics can be seen from which the secretion oozes. The process spreads widely and rapidly, and cancerous nodules appear here and there in the infil- trated area; the prognosis is, of course, very grave. In the later stages, the patient passes into a state of cachexia, becoming emaciated and exhausted. Ulcerated surfaces of con- siderable size may exist, and the tumour is fixed to the thoracic wall, even in- vading the ribs. The arm on the affected side is swollen and brawny, owing to the pressure of enlarged giands on the main lymphatics and veins of the limb, constituting a condition of solid or lymphatic oedema (Fig. 453). Severe neuralgic pain of the arm results Jfrom involvement of or pressure upon the brachial neives iii the supraclavicular fossa. Secondary deposits also develop in the viscera, especially the pleura, lungs, and liver, and may lead to various symptoms. Not unfrequently recurrence takes place in the connective tissue between the rib cartilages and the pleura, and nodules of growth develop, which may in time project forwards through one of the intercostal spaces (usually the second) . Deposits in the bones (p. 596) are also not unusual, the sternum, vertebrae, and upper ends of femur and humerus being perhaps most often affected . Fig. 453. — Lymphatic CEdema'of the Arm Secondary to Carcinoma Mamm^, which HAD recurred AFTER OPERATION. 952 A MANUAL OF SURGERY Severe pain is caused by such lesions, followed probably by spon- taneous fracture, which may heal quite effectively or remain un- united. Finally, death from exhaustion ends the scene. Acute Cancer is fortunately not common, and appears as a some- what 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 cause retraction 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 stretched and gradually invaded by the tumour, and if ulceration follows, a foul fungating mass sooner or later sprouts up through the opening. This variety i > Fig. 454. — Atrophic Cancer of Both Breasts. (From a Photograph. ) The nipples are both retracted, and the skin around puckered and fixed to the growth. On the right side the axillary glands are obviously enlarged. The patient was an old woman over 70 years of age. usually attacks young women under thirty-five years of age, and runs a rapidly destructive course, especially if it occurs during pregnancy or lactation, when it is likely to be mistaken for an acute mastitis. Finally, in elderly women, a chronic form of cancer is met with known as Atrophic Scirrhus (Fig. 454), 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 dissemination has ultimatel}' 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 DISEASES OF THE BREAST 953 nature of which is still uncertain, 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 epithehum, and may, indeed, be looked upon as forms of columnar cancer. They are exceedingly vascular, and a blood-stained discharge from the nipple is usual. They 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 papilloma- tous growths, whilst cystic degeneration also occurs. Either of these varieties may be associated with a development of ordinary scirrhus in some other part of the breast. The diagnosis can only be established with certainty by microscopic examination after removal. Adeno-carcinoma is the term given by Halstead to a condition very similar to the latter variety of duct cancer. The growth con- sists of tubular spaces heavily lined with epithelium; it develops slowly, but frequently fungates through the skin, and presents as a localized pedunculated growth, which readily bleeds. 1 he axillary glands are usually free from infection, and the prognosis is good. The duration of cancer varies considerably in the different forms. The encephaloid type runs a rapid course, and will probably destroy the patient's hfe in six to twelve months. Duct cancer is very shghtly malignant, whilst atrophic scirrhus is similarly slow in growth, and in both death may be postponed for a considerable 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 opera- tions performed before the general adoption of the more exact and extensive measures which are now usualh' undertaken, and it is likely that they underestimate considerably the benefits derived from such interference. The Pathological Anatomy of cancer is discussed at p. 218. The Diagnosis of scirrhus from chronic interstitial mastitis and chronic abscess or cyst has been already considered (p. 939)- 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 character- istics to be noted. Non-malignant tumours are more elastic to 954 A MANUAL OF SURGERY the touch, more moveable, and usually quite circumscribed in out- line, 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 examination; a round- celled sarcoma closely resembles an acute cancer, although it is usually more circumscribed— at any rate, in the early stages. A fibrosarcoma may sometimes be mistaken for scirrhus, but it is more defined in outline, does not cause retraction of the nipple or dimphng of the skin, whilst lymphatic enlargement is not a constant accompaniment. A cysio-adenoma presents no difficulty in diag- nosis if the skin is entire, and the cysts prominent; but when ulceration has taken place, and a fungating bleechng mass protrudes, it is not unhke the later stage of an encephaloid cancer or fungating round-celled sarcoma. It can be distinguished, however, by the fact that a probe can sometimes be passed under the skin for some distance into the cavity of the cyst, whilst lymphatic enlargement is rare. For the diagnosis of scirrhus from a tense single cyst, see p. 941. Treatment. — This necessarily consists in the removal of the tumour by operation in all cases where there seems a reasonable chance of eradicating the disease. The only conditions that would contra- indicate operation are extensive adhesions to the thoracic walls, the juesence of visceral deposits, and extensive diffusion of a rapidly growing acute cancer in a young subject. Atrophic scirrhus is often left alone, on the 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. Disease of both breasts, although rendering the prognosis more grave, is, cceteris paribus, no hindrance, since both organs have been removed success- fully, even at one operation. Speaking generally, rapidly growing tumours in vigorous patients are very unfavourable cases to deal with, whilst slow growth of the tumour, and definite limitation of its outline, are favourable signs. In the old days, only the more prominent portion of the breast was removed with the tumour, and consequently recurrence was so extremely 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 evolution of the disease (for which we are mainly indebted to Heidenhain and Stiles), more extensive pro- ceedings 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 recurrence at the end of three years. It was suggested by Volkmann that any case which remains free from recurrence for three years may be claimed as a cure, but this is now generally considered too short a period, since the disease sometimes reappears at a much later date (even nine or ten yearsl. The breast is a much more extensive organ than was foimerly DISEASES OF THE BREAST 955 supposed, its lobules extending upwards nearly as high as the clavicle, outwards into the axilla, and for some distance downwards, so that removal merely of the prominent part of the gland may leave much behind, and thereby favour recurrence. Moreover, the deeper lymphatics pass into the fascia covering the pectoralis major, and so to the axilla;, hence, this structure should alwa\'s be taken away, as well as a thin layer of the muscular fibres, but the wiser course is to remove the whole of the sternal portion of the pectorahs major, lea\'1ng only the clavicular. Many surgeons also remove the pectoralis minor muscle; this procedure certainlv favours the axillary dissection, and does not seem to have any harmful influence on the subsequent movements of the arm. xAgain, lymphatics travel along the fibrous bands reaching from the breast tissue to the over- hing 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 h-mphatics converge to a plexus around it, and thence pass to the axilla by three or four main trunks. The axilla itself should be opened in every case, and entireh* cleared of its lymphatic contents, since deposits in the glands are often found on microscopic examination, where no chnical evidence of their presence had been pre\-iously noted. It is also important to remove the breast and axillary tissues in one piece, so as to avoid dix'ision of the lymphatics and" possible infection of the wound with their cancerous contents. Operation for Cancer. — The patient hes on the back, with the head directed towards the opposite side, and the arm raised to a little more than a right angle, so as to put the pectoralis on the stretch. An aseptic towel should be WTapped round the head, so as to keep the hair out of the way, and a similar sterilized towel may be placed below the chin on a cross-bar, to form a barrier between the anaesthetist with his apparatus and the field of operation. The axilla should be pre\4ously shaved, and the skin carefully purified. The incisions employed vary with the size and position of the tumour; the primary object is to remove the growth together wath the whole gland and all its accessible h-mphatic connections; the question of being able to close the wound subsequently is quite a secondary and minor consideration. x\s a rule, sufficiently* wide undercutting \^-ill allow very extensive wounds to be closed; but when this is impossible, skin-grafting can be adopted, and no lengthy convalescence need ensue. Fig. 455 suggests the tj-pes of incision that may ser^^e for the removal of tumours on the outer and inner sides of the breast respectiveh'. Slight modifications will suggest themselves when the growth is in other positions. ^^"hen the incisions have been made, they are deepened, but not directly inwards. The skin around is dissected up so that the subcutaneous connective tissue may be removed together with the breast over a wide area extending as high as the cla\icle above, down to the epigastric notch below, and behind the posterior border of the axilla on the outer side. The surface of the pectoralis major 956 A MANUAL OF SURGERY is then exposed throughout the whole length of the inner or upper incision, the connective tissue over it being turned downwards. The junction between the sternal and clavicular portions is defined, and opened up by finger and knife throughout its whole length. The insertion of the sternal portion is divided about an inch from the humerus, and then the finger is introduced under its origin from the sternum and costal cartilages, and this is severed by the knife close to the bone. Several perforating branches of the internal mammary will be divided in this procedure, and must be at once secured, so as to prevent their retraction through the intercostal spaces. The pectorahs minor comes into view, and is divided at its costal attach- ments and also close to the coracoid process. The breast and underlying tissues can now be drawn downwards ,jmM^ ■P^*^- 455- — Incisions for Removal of Cancerous Breast when the Tumour is Situated in the Upper and Outer, or in the Inner Segment Respectively. and outwards, thereby opening up the axilla freely; the next step consists in thoroughly clearing it. The main vessels are first defined below the lower border of the pectoralis minor close to the outer angle of the wound; a layer of fascia needs division in order to accomplish this. The dissection is then carried inwards along the vessels and nerves, which are freed from fat and glands both in front and behind, if necessar5^ Arterial and venous branches are best secured by ligature before division. If the glands are closely adherent to the vein, it is wise to excise a portion of it rather than to attempt to peel them off. The most careful search for glands must be made in the apex of the axilla, and in removing them every effort must be used not to rupture the glands by careless handling, as thereby dissemination of cancer cells may occur. DISEASES OF THE BREAST 957 The suj'gcon next proceeds to remove the fat and fascia from the serratus magnus on the inner side of the wound, care being taken to secure the lateral branches of the intercostal arteries as they are divided, and to protect the nerve of Bell. The subscapularis is then cleared, and possil)ly the subscapular vessels may need division, but the subscapular nerves must be spared. Not unfrequently there are many enlarged lymphatic glands in this part of the axilla. When this has been effected, but little more remains to be done except to free the breast, pectorals, and connective tissue from their external attachments, and this is quickly accomplished by a few sweeps of the knife. An enormous wound results, and during the later stages the exposed tissues must be protected as far as possible by covering them with warm steriHzed cloths. Bleeding-points are secured, the wound washed out with hot sterile salt solution, and preparations made for closing it. Surrounding parts may need to be extensively undermined, or even plastic proceedings carried out in order to bring forwards redundant skin from the side and back. As a general rule the wound can be more or less completely closed by the exercise of a little patience and ingenuity. Under no circumstances should the upper part of the wound be left open, as thereby the axillary contents would be exposed, and harmful cicatrices might form. Should any part be left open, it is probably wise to defer a grafting operation till later. Deep tension stitches are often useful, and the margins of the wound are approximated by ordinary catgut or silk sutures. Drainage is usually desirable, and the tube may be placed through an opening made for it in the posterior axillary wall. A large and efficient dressing is applied back and front to receive the sero-sangiiineous discharge, which is sure to be abundant. The arm is left at right angles to the side throughout the healing with the object of preventing the subsequent stifcess and limitation of movement, which was so marked formerly when the arm was bandaged to the side. The first dressing will be required in twent}^- four or forty-eight hours, and the drainage-tube may then be removed. Healing should be complete in from ten to twelve days. The immediate results of this operation are exceeding^ satisfac- tory, the mortality being under 5 per cent. The ultimate results necessarily vary with the period at which the operation is under- taken, with the extent and character of the disease, and with the thoroughness and skill of the operator. When the supraclavicular glands are enlarged, the operation must also include the supraclavicular fossa in its scope, as recommended by Halstead; 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 cancerous invasion will have already occurred. Without going quite so far as this, we would advise that wherever there is much axillary involvement, the supra- clavicular fossa should alwavs be cleared. The cervical incision is 958 A MANUAL OF SURGERY a curved one, extending along the posterior border of the stcrno- 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. Some surgeons have even proposed to divide the clavicle, but this seems to be a needless proceeding. The axillary and the supraclavicular wounds can easily be made continuous under the clavicle. Local recurrence after operation is always due to incomplete removal of the growth, or to infection of the wound during the operation. The surgeon must ever keep m mind that although in a healthy organism the implantation of cancerous material has apparently but little or no efiect, 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, in the other breast, or in the retrocostal connective tissue. The progress is often slow, but occasionally the disease spreads more rapidly than if no operation had been under- taken. To prevent the likelihood of this, exposure to X rays after the operation may advisably be adopted. Diffuse cancer of the skin en cuirasse is not suitable for operative treatment, but much may be done by exposure to the X rays (p. 56) or by radium. It has been suggested to treat lymphatic or solid oedema by intro- ducing subcutaneous strands of carefully sterilized silk from below upwards into the healthy tissues so as to act as artificial Ijmphatics. In some of the cases hitherto reported improvement has followed to a certain extent. Some years back Beatson of Glasgow proposed to treat inoperable cases by double oophorectomy and the administration of thj-roid extract. Many patients have been dealt with in this way, and the results gained thus far show that, whilst a few cases have been appar- ently cured, in a much larger number no effect was produced, but that in quite an appreciable proportion the disease seems to have been temporarily controlled (perhaps for j^ears), and the pain and discomfort very definitely diminished. The operation should of course only be undertaken in w^omen who have not yet reached the climacteric. Amputation of the Breast for non-malignant conditions is a very different operation to that described above. The incisions usually employed are crescentic and placed obliquely ; they need not include much more skin than that indicated by the breadth of the areola. The integument is dissected up from the glandular tissue on either side, and the organ freed from its attachments to the pectoral fascia; the axilla is frequentl}- not opened. CHAPTER XXXV. ABDOMINAL SURGERY. General Remarks on Abdominal Operations.— No branch of the sur<^ical art has grown so rapidly or attained such importance as that directed to the abdominal contents. Operations which formerly were advisably rare are now of everyday occurrence, and no surgeon hesitates to open the peritoneal ca\dty whenever it appears necessary, and even sometimes merely with the object of exploring the con- dition of its contents. Success is, however, entirely dependent on a minute and careful attention to details, which can only result from attentive observation and considerable experience. The peritoneum carefuUv treated is a good friend to the surgeon; it resents, however, rough handling or prolonged exposure, and serious inflammatory trouble may foUow slovenly work, jeopardizing the patient's hfe, or even, if he live, gi\dng rise to such disabilities and discomfort as mav impair his usefulness. In no department of operative surgery is rapid and yet minutely careful work so well repaid. The 'following are a few points which may prove helpful to those aspiring to success in this important branch of surgery : The patient should be prepared, when circumstances permit, by re°Tilating the diet and bowels for some days previously, and thoroughly cleansing the teeth and mouth, so that the intestinal canal may be as free from organisms as possible ; a course of internal antiseptics, such as salol, calomel, or /3-naphthol, may be advisable. During the prexious da\^ an effective purgative is given — e.g., I ounce of castor oil — and" an enema may be desirable in the morning to ensure that the lower gut is empty. The abdominal wall is shaved, as also the pubes, and purified beforehand in the usual way, special care being directed to the umbihcus, where dirt is very liable to lodge. No food should be allowed by mouth for three or four hours, and immediately before being placed on the table the bladder should be emptied, if need be, by catheter. If the proceedings are likely to be protracted, it is ad\'isable to give a rectal injection of warm saline solution, or of beef-tea and coffee, half an hour beforehand, and possiblv'a h\'podermic injection of strychnine (gr. ^^). The patient should be warmly wTapped up and protected from cold, no unnecessarv exposure being allowed. The operating room should be well warmed, and not below 70° F. ; a temperature of 959 96o A MANUAL OF SURGERY 80° F., though trying for the surgeon and his lielpers, is better lor the patient. Complete anaesthesia is desirable, so as to chminisli shock, but this should be obtained with as small a dose of anctsthetic as possible. Intraperitoneal operations are not painless, for although the visceral peritoneum is not acutely sensitive, yet the parietal layer is, as well as that included in the mesenteries, and any handling of these structures gives rise to pain and necessarily to increased shock, if the patient is conscious. If the patient is very collapsed before the operation, as in emergency work — e.g., perfora- tion of the stomach — it is often advisable to administer ether dis- solved in saline solution by the intravenous method. As a general rule the patient lies flat on the table, but if the operation involves the pelvic viscera, the Trendelenburg position is often adopted. In it the patient is placed with the head con- siderably below the rest of the body, which is more or less inverted (Fig. 456). The knees are bent over the end of the table, and help to keep the body in position. The head- piece of the table must be lowered, or the neck will be bent forwards into a posi- tion that impedes re- spiration. The arms must not be kept above the head, or musculo-spiral paraly- sis may follow; they are best placed behind the patient's back or close to the sides. This position must not be adopted when it is probable that the pelvis is occupied by a fluid inflammatory exudate, nor in conditions where obstruction is present, and the stomach is likely to be filled with offensive material which might gravitate into the mouth and suffocate the patient. Antiseptics are avoided as far as possible in intraperitoneal operations; after efficient sterilization of the hands of the surgeon and his assistants and of the skin of the patient, nothing is employed in the shape of lotion except sterilized salt solution. Instruments are boiled previously and counted. Swabs are best done up in packets of a dozen, wrapped in gauze; it is thus easy to keep account of the number employed. Gauze strips for packing, ab- dominal cloths, etc., are dealt with in the same way; a careful lecord of the number employed must be made. If irrigation of the abdomen is required, warm salt solution is the best lotion to use for the purpose Fig. 456.- -Trendelenburg's Position for Pelvic Operations. ABDOMINAL SURGERY 961 Parietal Incision. — In planning the incision for any abdominal operation, throe desiderata have to be kept in view: (i.) Suitable access should be provided to the part to be explored ; naturally the middle line gives the best approach in the majority of cases, where a general exploration is desirable, and in many other conditions it is most useful. But when dealing with such structures as the appendix or gall-bladder, an incision placed laterally is usually more convenient. It is always well to remember that incisions should not be placed too near to the bony or cartilaginous boundaries of the abdominal wall, (ii.) It must be so placed as to ensure an effective blood-supply, and thereby avoid as far as possible the risk of defective union or a post-operative hernia. Naturally the middle line from this point of view is not always desirable, and the linea semi-lunaris is even worse. Particularly is this the case when the linea alba has been stretched, and the recti muscles separated one from the other. Perhaps the best incisions from this point of view are those which pass through muscular fibres, sphtting and separat- ing them, but not dividing them. MacBurney's incision for the removal of a quiescent appendix (p. 1053) is of this nature; it gives a sufficient approach when there are no adhesions, and when the appendix is not displaced. Should these conditions not be present, or if the patient is very stout, it will prove most inconvenient ; a similar incision may also be used in ihac colostomy. Lennander's trap-door incision is somewhat similar in character. It consists m opening the sheath of the rectus in front, displacing the muscle in or out, and then making the incision in the posterior layer of the sheath, and through the peritoneum, so as not to correspond with that in front, (iii.) A point to which considerable attention has been given in recent years is the nerve-supply of the abdominal wall. As far as possible the incisions should be planned so as to avoid division of the motor nerves, especially those going to the rectus abdominis, inasmuch as paralysis of this muscle may result in considerable discomfort, and loss of tone of the abdominal wall may follow. From this point of view an incision through the hnea semi-lunaris is one of the worst that could be devised. To avoid trouble of this type, various suggestions have been made which will be noted in the descriptions of different operations mentioned in this chapter. Some surgeons have recommended a transverse incision of the abdominal wall, especiallv in deaHng with pelvic lesions; the chief difficulty Hes in gaining effective union of the divided ends of the rectus muscles. "To prevent their retraction the fibres must be carefuUv stitched with mattress sutures to the anterior wall of the sheath before being divided; on the whole this method of approach has not commended itself to the majority of surgeons, and it is not much employed. As far as" possible the muscles and aponeuroses should always be cleanly divided, and it is wise to see that bleeding is stopped before opening the peritoneum ; this membrane can usually be picked 962 A MANUAL OF SURGERY up by dissecting forceps, and opened with scissors or a knife; air rushes into the cavity, and it is easy to secure the margins with Spencer-Wells, or other suitable forceps. Holding these well up, the incision can be prolonged up or down as far as may be considered necessary. The intestines must be carefully guarded during the intraperi- toneal portion of the operation, as if they are unduly exposed to the air, the endothelial lining is quickly shed, and adhesions may form subsequently, whilst bacterial invasion from the gut is favoured. If they have to be withdrawn from the abdomen, they should be wrapped in cloths wrung out of warm salt solution, and it is the assistant's duty either to replace these from time to time by warm cloths, or better to keep them moist and warm by pouring fresh salt solution over them; no unnecessary handling of intestine is per- mitted. If any infective focus is to be opened, or the intestine incised, the surrounding parts must be carefully protected from infection by ' walhng off ' the area of operation ; this is effected by surrounding it with abdominal cloths of suitable size and material, or strips of sterilized white gauze, wrung out of warm salt solution, or by placing them in directions where pus or other fluid might gravitate. A record of these must be kept, and it is wise not to cut any of them into smaller pieces. It is undesirable to use dry gauze for this purpose, as it is likely to stick to the intestine, and its removal may disturb the endothelial covering. Closure of the Wound. — A careful toilette of the peritoneum must be undertaken before the abdomen is closed. All bleeding is stopped and blood-clot removed ; swabs are counted, and, if thought neces- sary, the site of operation cleansed with steriHzed salt solution at a temperature of about 105° F. Many different methods of closing the parietal incision have been adopted, but perhaps the best consists in first securing the peritoneum by a continuous catgut or silk stitch; then the muscular coats are approximated by deep inter- rupted stitches, either of purified silk or of catgut, which remain buried; and, finally, the skin is united by means of a continuous suture of catgut or silk, which is subsequently removed. In some parts it is difficult to secure the peritoneum separately, and then it is well to include everything except the skin by deep interrupted sutures, and some surgeons even include the skin in the grasp of these deep stitches. Drainage is not usually called for in abdominal operations. If the surgeon is careful in his manipulations, and avoids measures which are liable to lead to subsequent oozing, the peritoneum may be closed with safety. When adhesions likely to bleed have been divided, or raw surfaces left such as occur after enucleating a parovarian cyst from the broad ligament, some means should be provided whereby any considerable effusion of fluid can escape, and this can often be best effected by the use of a rubber drainage- tube or a Keith's glass-tube, which can be removed in twenty-four hours. Into the latter it is perhaps as well to introduce a strip of ABDOMINAL SURGERY 963 aseptic gauze, which will act as a lamp-wick, and along which, b}' capillary action, the effusion finds its way into the general dressing placed over the wound. On the other hand, when an infected focus has been opened and needs to be drained — e.g., an acute appendix abscess — surrounding parts must be protected from the spread of infection, and this is best accomplished by the use of a rubber drainage- tube, around which sterile gauze is packed in such a way as to induce the formation of protective adhesions. After - Treatment. — x\fter the completion of the opera- tion, the patient is replaced in bed with the head low; but this position need not be main- tained for any length of time, and after a gastro-enteros- tomy, or in cases of diffuse peritonitis, it is better to place him in the Fowler position (p. 97G) at once. If there is much shock, hot-water bottles are placed in the bed, and a rectal injection of hot coffee (4 or 5 ounces) is desirable. The continuous administra- tion of hot saline solution per rectum is also inaugurated at once; this is best under- taken by emplo5dng an ap- paratus similar to that repre- sented in Fig. 457. The fluid is kept at a temperature of 105° to 110° F. in a thermos flask, and allowed to escape through a suitable dripper into a tube which passes 6 inches up the rectum ; the fluid is introduced into the rectum very slowly, so that it takes perhaps an hour and a half to administer a pint. This is generally tolerated very well, and may be continued for a day or two. It is of value not only to relieve shock, but also to make good the results of haemorrhage, to allay thirst, and to assist in ridding the body of harmful toxic products by increasing diuresis and diaphoresis . Fig. 457. — Apparatus for Saline Infusion. The flask to hold the fluid is supported by a bar fixed to the bedpost, and the rate of flow is regulated by the tap placed just below the flask and above the glass dripper. 964 A MANUAL OF SURGERY Sedatives may be employed if the patient is restless or irritable, and a hypodermic of morphia (gr. J) or hydrochloride of heroin (gr. -^) may be administered. Where there is no necessity to steady the bowel in order to gain adhesions, heroin is the better drug to employ, since its paralyzing effect on the secretions is so much less ; but in some cases, where it is desirable to localize an infection, morphia is more suitable. At the same time it is important to use as little sedative as possible, and in not a few cases of simple operation, such as the removal of an appendix, it will sufllce to introduce into the rectum, immediately after the operation, 30 grains of bromide of potassium and 15 or 20 grains of aspirin. The feeding of abdominal cases has undergone a certain amount of change during recent years. There is no necessity to observe the prolonged abstention from food that used to be practised. Natur- ally, after the anaesthetic nothing is given by mouth for some hours, but if the patient does not complain of sickness there is no reason why fluids should not be administered after a short interval, and if the patient feels inclined to take his ordinary diet next day, this may be quite well permitted; in fact, the tendency of the modern surgeon is rather to look on a simple abdominal operation as merely an incident, and to interfere with normal nutrition as little as possible. In the more serious cases, especially with nervous patients where vomiting is hkely to ensue, greater care must be taken. No food is permitted to enter the stomach for the day of operation, and then, when post-operative vomiting comes to an end, hot water in teaspoonful doses should alone be administered. Towards the end of the first twenty-four hours a little tea or albumin water, or milk and water, may be given, and gradually the diet may be increased. Special directions will be found for the feeding of particular cases, such as gastro-enterostomy, where the continuity of the intestinal canal has been interfered with. Not uncommonly there is a good deal of discomfort and abdominal distension for the first day or two. This is usually due to a collec- tion of flatus, which the patient is unable to expel. Relief is best obtained by the administration of a turpentine enema (i ounce of turpentine to i pint of soap and water), which may need to be repeated. If the condition persists, and is accompanied by flatu- lence and vomiting {perilonism), suggesting the possible onset of peritonitis, the administration of a saline purgative — e.g., 20 grains of sulphate of soda every half hour — or five doses of i grain each of calomel every hour, may stop the process by re-establishing peristal- sis, removing bacteria and their products, and lessening the vascular tension. A hypodermic injection of strychnine or of eserine may also help by its direct stimulating action on the muscular coat of the intestine. Enemata containing castor oil (jii.) and olive oil (siv.), as well as turpentine (gi.), are also sometimes employed. The Treatment of the Wound requires no special attention. The stitches are generally removed at the end of eight or ten days, and the scar may then be supported by a collodion dressing or suitable ABDOMINAL SURGERY 965 strapping. External support in the form of a belt is sometimes thought desirable, and to be effective must be sufficiently extensive. Where there has been suppuration and the wound has healed by granulation, it is often desirable to keep the parts together by the use of strapping for some months, so as to prevent the abdominal muscles from dragging upon the scar and separating the united segments of the abdominal wall. For this purpose an unirritating zinc-oxide-rubber strapping is obtainable. Treatment of this type is much more effective than the use of a belt, and should particu- larly be employed after the draining of abscesses, and in appendicitis where the muscles have had to be divided. Stitch Suppuration is a troublesome and irritating sequela of abdominal operations. It may be due to faulty technique, but occurs quite apart from this. The most careful steriHzation of suture material will not always prevent its occurrence, and then it must be attributed either to tying the suture too tightly and strangling the tissue within its grasp, or to its becoming drawn too tight owing to post-operative abdominal distension, and to auto- infection of this strangled tissue, or of some collection of blood around it. Not a few cases have also been attributed to the employment of sutures taken directly out of spirit, which acted thereby as a caustic. All suture material should be carefully washed in sterilized salt solution or weak antiseptic lotion before using it for this purpose. The trouble may start early or late, and its occurrence is not unfrequently indicated by a shght but per- sistent rise of temperature (say, "to 100° every night), associated, perhaps, with an increased rate of pulse. The external wound may apparently heal perfectly, and then ten or twelve days after the operation the cicatrix yields, and a quantity of pus may escape. Under these circumstances efficient drainage should be arranged, and if need be, the exposed stitches must be removed. Of course, this process weakens the abdominal wall, and extra precautions must be taken to prevent the formation of a ventral hernia. Intestinal Sutures. — The interior of the bowel is occupied by . material which, as long as it remains in its proper place, is innocuous enough; but should it find its way into the peritoneal cavity, an acute and often 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. It is also essential that on its peritoneal aspect the Hne of union should present nothing but serous membrane, as otherwise adhesions are likely to form, and the comfortable action of the bowel may be subsequently impaired. Special forms of stitches have therefore been adopted, the more important of which are described below. Lemhert's Suture, originally proposed at the end of the eighteenth century, has for its object the bringing of surfaces of peritoneum together without encroaching on the mucous membrane ; any stitch which involves the whole thickness of the wall is liable to be followed 966 A MANUAL OF SURGERY by leakage of the intestinal contents, and possibly by peritonitis. The needle is passed at right angles to the axis of the wound through a small fold of the serous and muscular coats, going down to the submucosa; each fold is placed about jV inch from the margin of the incision (Fig. 458). On drawing up and tightening the stitch, the margins of the wound are tucked in (Fig. 459), and only the serous coats brought into apposition. A series of similar stitches ^■/y Fig. 459. — Lembert's Suture SEEN IN Section, to show Character of Approxima- tion. I., Suture; a, serosa; b, mus- cularis; c, mucosa. Fig. 458. — ^Lembert's Suture as applied for A Longitudinal Wound of the Bowel. The stitches are carried well beyond the ex- tremities of the incision, so as to obliterate the groove always caused by this method of suturing. are inserted along the whole extent of the wound, numbering about ten or twelve to the inch, or it may be carried on as a continuous stitch. 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 Fig. 460. — Czerny-Lembert Fig. 461. — Halstead's^Mattress Suture. Suture. I., Stitch securing divided mucous membrane; 11., ordinary Lembert suture, for the serous coats; a, serosa; b, muscularis; c, mucosa. utilized, but it may be introduced circularly around the opening like a purse-string, and by tightening it the margins of the aperture are turned in and buried (Fig. 499). The Czerny-Lembert Suture is very similar in its nature, but con- sists of two rows : the first has for its object the closure of the wound in the mucous membrane (Fig. 460, L), and in a longitudinal wound this may be of the continuous type ; the second row consists of the ordinary Lembert stitches, continued or interrupted according to the requirements of the case (Fig. 460, IL). By this means the ABDOMINAL SURGERY 967 Fig. 462. — ^Wolfler's Suture. , Stitch through serous and mus- cular coat applied and tied from within; II., stitch uniting divided mucous membrane over the former, so as to cover it in; a, se- rosa; b, muscularis; c, mucosa. knots of the first series of sutures are covered over and buried by the second row. When carefully introduced, these stitches not only serve to approximate the divided walls of the intestine, but also are valuable haemostatic agents, especially if inserted continuously. Ha I stead's Mattress Suture (Fig. 461) is a very useful one, and constantly utilized. It consists practically of a double Lembert, a loop being thus formed at one end, whilst the knot is tied at the other. It is introduced with ex- actly the same precautions as the original Lembert. Occasionally it happens that two segments of bowel have to be stitched together from inside, since the surgeon cannot reach the outer coats owing to this portion being fixed. Thus, in an exploratory gastrotomy it may be necessary to stitch up the posterior wall of the stomach after having opened it from the front. The stitches must then be inserted by what is known as Wolfler's Method (Fig. 462). They are 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 viscus. The mucous membrane is then secured by a second row of stitches (II.), so as to cover over 1:he first series of knots. In many forms of intes- tinal anastomosis this plan has also to be em- ployed; as soon as possi- ble, however, one changes to the Czerny-Lembert Fig. 463. — Cushing's Right-Angled Suture j^pfV,Q(4 FOR Uniting the Sero-Muscular Coats : , ^ • 7 ^ t 7 j OF THE Stomach or Intestine. Lushing s Rtght- Angled For the sake of clearness the preliminary row j: 1 ° ' 1 -^' j- of stitches through the mucous membrane USeiUl one Wlien SUIiaces is omitted in this diagram. of some extent have to be approximated by a con- tinuous stitch. The suture is introduced at one end of the incision and tied according to the usual Lembert method, and then it is carried on as a continuous Lembert suture, except that the needle is intro- duced parallel to the margins of the wound and at a distance of about i inch from it, instead of at right angles to it. The edges are thereby tucked in very neatly. Of course the mucous membrane is first dealt with separately by some form of continuous suture. It may be employed very advantageously in gastro- enterostomy or any similar procedure. g6S A MANUAL OF SURGERY Injuries of the Abdominal Wall. These may be divided into three main classes — contusions, non- penetrating and penetrating wounds; but, of course, the most important point about them is as to whether or not visceral com- plications are present. Simple Contusions of the abdominal parieties differ but little from those of any other region of the body. Any form of lesion, from a slight bruise to an extensive muscular laceration, may be included in this category. The rectus is the muscle most often involved, and its laceration may result not only from injury, but also as a conse- quence of sudden and forcible contractions, e.g., in tetanus. Blood is extravasated between or under the muscles, and a well-marked haematoma may follow. In connection with the rectus the haemor- rhage may be limited by the linse transversse if it only involves the anterior aspect, but may diffuse itself widely through the sheath if the back of the muscle is torn. All abdominal ha^matomata are very liable to suppurate, the abscess either pointing locally or burrowing widely between the muscular planes, and coming to the surface at some weak spot, e.g., Petit's triangle or the external abdominal ring. The pus is usually redolent of the B. coli, suggesting that the organism found its way into the extravasated blood from some damaged coil of intestine in the neighbourhood. Occa- sionally the parietal peritoneum is torn, causing shock and intra- peritoneal extravasation of blood. In almost all cases of abdominal contusion shock is an important early symptom, but in the absence of visceral lesions it is neither severe nor prolonged. Treatment consists in keeping the patient in bed until the tender- ness and pain have disappeared. Shock is dealt with in the usual way ; and fomentations or a firm compress of dry hot wool will give much comforting support. Rupture of the rectus muscles necessi- tates the adoption of the sitting position, with the knees flexed over pillows: at a later date support, as by strapping or a well-fitting abdominal belt, will be required. Non-Penetrating Wounds of the Abdominal Wall have no special significance, and if uncomplicated by visceral lesions are treated on general principles. If the epigastric artery is divided, extensive extravasation is likely to ensue; the wound must then be enlarged, and the bleeding points secured. If the abdominal muscles are widely divided, steps should be taken, after thorough purification, to draw together the severed muscular or aponeurotic fibres by deep stitches, so as 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 haemorrhage, 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 ABDOMINAL SURGERY 969 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, causing them to be more or less con- gested or even strangled. Necessarily, in all cases the great danger is that of diffuse septic peritonitis, caused either by rupture of the intestine or by infection from without. Treatment. — The external wound is carefully cleansed, whilst protruding viscera are similarly purified. If omentum has escaped, it is wise to ligature and remove it, whether it is injured or not. Intestine should be carefully washed with warm saline solution and replaced; if slightly bruised, it may be returned, but the external wound should not be entirely closed, and a drainage-tube or gauze wick is inserted, so that if bacillary invasion or faecal extravasation occurs subsequently a ready exit is provided. Small incisions or punctures must be infolded and sutured, but when small intestine is seriously damaged, enterectomy should be undertaken if the patient's general condition is sufficiently good ; otherwise it must be fixed to the abdominal wall, and a temporary artificial anus pro- vided. With the large intestine, this latter course is required more often, and especially in cases where the bowel is loaded with faeces ; the gut must then be fixed in the wound as in colostomy, and the defect dealt with at a subsequent period. In cases where it is not certain whether the peritoneum has been implicated, the surgeon should always enlarge the wound so as to make sure, and if the serous membrane has been involved, he should carry his investigations still further, and ascertain, if possible, whether any damage has been done to the viscera. The external wound must (with the exception mentioned above) be carefully closed with sutures, so as to minimize the risk of a subsequent ventral hernia. Visceral Complications are hkely to be associated with any injury to the abdominal wall, and may transform it into a lesion of the gravest import. The habihty to visceral injury varies with the character of the violence, and with the condition of the abdominal wall and of the subjacent viscera. If the blow is shght, the effects are probably not serious, and the patient merely suffers from a localized contusion with some amount of shock. If the blow is expected, and the muscles are rigid, but Httle harm may follow, even when the violence is great; but when the abdominal wall is relaxed and the blow unexpected, a shght injury may do much mischief. Hollow viscera, such as the stomach, intestine, or bladder, may be torn, and when distended they are more liable to such an accident. Sohd viscera, such as the liver, spleen, or kidnej^s, may be bruised or torn, and grave haemorrhage may result theVefrom; a soft fatty condition of the organs, especially of the liver, may predispose to such a lesion. Displacement of organs may some- times occur, and it must not be forgotten that any sudden sharp concussion, especially if directed to the epigastrium, is hable to be followed by severe shock from irritation of the subjacent solar 970 A MANUAL OF SURGERY plexus, and life itself may be destroyed in this way by syncope without the appearance of an evident lesion. The omenta, mesen- teries, and peritoneal ligaments may also be torn, and give rise immediately to haemorrhage, or subsequently to the formation of apertures or bands, which may determine obstructive phenomena at a later date. Thus, a blow in the epigastrium was followed by detachment of the round ligament of the liver from the falciform ligament, constituting a band which compressed the transverse colon. The clinical history of these injuries will be described under the various organs, and only a few general statements need be made here. It is obvious that a serious responsibility rests upon the medical attendant in any case of abdominal injury, and that the gravest results may follow a mistaken conclusion as to the nature of the lesion, or a hesitant policy in undertaking operation. In a large proportion of cases abdominal injuries, even including rupture of intestine, are amenable to treatment by operation, if only it is performed sufficiently earl\-; if, however, it is delayed until the gut is paralyzed and peritonitis well established, death is almost certain to ensue whether the abdomen is opened or not. Unfortunately, no absolute rules can be laid down as to when opera- tion is necessary, but the surgeon should remember that exploration in a doubtful case will probably do far less harm than by waiting until the diagnosis is made certain by an outbreak of diffuse in- flammation, providing always that the patient is not so profoundly collapsed as to contra-indicate all interference. Cases of serious abdominal injury group themselves into three sets : (i) Where, in addition to a localized lesion of the parietes, there is severe shock due to contusion of viscera, but with no justification for laparotomy ; (2) where there is serious intraperitoneal haemorrhage, as from a ruptured liver or spleen, or a tear of the mesentery ; and (3) where a hollow viscus is opened, and peritonitis is at once lighted up. Shock is almost always w^ell marked in abdominal lesions, but unless there is a serious wound of some viscus, it usually passes off in less than twenty-four hours if the patient is left quietly in bed. Jntraperito7ieal hcemorrhage causes various symptoms according to its amount and site of origin; in addition to the initial shock, the general signs characteristic of this condition show themselves, viz., pallor, restlessness, ' air-hunger,' and possibly the large-waved hemorrhagic pulse. Dulness may be noted in one or both flanks, according to the situation of the lesion, being influenced by the attachment of the mesentery; thus blood from the liver may gravi- tate into and for a time be limited to the right lumbar region and ihac fossa without reaching the pelvic cavity ; blood from the spleen will pass freely down into the pelvis along the left side of the mesentery, producing dulness in the left loin and not in the right. It must be remembered, however, that a large quantity of blood may escape into the peritoneal cavity without the production of any recognisable area of dulness; it is then lodged under the costal arch, or amongst the intestines, or in the pelvis. When the bleeding is ABDOMINAL SURGERY 971 less severe, the patient complains of a severe tearing pain, becomes pallid and anjemic, but may recover, and the blood be absorbed; not unfrcquently the temperature runs up after the initial shock has passed, and remains up for some days. The onset of peritonitis is indicated by persistence of the collapse, and vomiting or hiccough, whilst the abdomen becomes distended, its wall is held rigidly steady, and the breathing becomes thoracic; probably some fixed spot of maximum tenderness will be noted, especially when the intestine is injured. Treatment. — The patient having been put to bed, and the initial shock combated in the usual way, a most careful examination of the patient and his abdomen is instituted. Conditions which indicate immediate operation are: {a) the signs of intraperitoneal hgemor- rhage; (6) blood-stained vomiting, indicating a rupture of the stomach; (c) a fixed and rigid abdominal wall coming on quickly after an injury, with severe pain and locahzed tenderness, suggesting a rupture of the intestine ; and [d] the phenomena due to a ruptured bladder. Under such circumstances, no delay is justifiable, and, even if severe shock is present, operation should be commenced, unless death is evidently imminent. A large intravenous injection of hot saHne solution will usually rally the patient sufficiently to warrant the surgeon in proceeding, or better still, ether may be administered by the intravenous method. If, however, well- marked shock is present, with perhaps localized pain, but with no absolute e\ddence of visceral lesions, expectant treatment should be adopted. The patient is kept warm in bed; perhaps a little opium is administered to allay pain and restlessness and to check peristal- sis, but as httle as possible should be given, since symptoms are so completely masked thereby. If there is any vomiting, rectal ali- mentation should be employed after the lower bowel has been washed out. If the manifestations of intraperitoneal haemorrhage subse- quently make themselves e\adent, or if at the end of not more than twent^'-four hours the patient is still, more or less, in a condition of collapse, and especially if he complains of a fixed tender spot with a rigidly contracted abdominal wall over it, or if vomiting or hiccough has supervened, then operation can still be undertaken with some prospect of success. There are but few other conditions of the abdominal wall which require notice. The rectus muscle may be torn as a result of injury or of tetanic comnilsions, 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 hys- terical females, and disappearing under an anaesthetic. Aiieetions of the "Dmbilicus. The various forms of umbilical hernia are described elsewhere. Inflammation and Ulceration, perhaps running on to eczema, may arise from want of cleanliness after separation of the cord. Tetanus 972 A MANUAL OF SURGERY neonatorum probably owes its origin to this source, as also the erysipelas of infants, both of which diseases are exceedingly fatal, whilst the latter is often accompanied by sloughing of the neigh- bouring abdominal parietes. The eczcmatous condition merely requires cleanliness, and the application cither of an antiseptic dusting-powder or of some simple ointment. In adult life inflam- mation is occasionally seen as a result of the accumulation of dirt in the umbilical fossa; this accumulates at times to such an extent as to constitute a calculus, which gives rise to suppuration and ulceration. Occasionally a Polypoid 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 consist of a number of tubular glands held together by connective tissue. All that is needed is to ligature the base and cut it away. Warts and Nsevi are also found here, but have no special features. Cancer of the umbilicus may be primary, occurring either as a squamous epithelioma, starting in the skin as a result of prolonged irritation, or as a columnar carcinoma, arising in some foetal relic. More frequently it is secondary to some deep abdominal focus, such as cancer of the stomach or ovary. Umbilical FistiUee not unfrequently occur, and may be congenital or acquired. Three varieties are described: {a) A F cecal Fistula of congenital origin arises from non-closure of the vitello-intestinal duct, and opens into the intestine either directly, or by means of a passage of greater or less length, which corresponds to Meckel's diverticulum, and is connected with the lower part of the ileum. Sometimes this passage is closed at the intestinal end, and then only discharges mucus. Acquired cases are usually due to perforation of the bowel following strangulation of an umbilical hernia, or to tuberculous peritonitis. {b) A Congenital Urinary Fistula is due to non-closure of the urachus; occasionally merely a sinus persists, leading towards the bladder, but not opening into it. It may be dealt with by excision of the mucous membrane, its destruction by the galvano-cautery, or by freshening the edges and subsequent sutiire. (c) A Biliary Fistula sometimes forms at the umbilicus, resulting from an abscess connected with the gall-bladder. Affections of the Peritoneum. Peritonitis arises from many different conditions and presents many diverse manifestations. It may be acute or chronic in its course, localized or diffuse in its distribution, and protective or rapidly destructive in its results. .etiology. — Peritonitis is almost invariably due to the action of micro-organisms, and the symptoms largely depend on the toxaemia determined thereby. The bacteria light up an inflammatory re- action characterized by effusion of varying type; in the mildest ABDOMINAL SURGERY 973 forms it is usually abundant and localized, in the severer types it is generalized, and in the worst cases death in ay ensue from toxtemia before there lias been time for the development of_^marked anatomical changes. 1. Infection may start from any part of the intestinal canal or its adnexa, included in the abdomen, from stomach to rectum. It may be due to traumatic or pathological rupture or perforation, to the extension outwards of ulcers, to the impaction of foreign bodies, or the damaging influence of interference with the blood-supply, as in strangulation, volvulus, etc. The vermiform appendix is the com- monest site of onset of this group of cases. The Streptococcus pyogenes and B. coli are the organisms most frequently present, but some of the other inhabitants of the intestine, especially those'that are anaerobic, are occasionally causative. On the whole the gastric contents are less noxious than those of the intestine, and the fluid contents of the small gut are more hable to be diffused, and therefore do more harm than the more soHd fasces in the large. 2. A somewhat similar type of origin causes puerperal peritonitis, the organisms (usuaUy streptococci, but of any pyogenic form) extending from the uterus through the lymphatics of the broad ligament, etc., to the peritoneum; it is therefore possible for the mischief to limit itself to the pelvic viscera. 3. Infection may occur from without, as in perforating wounds, operations, etc., any of the ordinary pyogenic organisms being responsible, but especially the streptococcus. The hkelihood of infection depends largely on the peritoneum remaining unbraised; rough handling and prolonged exposure are only too likely to destroy the surface endothelium and diminish its resisting powers, whilst the same conditions check the power of absorbing fluids, and hence permit of bacterial growth. 4. Peritonitis may be due to the gonococcus, and then has usually spread up the Fallopian tube (p. 982) ; to the pneumococcus, probably as a blood infection, or secondary to pneumonia or pleurisy, the bacteria travelhng through the lymphatics of the diaphragm (p. 982) ; and possibly to the organism of acute rheumatism, then, perhaps, starting in the appendix. 5. The B. tuberculosis is responsible for the development of a chronic tuberculous peritonitis. 6. Simple chronic peritonitis is of a protective character, and arises when any irritative lesion of a viscus slowly approaches the peritoneal surface, which becomes thickened in consequence. Ad- hesions of various types may result from this reaction, and grave developments (obstruction, strangulation, etc.) may follow at a later date. 7. A group of cases occurs in which the causative lesion is mechanical or chemical in the first place — e.g., extravasation of bile from a ruptured gall-bladder, or the irritation produced by torsion of a wandering spleen, of an ovarian cyst, or even of the omentum. Severe reaction follows such a lesion, but it is possible that the focus 974 A MANUAL OF SURGERY may be shut oft from the general cavity by plastic adhesions, and be thereby encapsuled or absorbed; or the inflammation may extend to neighbouring coils of intestine, and when once these become paralyzed bacterial invasion is almost certain to follow, and septic peritonitis to ensue. It is interesting to note that a localized immunity can be developed in the peritoneal cavity of animals by injecting gradually increasing doses of toxic material; it is probable that a similar condition obtains in man, and this explains why the sites of old peritonitic trouble are often favourable for operations, an attack of generalized inflamma- tion being unusual. Varieties. — From a purely clinical standpoint, peritonitis may be discussed under two main headings^ — the acute and the chronic. The acute is again divided into the diffuse and localized, and the chronic into the simple and the tuberculous. I. Acute Diffuse Peritonitis results from infection of the peritoneal cavity with a large dose of infective material (as by rupture of the stomach or intestine), or by the introduction of a small dose of virulent organisms when the resisting powers are low. Pathological Anatomy. — The peritoneal surface becomes con- gested and a little sticky, and its shiny appearance is lost as a result of the proliferation of the endothelial cells and a commencing oedema of the subserous connective tissues; this change is most advanced in the neighbourhood of the site of infection, but rapidly spreads, and in the gravest forms of peritoneal toxaemia, where death takes place under twenty-four hours, there is but little other evidence of the disease. In the great majority of cases, however, effusion occurs; sometimes the fibrinous element is most marked, the intestines being matted together, and the fibrin thickest along the lines of contact of adjacent coils; sometimes there is an abundant serous exudation, but more frequently it is sero-purulent or consists simply of pus, which may gravitate to the loins and pelvis, or travel upwards under the diaphragm, or be shut up in pockets by the development of adhesions. The effusion is intensely infective, and the surgeon should always protect his hands by rubber gloves, since any wounds caused during operation or in the post-mortem examination are likely to be followed b}^ severe cellulitis or even septicemia. Gas may be present, resulting either from the laying- open of an air-containing viscus, or from the presence of a gas- producing organism. The intestinal walls become paralyzed, as a direct result of the toxins upon the contained nervous plexuses, and in consequence the contents of the gut stagnate and undergo decomposition. The omentum becomes congested and infiltrated with eftusion, or even pus; it may occasionally, however, form a barrier across the abdomen, shutting off the lower from the upper part, and thus limit- ing the mischief to one or other section. The toxins developed in the exudate are absorbed by the peri- toneum, and whilst causing a generalized toxaemia of varying ABDOMINAL SURGERY 975 severity, they may also determine a well-marked subperitoneal oedema. The rapidity of absorption is very considerable, especially from the under surface of the diaphragm, where the lymphatics are practically continuous with the peritoneal cavity, and quickly carry toxins and bacteria to the mediastinal glands. The upper half of the abdomen is therefore a less favourable site for peritonitic trouble than the lower, and all available means, such as position, drainage, etc., must be employed to limit or prevent the extension of the trouble in this direction. Symptoms. — The onset varies somewhat with the cause of the affection; but when due to traumatic infection from without, the symptoms usually commence with abdominal pain and distension, together with flatulence and vomiting. The pain may be localized at first to some particular region, or is referred to the umbilicus ; soon, how^ever, it 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 the knees drawn up, partly to relax the abdominal muscles, partly to prevent the bedclothes touching the body. The abdomen is distended, hard, and extremely tender; it is at first generally tympanitic, but later on, if effusion should become marked, dulness may be noted in the flanks, although this is not a common feature. The pulse is quick, hard, and wiry in the early stages, though later it becomes weak, rapid, and compressible. The respirations are quick, shallow, and thoracic in character. The temperature, perhaps raised at first as a result of the causative lesion, sometimes becomes 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, but later on the^^ may be mixed with bile, or with the decomposing contents of the upper coils of intestine. Though very constant and troublesome, it is much less distressing than that which arises from intestinal obstruc- tion, and, owing to the pain induced by any sudden contraction of the abdominal muscles, the patient ejects the vomit with but little force. Constipation and the absolute arrest of flatus are almost always present in peritonitis, owing to the cessation of peristalsis induced by the inflammation, and hence meteorism is a marked symptom. As the case progresses, the patient's strength rapidly diminishes, his face becomes pinched and drawn {fades Hippocrafica) , the extremities are cold, the temperature is usually subnormal, and death results from collapse and toxaemia. When due to sudden perforation of the bowel, the onset of the symptoms is associated with profound shock, and the course is very rapid if the opening is large, and the intestinal contents early extra - vasated. Vomiting, too, is usually more marked than when due to other causes. If, however, the perforation is small, the immediate shock is less, and the symptoms progress more graduall}'. As already mentioned, there are certain grave cases in which the general toxaemia is the most marked phenomenon, and these may 976 A MANUAL OF SURGERY succumb from exhaustion in from twelve to twenty-four hours. The majority of cases, however, last for three or four days. Recovery is heralded in by a diminution or cessation of the vomiting and the passage of flatus, whilst the pulse-rate falls, and the local symptoms gradually clear up. . Treatment— In the early stages, if the diagnosis is m doubt, or the desnability of operation is in question, the patient is kept Fig. 464. Fig. 465. Figs. 464 and 465. — Diagrams to Represent the Value of Fowler's Position in the Treatment of Inflammatory Affections within the Abdomen. In Fig. 464 the patient is horizontal, and it is obvious that an inflamed appen- dix lying over the brim of the pelvis will cause effusion, which drains in two directions: upwards towards the liver (shaded dark) and diaphragm, and downwards to the pelvis. In Fig. 465 the body is in Fowler's posi- tion, and the resulting effusion will collect in the pelvis. quietly in bed, and preferably in what is known as Fowler's position (Fig. 465) — i.e., with the head and trunk raised from the horizontal plane about 30° or 40°, so as to determine the flow of fluid exudate down towards the pelvis rather than backwards into the kidney ABDOMINAL SURGERY 977 pouches, whence it may spread up to the dangerous subdiaphrag- matic area. No food is administered by the mouth, and no purga- tive given ; the lower bowel may be emptied by enema, and subse- quently saline injections administered to relieve thirst. Morphia and opium are used with the utmost caution as long as the diagnosis is uncertain, for fear of masking symptoms. By determining a cessation of vomiting and a false sense of comfort, unjustified hopes may be encouraged, and delay in operation result ; at the same time they may be useful in localizing the trouble and allowing adhesions to form. Whilst the patient is being prepared for operation and the necessary arrangements are being made, a moderate dose of morphia may save him much suffering and help to conserve his powers. The actual scope and particular features of the operation vary naturally with the many causes that may have been operative in determining the outbreak of the condition, and these will be suitably referred to afterwards. It is only possible here to deal with the general features. The incision is made in the hnea alba, unless the causative lesion is obviously on one side, as in the case of a per- forated appendix; and the lower half of the abdomen is opened rather than the upper, unless the latter is distinctly indicated. The objects of the operation are threefold: (i) To find and deal with the cause of the affection, such as a perforation which needs to be closed, or a perforated or gangrenous appendix which must be removed. (2) To cleanse the peritoneum and remove the effusion. Some surgeons rely on mopping up the exudate with dry sterile swabs, and if it is locahzed, and not diffuse, this may act excellently. When, however, there is a considerable sero-purulent effusion, occupying the pelvis, and perhaps spreading up through the kidney pouches to the under surface of the diaphragm, irrigation of the cavity is probably desirable. Sterile salt solution at a temperature of about 107° is used, and the whole proceeding should be effected without the escape of much of the intestine. Counter-openings in the loins or above the pubes may be required to give exit to the fluid, and then the end of a steriHzed rubber tube coming from the irrigator is carried here and there through the abdomen by the hand, and the exudate effectively washed out through glass or rubber tubes placed in the various incisions. It is most undesirable to allow the escape of many coils of intestine, and general evisceration wdth the object of cleansing the intestines adds seriously to the shock, and usually does more harm than good. ' Quickly in and more quickly out ' is an ideal that ought to be striven after. It must be remembered that the peritoneum has a considerable power of absorption, and unless the inflammation has gone very far, this may be rehed on to a considerable extent to deal with inflammatory exudates, which are not frankly purulent. (3) Drainage is necessary in almost all cases, and may be effected by the use of glass or rubber tubes with or without gauze wicks. When employing a Keith's tube, the enclosed gauze wick is removed twice a day, and any effusion lying at the bottom sucked up through a sterile rubber 62 978 A MANUAL OF SURGERY catheter attached to the nozzle of a glass syringe. It is probably wise to omit the glass tube at the end of forty-eight hours, and replace it by a smaller and shorter rubber tube, which in turn is followed by a gauze drain as soon as the discharge diminishes sufficiently. The abdominal wall is, of course, only partially closed after these proceedings. When intestinal distension is very great, so that it may be difficult to reach the cause of the trouble or to return the extruded viscera, it may be ad\isable to tap a coil of small intestine and empty the contents, or to stitch in a rubber tube and allow the bowel subsequently to empty itself, dealing with the fistula so produced at a later date. The reduction of the distension is an essential element if a successful issue is to follow, but undue manipu- lation must be avoided. If the bowel is merely tapped and at once closed, it may be advisable to follow the plan suggested by McCosh of injecting several ounces of a saturated solution of Epsom salts before closing the abdomen. With the same end in view the hjrpodermic administration of strychnine or eserine may be employed after the operation with the idea of stimulating the un- striped muscle fibres of the intestinal wall. As soon as the patient has recovered from the anaesthetic, he should be raised from the recumbent to the sitting posture {Fowler's position), with a view to permitting the fluid effusion to gravitate into the pelvis. Continuous infusion of salt solution into the rectum {proctoclysis) or subcutaneous tissues should also be employed in order to dilute the toxins and facihtate their ehmination (p. 963). For infusion into the subcutaneous tissues the outer side of the thighs will be convenient. Two needles are introduced, only one of which is used at a time. Four or five ounces are injected on one side, and then the other limb is employed; the needles are kept in place whilst the fluid is being absorbed. Improvement in the con- dition of the patient shows itself almost at once by a fall of tem- perature and of pulse; the vomiting ceases or becomes less urgent, pain and tenderness decrease, and the patient looks and feels better. On the second day the bowels are hkely to become distended with flatus, and it is necessary to obtain relief; this is best effected by a turpentine enema in the first place, followed by a dose of castor oil, or of sulphate of soda, or repeated small doses of calomel. As soon as the bowels have acted well, the urgency of the symptoms diminishes, and it is probable that the patient will recover. The wound requires constant dressing for some time, as there wiU be a good deal of discharge, and perhaps the fatty and fascial margins of the wound will slough. The tubes are gradually dis- pensed with as the discharge diminishes, and replaced by gauze drains; and when the deeper tracks have filled with granulations, the superficial wounds may be drawn together with strapping, and thus the strength of the abdominal wall may be maintained. It will be wise to order an efficient belt or support after operations of this type. ABDOMINAL SURGERY 979 2. Acute Localized Peritonitis usually arises in connection with some limited lesion of the abdominal contents, which is of such a nature as to permit of the general peritoneal cavity being shut off by adhesions, the process being thereby locahzed. It is frequently followed by suppuration, the abscess being thus intraperitoneal, although not involving the general peritoneal cavity. The abscesses arising in connection with appendicitis or pelvic peritonitis are not uncommonly of this nature. They may burst through the barrier of adhesions, and thus light up a diffuse inflammation of the peritoneal sac, or they may burrow to the surface and point 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 fever, vomiting, and constipation. At first no swelKng 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 guarding some focal point of mischief. As the effusion increases in amount, a tumour dull or tympanitic on percussion may become evident ; it is mainly due to a matting together of the intestines and omentum, but is often asso- ciated with a variable amount of effusion ; if, however, it is placed deeply, the dulness may be absent owing to the fixation of one or more coils of intestine in front of the inflammatory focus. If an abscess forms and travels towards the surface, the abdominal wall becomes infiltrated, red, and oedematous, the component tissues being brawny to the touch, and cutting hke bacon. Finally, a fluctuating area presents itself in the midst of this indurated mass, and the abscess either discharges itself or is opened. The pus con- tained therein is often offensive, owing to the presence of the B. coli. Of course this process is attended with considerable increase in the pain and constitutional disturbance. If the cavity is opened aseptically and drained, it rapidly contracts and a cure is accom- plished, although intraperitoneal adhesions may persist and lead to subsequent trouble from hampering the intestinal movements. If a communication is established with the intestine, a faecal fistula is apt to follow ; whilst if the cavity becomes septic, chronic suppura- tion may result, and thereby the patient's health and strength are undermined. The determination as to the existence or not of suppuration is by no means easy, and a blood count, perhaps repeated more than once, is often of the greatest value (see p. 62). Treatment. — In these cases resolution can sometimes be obtained by keeping the patient absolutely quiet and on a low diet, with perhaps a little morphia, and by appljdng fomentations locally, whilst the lower bowel is emptied by an enema. Such a course must, however, not be persisted 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 ad\dsable under such circum- stances. The line of treatment marked out for appendicitis (p. 1056) is that which should always be followed. gSc A MANUAL OF SURGERY 3. Simple Chronic Peritonitis in itself rarely requires surgical attention, since it is to be looked on rather as a protective than as a destructive process. It is characterized by infiltration and thicken- ing of the peritoneum, whereby the intestinal wall is strengthened and bacterial invasion hindered. It is localized or diftuse in character, and arises as the result of some pre-existing inflammation. In the more diffuse forms the intestines may be hopelessly matted together, or the omentum rolled up and contracted into a rounded cord-like mass, lying transversely across the upper part of the abdomen; chronic obstruction is almost certain to arise sooner or later from this condition. More frequently it is the consequence of some localized injury or inflammation. In the former plastic lymph is deposited over any breach of continuity of the serous membrane, and to this the omentum or intestine becomes adherent; the under surface of a laparotomy wound is not unfrequently affected in this way. Local- ized areas of inflammation are similarly liable to originate adhesions, which are thus found in connection with gastric ulcers, an inflamed vermiform appendix, enlarged mesenteric glands, or a pyosalpinx. Under favouring circumstances many such adhesions are absorbed in the early stages; but if they persist, they are modified by the intestinal movements, and are likely to become lengthened and rounded, thus originating the bands and cord-like structures so often the causes of acute obstruction. The anatomical arrangements of the omentum explain why this structure is so frequently involved in this process, and thereby it constitutes one of the most important agents for checking the spread of inflammatory affections. Intes- tinal adhesions often give rise to no symptoms ; but sometimes they determine attacks of colic and of irregular peristalsis, and occa- sionally an adhesion to the abdominal wall — g.g., one springing from the stomach — causes a localized constant pain which justifies ex- ploration. 4. Tuberculous Peritonitis. — This disease is almost limited to young people, and is usually secondary to some other focus of tuber- culosis — e.g., in the intestine, mesenteric glands, Fallopian tube, testis, etc. It is sometimes limited in its development to a portion of the peritoneal cavity, especially when originating from the pelvis or vermiform appendix, but is more frequently diffuse. It manifests itself in several different ways, which may be associated with or follow one another: (i) In the ascitic variety the peritoneum becomes thick and hyperaemic, and is studded over with tubercles, some of them small, gray and translucent, others larger and undergoing caseation. The effusion is generally abundant, and consists of straw-coloured or opalescent serum, perhaps blood-stained in the more active cases. Flakes of fibrin may be found covering the membrane here and there, but there is no extensive matting of the intestines. Occasionally the effusion becomes encysted, giving rise to localized fluid swellings shut in between the coils of intestine. (2) In the fibrous variety the in- testines are matted together by extensive adhesions, and between ABDOMINAL SURGERY 981 them foci of tubercle are found. The mesentery may become in- filtrated and shrink, fixing the intestines back en bloc to the posterior abdominal wall. The omentum is often invaded, and contracts upwards to form a sausage-like tumour lying transversely above the umbilicus. There is but little effusion, and that is usually encap- suled. It is obvious that such a condition is very likely to lead to obstructive phenomena, due to kinking of the mtestme. (3) The siippnrative variety is characterized by the presence of tuberculous foci of some size between the coils of intestine; caseation and sup- puration follow, and the abscesses are hkely either to open into the intestine, possibly into two coils, causing thereby a fistulous com- munication {fistula himncosa), or perhaps to travel to the surface and open externally, and then most frequently at the umbilicus, possibly giving rise to a faecal fistula. In each of these varieties acute manifestations may develop at any time as a result of infection from the bowel with the B. coh, and then the symptoms of acute diffuse peritonitis may supervene. The Symptoms are extremely variable, and the early stages ol the disease are sometimes not easy to recognise. A few cases have an acute onset with abdominal pam and disten- sion, and continued pyrexia which may suggest the existence of enteric fever. The abdominal wall, however, is not rigid ; the tender- ness is not great ; there is well-marked evidence of free fluid, and though vomiting and constipation may be present, they are not marked features. Naturally the patient in such a condition wastes quickly. . , In the more chronic forms the earhest symptoms are weakness witn some shght abdominal discomfort, and not uncommonly diarrhoea, alternating perhaps with constipation. The temperature becomes of a hectic type, and periods of improvement may alternate vnth attacks of increasing pain and weakness. On the whole, the patient gradually gets worse, his wasted frame comparing markedly with the protuberant and enlarged belly. The phenomena discoverable on abdominal palpation vary considerably with the conditions present within. Treatment in the early stages, and especially m the acute variety, is often successfully undertaken by the physician. Hygienic measures are adopted, the patient living in the fresh air, and, ol course, being always in the recumbent position. Plenty ot good digestible food is given, as also cod-liver oil and perhaps intestinal antiseptics, such as salol, creasote, etc. The external apphcation to the abdomen of iodine, either as a paint or an ointment, is much commended by some physicians, whilst Scott's dressing is relied on by others. Tuberculin injections may also be of value. Should the condition undergo no improvement, it may be justifiable to operate. When chronic ascitic accumulation is present, all that is needed is to remove the fluid by tapping or laparotomy; in the latter case irriga- tion is not required, and the wound should be closed completely ,in nearly 75 per cent, of the cases a cure may be anticipated. Possibly 982 A MANUAL OF SURGERY it may be well to ascertain first the condition of the opsonic index, and, if need be, to raise it by injections of tuberculin. In the acute forms tuberculous infection of the wound usually follows the escape of the highly infective fluid from the peritoneal cavity, and healing may be thereby delayed; hence it is undesirable to operate in such cases. Where diffuse or localized suppuration is present, adhesions which can be reached may be gently broken down, and exit given to the pus; but no prolonged search after suppurating foci should be made, or the intestine may be torn. The results of treatment in this variety 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, two factors probably co-operate: (i) the removal of the exudation and its contained toxins; and (2) a flushing of the intra-abdominal tissues with blood plasma (a well-ascertained fact after laparotomy) and the effect of the antibodies contained therein, the tubercles thereby having their vitalit}' destroyed. In this connection one may note the statement that too early a laparotomy does but little good, an insufficient amount of antibody having presumably de- veloped in the system. Pneumococcal Peritonitis is in the majority of cases secondary to a similar infection of tlie lungs or pleura, the organisms being transmitted by the blood or through the lymphatics of the diaphragm; less frequently the primary focus is in the pharynx or middle ear. Occasionally the trouble is apparently primary, the pneumococci finding their way through a healthy mucous mem- brane, as from the bowel or appendix, or more directly b}' the Fallopian tube. The disease is specially common in female children, and usally sets in acutely. In some cases the trouble quickly becomes circumscribed, and a chronic encapsuled abscess results; in other cases the course is acute, and the sjonp- toms are persistent and more violent. In the former, pain and vomiting are moderately severe in the early stages, but diarrhoea is often present, and pyrexia is moderate Pus is likely to accumulate slowly, and without marked pain and discomfort; at first it occupies the lower part of the abdomen, but gradually encroaches on the whole cavity, and typical dulness may be noted, whilst the patient wastes rapidly. In some cases the pus has pointed at the umbilicus, and a spontaneous cure has followed its discharge. In the more acute cases the course is very similar to the diffuse pyococcal type described above; prostration is generally rapid, and death early; the only distinguishing feature is the existence of diarrhoea in some cases. The pus is usually like that in a pneumococcal empyema (p. 923), with abundance of false membrane, but in other cases it is of the ordinary t5-pe; pneumococci can easily be found in it. A blood count will show a well-marked leucocytosis, which is usually absent in the worst forms of pyococcal peritonitis. Treatment consists in laparotomy and drainage in the more acute varieties, but in the milder the patient must be carefully watched for localizing phenomena. Gonorrhoea! Peritonitis almost always occurs in women as a direct extension of a gonococcal inflammation upwards from the uterus, being preceded or accompanied by the phenomena of salpingitis or ovaritis; it has, however, been known to develop in men. There is usually a definite history of gonor- rhoea with a more or less abundant discharge, but the attack generally follows a menstrual period, or the manipulation of the tubes and ovaries. The onset is sudden and acute, the patient complaining of severe pelvic pain, which is accompanied by vomiting, abdominal distension, and fever. A swelling may be felt above the brim of the pelvis. Under suitable treatment the trouble often abates rapidly, and the patient recovers; but adhesions are likely to be left, determining sterility, or the tubes may remain full of pus (pj'osalpinx). In other cases exudation is abundant, though there is a tendency to limitation ABDOMINAL SURGERY 983 of the trouble, and the prognosis is generally favourable. „.^/^ « " f/, ^^^^^^^^^^ in absolute rest, fomentations to the abdomen hot ^^g'^Vow . r^'Xn suitable limitation of diet. If rapid improvement does not follow a median laparotomy should be undertaken in order to let out the pus and permit of suitable drainage. The tubes and ovaries should always be explored m such cases, and may perhaps need to be removed. Subphrenic Abscess is the term applied to a suppurating focus which IS hi more or less intimate relation with the under surface of the diaphragm. Two main varieties are described, viz., the mtrapen- toneal, which is much the more common, and the retro- or extra- peritoneal. The former are not unfrequently subhepatic as well as subdiapJiraginatic . The causes are very diverse, and the manifestations vary some- what with the causative lesion. I . The stomach is the most frequent source of the trouble, the infection being due to the extension of a chronic ulcer. If the anterior wall is involved, the pus will be Hmited by the lesser omentum and stomach behind, by the dia- phragm and left lobe of the Hver above, by the falciform Hgament on the right, and by adhesions be- tween the stomach or omentum and anterior abdominal wall below (Fig. 466). This type of abscess usually points to the left of the Fig. 466. — Diagram of Subphrenic AND Subhepatic Abscess, due to Extension from an Ulcer of the Anterior Wall of the Stomach. S, Stomach; C, colon; I, small intes- tine; L, hver; GO, great omentum; SO. small omentum; LPS, lesser peritoneal sac ; P, pancreas; D, duo- denum. ensiform appendix. Should the ulcer be situated on the anterior wall near to the fundus, the abscess may get into close relationship with the spleen, and point beneath the left costal margin. When the abscess arises in relation with the posterior wall, the lesser sac of the peritoneum may be filled with pus, which is prevented from escaping from the foramen of Winslow by adhesions, whilst the stomach itself is pushed forwards, and the pus travels up and presents above it to the left of the middle Hne. More often the lesser sac has been previously obhterated, and the abscess develops in the retroperitoneal tissues'. 2. Ulcer of the duodenum may give rise to very similar conditions. If the ulcer is in the first or second part, an intraperitoneal abscess is likely to form, bounded by the liver, colon, omentum, and anterior abdominal wall; occa- sionally the pus also tracks up behind the liver. When retroperi- toneal suppuration occurs in connection with the duodenum, the 984 A MANUAL OF SURGERY pus travels up between the liver and diaphragm, or downwards towards the loin. 3. The appendix vcrmiformis is also a cause of subphrenic abscess, the pus burrowing behind the peritoneum, or hnding its way along the inner or outer walls of the ascend- ing colon. 4. It may be caused by extension of suppuration from the liver, colon, intestine, or from retroperitoneal structures, such as the kidney, ribs, or vertebrae. According to Fenwick, however, 80 per cent, of all cases of subphrenic abscess are due to ulceration of the stomach or duodenum. The abscess thus induced may contain pus alone or, in addition, gas, which is derived either from a direct communication with the bowel, or from the activity of the B. coli without any definite open- ing being present. It was to this condition that Leyden originally gave the name of subphrenic pyo-pneiimothorax. The extension of the abscess along the under surface of the diaphragm often leads to that structure being displaced considerably upwards, and to a second- ary infection of the pleura, either by lymphatic absorption and ex- tension, or by an actual solution of continuity. The effect is an effu- sion of serum or piis into the base of the pleural cavity, the latter constituting a basal empyema.* The Symptoms vary considerably. They may be preceded by those referable to the causative lesion, and their onset may be sudden or gradual. Ordinary febrile phenomena, and perhaps one or more rigors, may occur, whilst the patient complains of pain in the upper part of the abdomen, together with vomiting and constipation. The pain is often increased on respiratory movements, and may extend upwards to the shoulder. On palpation, the abdominal muscles on one or other side are held rigidly contracted, but possibly a swelling, either dull or tympanic according to its contents, may be noted. There may be some bulging of the intercostal spaces. On the right side the diaphragm may be pushed up, and the liver downwards ; and if the abscess contains gas, an area of tympanitic resonance may be noted between the dulness of the liver and the resonance of the lung. On the left side the heart may be pushed upwards together with the diaphragm, and the absence of lateral displacement of the heart is an important diagnostic feature from a pure empyema or pneumothorax. The X rays will sometimes be useful in recognising displacement upwards of the diaphragm, and immobility of the affected half. A blood count is important in indicating the existence of suppuration. The Treatment consists in opening and draining the abscess wherever it is most accessible. In many cases this can be effected through the anterior abdominal wall along the lower margin of the ribs, but even then a counter-opening is often needed. \\'hen the abscess does not project anteriorly, the best situation for an opening is through the pleural cavity, as for some abscesses of the liver. The incision lies behind the mid-axillary line, a portion of the * For a complete and masterly study of subphrenic abscess, by the late Mr. Harold L. Barnard, see British Medical Journal, February 15 and 22, 1908. ABDOMINAL SURGERY 985 eighth or ninth rib being excised. If, as often happens, there is also an empyema, this is drained, and then an additional opening can be made through the diaphragm if one does not already exist ; if, however, the pleural cavity is not affected, the serous membrane covering' the upper surface of the diaphragm must be stitched to the parietal pleura before the diaphragm is incised. Ascites. — By this term is meant an accumulation of fluid, and that usually of a serous type, within the peritoneal cavity. It results chiefly from lesions which fall to the care of the physician— viz., cirrhosis of the liver, chronic Bright's disease, and various cardiac affections. It is also a consequence of any obstructive pressure on the portal vein, as by malignant glands in the portal fissure secondary to carcinoma of the stomach or of the intestine, or by fibrous adhesions, the consequence of duodenal ulceration or stones m the gall-bladder. Fluid also collects in the abdomen as the result of diffuse malignant deposits scattered over the peritoneum, or from the presence of mildly irritative foci, such as hydatid cysts, etc. Chylous ascites is a condition in which the fluid is milky from an admixture of chyle, and usually results from rupture of the recep- taculum chyli in"^ consequence of the pressure on the thoracic duct above it of malignant glands secondary to cancer of the stomach. Encysted ascites results from the distension of a portion of the cavity which has been shut off bv inflammatory adhesions. The Physical Conditions resulting from ascites are easy of recog- nition. The abdomen is distended, hke a barrel, but with bulging flanks . Dulness is present in the loins when the patient is recumbent , and extends forwards to about the same level all round, the only resonant area being about the umbiUcus ; this is due to the floating forward of the intestines. On rolhng the patient over to one side, the dull and resonant areas shift, the part that is highest becoming resonant. This sign is occasionally absent if the mesentery is short or if the intestines are tied down posteriorly. On flicking the abdo- men, a well-marked thrill is usuafly transmitted from one side to the other. Necessarily, the fluid also finds its way into any diverticula of the peritoneum, such as an unclosed funicular process or a hernial sac. The diagnosis of ascites should not be difficult, but the prac- titioner must not be satisfied until he has discovered the cause, and this may not be easy even when the fluid has been removed, so that the abdominal viscera become palpable. Treatment necessarily varies with the cause of the accumulation. Should it persist, and the patient's breathing be hampered by the abdominal distension, removal by paracentesis is essential. 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 spht to withm 6 inches of the middle hne. The unslit portion is placed over the abdominal wall in front, whilst the divided portions cross behind, and are held by assistants, so as to make continuous pressure upon the abdominal contents. The bladder is completely emptied, and then 986 A MANUAL OF SURGERY the abdomen is carefully percussed, and a spot of absolute dulness selected; here a small incision is made with a scalpel after careful purification of the skin, and a suitable trocar and cannula inserted. The median line below the umbihcus 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 prevent the shock often experienced from its rapid removal. Two or three Southey's trocars and cannulse may then be inserted. Not unfrequcntly the fluid re-accumulates, and the process has to be repeated after a time. When the cause of the collection is doubtful, the practitioner will take the opportunity^ offered b\^ the lax abdominal wall to palpate the viscera ; light ma}^ also be thrown on an obscure case b}^ a cytological examination of the fluid. In malig- nant disease, cancer cells and blood may often be found. If the cause is still uncertain, an exploratory laparotomy may be advisable. In cases due to hepatic cirrhosis, Epiplopexy (the Talma-Morison operation) may possibly be of some use. The object is to reheve the obstruction to the portal system by opening up fresh communica- tions between it and the systemic veins. The method consists in fixing the great omentum to the abdominal wall and determining the formation of adhesions; necessarily the peritoneum has to be drained and kept dry during this procedure, and the question arises as to whether this drainage is not the cause of the improvement. The mortality is not inconsiderable, especially when the liver is small; the best results have been gained with h3-pertrophic cirrhosis. The method is still on its trial, but appears to be justifiable in suit- able cases. Affections of the Great Omentum. The omentum is of great surgical importance in the abdomen, in that it covers in and protects the viscera, and by its mobility is able to apply itself to many a weak spot where perforation or infection might occur, and thereby guard the patient from serious inflam- matory mischief. The result of this process is, however, the formation of adhesions which by the irritation of constant movement may stretch and become rounded and cord-like, and various forms of intestinal obstruction (by strangulation, kinking, etc.) ma\- result therefrom. The value of this protective power of the omentum is recognised by surgeons in the employment of omental grafts to add security to a line of junction in the intestinal wall with which they are not quite satisfied. It is only occasionally that such a provision is required. The best method to adopt is to detach the graft entirely from its former connections, wrap it round the gut, and stitch it in place. The^omentum may be torn, and holes may be formed in it as a result of injury. The immediate s3'mptoms would be pain, shock, and the phenomena of intraperitoneal hemorrhage; but it is likely that other injuries co-exist. At a later date the hole might be the site of an attack of internal strangulation. ABDOMINAL SURGERY 987 Acute Inflammation (epiploitis) has been lighted up as a result of the application to the omentum in a hernia operation of a septic liga- ture. The phenomena vary with the virulence of the organisms, an acute diffuse peritonitis perhaps resulting. In the milder forms a localized inflammatory disturbance follows, with all the phenomena of a limited peritonitis , suppuration may ensue, and a large intra- peritoneal collection of pus may result. Torsion of the omentum is an occasional complication of an irre- ducible hernia, and that usually on the right side. The lesion gener- ally follows some heavv strain, and results in venous stasis, effusion of a blood-stained fluid, the formation of extensive adhesions, and possibly gangrene and general peritonitis, if left long enough. The symptoms often start abruptl}' with colicky pain in the right ihac fossa and scrotum, together with constipation and sickness; the hernial swelling becomes enlarged, and extending upwards from the ihac region a sensitive mass may be detected on palpation, which is dull on percussion, and sometimes reaches to the epigastrium. The temperature is normal, though the pulse-rate is accelerated. Treat- ment is ob^dously operative, and consists in removal of the omentum. Chronic peritonitis, whether simple or tuberculous, maj^ cause the omentum to be rolled up into a more or less sohd mass, which lies transversely across the abdomen a little above the umbilicus. There is usually a band of clear resonance between it and the hepatic dulness, w^hich is of great diagnostic importance. The omentum also becomes infiltrated with secondary cancerous nodules, which can sometimes be palpated, and their presence gives important indications as to the desirabihty or not of operative treatment. Colloid degeneration is not uncommon in omental cancers, and huge masses of this growth have been sometimes dis- covered in the dead-house. Omental carcinoma usually leads to a considerable effusion of fluid into the peritoneal sac. Affections of the Mesentery. Wounds result from penetrating or non-penetrating injuries. They are usually associated with laceration of the intestine, and the result- ing phenomena will be those of hemorrhage, followed by general peritonitis from the intestinal lesion. Pure mesenteric wounds not involving the bow^el are generally due to penetrating or gunshot injuries. Haemorrhage to a varjdng degree may result, and if the patient hves, the nutrition of the intestine may be seriously en- dangered. If such a lesion is found on exploration, bleeding points must be secured and the opening in the mesentery closed ; before this is accompHshed, however, careful consideration must be given to the vascular supply of the intestine, as the ligature of a main branch of a mesenteric artery may determine gangrene, and necessitate resection of a portion of the bowel. Thrombosis of the Mesenteric Vessels, apart from strangulation or volvulus, is usually the result of emboHc obstruction of the artery, 988 A MANUAL OF SURGERY but may sometimes commence in the veins, spreading down from the liver, or originating in some intestinal ulcer. The process is associ- ated with acute pain, and is followed by the symptoms of acute obstruction. The bowel becomes engorged with venous blood, and dies; it is often occupied by a blood-stained effusion, and the passage of dark tarry stools may be noted. The peritoneal cavity contains a quantity of blood-stained serum, which after a time becomes offen- sive. A diagnosis is rarel}' reached apart from operation for the ob- structive phenomena, and the only hope for the patient is removal of the gangrenous bowel (if that be possible), and a temporary entero- stomy. Should the patient live, a very doubtful contingency, the continuity of the gut may be subsequently restored. The Mesenteric Glands frequently become inflamed in consequence of some intestinal lesion — e.g., typhoid ulceration. No special notice is taken of this occurrence, unless suppuration ensues, when the abscess must be opened. In less severe cases, however, it is often associated with a patch of locahzed peritonitis, resulting in the de- posit of plastic lymph; to this some other viscus — e.g., the free end of the omentum, the fimbriated extremity of the Fallopian tube, the vermiform appendix, one of the appendices epiploicee, etc.- — may become adherent, and an adhesion may develop which subsequently leads to intestinal obstruction. As a matter of fact, the great majority of intra-abdominal bands are connected at one end with the mesentery. Tuberculous Disease of the mesenteric glands is a common affection in children, constituting a condition known as tabes mesenterica . It is probably secondary to intestinal lesions, and when widely diffused tlirough the mesentery is, of course, to be dealt with only by hygienic and medical measures. The results of such treatment are frequently' very satisfactory, but tuberculous peritonitis may follow. Some- times the glands undergo calcification, and these may lead to a mis- taken diagnosis if a patient is examined radiographically for sup- posed ureteral calculus. At other times the caseated glands may liquefy and give rise to an inflammatory attack that may be mistaken for appendicitis, if the mesentery of the lower end of the ileum is involved. Limited masses in the iliac fossa may sometimes be amenable to surgical measures, and be removed ; whilst occasionallj^ the surgeon has to deal with a gland which has suppurated, and requires to be opened with the same precautions as one would take in dealing with an appendix abscess. Adhesions also form between the glands and surrounding parts, and intestinal obstruction may result. Cysts of the mesentery are not common, and, as might be expected, they are usually of lymphatic origin; they may be single, containing either lymph or chyle, or multiple, then constituting a cavernous lymphangioma. Blood cysts have also been known, and also der- moids, which are usually located in the mesentery of the ileum. A rounded, tense intra-abdominal swelling gradually develops behind or below the umbihcus; it is freely moveable from side to side, and is ABDOMINAL SURGERY 989 usually accompanied by some derangement of intestinal movement or function. When of large size, the swelling is dull, but is (jften crossed by the affected loop of bowel; it may possibly be mistaken either for an ovarian or a pancreatic cyst. The diagnosis is usually made on the operating-table, and the treatment consists in enu- cleation or drainage, with or without removal of the affected coil of intestine. Tumours form occasionally in the root of the mesentery and behind it, constituting the retroperitoneal lipoma or sarcoma. The former may grow to a large size, and destroy life by its pressure phenomena ; the latter, though sometimes resembling the former in structure, invades surrounding tissues earlier. The diagnosis is uncertain until the abdomen is opened, and the question of removal is dependent on the relation of the growth to the mesenteric vessels, which must not be injured. It is seldom that a retroperitoneal sarcoma can be enucleated. Affections o£ the Stomach. The cardiac orifice lies about 4 inches behind the junction oE the seventh costal cartilage with the sternum; the highest part of the fundus reaches the fifth left rib in the mammary line ; the pylorus when the stomach is empty is in the middle line midway between the suprasternal notch and the symphysis pubis (Addison's transpyloric plane). When the stomach is full, the pylorus passes more or less to the right of the middle line and descends slightly. The lower border can usually be defined with tolerable accuracy by auscultatory percussion; this is performed by applying" a stethoscope over the centre of the stomach area and percussing outwaras over the margin; a change in note is readily recognised on reaching the border of the stomach. When pathologically dilated, the stomach becomes enlarged downwards, the pylorus and lesser curvature being retained more or less in position by the gastro-hepatic omentum, so that the organ pouches down towards the pelvis and becomes an elongated sac in which fluids accumulate and decompose and gas collects. Peristaltic waves can often be seen crossing the viscus, and on succussion or tapping the organ with the finger-tips, gurgling and splashing sounds are heard. The stomach can be inflated and its exact size and shape thereby determined more accurately either by passing an oesophageal tube and injecting air with a bicycle pump, or by the administration of effervescent solutions, such as tartaric acid and bicarbonate of soda (10 to 20 grs. of each), or of the component parts of a Seidlitz-powder separately dissolved in water. Radiography has also proved of service in demonstrating the activitj^ and shape of the stomach after the administration of a bismuth meal, which con- sists of a mixture of i or 2 ounces of bismuth oxychloride in gruel or bread and milk X-ray photographs or screen examinations are then made at intervals so that the changes in shape of the stomach as indicated by the shadow cast by the bismuth can be ascertained (Figs. 467 to 470). The greater curvature of the stomach should reach to a little below the level of the umbilicus (this owing to the weight of the bismuth meal), and the viscus should empty itself in about four hours. Direct visual examination of the gastric cavity is also possible (gastroscopy) . Much may be learnt of the functions of the stomach by a careful examination of its contents and secretions. This is best accomplislied by administering a test meal consisting of a piece of toast, or a rusk and a cup of tea without milk, on a fasting stomach. This is withdrawn in one or one and a half hours by a stomach pump or oesophageal tube, and the fluid thus obtained is exam- ined as follows : {a) Chemically — to ascertain the amount of total acidity, the amount of free hydrochloric acid, and the presence or not of lactic acid. 990 A MANUAL OF SURGERY (b) Microscopicallj- — -for the presence of yeasts, sarcinae, or bacteria, es- pecially the long non-motile Oppler-Boas bacilli; shreads of tumour, pus cells, or blood, may also be found. The healthy stomach is practically free from organisms, as those swallowed with the food soon disappear. Not unfre- cjuentl}', however, they are found in the empty stomach of those suffering from pyorrhoea alveolaris, and are then likely to be of the same character as those around the teeth. The following are suggestive samples of the results obtained by test meals: 1. In the normal stomach the amount of fluid withdrawn is about 2 to 4 ounces. It contains no undigested food. Free hydrochloric acid is about 1-5 to 2-0 per cent. No lactic acid or organisms are found. 2. In gastric ulcer the amount withdrawn is normal in quantity or decreased. Digestion is complete. Free hydrochloric acid is increased (hyperchlorhydria) — 2'5 to 3'0 per cent. No lactic acid, organisms, or growth found. Blood may be present. 3. In atony of the stomach the amount withdrawn is increased (6 to 8 ounces) and digestion is imperfect. Free hydrochloric acid is decreased or absent (hjqDochlorhydria) — 0-5, i-o, or o-o per cent. Traces of lactic or butyric acid present. Yeasts and sarcinae present. 4. In carcinoma of the fundus the amount withdrawn is normal or increased 3 to 5 ounces. Hydrochloric acid is absent, but lactic acid exists (0-2 to 0'5 per cent.). Oppler-Boas bacilli may be present, and fragments of growth or blood may be found. Rupture of the Stomach results from blows or falls upon the epi- gastrium, especially after a heavy meal, and then usually involves the pyloric end or the greater curvature near the cardiac oriiice. It may also follow a penetrating injury, such as a stab or a fall upon a spike or railings. Neighbouring viscera are not unfrequently in- volved in the lesion, especially the liver or spleen. The Symptoms are those of severe and prolonged shock, with epi- gastric pain and vomiting, the ejected material sometimes containing blood; acute septic peritonitis usually ensues in a very short time, causing rapid collapse and death. Occasionally, when the wound is small, or the organ empty at the time of the accident, there is little or no extravasation, and then a localized intraperitoneal abscess may form, shut off from the general peritoneal cavity by adhesions, and sooner or later bursting and discharging into the stomach, colon, or one of the hollow viscera, or else coming to the surface and burst- ing externally; sometimes the barrier of adhesions gives way, and a late general peritonitis results. If the posterior wall of the stomach is alone injured, the resulting phenomena are very similar to those due to the perforation of an ulcer in this region {q.v.). Treatment. — No time must be lost in undertaking a laparo- tomy when the diagnosis is tolerably certain, since the only hope of saving the patient's life lies in early interference. A median incision is made above the umbilicus, the situation of the injury in the stomach ascertained, and the aperture closed by a double row of sutures (Czern^^-Lembert), which infold the margins, and extend a little beyond the lesion at either end (Figs. 458 and 460). All extra- vasated material should be carefullv sponged or swabbed away, and if the general cavity has not yet become inflamed, irrigation should be avoided for fear of carrying infective material to other regions. If the posterior wall is also injured, as by a bullet wound, an opening ABDOMINAL SURGERY 99' RADIOGRAMS OF THE STOMACH AFTER BISMUTH MEALS. Fig. 467. — Normal Stomach. Fig. 468. — Moderate Gastroptosis. Pjg 469.— Hour-Glass Contraction Fig. 470.— Cancer of Stomach. OF Stomach The , excavation of the upper border of the shadow marks the site of the cancer. 992 A MANUAL OF SURGIERY should be made through the omentum so as to explore and cleanse the lesser sac of the peritoneum. If the case has been operated on early and there is but little peritoneal inflammation, it may be possible to close the parietal wound entirely; but, as a rule, it is necessary to insert a gauze drain in the upper part of the serous cavity. If the general cavity is inflamed, the treatment suitable to acute peritonitis must be instituted (p. 976). Foreign Bodies in the stomach consist either of those which have been swallowed accidentally or intentionally, or of concretions, e.g., hairs, wool, etc., due to the constant ingestion of small portions, which remain in the viscus and may after a time form large masses. The presence of the former is known from the history, whilst the latter may give rise to s3miptoms of gastric irritation, the cause of which is inexphcable until the mass has attained such a size as to suggest the presence of a tumour. The onl}' treatment possible for a foreign body of any size is to open the organ and remove it (gastrotomy) ; where, however, it is of small dimensions, e.g., a coin, it may be allowed to pass onwards. Acute Phlegmonous Gastritis is an affection due to bacterial in- vasion of the submucous coat of the stomach, which is infiltrated with leucocytes and fibrinous exudation, together with many organisms, especially streptococci. This process usually ends in suppuration, wliich may manifest itself as a diffuse purulent infiltra- tion, or as a more or less localized abscess; or the whole mucous lining of the stomach may be cast off as a slough and vomited. Such a condition, if not fatal from exhaustion, toxaemia, or general peri- tonitis, will be followed by extensive stenosis, which may demand operative treatment. The disease usually occurs in men who suffer from chronic d\^spepsia, and is lighted up b}- injudicious dietary, excess of alcohol, or possibly the taking of corrosive poisons. It may develop as a secondary result of ulceration or of operation. The symptoms consist'of Epigastric pain, persistent vomiting, and marked restlessness, going o^ to delirium or collapse ; the pulse is quickened, and there is moderatj^Jfever. The diagnosis is usually uncertain, and treatment is conseqaently merely symptomatic. Lavage of the viscus will be of some use. Ulcer o£ the Stomaq^ is an exceedingly common ailment, the conse- quences of wdiich are often very serious, a considerable mortality being associated witbr it, its complications, or its sequelte. Two chief types may be mentioned here, although others are not un- known. [a] The acute ulcer is rarely larger than a sixpenny-piece, and ' develops with almost equal frequency at any spot between the cardia and the pylorus along the upper margin of the stomach, and more frequently on the posterior than on the anterior surface ' (Fen- wick). It is not unusually multiple, two ulcers being often found exactly opposite one another, suggesting an infective origin of the trouble. They are circular in shape, and with the edges sharply defined and clearly cut ; each successive coat is destroyed to a lesser ABDOMINAL SURGERY 993 degree than the one internal to it, so that the sore is truncated or funnel-shaped. Should perforation occur, the opening is not central, but slightly to one side. These acute ulcers heal without much diffi- culty, as is evident from the number of radiating cicatrices seen on the post-mortem table. They give rise to no stenosis, except perhaps when they are actually situated within the pyloric orifice. Haemor- rhage from this variety is not uncommon, but rarely fatal.* (6) The chronic ulcer may attain considerable dimensions, perhaps many square inches of each surface being involved. It is usually single, and situated on the posterior wall near the pyloric orifice, which ma.y be involved in the trouble by extension. Its shape is very variable, though in the earlier stages it is rounded ; one impor- tant type is the horseshoe ulcer, which spreads down along either surface from the lesser curvature, and may subsequently cause an hour-glass contraction of the organ. The edges are often raised, hard, and infiltrated, whilst the gastric wall is generally thick and sclerosed. In old-standing cases there may be considerable destruc- tion of tissue, surrounding viscera, such as the pancreas, being some- times exposed thereby. Haemorrhage is not uncommon, and may prove fatal; one of the larger branches of the coronary artery, or perhaps the splenic, is then involved, or the bleeding may arise from one of the enlarged varicose gastric veins which are often found in the neighbourhood of an old ulcer. Perigastric inflammation of an adhesive or suppurative type is almost certain to occur, and cicatricial contraction of various forms is likely to follow. Women are much more liable to gastric ulcer than men, in the pro- portion of three to one ; but it is the acute variety to which they are most prone, and from which, apart from perforation, they seldom die. The usual age of such patients is from fifteen to thirty years. Men, on the other hand, are more liable to chronic ulcers, and though acute perforation is less common, they are subject to a number of serious complications which may prove fatal. Their average age when attacked is from thirty to fifty years. Into the aetiology, general symptoms, and routine treatment of gastric ulcers it is unnecessary to enter; they are sufficiently de- scribed in medical text-books. A number of comphcations, however, arise which may require surgical assistance, whilst it must be remem- bered that the mere persistence of symptoms may justify operative measures, especially since the observation has been made and con- firmed that malignant disease may commence on the site of an old- standing ulcer. I. Excessive and Persistent Haemorrhage is responsible for a con- siderable proportion of the deaths from gastric ulcer. It may arise from arteries, veins, or capillaries. In the superficial ulcers of young people the bleeding is usually of capillary origin, or at worst is derived from some small arteriole. In the more chronic ulcers * See Fenwick, ' Ulcer of the Stomach and Duodenum,' J. and A. Churchill, 1900; and Mayo Robson and Moynihan, ' Diseases of the Stomach and their Surgical Treatment,' Bailliere, Tindall and Cox. 63 994 A MANUAL OF SURGERY deeper and larger vessels may be laid open, and it is in such instances that a fatal result may follow; thus the splenic or coronary artery may be involved, and hopeless haemorrhage ensue. Occasionally bleeding occurs as a generahzed gastrorrhagia, where, on opening the stomach, the whole surface seems to weep blood; this condition is but httle understood. It is uncommon for the patient to succumb to the first attack of bleeding, which yields to medical treatment, and hence the rule of practice which is usually adopted, viz., to treat the first acute haemorrhage by medical means ; but should it recur or persist unduly, surgical assistance may be required. If the bleeding is small in amount, but recurs constantly, gastro- enterostomy should be undertaken, in order to put the organ at rest and allow the ulcer to heal. When, however, the haemorrhage is more severe, a determined attempt must be made to find the bleeding spot and deal with it. The abdomen is opened and the stomach carefully explored. Some puckering or thickening of the coats may indicate the situation of the ulcer; failing this, a free opening in the longitudinal axis is made through the anterior wall, and the interior of the viscus methodically examined. When the bleeding point has been found, it may be possible to pick it up and tie it ; or the whole ulcer may be picked up and hgatured en masse ; or the base of the ulcer may be cauterized; or excision of the ulcer may be practicable. Failing these measures, gastro-enterostomy will be indicated, and the result is usually satisfactory. 2. Perforation is by no means an uncommon occurrence, and un- less recognised and treated early is fraught with the greatest danger. The anterior wall is more frequently involved than the posterior (7 to i), owing to its greater mobihty, which prevents the formation of protective adhesions. The cardiac end is more often affected in young people, but the majority of perforations are to be found near the pylorus and towards the lesser curvature in middle-aged people with chronic ulcers. In 20 per cent, of the cases two perforations are stated to be present (Moynihan), but this is very doubtful. The character of the perforation varies considerably; it may be small as a pin-prick, or as large as a threepenny piece. The margins may be oedematous and inflamed, or in cases associated with chronic ulcers may be thick and cicatricial in character, with no tendency to close spontaneously. The symptoms necessarily vary with the size of the perforation, and with the distension or liot of the \ascus. If a large opening is produced in the anterior wall, so that the gastric contents are allowed a free entrance into the peritoneal cavity, the patient is seized with severe epigastric pain and profound shock, and this is followed by acute diffuse peritonitis, which rapidly proves fatal if surgical interference is not at hand. When the per- foration is small and the stomach empty, the initial symptoms of pain and shock may quiet down in twenty-four hours, and the patient recover spontaneously; the opening is then closed by lymph or the omentum. Sometimes, however, a gradual leakage occurs; the onset is then subacute; the primary shock is often inconsiderable, ABDOMINAL SURGERY 995 but epigastric pain and tenderness are present, together with marked rigidity of the abdominal wall; a short period of improvement follows the primary shock, and then the symptoms steadily increase until the characteristic features of general peritonitis supervene. The Prognosis of gastric perforation is exceedingly grave, since, unless active surgical interference is obtainable within a compara- tively short time, hopeless peritonitis ensues. Statistics indicate that 95 per cent, of untreated patients die, whilst the later the operation, the worse the results. If operation is undertaken within six hours, recovery is usual ; if within twelve hours, it is not unusual ; but later than that it is. most uncertain. Treatment. — Should it be decided for any particular reason not to operate in a given case, the horizontal position, rectal feeding, and the use of morphia to check peristalsis, are the only means which hold out any prospect of benefit. Operation, as already indicated, must be undertaken at as earty a period as possible, although it is often wise to delay for an hour or two to allow the patient to recover in measure from the initial shock. The median incision is the best to employ, since it is not possible to be certain as to the situation of the lesion. The rules given above as to the treatment of a pene- trating injurj;' 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 found; all that is required is to close the aperture by means of Lembert's sutures, which infold and bury the perforation; this is sometimes a matter of some difficulty when the margins are thick and sclerosed. In a few cases it may seem unwise to attempt closure of the lesion, whilst in others it may be so situated as to render such closure impossible; a drainage-tube, free from lateral openings, is then introduced into the stomach, and gauze packed around it so as to lessen the risk of intraperitoneal leakage. The patient is fed by the rectum for some time, and the fistula usually closes without much difficulty at a subsequent date. The operation should always include an examination of the lesser sac, which may have been infected through the foramen of Winslow or by a second perforation. This is the more necessary when the clinical s^nnptoms point to a serious lesion, and nothing is found in the main peritoneal cavity to explain them; under such circum- stances, if the lesser sac is also free from inflammation, the vermi- form appendix should be examined, as it is often responsible for many atypical conditions. Another point may also require con- sideration before closing the abdominal wound, viz., whether or not it may be desirable to undertake a gastro-enterostomy at once. If the opening involves the p57loric region so as to threaten subsequent stenosis, and if the condition of the patient is sufficiently good, the anastomosis should always be performed. If left till a later date, it may be rendered extremely difficult or almost impossible by the development of adhesions. After-treatment is as for all cases of diffuse septic peritonitis (p. 976). 996 A MANUAL OF SURGERY The patient is placed as soon as possible in the sitting position. Mouth-feeding is of course forbidden for two or three days, and rectal alimentation relied on. Turpentine enemata are employed to relieve distension and empty the bowel. 3. Perigastric Inflammation is a common result of ulceration; it may be either adhesive or suppurative in character. Adhesive Perigastritis is in the first place protective in nature, con- sisting of a localized thickening of the serous wall. It is more marked in connection with chronic than with acute ulcers. The posterior gastric wall is often adherent across the lesser sac of the peritoneum to the serous membrane \ymg in front of the pancreas, and this fixity may be one of the factors which prevent the ulcer from healing, even as fixation to the periosteum over the tibia delays healing in an ulcer of the leg. In a few cases adhesions form between the anterior wall of the stomach and the parietal peritoneum, and these may give rise to a localized fixed epigastric pain, usually increased considerably by distension of the organ. It can sometimes be treated by abdominal section and di\'ision 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. Suppurative Perigastritis may follow a small perforation with limited leakage, but is more usually due to an extension of the ulcer and an invasion of the perigastric tissues by organisms which escape from the stomach. The result of this is the formation of what has been already described as a subphrenic abscess (p. 989), which may or may not contain gas. It may burst anteriorly through the abdo- minal wall, or may perforate the diaphragm, gi\'ing rise to a basal empyema ; and this in turn may burst into the lung or through the chest wall, so that fistulae may appear in various places, through which the contents of the stomach may be discharged. The abscess should be opened and drained in the wa}^ already indicated, but should a fistula form, it is almost hopeless to attempt to deal with it locally, and a gastro-enterostomy may then be required. 4. Stenosis is always Hable to follow the cicatrization of ulcers of the stomach. In the small acute ulcer the contraction rarely leads to more than a puckering of the organ; but in the chronic ulcers of large size the organ may be much altered in shape, and definite stenosis may arise. If the contraction is in or near the cardiac orifice, s^'mptoms akin to oesophageal stenosis may be produced, the patient returning his food shortly after swallowing it . If the pylorus is affected, the stomach is often much dilated, and vomiting of a special type ensues (see Simple Stenosis of the Pj^orus, p. 1002). It is important to note that muscular spasm plays a considerable part in the production of these symptoms when due to ulcer; the spasm is probably induced by the hyper-acidity of the gastric juice (hyper- chlorhydria) w'hich is often present. The most exaggerated forms of gastric stenosis follow the cicatriza- ABDOMINAL SURGERY 997- tion of a horse-shoe ulcer, and this constitutes the most common cause of an hour-glass stomach ; adhesive perigastritis and cancer are also occasional causes. The constriction is usually situated about 4 inches from the pylorus, and may be so narrow as almost to divide the organ into two halves. Generally the great convexity is drawn up towards the lesser, and thereby two pouches are formed which sag downwards ; in them food coUects and undergoes decom- position. Vomiting more or less of a pyloric type ensues from the distension of the cardiac pouch, which is usually much the larger. On washing out the organ with a measured quantity of water, a smaller quantity often returns, some being retained in the lesser sac. On palpation this latter may occasion a succussion splash, even when the organ is apparently empty. On again passing the tube after a short interval, offensive fluid may return, especially if the pyloric pouch has been palpated. Distension of the viscus causes a definite bulging on the left side of the epigastrium in the first place; subsequently this may diminish, and the pyloric pouch become evident on the right side. Sometimes both pouches can be distinctly felt, or even seen, as well as the sulcus between them. Radiography after a bis- muth meal will often demon- strate satisfactorily the exist- ence of this condition (Fig. 469) . No treatment is of any avail which does not provide for the drainage of both pouches and the efficient emptying of the whole organ. A few cases may be treated by excision of the stricture, or by its longitudinal division and suture transversely by a method similar to that employed for the pylorus (see Pyloroplasty, p. 1008). In the great majority of cases treatment is best effected by a double gastro- enterostomy (Fig. 471), which gives a direct communication between each segment and the jejunum. 5. Finally, cases are met with in which the symptoms of gastric ulcer persist or recur in spite of the most careful dieting and treat- ment, and it is now considered quite justifiable to submit such cases to operation. Two hues of treatment are possible, {a) The ulcer may be excised, if it be in a convenient position for such a proce- dure, and if the infiltration around it is not too extensive. This is the more desirable, since many cases apparently benign are really mahgnant, and the cicatrices of such conditions, even if benign, are hkely to become mahgnant. This practice is, however, seldom possible. (&) In most cases gastro-enterostomy (p. 1008) should be Fig. 471.— Treatment of Hour- glass Stomach by Double Gastro- enterostomy. 998 A MANUAL OF SURGERY undertaken in order to relieve symptoms by enabling the viscus more rapidly to empty itself after the ingestion of food, so that the ulcer may be given a better opportunity of healing. In some cases excellent results follow such a measure, but not in all. It must be remembered that gastro-cnterostomy is not a magic charm which at once and for ever cures all the troubles arising from gastric ulceration. The ulcer is still present when the opera- tion is completed, and if chronic may take a long time to heal, and require a continuance of the dietetic and medical treatment that preceded the operation, such as the limitation of the dietary to soft articles, and only a very gradual increase in the hst of things per- mitted, and the use of drugs, such as an alkahne bismuth mixture to neutrahze the h}'perchlorh3-dria usually present. The teeth must also be carefully attended to. Sometimes the sj-mptoms result from an atonic gastritis wdth absence of HCl, and then operation will do no good. In fact, it is probable that unless some degree of obstruc- tion is present to the onward passage of food through the pylorus and duodenum, gastro-enterostomy does but httle good. It is quite clear that, unless the practitioner selects his cases for operation with great care, he will often be disappointed with the results, which do not by any means always conform to the couleiir-de-rose picture of some writers. Recurrence of Symptoms after Gastro-enterostomy may be due to many causes : (i.) The ulcer may have broken down again, as a result of careless or unsuitable eiiet, or of a general loss of health and tone. A servant girl going back to her old work and habits is very liable to this, (ii.) Adhesions between the ulcerated stomach and surrounding parts may have been stretched as the result of some traumatic influence, (iii.) Adhesions due to the operation itself may be present and give rise to trouble, (iv.) The opening into the jejunum may have contracted, and difficulty in the onward passage of the food may again be present, (v.) A peptic ulcer may have developed in the efferent loop of the jejunum (p. 1012). The history and character of the symptoms should suffice to guide the practitioner to a correct diagnosis. Treatment. — The patient should be put to bed and treated on medical lines for a while; this will suffice in most instances to give relief. Should it fail and s\TTiptoms persist, it may be necessary to open the abdomen again and explore the parts involved. Adhesions may be divided, and if it seems Hkely that the opening has con- tracted, it may be enlarged, or a fresh anastomosis may be per- formed. Cancer of the Stomach. — The stomach is more frequently invaded by cancer than any other organ in the body in the male sex, whilst in females it comes next to the breast and uterus in order of fre- quency. Any and every part of the viscus may be affected, but in 60 per cent, of the cases the tumour starts in or about the pylorus. It may be of a spheroidal- or columnar-celled type, but is often sufficiently hard to warrant the use of the term ' scirrhous ' which is ABDOMINAL SURGERY 999 usually applied to it. When the cardiac end is attacked, the disease may spread from the oesophagus and is a squamous epithelioma ; but when the body of the organ is invaded, the condition is generally a columnar carcinoma. Cancer frequenth' starts at the site of an old ulcer, but often there is no assignable cause for its onset, except an indefinite history of injury. It may occur as a nodular outgrowth, perhaps covered with papillomatous projections and early undergoing ulcera- tion ; if it is of a hard type, the ulcerated surface has a characteristic everted margin. Sometimes the whole organ becomes infiltrated by a diffuse carcinomatous growth, constituting a firm miass incapable of dilatation or much contraction, which has been aptly termed the ' leather-bottle stomach.' At the pyloric end (Fig. 472) the growth is always of a hard nature, and forms an annular constriction. Fig. 472. — Cancer of Pyloric End of Stomach. (King's College Hospital Museum.) The abrupt limitation of the growth at the commencement of the duodenum is well seen. through which it may be difficult to pass even a small catheter; it is sharply hmited on its duodenal aspect, but spreads into the body of the organ, and especially towards the lesser curvature, following the main hue of the l^onphatic stream. The lymphatic glands lying along the lesser curvature are involved, usuallj^ extending as far as the point where the coronary artery reaches the stomach, whilst those along the pyloric end of the great curvature are impHcated to a less degree (Fig. 476). Thence the affection spreads to the hver and to the cceliac glands, and may there compress the inferior vena cava and thoracic duct. Adhesions form around the growi;h, but are relatively later in appearance than in a single ulcer; the}' may fix the tumour to the under surface of th/e liver, to the head of the pancreas, the colon, and even when of large size to the anterior abdominal wall. These adhesions often prepare the way for an looo A MANUAL OF SURGERY extension of the disease to the peritoneum, over which disseminated nodules of cancer may be scattered, giving rise to a considerable effusion of serous fluid. The omentum also becomes infiltrated, and colloid degeneration is not unusual in this region, the omentum being converted into a solid translucent mass, looking sometimes like firm sago pudding. Speaking generally, the malignancy of gastric carcinoma is decidedly less than that of such organs as the breast or uterus, in that secondary glandular affections are later in developing, and even when the nearest group is involved it may be some time before the affection spreads to distant parts. Clinical Phenomena. — Gastric cancer begins with certain inde- finite symptoms, the significance of which is easily overlooked in the early stages, so that a thorough and exhaustive examination is not made, and the time for radical interference passes without the disease being recognised. Pain is generally the eai-liest symptom, shght at first, but gradually increasing, and referred to the epigastrium or back. Food may increase or reheve it, but as time progresses the pain comes on independently of meals. Acid eructations and a sense of epigastric oppression soon follow, and these in time give place to actual attacks of vomiting, the ejecta perhaps containing blood, but usually not till late in the case, and as a rule not in great quantit}-. Loss of appetite and steady wasting are also marked features in the early stages, but the patient usually has a clean tongue. The per- sistence of such a group of symptoms should always determine a complete investigation of the stomach and its functions, (i.) The epigastric region is carefully palpated, and the nature and position of any unusual swelling noted. It may be desirable to inflate the organ with air or gas and ascertain its exact size; by this means it is sometimes possible to detect a tumour which would otherwise escape notice, (ii.) The composition of the gastric juice is investigated by the use of a test meal (p. 989). In cancer the amount of HCl is usually diminished, whilst that of lactic acid is increased ; the latter is probably a fermentation product. This test must be looked on as a valuable, but not as a constant, indication of the presence of cancer. HCl is generally increased, and not diminished, in the cancer that supervenes on a chronic ulcer. Moreover, HCl is absent in many gastric lesions other than cancer, and hence the results of this inves- tigation must always be considered in conjunction with the clinical symptoms, (iii.) The motor power of the viscus is very considerabl}' lessened, so that the passage of its contents into the duodenum is delayed; this is due to a chronic interstitial gastritis, (iv.) A blood count in carcinoma usually reveals a well-marked secondary anaemia, together with a moderate leucocytosis (p. 67). (v.) Microscopic examination of the vomit may also throw light on the case by the discovery of fragments of the growth, (vi.) Radiographic examina- tion after a bismuth meal may reveal a decided excavation of the normal shadow cast bv the bismuth whilst still in the stomach (Fig. 470). ABDOMINAL SURGERY looi To these general signs certain special ones may be added, varying with the location of the growth, i. If the cardiac end is involved, a tumour can rarely be detected, the stomach being small and con- tracted. The patient complains chiefly of pain on swallowing, and the vomiting occurs immediately after each meal. The symptoms are practically those of oesophageal cancer. 2. When the pylorus is affected, a tumour can often be felt a httle above and to the right of the umbilicus, which is at first rounded and nodular ; it is moveable in the early stages, but later on becomes fixed by adhesions ; it is firm in consistence, and somewhat tender on manipulation and pressure, and may receive pulsation from the underlying aorta. Owing to the stenosis of the pylorus, which almost invariably accompanies this condition, the stomach becomes dilated, and its great curvature displaced downwards, perhaps almost into the pelvis. In this a large accumulation of fluid takes place, which can be heard splashing about when the patient is moved; every day or two he brings up a large quantity of fluid and decom- posing food, covered with a yeast-like scum, and sometimes contain- ing sarcinae in abundance. Hsematemesis is not uncommon. 3. When the body of the organ is involved, a tumour may or may not be felt, according to its situation. In these cases the amount of pain and vomiting depends on the degree of ulceration of the growth, and is sometimes comparatively slight, especially if the exit to the organ through the pylorus is not obstructed. It is quite possible that the tumour may have attained considerable proportions before it is discovered. The ' leather-bottle ' stomach can be sometimes detected as a solid mass emerging from under the left costal margin. The organ is not dilated, and the vomiting has no special characters ; hsematemesis is usually absent, but the dyspeptic phenomena are pronounced. In the latter stages pressure phenomena manifest themselves. Ascites may result from compression of the portal vein; jaundice, from implication of the common bile-duct; oedema of the legs and varix of the superficial abdominal veins may arise from pressure upon the inferior vena cava, whilst the peritoneal cavity may be distended with chyle owing to the pressure of lymphatic glands on the receptaculum chyli or thoracic duct. All these later signs are indications that the time has passed when radical treatment is possible. A similar indication is given by enlargement of a gland in the left supraclavicular fossa, which sometimes occurs; this results from dissemination of cancer cells up the thoracic duct. Treatment. — When the symptoms of chronic gastritis persist in spite of careful dieting and treatment, and the patient is losing flesh, one should always look on the case with suspicion. Granted that the examination of the gastric juice reveals the characteristic changes referred to above, and still more when a blood count indicates leucocjrtosis and a diminishing quantity of haemoglobin, then an ex- ploratory operation is quite justifiable whether a tumour is to be felt or not. On the other hand, the discovery of a tumour in the I002 A MANUAL OF SURGERY epigastrium does not warrant an operation. It is quite possible that under such circumstances the disease has extended beyond the reach of surgery, and therefore, unless there are distinct indications for palliative treatment — e.g., the signs of pyloric stenosis — the patient is often better left to the care of the physician. Of course, in many cases an operation is undertaken in the almost vain hope of being able to do something to prevent the patient being condemned to certain death ; but when ascites, jaundice, or definite evidences of dis- semination are present, the surgeon should be very chary of inter- fering. For cancer of the cardiac orifice, gastrostomy (p. 1005) may possibly be desirable, the artificial stoma being placed nearer to the pylorus than usual. For cancer of the body of the stomach, a partial or total gastrec- tomy (p. 1007) may be feasible in the absence of massive adhesions; but the conditions which permit of such procedures are unusual. If there is any evidence of obstruction to the passage of food, a gastro- enterostomy (p. 1008) is undertaken; owing to the usual location of the carcinoma on the posterior w^all, the surgeon may be driven to utilize the anterior operation. Sometimes the disease is so extensive that even this procedure is impracticable; the patient's nutrition is then likely to fail rapidly, but possibly life may be prolonged (if such be desirable) by the formation of an artificial opening into the jejunum (jejunostomy), through which he may be fed without using the stomach. For cancer of the pylorus, operation is more frequentl}- possible. If the mass is comparatively moveable, and there are but few adhesions, removal of the diseased portion of the organ may be undertaken, and even should secondary deposits be present in the liver, the patient is probably better off after such a procedure than if left alone. When the growth is firmly adherent to adjacent viscera, gastro-enterostomy is alone practicable, and will be most beneficial. Failing all operative measures, the patient's nutrition must be maintained by such food as causes him the least discomfort, and considerable relief will be experienced from regular and sj-stematic lavage of the organ. Opium will be needed for pain. Simple Stenosis of the Pylorus results from a number of different conditions. It gives rise to hypertrophy and dilatation of the stomach, which becomes enlarged downwards, and forms a sac, in which food collects perhaps for days, and, undergoing fermentative changes, is finally ejected in large quantities, mixed with frothy mucus and a yeast-like scimi containing an abundance of sarcinse. The stomach may in time almost reach the pelvis, the pylorus being dragged down with it. The causes of this condition are as follows: (i) Most frequently it is due to the heahng of a gasiric ulcer, situated within or close to the pyloric orifice; in the acute form, w^here the ulcers are small, spasm as a result of the associated hj-perchlorhydria is ABDOMINAL SURGERY 1003 an important element in aggravating the symptoms caused by a slight contraction. The treatment in these cases is at first medical, and includes daily washing out of the organ. Should it fail to give relief, operation is required, and consists in excision of the pylorus or in gastro-enterostomy. (2) It may result from the contraction of extrinsic adhesions. These may be massive or band-like; in the former case the pylorus is imbedded in the newly-formed fibrous tissue; in the latter it is kinked, and subsequently contracted. Such adhesions may be secondary to gastric ulcer, or may arise from an inflamed gall-bladder (peri-cholecystitis) . Operative treat- ment is usually necessary in order to divide the adhesions, or to remedy the dilatation by gastro-enterostomy. (3) It is occasionally met with as a congenital hypertrophy of the pylorus, in which the over- growth chiefly involves the muscular fibres. It usually occurs in male children, and the pylorus is transformed into a sohd cylindrical mass, about an inch in length, pale in colour, and as hard as cartilage. Symptoms commence within two or three weeks of birth ; after taking food there is not much evidence of pain, although the child may appear to be uncomfortable, and relief is obtained by vomiting. But little food appears to pass into the intestine, so that constipation is marked and the child soon wastes. The stomach becomes enlarged after a time, as in the other varieties, and the pylorus can sometimes be palpated as a moveable tumour. There has been a good deal of discussion as to the treatment of these cases, but practically it is limited to two procedures: [a] The pylorus is dilated by a modification of Loreta's method, metal dilators of the Hegar type being employed (Burghard); or (6) pyloroplasty is relied on by others. Gastro-enterostomy is, of course, desirable, but the mor- tahty is high, the children not having sufficient vitality to stand such a serious operation. Gastroptosis is a condition met with not very unfrequently, in which the stomach is displaced downwards and dilated, usually as a complication of a generalized enteroptosis (Glenard's disease, q^.v.), and hence is likely to be associated with dropping of the liver and mobility of the right kidney. The symptoms produced are those of a chronic atonic gastritis with a dilated stomach; vomiting is not a marked sign, but acid eructations, gastric discomfort, and constipa- tion are very troublesome, and the patient steadily loses weight; neurasthenic manifestations are prominent. The downward dis- placement of the stomach may be such as to permit the pancreas to be felt above the lesser curvature. Haematemesis is sometimes present, but the acidity is normal or diminished, and the diagnosis from gastric ulcer is thereby determined. Radiographic examina- tion after a bismuth meal assists in determining the extent of the displacement (Fig. 468) . Treatment consists in lavage and electricity to the organ in the first place with careful dieting, and external support by a suitable belt is of some value. In more advanced cases, operative treatment is necessary, and many different methods have been suggested. Theoretically, it is desirable to hft the stomach 1004 A MANUAL OF SURGEHY by folding up and shortening the lesser omentum, as suggested by Beyea; but unfortunately this structure is often so thin and attenu- ated as to render this procedure impossible. Eve* points out that it is essential in many cases to deal with the liver first, fixing it up to the anterior abdominal wall by suitable sutures, and then the lesser curvature of the stomach may be raised by passing sutures through it and through the liver itself along the attachment of the lesser omentum. Four or five sutures of this type will fix the stomach satisfactorily. It may be needful in a few cases to diminish the size of the cavity by the formation of a series of tucks or folds in the anterior wall by sutures passing from above downwards [gastro- plication) ; whenever obstruction is present, gastro-enterostomy will also be required. Acute Dilatation of the Stomaehf is a curious condition occasion- ally met with in surgical practice, as an unexpected and unwelcome sequela of injury or operation, and that by no means necessarily hmited to the abdomen. It is rather more common in medical work, arising either without apparent cause, or in the course of debilitating illnesses. It is characterized by a sudden onset, the vomiting of enormous quantities of fluid, and severe general symptoms, which usually terminate fatally in a few days. The stomach becomes enormously dilated, even sagging down into the pelvis, and the walls are more or less paralyzed, as peristalsis is rarely e\'ident. The pathology of this condition is uncertain, but it is possibly due to constriction of the third piece of the duodenum by the root of the mesentery through a downward drag of the intestines. Treatment consists in regular lavage, and in some cases the abdominal decubitus has given rehef ; rectal ahmentation is required. Surgical treatment is very unhkely to do good, unless there is some associated obstruc- tion near the pylorus. Operations upon the Stomach. 1 . Washing outthe Stomach is needed in cases of poisoning, in chronic catarrh, in dilatation of the organ, and as a preHminary to some operations in which its cavity is to be laid open. It may be accom- phshed by the ordinary stomach-pump, or by the simpler method of passing a long tube of good-sized cahbre, to the upper end of which is attached a funnel. Fluid is introduced through the funnel, and syphoned out by lowering it below the level of the stomach. 2. Gastrotomy, or opening the stomach, is required for the removal of foreign bodies from it or from the lower end of the oesophagus, for exploratory purposes, and as a means of dilating simple strictures of either the pyloric or cardiac orifices (Loreta's operation). Operation. — An incision is made in the middle line above the umbilicus unless there is some special indication to the contrary. * Sir F. S. Eve, Trmisactions of Medical Society, vol. xxxiii., p. 252. t For further details, see ' Acute Dilatation of the Stomach,' byH. Campbell Thomson, M.D. Bailliere, Tindall and Cox, 1902. ABDOMINAL SURGERY 1005 The peritoneum is opened, and the stomach recognised by its posi- tion immediate!}' under the Hver, and by the thickness, pink colour, and opacity of its walls. If the omentum or transverse colon pre- sents in the wound, it must be pushed down, and the stomach looked for above. The spot where the stomach is to be opened is now selected, and the part drawn out and carefully packed around with sterilized gauze so as to prevent contamination of the general peritoneal cavity. The incision is made in the long axis of the stomach, and the finger inserted. The removal of a foreign body must be undertaken with great care, so as not to inflict injury on the organ, the wound being enlarged, if necessary. The stomach is subse- quently closed by Czerny-Lembert sutures, and replaced; all traces of blood, etc., are removed, and the external wound is closed in the usual way. The cardiac orifice is not easily reached, as it lies deeply just in front of the aortic opening in the diaphragm. It can be dilated by the fingers or by suitable dilators, and a foreign body by this means removed from the lower end of the oesophagus. The utmost gentleness must be observed in this proceeding, as serious symptoms may be caused by irritation or injury of the pneumo- gastric nerves, the terminations of which pass through this opening in the diaphragm. The operations on the [pyloric orifice are dealt with below. 3. Gastrostomy consists in the formation of a permanent artificial opening into the stomach, through which the patient can be fed. It is needed in cases of malignant disease or intractable stenosis of the oesophagus, where the patient is exposed to the risk of starvation, owing to his inabihty to take nourishment. It is most important that the opening should be of a valvular type so that there shall b e no escape of gastric juice, followed by irritation and digestion of the surrounding skin, which were so constantly seen in the old days. The chief methods of operation are those known as Frank's, Witzel's, and the Kader-Senn procedure. Frank's Operation. — Fenger's obhque incision (Fig. 473, A) for exposure of the stomach is first made, the viscus withdrawn and Fig. 473. — Incisions utilized Various Abdominal Operations. A, Fenger's incision for exposing the stomach; A^, additional in- cision in Frank's gastrostomy; B, incision for exposing the gall- bladder ; C, incision for opera- tions on appendix; D, left iliac colostomy; E, median incision for ovariotomy or suprapubic cystotomy; F, for radical cure of inguinal hernia or varicocele ; G, for femoral hernia; i, anterior superior iliac spine; 2, pubic spine. ioo6 A MANUAL OF SURGERY 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 be drawn up into the wound. The parietal peritoneum is then sutured all round to the base of the cone, so as to shut it off from the general serous cavity. A second in- cision (A^), about I inch in length, is now made on the outer side of the first wound, parallel to it, and about i^- 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 of gastric wall drawn under the bridge into the second wound. A small opening is then made into the viscus through the apex, and the mucous Fig. 474. Fig. 475. Gastrostomy (Frank's Modified Operation). In Fig. 474 the base of the cone is seen sutured to the peritoneum and sheath of the rectus; in Fig. 475 the stomach has been opened, a tube stitched in, and the sutures passed through the rectus are in place. membrane stitched accurately to the skin. The remainder of this incision is then closed in the ordinary way, as also the first. Healing readily occurs, and a valvular opening is established, through which the patient may be fed at once. As a modification of this procedure, a vertical incision (as suggested by Kocher) is emploj^ed instead of the oblique, extending for 3 or 4 inches downwards from the eighth costal cartilage and passing through the substance of the rectus muscle (Fig. 474), which is split by the fingers or handle of the knife into two portions. A cone- shaped portion of the stomach wall is withdrawn, and its base stitched to the parietal peritoneum and posterior la3'er of the sheath ABDOMINAL SURGERY 1007 of the rectus. A small hole is made in the apex of the cone, and into this a piece of rubber drainage-tube, free from lateral openings, and not larger than a No. 10 catheter, is stitched, so that about i-| inches project inside the cavity (Fig. 475) . The halves of the rectus muscle are freed from the posterior layer of the sheath and drawn together by sutures, so as to cover in all the exposed gastric wall except the apex of the cone, which with the tube is drawn to the upper end of the wound, and projects from it. The incision in the skin is then closed, and finally the serous and muscular coats of the projecting portion are carefully stitched to the skin. The results of this pro- cedure have been most satisfactory, many cases having run their course without a drop of gastric juice escaping. The amount of food at first administered is small, and rectal feeding may be required in addition ; but it is gradually increased until perhaps 17 ounces can be retained four times a day. The patient should be kept in the recumbent posture for three weeks.* Witzel's Operation consists in making a valvular opening into the stomach 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 together over it. The stomach is then fixed to the abdominal parietes and the skin closed. The result of this operation is very good, but the fixation to the abdominal wall is not so secure as in the former plans, and inasmuch as the newly-formed passage is lined with serous membrane con- traction is liable to occur. It may be employed advisably when the stomach is small, and it is difficult to find enough tissue for the per- formance of Frank's operation. In the Kader-Senn Operation a tube is stitched into the stomach and buried in the stomach wall by a series of purse-string sutures introduced at intervals of about ^ inch. The stomach itself is then secured to the margins of the abdominal incision. 4. Gastrectomy. — A good many cases have now been reported in which a limited portion of the gastric wall has been removed success- fully, either for simple or mahgnant ulcers or growths. Incisions are made so as to include the mass, and the wound is subsequently closed by Czerny-Lembert sutures. Total excision of the stomach has been undertaken for extensive mahgnant disease, which, however, has left enough of the oesophageal end free to allow of its apposition and fixation either to the upper end of the duodenum, or, if that cannot be brought across to it, to a suitable coil of the jejunum. 5. Partial gastrectomy for malignant disease of the pyloric end of the stomach is now frequently undertaken and with excellent results, if the patient is not too debilitated and if too many adhesions are not present. Operation. — ^The abdomen is opened by a median incision, through which the diseased area is explored, and a final decision made as to * For further details, see Carless, ' On Gastrostomy,' King's College Hos- pital Reports, vol. v., 1897-1898, and in Edinburgh Medical Journal, July, 1902. ioo8 A MANUAL OF SURGERY the practicability or not of removing it. If an operation is deter- mined on, the growth is carefully isolated from surrounding parts by dividing the attachments of the great and lesser omenta, any en- larged glands being also included in the scope of the operation. Clamps are then applied to the stomach and duodenum, and the surrounding part of the abdomen carefully protected with sterilized gauze. The mass is now removed (Fig. 476), the incisions being so placed as to extend beyond the pylorus about f inch into the duo- denum on the one side, and on the other so as to include the greater portion of the lesser curvature, thereby remo\ang the lymphatic glands. Bleeding-points are secured, and the two incisions com- pletely closed, no attempt being made to appose or unite them. The first part of the jejunum is then drawn up, and an ordinary gastro- enterostomy performed ; this is sometimes undertaken as a pre- liminary operation. The chief danger of the opera- tion is shock, but if this can be avoided by careful protection of the viscera, by the preven- tion of haemorrhage, and by rapidity of execution, a good result may be expected. The patient is fed per rectum for the first forty-eight hours, if possi- ble, but after that interval small quantities of fluid may be allowed, and the dietar}^ gradu- ally increased. 6. Pyloroplasty consists in incising the pylorus and reclos- ing the incision in such a way as to increase the cahbre of the tube. It has been performed for various types of stricture, but is now rarely employed (except for congenital stenosis), having been replaced by gastro-enterostomy. The operation commences b}' clearing the pylorus from adhesions. A longitudinal ir/ ision is then made through the stricture, and by a httle carelul manipulation this wound can be opened out and brought log';:ther in a transverse manner so as greatly to increase the lumen of the orifice (Fig. 477). Two rows of stitches are inserted, one through the mucous mem- brane, and the other through the muscular and serous coats. 7. Gastro-enterostomy, or, more correctly, gastro-jejunostomy, is constantly resorted to in the treatment of gastric, pyloric, or duodenal lesions, and in careful and skilful hands the death-rate is now small (well under 10 per cent.). Indications. — i. For obstruc- tion to the onward course of the food, whether in the stomach, pylorus, or duodenum, and whether simple or malignant in origin. 2. For persistent phenomena of ulceration, either of stomach or duodenum, in spite of suitable treatment, but it is doubtful whether Fig. 476. — Cancer of Pylorus, in- dicating THE Situation of the Lymphatic Glands along the Two Curvatures, and of the Incisions NEEDED to INCLUDE THEM. A BDOMINA L S URGER Y loog it is uf much value apart from a lesion which obstructs more or less the passage of food. 3. For recurrent haemorrhage under similar conditions, in order to put the parts at rest by rapidly emptying the stomach, or by diverting the food from the duodenum. 4. As a part of the modern operation of pylorectomy or hemi-gastrectomy. The operation consists in the formation of an artificial communica- tion between the stomach and intestine. It is important that the selected portion of bowel should be the upper part of the jejunum, since, if the communication is established too low, a much greater absorbing surface is isolated, with the result that, even if the opera- tion is immediately successful, the patient gradually loses ground owing to lack of nutriment; and the rapidity of the emaciation will increase as the communication is placed further from the duodenum. Operation. — The abdomen is opened in the middle line and the stomach is readily found; a careful examination of the parts is made to confirm the necessity for the anastomosis and to select the most favourable site. This should be placed on the posterior wall of the stomach, if possible, close to the greater curvature, but well away from the growth or ulcer, and yet as near to the pylorus as is prac- FiG. 477. — Pyloroplasty. The contracted bowel is divided longitudinally, and the aperture thus made opened out, so that it can be brought together transversely. ticable. The selected spot in the jejunum must be as near to its commencement as possible, so as to leave only a short loop between its origin and the anastomosis. The anti-mesenteric border is utilized, and the jejunum must be so placed that the peristaltic wave passing from stomach to jejunum shall be continuous — i.e., shall travel from left to right. To find the upper end of the jejunum, the transverse colon is withdrawn from the wound, together with the omentum. By tracing down the transverse meso-colon to its attachment the termination of the duodenum is reached as it crosses the middle fine at the lower border of the pancreas, and the coil of bowel which emerges on the left side is necessarily the commence- ment of the jejunum. It is now possible to decide finally whether the anastomosis is to be effected to the anterior or posterior wall of the stomach. (i) The anteyior operation (Fig. 478) has fallen into disrepute of recent years, but with care excellent results can be obtained when the condition of affairs prevents the posterior wall from being employed. The objections to it are twofold: (a) The jejunum is drawn up over the transverse colon, and may possibly constrict it and lead to obstruction; this is the more likely to occur when the 64 A MANUAL OF SURGERY opening in the jejunum is as near as possible to the duodenum, a desirable arrangtmcnt from many other points of \'itw; and (6) the necessax}' drag of the gut is apt to bring the two ends paredlel to each other, and thus proeluce a spur, or kink, by means of which the bile is directed into the stomach instead of into the efferent limb, thus estabhshing a vicious circle. Severe bilious vomiting results, which may prove fatal. The actual method of anastomosis is similar to that for the posterior operation. (2) In the posterior o-ptxdXiow of Von Hacker the jejunum is united to the posterior wall of the stomach through an opening in the trans- verse meso-colon, the lesser sac of the peritoneum being thereby traversed. Long metallic clamps, with or without rul:)ber guards over the blades, are then applied to the stomach and intestine in such a way that they can be brought easily into apposition one with the other (Fig. 479), and with sufficient force to prevent ex- travasation of the contents, and to control haemorrhage. A suitable packing of strips and abdominal cloths is then made, and all other viscera are re- placed. Incisions, 2 inches in length, are made into stomach and intestine so as to corres- pond exactly, and any fluid which escapes is received on swabs or gauze strips. The actual anastomosis is effected by simple suturing without the aid of any other mechanical contrivance; either sterihzed silk or iodized catgut may be employed for the purpose. The suturing is undertaken in four stages. Firstly, a sero-muscular suture secures the posterior aspects of the viscera in apposition, the stitches extending beyond each end of the incision. Then the mucous membranes of the stomach and jejunum are united by a continuous suture. T his may be performed in two sections, back and front, or one stitch may suffice for the whole anastomosis. Finally, the anterior sero- muscular suture completes the junction. Occasionally a few extra supporting stitches are required in addition to the two rows, and it is weh to secure any large vessel going to the site of anastomosis by passing a suture under and tying it. The suturing must be accurate and close, as one depends on it to prevent bleeding from the divided visceral walls. The usual peritoneal toilette follows : clamps are removed, blood is sponged away, swabs and strips of gauze are removed and counted, the viscera replaced, and the abdominal incision closed. Fig. 478. — Anterior G.\stro-extero- STOMY. A, Transverse colon ; B, jejunum dragged up over the colon and omentum (pur- posely omitted) to be brought into apposition with the stomach. ABDOMINAL SURGERY The after-treatment consists in the adoption of the sitting posture, and in abstaining from stomach-feeding for twenty-four to forty- eight hours, if practicable, rectal ahmentation being resorted to in the interval. Ilcemorrhage from the divided visceral walls is sometimes troublesome, the patient vomiting blood-stained fluid. Ice is then applied to the epigastrium, and a full dose of ergotin administered hypodermically, or 20 grains of lactate of calcium by rectum. Not unfrequently there will be some regurgitation of bile into the stomach, and this may lead to troublesome vomiting for a few days ; but if the junction is satisf actor}', it soon passess off, especially when food is administered by the mouth, as may usually be undertaken on the third day, or earlier, if necessary. At first only fluid nourishment should be permitted, but in a week's time soft sohds may be given. .^yr' Fig. 479. — Posterior Gastro-enterostomy. Clamps guarded by rubber tubing have been applied to the stomach and jejunum, and their apposition is maintained by clipping the rubber tubing with Spencer Wells forceps at each end. The incisions have been made, and the posterior walls have been sutured together. and gradually a more liberal diet is ordered. The effect of the opera- tion is necessarily only palhative when cancer is present, but the general condition often improves considerably for a time, and the final exitus lethalis is associated with less suffering. Should serious biliary vomiting occur, the patient must sit up and the stomach be washed out. Faihng that, it may be necessary to open the abdomen, and establish a fresh opening between the afferent and efferent coils. To prevent the possibihty of such an occurrence, Roux has suggested making a Y-anastomosis. The jejunum is cut across, the lower segment being implanted at right angles into the stomach wall, and the upper or duodenal end into a second opening in the gut lower down. Excellent results have followed this pro- cedure. 10I2 A MANUAL OF SURGERY Pc'pUc Ulceration may occur at the site of anastomosis or a little below it, but is uncommon, except after the anterior operation, and even then only occurs in 2 per cent, of the cases. It may determine pain and vomiting after food, accompanied perhaps by hiemorrhage or perforation. Treatment is as for ordinary ulcer of the stomach. 8. Finney's Operation, or gastro-duodenostomy, is employed by some surgeons as an alternative to the gastro-jejunostomy just described. It consists in an anastomosis between the second piece of the duodenum and the immediately adjacent stomach. It has its advocates, but has not come into general favour. Ulcers of the Duodenum are very similar in nature and origin to those of the stomach, to which indeed they may be secondary. They occur most frequently in men thirty to forty years of age, and often without any obvious cause. Oral sepsis is not uncommonly present, as also hyperchlorhydria; in some cases chronic nephritis or arterio- sclerosis has existed, and in others the lesion follows some operation. The ulceration which forms a very occasional sequela of burns has been already alluded to (p. 126). The first part of the duodenum is that usually affected, and tfie anterior rather than the posterior wall ; the character of the ulcer is similar to that seen in the stomach. The Symptoms are tolerably characteristic, even apart from the dangerous complications, hcemorrhage, perforation, and stenosis. The patient, who may appear to be fairly well nourished, complains of pain coming on after meals, not immediately, but after an interval of two or three hours, and often relieved by taking more food. Be- ginning with a sense of fulness and heat in the epigastrium, it develops into acute pain located in the right hypochondrium and shooting through to the back. On examination of the abdomen a tender spot is usually to be detected a little above and to the right of the umbilicus (Fig. 480, D). The patient complains much of acid eructations, but vomiting is not a very frequent symptom; when present, it may reheve the pain. The ejecta may contain a certain proportion of bile. The patient is constipated and loses weight durhig an attack. Frequently he has intervals of complete freedom from pain, in which he can digest anything and enjoy life. In a considerable percentage of cases, moreover, the condition is abso- lutely latent and free from symptoms until acute manifestations of perforation or haemorrhage supervene. Perforaiion usually involves the first part of the duodenum, and may be intra- or retro-peritoneal. The conditions produced are practically identical with those following a perforated gastric ulcer, but with slight differences due to the change of situation. Thus, with the usual acute intraperitoneal perforation the fluid on escaping from the duodenum is guided downwards by the ascending meso- colon to the right iliac fossa, and hence the symptoms of acute appendicitis are somewhat simulated; but it may be possible to locate the primary pain to the hypochondrium. The mischief soon spreads, however, to the general cavity, and the locahzing symptoms ABDOMINAL SURGERY 1013 disappear. The effusion includes the fluid duodenal contents, often very abundant and perhaps bile-stained, and usually free gas. If the opening in the duodenum is small and the contents escape slowly, a subphrenic or subhepatic abscess may form, but the adhesions are not very firm, and it may burst secondarily into the general serous cavity. A retroperitoneal perforation of the duodenum is the origin of a subacute subphrenic abscess, which is placed behind the peritoneal cavity, but always to the right side of the falciform ligament. HcBinorrhage is evident in most cases in the form either of hsema- temesis or melaena. The history generally given is that during a dyspeptic attack a sensation of faintness occurs, followed by anaemia. Part of the blood lost may be vomited, but the greater portion passes down the intes- tine, giving rise to melsena. The patient may die from loss of blood, and then usually some large branch of the pancreatico- duodenal vessels has been laid open ; more frequently it ceases after a time, but may be repeated again and again. Stenosis of the duodenum re- sults from the cicatrization of ulcers, and may lead to fre- quently repeated vomiting, dys- pepsia of an intractable type, a greatly distended stomach, and emaciation to an alarming degree. Treatment. — ^If a diagnosis can be made and no complications are present, the same treatment is instituted as for gastric ulcer — viz., rest in bed and rectal alimentation. Persistence of symptoms — e.g., vomiting, haemorrhage, etc. — is treated by gastro- jejunostomy, and the results are most satisfactory. Perforation, of course, needs immediate operation, as described for the stomach (p. 994). In the earlier stages of a duodenal perforation, the incision will probably be located along the right semilunar line for 4 or 6 inches. The opening, when found, should be stitched up in the transverse axis of the bowel, so as not to diminish its calibre. Stenosis of the duodenum is treated most successfully by gastro- enterostomy, and there are few operations in surgery which give more gratifying results. Fig. 480. Tender Spots in Abdom- inal Lesions. C, In ulcer of stomach near the cardiac orifice; G, in the ordinary t5rpe of gastric ulcer; D, in duodenal ulcer; GB, in affections of the gall-bladder ; A, in appendicitis (McBurney's spot) . IOI4 A MANUAL OF SURGERY Affections of the Intestine. Bismuth Radiography of the intestines is often of great assistance in the diagnosis of the condition and position of various lesions. As already men- tioned (p. 989), the stomach should be empty in about four hours, and about the same time (four and a half hours) the bismuth should begin to enter the cascum; it is not usually possible to trace the bismuth in the duodenum or along the small intestine. There is not uncommonly some hindrance to the escape of bismuth through the ileo-caecal valve, and the bismuth may collect in the lower end of the ileum, and be seen in the pelvis. The hepatic flexure is generally reached in five to eight hours, the splenic flexure in seven to four- teen hours, and the iliac colon in eight to sixteen hours; the bismuth normallj' disappears from the bowel in from twenty-four to thirty-six hours. Irregu- larities in the course of the intestine can often be detected by this means, such as strictures, kinks, diverticula, etc. The appendix can occasionally be recognised, but difficulty in the escape of the bismuth from the small to the large intestine may suggest the existence of adhesions binding down the appendix. Too much stress must not be laid on radiographic reports apart from a careful consideration of the clinical phenomena. Bismuth is heavy, and a downward displacement of the intestine when loaded with it is a natural consequence; it is also somewhat astringent in type, and determines con- traction of the intestinal wall, so that the diverticula of the colon become exaggerated. Finally, it must ever be remembered that radiographs are shadow pictures, and unless taken stereoscopically it is possible to imagine the existence of severe kinks due to the overlapping of the shadows, when in reality nothing of this type is present; this warning especially needs emphasis in interpreting radiographic representations of the flexures of the colon. Congenital Conditions are occasionally met with affecting the intes- tine, and perhaps giving rise to serious complications, (a) The most common of these consists in what is known as Meckel's diverticnlwn, which occurs as an outgrowth from the lower end of the ileum. Tt may be patent for i or 2 inches, terminating possibly in a fibrous cord, which floats free among the intestines, or ma^^ contract ad- hesions, and thus determine an internal strangulation ; sometimes it persists as an open tube as far as the umbilicus, giving rise to a con- genital faecal fistula. It is due to non-obliteration ot the omphalo- mesenteric duct. Many forms of acute abdominal trouble have been caused by this structure, and even inflammatory attacks similar to acute appendicitis; gallstones or enteroliths have lodged within it and caused perforative peritonitis. (&) Congenital stenosis of the duodenum occurs opposite the 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. Contusion of the Intestine may result from any serious blow on the abdomen, and necessarily varies 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 simplest form, it merely produces a little bruising of the intestinal wall, fol- lowed by a subacute or chronic enteritis, from which with care the patient quickly recovers. In the more severe cases, an acute enter- itis ensues, due to bacillary invasion, which may even run on to ulceration or sloughing of the coats of the bowel. The latter result A li DOM IN A L S URGER Y 10 1 5 BISMUTH RADIOGRAPHY OF THE INTESTINES. Fig. 481. — Slight Downward Displacement of Transverse Colon. Fig. 482. — Enteroptosis with Transverse Colon in the Pel- vis. The stomach is occupied by a bis- muth meal given two days after the former, part of which had not escaped. Fig. 483. — • Intussusception of Cancer of C^cum into Trans- verse Colon. The bismuth does not extend much beyond the hepatic flexure; the pre-operative diagnosis was cancer of the transverse colon. For speci- men removed from this case, see Fig. 485. Fig. 484. — Enteroptosis with Ob- struction IN Transverse Colon. The bismuth can just be traced in the splenic flexure and beyond; it is evidently retained in caecum and ascendina; colon. ioi6 A MANUAL OF SURGEIiY is more likely to follow if the mesentery has also been involved in the injury so as to produce thrombosis of the mesenteric vessels. Under these circumstances, the final issue depends largely upon the rapidity of the inflammatory process. If adhesions luu'c had time to form between the parietcs and the injured gut, the mischief is limited, and the patient may recover with a fsecal fistula, the formation of which has been preceded by a localized intraperitoneal abscess, containing extremely offensive pus, owing to the presence of the B. colt, which has migrated through the intestinal wall. If, however, the inflam- matory 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 the bowel is retro-peritoneal, as in the duodenum or colon, a retro-peritoneal abscess may form. The Symptoms of intestinal contusion consist primarily of shock and pain. The amount of shock varies necessarily with the severity of the injury and the nervous susceptibility of the patient. The pain may not be severe at first, but is always very marked subsequently, and increased by examination, movement, or during violent respira- tory efforts. To limit 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 contusions of the abdominal wall (p. 971) ; viz., where there is no absolute evi- dence of rupture, an expectant attitude may be adopted, but the surgeon must be ready to interfere should any grave or suspicious symptoms arise. Acute enteritis induces diarrhoea 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 or rectal feeding is alone permissible. Rupture of the Intestine folic ws abdominal injuries of a more severe character, such as when a cart or cab has traversed the abdo- men, or when the patient has been tightly squeezed or kicked. The bowel does not always give way at the point of impact, but occasion- ally at a distance from it ; under these circumstances 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. The fluidity of the contents of the small intestine has a grave prognostic significance, since they are readily diffused. The early Symptoms consist of severe and u.-.ually lasting shock, accompanied by intense abdominal pain, which may at first be localized. If there is an abundant escape of the intestinal contents, a virulent form of acute peritonitis follows immediately, frcm which the patient rapidly succumbs. If, however, the gut was empt}^ at the time of the accident, the symptoms are less severe; acute peri- tonitis ensues, but it is slower in onset, and some attempt to hmit it ABDOMINAL SURGERY 1017 is observed. An important diagnostic point is that the maximum tenderness is always fixed to a localized area. Free gas is sometimes, but not frequently present in the peritoneal cavity, as in rupture of the stomach In a few cases emphysema of the abdominal walls has been noted, 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 uncer- tainty in the absence of emphysema of the abdominal walls, which is very uncommon. Formerly it was supposed that free air or gas in the peritoneal cavity would be certain to find its way up between the liver and the abdominal wall ; hence loss of the liver dulness was con- sidered an important sign. It is by no means certain, however, that the gas does travel in this direction, and a resonant note over the liver is a common result of distension of the colon. If, however, the abdominal wall is retracted and not distended, the existence of this sign IS suggestive. The amount of shock is also an uncertain guide, as it varies both in degree and duration. The temperature does not help much, although a secondary fall below normal after reaction, especially if associated with increasing rapidity of pulse and respira- tion, is very suggestive of grave mischief. 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 certamty. The history and nature of the accident are important, and should be carefully investigated. In the non-existence of any distmct signs of rupture. Treatment in the early stages can only be expectant, and directed towards com- bating 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 contents; but as little as possible should be given, since it tends to mask symptoms. If the surgeon has good grounds for suspecting that the intestine is torn, he ought at once to undertake an exploratory laparotomy, and deal with the condition found. Punctures or Stabs involving the intestine lead to a similar series of phenomena ; but the diagnosis may be easier, as gas or fascal material may escape through the external wound. The direction of the in- cision in the gut is of importance, since a longitudinal cut (running parallel to the axis of the bowel) is more likely to gape than a trans- verse one, owing to the greater power of the circular muscle fibres ; a small puncture may be almost closed by a protrusion of mucous membrane. Shock is not necessarily so severe as when the intestine is ruptured by violence without penetration; abdominal pain is always present, and the phenomena of acute peritonitis may quickly follow. iox8 A MANUAL OF SURGERY Treatment. — Every case of suspected penetration should be care- fully explorc'd. The skin and superlicial parts of the wound are first thoroughly })uriried, and then the wound is enlarged and the deeper parts are examined. If the peritoneum is not opened, the different layers of the abdominal wall are sutured togi^ther. 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 invaginated and closed by a purse-string stitch or by a row of Czerny-Lembert sutures. If a more extensive lesion exists, excision of 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 temporary artificial anus, which is subsequently dealt with when the patient's general condition has improved. As to the treat- ment of the resulting peritonitis, the reader is referred to what has been written concerning rupture of the stomach (p. 990). For Gunshot Wounds and their treatment, see pp. 248 and 249. 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. The phenomena resulting from the perforation of an ulcer of the stomach or duo- denum has been already discussed (pp. 994 and 1012), and another variety caused by perforation of the appendix will be alluded to sub- sequently (p. 1044). When the jejunum or upper portion cf the ileum is involved, per- foration is usually due to the impaction of a foreign body, such as a fish-bone, or to yielding of a tuberculous ulcer. In the former case, general peritonitis is almost certain to follow, but in tuberculous cases the lesion is of a more chronic type, 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 spontaneous closure of the fistula, and no operation should be undertaken until suilicient time has elapsed to determine whether or not this will occur. In the lower portion of the ileum, typhoid fever is the most usual cause of perforation. Occasionally in cases of the so-called ' ambula- tory typhoid ' it is the first evidence of the presence of the disease, but it generally occurs about the end of the second or in the third week, and rarely more than one perforation is present. It is most commonly seen in bad cases associated with meteorism and hcxmor- rhage, but is not limited to such. 1 he symptoms are usually those of sudden collapse, as indicated by a falling temperature and a quick and feeble pulse, whilst severe and persistent abdominal pain fol- lowed by increasing distension indicates the development of general peritonitis. Even when the patient is already collapsed by the dis- ease, some shght fall of temperature with acceleration of the pulse may occur, associated with al:»dominal pain and meteorism. Early ABDOMINAL SURGERY toi.j rigidity of the belly wall is an important diagnostic sign, whilst there may be some irritability of the bladder. The only treatment which holds out an}^ prospcc^t of saving the patient is operation, but owing to his depressed condition the outlook is not particularly bright. Obviously, when he is moribund, it is useless to interfere; but the facts that of some 300 cases operated on and reported 27 per cent, have recovered, and that the death-rate has gradually fallen from go to 69 per cent., indicate that in cases diagnosed early a fair propor- tion of success may be anticipated. The abdomen should be opened in the middle line below the umbilicus, or directly into the right iliac fossa, and if the lesion is not at once obvious, the ileum is sought for at its junction with the csecum, and the bowel brought up and care- fully examined inch by inch till the perforation is found ; it may then either be closed by sutures introduced so as to close the wound in the transverse axis of the gut and thus diminish the risks of a sub- sequent stenosis, or the edges of the ulcer stitched to the margins of the wound so as to create a temporary fistula. The peritoneum is cleansed and drained in the usual way, after determining that no second perforation is present or imminent. In the large intestine the most common cause of perforation is ulceration due to chronic obstruction or malignant disease. Masses of faeces accumulate within the bowel, and bj^ their pressure give rise to inflammation of the walls, which runs on either to ulceration or to actual necrosis. Most usually the peritoneum is by this means laid open, either just above the growth, or as a consequence of its local extension ; sometimes, however, the bowel gives way at a higher level, where faeces mainly accumulate, and then geneially in the csecum. In many cases acute perforative peritonitis follows, but occasionally the mischief is limited, and an intraperitoneal abscess forms, followed by a faecal fistula. Foreign Bodies in the intestine are of three types : 1. Gallstones give rise to no symptoms unless they are of large size ; the smaller ones enter the canal through the common bile-duct after an attack of biliary colic, and are voided in the stools. Larger stones usually gain entrance to the intestine by ulceration from the gall-bladder into the duodenum. A coating of faecal matter 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, so that they are likely to become impacted in the lower ileum. Women over hity 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 biliar}' colic. 2. £"';2/erc'/i;'//s are of three classes : [a) CalcuH of phosphate of lime or inspissated fasces form around some foreign body as a nucleus. [h] Masses of indigestible vegetable material may be matted together with inspissated faeces, mucus, etc. ; they are said to be not uncom- mon in Scotland (the so-called avenolith), consisting largely of the husks of coarse oatmeal. They have also been known to consist of I020 A MANUAL OF SURGERY hair, or of cocoanut fibre in a patient engaged in mat-making, (c) Calculi have been found consisting of insoluble mineral salts — e.g., carbonate of magnesia or chalk, taken as medicine. Whatever their origin, such enteroliths are likely to become imi)actcd near the cae- cum, and may cause acute obstruction. In thin persons their pres- ence may be detected by palpation of the abdomen. 3. Foreign Bodies accidentally or intentionally swallowed occasion- ally pass through the stomach and become lodged in the intestinal canal. Lunatics and children are most frequently affected, and in the former the most astonishing collections arc occasionally found. I he Symptoms caused by such conditions will be either those of intestinal obstruction (p. 1130) or of perforation. In the latter the process is usually gradual, rather than sudden, giving time for adhe- sions to form, thereby limiting the mischief. Suppuration follows, and possibly the foreign body may be extruded naturally or removed by the surgeon through the abscess cavity, with or without the for- mation of a faecal fistula. Small spiculated foreign bodies — e.g., fragments of glass or metal, the husks of cereals, etc. — may sometimes lodge in the pouches of the colon, and give rise to localized inflammatory phenomena, perhaps in one or more of the appendices epiploicae. The symptoms w'ill very closely resemble those of a localized appendix abscess, and similar operative treatment will be required. In other cases a chronic in- flammatory mass may be produced which simulates a neoplasm of the intestinal wall, and may disappear spontaneously or after ex- ploration. The supposed cure of certain cases of intestinal cancer by quack remedies may be explained in this way. Enteritis, or inflammation of the mucous membrane of the intes- tine, is a condition usually treated by the physician ; occasionally it complicates surgical cases and needs effective treatment. Thus it may follow the exposure of a coil of intestine in the depths of a wound which has to be packed for drainage purposes. Severe diarrhoea may result, and the inflammation may even spread through the whole thickness of the gut wall, and lead to the establishment of a faecal fistula. Enteritis also occurs as a post-operative complication of strangulated hernia (p. 1121). Whatever its origin, it is always characterized by diarrhoea of varying type, and by pain or abdominal discomfort and perhaps vomiting. Treatment consists in the use of a bland diet- — e.g., milk — and the administration of soothing astringent drugs, such as bismuth and perhaps opium. It must not, however, be checked without ascertaining so far as possible that the causative irritant has been removed, and not uncommonly the best treatment to start with is the administration of a good dose of castor oil. Colitis is an affection occasionally needing surgical treatment. The cause is usually chronic constipation, but bacteria of various t^'pes or the Amceha coli may be present. In the simpler cases {mucous colitis) the patient complains of griping pains in the course of the colon, diarrhoea, the passage of mucus in the stools, perhaps in membranous flakes, and definite tenderness of the colon on ABDOMINAL SURGERY ro2i palpation. The appendix is not unfrequently inflamed at the same time, and one of the most tender spots may be over this organ. Ti'cahncnl of this form eonsists in emptying the bowel by enemata, Iceeping tlie patient quiet in bed on a milk diet, and possibly ordering bismuth or a little chlorodyne. When the patient is convalescent and all tenderness has disappeared, the causative chronic constipa- tion must be treated. Purgatives usually cause irritation and pain, and must be as far as possible avoided. Abdominal massage and the methodical use of the so-called Swedish exercises, which increase the power of the abdominal muscles, and thereby give tone to the re- laxed colon, will often work wonders in these cases. The use ot medicinal waters and irrigation of the colon, as practised at Harrogate and Plombieres, often give excellent results. In a certain percentage of cases removal of the appendix does good in colitis, but before undertaking the operation the surgeon must be careful not to promise too much. The graver cases [ulcerative colitis) are associated with the dis- charge of pus and the exfoliation of patches of mucous membrane. The patient's health may be profoundly affected in this disease, pus of a most offensive type pouring out from the rectum, or fever of a marked hectic character being present. The nutrition is necessarily impaired, and the patient wastes to a shadow. Under such circum- stances, and especially when rectal irrigation has failed, the surgeon may be asked to make an artificial opening into the caecum in order to permit of more thoiough irrigation, and also perhaps to divert the intestinal contents. For the method of operating, see p. 1031. The fluid employed for irrigation must be bland, non-toxic, and unirri- tating. Warm saline solution should be first used, and subsequently a weak boric acid solution, or possibly, with great care, a i in 5,000 solution of nitrate of silver. The patient sits over a bed-pan, and the fluid is injected through the fistula from an irrigator; distension of the bowel must be avoided, and to this end the introduction of a rectal speculum to keep the anus open during the irrigation is desir- able. Latterly the vermiform appendix has been used for this pur- pose ; it is stitched into the wound and opened {appendicostomy) , and the bowel irrigated through it. The escape of intestinal contents is less than if the bowel is opened, and subsequent closure of the fistula after the disease is cured is more easily effected. It is probable that some amount of stenosis of the bowel may result from the cicatriza- tion of the ulcers in the colon, and then the fistula may have to remain permanently. Tuberculous Disease of the Intestine usually occurs in the ileo- csecal region, and manifests itself in two main varieties : I. Tuberculous Ulcers are generally multiple, though occasionally single. They are of the usual tuberculous type, with undermined margins (Fig. 45, p. 183), and extend along the course of the blood- vessels and lymphatics — viz., around the gut, so that if they heal stricture is almost certain to follow. In their early stages they do not require surgical assistance, but later on obstructive phenomena 1022 A MANUAL OF SURGERY may supervene, and these may be due not only to the stenosis, but also to associated peritonitis; neighbouring mesenteric glands are usually infected, and together with the bowel and omentum may form a pal])able mass, in the midst of which suppuration may occur. Should the abscess burst externally, a ftecal listula may result. Operation may be needed for the relief of the obstructive phenomena, or for the suppuration, and some form of anastomosis, or even excision of the mass, may be required. 2. The disease is sometimes of a hyperplastic type, and is then chiefly limited to the caecum, producing a well-marked tumour, which can be palpated from outside, known as the Tuberculous Csecal Tumour : the disease is liable to extend along the ascending colon for some distance, and less frequently along the ileum. The intestinal wall is thick, congested, and infiltrated with a tuberculous deposit ; the outer coat is rough and nodulated ; the mucous lining is ulcerated and often presents vegetations and polypi of a granulomatous type ; the mass is firm, but not hard to the touch. The neighbouring mesentery is occupied by enlarged glands, and these may also be found on the inner border of the ascending colon. Adhesions may be present, and lead to kinking or twisting of loops of bowel, which may assist in producing intestinal obstruction. The sj'mptoms vary a good deal, but in the early stages constipation and diarrhtea may alternate, whilst later on obstructive phenomena may supervene, or even well-marked pyrexia of a hectic type. The diagnosis from a caecal carcinoma is not always easy ; the chief points in favour of tubercle are the earlier age (under forty years), the longer duration of symptoms (two or three years), the associated pyrexia, and the presence of tuberculous lesions elsewhere. The diagnosis is, how- ever, not uncommonly made on the operating-table. Treatment consists in short circuiting, or excising the mass. The latter may involve an extensive procedure, but even when enlarged glands have to be left behind, the case may do well. Stenosis of the Intestine arises from two main causes — the contrac- tion of cicatrices or adhesions, and the development of tumours, usually malignant. Simple or cicatricial stricture usually results (i) from the healing of ulcers which have extended more or less circularly around the bowel, or have involved its walls extensively. Hence, tuberculous ulcers lend themselves to its development more than the typhoid lesion, and it is a little doubtful whether it has ever occurred as a sequela of the latter. Syphilitic ulceration is followed by it, especi- ally when involving the rectum; but the upper part of the jejunum is also occasionally affected. In the large intestine dysentery is the most common cause, and the stenosis, like the ulceration, may be irregular and extensive. (2) It may follow strangulated hernia as the result of ulceration along the actual site of constriction; and, similarly, it may develop after the separation of an intussusception. (3) An end-to-end anastomosis of the gut may lead to stenosis unless considerable car€ is taken not to tuck in too much of the ABDOMINAL SURGERY 1023 gut Willi. (4) The contraction of adhesions outside the intestine is by no means an uncommon cause; thus it may be due to many forms of localized peritonitis, and frequently ensues after pelvic cellulitis. Owing to the contents of the small intestine being of a somewhat 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 mucous membrane or by a portion of 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 recur- rence 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 relieving the patient, as they often do m the earlier attacks in the small gut, always aggravate the symptoms; there is also much greater dis- tension of the abdomen. The diagnosis of stricture, though strongly suggested by the symptoms, can only be confirmed absolutely by an exploratory operation, except when the lower part of the rectum is involved. The Treatment in the earlier stages consists of suitable dieting, and the administration of purgatives or of large enemata, and for a time such will be successful. Sooner or later, however, a more than usually serious attack of obstruction will call for something more radical, and readers are referred to the chapter on obstruction for details of the treatment to be adopted. Apart from the question of obstruction, a stricture of the small intestine is to be treated by enteroplasty or enterectomy. For stricture of the caecum or ascend- ing colon, some short-circuiting method, whereby the ileum is im- planted into the colon below the stricture (ileo-colostomy) , is per- haps the best plan to adopt ; in the transverse colon excision is pos- sible, as also in the sigmoid flexure. Failing any of these measures, the establishment of an artificial anus will be required to give relief. It must be remembered, however, that no permanent opening of this nature can be permitted in the small intestine since the absorp- tion of nourishment is thereby so interfered with that death from asthenia is certain to follow in a comparatively short time, whilst the intestinal contents are fluid and extremely irritating to the skin. Tumours of the Intestinal Wall maj^ be simple or malignant, primary or secondary. Simple tumours are unusual, and consist of papilloma, adenoma, myoma, lipoma, and a few other varieties. They may cause irritation and irregular action of the gut, resulting perchance in intussusception (p. 1136) ; haemorrhage, sometimes of a serious character, is associated with multiple papilloma or adenoma ; and obstruction occasionally ensues. It is unusual for a diagnosis to be made apart from an exploratory laparotomy, unless the rectum I024 A MANUAL OF SURGERY is affected. The treatment is governed by the location of the growth and by the symptoms it causes. Scino))ia of the intestine is not common; it may involve the ileum or ciecum, and give rise to a localii^ed tumour or diffuse iniiltratioii. Obstruction may ensue, or considerable ])eritoneal irritation resulting in an abundant blood-stained exudation which leads to al)dominal distension, and may be recognised as due to a new growth on taj)- ping. Treatment consists in removal of the affected coil of gut if the disease has not progressed too far. Cancer of the Bowel is almost always primary in nature, and is then usually a columnar carcinoma, to which colloid degeneration is sometimes added. The small intestine is rarely involved, but any part of the colon may be affected, and even the vermiform appendix. vSecondary growths are occasionally met with, and are necessarily of the same nature as the original tumour. The physical characters of the growth vary considerably, but usually conform to one of two types — viz., (i.) the hypertrophic, in which a large mass forms, perhaps occupying the whole lumen of the bowel (Fig. 485). It IS a fairly rapid groNvth, and usually associated with ulceration and haemorrhage, whilst obstructive phenomena are late in appearing, (ii.) In the sclerosing form the tumour develops as an annular con- striction around the bowel, the lumen of which is contracted so that it may be almost impossible to pass a crow's quill or a probe through it (Fig. 486). It is an astonishing fea.ture of these cases that the func- tion of the bowel is carried on without much pain or difficulty until the lumen is almost obliterated, and then suddenly a serious attack of obstruction occurs. Sometimes the bowel looks from outside as if a piece of string had been tied round it, so great is the constriction. Above the gro^vth the bowel is hypertrophied and dilated; the mucous membrane is often congested, inflamed, and even ulcerated; the latter lesion is usually due to the irritation of stagnant faeces, and the ulcers are termed ' stercoral.' Bacteria may find their way into and through the intestinal wall from these foci, and lead to peri-intestinal suppuration, and as a sequela a fsecal fistula may develop. The bowel below the growth is often distended (' bal- looned ') from paralysis of its walls, and the development of gases from the faecal material which may accumulate from the loss of the vis a tergo ; this can often be remarked in cancer of the rectum. The irritation of the tumour leads sooner or later to the formation of adhesions, which may assist in hampering the action of the bowel. Secondary deposits occur in the mesenteric glands and omentum, and less commonly in the liver or distant regions ; but there can be no question that the growth is often much less malignant in type than cancer elsewhere, and both adhesions and secondary deposits are usually late developments. On the other hand, there is a con- siderable degree of permeation by cancer cells, and this over an area so extensive that it is useless to undertake removal of merely the affected portion of the bowel; a wide and extensive excision will alone suffice to cure. ABDOMINAL SURGERY 1025 The Symptoms are at first vague in the extreme, and the disease is likely to ha\-c progressed for some time before a diagnosis is reached. The patient complains of indigestion of an intestinal type ; there may be some pain of a cohcky character, and either constipation or diarrhrea may be present; not unfrequently they alternate, the constipation being primary, and the diarrhcea result- ing from the decomposition of retained faeces, or a catarrhal enter- itis set up thereby. A discharge of mucus or blood mav be noticed in the stools, and the patient's nutrition begins to suffer, although wasting is at first slow. Fig. 485. — Hypertrophic Cancer of the c^cum, invaginated into the Transverse Colon. For bismuth radiograph of this case see Fig. 4S3. This growth was successfully removed, and an ileo- colostomy performed. Fig. 486. — Carcinoma of the Descending Colon. The growth was of the sclerosing type, and had given rise to no symptoms except a httle diar- rhoea until the onset of a fatal attack of obstruction. The conditions which may require and justify interference by the surgeon are as follows: (i) Repeated attacks of slight ob- struction, especially if localized resistance of the abdominal wall or an indefinite sense of fulness in some region is associated there- with; (2) an acute attack of obstruction, the nature and s\Tnptoms of which vary A\ath the site of the lesion; (3) the existence of a tumour, which, though at first readily moveable, becomes fixed after a while, owing to the formation of adhesions ; and (4) the development of a peri-intestinal abscess. On the other hand, if it 65 1026 A MANUAL OF SURGERY is evident that secondary deposits are present in the omentum or elsewhere, and the primary growth is so large or fixed that its removal is doubtful, it is useless to undertake merely an exploratory operation. In these cases it will suffice to interfere when obstructive phenomena make their appearance. The mere handling of such a growth, the inner surface of which is probably ulcerated, is some- times sufficient to determine increased activity of the bacteria, and the development of an abscess around the grow'th, which may be followed by diffuse or localized peritonitis, and even by a faecal fistula. The importance of an early Diagnosis cannot be over-estimated ; every case of irregular intestinal function, especially if associated with pain, should be carefully investigated by abdominal palpation, and if need be by bismuth radiography. Sigmoidoscopy is also of value in examining the lowest lo or 12 inches of the bowel. Treatment. — Unfortunately, cases are usually left until the pro- gress of the disease has settled the question of diagnosis, and then palliative treatment may alone be possible. If found early enough, a radical operation for removal of the growth may be undertaken, and the intestinal canal restored by enterorrhaphy. Affected mesenteric glands are included in the part excised, if possible, but the total removal of the growth is quite justifiable, even if glands have to be left, inasmuch as it restores the functional activity of the tube. It must be remembered, however, that unless the bowel has been thoroughly emptied previously it is always wiser to make a temporary artificial anus, and restore the continuity of the canal at a later date. Hence excision should never be undertaken when obstruction is present. Cancer of the caecum requires removal of the lower inch or two of the ileum, as well as of the caecum and a varying portion of the ascending colon (possibly, for choice, the w^hole), in order to include the l}Tnphatic area; the ileum is then united to the transverse colon. In cancer of the ascending colon or hepatic flexure, the excision must extend well into the transverse, and it is then easier to include the caecum in the scope of the excision and unite the ileum to the transverse colon than to leave it behind. Cancer of the transverse colon must be removed with a free hand, and then, by ' mobilizing ' (p. 1038) the ascending and descending portions of the colon, it may be possible to anastomose them effectively; failing this, an ileo- sigmoidostomy must be performed. Cancer of the splenic flexure is often difficult to remove because of its greater fixation, but when practicable must include the left half of the transverse colon and a portion of the descending colon. The continuity of the intestinal canal is restored by uniting the proximal end of the transverse to the iliac colon, or by performing an ileo-sigmoidostomy. Cancer of the iliac colon involves removal of the greater part of the descend- ing colon with it, and the union of the transverse colon to the pelvic colon or rectum; in some cases it is wiser to perform an iliac colostomy, and remove completely the segment of bowel below it. The same practice holds good for many cases of cancer of the pelvic ABDOMINAL SURGERY 1027 colon or upper end of the rectum, where it is impossible to restore the continuit}' of the canal. Should excision be impracticable, owing to the extent or hxity of the tumour, the following plans of treatment may be considered, and that which best suits the requirements of the particular case undertaken. 1. The growth may be short-circuited by uniting portions of gut above and below it. This is usually accomplished by one of the forms of lateral anastomosis described hereafter; thus, the caecum may be 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 lower end of the divided bowel being closed (Fig. 487). This lateral implantation is the best plan of treatment to emplo^^ for cancer of the caecum which cannot be extirpated; the ileum is divided above the valve, and its upper end implanted into the ascending or transverse colon well beyond the growth (ileo- colostomy) , whilst the lower end is totally closed. 3. The affected coil of gut has been excluded from the intestinal tube by dividing the bowel above and below, and uniting the upper and lower segments. One end of the diseased coil is closed, and the other is brought to the sur- face and fixed there so as to establish a fistulous track. There is always a certain amount of discharge from the cancerous growlh, and the mucous mem- brane itself secretes, so that total closure of the excluded loop would be accompanied by danger. 4. Finally, if none of these measures are appHcable, 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 may be established. Idiopathic Dilatation of the Colon (Hirschsprung's disease) is a rare affection met \\dth in infancy, but occasionally lasting on till young adult life. The cause in many cases is unknown, but con- genital contraction of the rectum has been found in some. It is characterized by enormous distension of the colon, and usually of the sigmoid flexure ; possibly on opening the abdomen nothing but the colon is seen. The walls are h5^pertrophied, and stercoral ulcers may be present. The abdomen is distended, but soft and free from rigidity; the child does not complain of pain and tenderness, and Fig. 487. — Lateral Implantation of Divided End of Ileum into the Transverse Colon for Irremove- ABLE Cancer of the C.a;cuM (Ileo- colostomy) . 1028 A MANUAL OF SURGERY vomiting is unusual. The most prominent symptom is constipation, and that generally of a most obstinate character, purgatives having no effect but to cause pain and vomiting. Enemata are often re- tained, and even gas cannot easily be passed; the introduction of a long flatus-tube is followed by the escape of very putrid gas in large quantities. Death results from cachexia, perforative peritonitis, or obstruction. Treatment. — Purgatives must be avoided, but massage and electricity may do good, together with the routine use of ene- mata. Excision of the distended portion, followed by a lateral anastomosis, is probably the best surgical treatment. In one case, operated on by Sir F. Treves, excision of the rectum, sigmoid flexure, and descending colon was performed, and the transverse colon was dragged down and fixed in the perineal opening. Enteroptosis, or Glenard's disease, is a condition not uncommonly met with in which there is a general displacement downwards of the viscera. The small intestine, transverse colon, kidneys, and stomach are the organs chiefly involved, but any of the viscera may be affected. The cause varies and cannot always be ascertained ; some- times it commences after an acute illness, more usually it is chronic and develops gradually. Ihe relaxed abdominal wall which follows repeated pregnancies is often present, and tight-lacing may be an important causative factor. Women are much more frequently affected than men. The condition per se is not necessarily associated with symptoms, but in a considerable number of cases marked neurasthenia is present, possibly from the drag of the viscera upon the sympathetic plexuses in the posterior abdominal wall. The amount of displacement is no measure of the severity of the symp- toms. The stomach may be well below the costal arch, and when inflated stands out prominently, both curvatures being visible; it is usually distended atonically, and succussion sounds may be heard. The relaxation of the small intestines is alluded to in connection with the setiology of hernia (p. 1086). The transverse colon may sag downwards into the pelvis, and the kinking of the splenic and hepatic flexures thereby induced may be an important element in the production of constipation. For bismuth radiograph of pro- lapsed transverse colon, see p. 10 15. The spleen and liver may also slip downwards. Displacement of the kidneys is referred to under the heading ' Moveable Kidney.' Treatment must be wisely modified according to circumstances, and due allowance made for the neurasthenic element. A course of Weir Mitchell treatment (i.e., rest and feeding) is often valuable, both for its influence on the nervous state and also in assisting to increase the deposit of fat. Electricity and massage to the ab- dominal walls, together with suitable gymnastic exercises, help to restore their tone and to improve the condition of the underlying viscera. An abdominal belt or bandage will do much to relieve symptoms, especially if applied with the patient in the Trendelen- burg position. Operation is not to be lightly undertaken; but if a fair test has been given to the above measures, it may be justifiable ABDOMINAL SURGERY 1029 to open the abdomen and stitch up into place organs like the stomach, liver, or spleen, or to brace up the abdominal wall by some plastic operation, such as that suggested on p. HOQ- For treatment of moveable kidney, see p. 1190. The question of removing or short- circuiting the kinked colon may also have to be considered. Intestinal Stasis is a term recently introduced to indicate a con- dition of abnormal delay of the bowel contents in some part of the intestinal canal, especially the colon. This delay allows marked putrefactive changes to occur, and in consequence abnormal ab- sorption of toxins, which, circulating in the blood-stream, produce not only a general depreciation of health, but also considerable degenerative changes in many of the viscera and tissues. Sir Arbuth- not Lane has done most excellent work in emphasizing the char- acter and dangers of this condition, although his theories and con- clusions are not generally accepted by all surgeons. He attributes the whole range of phenomena to the assumption by man of the erect attitude and the natural consequential tendency of the in- testines to drop. To counteract this, a reactive formation of peri- toneal bands and membranes occurs, producing results more or less similar to those following peritonitis, and attaching the intestines to parietal structures. Thus to the outer side of the ascendmg colon one often finds a set of membranous bands running down- wards and inwards from the parietal peritoneum to lap over the intestine and be attached to the front of the ascending meso-colon ; this thin vascular veil is sometimes teimed Jackson's membrane, and if at all exaggerated may cause interference with the activity of the colon. At the hepatic and splenic flexures similar developments occur, and may cause such contractions as to kink the gut severely. Even more importance is attached by Lane to a band of adhesions running from under the surface of the mesentery to the anti-mesen- teric border of the ileum, a few inches from the caecum; the contrac- tion of this band causes a kink at the termination of the ileum [Lane's ileal kink) , and thus determines retention of the ileal contents. The result of this is increased sagging of the small intestine m the pelvis and dragging on the duodeno-jejunal flexure; this is stated to cause a reactive formation of bands, which first support the flexure, but, if excessive, subsequently kink it, causing dilatation of the stomach and duodenum. Similar bands and kinks are de- scribed elsewhere. The whole series of phenomena is looked on as mechanical and reactive, and not of an inflammatory nature, although structures, such as the appendix or gall-bladder, are often involved in the adhesions. This view of the condition is not uni- versally accepted; many surgeons look on the bands as the result of inflammatory attacks, and Professor Arthur Keith has shown that many of them are of congenital origin and due to an exaggera- tion of the ante-natal plastic peritonitis which fixes the colon in its place. The subject, however, is too large to discuss here, and opinions at present too divided to allow of dogmatization. * For further details, see Report on Discussion on Intestinal Stasis, Royal Society of Medicine, vol. vi., Nos. 5 and 7 (Supplements). I030 A MANUAL OF SURGERY The Symptoms arising from intestinal stasis are threefold: (i.) Mechanical results follow from distension of various portions of the intestinal canal- — e.g., the stomach, duodenum, ileum, or colon. Most of these have been alluded to already, but one would especially emphasize the troubles that arise from prolapse of the colon into the pelvis, which can be readily demonstrated by bismuth radio- graphy (Fig. 482). The colon becomes filled with liquid faecal material which cannot be passed on. (ii.) Inflammatory phenomena of various types follow this stasis- — e.g., gastric and duodenal ulcera- tion, appendicitis, colitis, etc. (iii.) Toxic results necessarily ensue, and include such conditions as enfeebled circulation, cold sweating, cyanosed extremities, facial pigmentation, muscular weakness, with various nervous and perhaps mental perturbations. The resistance of the individual to bacterial invasion is also lowered, and sundry infective diseases may supervene. Treatment. — Early and mild cases can often be treated effectively by improving the tone of the abdominal wall and increasing the motor power of the colon by a course of abdominal massage and suitable gymnastic exercises. Purgatives, intestinal antiseptics (such as liquid paraffin), careful attention to diet, and a sufficiency of rest in the recumbent posture, will do good; a relaxed abdominal wall, of course, requires suitable external support or some operative treatment to tighten it up. In the worst cases, where the caecum and transverse colon sag into the pelvis and have become literally transformed into cesspools filled with putrid faecal material, ileo- colostomy or -sigmoidostomy , with or without an extensive colectomy, according to the extent and gravity of the case, may be the only practicable treatment that holds out any prospect of amelioration ; but it must not be undertaken unnecessarily, as sometimes the result is a persistent diarrhoea, owing to the loss of the colon, which acts largely as a drying-ground for the faeces. See also on treatment of Enteroptosis (p. 1028). Operations on the Intestines. 1. Enter otomy is a term which is only correctly applied to an in- cision made into the intestine either for the removal of a foreign body or for the examination of its interior. The wound should always be placed in the longitudinal axis of the gut, and along its anti-mesen- teric border; it is closed by a row of Lembert, Czerny-Lembert, or Halstead stitches. 2. Enterostomy, or the formation of an artificial opening into the bowel, may be undertaken for several reasons, and any part of the gut may be opened, {a) The jejunum may be brought to the surface and opened [jejunosfomy) in cases of cancer of the stomach where gastro-enterostomy and pylorectomy are impossible and the patient is dying of inanition; he can subsequently be fed by the fistula in this way produced, {b) The ileum may need to be opened, and drained in cases of obstruction not lower than the caecum or ascend- ABDOMINAL SURGERY 1031 ing colon, when the small gut is much distended and the patient's general condition so bad that no prolonged search for the cause and no attempt to deal chrectly with it, even if obvious, are possible. The abdomen is opened either in the middle line or in the right iliac region; a suitable distended coil is withdrawn and opened after carefully protecting the peritoneal cavity from faecal infection. A large trocar and cannula are first introduced, so as to allow the first gush of flatus and fluid contents of the gut to escape ; the opening is then enlarged and a rubber drainage-tube stitched in, or a Paul's (glass) tube tied in (Fig. 488) by means of a purse-string suture passing in and out through the whole thickness of the bowel wall, and the affected coil of intestine fixed to the abdominal wall. A thin tube of rubber is attached to the other end of the glass tube, and through this the intestinal contents are temporarily allowed to escape without contamination of the peritoneal cavity or of the wound If the patient recovers from the acute symptoms, a second opera- tion will be needed in order to re-establish the continuity of the intestinal canal. Life is not likely to be of long duration if an artificial opening exists above the caecum, as the exclusion of the absorbing mucous surface of the large intestine seriously hampers nutrition. The fluid contents of the small intestine also act as a serious irritant to the skin of the abdominal wall- (r) Colostomy, or, as it is more usually termed, ' colotomy,' is frequently employed in dealing with diseases of the lower bowel, and is an extremely successful proceeding. The character of the artificial opening varies considerably according to whether or not it is intended to be a permanent condition, a temporary opening is required, the smaller the bowel secured to the parietes the better, since the operation for its closure is so much simpler (Fig. 489). a permanent aperture has to be established, the surgeon's aim should be to divert totally the course of the faeces; and hence it is desirable to 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 mesen- tery (Fig. 490). The ascending colon, or preferably the ccBcum, is occasionally opened in cases of membranous or ulcerative colitis where there is an abundant secretion of pus, and the patient's life is threatened by pyrexia and toxic exhaustion. The object of the operation is two- fold — viz., to prevent the irritation caused by the passage of the faeces over the ulcerated mucous membrane, and to permit the colon Fig. 488. — Paul's Tubes (Glass), Large and Small Sizes. Tf merely portion of subsequent But where I032 A MANUAL OF SURGERY to be irrigated. Inasmuch as the contents of the bowel at this level are fluid and very irritating, it is wise to mal-:e the opening as small as possible, and this ma}' be done by stitching lirmly into the bowel a piece of rubber drainage-tube as in Witzel's operation for gastros- tomy (p. 1007) and then fixing the bowel to the skin and abdominal muscles. It is possible, however, that in spite of every precaution the skin will become inflamed. If the opening has to remain for some time, the patient must be provided with an abdominal belt to which is fitted an elastic pad carrying a solid rubber plug which fits into the aperture. Intestinal obstruction at the hepatic flexure sometimes necessi- tates a csecal colostomy, which is performed as for the small intes- ' ' ^-.. . , ■vs&^ilr \ ■■! 1 / 4 ■"^ ^X"- Fig. 489. — Diagram of Tempor- Fig. 490. — Diagram of Permanent ARY Colostomy, showing the Colostomy, showing the Two Open- Single Opening on a Level ings separated One from the with the Skin, the Passage Other by a Section of the Mesen- To THE Lower Bowel being tery, MERELY BLOCKED BY A SPUR OF Mucous Membrane. tines, a Paul's tube being tied in. A secondary operation is usually required in order to excise the cause of the obstruction, or to short- circuit it. The transverse colon is most likely to need to be opened for an ob- struction located in the splenic flexure, as by carcinoma or adhesions. In all probability the source of the trouble has not been recognised prior to operation ; the abdomen is explored through an incision in the middle line, and in order to relieve the urgent symptom? the dis- tended transverse colon has to be opened at once and a Paul's tube tied in. If the case is less urgent, and yet a considerable amount of fsecal material is present in the gut, a small portion should be stitched to the surface, and after adhesions have formed, it may be opened and drained for a few days. Necessarily the situation is not a desirable one for an artificial anus, and therefore it should be only of a temporary character. When the bowel has been satisfactorily emptied, the abdomen should be again opened, and some form of ABDOMINAL SURGERY 1033 anastomosis performed to short-circuit the obstruction if excision of the growth is impossible. The descending colon or sigmoid flexure is the most frequent situa- tion for colostomy. Two chief methods have been employed — viz., the lumbar operation, in which the upper part of the descending colon is reached behind or through the peritoneum, and the iliac, in which the upper part of the sigmoid flexure or lower end of the descending colon is brought to the surface after opening the peri- toneal cavity. Uses of Left Lumbar or Iliac Colostomy. — The operation is required under the following conditions: (i) For congenital absence of the rectum, when a perineal incision has failed to discover it; (2) for chronic obstruction of the lower end 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 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, tuberculous, and other forms of ulceration of the rectum, which cannot heal as long as they are irritated by the passage of fseces: (5) for irremediable cases of recto-vesical and recto-vaginal fistula, whatever their origin; (6) for volvulus of the sigmoid flexure, the iliac operation being needed not only to relieve the obstruction, but also to prevent recuirence. Left Lumbar Colostomy (Amussat's Operation) has been niuch neglected of recent years, and practically replaced by its iliac rival. Performed as it was in the old days without opening the peritoneal cavity, this operation was certainly not a desirable one; but if the method described below is adopted, it will probably be found as eflicient as the iliac proceeding. The patient lies on the right side, with a sandbag beneath the loin, so as to increase the space between the last rib and the crest of the ilium. The position of the colon is indicated by a vertical line drawn upwards from a point | inch behind the centre of another line, passing from the anterior to the posterior superior iliac spine. The centre of the incision should correspond to this line midway between the last rib and the crest of the ilium. It should be made parallel to the last rib, and for practical purposes may commence at the outer border of the erector spina, and pass outwards for about 4 or 5 inches (Fig. 534, A, p. 1175) • This incision is carried through the layers of the abdominal muscles and the fascia lumborum, and opens up the loose fatty subperitoneal tissue. If the gut is distended, it may at once come into view; but if collapsed, it is not recognised at first. In about 20 to 30 per cent, of individuals a true peritoneal descending meso-colon is present. Under any circumstances the peritoneum is opened in the anterior portion of the wound, and the colon definitely looked for and identified. The highest portion that can be reached is secured, so that there shall be no slack intestine above the opening to give rise I034 A MANUAL OF SURGERY later on to prolapse; for choice, one fixes the end of the transverse colon to the skin. If the case is not urgent, the loop of bowel is withdrawn and secured to the skin by sutures through the sero-muscular coats; the rest of the parietal incision is closed. After a few days the bowel is opened. It is well to fix it as far back in the wound as possible, so as not to leave a pocket behind in which discharges can accumulate. If, however, urgent obstruction is present, requiring immediate relief, the bowel is drawn out of the wound and opened with the same precautions as in the iliac procedure. A trocar and cannula is introduced to give exit to the first gush of flatus and fluid faecal matter, and then a Paul's tube is tied in, the bowel stitched to the skin, and the rest of the wound closed. Lumbar colostomy is not much in favour at the present day, but there are surgeons who maintain that in reality a lumbar opening is more comfortable and convenient than one in the iliac fossa, and that it is much easier to control the escape of faeces than in the latter proceeding. Iliac Colostomy, or Littre's Operation, consists in opening the lower portion of the colon or sigmoid flexure through the anterior abdom- inal wall. Various incisions are used; some surgeons employ a vertical incision through the outer fibres of the rectus muscle in the hope of gaining some measure of sphincteric control. Others employ an incision 2 or 3 inches in length, 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. 473, D). The abdominal parietes are divided, either in the line of the cutaneous incision, or by McBurney's method of splitting the muscles in the line of the fibres; the latter is only desirable when there is but little distension, and when it is not neces- sary' to make an extensive exploration of the viscera. The sigmoid flexure is sought for, and recognised by the presence of the appen- dices epiploicae and the longitudinal bands of muscle fibres. It is gently drawn out, and the upper part is selected for fixation in the wound, so as to diminish the risk of subsequent prolapse. Many different plans of fixation are in vogue, (i.) Undoubtedly the best, if possible, is to make an opening through the meso-colon, and through this to draw together the segments of the abdominal wall by suitable deep stitches and superficial sutures in the skin (Fig. 491). The possibility of undertaking this operation depends on the degree of laxity of the sigmoid flexure ; where the meso-colon is short, the peritoneum to its outer side should be freely divided, and the colon ' mobilized ' inwards to a sufficient extent to enable this type of operation to be undertaken, (ii.) If, in spite of its mobilization, it is not very free, it is better to make a hole through it and to introduce a glass rod which, resting on the abdominal wall on either side, supports the gut until suitable adhesions have formed. It is wise to pass one stitch through the skin at each end of the rod and tie the latter securely to it, so as to prevent the risk ABDOMINAL SURGERY 1035 of it slipping aside, (iii.) A useful and effective method of fixation is to pass a mattress suture of strong silk through the parietes (in- cluding the skin, muscles, and peritoneum) on either side, the stitch traversing the meso-colon en roiUe (Fig. 492). By tying the ends together, the parietes are brought into close apposition with the meso-colon. In all cases a few additional stitches should be in- serted, uniting the skin to the longitudinal muscular bands at each end of the incision, and the ends of the parietal wound itself should be closed as much as possible, so as to prevent subsequent prolapse. If the bowel does not need to be opened at once, it is covered with purified protective, and a dressing is applied. At the end of two or three days the gut is usually opened, and a glass or rubber tube stitched or tied in; no anaesthetic is required for this. At the end of three or four days these tubes become loose, and by the end of a week it is wise to ' trim up ' the bowel, removing any unnecessary redundancy, and separating completely the upper and lower ends. Fig. 491. — Iliac Colostomy fixed BY suturing Abdominal Wall through an opening in the Meso-Sigmoid. Fig. 492. — Iliac Colostomy to SHOW Fixation Stitch passing THROUGH Mesentery and Ab- dominal Parietes. Should it be necessary to open the gut at the time of the first opera- tion, precautions similar to those already suggested for enterostomy must be taken in order to prevent the peritoneum from being defiled. When cicatrization of the wound is complete, a protective ap- paratus 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 by means of an enema, so that no further disturbance need occur during the day. Comparison of the Two Operations. — At the present time the methodical and deliberate opening of the peritoneal cavity obviates nearly all the difficulties which were formerly experienced in con- 1036 A MANUAL OF SURGERY nection with the lumbar operation, and the advantages of the iliac operation are not nearly so pronounced as formerly- (a) One great advantage is the closer proximity to a pelvic grovvth, which can be carefully examined, as also the lymphatic glands in the meso-rectum or lumbar region, and valuable indications as to the advisability or not of excision of the rectum can be thereby obtained, {b) An artificial anus situated in the iliac region can be attended to by the patient himself without assistance, and is more easily cleansed and protected, (c) It is occasionally possible for a certain amount of sphincteric control to be developed after the abdominal operation, especially if the gut is brought out between the divided segments of the rectus. It is sometimes desirable to close a colostomy wound after a shorter or longer interval. The plan usually adopted at the present day is to dissect up the margins of the wound, freeing the gut from its attachments to surrounding parts, and excising the affected seg- ment ; in this way the continuity of the canal can be restored without leaving parietal adhesions. Occasionally it may seem desirable to close the opening without encroaching on the peritoneal cavity. This, of course, is only possible when the whole circumference of the bowel has not been encroached on, and the spur consists of a valve or flap of mucous membrane (Fig. 489). It is then necessary to efface or remove the spur, which would otherwise hinder the onward passage of the faeces. This may be effected by stitching a piece of drainage-tubing of large calibre into the bowel so as to reach above and below the opening ; the margins can then be pared and closed in some suitable way; after a time the stitches in the drainage-tube (catgut by choice) wiU be absorbed, and it will pass on down the canal. This latter method of dealing with an artificial anus is ex- tremely unsatisfactory, as it leaves an adherent coil of intestine, which is certain to hamper peristalsis and may cause recurrent colic, or may even determine an attack of obstruction ; the open operation is usually very successful. 3. Enteroplasty is a plan of treatment which has been devised for dealing with cicatricial strictures of the intestine, and is based on the same idea as the operation of pyloroplasty foi fibrous stenosis of the pylorus (p. 1009). 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 carefully sutured, the lumen of the bowel being thereby considerably increased. 4. Enterectomy, or excision of a portion of the bowel, is required in the following conditions: (a) For the removal of gangrenous gut after strangulation, whether internal or external ; [b) in the treatment of multiple penetrating wounds, as after a stab or gunshot injury; (c) for the closure of an artificial anus or faecal fistula; (d) for the removal of simple or malignant strictures; and (e) in some cases of intussusception. Naturally, the results vary largely with the con- dition for which it is performed, with the site of the lesion, and with the experience and skill of the operator; a much higher rate of ABDOMINAL SURGERY 1037 mortality follows when the excision is done for mahgnant disease, for gangrene following strangulation, or for intussusception, than when performed for other causes. Operations on the large intestine are cilso much less favourable than those directed to the small gut. 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, /3-naphthol, naphthalene, bismuth subnitrate, etc., for a few days previously. Should this be impossible and when the bowel is distended, it is usually wise to open and drain it for a few days, and then subsequently perform the anastomosis. The abdomen is opened by any suitable incision, and the portion to be removed clearly defined, the general peritoneal cavity being protected by a careful packing with abdominal cloths or gauze. The bowel rnust then be clamped on either side of the seat of opera- tion, so as to prevent the escape of intestinal secretions or faeces. Any of the forms of clamp figured in surgical instrument catalogues will effect this purpose; but if they are not obtainable, the same result can be obtained by passing a piece of drainage-tube through the mesenteric attachment, and tying or clamping it around the gut. The affected portion is now removed by scissors, cutting through the bowel and taking away a V-shaped portion of the mesentery, after securing as far back as possible the main nutrient vessels to the diseased area, according to Murphy's recommendation. It must be remembered that the terminal vessels run circularly round the gut, and have but few lateral anastomoses, and therefore it is desirable that the incisions should diverge slightly from the mesen- teric attachment, otherwise the projecting edge of the anti-mesen- teric border is certain to slough, and septic peritonitis will result. Some operators recommend that the mesentery should not be cut into, but that the gut should be detached from the mesenteric junc- tion ; such practice will suffice when merely a small segment of bowel is to be 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 either an end-to-end or a lateral anastomosis. For end-to-end union the following are the chief plans that have been adopted: A. Entero-anastomosis by simple suturing. In this the surgeon utilizes no special apparatus, but trusts to the deftness of his fingers and the accuracy of his stitches. The mesenteric and anti-mesenteric borders are first united by stitches which are left long for the assistant to hold; the gut is there- by steadied (Fig. 493). The mucous membrane is then sutured by catgut or silk stitches, which should not be continuous all round the junction, as thereby it might be drawn in too closely and contracted; it is best taken up in two or three portions. The sero-muscular coats are. now united all round by one or two continuous stitches of the 1038 A MANUAL OF SURGERY Lembert or Gushing type. Extreme care must be taken in dealing with the mesenteric attachment, as the peritoneal coats separate there in order to enclose the bowel, and the muscular coat retracts considerably ; leakage is more likely to occur at this point than at any other. Some surgeons advise that the first row of stitches should include the whole thickness of the gut, and that the second row should be of the Lembert type. This is unnecessary and undesirable as a routine procedure, as it involves too great an infolding of the gut wall, and thereby the lumen at the site of anastomosis is unduly encroached on, and some amount of stenosis may result. B. A vast amount of ingenuity has been expended in the produc- tion of a variety of bobbins and buttons, with the idea of facilitating entero-anastomosis and making it safer, but they have been almost entirely discarded at the present day in favour of simple suturing. 3. Colectomy, or ex- cision of a larger or smaller portion of the large intestine, is not quite so simple a matter as removal of a part of the small bowel, owing to the greater complexity of the peritoneal reflec- tions and its less mobihty. The latter difficulty can, however, be largely over- come, and the colon freely ' mobilized,' by dividing the peritoneal attachments on the outer sides of both ascending and descending colon, and by detaching the transverse colon from the under side of the omentum ; the varying portions of the bowel can then be freely drawn over to the middle line with the vessels, nerves, etc., being held merely by one layer of peritoneum. By the assistance of this pro- cedure, large portions of the colon can be removed without much danger or difficulty, and union of the upper and lower segments can be readily affected either by end-to-end anastomosis, or pre- ferably by lateral anastomosis, after closing the divided ends. One essential precaution must be observed if success is to be obtained — viz., the colon must be satisfactorily emptied beforehand; in any case of partial or complete obstruction with retention of the faecal contents a preliminary colostomy must be undertaken. 6. Lateral Anastomosis of the intestine is often employed in order to effect the short-circuiting of some malignant growth, or of a Fig. 493.- -End -TO -End Anastomosis Simple Suturing. For clearness' sake, the first row of stitches in the mucous membrane has been omitted, and the sero-muscular sutures of the Lembert type are represented as interrupted. In practice one would use a continuous stitch. ABDOMINAL SURGERY 1039 stricture which cannot otherwise be dealt with. It is also used instead of end-to-end anastomosis to unite divided segments of intestine. The open ends are hrst entirely closed, and to effect this the bowel should be divided by the knife or thermo-cautery between two pairs of powerful clamp-forceps or enterotribes. If these are left in situ for a minute or two, the divided end of the bowel will be found effectively sealed, and can be readily invaginated by a row or two] of Lembert's sutures. The portions of bowel are now made to overlap, and the actual anastomosis is performed as for gastro-entero- stomy (Fig. 494). Robson's or other suitable clamps are applied, and the coils are brought into suit- able apposition. Longitudinal in- cisions are made through the sero- muscular coats, and these are then unitedjpn the posterior aspect of the proposed junction. The seg- ments of bowel are then opened, and any fluid or solid contents carefully mopped up and removed. A continuous stitch unites the mucous membrane all round, and finally the external sero-muscular stitch secures the anastomosis. The operation is completed by securing the divided edges of the overlap- ping segments of the mesentery so as not to leave an aperture through which internal strangulation might occur. 7. Lateral or End-to-Side Im- plantation is a procedure not un- commonly required in order to short-circuit a malignant growth (Fig. 487). It is perhaps employed most frequently for irremoveable cancer of the csecum or ascending colon; the ileum is divided well above the growth; the lower end is closed, and the upper united to the transverse colon. The junction may be made by simple suturing, two rows of stitches being introduced. It is probably wiser, how- ever, to close the end of the ileum and perform a lateral anasto- mosis, as described above, inasmuch as it is possible thereby to secure a larger opening. Fig. 494. — Lateral Anastomosis OF Bowel after Complete Division. The divided ends are closed by- sutures and approximated by a sero-muscular continuous stitch (A, A') ; the incisions in the bowel are then made, and the mucous membranes united by a continu- ous stitch (B, B'); and, finally, the sero-muscular suture is carried round the whole opening. Only the deep layer of sutures is shown here, and they have not been drawn tight, so as to indicate their relative positions. I040 A MANUAL OF SURGERY Appendicitis {Syn. : Perityphlitis, Epityphlitis, etc.). Appendicitis is an affection which may appear at any time of life, but it is most common in young adults, and the male sex is more frequently attacked than the female. The disease is sometimes of but slight significance, but occasionally runs such a virulent course as to destroy life in a few hours. Its importance lies in the fact that it is an infective process, and inasmuch as the peritoneal envelope is generally involved, a certain degree of peritonitis is almost neces- sarily a consequence. etiology. — Many different conditions contribute either directly or indirectly in determining an attack of appendicitis, (i) The appen- dix is to be looked on, not as an actively functional structure, but as a degenerated relic or remnant, which is apparently of little value or importance. Hence, as in other similar structures, it often has but a poor blood-supply, derived from the posterior ileo-cascai branch of the ileo-colic artery. Ihe main nutrient vessels traverse or run along the free border of the meso-appendix, but a second twig often runs down the base of the mesentery, and is more or less independent of the others. Some authorities join issue with the above-mentioned view as to the inutilit}' of the appendix, and maintain that it secretes a fluid which stimulates the peristalsis of the Ccecum or colon (MacEwen). This may be so, but the fact remains that a vast number of people who have lost their appendixes by operation get on quite well without them. (2) A large amount of l\Tnphoid tissue is present in the mucous membrane, especially in young people, so much, in fact, that the title of ' abdominal tonsil ' has been applied to it. Ihe lymphoid follicles have a tendency to atrophy with ad- vancing age. Inflammatory processes are readily set up \\'ithin its walls as a result of the absorption of toxins or organisms, which are almost constantly present within it. It is interesting to note here that some look on appendicitis as an outcome of rheumatism, and the association of that disease with tonsillitis is suggestive. (3) Its length and direction vary considerably in different individuals. In length it may measure anything between ih and 11 or 12 inches, but is usuall}^ 3 to 4 inches long, whilst as to direction, it may lie in any axis, and the clinical picture is largely influenced by its ana- tomical position (Plate \TII.). The commonest situation is behind the caecum in relation with the lowest end of the mesentery, pointing towards the spleen ; but it is not unusual for it to lie deeply behind the csecum, pointing down towards the pelvis, and then pelvic com- plications almost always accompany an attack of appendicitis. At other times the appendix lies to the outer side of the csecum, and the inflammatory reaction then may be more localized. The posi- tion of the appendix also governs the facility- with which the intes- tinal contents find their wa}' into its lumen, and it seems probable that appendicitis is more commonly met with where it is so placed as readil}' to admit material which is with difficulty expelled — i.e., when it is transverse, or directed downwards. A longer appendix ABDOMINAL SURGERY 1041 is also more liable to become twisted and kinked on itself. (4) The extent to which the meso -appendix is attached is also an important element, since the portion which projects beyond its free border is less well supplied with blood. As a matter of fact, the mesentery often does not extend beyond the junction of the middle with the distal third, and perforation not unfrequently occurs about this spot. The vessels often run in the free border of the mesentery, and kink- ing of the appendix may result in thrombosis of the vessels and gangrene. (5) The communication with the caecum is usually a small one, and is guarded by an insignificant fold of mucous mem- brane, known as the valve of Gerlach. Sometimes this aperture becomes blocked, or the orifice stenosed, as the result of a preceding attack of typhlitis or inflammation of the mucous lining of the caecum, so that an accumulation of mucus occurs within the appen- dix, leading to its dilatation into a cystTike pouch. (6) The contents of the normal appendix consists of a little mucus and a certain num- ber of bacteria, similar to those found in the neighbouring intestine ; they do no harm unless the mucous lining is so damaged as to permit them to invade the living tissues, and then they become viru- lent. A generalized infection of the intestinal canal, perhaps the result of oral sepsis, will obviously be a favourable condition for de- termining inflammation of the appendix. Foreign bodies, such as pips, pins, etc., are occasionally found within it, and by their presence and irritation may light up an attack of appendicitis. They are much less common than was formerly imagined, and the fact that the opening into the intestine is generally not larger than to admit a No. 8 catheter will explain this rarity. FcBcal concretions are compara- tively common ; they are oval bodies, varying from | to i inch in length, and usually laminated, consisting of dried faecal material mixed with myriads of bacteria, and perhaps with a pip or foreign body as a nucleus. They are not very hard, and can easily be cut with a knife, or even crushed between the fingers. Occasionally they can be recognised in a radiograph of the pelvis taken for other reasons (Fig. 495). They are sometimes the result of a preceding attack which has left the tube contracted, and thus determined stasis and retention of its contents, which have become inspissated. (7) Appendicitis is not unfrequently associated with a true typhhtis or with a more generahzed colitis, probably due to chronic constipa- tion; the continuity of the mucous lining of the caecum and appendix explains this fact, which must always be taken into consideration in estimating the benefits which may be expected from removal of the appendix in a quiescent stage. Much disappointment in the non- relief of symptoms has arisen from the persistence ot a typhlitis or colitis after the appendix has been removed. Dysenteric ulceration may involve the appendix, or lead to stenosis of its orifice, but it is rarely imphcated in typhoid fever. (8) Injujy in the shape of a strain or sudden twist is not unfrequently mentioned as the cause of an outbreak, and probably acts by displacing a long appendix m such a way as to lead to kinking and possibly to obstruction of the 66 1042 A MANUAL OF SURGERY nutrient vessels. When a concretion is present, it is easy to under- stand that the final attack is determined by some traumatism which modilies the vascular conditions around it. When an appendix is filled with muco-pus as a result of stenosis, either at the orifice or in the tube itself, a blow may lead to its rupture and cause an outbreak of fatal peritonitis. There can be no question as to the greatly increased frequency of appendicitis at the present day, especially amongst those who live in large towns or cities. It is difficult to assign any one cause for this, Fig. 495. — Radiograph of Right Iliac Fossa, showing the Presence of an Elongated F^cal Concretion in the Appendix. (A. D. Reid.) but possiblv many conditions may be at work — e.g., {a) dental disease and degeneration, and consequent oral and intestinal sepsis; (b) the bolting and non-mastication of meals associated with the hurry and scurry of modern life, leading to chronic irritation of stomach and bowel, (c) Chronic constipation is a most important factor, {(l) The presence of minute foreign bodies in imported corn and other food-supplies, and the chips derived from enamelled cooking utensils have been suggested as causes, but there has been forthcoming no proof of any connection, (e) The greatestTdietctic change of recent years consists in the increased amount of meat that c a < X •3 c V a < ^ U N 3 b^-iS * O o o cr ,, i> c -j^ ^ a. ^ o; ? o .-^ " = ■■;£ op j=.- s S " ^ »5 o i/i 3 "" =^ ,^ ^ Ji - S.' . -, u CJ jj •■^ — , ^ t" r, ^-73 ° « =^ oi iS =" O ci ^~. • OJ rt C 53 c : &^ - ^ I :Sf "* J! O -g O H rt S 5: JS ABDOMINAL SURGERY 1043 is eaten. The cheapness of imported frozen meat has made it generally available, and it is quite possible that meat which has been frozen for some time is more putrescible than that which is fresh, and hence intestinal sepsis may be favoured. In favour of this idea is the fact that races that live on fish or vegetables are largely immune, whilst members of the same race transported to other regions and put on a meat diet develop the disease. Pathological Anatomy. — Whatever the assigned cause may be, it must ever be kept in mind that appendicitis is an infective malady, due to invasion of the walls of the appendix by organisms, especially the Streptococcus pyogenes, the B. coli, and other anaerobic intestinal bacteria. These find an entrance into the wall of the appendix either through an eroded area of the mucous membrane due to the impaction of a foreign body or of a fsecal concretion, or else they are absorbed into the Ijonphoid tissue so abundantly present, and at once commence to develop and multiply. The results may be best described under the following headings : (i) Changes in the Appendix itself. — These vary considerably in intensity and character according to the cause and the power of resistance of the individual. In the simpler forms a mere catarrh of the appendix results. The organ looks red and swollen, and its peritoneal surface may be smooth, or roughened by loss of endothelium and deposit of lymph. It feels stiff from effu- sion, and has lost its natural flexibility. The muscular coats are often infiltrated with leuco- cytes, and this is especially noticed around the hiatus muscularis through which the vessels enter. The mucous membrane is thickened, engorged, and infiltrated with polynuclear leucocytes, and here and there erosion or ulceration is present. If the process goes no further, healing occurs after a time, and this is often associated with fibrosis, which may show itself {a) as a more or less generalized sclerosis of the whole appendix (Plate VII., Figs, i and 2), which may remain stiff and hard, and is perhaps twisted on itself (Fig. 497) ; or (&) as a stricture of the tube (Fig. 496), which leads to retention of a mucous or muco-purulent effusion (hydrops or empyema of the appendix) ; sometimes a fsecal concretion forms distal to the stricture, and in aU cases there is a greater tendency to recurrence, which is often of a severer type than the original attack; or (c) obhteration of the appendix may occur from the union across its lumen of granulating surfaces. This usually commences at the tip and works up towards the gut, but Fig. 496. — Appendix WITH Stricture at Proximal End. The patient was a boy, aged seven years, who had had several attacks of pain in the abdomen, with high temperature lasting a few hours, sickness, and tenderness in the right iliac fossa, evidently due to re- tention of secretion. I044 A MANUAL OF SURGERY is not completed until the patient has suffered from many attacks. {(i) Occasionally small diverticula or pouches form as the result of a nernial protrusion of the mucous meml)rane through some gap in the muscular wall — eg'., the hiatus muscularis. They are usually not larger than a hemp-seed, but are of importance, since the thin walls would readily give way as the result of any intra-appendicular tension from effusion, and thereby a perforative peritonitis might be lighted up. \\'hen ulceration occur?, the loss of substance of the mucous mem- brane may be slight or extensive; it may be a simple erosion asso- _^ ciated with a mild catar- iSHf"" rhal attack, or a deeper loss of substance due to the presence and impac- tion of a faecal concre- tion; or it may result from a specific infec- tion, as from typhoid fever or tuberculous dis- ease. The appendix is then likely to be more seriously invaded with micro - organisms, and suppuration of many types may ensue. It may contain muco-pus in its lumen, and this may increase to the point of determining rupture of the appendix within a few hours, or the whole wall of the tube may be yellow with a diffuse purulent infiltration. The ulcer- ation may gradually spread through the walls and lay open the peritoneal cavity, giving rise to a local or diffuse suppurative peritonitis. Necrosis or sloughing of the appendix occurs in the more severe forms. It is due to an acute interstitial inflammation spreading from an impacted concretion, or from an ulcer of the mucosa; or results from kinking and thrombosis of the appendicular vessels in the meso-appendix. The whole appendix may slough, or merely a portion (Plate VII., Figs. 3 and 4), and then usually the tip or the part immediately opposite the distal end of the meso- appendix. The necrotic tissue is soft and easily torn, of a blackish, brown, or green colour, and usually extremely offensive. It rnay be associated with a perforation, through which the concretion Fig. 497. — Vermiform Appkndix tied down Both to Caecum and Ileum, and doubled ON itself by Old-standing Adhesions. The appearances in this illustration are very characteristic of what is frequently seen ; but the case from which it was taken was a very unusual one. It occurred in a baby of seven days, who was operated on for acute obstruc- tion due to the adhesions, which were old- standing, and evidently ante-natal. The child died, and the caecum was subsequently removed. ABDOMINAL SURGERY t045 may escape (Fig. 498) . In all these cases a grave peritoneal infection follows. (2) Changes in the Csecum often accompany appendicitis. In the caliinhal \arict\- a geneialized typhlo-colitis is often present, and perhaps it would be more correct to speak of appendicitis as a com- plication of that condition. It is in these cases where the csecum and colon are inflamed and tender, as well as the appendix, that most careful discrimination is needed in order to prevent needless operation which will not improve the patient's condition. In sup- purative appendicitis the caecum is generally inflamed and infiltrated, but rather from the peritoneal aspect than from within; operative treatment will in these cases be quickly followed by resolution. Rarely does the inflammation become so severe as to lead to sup- puration or necrosis of the wall of the csecum ; should this occur, it usually involves the ,-rrv-— origin of the appendix, /" ■'s: and may be followed by a fsecal fistula. (3) The Peritoneal Phenomena associated with appendicitis are of the utmost import- ance. In the milder cases the peritonitis is pro- tective in type. The serous coat of the ap- pendix becomes in- flamed, sheds its endo- thelium, and becomes roughened by a deposit of lymph, and this results either in a thickening of the wall, or in a formation of adhesions which tie down the appendix in various directions and positions. Most com- monly it is simply fixed to the csecimi along part of its length, but sometimes it is firmly united to it for its whole extent. iVdhesions may pass between the appendix and the omentum, the mesentery, or ovary, etc. ; in fact, the appendix may be united to almost any of the viscera, and may thereby hamper their action or give rise to some form of acute obstruction. It may also contract adhesions to the fasciae — e.g., over the psoas sheath or iliac vessels, and various s\miptoms may be caused thereby. In the graver cases an infective peritonitis occurs, and, according to the virulence of the organisms, the defensive powers of the patient, and the character of the infection, the process may be localized or not. A localized intraperitoneal abscess is by no means uncom- mon; its extension is limited by the formation of adhesions be- tween the omentum, the parietes, and neighbouring coils of intestine. Fig. 498. — Perforation of the Appendix FROM AN Impacted Concretion, causing an Acute Abscess (Semi-diagrammatic). 1046 A MANUAL OF SURGERY Its exact anatomical relations depend on the original situation of the appendix (see Plate VIII.). Frequently it is located below and behind the caecum; sometimes it burrows down into the pelvis; in other cases it passes inwards amongst the intestines; it may track up towards the liver either on the inner or outer side of the ascending colon. Ihe abscess may burst externally, and its approach to the surface will be heralded by brawny swelling, redness, and (edema; the most frequent sites for external pointing are the outer part of the iliac fossa and the lumbar region (Petit's triangle). It may burst into any of the viscera, and then most commonly into the caecum or bladder. Finally, it may break through the peritoneal adhesions, and involve the general serous cavity, causing acute diffuse peritonitis ; in other cases a serous effusion into the peritoneal cavity is found, resulting from the irritation of the abscess, and dis- appearing when it is opened. Ihe pus contained in the abscess is usually of a stinking character, and in cases of sloughing of the appendix the foetor may be intense ; but it must be remembered that the amount of smell is no gauge of the virulence of the process. Sometimes the debris of a broken-down concretion can be recognised in the pus, and sometimes a portion of the appendix as a slough. Gas is also present in some cases, having escaped from the bowel, or been generated by the activity of gas-producing organisms. It is not always possible to distinguish the appendix in these abscesses, even when it has not sloughed off ; it may be firmly adherent to the caecum, and unrecognisable to the examin n ; finger. In the worst cases, associated with perf ration or necrosis of the appendix, a spreading septic peritonitis is frequently observed, with but little tendency to limitation ; an abundant sero-purulent effusion occurs, due largely to the presence of streptococci, and later to invasion by the B. coli. The line of diffusion is governed by the anatomical relations of the appendix; most commonly the effusion involves the pelvis, and after filling Douglas's pouch, spreads up on the left side to the inner aspect of the sigmoid meso-colon. If the appendix is situated above the brim of the pelvis, the effusion will extend to the right kidney pouch, and a subphrenic abscess be thereby detemiined. If it spreads beyond these limits, the whole peritoneal cavity will be affected, and operative treatment is little likely to be successful. The efiusion in the first place is serous, but soon becomes turbid, and finally librino-purulent or frankly purulent. Experience proves that as long as the exudate is serous or merely sero-purulent, operative treatment holds out good prospects of re- covery. In later stages the intestine becomes matted together b)^ lymph, and paralyzed, and a cure is almost hopeless. (4) Extra-peritoneal suppuration occasionally follows, and is then usually due to extension backwards through adhesions formed between the appendix and the peritoneum on the posterior wall of the abdomen or pelvis, thereby leading to infection of the retro- peritoneal connective tissue. The pus may collect in the iliac fossa and point anteriorly; or may track downwards into the pelvis and PLATE VIII. Fi^. I. Fig. 2 ^k- 3- Fig. 4. Diagrammatic representation of the distribution of the effusion in acute ^ Appendicitis according to the position of the Appendix {after Quervain). Fig. I. —Appendix in right iliac fossa ; abscess localized in fossa, but diffuse effusion spreads widely up along the colon down to the pelvis, across the middle line to the left side. Fig, 2. ^Appendix to outer side of caecum ; abscess localized. Fig. Z' — Appendix in pelvis (pelvic appendicitis). Fig. 4. — Appendix reaching up towards the liver with csecum twisted ; abcess subhepatic and mainly localized to the right loin. Yellow — serous or sero-purulent effusion. Green — pus. [To face page 1046. ABDOMINAL SURGERY 1047 Open into the roctum; or may travel along the psoas tendon and open into the thigh; or burrow upwards into the loin, forming a perinephritic collection, or a retroperitoneal subphrenic abscess, and then may extend even into the thorax. (5) Various complications may be associated with any of these different types of appendicitis, (a) The veins in the meso-appendix may become thrombosed and infected with pyogenic organisms; detachment of emboli may lead to the occurrence of pylephlebitis and pyaemia. (6) Thrombosis of the femoral veins may develop ; if on the right side, it is probably due to imphcation of the right ihac vein in the inflammatory process ; but if it happens, as is much more com- mon, on the left side, it must be clue to general toxic causes; or, if it occurs after operation, to spreading thrombosis from vessels divided in the anterior abdominal wall (p. 343). (c) Chronic or subacute ovaritis often accompanies appendicitis in women ; it is probably due to the position of the appendix which hangs over into the pelvis. {d) Various renal complications may supervene, usually from pres- sure of the inflammatory mass on the renal vein, or on the ureter as it crosses the pelvis brim, resulting either in hsematuria or in renal colic, {e) Inflammation of an appendix located in a hernial sac is referred to hereafter (p. 1087). (/) Lastly, intestinal obstruction maybe induced by the acute inflammatory attack leading to paraly- sis of the intestinal wall, or it may develop subsequently as a result of kinking or strangulation by bands or adhesions. Clinical History. — (i.) The mild variety of the disease, known as a simple catarrhal appendicitis, to which is added merely a localized plastic peritonitis, usually commences somewhat suddenly, the patient being seized with pain, which is at first referred to the um- bilicus or to any part of the abdomen, but at the end of twenty-four to forty-eight hours localizes itself in the right ihac fossa. It is often of a sharp, cutting character, but varies much in intensity and dura- tion. Fever is usually present, and the attack may start with a rigor. The patient may complain of nausea and vomiting, but the latter symptom does not last long. Constipation results from the intestinal paralysis due to the inflammatory lesion, but in children it is sometimes replaced by diarrhoea, and that even blood-stained, so that a diagnosis may need to be made from typhoid fever. On examination the abdominal wall is found to be more rigid than usual; the right leg is often drawn up to relax the muscles, and in bad cases all abdominal respiratory movements are abolished. Even in mild cases the muscles over the right iliac fossa are held tense and rigid so as to guard the underlying structures. Definite tenderness is noted on pressure, and the patient will often, but by no means constantly, refer it to a spot about i| inches from the anterior superior iliac spine along a line drawn to the umbilicus (McBurney's spot; Fig, 480, A). In many cases, when the appendix is directed backwards, there is marked tenderness in the lumbar region; but if it points downwards into the pelvis, the pain and tenderness may not be evident except on rectal or vaginal examination, which should 1048 A MANUAL OF SURGERY never be neglected. A delinite swelling may sometimes be detected by pal])ation, usually above the outer half of Poupart's ligament, but varying in its position with the site of the appendix ; it may be dull on percussion, but is frequently tympanitic, since it consists of coils of intestine and omentum matted together around the a])pendix. The absence of a dehnite lump is due to the non-develo})ment of protec- tive adhesions, and hence is noted in the worst cases of perforative appendicitis; or it may be caused by the inflamed mass lying deep in the abdomen, and being covered o\'er by distended and uninflamed intestine. This simple form of the disease usually lasts three or four days, and then, if properly treated, resolves satisfactorily without abscess formation. It is exceedingly common, and the prognosis is, on the whole, favourable. Tofft, of Copenhagen, found adhesions in the 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, may commence in a similar way, but with more acute symp- toms. There may be an initial rigor, and the temperature soon runs up, even to 104° F. Some general abdominal tenderness and distension follow ; constipation is often absolute, and fitcal vomiting may occur, although diarrhcxa is not unknown, especially in children. The muscles on the right side of the abdominal wall are held tense and rigid, and a well-marked fulness can sometimes be detected in the iliac fossa. In other cases a distinct swelling can be seen as well as felt, and is not necessarily limited to the right fossa, but may be found in the middle line of the abdomen or elsewhere. Under a careful regime this may disappear, and the symptoms gradually abate in their severity, the temperature and the pulse falling con- currently; but it is very common for suppuration to ensue, and this is indicated by the temperature persisting at its original high level, or by the pulse-rate increasing in rapidity, whilst the tempera- ture falls. Fluctuation 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 considerable 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 round the appendix, and is, of course, primarily intraperitoneal. Occasionally it bursts into the bowel, and thereby relief is gained without the assistance of surgery; some authorities, indeed, maintain that this occurs in e\'ery case of the more severe type w^hich resolves. In other in- stances it may point externally, either through the anterior ab- dominal \\all, which becomes congested and cedematous as the pus approaches the surface, or through the loin. Not unfrequently it tracks up along the inner or outer side of the ascending colon, and then may get into relation with the under surface of the liver. 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 ABDOMINAL SURGERY 1049 collectiuii in front of the rectum; the surgeon must never omit a rectal examination in appendicitis, where the temperature is of such a nature as to suggest the existence of an abscess, and yet no evi- dence of one can be found. Should it burst into the peritoneal cavity, all the phenomena of acute perforative peritonitis with grave toxcemia supervene, probably indicated by severe pain, sudden fall of temperature, rapid collapse, and failure of the circula- tion, leading rapidly to a fatal issue, preceded by increasing ab- dominal distension. In not a few cases the patient's general symptoms improve after the first outbreak; the temperature may become normal, the pain decrease, and the vomiting cease. It is often difficult to be certain whether this improvement is merely temporary, or is the commence- ment of a true convalescence. Under the former circumstances— i.e., if it is merely an interval of quiescence — -careful examination will probably reveal some disturbing factor; either the abdominal dis- tension persists, or perhaps hiccough is present, or well-marked tenderness continues, perhaps only to be detected per rectuyn, or the pulse-rate may remain unduly high. After a few days the tempera- ture begins to rise once more, the focal symptoms become more urgent, and a localized abscess forms. It is often by no means a simple matter to make certain that pus is present ; but considerable assistance can be derived from a blood count, which is advisably made each day that the uncertainty per- sists. Readers are referred back to p. 62 for a full consideration of leucocytosis ; it will suffice here to state that a leucocyte count under 20,000 is merely indicative of an inflammatory attack well resisted; if suppuration is present, the leucocytes are usually over 20,000. In the early stages, however, a high leucocyte count means comparatively little; but a maintained leucocytosis is a valuable sign of suppuration. A comphcation likely to occur in the more severe types of the disease is pylephlebitis, or infective thrombosis of the branches of the portal vein in the liver. This would be indicated by recurrent rigors, and possibly by pain and tenderness in the hepatic area. Necessarily it is alinost invariably fatal. (iii.) In the graver forms of diffuse or generalized peritonitis, the onset is usually sudden, the patient becoming collapsed with the severity of the pain; vomiting often accompanies the outbreak and occasionally a rigor. These symptoms sometimes pass over directly into those of generalized peritonitis, as described on p. 975, death ensuing in two or three days ; the temperature in such cases may be low, and the absence of reactive phenomena is indicated by a leuco- penia. More frequently the course is not quite so acute; the pain which at first is referred to the umbilicus becomes localized to the right iliac fossa ; the abdominal wall on that side is held rigid, and the rigidity gradually spreads across the abdomen to the left iliac region and upwards towards the liver; vomiting and absolute con- stipation are present, and the temperature is usually raised three or I050 A MANUAL OF SURGERY four degrees; the pulse varies from lOo to 120, and the amount of urine passed is diminished in quantity. If surgical treatment is not undertaken early, the typical phenomena of acute diffuse peritonitis are soon developed. (iv.) Relapsing Appendicitis is the term apphcd to a condition when an attack passes oh, but not cjuite satisfactorily. There may be a slight persistent rise of temperature at night ; or the a])pendix remains palpable and tender; or some amount of apj^endicular pain often of a colicky character may be noted. In many of these cases the symptoms are due to unhealed ulceration of the mucous lining or to stenosis of the tube. If left alone, a more acute outbreak may supervene, or bacterial invasion of the vessels in the meso- appendix may follow, and serious consequences develop. If an attack of appendicitis has not cleared up completely at the end of a week or ten days, an operation is always advisable for the removal of the organ. (v.) Recurrent Appendicitis is characterized by repeated attacks of varying gravity in an individual who has been once the subject of the disease. They may occur only at prolonged intervals, or be so frequent as entirely to incapacitate the patient, and are usually asso- ciated with the presence of some abnormal adhesion or constriction of the appendix. It is not uncommon for the appendix to become fixed to the sheath of the psoas muscle, and then any excessive move- ments of the limb may light up an attack. Where stenosis exists, secretions containing bacteria may be pent up behind the constric- tion, and from time to time the patient suffers from severe pain of a colicky nature with or without fever, supposed to be due to an attempt to get rid of the excess of mucus. Such attacks have been named appendicular colic. In a few cases the appendix becomes totally obliterated after a time and incorporated in a mass of adhesions, a natural cure being thus established, but more frequently, if these occurrences are allowed to continue, the patient finally develops an abscess, possibly from the infection of some unobliterated portion of the tube, or succumbs to diffuse peritonitis. Recurrences are more common after the simpler forms of the disease, and it has been calculated that over 30 per cent, of the subjects of a mild catarrhal attack suffer in this way. In the more acute forms recurrence is less common, and it is unusual for a case to recur when suppuration has existed; we have, however, seen cases where an abscess has developed two and even three times in con- nection with attacks which were separated by intervals of complete disappearance of symptoms. (vi.) Appendicular Gastralgia is the name applied to cases in which all the signs and symptoms of the disease are referred to the epi- gastrium, and closely mimic those of a gastric or duodenal ulcer. The patients are usually women, and a test-meal examination reveals a hypersecretion of gastric juice, in which the hydrochloric acid may be increased or diminished. Laparotomy shows no lesion in the stomach or duodenum, but chronic appendicitis is usually present. ABDOMINAL SURGERY 1051 That the previous symptoms were due to the condition of the appendix is proved by the reUef to the symptoms and the changes in the gastric secretion after appendicectomy. The probable ex- planation is that the condition of the appendix causes intestinal stasis, and this in turn sets up a toxaemia which reacts on the gastric mucous membrane. The condition is important clinically, as it emphasizes the importance of hnding definite evidence of a lesion in the stomach or duodenum before performing gastro-enterostomy for supposed gastric or duodenal ulcer. Not unfrequently these patients are also the owners of a moveable and tender right kidney. Diagnosis. — In a well-marked case the symptoms of appendicitis are so typical that the diagnosis can never be in doubt. The pain, tenderness, fever, vomiting, constipation, abdominal rigidity, and perhaps tumour, constitute a picture that is quite characteristic. The disease, however, often presents symptoms so varied, and mani- festations so protean, that one is never surprised to meet with it in all sorts of diverse settings, and many mistakes of diagnosis are made, even by the most skilled clinicians. The early stage of pneumonia is sometimes associated with severe pain and tenderness in the iliac fossa, especially in children, and the resemblance to appendicitis is the more marked when the onset is sudden, and abdominal rigidity and vomiting are present. A careful examination of the lungs should never be omitted in the case of children with suspected appendicitis. Cases which commence with diarrhoea may be mistaken for enteric fever, but the absence of the rash and a negative Widal's reaction should guard the practitioner from error. Recurrent appendicular pain may be mistaken for that of renal colic or for the painful attacks associated with displacement of a floating kidney {Dietl's crises), or vice versa ; and the difficulty is increased if hEsmaturia or irritation of the bladder are caused by an appendicitic effusion or abscess. Biliary colic may be simulated, whilst a distended and inflamed gall-bladder may closely resemble an appendix abscess which has travelled upwards. Perforation of the duodenum, or even of the stomach, may lead to symptoms very similar to those of appendicitis, due to the inflam- matorv mischief tracking downwards. The initial pain will usually be referred to the upper part of the abdomen, and there may be e\ddence of free gas in the peritoneal cavity. If gas escapes from the abdomen on operation, and is free from odour, the probabihty is that the lesion is gastric or duodenal. Mucous colitis simulates chronic appendicitis, and the appendix is indeed often involved m the mischief. The distinction is made by the tenderness bemg located over the whole course of the colon, and by the passage of mucus in the stools. Tubal and ovarian diseases are recognised on pelvic examination ; but the fact must not be overlooked that chronic appendicitis is often associated with inflammation of the right ovary, and then attacks of pain may occur at each menstrual period. A sm^all ovarian dermoid with a twisted pedicle may resemble appen- dicitis very closely in the absence of a vaginal or rectal examination. I052 A MANUAL OF SURGERY A considerable swelling in the right iliac fossa may result from repeated attacks due to a matting of the parts together, and a diagnosis from tuberculous or malignant disease is sometimes diffi- cult apart from operation. 1 he history may be spread over a longer time, however, in appendicitis. In abdominal abscesses the possibility of an appeudic;ular origin must always be kept in mind, as they may occur in any ])art of the abdomen ; and it is often only by a careful exploration of the cavity that we can trace the cause to the appendix. The diagnosis from acute obstruction is noted hereafter (p. 1131). The Prognosis is never absolutely certain, for, as has been well pointed out by many acute observers, the initial symptoms are fre- quently alike in all the varieties, and hence one can never know what course the case is going to take; as R. Morris, of New York, says, ' The infected appendix is a cap which sometimes snaps, sometimes flashes, and sometimes causes an explosion, and none of us can tell in advance just what is going to happen.' As particularly bad signs may be mentioned a continued high temperature, in spite of rest and careful dietetic measures, or a fall of temperature with increased rate of the pulse. Persistent hiccough is also a bad sign. The existence of a swelling in the iliac fossa is not a bad sign, but rather the reverse. Absence of a localized swelling is due either to a defective formation of protective adhesions, and hence is likely to be noted in the most acute cases, or to the appendix being placed behind the c?ecum in a position less favourable to operative measures. Treatment.^ — So much has been written on this subject during the last twenty years, that it is extremely difficult to compress even a brief summary of the many facts observed into a necessarily limited space. Formerly perityphlitis was the exclusive property of the physician; but a great change has occurred, and many authorities consider that appendicitis is more justly within the realm of the surgeon, or, at any rate, that a surgeon should always share the responsibility of treatment with the physician. At any moment complications may develop even in cases which appear to be simple, when immediate surgical assistance will alone hold out any hopes of saving the patient. In America surgery is the recognised treat- ment for almost every case of the disease, as soon as it is diagnosed ; in this country conservative ideas still persist, but a more healthy opinion is gaining ground, and surgical interference is becoming recognised as the most appropriate means of treatment in most instances. I. In the mild catarrhal type of appendicitis, where the tempera- ture does not run above 101° F. and the symptoms are not severe, all that is required in the majority of cases is to put the patient to bed, and apply fomentations locally ; the lower bowel should be emptied by an enema after a rectal examination has determined that no abscess or serious pelvic complication is present ; if it seems likely that there is an accumulation of irritating faeces within the intestine, one dose of castor oil or of calomel may be administered, but not ABDOMINAL SURGERY 1053 without due consideration. A fluid, unstimulating diet is all that is permitted, and should there be much vomiting, rectal alimenta- tion may be resorted to. Possibly morphia may be given with advantage to quiet the patient and check peristalsis, thereby facili- tating the formation of protective adhesions ; but the less the better, since it tends to mask symptoms. The question of operation for this mild type of disease can be readily compressed into the three following propositions: {a) If the condition is not showing signs of improvement at the end of forty-eight hours — i.e., on the third day — in spite of appro- priate treatment, the case should be looked on with suspicion as probably one in which suppuration is occurring, and operation is desirable. [b) If the appendix remains tender and palpable after an attack, and especially if the temperature rises slightly at night, the organ should be removed without delay. (c) As soon as the attack is really quiescent — i.e., generally in nine to ten days — the appendix should be removed. This proposition may not be generally accepted ; but it is absolutely logical , and daily experience is emphasizing the conviction as to its accuracy. In the first place, recurrence is common, and the figures given above (viz., 30 per cent.) probably underestimate its frequency. Then, too, it is impossible to tell which cases will recur and which escape, whilst the recurrent attack is frequently more severe than the first, and often accompanied by suppuration. Moreover, each recurrent attack is likely to add to the adhesions present, so that whilst removal after a first attack is an easy proceeding, removal after many recurrences may necessitate a long incision and a troublesome or dangerous dis- section, complicated, perhaps, by unintentional perforation of the bowel, or even enterectomy. Finally, it may be necessary to keep the patient very quiet and to limit his diet and his activities consider- ably if recurrence is to be avoided; and such practice in a bread- winner may be a serious matter. By removing the appendix, either during or immediately after the attack, this period of disability will probably be reduced to a minimum. Operation in the Quiescent Period. — The muscle-splitting plan suggested by McBurney may weU be adopted when it is probable that but few adhesions are present. The incision is an oblique one, about 2 to 3 inches long, crossing McBurney's spot or a little below it, and parallel to the outer end of Poupart's ligament, somewhat similar to that for ligaturing the external iliac artery (Fig. 473, C). The external oblique is exposed, and incised in the course of its fibres ; the divided segments are held well aside by retractors, so that about 2 inches of the internal oblique muscle come into view. The exposed fibres of this muscle run nearl}^ in the same direction as those of the transversalis muscle, and the two can be split together by a transverse incision. The introduction of large deep retractors will expose a square or diamond-shaped area of subperitoneal fat or peri- toneum about i^ to 2 inches in diameter. The peritoneum is I054 A MANUAL OF SURGERY divided transversely, and the margins grasped for identification purposes by Spencer Wells forceps. The caecum probably presents, and is gently withdrawn. The anterior longitudinal muscular band conducts to the appendix, which is freed from adhesions and removed. The meso-appendix is first divided after securing the vessels in it by a ligature. The serous and muscular coats are then divided by a circular incision and peeled back like a cuff, leaving the mucous membrane as a narrow tube. The retraction is carried back so as to enable a hgature to be placed around the tube of mucous membrane flush with the caecum (Fig. 499). The distal end is grasped with Spencer Wells forceps, and cut away after protecting the parts below with a strip of sterilized gauze. The protruding portion of mucous membrane is carefully curetted, and the sero- muscular cuff replaced over it. A purse-stiing suture is then intro- duced through the serous and muscular coats all round it ; the ap- pendix stump is gently invaginated into the csecum by a pair of forceps, and the suture tied ; b}' this means the stump of the appendix is buried and covered over completely with peritoneum (Fig. 500). The site of detachment of the meso-appendix, or of the position from which the appendix itself has been detached, may require a few sutures in order to ensure a complete peritoneal coating, and thus minimize the risk of subsequent adhesions. All bleeding-points having been secured, the ciecum, which has been protected during the operation by a warm wet sterilized cloth, is returned into the abdomen, and fmally in the female the right ovary and tube are carefully examined. The abdominal wound is then closed, layer by layer, without drainage. If, however, it seems probable that many adhesions are present, the muscle-splitting operation should be avoided, and the abdominal parietes divided in the line of the cutaneous incision, so as to allow the wound to be enlarged up or down as may be desired. The severance of these adhesions may be a most tedious and troublesome procedure, but when once it is effected the appendix is amputated as described above. In some of these more serious and prolonged operations it may be desirable to drain the iliac fossa by a tube or gauze wick for a short time. In the more serious cases the patient should remain in bed for three weeks, to allow the bond of union to become firm, and avoid all needless strain for some months, but in the simpler cases may be allowed up in a fortnight. 2. In the gravest variety oi fulminating appendicitis, associated with diffuse septic peritonitis, there can be no question that the only hope of recovery lies in immediate operation. When the peritonitis is extensive and the exudate purulent, this hope is but slender in the extreme; if, however, the effusion is mainly pelvic, and still of a sero- purulent type, it is possible that a considerable percentage of the cases may be saved. Hence, whenever the attack starts with severe pain, frequent vomiting, and early collapse, whilst the abdomen shows marked signs of rigidity, but may not be distended, no time ABDOMINAL SURGERY 1055 should be lost in operating. In such cases the appendix is either perforated, and then every hour adds to the mischief; or it is acutely distended with muco-pus, and may perforate at any moment, giving rise to a general infection. No possible good can be derived by delaying operation in these severe cases. The abdomen is opened, either through the middle line or in the right iliac fossa ; the appendix is looked for and removed, and effusion, if present, is swabbed or washed away with sterilized salt solution at 108° F. Drainage may be omitted in some of the early operations, even if effusion has been Fig. 499. Fig. 500. Amputation of the Appendix. In Fig. 499 the cuS of sero-muscular tissue has been dissected up, exposing the tube of mucous membrane, to which a pair of Spencer Wells forceps is applied distally, whilst a ligature is placed on its proximal end. The purse-string suture has been introduced around its base. In Fig. 500 the purse-string suture has been tied after tucking in the sero- muscular cufi, thereby burying the stump of the appendix. present ; but in most instances it is necessary, and may then be provided by tubes or gauze wicks. 3. When an abscess is evidently present, being indicated either by fluctuation or by a commencing oedema 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 may suddenly sink into the abscess cavity, and a gush of foetid pus follows. The cavity is gently explored, so as 1056 A MANUAL OF SURGERY to ascertain whether or not the appendix can be felt; no undue force should be used, for fear of breaking down adhesions and thus open- ing the general peritoneal sac. If the appendix cannot be readily found, it is best left alone; the abscess may be gently irrigated, drainage is provided for, and the incision partly closed. Probably the case will go on well, the discharge losing its smell about the third day, and the remaining sinus will gradually heal by granula- tion. Should the appendix, howe\-er, present itself, it should be removed. 4. There is still, however, a large group of cases in which none of the above conditions is manifest, and yet the symptoms, botli local and general, indicate that a lesion of considerable gravity is present. The attack may have commenced more or less acutely, but has progressed steadily. Much difference of opinion has existed as to the desirability of operation in these cases, and especially as to the most favourable time for such a procedure. It must be admitted that in many instances conservative or medical treatment will suffice to bring about a satisfactory result, but this can never be depended on, and, unfortunately, the experience of all surgeons is that only too frequently have they been called in to operate on patients who have been brought into the gravest jeopardy of their lives through undue delay. Either they are suffering from generalized peritonitis, or are profoundly toxaemic by absorption from a large abscess, or exhausted by previous suffering ; possibly other complications have arisen due to extension of thrombosis or dissemination of emboli. Operation under such circumstances is alw^ays risky, and even if the local conditions are effectively dealt with, the patient may subsequently succumb to toxaemia, septicaemia, pulmonary embolus, or other manifestations of blood-poisoning, perhaps aggravated by the operation. The objections usually raised to early operation are that it involves the removal of the appendix from a certain number of people who might get well without operation, and that it is not the best time to operate when inflammatory phenomena are present. The answer to these objections is quite obvious, viz., that the prognosis in any case is so hopelessly uncertain that the risks involved in waiting for a quiescent interval on the one hand, or for the development of un- doubted indications of the presence of pus on the other, are much greater than those of an operation undertaken at an early date by a skilful surgeon. Moreover, an appendix that has once been inflamed is of no service, and may be a source of grave danger to its possessor, and the sooner he is rid of it the better. Extensive experience of the early operation proves that pus is frequently present at quite an early stage of the affection — i.e., within twenty-four hours or less — and one rarely operates on ainy case where the symptoms are at all severe without finding cause for gratification that delay had not been counselled. Moreover, statistics prove that the mortality associated with operation during the infIammator\' attack is much less when it is undertaken on the first da}' (12 per cent.) than on any of the ABDOMINAL SURGERY 1057 successive days up to the sixth or seventh.* The chief advantages of an early operation may be indicated as follows: {a) That the patient is not in a state of collapse from toxaemia, and hence can easily stand the shock of an intraperitoneal exploration; {b) that the amount of effusion likely to be present is small, and hence can be easily dealt with and safely removed with but little risk of infect- ing the general peritoneal cavity or the abdominal wall ; (c) that the appendix can usually be found, isolated, and removed without much difficulty ; in the later stages where a large abscess exists this may be impracticable, and a second operation for its removal may be re- quired later on, and then the appendix may have to be ' dug out ' of a mass of adhesions, and serious risks taken; and (d) that a smaller incision will be required, and hence there will be less likelihood of the subsequent development of a hernia. One would therefore claim that the following rule is both reasonable and justifiable, and that its observance will be beneficial, viz., that in cases of moderate severity if in spite of suitable rest and medical treatment the symptoms, both general and local, are not commencing to abate at the end of forty-eight hours, operation shoiild be undertaken, and still more so if any of the following conditions, indicative of the formation of an intraperitoneal abscess are existent, viz., a steady rise in the leucocyte count, or one above 20,000, especially if maintained for twenty-four hours; per- sistent distension of the abdomen, a maintained high temperature, hiccough, or a continued high pulse rate, in spite of a falling tempera- ture. Of course, a localized swelling which persists or increases in size and becomes more tender, will also indicate operation. 5. Not a few cases will be observed in which the initial symptoms quiet down at the end of twenty-four or forty-eight hours, but after an interval of quiescence of varying length the phenomena suggestive of suppuration show themselves. In such patients opera- tion should be advised immediately, as an abscess is obviously developing. Operation for Suppurative Appendicitis. — Ether should always be the anaesthetic, if possible ; the mortality after operation when chloro- form is employed is decidedly higher. The incision will vary with the physical signs and the site of maximum tenderness. The whole thickness of the abdominal wall is divided, and it is well to make a sufficiently large opening ; an extra inch of incision may make all the difference between blindly groping in the dark and seeing clearly what one is doing. The general arrangement of the parts is noted, and the peritoneal cavity protected from purulent infection by pack- ing in sterilized gauze ; one strip is usually passed upwards along the ascending colon, one downwards into the pelvis, and one internally to protect the small intestines and general serous cavity. The caecum is then gently lifted from its bed, and the abscess will usually be found behind it. Every effort must, of course, be made to prevent soiling of the unaffected peritonermi. Whenever pos- * See Hugh Lett, ' The Present Position of Acute Appendicitis,' Lancet, January 31, 1914. 67 1058 A MANUAL OF SURGERY sible, the appendix should be removed, but not unfrequently a formal amputation is impracticable. A ligature, and preferably of catgut, which can be absorbed, is then tied around the base about I inch from the csecum, and the appendix cut away; the stump is guarded by a gauze strip passed down to it from the wound and used for drainage. Not unfrequently, however, the appendix does not appear, and then it may be better to leave it alone ; in many cases, however, an experienced surgeon will be able to detach and remove it. The cavity is emptied of pus by swabbing it out, and a careful but thorough exploration of the pelvis and right kidney pouch made to ensure that pus is not shut up in these regions. Finally, the cavity is packed in such a way as to drain it thoroughly, and yet to protect the surroundmg parts. The abdominal incision is partially closed. The packing is gradually removed in the next two or three days, and after the general cavity has been shut off by the development of adhesions, irrigation with salt solution or peroxide of hydrogen is permissible. The wound heals by granulation, and when nearly flush with the surface may be drawn together by strapping, so as to limit the chances of development of a ventral hernia. Sequelae." — A F cecal Fistula may result from a perforative appendi- citis when the abscess has been merely opened, and no radical treatment undertaken at the same time, or it may follow an amputa- tion of the appendix from sloughing or yielding of the stump. It is usually small in size, and sinuous in its course, and in the majorit}' of cases closes of itself. Occasionally it is necessary to deal with it by laying bare the csecum in the iliac fossa, and removing the appendix or suturing the opening. Failing that, it may be neces- sary to short-circuit the caecum. A Ventral Hernia sometimes follows from the yielding of the cicatrix in the 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 some cases it may suffice to protect and restrain it wath a truss, but in others operation is required; adhesions must be divided or broken down, and often the opportunity can be taken for removing the appendix, if this has not already been accomplished. The margins of the divided muscles are then sought for, and united by a row of buried sutures in the ordinary way, or overlapped as described in discussing the subject of ventral hernia (p. 1109). Tuberculosis of the Appendix is found not uncommonly in patients who have died of other manifestations of the disease, especially phthisis (30 per cent., Keen) ; it is not often seen as an independent condition, but most frequently comes under observation in men between the ages of twenty and forty, who are the subject of urino- genital tuberculous disease. The affection may develop as an ulceration of the mucous membrane, which slowly spreads from the tip and destroj's the walls of the organ, giving rise finally to a large pericsecal abscess, which opens into the bowel or discharges exter- ABDOMINAL SURGERY 1059 nally. In other cases the condition is merely an element in the e\-olution of the hyperplastic tuberculous growth of the cajcum described elsewhere (p. 1022). Occasionally the appendix is in- vol\-ed in a tuberculous peritonitis, and then the trouble may either ha\-e started in the appendix, or have reached it secondarily from the serous coat. The symptoms of these conditions are in no ways peculiar, and correspond to those of a chronic appendicitis. Actinomycosis attacks the appendix more frequently than any other abdominal organ. The disease originates usuall\- from the ingestion of infected material, and the result is the production of a hard, slowh'-enlarging mass, infiltrating the tissues in the right iliac fossa. Sooner or later the skin gives way, and then the discharge of glairy pus and of the yellow sulphur-like granules, together with the musty smell, is pathognomonic. Pyococcal infection of the sinuses is only too likely to follow, sometimes originating from within the bowel, and the case then becomes complicated by a suppurating element which has an important bearing on the result. Secondary foci are common, especially in the hver (p. 1067). Treatment consists in the excision of the appendix and even of the csecum, if such be practicable, or in the exhibition of large doses of iodide of potassium with curettage and drainage; but even when the organisms have been destroyed by the drug, the discharge of pus may continue, and the affection may prove fatal. Primary Carcinoma of the appendix is noteworthy on account of its slight malignancy. The case presents the history of a chronic appendicitis, in no ways peculiar, and on operation the growiih is discovered. Removal is usually followed by freedom from recur- rence. The condition is, however, very uncommon. Sarcoma has also been known to occur in connection with the appendix, but the prognosis is less favourable. Affections of the Liver. Displacements of the Liver are obviously not likely to be common, since the organ is well supported, both by ligaments and attach- ments to deep structures, and by the intra-abdominal pressure. Should, however, the abdominal parietes be relaxed and the intra- abdominal pressure lessened, it is possible for the liver to sink, and thus hepatoptosis becomes an element in the syndrome known as Glenard's disease (p. 1028) . The displaced liver is rotated fonvards so that its upper wall presents anteriorly, with obvious resulting physical signs. An enlarged liver may manifest somewhat similar phenomena, but dulness is then found over the normal hepatic area; in hepatoptosis the normal site is resonant. Some amount of dragging pain and discomfort may be complained of, but this is not generally great enough to demand treatment other than the support of a belt, together with such measures as shall assist in the restoration of the abdominal wall to a state of normal tonicity. In the worst cases it is justifiable to expose the liver by an incision io6o A MANUAL OF SURGERY parallel to the costal margin, and fix it to the parietal peritoneum by sutures. The operation is conducted in the Trendelenburg position, and the patient must remain with the lower end of the bed raised for some weeks after operation. Riedel's lobe is the name applied to a linguiform enlargement of the right lol)c, which projects downwards into the loin, and is likely to be mistaken for a floating kidney. It is sometimes stated to be the result of tight lacing, but this is not invariable, and more fre- quently it is associated with an enlarged gall-l)ladder, probably containing stones, which is covered in by the projection, llie lobe may have a broad base of attachment to the liver, or may be almost severed from it, and then its mobility is considerable, and may be independent of the liver. A little care in examination should enable the surgeon to differentiate between this condition and a floating kidney; if the patient be laid over on the left side, the examining hand can be insinuated between the lobe and the kidney. Treat- ment is not required, except, perhaps, for the condition of the gall- bladder. Rupture o£ the Liver is produced by injuries to the abdominal walls, such as blows, kicks, or crushes, or it may be torn by the broken end of a rib. Penetrating injuries also occur, as from sword or dagger thrusts, and the organ may be involved in a gunshot wound. The resulting lesion varies considerably; the gland may be merely torn or contused from a non-penetrating blow, or freely incised by a sharp-cutting implement, in which case some of the larger venous trunks are likely to be divided ; a bullet sometimes produces almost total disorganization. The amount of injury depends, to some extent, on the condition of the organ ; if it is firm and sclerosed, it may receive little damage from a blow which would otherwise do it considerable harm, whilst if it is enlarged and fatty, it is readily torn. The chief Symptoms are shock, which is often not very excessive, pain and tenderness in the right hypochondrium, and the evidences of loss of blood. The last is, perhaps, the most important, and upon its severity depends to a large extent the result. vShould the capsule remain intact, there is considerable intraglandular ecchy- mosis and laceration, but no free blood escapes into the peritoneal cavity. Such a lesion is not unlikely to be followed by an abscess of the liver. When the capsule is torn, intraperitoneal haemorrhage is sure to ensue; if slight, the patient, though suffering from all the phenomena characteristic of loss of blood, may recover, the blood being absorbed, and the wound in the liver cicatrizing. This process is usually attended by a certain amount of jaundice and some vomiting, whilst the urine is also tinged with bile-pigment. Well-marked pyrexia may follow the initial shock, and the abdom- inal wall is held rigid. In other cases, the blood collects at first in the upper part of the abdomen, but gradually extends downwards ; if the bowel is uninjured, recovery may ensue, but not uncommonly there is some associated contusion of the gut wall, through which ABDOMINAL SURGERY 1061 intestinal bacteria find their way, giving rise to a localized or general peritonitis. Of course, in the more severe lesions, where perhaps the left lobe is entirely torn off or a portion hopelessly contused, death from haemorrhage is almost certain to ensue in a very short time. The Diagnosis of hepatic rupture turns mainly on the history of the accident, the situation of the blow, and the resulting symptoms. Evidences of intraperitoneal bleeding, associated with pain in the right side, are extremely suggestive. It must not, however, be for- gotten that the passage of a hansom cab or other vehicle over the body may give rise to much shock, and to considerable local pain and tenderness, and yet no serious mischief need have happened to the liver. The Treatment in the more simple cases consists merely in careful expectancy, the surgeon holding himself in readiness to interfere should any untoward symptoms supervene. The patient is kept quietly in bed; ice may, if necessary, be applied to the side, the diet is limited to fluids, and the bowels emptied by enemata. In the more serious cases, where the diagnosis of ruptured liver is tolerably certain, an exploratory laparotomy should be undertaken, and an attempt made to deal with the wound. Possibly a median incision is as good as any, since the left half of the liver often bears the brunt of the injury. Outlying ragged portions of the gland may be totally removed, preferably by the cautery, though one usually has to de- pend upon plugging the wound with gauze in order to effect hsemo- stasis. Clean linear cuts may be sutured with silk, but there is considerable 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 wide margin of the gland substance before attempting to tie any. The wound is then carefully closed by the fingers, and the sutures slowly and gently tightened. 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 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 emboli are carried by the hepatic artery or by the portal vein. In the former case, the condition arises as a comphcation of general pysemia of systemic origin; in the latter, the originating 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 sometimes in typhoid fever, whilst suppurating piles may also lead to it. It is character- ized clinically by high fever, rigors, vomiting and abdominal disten- sion ; the liver is enlarged and tender, and the spleen may also be engorged with blood. 2. Suppurative Cholangitis is another cause of multiple abscess of the liver. It consists of an inflammatory affection of the biliary duct and passages, and is due to the spread of organisms from the io62 A MANUAL OF SURGERY intestine, or occasionally from the gall-bladder after an operation. The biliary ducts in the liver become enormously dilated, and tilled with a mixture of bile and pus which closely resembles 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 those which, from their size, demand operative treatment. They may result from traumatism in the way stated above, or may arise in connection with hydatid cysts, but more commonly are of the type known as tropical abscess. The latter usually occurs in men who have travelled in the tropics, and 75 per cent, of the cases are attri- buted to dysentery. It is probable that unwise indulgence in alcohol is a predisposing factor, and that the abscess itself is embolic in origin. A large proportion of the cases are stated (by Dr. Leonard Rogers*) to be free from ordinary pyogenic organisms when first opened, but to contain in abundance the A mceha coli, which is looked on as being an important factor in the aetiology of dysentery. In the less acute cases the pus becomes sterile after a time, the organisms apparently dying. It is probable that in the more acute cases ordinary pyogenic cocci are usually to be found. A tropical abscess is most frequently situated at the back of the right lobe, but, of course, any part of the viscus may be involved. Though often single, the cavity is generally loculated, indicating that several original foci of suppuration have united together. 1 he abscess wall consists of disintegrating hepatic tissue in acute cases, but may have a fibro-cicatricial wall in the more chronic forms, and in an old- standing abscess the limiting membrane may be as tough as leather. The pus is sometimes of the ordinary type, but not uncommonly reddish-brown 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, or retaining the pus encapsuled for years. The individual usually complains of a sense of pain and fulness in the right h^^^ochondrium, and in the more acute cases this may be accompanied by severe pain and localized tenderness over the whole hepatic region, the pain being also referred to the right shoulder. When the pus encroaches on the upper surface of the liver, a cough on taking a deep breath is rather characteristic. 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 ; in the more chronic variety there is some fever in the evening, and * British Medical Journal, June 16, 1906? ABDOMINAL SURGERY 1063 night sweats occur. The pyrexial phenomena are associated with loss of appetite, rapid and well-marked emaciation, and perhaps a slight amount of icterus. On physical examination a more or less e\ident enlargement of the liver will be detected; but there is neither fluctuation nor a sense of elastic tension unless the abscess is very superficial. The dulness often extends up towards the thorax rather than downwards, though the contrary obtains when the abscess is situated not far from the free margin of the liver. 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 con- gestion and cedema of the parietes ; it may open into the peritoneal cavity, or into one of the hollow viscera, such as the colon or duo- denum; 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 abscess, and then the walls become very thick, as in a case operated on by one of us, which had been diagnosed by an exploring needle twelve years previously, and left alone. It contained about 2 pints of pus, and the walls were fully h 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. In many cases the diagnosis of suppuration is by no means easy, and mistakes are likely to be made, the condition being looked on as one of hepatitis. A blood count may be of some assistance, and especially a diferential count; but sometimes it is of little value, since a le.ucoc\i:e count of 20,000 or more can occur without suppura- tion. A marked increase in the polynuclear leucoc\i;es and a dimi- nution in the small lymphocj' tes is always suggestive of the presence of pus, due to pyogenic organisms ; in a pure amoebic abscess, leuco- cytosis occurs with a comparatively small increase of polynuclears. A doubtful diagnosis can sometimes be confirmed by the aspirator or exploring syringe, but this should not be utilized unless one is fully prepared for immediate operation 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 m the right nipple line ; (3) immediately below the lung in the line drawn downwards from the angle of the right scapula. Treatment. — It is unnecessary to discuss the medical treatment of cases of suspected abscess of the liver ; but we must refer in passing to the diagnostic and curative value of ipecacuanha in the hepatitis that accompanies amoebic dysentery when pus is not present. Doses of 20 to 40 grains are administered once or twice a day tw^enty minutes after a small dose of tincture of opium, and if suppuration is absent the s\Tnptoms usually yield rapidly. When an abscess is present, operative treatment 'is' of course necessary. Aspiration, repeated once or twice, has been frequently employed, but is of little 1064 A MANUAL OF SURGERY value, and not a few cases are on record in which septic peritonitis or pleurisy followed the introduction of the needle from the front or side respectively. The practice usually followed is in accordance with the surgical law of treating suppuration — 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 was formerly thought best to plug the wound with sterilized or antiseptic gauze, or to introduce sutures between the liver and the parietal peritoneum so as to determine the formation of adhesions to such an extent as to shut off the general peritoneal cavity; in a few days the abscess could then be opened with safety. At the present time the operation is usually done at one sitting, with pre- cautions similar to those taken in dealing with an intraperitoneal abscess connected with appendicitis. The general serous cavity must be carefully protected by sterilized gauze before letting out the pus, w^hich is of course done slowl3% and the assistant must keep the parietes in close contact with the hepatic tissue. It may be possible to insert a few stitches through the liver substance, securing it thus to the parietal peritoneum; otherwise one must trust to careful packing. After opening the abscess, it is usually advisable to wash it out, and this may with advantage be repeated subsequently. A large drainage-tube is inserted, and packed around with gauze to prevent purulent extravasation. When the abscess is in its most common situation, viz., the back of the right lobe, it is often most satisfactory to open it from the side ; a similar proceeding is sometimes needed when an abscess has been opened from the front, and does not drain properly. An incision is made a little behind the mid-axillary line through the ninth or tenth intercostal space, and a portion of one of the adjacent ribs removed. The pleural cavity is opened, and the costal pleura stitched carefully to that portion which covers the diaphragm; it will be found that this structure lies nearly vertical in this position, and but little difficult}^ is experienced in shutting off the general pleural cavity. The diaphragm is then divided, and not unfre- quently the peritoneal cavity is opened; it must be carefully pro- tected by gauze packing, and then the liver incised ; less commonly adhesions may have already formed, or a bare area of the liver may be found, through which the pus can be withdrawn and the abscess opened. Recently, however, some doubt has been thrown on this practice by Dr. Leonard Rogers,* who finds that the Amwha coli is easily killed by comparatively weak solutions of quinine, and hence has suggested that in amrebic abscesses all that is needed is to empty the cavity by aspiration, introduce 30 or 40 grains of bi-hydro- chlorate of quinine, and employ no drainage. The results hitherto * Op. cit. ABDOMINAL SURGERY 1065 reported have been most encouraging. A rapid microscopic ex amination of the pus must of course be made at the time, and if pyogenic organisms other than the amreba are found, the ordinary operation can be carried out. Hydatid Cysts occur in the liver more frequently than m any other part of the body. For general details as to the life-history of the TcBnia echinococcus and the structure of hydatid cysts, see p. 233. They produce a localized painless enlargement of the liver, the cysts varying in size from a small marble to a child's head; the outline is well defined if superficial, but not so if placed deeply ; the cavity is usually filled with fluid and daughter-cells. Fluctuation may be dis- tinguished, and a hydatid fremitus or thrill (arising from the concus- sion of the contained daughter-cysts) may, it is said, be elicited on palpation. The diagnosis is easily made if the cyst projects from the lower border, but when deeply embedded in the organ it may be exceedingly difficult, and the tumour can only be distinguished with certainty from carcinoma or syphilis by the use of the aspirator, or preferably by an open exploration. The character of the fluid with- drawn from a hydatid cyst is at once conclusive, as it is of low specific g^a^^ty, viz., 1007 to loog, slightly opalescent, with no albumen, and a trace of salt; the presence of scolices or booklets is the pathognomonic feature. Terminations. — The cyst may remain latent and innocuous, or maj- actually dry up and form a mass somewhat like wet mortar, owing to the death of the organism ; or it may burst and be evacuated in different directions, with or wdthout suppuration. Thus, it may open externally through the abdominal parietes, or into the peri- toneal cavity, causing fatal shock and in many cases peritonitis ; or into the stomach or intestines, spontaneous cure usually resulting; or it may penetrate the diaphragm, and the contents be expector- ated, or set free in the pleural cavity, causing a rapidly fatal pleurisy. It has been known to open into the pericardium, or even into the hepatic veins, the contents then being impacted in the right auricle ; in both cases immediate death resulted. Treatment. — The best plan of dealing with a hydatid cyst is to lay it open either through the anterior abdominal wall, or through the costal parietes and diaphragm, to empty it of its contents, and if possible to enucleate the lining wall or endocyst, which is often but loosely connected to the fibrous ectocyst. This is usually accom- plished at one sitting. Similar precautions as to protecting the peri- tonemn are taken as for an abscess. When the surface of the liver is exposed, it is advisable to puncture the cyst first with a trocar and cannula, so as to reduce the tension within it. It is then incised freely and the loose daughter-cysts removed. This is facilitated by flushing out the cavity with sterilized salt solution. The endocyst is removed either by enucleation wdth the fingers or a blunt dissector, or it may be possible to detach it by irrigation, the nozzle of the irrigator being inserted beneath it. If enucleation is completely successful, the lesion in the liver may be closed, and the abdominal io66 A MANUAL OF SURGERY wound sutured in the ordinary way without drainage (Hamilton Russell), dependence being placed on the aseptic organization of the blood-clot which fills up the cavity in the liver. If for any reason this seems undesirable, a gauze packing is introduced into the cavity, and healing by granulation is allowed to proceed. If, however, part of the lining wall is left, a drainage-tube must also be introduced, and the cavity subsequently irrigated at each dressing. No attempt should be made to remove the fibrous ectocyst, as it is closely connected with the liver substance, and grave haemorrhage might follow any interference with it. Formerly aspiration and electrolysis 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 it was not unaccompanied by risk of peritonitis, and that recurrence was often observed. Moreover, some of the fluid not unfrequently leaked into the peritoneal cavity, 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. Angiomata, adenomata, and simple cysts have been described, but primary gro\\i:hs are more often carcinomatous in nature, and develop either as a large well- defined infiltrating mass, or as a small central tumour, with secondary nodules scattered around. Sarcomata are rare. Secondary tumours of the liver are common, and either arise by direct extension from the gall-bladder, or follow a carcinoma of the intestinal canal, especially of the stomach or large intestine, or perhaps may be a sequel of cancer of the ovary, uterus, or breast. The liver is also involved secondarily in melanotic disease of the skin or retina. In all these cases the organ becomes enlarged and its surface irregular, due to the projection of nodular masses of the growth; in cancer they are frequently more or less umbilicated. The simple growths are occasionally pedunculated, and may arise from the left lobe, and thus become amenable to surgical treatment. Pain is not generally a prominent symptom, but ascites and jaundice develop in malignant cases from pressure on the portal vein and biliary ducts in the portal fissure, and oedema of the legs may be caused by compression of the inferior vena cava. Gummata are developed in inherited and acquired syphilis, and are of sufficient size to need careful diagnosis from the more serious growths which develop in the liver. They are single or multiple, and occur in the form of rounded yellowish avascular masses, tending to caseate, and surrounded by much fibrous tissue. Absorption is followed by considerable cicatrization, which leads to deformity. The diagnosis from secondary carcinoma is not always easy. The ABDOMINAL SURGERY 1067 history of the patient must be carefully considered, and if any doubt arise the W'assermann reaction is tested. Carcinomatous growths have a hard umbilicated surface, if it can be felt, enlarge rapidly with marked cachexia, and early produce jaundice and ascites. Gummata are slower in their progress, do not generally affect the structures in the portal fissure, and may be associated \vith an enlarged spleen from lardaceous or gummatous disease. A course of antisyphilitic medicme will necessarily influence the case verv decidedly. Actinomycosis of the liver is usually secondary to an affection of the alimentary canal, particularly the" appenchx or transverse colon, or may be due to a direct spread of the infection. The liver is enlarged, and may be covered with adhesions. On section the affected area presents a trabeculated honeycombed appearance, which has been compared to a sponge soaked in pus. There is much fibrosis around, and the trabeculae are markedly fibrous. The pus contains the characteristic granules of the fungus. The clinical history is that of an hepatic abscess, and the prognosis is bad. Treatment is as for the disease elsewhere (p. 193). Affections of the Gail-Bladder and Bihary Passages. The Gail-Bladder (Fig. 501, GB) is a pear-shaped sac lying under cover of the liver and proj ecting into the peritoneal ca\ity. Its average length is about 3 to 4 inches, and it is normally capable of holding about an ounce of fluid. \Mien one remembers that the liver secretes about an ounce of bile every hour, it is ob%-ious that its function as a biliary reservoir must be verv limited ; in fact, it is possible that in a state of health it does not contain bile at all, and that it merely acts as a pressure-gauge regulating the flow of bile into the intestine or secretes a mucoid fluid which dilutes the bile. An enlarged gall- bladder projects do^\-n wards and towards the umbiHcus, constituting a rounded swelling which moves with respiration, and is almost always in close relation ^\-ith the anterior abdominal wall; it is freely mobile from side to side, and has attained such dimensions that it has been operated on in mistake for an ovarian cyst. It is attached to the liver by reflections of the peritoneum, which vary somewhat in their insertion; as a rule, about a fiith of the circum- ference of the gall-bladder is in contact -with the liver. The attachment is loose, and when once the right layer has been reached, it is easy to strip the gall-bladder from the liver. The cystic arterv' reaches it at some distance from the fundus. In a few cases the gall-bladder has a complete peritoneal investment, swinging loose from the Uver on a mesentery, and in two cases one has seen serious colic develop apparently from this lax attachment, much in the same way as a long appendix can cause appendicular cohc. Removal of the gall-bladder demonstrated the absence of stones and cured the condition. Such a condition may be termed Gall-Bladder Colic, to distinguish it from the biliary colic produced by gall-stones. The Cystic Duct (Fig. 501 , CD) is about 2 inches in length, or rather less, and is arranged more or less in a spiral fashion by the attachment of the peritoneum. It will ordinarily permit of the introduction of a Xo. 5 catheter, but probablv in a healthy state the mucous membrane is in such folds that a probe cannot be passed along it. The Hepatic Duct [HD) is 2 inches in length, and is formed by the junction of the right and left ducts which issue from the liver at either end of the transverse fissure and unite together at a verv obtuse angle. The duct passes down with the hepatic artery, and a httle above the upper border of the first piece of the duodenum is joined at a very acute angle bv the cystic duct. The Common Bile Duct {CBD) is about 3 inches in length, and takes a Xo. 7 catheter; one inch or more of it is to be found above the duodenal border, and io68 A MANUAL OF SURGERY then it dips bcliind the viscus; and after lying between the inner bonier of the gut and the head of the pancreas, it perforates the bowel obliquely (A'), some- times being distended just before its termination to constitute the ampulla of Vater, and into this the duct or ducts of the pancreas also open. Rupture or Perforation of the Gall-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 ulcera- tion from within, as from a large impacted gall-stone. Blood and bile are in consequence extravasated into the peritoneal cavity. Pure bile is sterile, but if any inflammation of the bihary passages has been present, organisms are sure to have found their way into the gall-bladder, and thus complications may readily ensue. If a DTV Fig. 501. — Diagram of the Biliary Passages and their Relation to the Duodenum, which has been laid open, and Pancreas. GB, Gall-bladder; CD, cystic duct; HD, hepatic duct; CBD, common bile- duct; DS, duct of Santorini; DW , duct of Wirsung; A', opening of common bile-duct and duct of Wirsung in the duodenum; A, aorta; SA, splenic artery; SM, superior mesenteric vessels. considerable quantity of bile escapes suddenly into the peritoneal sac, acute peritonitis is certain to follow sooner or later, whether organisms are present or not; slight jaundice arises from absorption by the peritoneum of bile, which 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 jaundice 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 liy])o- chondriac pain, and this will be succeeded either by acute peritonitis or b}^ the formation of a localized intraperitoneal swelling, together with mild jaundice. When the existence of such a lesion is sus- ABDOMINAL SURGERY 1069 pected, Treatment always consists in an exploratory laparotomy. The fluid within the abdomen is 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, be 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. 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. Inflammation of the Biliary Passages is of frequent occurrence, and generally arises as a sequela of a gastro-duodenal catarrh. The affection is similar in nature to that commonly seen in other tracks lined with mucous membrane, and may be limited to the main bile- ducts and their extensions into the liver {cholangitis), or may also involve the gall-bladder [cholecystitis). The catarrh is determined by the presence of micro-organisms, and streptococci, staphylococci, or the B. coli, are most frequently present; the condition may be limited to a simple catarrh, or suppuration may follow. Catarrhal Cholangitis is more of medical than of surgical interest, but its frequency and its setiological connection with the develop- ment of gall-stones warrants its introduction into a surgical text- book. In the acute form it is common in young people, arising from over-eating or injudicious food, combined perhaps with exposure to cold and wet. The patient feels ill, perhaps shivers, looks a little sallow, or maybe is actually yellow [catarrhal jaundice) . Abstinence from all but fluid food, and the administration of mild purgatives, especially of the saline type, will generally free the patient from his symptoms in a very short time. Sometimes the condition is of a more chronic type, occurring then in people of middle hfe, who are the subjects of persistent dyspepsia, often caused by late hours, irregular and injudicious meals, constipa- tion, and perhaps mental and nervous tension. Indulgence in alcohol adds to the trouble. Such people are frequently ' livery, ' and look more or less sallow, but are not actually jaundiced; they lose weight, and are irritable to a degree ; but none of the graver symp- toms of malignant disease are to be found. The liver is probably a little enlarged and may be tender, and the gall-bladder may be palpable. It is this type of patient in whom gall-stones are liable to develop, and for whom courses of waters do so much good, as at Carlsbad or Harrogate, where hydro-therapeutic measures are com- bined with a rigid dietary. The essential elements of the treatment can be quite well carried out at home if the patients will submit to the restrictions that must be enforced. Infective Cholangitis is a much more serious affection, and may lead to a fatal issue. It is usually due to the presence of a stone or stones in the common bile-duct, but may arise from other causes, e.g., ascarides or hydatid cysts which have escaped into the biliary passages, from malignant disease, or it may spread backwards into I070 A MANUAL OF SURGERY the liver from a suppurating gall-bladder. The general phenomena which follow an attack of biliary colic, due to the attempted or successful passage of a gall-stone, are due to this cause, and hence fever with or without a shivering fit, a certain amount of jaundice (which is easily comprehended when one remembers the low pressure at which the bile is secreted), enlargement and tenderness of the liver are to be looked on as the characteristic features of a mild attack. Treatment necessarily consists in removal of the cause, if possible, or, faihng that, in drainmg the biliary passages by cholecystostomy. It must not be forgotten that the persistent presence of such a condition may lead not only to mischief in the liver, but also to chronic pancreatitis, and to adhesive peritonitis, which may complicate future operative procedures, and therefore in any patient with well- marked symptoms operation should never be delayed too long. In the more serious types of this affection suppuration may ex- tend up the passages and lead to multiple abscesses in the liver, a condition already noted at p. 1061. Drainage of the gall-bladder and removal of the causative stones is the only hope of cure, but the prognosis is very grave. Cholecystitis, or inflammation of the gall-bladder, is most com- monly the result of the presence of stones in that cavity, but may also arise as a sequela of typhoid fever. Indeed, the B. typhosus seems to have a special predilection for this viscus, and may reside there for years after the primary attack, the individual or typhoid carrier being thus a danger to the community from his ability to discharge living organisms at intervals. Streptococci or staphylo- cocci are present in the other cases, with or without the B. coli. There is nothing specially noticeable about the pathological phenomena, except that the viscus is intraperitoneal, and that there is some analogy between the troubles arising here and in the appendix. There is, however, less tendency for the peritoneum to be seriously involved owing to the greater thickness of the wall, and its greater capacity for stretching ; thus a distended gall-bladder may contain a large quantity of muco-pus without giving way, and the viscus has even been opened in the pelvis or through the sac of a hernia. Protective adhesions frequently develop between the gall- bladder and the stomach, duodenum or transverse colon, and not a few of the uncomfortable symptoms produced by gall-stones are due to their existence. The clinical history varies according to whether the condition is chronic or acute. In the chronic variety produced b}' gall-stones, the symptoms are part of the syndrome characteristic of that condition, and are but little noticeable in themselves. The gall-bladder may be enlarged, and a little tender on pressure ; should the cystic duct be blocked, it will be distended with mucus or muco-pus according to the degree of irritation present. The acute form is evidenced by marked pain and tenderness in the right hvpochondrium, together with vomiting, constipation, and fever. The constipation may be very marked, as it is due to paralysis of neighbouring coils of intes- ABDOMINAL SURGERY 1071 tine, and especiall}- the transverse colon. The abdominal wall is held rigid, and the right rectus is very tense; but the enlarged gall- bladder can usually be detected beneath it. In one case it was as large as a cocoa-nut, and on exposure was of a brilliant red colour, and contained about 8 ounces of muco-pus; it was absolutely free from adhesions and contained two gall-stones, one of them embedded in the cedematous wall and near the point of perforation. As a rule, a sufticienc\- of adhesions forms to protect the general cavity of the peritoneum, and then the abscess, if unrelieved by art, may burst into the bowel, or ma\- open externally and discharge itself. In the most severe forms sloughing and gangrene of the wall follow {phlegmonous or gangrenous cholecystitis), and then general peritoneal infection may ensue. In the milder forms the inflammation may in time subside, the gall-bladder emptying itself per vias naturales ; but adhesions of a more or less severe character are likely to be left and may cause much trouble, whilst the gall-bladder itself may shrink and atrophv. Treatment consists in dealing with the cause, if such be gall-stones. In the acute variety of suppurative inflammation, the gall-bladder should be removed without dela}', just as one removes an inflamed appendix. There are frequently many newly formed omental adhesions, but it is not difficult as a rule to clear the gall-bladder and excise it completely. Only if there are dense adhesions of old standing is it necessary to open it, remove the contained stones, and drain it. The operations are described below, and need no special reference. Cholelithiasis is the term applied to the presence in the gall-bladder or biliary passages of Gall-stones. 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 gra\'ity is a little higher than that of water, and hence when immersed in it they sink; after dr^-ing, however, they are found to float. The number present varies immensely; some- times a single large one exists, which is more or less barrel-shaped (Plate IX.) ; more frequently they are multiple, scores or hundreds being present, and are then usually faceted, and with a satin-like yellowish lustre. If they have lain long in the gaU-bladder, they are usually of a deep brown or almost blackish colour. The Origin of gall-stones is not yet fuUy understood, but there seems no doubt that they are primarily due to a chronic catarrhal aftection of the gall-bladder or biliary passages, the cholesterine being formed bv the lining epithelium. Ihe original trouble is probably a gastro-duodenal catarrh, and the inflammation spreads upwards from the bowel to the gall-bladder. Gall-stones usuall}^ develop in the gall-bladder or the lower biliary passages, but they can also form in the ducts ^^^thin the liver, especially in cases where the hepatic derangement has been of long standing. Ihey occur most com- monly in women who have suffered from dyspepsia and constipation, and mav be associated with cancer, either as cause or eftect. In one I072 A MANUAL OF SURGERY case the origin of the trouble seems to have been the swallowing of a pin many years previously, which worked its way into the gall- bladder, set up an inflammation, which resulted in the formation of calculi, and only appeared again after a successful operation, when sixty-six stones had been removed. The fact that gall-stones are frequently found unexpectedly on the operating-table or in the post-mortem room suggests that they may remain quiescent for years, and only cause trouble when attempting to escape, or if associated with some inflammatory disturbance. Thus the first evidence of their presence may be an attack of acute suppurative cholecystitis, and then, unless prompt attention is given, diffuse peritonitis may result. Sometimes they cause chronic irritation of the gall-bladder, resulting in the walls" becoming thick- ened and hypersemic at first, but subsequently white and opaque; and in time a process of sclerosis supervenes, which may lead to con- traction of the wall upon the stones which are thereby encapsuled, and all attempts to displace them come to an end ; cancer may also supervene. Adhesions also form between the gall-bladder and surrounding tissues, and thereby the movements of the pylorus or transverse colon may be hampered. More frequently the gall- bladder contains enough fluid to keep its walls distended, and then efforts to expel the stones follow, giving rise to definite painful symptoms. Sometimes the stones slip back ; at others they pass on and may escape into the bowel, or may be blocked in the cystic or the common bile-duct, and find it impossible to progress further. Such stones may ulcerate through into various viscera, such as the stomach, duodenum, or colon, and thereby relief be given to the symptoms, or they may escape into the general peritoneal cavity and cause peritonitis. The Clinical History of a case of cholelithiasis is obviousl}^ very variable according to the exact location and condition present. 1. In what has been termed the Prodromal Stage, when the stones are free in the gall-bladder, and not doing much harm, the symptoms are referable rather to the stomach than to the hypochondrium. The patient complains of a sense of weight and fulness in the epigastrium, particularly after meals, accompanied by fleitulent distension, which is relieved by belching, or entirely removed by vomiting. This may have lasted for years, and is usually accom- panied by constipation. vSometimes the discomfort amounts to acute pain, which doubles up the patient, and may be more severe on taking a deep inspiration. With these phenomena there may be a sense of chilliness scarcely amounting to a rigor, and when the pain passes the patient may perspire. He is often a little sallow, especially on days when he feels bilious, and there is some tender- ness over the gall-bladder; but the diagnosis of gall-stones is scarcely warranted unless the pain is very acute. Unfortunately, radio- graphy does not often help in the diagnosis. 2. When the gall-stones are loose in the bladder and attempting to escape, more definite and distinct phenomena result. Pain is perhaps PLATE IX. # '^SB^ Various types of Gallstones (natural size) In lirmly I is a large bairel- shaped slone removed with ihe gall-bladder, in which it was held. Fig. 2. — An ordinary gallstone of moderate size. Fig. 3. — Dark gallstones, evidently old inhabitants of the gall-bladder, and deeply stained with bile- pigment. Fng. 4. — More recently-formed gallstones with but little bile-pigment, and one on section showing laraination. Fig. 5. — Bright brownish stones with facets. [ To face page 1072. ABDOMINAL SURGERY 1073 the most marked feature, and may be of various types, {a) There is the locahzed pain, due to the irritation of the gall-bladder itself, which is rather a dull ache referred to the right hypochondrium, shooting through to the back about the level of the tenth rib, and perhaps up to the right shoulder ; this form is usually increased on mowment. [b] Pain is also complained of, due to the adhesions which form about the gall-bladder, and hamper the movements of the stomach or intestine ; this is often epigastric in location, and may be of a colickv nature, especially after meals, (c) The worst pain is the typical biliary colic, due to the efforts of Nature to expel the stones. This is often of an excruciating character, starting suddenly, continuing for a while, and often ceasing as suddenly as it com- menced when the stone passes on or slips back ; the patient may be collapsed owing to its severity. It radiates from the right hypo- chondrium, shooting over the scapular region and into the back ; the gall-bladder mav be enlarged and tense during the attack, and the liver somewhat swollen. Vomiting occurs during or after an attack of biliarv colic, especially when adhesions to the stomach or duodenum are present. Jaundice is not usual except after an attack of biharv colic, and is then due to the swelling of the mucous lining of the biliarv passages, preventing the escape of bile ; if the stone slips back, it is not so likely to occur. The presence of many loose gall-stones usually determines an enlargement of the gall-bladder, which can be felt from the outside. 3. Impaction of a stone in the cystic duct is characterized by pain, which is more or less persistent, but wdth paroxysmal exacerbations, and the gall-bladder becomes distended with its own mucoid secre- tion [kvdrops), until it mav attain a considerable size. Jaundice is usuaUv absent. Not uncommonly acute inflammatory phenomena follow" (acute suppurative cholecystitis), and this may lead to ulcera- tion or perforation. Less frequently chronic suppuration occurs, constituting an empyema of the gall-bladder. 4. Occasionallv a stone becomes lodged at the junction of the cystic and the hepatic ducts, and then the manifestations of obstruc- tion are verv severe, and the pain may be very acute. Icterus is intense, but" the gall-bladder may be empty; the liver is certain to be much enlarged. 5. The presence of gall-stones in the common duct may give rise to s\Tnptoms of the most diverse tvpe; a small stone may originate ver^- severe phenomena, whilst a much larger stone may cause less trouble. Frequentlv several stones are present, and sometimes they are embedded in a mass of soft ' biliary mud,' consisting of inspis- sated bile salts. Their location, too, varies considerably; a single stone is perhaps found most frequently in the lower part of the duct, whilst multiple stones involve its whole length. The sjmiptoms caused are pain of a paroxvsmal character accompanied by vomiting, and jaundice, sometimes of a severe type, occasionally less marked, but rarelv as persistent as the jaundice due to mahgnant disease. The stone is more or less moveable, and acts as a ball- valve, at times 68 I074 A MANUAL OF SURGERY allowing a certain amount of bile to pass. In malignant disease the obstruction is absolute, and the jaundice is thereby maintained. The Hver is enlarged owing to back pressure of bile, l)ut the gall-l)Iadder does not participate in this distension, whereas in malignant disease or other causes of persistent jaundice it is often dilated to a consider- able degree (Courvoisier's law). If the stone is located in the ampulla of Vater, it is easy to understand that pancreatic troubles are likely to be associated with the jaundice, but it may ulcerate into the duodenum without much difficulty. Should a perforation form posteriorly, the retroperitoneal cellular tissue becomes involved, and a subphrenic abscess may result. The Treatment of gall-stones is, in the first place, medical in character, and consists in a rigid attention to the diet which should be simple and easily digestible ; this is accompanied by regular exercise and the use of alkaline purgatives of a saline character and an abundance of pure water. This is best carried out at a spa such as Harrogate or Carlsbad, but can be arranged for at home, if the patient will submit to the necessary regulations. Biliary cohc is treated by fomentations, and if need be by an injection of morphia; it is perhaps wise to administer salol or some other intestinal antiseptic, whilst salicylate of soda assists in increasing the fluidity of the bile. It is quite an arguable question as to what happens in such cures, whether the stones are softened and passed, or whether they become acclimatized in the gall-bladder and cease to cause trouble. At any rate, it is important not to waste too much time in this direction, should the s}Tnptoms persist. It has been already pointed out that gall-stones are not to be looked on as perfectly innocuous; inflammatory troubles of a serious character and even malignant disease may be caused by them, and therefore the per- sistence of symptoms, and especially their aggravation, indicates the necessity for surgical interference. The proceedings required vary somewhat according to the location of the stones, and different operative measures have been devised in order to deal effectively with these varied conditions. It must be remembered that the existence of gall-stones is an evidence of chronic inflammation of the lining mucous membrane of the gall-bladder, and that the mere presence of the stones maintains and increases this irritation so that the walls are usually in a sclerosed or thickened condition. The simple removal of the gall-stones does not necessarily cure the inflammatory trouble, and hence recurrence is by no means uncommon ; moreover, the sclerosed wall of the gall- bladder freed from irritation often contracts down, and the result is that the organ becomes shrunken and functionally useless. Hence in a large percentage of cases it is useless to attempt to save the gall- bladder, and the general rule of treatment is that when it is probable that recurrence of gall-stones may be expected or the functional value of the gall-bladder destroyed, complete excision of the organ and of the contained stones should be undertaken. Cholecystectomy is also indicated when a stone has been firmly impacted in the cystic ABDOMINAL SURGERY 1075 duct; a stricture in that position is almost certain to follow the removal of the stone, and hydrops or empyema of the gall- bladder will result. In acute cholecystitis of calculous origin, excision is usually desirable, as also in the more chronic suppurating cases. Incision with removal of the stones and subsequent suture of the gall-bladder {cholecystendysis) is occasionally permissible, but only when the calculous history is insignificant, or when a gall-stone is discovered by accident during an abdominal operation. Drainage is probably unnecessary in the majority of cases where the gall- bladder wall is tolerably healthy. In cases where the symptoms have not been very severe, but the patient has suffered for some time from pain and recurring ' bilious ' attacks, and looks sallow and slightly jaundiced, and yet on explora- tion the gall-bladder is free from adhesions and not much altered in its structure, it may be wise to drain it for a while after removing the stones [cholecystostomy) rather than to excise it. The flow of bile relieves the hepatic congestion, and improves the condition of the patient. Moreover, calculi in such cases sometimes develop in the biliary passages higher up, and an opportunity for the escape of these is thereby afforded. A drainage-tube is placed in the fundus of the gall-bladder and secured by catgut stitches, which are dissolved in about a week and set the tube free. The flow of bile usually persists for another week or two and then ceases, the wound in the gall- bladder closing by granulation when the wound is packed. Should it, however, continue for any length of time, further operative measures in the direction of closing the opening in the gall- bladder by invagination of the margin and over-stitching will be required, or the organ is removed completely and the cystic duct ligatured. Impaction of a calculus in the cystic duct usually necessitates excision of the gall-bladder, inasmuch as a stricture of the duct is almost certain to follow incision and removal of the stone. Should it, however, be fixed close to its junction with the common bile-duct, it may be better to free the gall-bladder and remove it by dividing the C3/stic duct on the distal side of the stone, which is then extruded by digital pressure or delivered by a scoop. The biliary passage may then be drained for a while, or the duct closed by ligature or suture. A stone in the common bile-duct is removed by exposing and incising the duct {choledochotomy) . There is but little difficulty in effecting this if the stone is in the upper part above the duodenum ; the stone is localized and fixed, and the duct incised longitudinally over it. The peritoneum is guarded by suitable swabs, and the stone is then removed. Careful examination should be made both upwards to the liver and down to the intestine by a probe to make certain that no further stones are present. If a stone is lodged behind the second piece of the duodenum, it may be possible to manipulate it up, and make it accessible above the intestine; but 1076 A MANUAL OF SURGERY otherwise the duodenum must be mobilized by dividing the peji- toneum on its outer edge. It can then be displaced inwards suffi- ciently to enable the dilated duct and stone to be reached from the outer side. In both of these operations an effort may be made to close the ducts with sutures which do not encroach on the mucous membrane; but it is probably wiser to introduce a drainage-tube into and up the duct for a few days so as to relieve the engorgement of the liver, which is certain to be present. These wounds usually heal quite satisfactorily. In a few cases, when the stone is lodged in the lowest portion of the duct, it may be necessary to incise the duodenum longitudinally front and back, and, after extracting the stone, to make a listula between the duct and the posterior wall of the intestine [internal choledocho-duodenostomy). An impacted stone should never be left in sihi, as, although it may pass at the end of a few days or weeks, it will cause much pain, and before becoming dislodged it may do much harm, not only to the biliary apparatus, but also to the pancreas. Operations on the Biliary Passages. — No special preparation of the patient is required, although some surgeons recommend that in cases which have been long jaundiced it is wise to give 20 or 30 grains of lactate of calcium per rectum once or twice previously, so as to lessen the bleeding, which has a tendency to persist; one's own personal experience does not confirm this statement. It is wise in all operations on the biliary passages to introduce a firm sand- bag horizontally beneath the patient's back, so as to throw the liver forwards, and thereby gain better access to the deeper parts. The incisions suggested vary somewhat, but that usually employed is a vertical one, 3 or 4 inches in length, to the outer margin or through the sub- stance of the rectus; this would suffice if the gall-bladder is merely to be emptied of stones, and is easily accessible. But when it is tied down by adhesions to the under surface of the liver, or has to be completely excised, or when the common bile-duct has to be explored or opened, a more extensive approach will be required, and this is gained by carrying the vertical incision inwards parallel to the costal margin and about i^ inches from it, extending across the rectus muscle to the middle line if necessary (Fig. 473, B). It has recently been recommended by Perthes* that the incision should be made close to the middle line, extending from the ensiform cartilage nearly to the umbilicus, and then crossing the rectus horizontally outwards to the margin of the ribs. The fibres of the rectus muscle are secured by mattre.ss sutures to the anterior layer of the sheath above and below before being divided so as to prevent retraction, and the rectangular flap of skin and muscle is then dissected up off the posterior layer of the sheath and peritoneum, which are divided by an obhque incision. The main object of this procedure, which gives an admirable approach to the biliary passages, is to avoid division of the nerves supplying the rectus muscle. It may be employed with advantage except in cases where drainage is likely to be necessary. The peritoneum being opened, the liver is drawn upwards and outwards, and the intestines, stomach, and omentum downwards and inwards after protecting them by abdominal cloths. In the absence of adhesions, the object of the operation can usually be attained without much difhculty, but not unfrequently the presence of adhesions complicates matters considerably; they must be carefully divided with a view to preventing subsequent haemor- rhage. If the gall-bladder is much distended, it is sometimes necessary to tap it and empty out its contents before a decision as to diagnosis or treat- ment can be reached. Care must be taken not to allow the peritoneum to M. W. Gray, British Medical Journal of Surgery, October, 1913, p. 200. ABDOMINAL SURGERY 1077 be soiled by the escape of bile, mucus, pus, or stones, which are almost always infecteil. For cholecystendysis, the trocar puncture is enlarged by the knife, and the stone or stones rcmoxeil by forceps, scoop, or by digital extrusion, and then the opening is closed by sutures which do not encroach on the mucous mem- brane. One or two rows of stitches may be employed according to the con- ilition of tlie gall-bladder wall, and it may be wise to strengthen the site of union by an omental graft. For cholecystostomy, a medium-sized drainage- tube without lateral openings is stitched into the gall-bladder by catgut sutures, which should last about a week. The gall-bladder is then fixed to the parietal peritoneum, and the remainder of the wound closed. It is often wise to protect the abdominal cavity from leakage by packing off the gall- bladder area. The outer end of the tube is passed into a bottle lying by the patient's side, in which the bile collects. When the tube becomes loose, the wound IS lightly packed with gauze, and for a time the patient's condition is uncomfortable, as the bile escapes into the dressings, which must be fre- quently changed. As, however, the wound granulates, it becomes more diflicult for the bile to escape externally, and more easy for it to follow its natural course, and hence after two or three weeks the external flow usually ceases, and the wound may be allowed to close. Should, however, the escape of bile persist, further treatment becomes necessary. If the presence of a certain amount of bile in the motions indicates that the common bile duct is free from obstruction, the opening in the gall-bladder may be completely closed by sutures after freeing it from adhesions. The absence of bile in the stools, however, suggests the presence of some stricture or obstruction in the bile-duct, and if this cannot be dealt with, cholecystenterostomy must be undertaken. Cholecystectomy, as already mentioned, is the operation of choice in the majority of cases of gall-stones. It is usually not a difficult proceduie. and the mortality is small. The serous coat is divided on either side and over the fundus about a centimetre from its reflexion from the liver, and a line of cleavage is generally found w'ithout difficulty between the capsule of Ghsson and the body of the viscus. It is then easy to separate it from the liver: the cystic vessels are secured by ligature, and finally the cystic duct is tied and divided. If possible, the peritoneal coat is drawn together over the gap left by the removal of the gall-bladder, but it is usually necessary to pack this space with gauze for a few days. Cholecystenterostomy, or the formation of an artificial communication between the gall-bladder and the bowel, is required in cases where jaundice persists, owing to absolute stenosis of the common duct. It has also been undertaken for the relief of jaundice due to malignant disease, either of the common bile-duct, the head of the pancreas, or of the intestine; the relief given under these circumstances is, of course, only temporary. The parts are exposed as described above, the gall-bladder and duodenum are brought into contact, and a lateral anastomosis made by simple suturing by a technique similar to that employed for a lateral anastomosis of the intestine. Tumours of the Gall-bladder and Biliary Passages are usually malignant, and of a columnar carcinomatous type ; benign tumours are very rare, and merely of pathological interest. Cancer is com- paratively common, and is so constantly associated with gall-stones (some authorities state that go to 95 per cent, of such cases also have gall-stones) as to suggest that the irritation of the latter may induce the neoplastic formation. The disease is about three times as common in women as in men. Cancer of the gall-bladder usually commences near the fundus and spreads upwards. The s\'mptoms and signs are those of a hard, painless swelling in the region of the gall-bladder, with progressive loss of weight, and later on jaundice 1078 A MANUAL OF SURGERY and ascites. Primary cancer of the common l:)ilc-duct is rarer, and causes jaundice, without pain, as an early symptom, together with distension of the gall-bladder. The jaundice is persistent, and gradually increases in severity. Gastric symptoms from pressure of the growth on the pylorus or duodenum may follow, and extension in various directions may determine different manifestations. In either of these affections lymphatic dissemination along the falci- form ligament may lead to the appearance of a secondary nodule in the region of the umbilicus, which may be of diagnostic import. Treatment is rarely practicable, as the disease is usually recognised too late. Excision of the gall-bladder, and, if need be, of the neigh- bouring portion of the liver, may be practicable in a few cases; for tumours of the common bile-duct, excision is usually impossible, but cholec\'stenterostomy may relieve the intense jaundice and add to the patient's comfort. Affections of the Pancreas. The pancreas is a glandular organ which secretes an active digestive juice, which escapes into the intestine through the duct of Wirsung (Fig. 501, DW), which traverses the whole length of the gland, and opens with the common bile-duct into the ampulla of Vater ; a small accessory duct of Santorini (DS) opens into the bowel about an inch higher up. The pancreas has only recently received much attention from surgeons; its depth and anatomical relations explain the neglect with which it was treated for so long. At the present time its affections are being studied with a keen interest, and considerable operative activity is being directed towards it. There are two chief methods of approaching it: (i) The transperitoneal, in which the abdomen is opened in the middle line above the umbilicus ; the gland is reached either above the stomach by dividing the small omentum, or by traversing the great omentum just below the great curvature of the stomach, or by opening through the transverse meso-colon. (2) The retroperitoneal method consists in an incision below the last rib in the lumbar region, but only the head or the tail is exposed b}^ this procedure. There are two chief risks associated with pancreatic lesions or operations: (i.) The organ is very freely supplied with blood, and it is extremely difficult to ensure haemostasis. Ligature of the pancreatic tissue causes necrosis, and from the necrotic tissue ferments are set free which act injuriously on the tissues around, and predispose to further haemorrhage. Deep stitches and effective tamponade can alone be relied on in this direction, (ii.) The leakage of pancreatic juice is a serious danger to the patient in that it is likely to determine necrosis of fat wherever it spreads; hence foci of fat necrosis may be found scattered extensively through the omen- tum and mesentery in all acute pancreatic lesions. Moreover, it acts most prejudicially on the peritoneum, and induces either an aseptic peritonitis and intestinal paralysis which may prove fatal, or deter- mines an infective peritonitis if bacteria are present. ABDOMINAL SURGERY 1079 Wounds of the Pancreas are due to direct violence applied to the ci)igastrium, and may result from penetrating or non-penetrating injuries. They are usually accompanied by lesions of other viscera, such as the stomach or duodenum, and surgeons should remember the necessity for examining this viscus in any traumatic condition hi the neighbourhood. Deep sutures and tamponade must be used in all cases where solution of continuity has occurred, the latter being needed not only as a haemostatic agent, but also in order to drain away any leakage of pancreatic fluid. Prolapse through an abdom- inal wound has been recorded in a few cases, the organ having been almost entirely separated from its connections ; however bruised or damaged, its total extirpation must never be resorted to, since diabetes is certain to follow; it should therefore be carefully purified and replaced. Acute Pancreatitis is a grave affection, frequently fatal, and not uncommonly mistaken for acute obstruction until diagnosed on the operating or post-mortem table. It may follow an injury, and is then due to an interstitial haemorrhage, which gradually increases ; a similar hemorrhage sometimes appears spontaneously in alcohohc subjects, and is termed a ' pancreatic ' apoplexy; it is quite possible for such cases to run an acute course and even prove fatal without infection. More usually the condition is infective, the bacteria reaching the gland from the intestine, or is determined by regurgita- tion of bile owing to the impaction of a bihary calculus in the ampulla of Vater. Pancreatic calculi also occur, and may light up an attack of acute pancreatitis; they are usually small and elongated, consist- ing mostly of carbonate of lime, fhe organ becomes enlarged, thickened, and congested; purulent foci are scattered here and there through it, and in and around it are found necrotic spots due to the action of the pancreatic secretion. Sometimes the whole gland or a large portion of it has been known to slough. An inflammatory effusion develops in front, which is usually purulent and sometimes haemorrhagic ; it may be limited to the lesser sac of the peritoneum, then following the lines of a subphrenic abscess, or it may involve the general peritoneal cavity. The Symptoms vary much, but usually start suddenly with acute epigastric pain, which soon becomes excruciating. This is accom- panied by nausea and sickness, by constipation and abdominal distension, and by a serious collapse which may quickly prove fatal. The pain is due to the swollen organ pressing on the coeliac plexus of nerves. The swelling of the abdomen commences in the epigas- trium, and may for a time be limited to that region, but subsequently the phenomena of acute diffuse peritonitis may supervene. Occa- sionally the trouble quiets down at the end of a few days, but much more frequently it is fatal. The Diagnosis usually made is that of acute obstruction, or acute generalized peritonitis, and the true nature of the case is only recognised on opening the abdomen. Treatment consists in laparotomy and giving an exit to the inflammatory exudate. If diffuse peritonitis is present, the abdominal cavity must be opened above and below and irrigated, and the local trouble io8o A MANUAL OF SURGERY exposed; dead pancreatic tissue should be removed, and effective drainage provided. If a localized abscess forms, the greatest care must be taken to guard against a generalized infection. Posterior drainage is advisable in all these cases. Chronic Pancreatitis is not to be looked on as a very uncommon lesion. It is frequently associated with gall-stones and inflammation of the biliary passages, and may follow gastro-duodenal catarrh or ulceration. The organ becomes harder than usual, or is shrunken and sclerosed. It may produce a swelling in the epigastrium which is likely to be mistaken for a pancreatic carcinoma, or the symptoms may be mainly of a dyspeptic type. Fixed epigastric pain is often present, and a tender spot a little above the umbilicus. Diabetes may arise in certain forms of chronic inflammation ; offensive diar- rhoea with undigested fat in the stools and rapid wasting are also suggestive symptoms. Operative treatment may be of value, since pancreatic or bihary calculi may be found obstructing the duct; apart from this, benefit has certainly been derived by cholecysto- stomy and drainage of the biliary passages. Cysts of the Pancreas have been observed and treated in so many cases since 1887 that their characters are pretty clearly known. Simple complete obstruction to the duct has been proved experi- mentally not to be a sufficient cause for the disease; some patho- logical condition of the epithelium must also be present, preventing the re-absorption of the retained secretion. Slight traumatism is not an uncommon cause, and a cyst may develop as a sequela of an attack of inflammation which has quieted down. The fluid within is usually turbid, and brownish from admixture with blood, odourless, and with a fairly high specific gravity; it is of an alkaline or neutral reaction, and contains albumen, but no urea or bile; it is capable of peptonizing albumen, of emulsif3ang fat, and of converting starch into sugar. The cyst can be felt as a rounded, tense, fluctuatmg or elastic swelling, placed deeply in the abdomen, immoveable, and perhaps transmitting the aortic pulsation. The relations of a cyst to the stomach and transverse colon vary (Figs. 502-504) ; the cyst primarily forms behind the stomach, but when it attains any con- siderable size it projects anteriorly, and then most commonly approaches the abdominal wall below^ the stomach and above the transverse colon (Fig. 503). More rarely it presents above the stomach (Fig. 502), or below the transverse colon (Fig. 504). Pan- creatic C3^sts usualh' develop in middle life, occurring most frequently in men. Emaciation is sometimes marked, since a good proportion of the fatty food passes away in the motions; the skin is often dirty, earth}-, and unhealthy-looking. Treatment consists in laying the cyst bare, the surgeon usually finding his way to it between the stomach and transverse colon. Its contents are then drawn off by trocar and cannula, and arrange- ments made for drainage. A large tube is inserted, either through the front, or from the back by the side of the vertebrse. The skin around usually becomes irritated by the discharge, owing to a process of digestion. The prognosis with such treatment is good, ABDOMINAL SURGERY 1081 although healing may be slow, and a permanent fistula may develop. Kortc collected loi cases operated on, and of these 5 died, 4 from the the direct result of the operation, i from infection of the fistula. Carcinoma of the Pancreas is met with cither as a primary growth of a spheroidal-celled type, usually scirrhus, or is secondary to a similar disease of the stomach or pylorus. The condition is not necessarily painful in the early stages, and produces an ovoid or oblong mass at the junction of the epigastric and right hypochondriac regions. As it develops, it becomes more painful, and the patient quickly wastes and loses appetite and energy. Jaundice gradually supervenes, and becomes absolute, with an enlarged gall-bladder; the abdomen is distended with fluid from pressure on the portal Fig. 502. Fig. 503. Fig. 504. Figs. 502-504.— Diagrams to represent the Varying Relations of Pancreatic Cysts. In Fi^^ 502 the cyst (P) projects forwards between the stomach (5) and liver into the lesser peritoneal sac, presenting through the lesser omentum. In Fio- 503 the cyst is located below the stomach, projectmg forwards between the stomach and the transverse colon (C). In Fig. 504. the cyst lies lower, between the transverse colon above and the small mtestme with its mesentery. vein, and the legs may become cedematous from involvement of the inferior vena cava; whilst the gro\\i:h may lead to distension of the stomach from pressure on and constriction of the pylorus. In one or two cases removal has been undertaken with success, although an exact diagnosis was not arrived at before the operation. Sarcomata and other tumours are very rare. Affections of the Spleen. Rupture of the Spleen occurs as a result of injury, causing great shock, pain in the left hypochondrium, and internal ^haemorrhage, usually to such an extent as to prove rapidly fatal. In less severe io82 A MANUAL OF SURGERY cases the l^lood collects in the left loin, and gravitates towards the pelvis, the right loin being often kept clear by the position of the mesenter}'. l.aparotomy should be undertaken whenever practic- able, and, if much damaged, the organ is removed, the splenic vessels being secured by ligature; the results of such treatment have been most satisfactory. In a few cast^ it has been possible to stop the bleeding by suturing the spleen, or by inserting a gauze tampon, which is removed in a few days. Abscess o£ the Spleen may develop in the course of pycemia, or follow an injury, especially if associated with a lesion of a neighbour- ing coil of intestine. The symptoms are merely those of deep suppuration in the left hypochondrium, and the abscess either hnds its way externally, or bursts into the peritoneal cavity. It may be opened and drained with the same precautions as for any other intra- peritoneal collection of matter, and the results hitherto obtained have been encouraging. In pyaemia the disease is often fatal before the local phenomena are recognised. Floating Spleen is occasionally congenital, but more commonly acquired, in consequence of tight-lacing, injuries, or the presence of tumours. It is characterized by the existence of a moveable intra- abdominal swelling, whose shape is that of the spleen, and having a notch in its anterior border; its size increases after meals. It may be so displaced as to lie in the right iliac fossa, or even in the pelvis, and then has a long narrow pedicle which has, in a few cases, led to its torsion and strangulation. Splenectomy was formerly the only treatment, if the displaced organ caused discomfort or pain; it has been found possible, however, to fix it, and several successful cases have now been recorded. Splenopexy, as the operation is termed, is best undertaken by preparing a bed for the organ outside the peri- toneum in the loose cellular tissue beneath the floating ribs on the left side. The spleen is then shpped through a small hole specially made for the purpose in the parietal peritoneum, and secured by stitches, which pass through its capsule and anchor it to the under surface of the diaphragm. Enlargement of the Spleen is not uncommon, and is due to many different causes. It is characterized by a swelling which extends downwards from the left hypochondrium towards the umbilicus, the notch, perhaps, being felt in front ; it hugs the anterior abdominal wall, so that intestine is not found in front of it, whilst a resonant note is obtained in the flank. It is usually moveable with respira- tion, and occasionally increases in size after meals. The commonest causes of this condition are as follows: i. Certain general diseases, such as malaria, inherited syphilis, rickets, lardace- ous disease, lymphadenoma, or generalized tuberculosis. 2. Passive hypersemia, as the result of back-pressure from the heart, lungs, or liver; thus it occurs in chronic valvular disease of the heart, chronic pulmonar}/ disease, and cirrhosis of the liver. 3. It is also met with in certain blood conditions, such as spleno-medullary leukaemia (for blood-count, see p. 67) ; splenic anaemia, in which the splenic enlarge- ment is associated with a chlorotic type of anaemia, and is followed ABDOMINAL SURGERY 1083 by cirrhosis of the liver, leucocytosis being noticeably absent, the syndrome constituting what is known as Banti's disease; and polycytluemia, in which there is an increase of the erythrocytes and an augmented iKemoglobin content accompanying the enlargement of the spleen. 4. A simple splenomegaly or hypertrophy of the spleen exists, in which the swelling is accompanied by no charac- teristic blood changes. 5. Tumours and cysts of the spleen also lead to its enlargement : the former are usually secondary and malignant in nature; the latter may be due to hydatid disease, or be of the nature of* a simple serous cyst. The differential diagnosis of these conditions cannot be discussed here, but it must suffice to point out that the chief reliance must be placed on a careful and thorough examination of the blood, together with a complete investigation of the condition of the other organs of the body. Treatment necessarily varies with the cause, but if medicine is of no avail, the question of splenectomy will have to be considered. This operation has been performed for many different affections, and its value and position as a surgical procedure are now fairly well established. For traumatic lesions it is both safe and justifiable. For splenomegaly and for malarial enlargement it may be performed, if serious discomfort is being caused and cannot be otherwise remedied. If drainage fails to cure a cyst, or if a primary growth is discovered in a sufficiently early stage, excision may be undertaken. Splenectomy for leucocythsemia is absolutely unjustifiable, all the cases operated on having died. In splenic ansemia excellent results have followed removal of the organ in the few cases in which it has been attempted; the red cells subsequently increased rapidly in numbers, as also their haemoglobin content, whilst the leucocyte count remained much the same. Such a result indicates that possibly the condition is due to an increased destruction of erythro- cytes in the spleen, which is brought to an end by removing the organ. The operation itself is performed through any suitable incision of sufficient length; probably one in the linea semilunaris is the best. The peritoneum having been opened, the organ is carefully examined to ascertain in particular whether or not adhesions are present, as, if extensive, any attempt to break them down might result in fatal hsemorrhage. If the organ is freely mobile, it is carefuhy drawn out of the abdomen, and the anterior layer of the gastro-splenic omentum divided so as to expose the vessels. Care is taken not to secure the main trunk at a distance, but the smaller branches as they enter the hilum. The lieno-renal and lieno-phrenic ligaments are divided, and the organ thus set free is removed. Gastric hemorrhage has been known to occur after this operation, but is probably due to absence of care in securing the vessels close to the hilum, as if the splenic vein is tied so as to include the veins returning from the cardiac end of the stomach (vasa brevia) congestion of this part of the gastric wall will result, and may cause hsemorrhage. CHAPTER XXXVI. 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 have been already described. The present chapter is limited to hernia as met with in 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). Hernial protrusions may, however, develop through the obturator foramen, sciatic notch, the diaphragm, and in various other situations. ^tiology.^ — A great many conditions may be associated, directly or indirectly, with the production of a hernia. They may, however, be described for practical purposes under two main headings — the con- genital and the acquired. Congenital Causes are rather predisposing than exciting in nature, and must be looked for amongst the many malformations and con- ditions of imperfect development to which the abdominal parietes and contents are liable. The follo^\^ng are the most important of these: (a) The non-obliteration of the funicular process of peri- tonemn, which in the male precedes and accompanies 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 results from this, although it must be re- membered that the rupture does not necessarily show itself at birth, and, indeed, may not appear till after puberty. It is probable that incomplete obliteration of this process is the cause of a great majority of the cases of oblique inguinal hernia, a small pouch being left at the upper end. It is often possible to demonstrate the existence of this in patients with weak, bulging groins, but with no actual hernia. In females under the age of twenty-five, hernia into the canal of Xuck, as this peritoneal tube is called, is the most frequent variety met with. 1084 HERNIA 1085 {b) The late descent of the testis, whether it finds its way into the scrotum or not, is usually associated with the formation of an inguinal hernia of the congenital type, or of some form 01 mterstitial 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 f amihes. {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 inducing forcible acts of micturition, acts as an excitmg cause. (/) Congenital apertures occur in the linea alba or linea semilunaris, especially opposite one of the tendinous 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 (con- genital umbilical hernia). (A) The diaphragm is also occasionally defective, allowing the stomach or other viscera to find their way into the thoracic cavity. Acquired Cawses.— Hernia may result from any condition whicli tends either to weaken the abdominal parietes, or to increase the intra-abdominal pressure. Thus (i) it may be post-operative, result- ing from the imperfect development of a cicatrix after a laparotomy. (2) It may be the outcome of direct traumatisfn, and is then just as likely to occur away from the hernial regions. If seen early, the affected area \vill probably show signs of injury, such as tender- ness, swelHng, and ecchymosis, but a hernia is by no means a neces- sary consequence. It is unusual for an ordinary complete hernia to develop after injury or severe strain, unless a pre-formed sac is present, and then immediate strangulation is not an uncommon sequence; apart from this, the hernia, if seen soon after the aUeged accident, is imperf ectlv developed, and in the bubonocele stage. 1 he fact that compensation may be required for the development of a hernia should make practitioners cautious in giving opinions as to ffitiology. (3) Much more frequently hernia is due to chronic strain, such as occupations which involve hfting heavy weights, and the more so if the individual is forced to maintain the upright position, or wears tight bands or girths round the abdomen. Prolonged and severe bronchitis, and frequent straining to pass water m cases of enlarged prostate or stricture, may determine the development of a hernia; whilst chronic constipation is a frequent factor m its pro- duction, especiallv if the patient makes use of a closet with a high seat, whereby the'inguinal canals are left unprotected; a patient with weak and bulging inguinal regions may with advantage use a low commode. (4) Relaxation of the abdominal parietes also favours hernia, especiallv if associated with or followed by severe straining^ Thus pregnancy brings about a stretching of the wall, especially if frequentlv repeated and followed by imperfect involution; and par- turition determines the development of hernia, either m the crural io86 A MANUAL OF SURGERY region or through the linea alba. Similarly the relaxed and atonic abdominal wall, which bulges down in the hypogastric region in old people, favours the occurrence of a direct inguinal hernia, should the patient have a bad cough or an enlarged prostate. 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 muscular tissue which normally exists behind the peritoneum, passing from the posterior abdominal wall to the base of the mesentery ; it is sometimes called the muscle of Treifz. (5) Obesity is also a predisposing factor to hernia, the accumulated fat being deposited in the omentum, mesen- tery, and subperitoneal tissue, thus increasing the intra-abdominal tension. Structure. — A hernia consists of a sac and its contents, the sac being formed of peritoneum, perhaps thickened by additional cover- ings, derived from the abdominal paiietes, and the contents being the protruded viscera. The sac, or peritoneal investment of an acquired hernia, is in the early stages funnel-shaped, small, and thin, being derived from that portion of the serous membrane which normally lies over the hernial aperture. As the rupture increases in size, the sac becomes larger, partly by stretching, and partly by the drawing down of fresh mem- brane from the neighbourhood. Occasionally it stretches irregularly and becomes sacculated, and sometimes the sac becomes hour-glass- shaped, probably as the result of inflammation. 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 exposed, either from the wearing of a truss or from the pressure of the contained viscera. The body, or fundus, varies much in size and shape, and may undergo considerable alterations in structure. {a) The sac soon becomes adherent to surrounding parts ; and with increasing irritation, as by a truss, these adhesions become more definite, [b) Inflammation may occur as the result of injury or pressure, constituting a form of localized peritonitis. 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 hernite. Acute or subacute inflammation is also met with, resulting in the formation of adhesions between the 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 occasionally be produced in this way 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 ad- hesions or by a septum of adherent omentum; this isolated cavity is sometimes the seat of a serous effusion, known as a hydrocele of a HERNIA 1087 hernial sac. {c) Hcemorrhage into the sac wall may result from violence, and will cause it to become much thickened, and even pigmented or leathery in appearance. The coverings of the sac are indurated in old-standing cases, and matted together in such a manner as to make it difficult 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 in the production of strangulation. The opening through which the hernia protrudes loses its characteristic features and shape, being enlarged, more or less circular, and displaced, so that an oblique 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, however, one finds only small intestine or omentum. An enterocele 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 super- venes. For a description of these conditions, see p. mo. 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 epiplocele. As long as it remains reducible, it is likely to retain its normal texture; but when large in amount, and especially if irre- ducible, 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, even when no adhesions are present. Serous cysts sometimes develop within it as a result of effusion be- tween opposed surfaces. In some cases openings are found in it of sufficient size to allow the gut to pass through and become strangu- lated. When omentum and bowel are present in the same sac, the condition is known as an enter o-epiplocele. The CcBctim sometimes occupies a hernial sac, either in aggravated and large hernise, or in children with congenital hernia; it has even been found in a hernia on the left side. Since the c^cum ha,s generally a complete serous covering and usually a mesentery, it is freely moveable, and may pass into a hernial sac in the same way as any other moveable part of the intestine. On the other hand, a few indisputable cases have been related in which the serous envelope was incomplete in a so-called ' csecocele.' The Vermiform A ppendix is occasionally found in a hernial sac on the right side. It is rarely free, but generally fixed by adhesions and irreducible. The hernia is more painful than usual, and on palpation the appendix can sometimes be felt enlarged and tender, pressure io88 A MANUAL OF SURGERY causing pain referred to the umbilicus. The patient is Hkely to give a history of recurrent attacks of inflammation in the sac. The Bladder may be associated with a hernial sac in two distinct ways, and usually in the inguinal region, (a) The fundus may be dragged downwards by the traction of the peritoneum, when the hernia has attained a colossal size. 'Ihere is then only a partial peritoneal investment, the bladder lying outside the sac, and being adherent to it. Considerable irritability of the viscus is induced, and, owing to stagnation of urine in the displaced part, a phosphatic concretion may form therein, and such has even been removed by incision through the scrotum, {b) Occasionally a saccule of the outer wall of the bladder becomes adherent to the peritoneum, and is drawn down by it into the inguinal canal ; its presence may be sus- pected if a small hernia is associated with much vesical irritability. The saccule consists merely of thickened mucous membrane and submucous tissue, and is devoid of muscular fibres ; it is very liable to be laid open when an operation for the radical cure is under- taken. If such an accident happens, the saccule should be excised, and the opening at once closed by sutures, which should not pene- trate the mucous membrane. Failure to recognise this accident is followed by urinary extravasation, possibly intraperitoneal, and will require prompt treatment if a fatal issue is to be avoided. Ihe wound must be re-opened, the gap in the bladder wall found and closed, and effective drainage provided. The Ovary and Fallopian Tube are occasionally found in an inguinal hernia, more often in a child than in an adult, and give rise to an irreducible swelling, pressure on which causes a sickening pain. Loose foreign bodies, somewhat resembling marbles in size, are occa- sionally, but very rarely, met with in hernial sacs. They are derived from the detachment of one or more of the appendices epiploicse, which subsequently become enlarged from a deposit of fibrin induced by movement in the peritoneal cavity, and may even calcify. Signs and Symptoms.^ — The characteristic features whereby a hernial protrusion is recognised consist in the presence of a rounded or pyriform swelhng, in one of the normal or abnormal situations already mentioned, which increases in size when the patient stands, coughs, or strains, having, as it is termed, ' an impulse on coughing.' If intestine is present, it may be possible to obtain a tympanitic note on percussion, whilst the tumour is tense and rounded, and on pres- sure slips back into the abdomen with a distinct gurgle. An entero- cele often gives rise to dyspeptic phenomena, and perhaps to colicky pains. An omental hernia feels soft and doughy, has a less distinct impulse, or even none, on coughing, and is replaced without a gurgle ; it is dull on percussion. When allowed to reappear, it does so slowly without any sudden impulse, the omentum insinuating itself gently down the inguinal canal, and gradually distending the sac. The Treatment of hernia, whether palhative by means of trusses, or radical by means of operation, differs so greatly in the various forms, that it will be better to discuss each one separately. HERNIA Special Forms of Hernia. Inguinal Hernia. — The term inguinal hernia is limited to those conditions in which a protrusion occurs into the inguinal canal, and, if allowed to progress, finally makes its way through the external abdominal ring. If it extends into the scrotum, it is termed complete, or scrotal ; whilst if it does not pass beyond the external abdominal ring, it is known as a bubonocele, or incomplete inguinal hernia. The neck is always in relation with the deep epigastric artery, and the structures of the cord are either spread out over the sac or are in close proximity to it. In the early stages, the pubic spine can be felt to the outer side of the neck of the sac ; but as it increases in size, it lies over the spine, which can only be felt after pushing the hernia up- wards and inwards. Fig. 505. — Oblique Inguinal Hernia. Fig. 506. — Diagram of Acquired Inguinal Hernia, showing Se- rous Sac with Intes- tine coming down to THE Top of the Testis. Two main varieties of inguinal hernia are described, viz., the oblique and the direct. An Oblique Inguinal Hernia (Fig. 505) is one which passes down the whole length of the inguinal canal, entering at the internal and emerging at the external abdominal ring ; the deep epigastric 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 parietes. Hence in cutting down on such a sac, the surgeon will divide, in addition to the skin and subcutaneous tissues, [a) the intercolumnar fascia, derived from the transverse fibres of the external oblique which pass across the external abdominal ring ; 69 logo A MANUAL OF SURGERY {b) the cremasteric muscle and fascia, representing and extending from the internal oblique; (c) the infundibuliform fascia derived from the fascia transversalis ; and {d) finall}', a laver of subserous tissue varying in thickness, and closely surrounding the peritoneal sac. Probably the surgeon will only recognise the muscular fibres of the cremaster, which serve as a useful landmark. There are three different forms of oblique inguinal hernia, viz., the acquired, the congenital, and the infantile oi encysted. I. An Acquired Inguinal Hernia (Fig. 506) is one in which the sac consists entirely of peritoneum protruded from within the abdomen. It gradualh' increases in size, and finds its way along the cord to the scrotum. The sac usually extends as far as the head of the epididy- mis, but if of a large size it may overlap the testicle, which lies behind it. The structuies of the cord are frequently spread out over the sac. In old-standing cases the internal ring is dragged downwards and inwards, and often lies behind the outer, and thus it Fig. 507. — Congenital Inguinal Hernia. A, Vaginal variety; B, funicular t^^pe. may be difficult, apart from operation, to determine whether any particular hernia is direct or obhque. Even in early cases the sac is distinctly flask-shaped, suggesting that the condition is due to the non-closure of the uppermost part of the funicular process. 2. Congenital Inguinal H srnia (Fig. 507) is due to non-closure of the funicular process of peritoneum, which passes down to the scrotum with the testicle, and is usually obhtc rated completely except 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 frequently met with on the right side of the body, owing to the fact that the right testicle descends into the scrotum at a later date than the left. It is always characterized by becoming complete at once, and its development may be immediately followed by acute strangulation. When the non-obliteration is complete and the patent funicular process is continuous with the tunica vaginalis, the protruded viscera HERNIA 1091 lie in contact with the testis, and somewhat obscure it ; this is known as a congenital vaginal hernia (Fig. 507, A). Less frequently the funicular process is patent only as far as the head of the epididymis, being shut off from the tunica vaginalis. The hernia under such circumstances exactly resembles the acquired variety, being unrecog- nisable from it except by the fact that it becomes complete at once. It is termed a congenital fiinicular hernia (Fig. 507, B). In congenital hernia the structures of the cord are usually more intimately adherent to it than in the acquired form. Phimosis is often associated with this condition in young boys. 3. Ihe Infantile or Encysted Hernia is one occurring in individuals in whom the funicular process, although shut off from the abdominal cavity above, remains patent below, communicating with the tunica vaginalis, which cavitv extends, in consequence, as high as the in- guinal canal (Fig. 508, A). The hernia has a distinct sac, which Fig. 508. — Infantile Inguinal Hernia. A, Prehernial condition with tunica vaginalis extending upwards to inguinal canal; B, hernial sac coming down behind tunica; C, sac invaginating the tunica vaginalis. passes down behind the open process, or invaginates it (Fig. 508, B and C). It cannot be recognised except on operation, when the surgeon is apt to open the tunica vaginalis, which, though reaching upwards, does not communicate with the general peritoneal cavity; on removing or displacing this, the true sac of the hernia is found behind it. This does not often occur at the present day, when the high incision is made. A Direct Inguinal Hernia (Fig. 509) is one which, though passing through the external abdominal ring, has only travelled through a portion of the inguinal canal; it is never congenital, and usually smaller than the oblique type, not becoming scrotal. The neck lies to the inner side of the epigastric artery, which is often arched very distinctly over it, passing also along its upper wall. 1 he hernia thus escapes through the lowest portion of the linea semilunaris, and traverses the space known as Hesselbach's triangle, which is bounded internally by the outer border of the rectus muscle, by the I092 A MANUAL OF SURGERY deep epigastric artery externally, and by Poupart's ligament below (Fig. 510). 'Ihe obliterated hypogastric artery passes across the space in a direction parallel to its outer border, dividing it into two parts, and according to whether the hernia protrudes through the outer or inner segment, it is known as an external or internal direct hernia (Fig. 510, 2 and 3). The spermatic cord usually lies to the outer side of a direct hernia, and its constituent elements are never spread out over the sac as in the oblique form. A direct hernia is rarely found in young people, and there is often a considerable amount of subperitoneal fatty tissue around the sac. The coverings are practically the same as in the oblique variety, although the cremasteric invest- ment may be less com- plete. Interstitial Hernia is the name given to an inguinal hernia which develops in some ab- normal relation to the abdominal wall. Three varieties are described : {a) Where a sac exists between the transver- salis fascia and the per- itoneum {intraparietal form, or properitoneal hernia), either with or without a hernia in the usual position; in the former instance one form of ' hernia en bis- sac ' is produced. This abnormal pocket of the sac is found either between the sj^mphysis pubis and the bladder (hernia inguinalis ante-vesicalis), or it extends outwards towards the iliac fossa (hernia inguinalis intra-iliaca). As no external swelling is caused by this condition, it is usually im- possible 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 having been pushed backwards from the superficial into the deeper portion of the sac. {h) An abnormal expansion of the sac is situated between the internal and external oblique muscles [interparietal form). A swelling is thus produced in the region of the inguinal canal, covered by", the external oblique aponeurosis, and gradually spreading upwards and outwards parallel with Poupart's ligament. It may be associated with late descent of the testis, the external abdominal ring being closed so that i'lG. 509. — Direct Inguinal Hernia. HERNIA 1093 the organ, and with it a hernia, has to travel beneath the external oblique aponeurosis. Sometimes the condition is due to the exist- ence of a more or less complete septum at the level of the external abdominal ring, formed either by adhesions or by a mass of adherent omentum. The sac is then shaped hke an hour-glass, and as the usual downward course of the hernial contents is prevented, the upper part of the sac yields laterally above the site of the obstruc- tion, and passes between the muscles, (c) The hernia escapes as usual from the external abdominal ring, but travels outwards along Poupart's ligament, somewhat simulating a femoral hernia [extra- pariefal variety) . This form is generally associated with late descent of the testis, and a contracted state of the scrotum, so that it is easier Fig. 510.— Abdominal Wall from Within, to show Hernial Apertures. A V External iliac artery and vein; SV, spermatic vessels; PL, Poupart's ligament; VD, vas deferens; E, epigastric vessels; R, rectus abdominis; H, obliterated hypogastric artery; i, internal abdominal ring; 2 and 3, sites of direct hernia in Hesselbach's triangle; 4, crural ring for femoral hernia; 5, obturator foramen and vessels. 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 some 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 cHnical features of a rupture (p. 1088). 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 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 down- I094 A MANUAL OF SURGERY wards, and in the oblique variety is continuous with the fulness in the inguinal canal. 'Ihe structures of the cord are masked by the presence of the hernia, but the testicle is to be felt more or less dis- tinctly 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 back- wards, 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 not unfrequent, however, 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 attains 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, be difficult, and in old-standing cases it is often impossible to distinguish the oblique variety from the direct. The conditions for which it may be mistaken are best considered in two groups. I. Whilst the hernia is still incomplete and in the bubonocele stage, it has to be distinguished from the 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 characteristic gurgle of a hernia is absent; traction on the testis, moreover, 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. (6) A chronic 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 im- pulse on coughing, and although the swelling is reducible, it has not the definite outline and characteristic sensation of a hernia, being usually soft and fluctuant. Other evidences pointing to the exist- ence of the original disease may also assist in determining the nature of the swelling, (c) Enlarged glands in the groin which have become adherent to the external oblique are sometimes mistaken for a hernia, owing to the fact that on coughing a distinct impulse is com- municated 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 testis can otten be detected. [e) Tumours consisting of fat or other tissues are occasional!}^ seen in the inguinal canal, but are characterized by the strict hmitation of their upper border, and usually by the absence of a distinct impulse on coughing. On the other hand, as described elsewhere, a mass of fat simulating a lipoma is often present, resulting from a protrusion of the subperitoneal tissue, a hernial sac being sometimes found HERNIA 1095 embedded within it. (/) Hcemaiocele of the cord is recognised by a history of injury, the presence of pain and ecchymosis, and the absence of an impulse on coughing, whilst reduction is impracticable. 2. When the hernia extends into the scrotum, less difficulty is ex- perienced in its diagnosis. By examination of the cord immediately outside the external abdominal ring, all purely scrotal swellings, such as hydrocele or sarcocele, are readily eliminated, since in them the cord can, in the early stages, be felt perfectly free. A varicocele can also be similarly recognised from an omental hernia by the con- dition of the cord in its upper region; moreover, if 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 swelhng immediately reappears if it is venous in character. To the practised hand, 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 ^— ^<:^^^^^^^s^S^^^^^:ss:^^ to distinguish between the two r^^'^sX "^"^^^^^i^ The Treatment of inguinal ^^====,y^^ ^^ss?^ hernia is either palliative by "^'"'^'''^^^^ ® 1\ f^^^^^^^^^^^^'^ means of trusses, or radical. ^\ //yi^^J-^^'^^=^^^^^^''''^^^ Palliative Treatment. — A vV^-Ty/^^^^^'^^^ truss is an appliance which is Vc:::^/^/^/^ worn around the body with the Fig. 511.— Inguinal Truss. (Down object of preventing by pres- Brothers.) sure the descent of the hernia. No one form is capable of dealing with every case, and hence the truss must be selected with care, so as to suit the special needs of the particular patient. A good truss consists of a pad kept in position over the hernial aperture by a steel spring (Fig. 511), which fits 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, may be 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, ro96 A MANUAL OF SURGERY 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 pubis; it is also advisable to indicate the size of the hernia, and whether the opening in the abdominal parietcs is large or small. In the earlier cases of obhque 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 directly over the opening. If such an apparatus is properly adjusted and continuously worn, a cure is sometimes established in the course of a year or two ; and in the congenital hernia of children a cure may be confidently expected if the mother or attendants of the child conscientiously carry out the necessary details. If the hernia is Fig. 512. — Wool Truss for Treatment of Left Inguinal Hernia in an Infant. Fig. 513. — Indiarubber Band Truss, WITH Air-pads, for Infants. The air-pads fit around the root of the penis, and are inflated through the tube tied up in front. The under- straps fit round the child's thighs. once allowed to slip down, even after six or twelve months' treat- ment, all the previous good will have been undone. In infants, an efficient support is afforded by a skein of wool (specially known as ' lingering '), 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 perineum, and tied to the transverse portion behind (Fig. 512). This apparatus is changed night and morning when the child is bathed, and also, if need be, at shorter intervals, the mother being previously instructed as to how to support the hernia whilst the apparatus is being removed. In cases of double rupture in infants, an indiarubber band with two pneumatic air-pads (Fig. 513), arranged so as to fit over the inguinal canals, and with suitable straps and studs, will often suffice, and is certainly more comfortable than a spring truss. In addition to such pressure, it is important to remove all causes of HERNIA 1097 iutra-iibdominal tension, as by circumcision, where phimosis is present, or by regulating the bowels. The Radical Cure of inguinal hernia is an operation to which much attention has been directed of late years, since its value was brought prominently before the profession by the late Professor John Wood and others. It is very largely employed at the present day, and may be expected to give excellent results if the cases are carefully selected, if the technique is satisfactory, and if the after-treatment is efficient. The mortality is very small, and in a series of 7,419 cases collected by Sultan, it did not exceed o"48 per cent.* 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 sortie- times termed, an operation de complaisance), is a matter requiring considerable judgement and discrimination. In an individual whose occupation does not subject him to heavy strain or exertion, and who possesses a hernia which, under ordinary circumstances, 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 possible occurrence of strangulation. If, how- ever, 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 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 constitutional disease as precludes all unnecessary operative interference. (4) Again, in cases of extensive irreducible hernia, the return of large masses of intestine which have lain for year? in the hernial sac so increases the intra-abdominal tension as frequently to determine recurrence locally or elsewhere, and therefore operative interference, though very desirable owing to the great risk of strangu- lation incurred by the patient, is often followed by very bad results, unless the patient has previously been put through a course of serni- starvation and persistent taxis in order to reduce gradually the size of the protrusion. As to the best age at which to operate, statistics definitely 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, or even later, owing to the risk of infection of the wound from the constant satura- tion of the dressings with urine. Very many different operations have been described and practised by various surgeons. One of the most satisfactory is that known as * Munch. Med. Wochens., February 3, 1903. log A MANUAL OF SURGERY Bassini's, which has now been extensively employed, and has been followed by a large measure of success. The operation may be described in the following stages: (i) Ihe pubic region having been previously shaved and thoroughly purified, an incision is made in the direction of the inguinal canal and cord, about 2| inches in length, its centre being a little above the external abdominal ring. Ihis 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 in the direction of the cord. (2) Ihe 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 cremaster and other coverings of the cord are incised longitudinally, and the sac looked for and isolated with as little handling and disturbance of the parts as possible. Enlarged veins may be removed, as also fatty protrusions from the subperitoneal tissues. It is sometimes necessary to lift up the struc- tures of the cord in order to define the sac, which is often recognised by the white convex border of the fundus. (3) If the sac is empty, it is freed from its connection wdth 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 con- tents freed from adhesions, and the intestine returned into the abdo- men, whilst omental tissue is removed and the stump replaced. Adhesions are carefully divided either by the finger or between ligatures; if the gut is closely adherent to the sac, it may be necessary to leave a small portion of this attached to the intestine, which is then returned. Omentum, whether adherent or not, should be removed, as the elongated fringes are very liable to contract ad- hesions to the abdominal parietes, which subsequently produce mischief. In removing omentum, it is not advisable to encircle a large mass with a single hgature, as it is then more difficult to replace, the vessels are less securely commanded, and a pocket or pucker may be produced, possibly leading to internal strangulation at a later date. Small portions, including one or 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 subse- quent 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 unsecured. The sac, being now emptied, is isolated as far as the internal ring. (4) The neck is transfixed as high as possible, and ligatured with sterihzed silk, and the sac cut off below the ligature, the stump retracting well above the internal ring, and presenting a flush surface towards the intestines. (5) The opening in the abdominal parietes is closed by a row of sutures passing through the arched fibres of the internal oblique and trans- HERNIA logg versalis muscles or through the conjoined tendon on the inner side, and through Poupart's hgament 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 (Fig. 514. C), whilst the divided margins of the external oblique aponeurosis are grasped by pressure forceps iK, A'). Gentle 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 oblique aponeurosis, and when dealing with Poupart's ligament the proximity of the iliac vessels must not be Fig. 514. — Bassini's Operation for Radical Cure of Hernia. A, A', Spencer Wells forceps, holding aside the divided portions of external obUque aponeurosis; B, arched fibres of internal oblique, continuous on the inner side with the conjoined tendon; C, hook or retractor holding aside the spermatic cord; D, D, D, D, deep silk stitches passed behind the cord through the deepest fibres of Poupart's ligament on the outer side, and conjoined tendon on the inner. (The cutaneous incision and the incision through the external oblique are here shown much greater than would actually be undertaken, in order to demonstrate clearly the deeper parts.) forgotten. Either interrupted or looped mattress sutures may be used, but if the latter, they must not be tied too tightty, as they may strangle the portions of tissue included in their grasp and cause necrosis. The opening in the abdominal parietes is in this way commanded as far down as the pubic spine, but sufiicent room must be left at the upper end for the passage of the cord, undue constric- tion of which would cause atroph}' of the testis; sometimes it is desirable to introduce a stitch above the cord, in order to command a spot where recurrence 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 iioo A MANUAL OF SURGERY together over it. (6) 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 knees slightly flexed over a pillow. 1 he 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 be- coming soiled. Occasionally retention of urine follows this opera- tion, necessitating the use of a catheter. In the case of children, it is well to employ the open method of treatment suggested on p. 281. 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, un- desirable, as its pressure is liable to produce atrophy of the newly- formed cicatricial tissue. When, however, the abdominal walls are congenitally weak, or if, unfortunately, the wound has suppurated, the deep stitches coming away, it is advisable to use a light truss for a time. The treatment of congenital hernia differs in no particular from that already described, except that the sac must be divided below as well as above, and the lower opening secured by suture or ligature, so as to close the cavity of the tunica vaginalis. The operation often proves difficult owing to the intimate adhesions between the sac and the structures of the cord, and it is sometimes impracticable to isolate completely the neck of the sac. The other operations which require to be mentioned are as follows : (fl) In Banks' Operation, the sac is isolated and removed as high as the internal ring without any division of the external oblique. Stitches are then introduced through the conjoined tendon and Poupart's ligament respectively, including the external oblique in their grasp, and passing in front o/the cord. It is ob\dous that by such a plan the deep ring cannot be closed as accurately as in Bassini's operation. It may suffice, however, in a few of the simpler congenital cases. {b) In Maceiven's Method the aponeurosis of the external oblique is most carefully maintained intact, and the inguinal canal is explored through the external abdominal ring. The sac is freed from its surroundings, and this liberation goes on for about an inch all round the internal abdominal ring. A silk suture is then tied to the fundus of the sac, and is carried by a curved needle through the centre of the sac from above downwards, and again through the neck of the sac from below upwards. The needle is then introduced through the inguinal canal under the loosened abdominal parietes, and is made to emerge through the abdominal muscles a little above the inguinal canal; the silk thread is carried through this, and by a little traction the sac is carried in, doubled up, and implanted as a pad across the HERNIA internal ring. Ihis thread is held by an assistant during the next step of the operation. This consists in closing the canal by one or more looped sutures, passed in such a way as to draw up Poupart's ligament over the arched fibres of the internal oblique in front of the cord. Finally, the thread used for the fixation of the sac is drawn tight, and its free end employed to close the external abdominal ring to a sufficient extent. The results of this proceeding are very good, but it is a more difficult operation than Bassini's, and one loses the advantage of opening the canal, and thereby ex- ;^ ploring the structures of the cord. Subperitoneal lipomata are frequently found in the canal, and these would inevitably be left, and would possibly lead to a recurrence of the hernia, if the canal had not been opened up. (c) In Halstead's*oipeTa.- tion the inguinal canal is opened up as in Bassini's method, and the cre- master divided longi- tudinally along the upper border of the cord, and dissected back, so as to enable the sac and any Fig. 515. enlarged veins, etc., to be removed. The lower border of the internal oblique is defined, and the upper edge of the cre- master is sutured to the under surface by a series of mattress stitches. The lower edge of the internal oblique and conjoined Operation for Inguinal Hernia (Carless.) The inguinal canal is opened up, and the sac re- moved as high as possible. The cord and cremaster (not represented here) are pressed back and covered over by approximating the internal oblique and transversalis to the under surface of Poupart's ligament by mattress sutures, which are introduced as indicated above, and tied on the outer aspect of the ligament. The divided segments of the ex- ternal oblique are then overlapped and sutured . tendon is then sutured in front of the cord to the under surface of Poupart's ligament, and finally the divided portions cf the external oblique closed by over- lapping. If there is much tension in the deeper stitches, a longi- tudinal incision through the sheath of the rectus muscle will give suitable relaxation. Excellent results have followed this procedure. (d) For the last few years extensive employment of a somewhat similar proceeding has given most satisfactory results. The canal is opened in the same way, and the sac excised, the ligature being placed as high as possible. The fibres of the internal oblique are * Johns Hopkins Bulletin, August, 1903. II02 A MANUAL OF SURGERY then exposed by thorough retraction of the divided external; and mattress sutures are introduced through the internal oblique and transversalis, or edge of the rectus sheath, carried across in front of the cord through Poupart's ligament, and tied on its outer surface (Fig. 515). This constitutes a firm muscular barrier across the canal; one or two such sutures usually suffice. The lower or outer segment of the external oblique is then carried up and stitched down to the internal oblique well above the mattress sutures; the inner segment of the divided external oblique is then made to overlap the outer, and stitched down to Poupart's ligament; the deep layer of fascia is also carefully secured by sutures, and the wound closed. Healing almost invariably occurs without suppuration; and even should this happen, the stitches are easily removed, as the knots are on the outer side of Poupart's ligament, and not on the inner, as in Bassini's and Halstead's methods. In all these three methods epididymitis and hydrocele occasionally develop as sequelae. The treatment of direct inguinal hernia is somewhat different at times, in that the condition usually occurs in elderly men. In many it is wise to order a double truss and avoid operation ; but in some operation is permissible. The prognosis is never so good as in the oblique variety- — [a) because it occurs in older subjects, and is often predisposed to by chronic obesity, cough, or difficulty in mictuiition; and {b) because the chief weakness is at the lower, and not at the upper, end of the canal, and hence the deep ring lies almost directly behind the opening in the external obhquc. In these cases ex- perience has taught one that the best plan to adopt is to displace the cord entirely, bringing it out through the muscles opposite the interna] abdominal ring, and closing up the rest of the canal com- pletely as in a woman. The more superficial position of the cord does not seem to affect it injuriously. Recurrence after Operation is much less common than formerly, and statistics go to prove that in experienced hands less than 10 per cent, of the cases recur, and that rarely after the first twelve months. As already stated, it may be due partly to an injudicious selection of cases, partly to errors of technique, and in part to a faulty after- treatment, the patient being given too much liberty at too early a date. In connection with this we would especially emphasize the necessity for isolating the sac as far as possible, since otherwise the infundibuhf orm opening at the top of the closed peritoneal canal is cer- tain to persist. Another, and that perhaps the most common, cause of recurrence is pyogenic contamination of the wound ; if the deep stitches are not involved, no great harm is done, but whenever they have been removed or come away it is wise to use a light truss for a time as a precautionary measure. Again, the mere restoration of a mass of intestine or omentum into the abdominal cavity may suffice to raise the intra-abdominal pressure, and thus predispose to a re- currence ; hence the importance of removing as much omental tissue as possible in all bad cases. Relapses may also be due to splitting or tearing of the tendinous structures around, either by the mere HERNIA 1103 passage of the needle, or by the traction induced by tightening the sutures; indeed, it is often the case that a hernia originally oblique may after operation be followed by one that is direct, and probably from this cause. Whenever it appears likely that recurrence may occur, a truss should be ordered. If, however, a hernia has developed, a second operation may be performed, if the condition of the abdominal parietes warrants it. ''^ Femoral Hernia. — A femoral hernia is one which, travelling down the crural canal, presents at the inner and upper part of the thigh through the saphenous opening. It occurs most commonly in women on account of the greater expansion of the iliac crests allowing in- creased space beneath Poupart's ligament, and especially in those who have borne children. During parturition the inguinal regions are in a measure protected, and hence inguinal hernia is rarely caused in this way. In young people, however, it is more common in the male sex. The crural canal constitutes the inner compartment of the femoral sheath, a space usually occupied by fatty cellular tissue, lymphatic vessels, and perhaps a lymphatic gland. It is about | inch in length anteriorly, and i^ inches along its posterior wall; it is closed above by a thickened portion of the subserous cellular tissue known as the septum crurale, and its lower end is formed by the saphenous open- ing, and closed by the cribriform fascia. Hence a femoral hernia, as it passes downwards, receives the following coverings: (a) peri- toneum; ih) subserous cellular tissue, including the septum crurale, a layer sometimes known as the fascia propria, and occasionally represented by a thick fatty envelope; (cj the anterior layer of the femoral sheath, derived from the fascia transversalis ; [d) cribriform fascia; {e) subcutaneous tissue; and (/) skin. In its passage through the canal it is situated immediately internal to the femoral vein, and pressure upon this may produce oedema of the leg, whilst Gimbernat's ligament lies to the inner side. The spermatic cord or round ligament is placed 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 may pass 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 usually travels 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. Femoral hernia 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. The Signs of a femoral hernia are very characteristic. A rounded II04 A MANUAL OF SURGERY swelling with an impulse on coughing, and more or less reducible, forms on the inner side of the thigh, its neck or aperture of com- munication with the abdomen lying to the inner side of the femoral vessels, and to the outer side of the pubic spine, which can always be easily felt (Fig. 516). There is usually but little difficulty in making a diagnosis, although occasional!}^ some care is needed. {a) An inguinal hernia is recognised by the fact that its neck occupies the mguinal canal, the saphenous opening being free; whilst it is also above and internal to the pubic spme, 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 other hand, usually (but not invariably) occurs in women over twenty- five 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, {b) An enlarged lymphatic gland over the saphenous opening may simulate this condi- tion very closely; but the absence of impulse on coughing and of the usual hernial signs is generally suffi- cient to distinguish it ; when, how- ever, the hernia is purely omental and irreducible, the impulse is so slightly marked that correct diag- nosis in a stout woman is often diffi- cult 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, should suffice to prevent a mistake, {d) A psoas abscess 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 that there is no gurgle on reduction; that the abscess, as it passes under Poupart's ligament, lies to the outer side of and 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. [e] In varix of the saphena, if a pouch or ampulla forms close to its entrance into the femoral vein, it may be mistaken for a femoral hernia on account of the marked impulse on coughing, and because the swelling disappears on assuming the recumbent position. It is, however, usually associated with the signs of varix below, and by the fact that, although pressure is maintained 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. The impulse Fig. 516. — Femoral Hernia. HERNIA 1105 is of a different character to that of a hernia ; the blood can be felt to be driven past the examining finger with a thrill, instead of there merely being an expansile bulge. Treatment. — When reducible and of small size, a femoral hernia may be treated by the use of a truss, similar in nature to that used for an inguinal hernia, except that the pad extends somewhat 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 the relief of strangu- lation, 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 princi- ples there enunciated, apply also to this variety. The apposi- tion of the anterior and posterior walls of the crural canal is the essen- tial element in the opera- tion, and this practically resolves itself into the fixation of the inner end of Poupart's hga- ment to the horizontal ramus of the pubis or the structures overlying it. The sac is exposed by a vertical incision along the course of the crural canal (Fig. 473, G), cleared of its fatty covering, which is often thick and abundant, emptied of its contents by reduction, and then cut away after transfixing and tying the neck. Some surgeons, however, retain the sac, pushing it back into the abdomen, and using it as a pad across the upper opening of the canal. The fatty covering of the sac must be dealt with in a similar way. The deep ring is then commanded by one of the following methods: (i) In the great majority of cases it will suffice to introduce stitches through the inner end of Poupart's hgament (Fig. 517), and deeply through the horizontal fibres of Cooper's hgament, which he in close apposition to the horizontal ramus of the pubis. There are but few cases where this manoeuvre, if effectively carried out, is not sufficient to determine closure of the canal; but for this purpose the hernia needle must be carried down to the bone, and not merely through the fascia over the pectineus. (2) In a few cases, perhaps, where the opening is larger, it may be desirable to approxi- 70 Fig. 5 17. ^Diagram of the Radical Cure FOR Femoral Hernia. The position of the femoral vein and artery is indicated, and the internal saphena vein passes up through the saphenous ring to join the former. The spermatic cord is seen above, and the situation of the suture to close the crural canal. iio6 A MANUAL OF SURGERY mate Poupart's ligament to the horizontal ramus by some other method, and for this purpose Roux has advised the use of a f| -shaped metal staple, which traverses the ligament, and the free ends of which are driven into the bone. This plan appears to us undesir- able, since the staple occasionally works loose, and then the prox- imity of the femoral vein makes it an unwelcome neighbour. (3) A good substitute for this plan has been practised by Nicoll* of Glasgow, who drills the horizontal ramus from below upwards in two spots, and then b}^ passing a mattress suture through Poupart's ligament and the free ends through these drill-holes, t\ang them below, the ligament is safely approximated to the inner and upper aspect of the pubis. Umbilical Hernia.- — Ihree different forms of umbilical hernia are described. 1. Congenital Umbilical Hernia, or Exomphalos, is an exceedingly rare condition, due to imperfect closure of the abdominal walls, as a result of which part of the intestine is found at birth in a cavity at the base of the umbilical cord, which is bulbous and enlarged. If the condition 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, if such be possible. 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 constipation or phimosis, necessitating continual straining in order to evacuate the bowels or bladder. The condition rarely persists till adult life, as it is easily cured. Treatment consists in regulating the bowels and in the performance of circimicision, if necessary, whilst the local condition is dealt with by strapping the abdominal wall in such a way as to tuck the umbilical cicatrix inwards; no pad is required. In per- sistent cases it may be necessary to lay the sac open and remove it, suturing the parts together, as described in detail below. In these cases the opening is often a transverse chink rather than a round hole, and it is sometimes advisable to introduce the sutures in a vertical direction, thereby securing transverse apposition. 3. The so-called Umbilical Hernia of Adults is usually due to a pro- trusion 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 frequenth^ in women who have borne children, being sometimes due to actual rupture of the linea alba and separation of the recti muscles. A peritoneal sac is present, but in old-standing cases it is extremely attenuated, and so adherent to surrounding parts as to be unrecognisable, whilst the contents may be matted together in an almost inextricable * Scottish Med. and Surg. Journ., December, 1903. HERNIA 1 107 confusion. Under such circumstances 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. More- over, 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 individuals, 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 divide 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 be cut away close to the opening, and all bleeding- points secured. The aperture is then closed in the following way : Several deep transverse sutures are passed through the whole thick- ness of the abdominal wall on each side and tightened, after a row of interrupted 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 surgeons have discovered by experience that such a pro- cedure is insufficient in any but the slighter cases, and that a much more radical operation is required when the hernia is large and irre- ducible, and the patient at all inclined to corpulence, (i) The early steps of the operation are identical, but it will be found advantageous to place the cutaneous incision to one side of the tumour rather than over its centre. The freeing of the omentum may be a matter of great difficulty, as it is often adherent to the margins of the opening. (2) It will then be found that the anterior layer of the sheath of the rectus is prolonged over, and soon lost on the sac. An incision is made all round the neck of the sac through this aponeurotic covering to reach down to the subperitoneal tissue; stitches are now intro- duced across the opening through the peritoneum and this detached ring of aponeurotic tissue in order to effect its closure (Fig. 518) ; all redundant sac is clipped away with scissors, bleeding-points being secured. (3) The recti muscles are now laid bare on either side, and their posterior surfaces and edges loosened so that they, together with the anterior layer of their sheaths, can be brought into apposi- tion over the closed neck of the sac, which is thereby buried. To do this effectively the incisions may have to be prolonged up and down iio8 A MANUAL OF SURGERY the abdominal wall for some distance, since the recti are usually displaced outwards some way above and below the opening. Silk- worm gut may be advisably used to bring the margins together. Redundant skin is now cut away with a free hand, so that the abdominal integument may not be unduly lax, but shall just cover the muscles comfortably. In stout patients this may involve the re- moval of considerable masses of fat. An operation of this type is a severe one, and not to be lightly entered upon; but if it is carefully conducted, the results in many cases are most successful. Of course it is very desirable that the abdominal wall should afterwards be supported by firm strapping for some time, and that no undue strain should be placed upon it. A Ventral Hernia is the term used in describing any protrusion occurring at some spot in the an- terior abdominal wall other than those already mentioned. Several forms may be met with : I. It consists not uncommonly of a protrusion of subserous, fatty tissue through a congenital or acquired opening in the linea alba, lineae semilunares, or lineae trans- versae, especially at the junctions of Fig. 518. — Diagrammatic Repre- the last with the former. 1 hey are sENTATioN OF THE Radical Cure j^^^e common above than below OF AN Umbilical Hernia WHERE ,-, -, ■,■ ■, -r x x , THE Recti Muscles are con- ^^e umbihcus, and if, as not unfre- siDERABLY DISPLACED. qucutly happcns, the fatty tissue The short cross-hnes represent the proliferates, a localized tumour sutures.which close the opening in resembhng a lipoma IS produced, the peritoneum; the long ones, which goes by the name of a the sutures needed for apposing y^/zy hernia of the linea alba. A S:atSo° wafiroMhT^Sf. P«rt.on of peritoneum is drawn through the opening into the centre of these masses when they have persisted for some little time, and a tnie hernia is thus induced. A similar condition is met with in the inguinal and crural regions, and probably most of the cases described as lipomata in these parts are of this nature. Considerable pain and abdominal disturbance (vomiting, colic, etc.) accompany almost every movement of the body, being caused partly by the traction of the peritoneum, partly by the constriction of the neck of the sac against the sharp edges of the small opening. Treatment consists in the removal of the projecting mass, care being taken not to include any viscera in the suture with which the base is surrounded. HERNIA nog The stump is pushed back into the abdomen, and the opening closed by^deep sutures. . 2. After operations involving the .'division of the abdominal parietes, ventral hernia may be caused by the yielding of the cica- trix, especially if the wound suppurates, and the deep stitches come away or are removed, or if the opening is left patent for the purpose of draining an intra-abdominal abscess. Treatment of such cases consists in dividing the skin and subjacent fibrous tissues, defining and refreshing the edges of the parietal wound, and drawing them together with buried sutures. Whenever possible, however, the object of the operation should be to overlap the margins of the open- ing by the use of mattress sutures, bringing surface to surface rather than merely edge to edge. A little more manipulation and freeing of the parts is necessary, but it is astonishing to note what extensive gaps in the abdominal wall can be effectively cured in this way. Sometimes, however, the defect is too extensive for treatment in this manner, and then the surgeon may advisably utilize a silver filigree, which is implanted across the opening on a level with the sub- peritoneal tissue. Of course it is effectively sterilized before use, and forms a permanent barrier against further hernial protrusions.* 3. In women who have borne children the linea alba often stretches and yields, allowing considerable separation of the recti muscles for almost their whole length. If placed in the recumbent posture, and told to raise their head and shoulders from the bed without using their elbows for support, the linea protrudes as a longitudinal ridge of considerable breadth. Much discomfort and dyspepsia arises from this cau^e, owing to the inefficient support given to the intestines. A firm abdominal belt may be used as a palhative measuie, but opera- tion is very desirable. The thinned linea alba is spht down the middle from top to bottom if need be ; on one side — say, the right — it, together with the neighbouring rectus muscle, is separated from the subcutaneous tissues and tucked under the rectus on the left side, its free end being secured by a row of mattress sutures passing through its edge and the left hnea semilunaris, and being tied super- ficially. The left free edge is subsequently secured to the right linea semilunaris by a row of stitches. Redundant fat and skin is removed, and the wound closed by sutures. In this way the abdominal wall is drawn together like a double-breasted coat, and excellent results follow. A Lumbar Hernia is a condition of considerable rarity, in which the abdominal viscera protrude by the side of the erector spiuce, coming to the surface between the latissimus dorsi and the external obUque, in the space known as Petit's triangle. It is perhaps seen most frequently after operations upon the kidney where suppuration has occurred, and the deep stitches have had to be removed. The ordinary signs of hernia are present, and with a little care the condi- tion is readily distinguished from a lumbar abscess. Treatment may be c onducted along the same lines as for a ventral hernia. * MacGavin, Practitioner August, 1906. iiio A MANUAL OF SURGERY 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, and 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 has usually been observed in elderly females. It is not often recognised in the living, except when strangulated, and even then it is more likely to be discovered from the abdominal aspect during a laparotomy for acute obstruction than diagnosed apart from operation. In a few cases, however, it has been noted 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 has generally been confined to cases of strangulation, and in these 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. If found during a laparotomy for obstruction, the same precautions must be taken as for a Richter hernia in the femoral region when discovered in the same way (p. 1123). Other forms of hernia — e.g., pudic, pudendal, vaginal, sciatic, etc. — have been described, but are so uncommon that they need no special mention. Abnormal Conditions of Hernise. Irreducibility of a Hernia is generally due to the presence of adhesions, either between the contents and the sac, or between the contents themselves, which are thus united into a mass too large to pass through the aperture of communication with the abdomen. This is often associated with contraction of the neck of the sac, which arises either from the pressure of an ill-fitting truss or the constant drag of the contents. Overgrowth or an excessive deposit of fat in the omentum may result in irreducibility, whilst cysts may occa- sionally form, as already described. The local signs of this condition are very evident, whilst dyspepsia, colicky pains, and a sense of dragging are among the most prominent symptoms. Treatment. — i. It may sometimes be remedied by forcible taxis applied at intervals, between which the patient is kept in bed, and an HERNIA III I icebag fipplied SO as to contract the parts; moreover, the patient, if fat, should be carefully dieted. It is most important not to operate on large hernije of this nature until some such preliminary treatment has been undertaken; the sudden reduction of a large amount of intestine into the abdominal ca\'ity has been responsible for several deaths from interference with the heart's action. 2. Another plan consists in the use of what is known as the hinged-cup truss ; the hernia is supported in a suitable leather bag hinged to the lower part of a truss, upward pressure being maintained by means of an elastic spring. By the use of one or other of these plans reduction may after a time be accomplished ; but we are not in favour of any such proceedings, except in very large hernice. 3. In healthy indi\aduals, and if the rupture is not too large, operation is preferable and much more satisfactory, omentum being removed and adhesions di\dded, as already described. 4. In a few very aggravated cases, it is only possible to support the hernia by an elastic bag. Inflamed Hernia is one characterized b\^ the existence]of a localized peritonitis in\-olving the sac, and perhaps also the contents. It usually arises from injury, such as ill-directed taxis, or from in- judicious truss pressure. The S}Tmptoms are those of a local inflam- mation, the part becoming hot, painful, tender, and swollen, and perhaps the skin over it congested; this is associated with general fe^'er, malaise, nausea, and vomiting, whilst constipation is generally present. A condition is thus induced somewhat resembling strangu- lation ; but it is distinguished from the latter by the presence of fever instead of shock, the absence of tension in the sac, and the character of the vomiting, which is not faecal. The hernia is irreducible, at any rate for a time, probabh' more on account of the pain, which prevents taxis, than from any mechanical reason, except in old- standing cases where pre\'iously formed adhesions exist. Lymph is deposited on the serous surfaces, and this usually leads to the forma- tion of adhesions. Occasionally, where omentimi is alone present, an attack of this type may result in a natural cure, especially in the umbilical variety. The Treatment consists in putting the patient to bed and restricting his diet to fluids, whilst fomentations are applied to the part. A little opium may also be administered to allay the pain, and the lower bowel is emptied by an enema. Should the condition persist in spite of treatment, it will be wise to operate, as otherwise strangu- lation might foUow. Obstructed Hernia is a condition in which the onward passage of fseces through the gut contained in a hernial sac is prevented. It is most frequently seen in the umbilical variety, and, of course, only in- volves the large gut . It is due to an accumul ation of undigested food or faeces, the condition being aggravated by the presence of flatus derived from the decomposition of the contents of the bowel. Nausea and vomiting are induced, the latter, however, rarely becoming faecu- lent, whilst constipation is usuall}^ present, although the lower bowel may empty itself and flatus may pass. Locally, the trunour becomes III2 A MANUAL OF SURGERY irreducible and distended, but not tense as in strangulation, and a doughy mass, which can be moulded and indented by the fingers, is fell within the sac. There is no tenderness, but the patient com- plains of a good deal of intermittent colicky pain. If unrelieved, a subacute form of inflammation may supervene, and this may pass on to strangulation, and even death. Treatment consists in the use of copious enemata, and the applica- tion of an icebag to the hernia, followed by carefully-applied taxis, so as to assist the onward passage of the impacted contents. As soon as the obstruction is overcome, a brisk purge should be adminis- tered. Strangulated Hernia. A hernia is said to be strangulated when the contents are con- stricted in such a way as to obstruct and ultimately to arrest the flow of blood in the vessels contained therein. Interference with the passage of faeces is not an essential in this condition, since omen- tum alone may be involved, or the intestine, if present, may only have a portion of its lumen constricted, as in the form known as Riehter's hernia (Fig. 519), whilst in Littre's hernia a diverticulum is similarly affected. Two chief varieties of strangulation are described: those occur- ring within the abdomen, which are dealt with more fully in Chapter XXXVII., and those which are extra-abdominal; it is only the latter to which we shall now direct attention. External Strangulated Hernia arises in one of two ways: {a) The hernia becomes strangled immediately after its formation; this is most frequently seen in children or adolescents, the hernia being then of the congenital type, and having a long narrow sac. {b) In adults it more frequently results from extrusion of an additional amount of the abdominal contents into the sac, as the outcome of some sudden violent effort. This condition usually obtains in old- standing herniae, the neck of the sac having previously become thickened and contracted, either by the pressure of a truss or the irritation of the protruded viscera. The former of these two con- ditions is generally acute in character, the latter more often subacute. The site of the constriction is either at the neck of the sac, or in the dense tissues external to it (Plate X.), but occasionally it exists elsewhere. Most frequently the active agent in the strangulation is the thickened sac wall itself; but in femoral and umbilical herniae structures outside the sac, such as Gimbernat's hgament or the linea alba, may be the actual cause of the constriction, whilst it may also be produced by the passage of a coil of intestine under a tight adhe- sion or through a sht or aperture in the omentum contained in the sac. In those herniae which become strangulated immediately after their protrusion, the constricting cause is invariably the resistance of the tissues surrounding the opening in the abdominal parietes. Pathological Phenomena. — ^The effects of strangulation vary some- what with the tightness of the constriction. The circulation is seldom PLATE X. Strangulated Hernia. [ To face page 1 1 1 2. HERNIA 1 113 arrested entirely at the onset of the symptoms; but the pressure affects first, and, more especially, the veins, and later, by the con- gestion and exudation thus produced, the flow in the arteries is brought to a standstill. Hence the constricted tissues are congested to begin with, and then, partly as a result of the deficient supply of arterial blood, mainly in consequence of bacterial invasion, gangrene ensues, with or without an intervening period of inflammation. When a portion of intestine is strangulated, it ftrst becomes of a dusky red, chocolate, or claret colour, owing to vascular congestion; it is thickened and stiff from exudation into its walls, and distended bv the formation of gas within its lumen, owing to the arrest of peristalsis and the putrefaction of its contents. The surface for a time remains smooth and shiny, but as the exudation into the sac increases, the endothehum is shed. Occasionally some of the super- ficial capillaries rupture, giving rise to ecchymoses, whilst in rarer instances, and possibly as the result of injudicious taxis, the con- gested vessels completely empty themselves into the sac, which is thus filled with clotted blood, the intestine in consequence becoming lax and vellowish-grey in colour. When the strangulation is re- lieved in this early stage, the bowel soon regains its former healthy appearance. If inflammation occurs, the surface becomes rough from the deposit of h^mph, and entirely loses its shiny and polished aspect. Gangrene results partlv from the prolonged stagnation of blood, and partly from the invasion of the intestinal wall by the B. coli and other 'anaerobic inhabitants of the gut, which, as soon as the vitality of the intestinal wall is sufficiently impaired, migrate through it, and by their development produce toxic bodies which still further assist the'^gangrenous process. As soon as it is established, the intestine turns an ashy grey or black colour, usually at one or more spots which gradually spread, lose all lustre and polish, and after a time become soft, lacerable, and offensive. Gangrene* 3s much more common in the femoral and umbiHcal forms of hernia than in the inguinal; it is generally developed in two or three days, but occasionally may supervene in less than twenty-four hours from the onset of the strangulation. It is more often seen in small herniffi of recent origin than in large old-standing ones. At the point ^ of strangulation the gut is completely anaemic and liable to ulceration or gangrene, which may subsequently result in perforation; adhe- sions may, however, form between it and the neck of the sac, thus preventing contamination of the general peritoneal cavity. The intestine above the site of strangulation becomes paralyzed, and peristalsis is entirely arrested, even in a Richter's hernia. Fsecal material, accumulating and undergoing decomposition, gives rise to a catarrhal enteritis, and even occasionally to stercoral ulcers, which may perforate and cause general peritonitis; this, however, is not very common in external strangulation, since the small intestine is usually involved, and soHd faces are absent. In more chronic cases * For a valuable paper on ' Gangrene in Strangulated Hernia,' see Comer, St. Thomas's Hospital Reports, vol. xxix. III4 A MANUAL OF SURGERY gangrene of the gut may be induced by the pressure of the accumu- lated contents and the action of the B. coli. The portion of the bowel below the constriction may be affected in a similar manner, owing to the arrest of the peristalsis, but to a slighter degree. Omentum, when strangled, is at first congested and of a dark red or purphsh colour, and later on infiltrated and matted together. If, however, it has contracted adhesions to the sac, and no gut is present, the trouble may subside, since its vitality may be maintained through the adhesions, and a natural cure of the hernia may result. Where such a condition is not present, gangrene supervenes, and the omentum then becomes ashy gray or brown in colour, and is pulta- ceous and friable. It does not become offensive unless associated with intestine, since it does not contain any intrinsic source of putrefaction. The sac is usually distended with fluid, which at the commence- ment is serous in character, and perhaps blood-stained, whilst subse- quently it becomes turbid and mixed with lymph ; finally, it is dark brown or yellowish-green, with a marked and most objectionable odour. Sometimes there is but little or no effusion of fluid, a con- dition generally due to complete strangulation of arteries and veins simultaneously, and often the precursor of earty gangrene. The serous lining of the sac is but slightly affected in the early stages; as, however, the case progresses to inflammation or death of the con- tents, it also becomes inflamed, and ultimately gangrenous from the activity of bacteria, which by this time have penetrated to the turbid serum contained within it. Ihe skin and surrounding tissues become cedematous, congested, and crepitant, and, finally, a natural cure may be determined by sloughing and the establishment of an arti- ficial anus. After the relief of strangulation, even if no gangrene has occurred, the patient is not free from risk, owing to changes which may possibly follow the temporary arrest of the circulation, since the prolonged blood-stasis in the bowel may be followed by inflamma- tion, owing to the damage done to the vessel walls, or by gangrene, owing to the diminished vitality of the bowel wall rendering it more vulnerable to the attacks oi the intestinal bacteria. The Clinical History of a case of strangulation is usually so char- acteristic that there can be but little uncertainty as to the diagnosis. The general symptoms are similar to those described at p. 1127, as occurring in all cases of acute intestinal obstruction. Ihe patient during some sudden effort notices a severe pain, localized at first to one of the hernial regions, or referred to the umbiHcus ; this is accom- panied by the usual evidences of shock — i.e., he feels faint, the pulse becomes slow and weak, the temperature falls, and the surface is covered by a cold, clammy sweat. 1 his shock is often not very pro- longed, 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. HERNIA 1115 Symptoms of exhaustion supervene, caused partly by the pain and vomiting, and partly by the inability to take food; probably the absolution of toxic material from the intestines also assists in its pro- duction. Complete constipation is usually present, but the patient may pass flatus or faces from the lower part of the intestine. The onset of gangrene is geneially accompanied by a sudden fall of tem- perature 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 fades 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, a tumour is found in one of the usual sites of a hernia, or if alreadV the subject of this condition, the patient may notice that his rupture has suddenly become larger. 'Ihe swelling is irreducible, tense, ex- tremely tender and painful, and without impulse on coughing. It is hard and rounded if bowel is involved, softer and more doughy to the touch, if omentum. When gangrene ensues, the tension wnthin the sac is reduced, pain and tenderness cease, whilst the skin over the tumour becomes dusky, inflamed, and oedematous; finally, evidences of gangrene show themselves externally, the parts becoming dark in appearance, and soft and emphysematous to the touch. If the patient survive, the necrotic tissues separate, and an artifi- cial anus is produced either naturally or through the intervention of the surgeon. Fig. 519. — Richter's Hernia. (Diagrammatic.) Suppuration within thesac is uncommon. Occasionally, however, cases are met wath in which the above-described signs are considerably modified, and gangrene of the gut may occur without the exaggerated pheno- mena of a serious toxsemic type indicated above. In one case the patient complained of no inconvenience beyond slight pain, although incipient gangrene was present ; he walked into hospital saying that he never felt better in his life. The early s\miptoms arising from strangulation of a portion of the lumen of the intestine [Richter's hernia, Fig. 519) are sometimes less marked than when a complete loop is constricted, but the later phenomena are always verj^ severe. It is usually of the femoral variety, and the ileum is most frequently involved. If less than half the circumference of the bowel is constricted, the obstruction is not alwa3's complete at first, flatus and faeces being sometimes passed; but w^here more than half the circumference of the bowel is engaged, Ili6 A MANUAL OF SURGERY complete obstruction from kinking or paralysis of the gut ensues. The vomiting is less marked than in other cases, and is not so commonly faeculent. The tumour produced is small in size, but tense and tender. It is quite possible, however, for it to be over- looked, even when the groin is examined, and the diagnosis is then likely to be made either on the operating or post-mortem table. The prognosis in these cases is always grave, partly from the difficulty ex- perienced in diagnosis, partly from the tightness of the constriction ; death usually results from perforative peritonitis, which is occasion- ally due to wounding of the gut by the hernia knife. The mortality in these cases is calculated at 62 per cent., which is in marked con- trast with that of about 35 per cent., which is usually said to be characteristic of strangulated hernia. The mortality for all cases of strangulated hernia admitted to King's College Hospital during the years 1892 to 1897 only amounted to i6-6 per cent. The occurrence o'f strangulation in a pure epiplocele is very rare ; the symptoms are vague in character, and the diagnosis is often difficult. The presence of a soft, doughy, tender swelling in any of the hernial regions, combined with pain, bilious vomiting, and possibly constipa- tion, is always a significant feature. So long as no kinking of the bowel is caused thereby, the symptoms may remain indefinite, the vomiting never becoming faecal; but as tmie goes on, arrest of peristalsis may lead to true obstruction, or even general peritonitis. As already mentioned, strangulated omentum does not per se be- come offensive; but occasionally a neighbouring coil of intestine may be dragged upon, and its circulation disturbed sufficiently to enable the B. c.oli to escape, and then it may find its way into the sac, and an infective inflammation may result. The Treatment of a strangulated heinia consists in reducing the contents by taxis, or by operaiton. 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 be first returned. The direction in which taxis is made varies in different cases. In inguinal hernia, it should be directed upwards outwards, and backwards. In a femoral hernia which has extended 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 up- wards, the margins of the saphenous opening being relaxed by flexing and slightly inverting the thigh. In umbilical hernia, the pressure is mainly directed backwards. HERNIA 1 117 It must be admitted that in the past taxis has often been used injudiciously and in cases where it could not be expected to do any good ; the bowel has sometimes been ruptured or its wall bruised, the mesenter}^ torn, and other serious results have followed. At the present day operative treatment for hernia is eminently successful, and open exploration of the sac enables one to judge of the condition of the gut and prevents the likelihood of returning to the abdomen an infected and even gangrenous focus. Hence it may be stated that taxis is permissihle when the hernia is of large size, particularly if inguinal, when the symptoms have a mild onset and do not become severe, and especially if taxis has been successful on former occa- sions. It may also be employed in old people with diabetes or albu- minuria, or in insanitary surroundings. Taxis is objectionable, and if emplo^-ed at all should be used very cautiously, when the hernia is small and tense, and particularly if femoral; when the onset is acute and sudden ; when the sj^inptoms are well marked, and especially if they become so in the early stages of the case ; if strangulation follows on the first development of the hernia; and of course if the case has lasted for some time and fsecal vomiting is present. A final attempt may always be made before operation when the patient is anesthetized. In some of the slighter and earlier conditions of strangulation, and especially if the patient has had similar attacks before which have been relieved without operation, reposition may be assisted by applying fomentations for half an hour, followed by the use of an icebag, reduction sometimes taking place spontaneously or being brought about bj^ taxis. Ihe heat relaxes the tissues around the neck of the sac, and the effect of the cold is not only to constrict these tissues, but also to induce contraction of the intestinal blood- vessels and muscles. Persistence of Symptoms after Apparently Successful Taxis. — It happens occasionally that although the surgeon may have apparently reduced the hernia satisfactorily, the symptoms of strangulation — viz., pain, vomiting, and constipation — persist. Such may be due to a variety of conditions, and considerable judgment is needed in coming to a correct decision in any particular case, (i.) Infective gangrene may involve the released coil of gut and spread to the portion above it, causing death from peritonitis and toxaemia, (ii.) Ulceration and perforation may occur along the ' constriction groove.' (iii.) The rupture reduced may not be the one which has given rise to the symptoms, an internal hernia, or one in some other region, co-existing, (iv.) The strangulation may have been caused, not by the neck of the sac, but by a slit in the omentum contained in the sac. Reduction in such a case would not relieve the symp- toms, the whole mass being returned into the abdomen, (v.) A volvulus may have been present, either wholly or partly in the sac, and may have been reduced untwisted. Occasionally a volvulus is produced by the manipulations of reduction, especially when the mesentery has been lengthened in long-standing hernia and the iii8 A MANUAL OF SURGERY bowel paralyzed by the strangulation, (vi.) The hernial sac may have a diverticulum or pocket communicating with it at its upper end (intraparietal interstitial hernia), or it may be shaped like an hour-glass. It is possible to reduce the intestine from the lower portion of this so-called hernia en bissac into the upper pocket, and then of course the symptoms persist, (vii.) Reduction en bloc or en masse ought never to be seen, as it can only occur when con- siderable, and therefore an unjustifiable amount of force has been employed. The sac and its contents are together reduced from their superficial position to the deep aspect of the abdominal parietes, the hernia then lying between the muscular planes or in the sub- serous areolar tissue, and the constriction remaining. The hernia gradually disappears, but without the characteristic gurgle. In such a case the sac sometimes gives way, the intestine and the portion of the neck which compresses it being pushed upwards. When occurring in the inguinal region it is recognised by the per- sistence of symptoms, and by the fact that a finger inserted into the canal, which is unduly patent, detects a tense rounded swelling at its upper end. It also happens, but less commonly, in the femoral region, and in either variety the hernia may slip down again a short time after its apparent reduction. In any case where, after an apparently successful taxis, the s'VTnptoms of strangulation are still present, a most careful investiga- tion is needed in order to ascertain, if possible, the cause. Thus, the character and frequency of the vomiting must be considered, since it may be due to the anaesthetic, but then loses its faecal character, and is less severe. If the vomiting is associated with a certain amount of local pain, and possibly with some blood-stained diarrhoea or the passage of mucus, the probability is that the coil of gut has been in reality reduced, but has subsequently become inflamed. Apart from such indications the affected region must be thoroughl}' explored with the finger, so as to ascertain whether any tumour can be felt at the upper or deeper end, as occurs in reduction en masse. Should this throw no light upon the case, the other hernial apertures must each in turn be examined, and finally an incision is made over the sup- posed site of strangulation, and an exhaustive search made for the sac. If no help is thus obtained, the abdomen must be opened, and some internal complication sought for. In the inguinal region, all that is needed is to prolong the first incision upwards and outwards ; in a femoral hernia, it is perhaps wiser to make a separate abdo- minal incision in the middle line, so as to avoid the division of Poupart's ligament; whilst in the umbilical variety, the require- ments of the case are met by simply increasing the size of the communication between the sac and the abdominal cavity. The Operative Treatment of strangulated hernia should always be undertaken at as early a date as possible, when once it is certain that the bowel is constricted. Nothing can be gained by waiting, whilst even the delay of an hour may make it doubtful whether the result will be successful or not. There is always sufficient time to HERNIA 1 1 19 permit of efficient purification of the parts, and it may be desirable to empty the lower bowel by an enema, or if there is much vomiting to wash out the stomach. T he administration of an anaesthetic needs care, and in the worst cases local anaesthesia or spinal analgesia must be depended on. A suitable incision is then made down to the sac, which should be recognised by its tense and rounded out- line. It is isolated as far as possible from surrounding structures, and then carefully opened. The amount of fluid varies much, and is sometimes very small, so that the possibility of injuring the bowel must be kept in mind. Having given exit to the fluid from the sac and noted its characters, the surgeon carefully examines the bowel or omentum. The cause of strangulation is then looked for and divided by a special hernia knife, which practically consists of a curved blunt-ended bistoury, the cutting blade being limited to an extent of about I inch from the blunt end. If such is not to hand, an ordinary blunt-ended curved bistoury will suffice. The index-finger is em- ployed to repress and guard the mtestine, and acts better than a director, since intestine is likely to curl up on either side of the instru- ment, and may thus be injured. The knife is then slipped on the flat under the constriction, and turned so as to divide it; it is better to nick it slightly in two or three places than to incise it by one deep cut. The gut is carefully drawn down into the wound, and its condition at the site of strangulation examined; it is sometimes a matter of difficulty to decide whether it should be returned or not. Of course when gangrene is obviously present further treatment is necessary ; but in many cases the condition of the bowel is doubtful. It is then well to delay action for a few minutes, and perhaps douche the parts with warm salt solution. A gradual change of colour from a deep claret to a more definite red indicates that the circulation is still active; occasionally, however, it will be found that no change occurs in spite of division of the constriction, or that the admittance of the circulation brings into evidence here and there patches that remain unaltered ; these are probably gangrenous, and it is wise to deal with them as such. Omentum, if smaU in amount and recently pro- lapsed, may be reduced, but it is better practice to remove any con- gested portion, or that which has evidently been in the sac for some time. The method of its removal has been already described (p. 1098). According to the condition of the intestine, the further steps of the operation are modified as follows : I. If the gut, though congested, shows no sign of gangrene or per- foration, it may be safely reduced. This is not always a matter of ease, owing to the fact that the effusion into its walls has made it stiff and fiim. Prolonged and steady pressure with the fingers will, however, sufficiently remove the exudation to permit of its reposition into the abdomen. All manipulation directed to the intestine must, of course, be of the gentlest nature, since its congested state makes it more friable than usual. II20 A MANUAL OF SURGERY 2. If the gut has been tightly strangled and gangrene is threaten- ing, it is advisable to resect it at once, the incisions being made well above and below the sites of constriction ; the divided ends are united by one of the plans detailed at p. 1037. If, however, the bowel is in a doubtful condition, but recovery thought possible, it is gently re- placed just inside the abdomen, after freely dividing the constriction, and a large drainage-tube is inserted down to it. There is no need to fix the bowel; it is already inflamed and paralyzed, and hence will not change its position, especially if a small dose of opium is subse- quently administered. In this way, even if gangrene or perforation occurs, a track is left for the escape of the contents, while a localized plastic inflammation will shut off the general peritoneal cavity. A faecal fistula may thus be formed, but it often closes spontaneously at a later date. 3. If the gut at the time of operation is evidently gangrenous, the ideal treatment consists in [a] total removal of the affected coil, and of some inches below and above it, especially the latter, so as to be well clear of the infected focus. The ends are united together in the usual way, and a considerable degree of success may be expected in patients who have not been left too long. The intestinal canal is at once restored to functional utility, so that the fluid and offensive fsecal material can pass onwards, whilst the absorption of toxins from the stinking gangrenous gut wall is stopped, [b) In only too many cf these cases, however, the general condition is almost hope- lessly bad through delay, and primary enterectomy, even in expert hands, takes some time. It is then necessary to open the bowel and make an artificial anus. It is essential that a free passage should be made under the constriction into the gut above, but if possible without detaching or loosening adhesions at the neck of the sac, whereby peritoneal infection is prevented. Ihe introduction of the finger up the bowel may be followed by a free flow of faeces ; but if not, then the constriction may be dilated from inside the bowel b}^ dressing-forceps and a large drainage-tube introduced; or the con- striction at the neck may be carefully divided from outside, and either a Paul's tube or a large drainage-tube inserted. Of course one should cut away as much of the stinking gut as practicable. 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 apphed, into which the faeces can be received ; possibly the best application is a layer of pro- tective with a sufficient hole in the centre to allow the faeces to pass, and then over it a thick layer of tenax. The relative value of the two methods cannot be fairly measured by statistics, since so many of the cases treated by the formation of an artificial anus are hopeless from the beginning. There can be no question that, with our prerent methods of intestinal suture, a large measure of success may be expected from the adoption of primary resection in the majority of cases. HERNIA 1 12 1 Having thus dealt with the hernial contents, it is always advisable to perform a radical cure in uncomplicated cases, so as to prevent any recurrence of the condition. This is undertaken according to the methods already described, and the external wound subsequently closed and drained. ihe After- Treatment in cases of strangulated hernia is of the greatest importance. The patient is placed in bed, and absolute quiet is maintained, no food being allcwed for twenty-four hours, although a little ice may be sucked or hot water sipped in order to relieve thirst. If there is no pain, opium need not be administered, as it helps to maintain the paralyzed condition of the bowel; severe pain may, however, call for the hypodermic injection of a small dose of heroin. Liquid food can usually be taken at the end of twenty - four hours, and, if the patient's condition remains satisfactory, it is unnecessar}- to administer any purgative, the bowels often acting naturally; if they remain unreheved for five or six days, a dose of castor oil should be given. \"arious Complications may arise after the operation, needing special notice, (i) Vomiting may persist for a time as a result of the anaesthetic. It loses, however, its fseculent character, and may generally be stopped b\' washing out the stomach or by the hypoder- mic injection of morphia. (2) The Paralytic condition of the gut may remain for some considerable time, causing prolonged constipa- tion. If there is no evidence of inflammatory mischief, it is best treated by the administration of a purgative or by a turpentine enema. (3) Aci.te Enteritis may arise either in the portion of strangu- lated gut or just above. This is usually indicated by localized pain, and perhaps the passage of mucus, w^hich may be so abundant as to amount to diarrhoea; the vomiting, moreover, persists, but is no longer stercoraceous. It is best treated by the administration of bis- muth combined with chlorodyne, whilst all solid food is interdicted. (4) It is possible that, although the gut looked healthy at the time of operation, its walls were in reality already infected, and in spite of the relief of the constriction, infeitive gangrene may follow, causing death from peritonitis. (5) Occasionally acute septic peri- tonitis results from a localized perforation, either of a small gan- grenous patch or from ulceration along the ' constriction groove.' Treatment. — The condition is obviously one of the gravest import, and must be dealt with actively if the patient is to be saved. The abdomen must be opened, the affected coil identified, and if need be resected, or fixed in the wound and opened for drainage purposes. The peritoneal cavity itself is dealt with according to the rules alread\' given. (6) Localized Peritonitis may be looked on as a conservative measure, whereby Nature isolates some focus of danger from the general peritoneal ca\aty. Occasionally localized sup- puration 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, but a fsecal fistula is very likely to follow. It is impossible to describe in detail every form of strangulated 7t II22 A MANUAL OF SURGERY hernia. A few facts, however, must be stated about tlie more important varieties. In Strangulated Inguinal Hernia the constric- tion most commonly occurs at the neck of the sac, usiiaUy close to the external abdominal ring, as a result of the condensation of the surrounding tissues. The signs are generally very characteristic, and the condition can rarely be mistaken. Some difficulty may be ex- perienced in distinguishing it from inflammation of an undescended testis ; in this, however, there is no persistent vomiting or constipa- tion, whilst the absence of the testis below, and the existence of the peculiar testicular sensation, when the swelling in the canal is com- pressed, should clear up the case. Occasionally the two conditions co-exist, and then a correct diagnosis, apart from an open explora- tion, may be almost impossible. Torsion of the testis, and subse- quent strangulation of the organ, give rise to a swelling not at all unlike a strangulated hernia, but the absence of constipation and faecal vomiting should prevent mistakes. Division of the stricture in the course of the operation is 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 oblique or direct, and thus the liability to injury of the epigastric artery is diminished. If, however, the modern method of operation is followed, and the external oblique aponeu- rosis exposed and freely divided, it will often be found that the con- striction is relieved by this means alone, and reduction becomes possible. The sac, however, should always be opened, and the condition of the bowel examined. In Strangulated Femoral Hernia it is more common to find bowel than omentum, and it is in 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 varicose saphena vein may not be altogether easy, particularly if omentum alone is present. The histor}' 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 three 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 wounded once in ever}- 150 cases. The accident would be recognised by the occurrence of free haemorrhage alter 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 constriction is very tight, so that it is almost impossible to pass a director between Gimbernat's ligament and the intestine, the plan already mentioned of dividing the constriction from without may be utilized with advantage. HERNIA 1 1 23 Gangrene is more than twice as common in femoral hernia as in inguinal (icj'S per cent, in femoral against O'l per cent, in inguinal). Where entcrectomy is feasibJe, it will often be necessary to open the abdomen by an additional incision above the pelvic brim, and then, having divided 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 mesentery renders it impossible to perform the necessary manipulations through the wound in the groin. It is quite possible to overlook the existence of a small Richter's hernia, and only to ascertain its presence during a laparotomy for an acute attack of obstruction. Under these circumstances the greatest gentleness must be exercised in any attempts to withdraw the bowel from the sac, for fear of tearing the gut and flooding the peritoneal cavity with fluid faeces. It is usually well to cut down on the hernia from outside, open the sac, and divide the constriction; and then partly from without, partly from within, to reduce the strangled portion of bowel, which is brought to the surface and carefuUy examined. In many such cases drainage of the gut by a Paul's tube will be required, and a subsequent enterectomy. Seguelse of Strangulated Hernia. — (i) Artificial Anus may arise from the sloughing of the intestine and overlying skin apart from operation; or from the surgeon's interference, either by his opening the gut in mistake for the sac, or b}^ his incising it when gangrenous ; or it may slough subsequently, if left in situ when gangrene is threatening. After a time the surrounding parts settle down and heal over, the diversion of the fasces from their natural course becoming more and more complete, owing to the formation of a spur of mucous mem- brane, which lies across and blocks the entrance to the lower portion of the bowel. This spur arises partly as a result of the kinking of the gut, partly from the intra-abdominal pressure, which pushes the exposed inner wall of the intestine forwards. The effects produced by an artificial anus on the indi- vidual vary with the portion of the bowel involved. If the jejunum or upper part of the ileum is thus opened, the patient soon loses ground and becomes emaciated, owing to the escape of the intestinal contents before the nutritive elements of the food have been absorbed. Eczema of the skin in the neigh- bourhood is usually produced, resulting from the irritation of the faeces. For treatment, see p. 1036. (2) Faecal Fistula occasionally results from a strangulated hernia, owing to a perforative inflammation of the gut after the relief of strangulation, whether at the site of constriction, or above or below it, in the latter case arising from a stercoral ulcer. Though the lesion may be intraperitoneal, it by no means follows that general peritonitis need result, since sufficient plastic material may be formed around it to shut off the general peritoneal ca\'it3^ and to allow the extravasated contents of the bowel to find their way outwards through a sinuous track to the external wound. It may be some days before any evi- dence of the existence of this condition appears. Not uncommonly the opening will close naturally as a result of cicatricial contraction, and hence no steps need be taken to deal 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 cautery to the interior of the fistula; but more frequently an operation to expose, if practicable, the wound in the gut, and to close it by suture, or to remove the affected segment, will be necessary. (3) Stenosis of the gut at the site of strangulation may ensue, giving rise to the symptoms already indicated (p. 1022), which may appear weeks or months later. CHAPTER XXXVII. INTESTINAL OBSTRUCTION. By Intestinal Obstruction,* or Ileus, is meant a condition in which the onward passage of faeces is prevented. It is often associated with vascular phenomena, due to strangulation or kinking of the gut, which result in a deficient supply of arterial blood reaching the part, thereby predisposing to gangrene. Various elements enter into the picture provided by a classical case of obstruction, and of these the most marked are: I. Coprostasis, or retention of faeces. The fact that simple con- stipation may last for a week or more at a time, and do no harm to the patient beyond a certain slight degree of toxic poisoning, demon- strates that this is not the only element in cases of obstruction, and indeed is often an almost insignificant factor in acute cases. Yet it colours the whole picture, and has very marked results in the clinical manifestations. Retention of the intestinal contents is certain to be followed by their decomposition and liquefaction, and this causes the intestinal canal to be filled with a quantity of offensive fluid material, partly due to bacterial activity, partly to the pouring out of a con- siderable quantity of secretion from the congested gut wall. If the obstruction is only partial, this liquefaction of the bowel contents may enable them to pass on, and the patient's attack of partial obstruction is followed by one of diarrhcea, whereb}' relief is ob- tained. If the obstruction, however, is complete, the intestine above the block is gradually filled with this decomposing material, from which toxins may be absorbed, the patient being thereby poisoned. A second result of this decomposition of the retained faeces is the development of gas, which ma}^ be so marked as to lead to great abdominal distension, or meteorism. Whilst present in almost every case to a certain degree, it is most marked when there is considerable involvement of the mesentery, and experiments on animals indicate that constriction of the nerves contained therein is the chief factor in its production. * For much of the material incorporated in this chapter we beg to acknow- ledge our indebtedness to Sir Frederick Treves' classical text-book on the subject (published by Cassell and Co.), than which nothing better has ap peared, and which we have freely utilized. 1124 INTESTINAL OBSTRUCTION 1125 2. Increased peristalsis, with the object of forcing the intestinal contents past the block, is often an important feature in the case, leading to severe pain of a colicky character. So violent may these efforts become that the bowel, weakened by distension and inflamma- tion, is finally torn, and perforative peritonitis rapidly ends the case. J. Regurgitant vomiting is always a prominent element. At first the gastric contents alone are ejected, but later the vomit becomes bilious, and even stercoraceous or faecal. The origin of this pheno- menon is still a little dubious. Some have considered it due to anti- peristalsis ; others maintain that the ordinary onward movements of the bowel are quite sufficient to explain it. The intestinal contents are urged forward 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 produc- tion, or as to its being chiefly reflex in character, which is evident from the fact that it occurs whether omentum or bowel is strangled. Hence, it is easy to understand that it commences early in children and sensitive women, on 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 occurrence. 4. Nervous phenomena also add their peculiar features to the picture. The affected coil of bowel is directly paralyzed by the lesion, but, in addition, various reflex manifestations occur. Thus, in acute cases the patient suffers almost at once from shock, which passes off after a time, and from collapse due to toxaemia at a later date; vomiting and perhaps hiccough develop reflexly, and the latter sign is always to be looked on with grave suspicion and as an omen of bad import. In the latest stages intestinal paralysis from the onset of peritonitis may dominate the scene. 5. Infective phenomena are likely to follow sooner or later, the bowel walls being attacked by the virulent organisms contained within them. Complete paralysis and want of blood-supply pre- dispose them to bacterial invasion, and hence the more acute forms of infective gangrene are chiefly seen in conditions of the strangula- tion type; when mere obstruction is present without vascular changes, microbic invasion rarely produces more than a patchy necrosis, or, more commonly, perforative ulceration. Of course, when infective gangrene is present, virulent toxins develop in the walls of the gut, and a rapid depreciation of the patient's general condition follows from their absorption. 6. Finally, death is almost certain to ensue apart from surgical assistance, although a few cases may recover spontaneously. The final event is due either to perforative peritonitis, or to simple exhaustion, the result of toxic absorption from the retained fceces or from the necrotic intestinal wall, of constant pain and vomiting, want of nutrition, and general dehydration of the tissues. II26 A MANUAL OF SURGERY Causes.- — Much elaborate work has been undertaken to produce a satisfactory classification of the many diverse causes of intestinal obstruction ; and when one mentions the fact that a recent attempt included eighty distinct causative lesions, it is ob\-ious that there is an abundant field for this type of ingenuity. It must suffice here to state that there are two great divisions — the dynamic and the mechanical. (i) Dynamic ileus is due to some paralytic or spasmodic condition of the intestinal wall, which results in interference with its power of transmitting onwards its contents. Paralysis of the bowel results from: [a) Diffuse or localized acute infective inflammation, as in septic peritonitis or acute appendicitis; ih) torsion of intra-abdominal viscera, such as the spleen or omentum, or of tumours — e.g., ovarian cysts, leading to the so-called ' aseptic ' peritonitis; (c) embolus or thrombosis of the mesenteric vessels, leading to necrosis; (d) nervous lesions, which may involve the spinal cord itself, or more frequently the peripheral nerves — e.g., a tumour at the root of the mesentery. Spasm of the gut, as by chronic lead-poisoning, may also determine obstructive phenomena. (2) Mechanical ileus is the variety most commonly seen, {a) The gut may be strangled by bands or through apertures, causing internal strangulation, (h) It may be kinked over bands, thereby determining not only occlusion of the lumen, but also a marked interference with the vascular supply, [c] The intestine may be twisted on its own axis, giving rise to a condition known as volvulus, {d) One portion of the bowel may be invaginaied into a neighbouring portion, constituting an intussusception, {e) The lumen of the bowel may be blocked by foreign bodies or accumulations of faeces (obturation). (/) The onward passages of the faeces may be rendered difficult or impossible by the gut becoming narrowed, as from cicatricial or cancerous stenosis, or the pressure of external tumours. The most useful division is, however, the clinical, grouping to- gether those cases which present a similarity of sxTuptoms; and this method will be employed here, the subject being discussed under the three headings^ — Acute Obstruction, Chronic Obstruction, and Intussusception. Acute Intestinal Obstruction. ihe following are the chief Causes which give rise to this con- dition : 1. Strangulation by bands or adhesions, or through apertures, etc. 2. Volvulus. 3. The impaction of foreign bodies. 4 Strangulation over a band or'acute kinking''of,'^the gut, both very rare conditions. 5. Acute intussusception. 6. It may be the termination of a chronic obstruction. 7. Acute localized paralysis of the gut due to an infective inflam mation — e.g., acute suppurative appendicitis. 8. Acute enterospasm. INTESTINAL OBSTRUCTION 1127 It will be noted that in the lirst five of these causes, where the ileus is primary, there is a definite vascular lesion in addition to the obstruction, which threatens the patient at an early date with per- forative ulceration or gangrene, and it is mainly on the presence of this element that the acuteness of the case depends. The General Symptoms of acute obstruction are practically iden- tical with those of a strangulated hernia. The patient is suddenly seized with severe abdominal pain somewhat of the nature of colic, and perhaps referred to the umbihcus, coming on sometimes during some special effort — e.g., lifting a heavy weight, or sometimes when lying quietly in bed. At the same time he suffers from shock, as evidenced by a weak pulse, pale face, and cold, clammy sweat, the Fig. 520. — Strangulation of a Coil of the Lower End of the Ileum by A Band developed in the Neighbourhood of the Vermiform Ap- pendix. (King's College Hospital Museum.) temperature of the body falling below the normal. The shock is usually more or less recovered from, but the pain persists, and is liable to exacerbation and intermissions, soon becoming continuous. Vomiting ensues, being at first limited to the contents of the stomach, but quickly changes to a bilious, stercoraceous, or even fsecal char- acter. Distension of the abdomen is generaUy present, but its amount and characters vary with the site of the lesion. Signs of constitutional depression and exhaustion follow in a short time, the pulse becoming weak, rapid, and thready, the temperature remain- ing subnormal (except occasionally after the supervention of perito- nitis, when it may rise a few degrees), the face looking drawn [facies Hippocratica), and the abdomen being distended and painful. Finally, if unrelieved by treatment, the patient dies, and usually 1 [28 A MANUAL OF SURGERY within seven to ten days from the onset, owing to exhaustion or perforative peritonitis. Constipation may be absolute from the hrst, not even flatus being passed, but at any time the lower bowel may empty itself, and raise false hopes as to the pnjgnosis. The Special Forms of Acute Obstruction must now be considered serial im. I. Strangulation by Bands or Adhesions, through Apertures, etc. — Causes.--(a) Isolated peritoneal hands and adhesions arc usually the result of old plastic peritonitis of a localized and chronic character. The greatest variety is met with in the appearance and situation of these adhesions; most frequently they are single and cord-like; sometimes they are broad and membranous, constituting a false liga- ment; or, again, they may be multiple. A common situation is between different parts of the mesentery, or between the mesentery and some other viscus, the cause being either dis- ease of that viscus (usually a pelvic organ, the caecum, or the appendix), or inflammation of a mesenteric gland with localized perito- nitis. Whatever the exact cause, the mischief is most frequently found either in the right iliac fossa or in the pelvis. Two methods of producing strangulation exist : either the bowel passes under the arch or loop formed by a short constricting band, and cannot return (Fig. 520) ; or, if the band is long, it may form a loop or noose through which the bowel passes, and so becomes strangled (Fig. 521). (b) Cords formed by the omentum result from union between its fimbriated extremities and some part of the viscera or parietes, forming at first a broad band-like adhesion, which is gradually moulded into a rounded cord by the constant dragging and puliing to which it is subjected. They are usually coarser and thicker than those due to peritonitis. The mechanism of strangulation is identical, the noose form being perhaps the more common, since the adhesions are likely to be longer, (c) Meckel's diverticulum (p. 10 14) is liable to cause strangulation when its free end becomes adherent either to the parietes or to the viscera; it is attached most frequently to the mesentery of the ileum, and after that to the neighbourhood of the umbilicus. Occasionally the diverticulum ends in a fibrous cord, which mav remain fixed to the umbilicus, or floats free in the abdominal cavitv, and subsequently becomes adherent to some other structure, thus producing a fibrous cord. Strangulation may be effected by bowel passing under the loop formed by the adherent diverticulum, [d) The vermiform appendix, appendices epiploic a, or Fallopian tubes may contract ab- normal attachments, and thus form arches or loops under which bowel may pass and become strangled, {e) Slits, pouches, and apertures in the peritoneal investment, whether normal or abnormal Fig. 521. — Strangu- lation BY Band. INTESTINAL OBSTRUCTION 1129 may lead to strangulation. All external herni^e may be grouped under tliio lieading, as also those conditions known as internal hernia, in which the abdominal contents find their way into pouches in the posterior wall of the peritoneum — e.g., into the lesser sac of the omentum, the fossa duodeno-jejunalis, or into some of the retro- csecal fossje. 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 young people, and is rare after forty ; it constitutes more than a fourth of all the forms of internal obstruction, and the lower 2 feet of the ileum are most frequently involved. There may be a previous history of peritonitis, but that may have been overlooked or forgotten; the onset is usually sudden, and the symptoms of strangulation, as detailed above, are of a typical character. The abdomen is flaccid at first, and not tender until peritonitis ensues, on about the third or fourth day. There is generally no obvious tumour, and no peri- stalsis or dilated coils of intestine are to be seen. Occasionally an area of locahzed fulness or of fixed and limited tenderness may indicate the site of the lesion. The average duration is about five to seven days, the patients dying of exhaustion or toxaemia following peritonitis. 2. Volvulus is the most common cause of acute primary obstruc- tion of the large intestine. By it is meant a rotation of the gut upon its own mesenteric axis in such a way as to interfere not only with the passage of the intestinal contents, but also sooner or later with the circulation, determining a condition of strangulation. Occasionally a similar result is brought about by the intertwining of one coil, usually of small intestine, with another. The sigmoid flexure is the part generally affected, although it occurs in the caecum when there is a definite meso-csecum, or in the small intestine. In the former situation it is predisposed to by a long narrow sigmoid meso-colon, so that the two ends of the loop are brought closely together ; this condition may be of congenital origin, but is usually due to the traction induced by prolonged chronic 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 abdominal walls suffices to cause rotation of the pedicle, and thus brings about the volvulus. 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 faeces also aggravates the condition. Symptoms. — Volvulus is rare before the age of forty, and appar- ently occurs more often in the male sex. A history of chronic con- stipation precedes it, but the acute symptoms start abruptly. Pain is always present, at first intermittent, but finally constant, and there is usually tenderness over the sigmoid flexure. The pain. II30 A MANUAL OF SURGERY vomiting, and collapse arc not so severe or marked as in other forms of strangulation, but abdominal distension from excessive flatus, and resulting dyspnoea and thoracic embarrassment, are very distressing. Tenesmus is occasionally present. A locahzed peritonitis is usually developed, but sometimes it becomes diffuse. Natural cure is un- known, the patient dying either in five or six days from collapse and interference with respiration, or at a somewhat later date from peritonitis. 3. Impacted Foreign Bodies, which may cause intestinal obstruc- tion, are of three types: gall-stones, foreign bodies that have been swallowed, or intestinal concretions (enteroliths). The general facts connected with their presence in the intestine have been already noted (p. 1019). Gall-stones only cause obstruction when of large size, and then usually gain entrance to the intestine by ulceration from the gall- bladder into the duodenum. The usual site of impaction is in the lower ileum. Women over fifty are most often the subjects of this condition, and there may be merely a history of some inflammatory lesion in the region of the gall-bladder, and none of bihary cohc. Such patients frequently suffer from intermittent subacute attacks of incomplete obstruction, which, though severe for a time, are re- lieved by purgatives. If the gall-stone is not passed, a final acute attack supervenes, M'hich begins suddenly with pain and slight col- lapse, followed b}^ vomiting, which is constant and copious, and in twenty-four to thirty-six hours becomes faecal. The obstruction is often incomplete, flatus and even faeces being occasionally passed. The abdomen is soft and flaccid, and the affected coil and the gall- stone are rarely to be felt. Necessarily the symptoms vary with the site of impaction, usually becoming more urgent as the duodenum is approached. Death results from peritonitis or exhaustion. Similarly, enteroliths are usually impacted near the caecum, and if causing acute obstruction the symptoms are similar to those pro- duced by a large gall-stone, being preceded by chronic attacks and severe colicky pain. In thin persons their presence may be detected by palpation of the abdomen. 4. Acute obstruction ensues when a coil of intestine lodges across a tightly-drawn adhesion, the lumen at each end being thereby entirely occluded, and the circulation arrested. The 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. 1138. 6. When acute symptoms are developed at the termination of a case of chronic obstruction, the pain which had been intermittent becomes constant, the vomiting more violent and faecal in character, and the fatal termination is due to acute peritonitis, or to exhaustion and toxaemia. Absolute constipation is always present, and the abdomen much distended. 7. True obstruction is sometimes associated with acute localized INTESTINAL OBSTRUCTION 1131 enteritis or peritonitis, such as is seen in appendicitis, when the intestinal walls are paralyzed. This symptom is sometimes very marked, and even faecal vomiting may occur, but by careful atten- tion to the history and general condition of the patient a correct diagnosis should be reached. We append a table illustrating the chief diagnostic points between acute strangulation and acute ap- pendicitis associated with peritonitis, one of the commonest causes of d3'namic ileus: Onset - Rigor - Temperature Pain - Tenderness - Vomiting Abdominal parietes Acute Internal Strangulation. Acute Appendicitis with Peritonitis. Abrupt. Absent. Subnormal at first, rising a1 onset of peritonitis. Severe; referred to the um- bilicus. Absent till peritonitis come.' on. Early, marked, and soon faecal. Flaccid till peritonitis is present. May be preceded by local pain. Often present. High at first, falling later from exhaustion or toxaemia. Severe ; usually referred to the right iliac fossa. Present over caecum even in early stages, and gradually spreading. Less urgent, and seldom faecal, except as a late symptom. Tense and rigid from the first. In most forms of dynamic ileus the obstructive phenomena are usually secondary to some peritonitic trouble, or to some intra- abdominal lesion which produces its own symptoms first, and then obstructive phenomena only as a secondary result of inflammatory paralysis. Thus in torsion of the pedicle of an ovarian cyst, the patient first complains of pain, and the tumour becomes large and tender. Should it be neglected, aseptic peritonitis ensues; after a variable period intestinal paralysis follows, and obstructive symp- toms of a distressing type are produced, which will probably prove fatal, even if the cause is removed. 8. Enterospasm is the name applied to a functional disorder occur- ring in patients of a neurotic type, in which one or more sections of the intestinal canal undergo purposeless tetanic contraction. The colon is more commonly affected than the small bowel, and especi- ally the csecal and sigmoid sections. In the acute form the symp- toms of urgent obstruction may be produced, and even peritonitis simulated; but more frequently the attacks are chronic, and per- sistent constipation results. Sometimes the appendix is tender, and has been removed for this affection without benefit. Anti- spasmodics of the belladonna tjrpe are required, and purgatives do but little good. For diagnosis and method of examination of cases of acute obstruc- tion, see p. 1140. The Treatment of acute obs^■ruction is practically included in one word — Laparotomy. The condition of the gut is in most cases II32 A MANUAL OF SURGERY identical with that found in a strangulated hernia, and although a few patients may recover by palliative measures — e.g., enemata, opium, ice, etc. — yet the majority would be gravely injured by 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 preparations 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 striven after in the opera- tive 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 dasirable, but unless at the same time the putrid contents of the upper portion of the intestine are removed, little real good has been accomplished, since the patient is being slowly poisoned by toxic absorption. The late Mr. Greig Smith declared most emphatically that ' no operation for intestinal ob- struction is complete if the patient leaves the operating-table with a greatly distended abdomen.' Hence, in many cases it is desirable to deal with the engorged bowel first by establishing an artificial anus, 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 statistics prove that, in cases where the cause of the obstruction is not at once obvious, primary enterostomy, if followed by a satisfactory discharge of the intestinal contents, gives results in many instances equal to, or even better than, treatment directed towards the cause of the trouble. In the most urgent cases, where the patient's abdomen is acutely distended, and faecal vomiting has been present for some time, it is not advisable to administer a general anaesthetic: if such is at- tempted, the patient's life is often lost from stoppage of the respira- tion, precipitated possibly by a severe attack of faecal vomiting. Local anaesthesia by Schleich's method of infiltration must be relied on, or spinal analgesia, and a small incision made through the linea alba below the umbilicus; the first presenting coil of intestine is withdrawn, and after protecting the peritoneal cavity with gauze or swabs, is tapped with a large trocar and cannula so as to allow the first gush of flatus and faeces to be carried away from the wound. The opening is then enlarged sufficiently to allow a rubber or Paul's tube 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 pre- liminary measure before administering the anaesthetic. The head must not be placed on a lower level than the stomach, for fear of fluid regurgitating along the (tsophagus and choking the patient ; several deaths from this cause have been reported. The abdomen is then opened in the middle line below the umbilicus, and a definite search made for the cause of the obstruction if it is not at once obvious. The INTESTINAL OBSTRUCTION 1133 hand is lirst passed to the hernial regions, and then to the right ihac fossa, so that the caicum may be examined. If this is distended, the cause necessarily lies below it; it collapsed, above it. In the former case, the condition of the sigmoid flexure should next be investi- gated, 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 caecum is collapsed, perhaps the best method to adopt IS gently to withdraw 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 with- drawn. The remainder of the intestines during this process are protected and kept back by the application of hot sterilized abdommal cloths. The cause of the obstruction is in this way sooner or later discovered, and may be dealt with according to cir- cumstances. 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 proceeding with any methodical search for the obstruction. For this pur- pose a small trocar and cannula is inserted through the anti- mesenteric border; the flatus and faeces are allowed to escape; and the puncture is subsequently buried by a purse-string suture. It IS sometimes necessary to perform this in two or three different situations. Omental bands or peritoneal adhesions should be divided between ligatures. The vermiform appendix may be removed, or a Meckel's diverticulum excised. A volvulus should be untwisted, if possible ; but this IS usually impracticable, owing to peritoneal adhesions] and in such cases it is advisable to withdraw the coil from the abdomen, and if the large intestine is involved, an artificial anus should be made. Foreign bodies are, if possible, displaced forwards or backwards to a more healthy portion of the bowel, and then removed by a longitudinal incision along the anti-mesenteric border, the wound being subsequently 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, but it must always be kept in view that the essential feature of the operation is drainage of the intestine, and therefore the establishment of an artificial anus as a temporary measure is often desirable; re-union can be effected when the gut has emptied itself. Chronic Intestinal Obstruction. The Causes of chronic obstruction are very numerous;, and, looked at from an anatomical standpoint, may be divided into the followini' groups: 1. Intra-intestinal conditions— g.g-., impaction of faces, foreign bodies, etc. 2. Affections of the intestinal wall, such as stricture, new growths, especially those of a cancerous type, adhesions or matting together of II34 A MANUAL OF SURGERY coils of intestine, contraction or kinking of the gnt from mesenteric gland disease, etc. 3. Compression of the bowel by tumours, cicatricial bands, etc, developing outside the intestine. FjEcaJ impaction and the development of a cancerous growth are far and away the commonest causes of chronic obstruction. The General Symptoms of chronic obstruction are more or less as follows: The patient suffers from gradually increasing constipation, alternating occasionally with watery diarrhoea, spurious in nature, and set up partly by a catarrhal enteritis due to the irritation of retained faces, partly by decomposition of the faecal material. At irregular intervals more severe symptoms arise, consisting of pain, colic, vomiting, and absolute constipation, owing to some temporary complete obstruction, as by the impaction of a mass of undigested food or faces, assisted perhaps by a valve-like fold of mucous membrane across the passage. The abdomen becomes distended, and coils of gut may be seen in a condition of active peristalsis. These attacks usually pass oh after a time, a copious- evacua- tion of the bowels taking place, either naturally or after the administration of a purgative. Finally, one of these seizures persists and destroys the patient, either by exhaustion or by per- foration follow^ed by peritonitis, unless suitable treatment is promptly adopted. The vomiting is never such a marked Fig. 522.— Diagram to in- feature as in acute obstruction, until DICATE THE USUAL SiTES OF ^J^g ^^-^^y ^^ ^^J^gj^ ^^ bcCOmCS fSCal. F^CAL Impaction — viz., t-i 1 j • 1 1 THE C^cuM, Transverse ^he abdomen IS always more or less Colon, and Sigmoid. distended and tympanitic, and its contour varies with the site of the obstruction; if this is situated above the ileo-csecal valve, the swelling is mainly central, whilst if in the rectum or lower portion of the colon, it is most marked in the flanks. Distended coils of in- testine can be plainly seen through the abdominal walls in thin subjects, as also evident peristalsis. When arising from simple stricture, no tumour is to be felt ; but if due to malignant disease, and if the abdomen is not very distended, the growth may possibly be detected. Fsecal Impaction occurs in adult females who have previously suffered from chronic constipation. The caecum and sigmoid fle.xure are the most common seats of obstruction, but the transverse colon is not unfrequently affected (Fig. 522) . A doughy tumour may often be felt at one of these spots, which can in some cases be indented with the fingers, whilst in others it may be of stony hardness. The surface of the mass is usually more or less nodulated, and the intestine tender from the accompanying inflammation. The tern- INTESTINAL OBSTRUCTION 1135 peiMturc is often raised, from toxic absorption through the intestinal wall, and there may even be a rigor. The acute symptoms are alwa^'^s preceded b}^ a prolonged period of malaise and ill -health, the appetite being] defective, the breath offensive, and the tongue foul. On rectal examination the presence of scybala may often be detected. The special s\'mptoms arising from the other conditions which give rise to chronic obstruction, such as stenosis of the bowel, have been already referred to. The Diagnosis of chronic obstruction is obvious, but it is often by no means easy to ascertain the exact cause of the trouble. A thorough investigation of the case, according to the plan given here- after, must be undertaken, and by this means some conclusion may be arrived at as to the nature and seat of the obstruction. The Treatment of chronic obstruction is always a matter of diffi- culty and anxiety, owing to the uncertainty often felt as to the diag- nosis. 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, and preferably in the genu-pectoral position, or lying on the right side with the pelvis well raised. Purgatives are studiously avoided, as also opium ; prob- ably 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 suggested 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 ca^^r If'the 'catis.e.of the trouble is easih' found, a coil situated just above is withdr^^n from the abdo- men, opened, and a Paul's tube 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 be readily found, any distended coil may be \vithdrawn 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. When the cause of the obstruction is located in the large intestine, colostomy is usually required. The lumbar operation may possibly be undertaken; but the majority of surgeons at the present time prefer the iliac proceeding. If the rectmn or sigmoid flexure is clearly the seat of the trouble, the usual incision on the left side can be made; but if there is no indication as to the part of the colon II36 A MANUAL OF SURGERY involved, a median laparotomy 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 Httle 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 administration 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 illus- trated in Fig. 523. The constituent parts are seen more diagrammatically in Fig. 524. The upper por- tion is always prolapsed into the lower, except occasionally during the irregular peristalsis which takes place during the death - throes. The in- vaginated portion {a) is known as the intussuscep- tum, whilst the lower por- tion (&) into which it is protruded is known as the intussuscipiens. An in- tussusception, then, con- sists 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 intes- tine 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., gan- grene, 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-Hke, by the swelling and con- gestion of the intestinal wall, or perhaps by the impaction of a Fig. 523. — Intussusception. (From Speci MEN IN College of Surgeons' Museum.) INTESTINAL OBSTRUCTION 1137 /T^ U nr n portion of undigested food within the kimcn of the gut. Peritonitis usually follows, being possibly due to the invasion of a portion of the damaged intestinal wall by the B. coli or other intestinal organ- isms. 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. In other cases, and es- pecially when ulceration or gangrene is present, a diffuse peritonitis may be lighted up, and this may result in the death of the patient. The bowel above the site of invagination becomes dilated, and possibly stercoral ulcers may be formed, particularly in the more chronic cases. The Cause of intussusception is generally stated to be irregular and violent peristalsis, however induced, whether by the presence of irritating ingesta, or by the exist- ence of polypoid tumours, malig- nant growths (Fig. 485), or possibly worms; the presence of scybalous masses of faeces may also lead to its occurrence. In a few cases injury ■ — e.g., blows on the abdomen, or severe strains during jumping— have been held responsible for its onset, but very frequently no cause can be assigned. Intussusception is met with in four chief situations: (i) The ileo- ccBcal variety is much the common- est, constituting 44 per cent, of all cases (Treves). In it the ileum is protruded into the colon^ the apex of the intussusceptum being formed by the ileo-csecal valve. Owing to the great mobility of the ileum, a considerable portion of gut may be thus invaginated, and a good many cases have been observed in which it has actually projected through the anus. (2) The enteric variety involving the small intestine comes next in order of fre- quency, being met with in 30 per cent, of the cases. It is most often seen in the lower jejunum, and is rarely of great size. (3) The colic form may occur at any part of the colon or rectum, and, owing to the fixity of this portion of the gut, is limited in extent. It is met with in about' 18 per cent, of the cases. (4) The ileo-colic only occurs in 8 per cent.; in it the ileum is prolapsed through the ileo-caecal valve, which for a time retains its normal position; but after the intussusception has attained a certain size, the valve and caecum 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 72 Fig. 524. — Diagram of Intussus- ception. a, Intussusceptum; b, intussus- cipiens; I., ensheathing layer; II., returning layer; III., enter- ing layer. 1138 A MANUAL OF SURGERY being alwa3-s formed by the same portion of gut ; but in the ileo-colic variety, as just stated, it increases by the passage of more and more ot the ileum through the valve; after a time this stops, and is re- placed by the ordinary form of growth. Intussusception is occasionally met with as a post-mortem pheno- menon, resulting from the irregular intestinal movements which occur during the death crisis. The condition is recognised as being 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 infants under two years, being the most common cause of obstruction at this age.* The onset is sudden, the child being attacked with severe pain, possibly localized and more or less paroxismal at lirst, but rapidly becoming continuous and diffused over the abdomen. This is fol- lowed by vomiting, which, however, is less severe than in acute strangulation, and not so often fseculent. The patient rarely suffers from absolute constipation; but diarrhoea and the discharge of blood-stained mucus, perhaps associated with tenesmus, and often without faeces, are common. Collapse soon supervenes, and in the worst cases this may be so severe as to kill the patient within twenty- four hours; otherwise a fatal issue from exhaustion or peritonitis is reached within a week. On examining the abdomen, but little distension or tenderness is noted, unless acute peritonitis is present ; in more than half the cases a distinct tiunour can be felt, cylindrical in outline, and sometimes described as ' sausage-shaped,' following the course of the intussusception and generally curved, owing to the traction of the mesentery. In the ileo-caecal variety it extends from the right iliac fossa across the brim of the pelvis to the left, the colon being dragged downwards. This may be associated with an absence of resistance in the right fossa, which feels empty, consti- tuting what is known as the ' signe de Dance.' In other cases the tumour may be more limited, and distinctly moveable. The rectum should always be carefully examined, and preferably under an anaesthetic so as to permit a thorough bimanual examination of the rectum and abdomen to be made. A natural cure occasionally follows, resulting either from spon- taneous reduction, or from sloughing of the intussusceptum, whilst the peritoneal cavity is shut off by a circle of plastic lymph uniting the ensheathing and entering layers of the gut. When the latter takes place, the subsequent condition is not ver}- satisfactory, owing to the formation of a fibrous stricture. The association of intussusception with Henoch's purpura is an interesting phenomenon. This disease is characterized by a pur- puric eruption, joint pains, vomiting, and intestinal colic, the latter * Out of 187 cases of intussusception, H. L. Barnard found 72 per cent, were under one year of age. INTESTINAL OBSTRUCTION 1139 probably due to hcemorrhagc into or from the intestinal wall. There is no regularity in the evolution of the symptoms, and when the intestinal phenomena are early, the diagnosis from intussusception may be dithcult. In not a few cases intussusception develops, its existence being suggested by the severity and persistence of the colic and perhaps by tenesmus and loss of blood per anwn, and confirmed by the discovery of a tumour. Chronic Intussusception occurs more frequently in adults than in children, the onset being gradual and the course varying widely in different cases. The patient complains of intermittent attacks of pain of a colicky nature, which recur at intervals, and become more frequent and prolonged as the case progresses. Vomiting is often but little marked during the intermissions. The bowels are irregular in their action, and there is sometimes a blood-stained mucous discharge. The general condition is not at first much affected, but as the case progresses, emaciation and general asthenia may supervene. On examination, the abdomen is found to be flaccid and free from tenderness, although visible coils of intestine may be observed in some cases, and perhaps a tumour felt. The symptoms are rather those of subacute enteritis and chronic obstruction than of strangulation, and the case may be brought to a fatal termination either by an acute attack of obstruction or by peritonitis. It may, however, last a long time before being recognised. Treatment. — In the most acute forms of the disease but little can be done, owing to the extreme prostration of the patient ; but in the less severe and in the chronic cases the results are generally satis- factory if the condition is recognised. In acute intussusception the patient should be at once placed under the influence of opium, in order to still peristalsis and prevent the increase of the tumour. Inflation of the bowel with air, or the injection of copious enemata of warm water or oil, may then be care- fully undertaken. No undue force should be employed in this pro- ceeding, and a hand placed over the tumour may enable the surgeon to detect whether or not it has been successful. It is performed by raising the patient's pelvis and inserting into the rectum a catheter, with which is connected an indiarubber tube and funnel, held about i^ or 2 feet above the abdomen. Should this not succeed, lapar- otomy should be performed without delay, and the condition of the intussusception investigated. An attempt is then made to reduce it by grasping the tumour in one hand and gently trying to peel off the ensheathing layer from the upper portion of the bowel, which is steadied by the other hand. In about half the cases re- duction is impracticable, owing to the presence of adhesions, and then, if the general condition of the patient is fairly good, the intus- susception should be removed and the divided ends of the bowel united by suture. If, however, the patient is in a condition of pro- found shock, all that can be done is to fix the bowel in the wound and make an artificial anus. The results of these procedures are anything but encouraging, as it has been shown that few children XI40 A MANUAL OF SURGERY recover if anything more than simple reduction is required during a laparotomy. Chronic intussusception is more favourable in its prognosis. It is frequently unrecognised until an exploration of the abdomen is made, and hence reduction by inflation is not commonly attempted. In some cases the tumour may be reduced by simple manipulation, but as a rule too many adhesions are present. Excision of the mass should then be undertaken, and the results gained have been very encouraging. Diagnosis and Method of Examination of a Case of Intestinal Obstruction. A grave responsibility rests upon the medical attendant in every case of obstruction. The condition is incompatible with life beyond a few days, and the time occupied in observing the patient and making up one's mind as to the nature of the case is valuable time lost, which may ruin the patient's chances of recovery. There are three things to be avoided in conducting a case of this nature: (i.) Purgatives.- — The patient has probably taken plenty before sending for assistance, and the only result to be expected is an increase of pain and vomiting, (ii.) Opium has its place in the treatment of obstruction- — viz., in relieving the agony associated with its onset ; but beyond this it merely masks symptoms, and can do no good but comfortably to conduct the patient to the grave. It causes intestinal paralysis, and therefore may check the most distressing symptom, vomiting, but it aggravates the condition which needs treatment, (iii.) Delay in sending for surgical assist- ance is responsible for more deaths than is the condition itself. When once the gut has become generally paralyzed, there is but little hope for the patient. In the investigation of a case various problems of some difficulty have to be solved, and it is well to undertake this task methodically. 1. The medical attendant must satisfy himself that obstruction is present, and not merely aggravated constipation. In the latter, how- ever, flatus passes readily, and the general condition is not much impaired. In obstruction there is usually a complete arrest of flatus, and abdominal pain and vomiting often point to the existence of some serious lesion. 2. It is essential to ascertain whether the obstruction is dynamic or mechanical. The differences and distinctions between these have been already alluded to (p. 1126). 3. The question as to whether the lesion is acute or chronic must next be settled. Initial severe pain and collapse, the rapid onset of vomiting, a localized spot of fixed tenderness, and the quick depre- ciation of the patient, all point to some acute vascular lesion of the intestinal wall, which will prove fatal in a few days unless suitably treated. On the other hand, chronic cases are often preceded by constipation and other troubles of defsecation; they come on gradu- INTESTINAL OBSTRUCTION 1141 ally, and arc at first unaccompanied by constant pain and vomiting, although colic of a severe type may be present. The. examination of the abdomen is also of the greatest assistance; in acute cases intes- tinal paralysis dominates the picture; in chronic cases, vigorous peristalsis can be felt and often seen, unless the patient has been left too long. 4. An effort must be made to determine the site and nature of the lesion. As to the question of site, the following points may be noted: (a) When the upper part of the small intestine is involved, the vomiting is early, tumultuous, and persistent ; the vomit is bilious, but not faecal. Abdominal distension involves the epigastrium, and particularly the stomach. The lower part of the abdomen may be retracted. Collapse is early and rapidly increases. The thirst is terrible, the urinary secretion slight or even suppressed; gas and fasces may pass from the lower bowel. (b) When the lower part of the small intestine or ccBcum is involved, faeces and flatus cannot pass; the vomiting becomes offensive, but scarcely faecal; meteorism is marked, and involves the central part of the abdomen, the flanks not being affected. In chronic cases peristalsis is very evident. (c) When the colon or rectum is the site of obstruction, the symp- toms are more chronic as a rule, and even in acute cases, such as volvulus, the initial collapse is slight. Vomiting is later in appear- ing, but may, of course, become faecal. Meteorism may be very marked, and involves the flanks as well as the centre; sometimes it IS possible to recognise that the lesion is not lower than the splenic flexure by distension of the left flank being absent. The determination of the nature of the case will largely turn on the patient's previous history, and not uncommonly one has to admit that, although one can locate the site of mischief, there is no clue as to its nature beyond the generalizations learnt from statistics. The actual examination of the patient is carried on along the following lines: 1. The Previous History of the case should be carefully gone into, in order to ascertain whether or not the patient has suffered from bihary colic, chronic constipation, acute diffuse or localized peri- tonitis, uterine derangements, syphilis or dysentery, etc. 2. The History of the Present Attack should then be ascertained, noting especially the manner of onset, whether acute or gradual, the duration of the symptoms, and whether or not preceding subacute attacks have occurred from time to time. 3. The more prominent Symptoms must then be considered. [a) Collapse is due partly to reflex nervous disturbance, partly to the absorption of toxic materials, and partly to withdrawal of fluid from the body as a result of the vomiting; the portal area is also much engorged, and this adds to the want of fluid in the systemic circulation. The nervous cause is most active in the early stage of acute obstruction, especially in infants, whilst the toxic is largely II42 A MANUAL OF SURGERY responsible for the exhaustion seen at the end of an acute attack or in the clu'onic variety. Hence colhipse is early in acute cases, late in chronic. Moreover, the higher the lesion, the greater the shock, owing to the fact that the upper portion of the bowel is more intimately associated with the sympathetic nervous centres. {b) Pain is a very marked symptom, being usually referred at first to a little above the umbilicus, and is more severe in lesions of the small intestine than in the colon. It varies greatly with the com- pleteness or not of the obstruction. This matter has been especially emphasized by Treves, who has pointed out that when the obstruc- tion is only partial, the pain is inteimittent ; but when the block is complete, the pain becomes continuous. Hence in acute strangula- tion pain is almost invariably constant, whereas in stricture it is markedly intermittent and of a colicky nature. The amount of pain, moreover, varies with the nervous excitability of the patient; it is increased by anything which induces peristalsis (e.g., food or purgatives), and it is diminished on the supervention of gangrene. (c) Abdominal tenderness is rarely observed in the early stages, being caused by the onset of peritonitis. [d] Vomiting is an almost invariable accompaniment of obstruc- tion. Its cause has been already discussed (p. 1125). When the obstruction is situated in the jejunum or upper part of the ileum, the vomiting is never absolutely fsecal, although, if it has been tem- porarily checked by opium, the ejecta may be exceedingly offensive and dark in colour, owing to decomposition ; fsecal or stercoraceous 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. (fl) 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 in the rectum or sigmoid flexure. The existence of visible peristalsis 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. Sometimes one coil remains persistently distended and always at the same spot; its appearance always suggests that the site of obstruction is not far away. Ihe rise and fall of the abdomen during respiration should be watched to ascertain whether the movements are equal on both sides, or if any prominence, such as would be caused by a tumour, is noticeable. Ihe 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 observed. (b) All the nomial and abnormal hernial apertures are thoroughly INTESTINAL OBSTRUCTION 1143 investigated, and a careful examination made from the rectum and vagina. (f) The abdomen is carefully palpated, so as to ascertain the existence of any tumour or increased resistance of the abdominal walls. {d) Percussion may also throw some light on the case. {e) Finally, some information may be gained b}' the use of enemata. When the obstruction is low down and not far from the anus, it may be impossible to introduce more than a small quantity of fluid, and this in spite of modifying the position. Too much reliance, however, must not be placed on this sign. It is also desirable to auscultate the colon during the administration of a large enema; it is sometimes possible to hear gurgling sounds as far round as the cfficum, indicating that the large intestine is free from obstruction. We would call attention here to the fallacy of using a long tube in the expectation of being able to pass it into the sigmoid flexure. A careful study of the rectum and its valves will show the difficulty of this, whilst the use of the genu-pectoral position renders it unnecessarv. CHAPTER XXXVIII. AFFECTIONS OF THE RECTUM AND ANUS. The rectum from the anatomical standpoint consists of the lowest 4 inches of the intestinal canal, but for the surgeon it represents the lower 6 or 8 inches which can be reached more or less from the anus. Examination of the rectum is carried out by the following methods: I. Digital Examination in which the index finger is inserted through the anus. Soap should be smeared under the nail and into the semilunar fold at its Fig. 525. — Examination of the Rectum by Martin's Proctoscope. The patient is in the genu-pectoral position, so that when the proctoscope is introduced air rushes in and distends the rectum; the observer, utilizing either an electric head-lamp or a laryngoscopic mirror, can easily see the interior. In the above diagram the projection of Houston's valves is clearly indicated. base, so as to prevent faecal matter from lodging, and vaseline may be applied both to the finger and to the anus to facilitate introduction. It is, of course, advisable to have the bowel unloaded b}' purgative or enema before an exam- ination is made. The patient lies on the left side in the gynaecological position, and the introduction of the finger is usually less painful if he strains down at 1144 AFFECTIONS OF THE RECTUM AND ANUS 1145 the same time. A bimanual examination can be conducted with the finger in the rectum, and the other hand pressed deeply ov^er the patient's hypogas- trium. Although the great majority of rectal lesions occur within the lowest inch and a half of the bowel, the surgeon must never omit to explore the upper part of the rectum, as an unsuspected polypus or tumour may often be dis- covered in this wa}-; the pelvic parietes should also be included in the scope of the investigation. 2. The introduction of the whole hand has been recommended by some, but the hand must be unusually small which can be thus utilized. 3. Visual Examination is a most valuable proceeding. Martin's proctoscope (Fig. 525) is the most suitable appliance to use for this purpose, but an ordinary Fergusson's speculum answers well. The patient is placed in the genu-pectoral or in an elevated lithotomy position; the former is preferable, in that it allows intestines and uterus to drop forwards away from the rectum. Two index fingers, well greased and held back to back, are then introduced into the bowel, and the anus stretched in several axes, so that its muscular tone is lost for a time. The proctoscope can then be introduced, and it will be found that if the patient is in the correct position the rectum becomes ballooned by an inrush of air, and its interior can be clearly seen ; a head-lamp or a laryngoscopic mirror is sometimes useful in order to illuminate the interior. Houston's valves stand out clearly, and often obstruct the view of the upper part, but they can usually be pulled aside by a hook, or pushed aside by the speculum, or even if necessary they can be divided. In this way 6 inches, if not more, of the bowel can be brought under the eye of the surgeon, and topical applications can be made. A sigmoidoscope may be employed for seeing the condition of the upper part of the rectum and of the lower end of the sigmoid flexure. It consists of a hollow straight tube, 14 inches long, -with its length marked on the outside so that one may know how far it has been introduced. Suitable arrangements are made for distending the bowel with air, and for illuminating and seeing its interior. A blunt-ended obturator is used to facilitate its introduction in the first instance, but this is withdrawn when it is well into the bowel. Congenital Malformations — Imperforate Anus or Rectum, — ^The lowest portion of the intestinal canal arises from the union of two separate divisions. The upper, developed from the lowest portion of the primitive hind-gut, is originally in communication with the bladder, and forms a joint cavity or cloaca, the two, however, being earh' separated; the posterior segment, which becomes the rectum, extends down into the pelvis, to be joined by an epiblastic pit or involution growing in from the perineum known as the ' procto- deum.' Failures in t\^pical development maj^ be due either (a) to the proctodeum being absent or stenosed; {b) to the rectum being absent (Fig. 526, A) or retaining in measure its cloacal condition and opening into some other viscus — e.g., the bladder, urethra, vagina, or vulva (Fig. 526, B) ; or (c) to want of union between the upper and lower segments (Fig. 526, C). The following are the chief clinical varieties of malformation met with: (i.) Absence of the anus, with or without development of the rectum, which, if present, may open in some abnormal situation. In these cases, the important question to be settled by the practi- tioner is the existence or not of a rectum, and this, unfortunately, cannot alwa^-s be determined without an open exploration 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 every likelihood of the viscus being present. If so, it is always distended and club-shaped, usually lined with peritoneum in 1 146 A MANUAL or SURGERY front, and often below. If the rectum is absent, it usually ends near the pelvic brim, and is merely represented by a librous cord below that IqvvI (Fig. 526, A), whilst the bony pelvis is often atrophic and its outlet much reduced in size. Thus in one such case an interval of only I inch was present between a sound passed into the urethra and the tip of the coccyx. (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. 526, C). (iii.) An anus is occasionally present, whilst the rectum ends blindly above the pelvic brim, or opens elsewhere. (iv.) The anus, though present, may be contracted. 'ihe Treatment of these ca.ses must be instituted at as earty a date after birth as possible, so as to prevent intestinal obstruction. A B C Fig. 526. — Three Varieties of Malformation of Rectum. (Tillmanns. ) 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. Anal stenosis is readily dealt wath by regular dilatation with bougies. Where a membranous septum persists between the proctodeum 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 rectum 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. It is an open question whether it is justifiable to proceed further by removing the coccyx and part of the sacrum (Kraske's operation, p. 1171), since the membranes of the spinal cord extend much further down in the infant than in the adult. 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 present, colostomy must be performed, and by AFFECTIONS OF THE RECTUM AND ANUS 1147 preference the iliac operation, since the space between the crest of the ihum and the last rib is exceedingly small in an infant. When once a passage for the faeces is established, abnormal openings into the bladder, etc., usually close without difhculty. Various malformations in connection with the post-anal gut have been already described (p. 703). Injuries of the rectum are usually due to falling on some pointed body, such as a stick or railing, or upon a piece of broken china. They are sometimes due to the forcible introduction of foreign bodies by lunatics or criminals. They may merely involve the mucous membrane, or may penetrate the perineal tissues, enter the bowel, and penetrating the upper wall, lay open the peritoneal cavity. Haemorrhage, pain, and shock follow, and acute peritonitis if the serous membrane has been encroached on. Inflammatory troubles may involve the peri-rectal tissues, and sinuses may result from suppuration. A thorough examination must be made under an anaesthetic, and the wounds either sutured or left open to granulate. In women the recto-vaginal septum may be torn, but the surgeon need be in no great hurry to interfere, since the opening usually closes as cicatrization progresses; in some cases, however, where the lesion is of some length, and the margins not bruised or inflamed, immediate suturing may be desirable. If the peritoneal cavity has been laid open, a laparotomy is usually required in order to cleanse it and close the wound; if, however, the wound is small and the rectum at the time of injury empty, it may be justifiable to delay interference till some sign of inflammatory reaction shows itself; a piece of sterilized gauze packing in the rectal wound will often suffice to limit the inflammatory mischief. Peri-rectal complica- tions are dealt with as they arise. Foreign Bodies are derived from various sources. Generally they have been swallowed, and have traversed the intestinal canal. Fish- bones and small tooth-plates are most commonly seen, and they usually lodge just above the anus in one of the so-called ' pouches of Morgagni.' They give rise to severe pain, especially on de- faecation, and possibly to some form of peri-rectal abscess. Large gall-stones are sometimes lodged in the lower end of the rectum, just above the sphincter. Foreign bodies may be introduced from without, and cause various forms of traumatic inflammatory lesions. Inflammation of the Rectum [Proctitis) causes pain of a bearing- down character, a sensation of fulness, constantly recurring tenesmus, accompanied by a discharge of mucus, muco-pus, or blood. It may arise from any local source of irritation — e.g., the presence of foreign bodies, or of a poh^pus, parasites, or piles; gonorrhoea is an occasional cause — in women possibly owing to infection from the vaginal discharge, in men probably from direct infection. In dysentery the rectum is often involved as well as the colon, and extensive ulceration may be present. If the inflam- mation becomes chronic, a simple fibrous stricture may result. Treatment. — Injections of lead and opium or of borax may be used 1148 A MANUAL OF SURGERY locally, whilst the patient is kept in a recumbent position and on a low diet, the bowels being reguhirly opened by the administration of laxatives or enemata. If much bleeding is present, hazehne will often serve as a useful styptic. Thread-worms [Oxyiiris vermicidaris) are the most constant source of irritation of the rectum in infants and children. They give rise to pruritus ani, a discharge of muco-pus, and many reflex pheno- mena. In treating such a case, a sharp purgative may be given every morning [e.g., pulv. scamm. co., grs. v.), and salt and water or an infusion of quassia used as an injection. Occasionally this is ineffective, and then it is possible that the csecum or even the ap- pendix is the main site of lodgement of the worms; santonin may then be necessary in order to clear the intestinal canal. The Bilharzia haematobia is occasionally found in the rectum as well as in the urinary passages (p. 1182). It gives rise to fibro- adenomatous polypi, in which the ova can be readily demonstrated; they are rounded or oval bodies, differing from those found in the urine in that they possess a lateral spine-like projection, whilst in the latter it is terminal. Considerable tenesmus, diarrhcea, and discharge of blood are present, and the haemorrhage may become so abundant as to destroy the patient's life, especially when urinary symptoms are co-existent. They occur in children who have been in South Africa, and, unfortunately, no satisfactory treatment is known. Rectal and Peri-rectal Suppuration. — Many forms of abscess are found in and about the rectum, and they are very liable to leave behind troublesome fistulous tracks. As regards causation, they are, of course, due to germs, and these are derived most commonly from the bowel as a result of the impaction of foreign bodies, the extension of ulcerative processes, or the suppuration of piles. Oc- casionally the trouble starts from the skin around the anus, and sometimes the pus reaches the peri-rectal tissues from other viscera — e.g., the neck of the bladder, prostate, etc.— or from above, in connection with spinal or pelvic abscesses. Not unfrequently the abscess is attributed to injury or to cold, as from sitting on a damp stone or a draughty closet. These latter, if having any influence, are merely the final exciting agents. 1. An Anal Abscess forms immediately under the anal integument, and superficial to the external sphincter (Fig. 527, A. A.) ; it is usually due to inflammation of one of the numerous sebaceous follicles in that locality. It may be acute or chronic, and is one of the most frequent causes of fistula-in-ano. It must be freely opened throughout its whole length, and packed. Occasionally a sebaceous follicle becomes affected, constituting a boil, and may infect several others. If these can be dealt with early, the trouble may be limited, but if neglected a somewhat ex- tensive anal abscess may result. 2. A Submucous Abscess (Fig. 527, S.M.A.) usually forms as the result of a suppurating internal pile. The pus spreads up and down under the mucous membrane, and gives rise to a blind internal AFFECTIONS OF THE RECTUM AND ANUS 1 149 fistula (Fig. 529, 5). It is usually confined to one side of the bowel, and causes great pain on defalcation. Digital examination is ex- tremely painful. Treatment consists in draining it at the most dependent spot, close to the anus, but it may be necessary to slit up the undermined mucous membrane in order to ensure healing. Considerable haemorrhage may follow this proceeding, and it is not easy to stop except by firm pressure. 3. Acute Ischio-rectal Abscess is due to infection of the loose fatty tissue filling the ischio-rectal fossa (Fig. 527, I.R.A.) with some pyogenic organism, reaching it either through the perineum or from the bowel. The B. colt is usually present, and in consequence the pus has the ordinary characteristic offensive odour. A red, painful swelling is noticed on one side of the anus, which is at|first hard and Fig. 527. — Diagrammatic Section of Abscesses situated near the Lower End of the Rectum. L.A., Levator ani; E.S., external sphincter; I.S., internal sphincter; I.R.A., ischio-rectal abscess ; A. A., anal abscess ; S.M.A., submucous abscess; P.R.A., pelvi-rectal abscess. brawny, but soon becomes soft and fluctuating. Defsecation is ex- ceedingly painful, as also digital exploration of the bowel, and the patient is unable to sit with any comfort. If left to itself, it may burst internally or externally, or in both directions, and a fistula-in- ano is very liable to follow. Treatment. — In the early stages the part should be well fomented, but when there is no doubt that pus is present, a free opening should be made, the cavity washed out, and packed 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. A T-shaped or crucial incision is perhaps the best to employ in the early stages, as indicated in Fig. 528; the cross limb of the T is parallel to the fold of the nates, and should extend through the whole of the in- flamed and infiltrated tissues. II50 A MANUAL OF SURGERY 4. Chronic Ischio-rectal Abscess is usually met with in run-down or tuberculous indi\icluals during young adult life, and is not unfrequently a complication of phthisis. A deposit of tuberculous material replaces the fat ordinarily occupying the ischio-rectal fossa, and this after a time undergoes caseation or forms an abscess, which gradually spreads without pain or other inflammatory disturbance, until it may extend very widely and almost entirely surround the bowel. After it has burst the orifices of sinuses may be found at a considerable distance from the anus. The Signs and Symptoms are those of a chronic tuberculous abscess. An indurated and painless mass may be first felt in the fossa, and this slowly spreads, softens, and is transformed into a more or less extensive abscess sac. Oper- ative Treatment is desirable in most of these cases, and if possible in the early stages, or before suppuration has occurred; incision, re- moval by a sharp spoon of all tuberculous tissue, the apphcation of Fig. 528. — Situation of T-shaped Incision required for Opening AN Ischio-rectal Abscess. pure carbolic acid, and dressing the wound with gauze infiltrated with iodoform are the essential elements. Where extensive sinuses or fistulae exist, treatment as for fistula-in-ano must be adopted. At the same time, suitable hygienic treatment is instituted, and the more so if physical examination of the lungs or bacteriological examination of the sputum indicates the co-existence of pulmonary tuberculosis. 5. The Pelvi- rectal Abscess (Fig. 527, P.R.A.) consists in a locahzed collection of pus in the loose cellular tissue above the levator ani between it and the rectum. It may be secondary to rectal lesions, such as penetration of the wall above the internal sphincter or extension of ulceration from a carcinoma; but not un- commonly it originates from pelvic lesions, and may be caused by pelvic cellulitis, or suppuration in the meso-rectum, prostate, etc. The ordinary phenomena of a deep abscess are produced, and the AFFECTIONS OF THE RECTUM AND ANUS 1151 pus ma}- burrow dowuwards through the levator ani to the ischio- rectal fossa, or may travel up and involve the pelvic peritoneum. Sometimes it extends laterally and may almost surround the bowel, causing one type of horseshoe ftstula. Other collections of pus may find their wa\^ into this region from different parts — -e.g., a. psoas abscess from spinal disease, appendix abscesses, etc. Rectal exam- ination indicates the existence of a painful swelling high up in the bowel. As soon as a diagnosis is made, the abscess should be freely laid open and drained, and, if possible, by an incision behind tlie anus. Of course an abscess which is secondary' to a tuberculous spine is an exception to this rule ; in this every effort must be made to prevent the necessity for an opening in this region, as infection is certain to follow. 6. Occasionally a diffuse form of cellulitis involves the peri-rectal connective tissue, not uncommonly resulting in gangrene {gangrenous periproctitis). It is most likely to be seen in wealdy individuals and old people, and the symptoms are very asthenic in type. The sup- puration may extend above the levator ani, and lead to deep fistu- lous 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 packed with iodoform gauze, and subsequently well irrigated twice a da^^ Free stimulation is always required in Ihese cases, but the prognosis is very bad, death being probably caused by acute toxsemia or pyaemia. Fistula-in-Ano. — The term ' fistula-in-ano ' is somewhat loosely applied to all those conditions in which suppurating tracks are found in the neighbourhood of the anus and the lower end of the rectum. Many of these are merely sinuses which have but one opening. The Cause of fistula is usuallj^ some suppurative condition — e.g., an ischio-rectal or anal abscess, or the breaking down of a tuber- culous deposit in the neighbourhood of the bowel; but it is some- times the result of a simple or malignant stricture of the gut, the inner opening being either above, in the substance of, or below the cicatricial mass. This is moie likely to be the case when multiple fistulge exist. Varieties. — i. The Complete Fistula is one in which there are open- ings both externally and into the bowel. When following an anal abscess, they are both close to the anus, and the track lies imme- diately beneath the skin and mucous membrane (Fig. 529, i) . When following an acute ischio-rectal abscess, the external opening is a variable distance from the anus, and the inner not more than i inch up the bowel, being situated in relation with the so-called internal sphincter (Fig. 529, 2) ; occasionalh' blind submucous or sub- cutaneous extensions are met wdth branching off from this (2'*), but not so frequently as when the fistula follows a chronic tuberculous abscess. In the latter case the skin ma}' be extensively undermined, looking blue and congested, and the fistulous tracks may burrow widely, opening even on the thigh, or in the perineum or buttock. The so-called horseshoe fistula passes round the bowel, usually behind II52 A MANUAL OF SURGERY the anus, either superficial to the external sphincter or beneath it, and opens also on the other side. Moreover, the mucous membrane of the bowel is often undermined, and stripped from the muscular coat for some distance above the internal opening by sinuses or an abscess cavity. Occasionally the complete fistula which follows an ischio-rectal or pelvi-rectal abscess opens some way up the bowel as well as externally, and traverses the levator ani (Fig. 529, 3), consti- tuting a much deeper and more serious lesion. In any of these conditions secondary tracks may form, burrowing in all directions, and sometimes the opening up of these passages is a serious matter. Thus they may run forwards to the scrotum, or outwards into the gluteal region. i 2. The Blind External Fistula (Fig. 529, 4) is the term applied to a sinus resulting from the opening of an ischio-rectal abscess in which Fig. 529.- -dlagrammatic representation of various forms of Fistula-in-Ano. I, Superficial fistula resulting from an anal abscess; 2, a complete fistula, not involving the internal sphincter; 20, secondary track burrowing under mucous membrane; 3, complete fistula opening above the internal sphinc- ter and traversing the levator ani; 4, blind external fistula; 5, blind internal fistula; E.S., external sphincter; I.S., internal sphincter; L.A.. levator ani. 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 deahng with these external fistulae the possibility of the original cause being at a distance must not be overlooked. 3. The Blind Internal Fistula (Fig. 529, 5) is constituted by a sinus 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 disturbance. The orifice can sometimes be felt by digital exploration; on the insertion of a speculum it may perhaps be seen, and can be ex- amined by a straight probe or one bent in the form of a hook; it is AFFECTIONS OF TIUL RECTUM AND ANUS ii53 often associated with considerable undermining of the mucous mem- brane, and if chronic with stenosis of tire bowel. In all these conditions it is difficult to obtain healing, owing to the introduction of septic material from the bowel, and to the state of unrest in which the parts are kept by the continuous movements, voluntary and involuntary, of the sphincteri. 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 prehrnin- ary, 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. In a superficial fistula, both sphincters may escape division, and in a deep one both may be in- volved ; in the majority of cases, some fibres of the external sphincter are divided. A careful search is made for pockets or tributary branches of the main track, and these, if found, are opened up and scraped out, undermined and unhealthy skin being snipped away with scissors; it is important, however, to remember that the sphincter ought never to be divided in more than one place. Bleeding-points are, if necessary, tied, and the cavity is carefully dusted with iodoform, and Hghtly packed with oiled lint or gauze soaked in iodoform and glycerine. Pressure by a graduated compress of sterilized wool should be applied by means of a T-bandage. When a sinus extends for some distance under the mucous mem- brane 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 mvolve serious haemorrhage at a spot where it cannot well be checked. It will often suffice partly to divide and scrape it, and then, if the mam fistula has been satisfactorily dealt with, it will probably heal with- out 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 horseshoe. The M'hole track must, however, be opened up, the cavity scraped, loose tags of skin removed by the scissors, and an ordinary dressing applied. A small superficial fistula, not extending beyond the anal margin, can sometimes be enrirely excised, and the wound closed by sutures, thereby securing heahng by primary union. 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 surrounding skin is well flushed with a warm carbohc solution. When the plugs 73 "54 A MANUAL OF SURGERY are removed, fresli small stri])s of gauze soaked in iodoform and glycerine are introduced night and morning after tfie wound has been syringed. On the fourth day a good dose of castor oil should be given, and subsequently an action of the bowels must be secured daily. 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 the incision is not carried very deeply, the patient's sphinc- teric control after operation is unimpaired; but if the internal sphincter has to be chvided, all control of the bowel is lost for some time. As cicatrization progresses, however, it is gradually restored, and when healing is complete, control is usually perfect except when the patient is suffering from diarrhoea. The presence of tuberculous material locally and in the lungs must be carefully considered and taken into consideration in advising operation. If the pulmonary trouble is early, there is no necessity for delaying operation ; the patient will derive much more benefit from sanatorium treatment if his fistula has been first cured, or put well on the way to recovery. In the later stages, however, it may be advisable to leave the fistula alone, or, at any rate, only to do such an operation as shall relieve any urgent symptoms. Fissure of the Anus.— Thia is a most painful and troublesome com- plaint, met with most commonly in men, though not unfrequently in women of a neurotic temperament. It is occasionally due to injury or to the irritation of a polypus, but more often to the pa:>sage of large scybalous masses in patients suffering from chronic constipa- tion. The fissure is usually single, extending through the posterior border of the anus tovv-ard the coccyx; a ' sentinel ' external pile is often situated immediately over it, and the crack may lead to a defi- nite ulcer just within the external sphincter. According to Ball of Dubhn, 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 sore place is reopened, and the valve pushed further on, until finally, having become swollen and cedematous, it appears at the orifice as the ' sentinel ' pile, with an ulcerated surface behind or 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, consisting of burning pain during and after defsecation, which often lasts for hours. The pain is usually associated with tenesmus, and may rachate down the thighs or up the back, and not uncommonly to the left sacro-ihac joint; it may be so severe as to lead the patient to refrain from defsecation for prolonged periods. The fseces may be streaked with blood or pus, and there is a certain amount of discharge from the anus. On examining the part, the sphincter is found to be con- tracted spasmodically, and the entrance of a finger is forcibly resisted. AFFECTIONS OF THE RECTUM AND ANUS 1155 Treatment in the earlier stages is undertaken by regulating the aetion of the bowels by suitable laxatives, by the u^e of cocaine sup- positories prior to defecation, and by improving the general healtli. bome_timcs the apphcation of a hamamelis ointment, combined with the Ung. hydrargyri nitratis dil., is most effective in giving relief. In confirmed cases the sphincter has been forcibly dilated, and the crack or ulcer cauterized; but by far the most satisfactory treatment consists m dividing its base with a straight blunt-ended bistoury, the incision at the same time including the superficial fibres of the external sphincter. The ulcer and the edges of 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 ex- plored with the finger, especially with a view to the possible existence oi a polypus, which, if undetected, would cause a recurrence of the mischief. Rest being thus obtained, heahng soon follows. It is sometimes possible to close this small wound with sutures and obtain primary union. Pruritus Ani is a condition characterized by intense and incessant itchmg of the anus and its surrounding skin. At first noticed mainly at night, and interfering with sleep, it may in time become persistent throughout both day and night, preventing the patient from fixing his attention on his work, and wearing him out through want of sleep. Scratching becomes a necessity, and yet aggravates the condition, tt IS generally due to parasites, such as thread-worms, or to some ulcerative condition of the anal canal, just at the muco-cutaneous junction, or it may arise from some neurosis of the sensory nerves. Ihe skm looks red and excoriated; it is usually swollen and thrown into oedematous folds, which radiate from the anus in a characteristic fashion. Treatment.— Any parasites present must be destroyed, and ulcers of the anal canal must be carefully looked for and cauterized. For cases which persist in spite of such measures. Sir Charles Ball has devised an operation which has proved of value, and consists in dividing the terminations of all the sensory nerves to the part. Two semi-elhptical incisions are made around the anus, leaving a narrow pedicle in front and behind; the wounds are deepened to expose the sphincter, and the flaps raised from the muscle inwards around the anal margin and up to the muco-cutaneous junction. The pedicles m front and behind are undercut, and the outer margins of the incisions also to an extent corresponding to the area of irritation : the flaps are then replaced and sutured. The immediate result of such an operation is complete anesthesia of the skin of the flaps • normal sensation returns after a time, but without pruritus. Haemorrhoids, or Piles, consist in a varicose condition of the veins 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 pelvic colon iijC' A MANUAL OF SURGERY is similar to that in the intestine generally, the vessels being distributed transversely around the gut; but in the rectum they run in longitudinal seiies 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 .-.udden variations of pressure before and aftcx defgecation. Their dependent position at the lowest part of the portal area, together with the absence of valves, and the fact that they constitute an important communication between the portal and general systems, and thus afford the chief means of escape from a block on the poital trunk- all these reasons may be looked on as Predisposing Causes of the con- dition. In addition to the^e we must also mention a sedentary occupation, alcohohc excess, and chronic constipation, which, by leading to congestion of the liver, are frequent precursors of piles. They are exceedingly common in young people, especially in men about twenty years of age forced to lead a sedentary life; up to middle age the tendency diminishes, but in elderly individuals many conditions — e.g., enlarged prostate, cr stone in the bladder — arise which favour their development. Simple stricture of the rectum or malignant disease may so interfere with the return of blood as to determine a development of haemorrhoids. Young women are re- markabl}. exempt from piles, owing probably to the regularity of the menstrual discharge; but uterine conditions, such as pregnancy, displacements, or tumours, which cause obstruction to the venous return, are liable to be associated with them. A varicose condition of the veins in the neighbourhood of the anus is often present without being recognised by the individual; but many different circumstances may bring the symptoms into promi- nence by causing an attack of thrombosis, such as the use of drastic purgatives, especially aloes, local exposure to damp and cold, as by sitting on a cold wet stone or in a draughty closet, or sudden con- gestion of the liver, as by alcoholic excess, or a chill. Two chief varieties of piles are described — \iz., the external and internal; but frequently a combination of the two conditions is present. External Piles are found at the margin of the anus, and are covered with skin. They consist of a small central vein in a varicose state, surrounded by a development of subcutaneous fibro-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 the}^ give rise to no Symptoms bej-ond a little pruritus, and perhaps a sense of fulness and irritation immediately before and after defaecation. They are very 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 AFFECTIONS OF THE RECTUM AND ANUS 1157 distended with blood-clot. Under suitable treatment the swelhn? subsides ni a few days, usually leaving the fleshy fold more bulky and harder than previously, owing to the partial or complete organi- zation ot the thrombus. Ihe Treatment of external piles, when uninflamed, is very simple w!n^ ^^''k'^" "'f ^ ^"^ relieved; the parts should be kept clean and well vv-ashed; a hamameli^ ointment or extract may be occasionally applied, and great care taken not to irritate the anus after defecation by the use of hard papei-^.g'., newspaper. Very soft curl-paper well crumpled, should be employed, or preferably absorbent wool! It is but rarely that operative measures are required in a simple ca.e of external piles; where, however, external and internal piles co-exist It IS advisable to complete any operation undertaken for the latter condition by the removal of the more prominent fleshy folds sur- rounding the anus. This is accomplished by grasping them with lorceps and snipping them away by scissors in a direction radiating inr\ n "'""i'' °^ ^t '^'^y'' ^^^ resulting wounds being sutured i^or inflamed and thrombosed external piles the patient should be kept in bed, the bowels opened by a copious warm enema, and fomentations apphed. If the pain and tension are very great, the tumour should be incised and the' clot turned out; the margins of the fold may then be cut away, and the wound dressed. Internal Piles consist of dilated veins held_ together by a certain amount of con- nective tissue, and covered by mucous membrane. At fir:,t they are quite soft and compressible, and easily emptied on pres- sure; but when they have existed for some time the connective tissue may be increased in amount and arterial twigs are often found running into the mass ihe condition is limited to the lower 2 inches of the bowel and may present very varied appearances in different cases. Thus' l^f r T7k / ^"V^^' dilatation of the veins in the submucous tissue ^ithout the formation of any distinct tumours. The mucous mem- fr r.f ^""V -^ ^T? ^^""''r* ^°^°^^' somewhat thickened, and liable to protrude during defsecation. There is a certain amount of glairy mucous discharge, and the faeces may be streaked with blood ; but foirnw.H K. ^/^•7^^^' ^' ^°* ^'%^^- S^^h ^ condition is usually followed by a definite formation of haemorrhoidal tumours, and not unfrequently runs on to prolapse. When distinct hfeniorrhoidal masses form, they may be of two types : [a] The lon^ttudtnal ox fleshy pile (Fig. 530) , consisting of broad sessile masses, dusky m colour, soft and compressible in consis- tency and covered by mucous membrane, which, although thin and stretched^ still remains smooth and shiny, like the skin of a black grape. Between the piles depressions are found, in which small FiG- 530- — Internal Piles. 1 158 A MANUAL OF SURGERY portions of feces may lodge and produce irritation. This form generally bleeds but little. (&) The globular or bleeding pile is single or multiple, and as a rule somewhat pedunculated; 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, and the columnar epithe- lium may be replaced by the squamous type. The haemorrhage may be abundant, and comes either from the dilated superficial capillaries, or occasionally 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 deftecation. The patient feels as if a foreign body were present in the bowel, and the mass not unfre- quently protrudes, giving rise to much pain and inconvenience until replaced by the patient, owing to the grip of the sphincter (Plate XT). Sooner or later haemorrhage is almost certain to be noticed, coming on at first after defaecation, and only a few drops being lost. After a time, however, the flow increases, and may con- tinue 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 obstruction, as in cirrhosis of the liver, the bleeding may be beneficial, and must nut always be checked. Complications of Piles. — Inflammation of the venous ampullae con- tained in piles leads to what is popularly termed an ' attack of piles,' although this is much less common with the internal than the ex- ternal variety, and the fleshy form is that usually affected. Evidences of a localized phlebitis manifest themselves in the shape cf a painful distension and swelling of the parts, which become blue in colour and exquisitely sensitive. They subside with or without suppura- tion; in the latter case a spontaneous cure may result, whiLt in the former the abscess may burst into the bowel or may burrow exten- sively, and even give rise to general blood contamination and pyaemia . Strangulation of the piles by the sphincter ani may follow protrusion where reposition is not effected, the mass becoming painful, tense, swollen, and livid in colour; inflammation running on to ulceration and sloughing follows, the patient suffering from sickness, pain, and toxaemia. Pyaemia may ensue, or a spontaneous cure be effected. The Diagnosis of piles from other swellings which occur in the neighbourhood is not difficult. From prolapse they are recognised by their irregularity, the swelling not being of a rounded smooth annular variety, as in the former case; the two conditions are, how- ever, often associated. From polypus piles are distinguished by PLATE XI. /&rl- Prolapse of mucous membrane of Rectum and Plaemorrhoiclal tumours in an old standing case of Piles. This case was treated most effectively by Whitehead's operation. \;ro face page 1 1 58. AFFECTIONS OF THE RECTUM AND ANUS 1159 being multiple rather than single, by being softer and more com- pressible, by their situation close to the anus, by the absence of a pedicle, and by the haemorrhage being usually more marked. Mucous tubercles and condylomata are often mistaken for external piles, but are easily recognised by being symmetrically placed, owing to infection of one lip of the gluteal fold from the other, by their moist surface, and their situation at a little distance from the anus. The consistency, appearance, and history of an epithelioma should effectually prevent any error in diagnosis. It is important also to remember that blood may be passed per ami III from many other conditions besides piles. In the latter case the blood is of a bright red, florid colour, and often coats the faeces, whereas if it originates higher in the intestinal canal it is dark or tarry in colour {mclcBua), and is more intimately mixed with the excreta. A visual and digital examination of the rectum should always be made in order to ascertain the exact cause of the bleeding. The Treatment of internal piles is both general and local. General Treatment consists in removing all possible sources of venous congestion, in regulating the bowels, and assisting the functions of the liver. The latter may be effected by the judicious administration of natural mineral waters, such as Hunyadi Janos and Friedrichshall, or by the use of some such mild aperients as the confections of senna and sulphur, or castor oil; aloes should generally be avoided. At the same time the food is regulated, alcohol for- bidden, and suitable exercise enjoined. When dependent on the pressure of a gravid uterus, little can be done beyond attending to the regular action of the bowels until the child is born. Local Treatment in the earlier stages consists merely in palliative measures. Thus the parts must be protected from injury and cold; only soft paper or cotton- wool used after defaecation; and when protruding, the piles should be sponged with cold water and gently returned. An ointment containing an extract of witch-hazel (hamamelis), or the injection of a hazeline lotion (i in 8), is also advisable, and bleeding from piles can often be arrested by this means. The Ung. gallae c. opio of the Pharmacopceia is often emploved, but is not so efficacious. When there is much pain or bleeding, and the piles have attained some size. Radical Treatment by operation is necessary. Care must be taken before advising it to ascertain that no other serious disease of the rectum. — -such as cancer — is present, and that the piles are not dependent on hepatic or cardiac disease, when an operation might be injudicious and harmful. 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 half an 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, ii6o A MANUAL OF SURGERY which never extends beyond 2 inches from the anus. The following plans of treatment are those chiefly used: 1. Removal by clamp and cautery, as introduced by the late Mr. Henry vSmith. The mucous membrane having been everted, as just described, each of the hfemorrhoidal 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 tlie gut, great care being taken not to include the external skin. The clamp is tightened 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 indicated above (p. 1157), the mucous membrane re-inverted, the parts dusted with iodoform, and a carefully graduated compress of antiseptic wool applied with a T-bandage. The parts are bathed each day with 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 da}', and then a good dose of castor oil — e.g., 1 ounce in adults - should be administered. It is better to allow the patient to sit on a commode for the evacuation of the bowels. This operation, if effici- ently carried out, is absolutely safe and free from danger, and suited to cases where definite hsemorrhoidal tumours are present ; any com- plications from infection, haemorrhage, etc., are due to the careless- ness of the surgeon, and not to the character of the operation. 2. Ligature is an operation much in vogue for the treatment of piles, and if carried out with due antiseptic precautions, is followed by a large amount of success. The hsemorrhoidal tumours are grasped by forceps, the mucous membrane divided around them, and the base ligatured with silk; the mass is then snipped off, and the hgature cut short, the knot being allowed to separate by subsequent ulceration. Sometimes it is possible to suture up this wound, and then healing is more expeditiously effected. 3. Excision of the individual piles is a very successful procedure, and consists in dividing the mucous membrane longitudinally around the pile, whicli is then removed, bleeding vessels being secured, and the wound sutured. Perhaps the best way of affecting this is to grasp the pile longitudinally with a pair of Kocher's artery forceps, and then, after cutting away the redundant portion, to introduce a continuous catgut suture, including the forceps and the mucous membrane on either side. The forceps is removed and the suture tightened, thereby preventing bleeding ; the wound is effec- tively sealed, and the bowels may be allowed to act at an early date. 4. Where the hsemorrhoidal condition is general, and both internal and external piles are present, there is no question tliat Whitehead's operation is much the best that can be employed. It consists in the AFFECTIONS OF THE RECTUM AND ANUS 1161 total removal of this pile-bearing area in the same way as for excision of the rectum. An incision is made round the margin of the anus at the junction of the skin and mucous membrane, exposing thereby the distended veins, which together with the mucous membrane are separated from the underl\-ing sphincter by successi\'e snips of the scissors, and cut away, all bleeding-points being secured. The lower end of the divided mucous membrane is united bv suture to the skin, the stitches passing deeply under the surface of the wound, and not merely through the margins. Excellent results follow such treat- ment in suitable cases. Rectal Prolapse. — A certain tendency to eversion of the mucous membrane of the bowel is a constant and normal accompaniment of the act of defaecation; if, however, this becomes abnormally increased, the condition may be maintained after the evacuation of the bowels is concluded, constituting a condition of prolapse. At first onl}' the mucous membrane is protruded, and this is known as an incomplete pro- lapse; if, however, the condition per- sists, the whole thickness of the bowel, mucous membrane, submucosa, and even the muscular and serous coats, may become involved, gi\dng rise to the complete variety (Fig. 531). The former condition (sometimes badly termed a prolapsus ani) is more com- monly met with in adults, and the latter (the so-called prolapsus recti) in children ; but it must be understood that the latter is always preceded bv Fi^. 531. —Longitudinal Sec- , ^ . 1 • • J 1 , , 1 - TioN OF Complete Prolap- an mcomplete stage, Imiited to the sus Recti. (Tillmanxns.) mucous membrane, and that in adults complete prolapse is occasionally observed. Causes. — i. It may be produced by a simple relaxation of the tissues, as met with in wealdy individuals, and those who have been much exposed to the debilitating effects of residence in tropical climates, especially when chronic constipation or diarrhoea has caused the evacuation of the bowels to be accom- panied b}^ straining efforts. In children the malnutrition following measles and whooping cough may predispose, whilst the loss of fat from the peri-rectal cellular tissue ma}' assist. 2. Conditions which have led to chronic tenesmus or violent expulsive efforts — e.g., piles, chronic constipation, diarrhoea, rectal irritation, as from worms in children — or diseases of neighbouring organs, such as vesical calculus, stricture, or 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 X Indicates the serous sac in the anterior wall due to protrusion of the peritoneum. ii62 A MANUAL or SURGERY iiiembiaiie; this piutiusion in the early stages can be easily re[)lacefl by a little pressure, but returns if the patient strains or coughs. When the swelling is of large size, reduction is increasingly difficult and painful from infiltration and fibrous overgrowth of the sub- mucosa, and it is very liable to become inflamed and ulcerated from friction. Incontinence of faeces is also a common result. When the whole thickness of the gut is protruded, the serous lining may accompauv the tumour, but this is usually limited to the anterior surface, and into the sac thus formed small intestine or omentum may pass, and even become strangulated (Fig. 531, X). The pro- lapse itself may also be constricted 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 this, however, the finger or a probe can be inserted into the rectum by the side of the protruding gut, which is impossible with a prolapse. Treatment. — Tn the earlier stages, all that is needed is the removal, if possible, of the cause of the tenesmus — e.g., dilatation 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 {q.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 defsecate lying on the side, one buttock being pulled up for the purpose. The prolapse is carefully washed, reduced by pres- sure with the fingers, and retained by strapping the nates together, particularly in children, or by apptying some suitable pad and a T- bandage. Electric treatment to tone up the sphincter and levatores ani may be of assistance, and in children palliative treat- ment of this type is usually successful. In adults, however. Operative Treatment has frequently to be undertaken. In the slighter cases of incomplete prolapse, it will suffice to diminish the size of the anal orifice by snipping away radiating folds of skin and mucous membrane, including any piles that may be present. In worse cases it may be advisable to remove a wedge of the posterior wall of the prolapse, including a portion of the sphincter, the edges being brought together by deep stitches. Where this has failed, or is thought insufficient, the prolapse may be completely removed by the following procedure: The patient's buttocks are well raised, so as to prevent any protrusion of intestine if the peritoneal cavity is opened. An incision is made at the junction of the skin AFFECTIOXS OF THE RECTUM AND ANUS 1163 and inuooLis moinbraiie at the anal niargiu, and is gfadually deepened. The base of the prolapse is divided anteriorly on a level with the anus, the opening in the peritoneum temporarily packed with steri- lized gauze, and the remainder of the mass removed by scissors, bleeding-points being secured as di\'ided. The serous cavity is then carefully closed by sutures, and the divided end of the bowel united to the skin at the anus. No motion is allowed to pass for a week, but tlie anal orifice and lower gut should be thoroughh' washed out twice or thrice daily to prevent accumulation of septic material. Control over the bowel is usually regained, though often somewhat slo^^•ly, and the after-treatment is likely to be prolonged. The ultimate results are often ^'ery disappointing, as the prolapse often recurs after operation, and it is probable that operations of this type should be entirely discarded. The most reasonable proceedings are those directed towards fixation of the rectum {rectopexy) either backwards to the posterior pelvic w^all, or fiom above. Various operations of this type have been described and practised, with some measure of success. Thus the posterior wall of the rectum may be exposed by an incision, extending from the tip of the coccyx to the anal margin; if need be, the posterior wall can be infolded in the long axis, and the lumen of the bowel diminished thereby. Stitches are then introduced transversely through the rectal wall (avoiding the mucous membrane), and the ends are passed through the sacro- sciatic ligaments on either side and tied firmly over a pad of gauze, being retained in situ for three weeks. The rectum is thereby fixed posteriorly, and, with careful after-treatment as to the action of the bowels, good results may follow. As a modification of this procedure, the post-rectal space may be opened up and packed with gauze, thereby determining cicatricial fixation of the bowel. Abdominal operations in the form of colopcxy have also been under- taken, the pehdc colon being fixed to the lateral wall of the pelvis by stitches, after stripping awa}- a portion of the parietal peritoneum. The former method of fixation is the more desirable. Tuberculous Disease of the Rectum occurs in the form of ulcers, which are usually multiple, and may be very extensive. Infection may be due to the swallowing of infected sputum, but is probably the result of dissemination by the blood; the affection is often secondarv to pulmonarv disease. It starts in the submucosa, and the ulcers w-hich follow ha^•e the usual features, with undermined edges and prominent granulations. There is usually a marked tendency to the production of fistulse by extension of the process outwards. The symptoms are those of rectal irritability, pain on defecation, and discharge of muco-pus and perhaps blood. Treat- ment is generally palliative, the rectum being emptied by enemata or medicine according to the patient's comfort, and possibly healing ointments introduced. In the worst cases, colostomy ma}^ be required in order to put the bowel at rest. Sanatorium and vaccine treatment will probably be required in addition. II 64 A MANUAL OF SURGHRY Syphilitic Disease of the Rectum and Anus. — The rectum and anus are attacked by syphilitic disease in a variety of ways, the most prominent being as follows: {o) The initial lesion or primary chancre is occasionally met with in the neighbourhood of the anus. (b) In the secondary stage mucous tubercles or condylomata are frequently seen, being placed either at the anal margin or sym- metrically on either side, cf the gluteal fold, the sores on one side having evident^ infected the other. They are of the usual type (p. 159), 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 not uncommon, occurring most often, but not solely, in \^oung married women of the poorer classes. It is a somewhat early tertiary manifestation, and usuall}' commences within easy reach of the finger, about 3 inches from the anus. It starts as a diffuse gum- matous infiltration of the rectal mucous membrane and submucous tissue, which become thickened and indurated, ulceration soon following. These phenomena are not limited to the rectum, but frequenth' spread up the intestine towards the sigmoid flexure and down to the anus, and likewise involve the recto-vaginal septum and vagina, passing down the latter canal to invade the perineum and neighbouring structures, so that in a neglected case the whole external genitals and anus may be involved in an irregular hyper- trophic mass, somewhat resembling elephantiasis. In addition, the ulcerative process may extend more deeply, leading to the forma- tion of fistulse, not only between the rectum and neighbouring viscera [e.g., vagina or bladder), but also communicating with the exterior. From the cicatrization occurring in the submucous tissue, contraction of the gut results, causing syphilitic stricture, which may extend for some distance up the bowel. The symptoms consist in pain, increased on defsecation, irritability of the bowel, and discharge of blood and pus by the anus, whilst obstructive phenomena, or alternating attacks of constipation and diarrhoea, may also be present. On examination, the diffuse ulceration and infiltration of the part are suggestive of malignant disease, but the patient's age and history, and the painlessness and course of the case, are usually sufficient to determine the diagnosis. The general health remains good in the earlier stages of the affection, but later on may be undermined by the pain and constant purulent discharge. Treatment consists in administering salvarsan, or mercurj^ and iodide of potassium, the former perhaps in the shape of suppositories, whilst locally contraction is prevented as far as possible by the regular use of bougies. Possibly thiosinamin or iodolysin will be found useful in the later stages to assist in the complete removal of the newly-formed cicatricial tissue. In advanced cases colostomy is essentia] in order to secure rest to the parts, and give theni a chance of healing. Possibly in a few instances only a temporary opening of the bowel may be required, but where much contraction exists AFFECTIONS OF THE RECTUM AND ANUS 1165 and a considerable tendency to obstruction, the artificial opening must remain permanently. Sometimes the ulceration persists in spite of colostomy, and care must then be taken to prevent the retention of discharges by the occasional passage of bougies. Fibrous Stricture of the Rectum is usually met with in women over forty years of age, and is most often situated 2 or 3 inches from the anus, or as high as its junction with the sigmoid flexure. In this position, it is generally due to the cicatrization and contraction of ulcers following prolonged diarrhoea and dysentery, although occa- sionally it follows tuberculous or syphilitic disease. Any form of chronic proctitis — e.g., gonorrhoea — may also lead to it. It occurs sometimes as a sequela of pelvic celluHtis and suppuration, from the contraction of fibrous bands which may bind the rectum backwards to the sacral wall, or may merely constrict it ; the stricture is in these cases usually at a lower jpoint than in the former. Repeated attacks of inflamed piles may also lead to steno5i:> at or just above the anus. A stricture sometimes results from traumatism, or follows operations invohdng the whole or at any rate the greater portion of the circum- ference of the bowel. As already mentioned, it may be associated with a fistula, especially if the latter has existed for long, and is then due to a chronic inflammatory fibrosis lighted up by the persistent irritation of the stricture; the inner opening is then found in the substance of the stricture. The earliest Symptoms of stricture are often alternating attacks of diarrhoea and constipation, in which, of course, the constipation is primary, and the diarrhoea due to a catarrhal enteritis arising from the irritation of the retained faces. Gradually the difficulty in pass- ing motions becomes more and more marked until no relief is obtained apart from medicine; the fseces themselves become narrow^ed, flat- tened, and elongated, something like pipe-stems, or small masses like shrimps may alone succeed in passing. This is associated with pain and uneasiness referred to the lower bowel ; a certain amount of blood and mucus may be mixed with the excreta, and sooner or later marked d3^spepsia and abdominal distension supervene. If the case is allowed to run on without treatment, absolute obstruction of a chronic type may result and lead to a fatal issue; or the mucous membrane of the bowel above the stricture becomes ulcerated, an abscess forms, and subsequently a fistula, through which a certain small amount of faecal material passes. If several of these fiatulse are estabhshed, the patient may finally succumb to chronic septic poisoning and exhaustion. An examination of the bowel with the finger may reveal a smooth, regular constriction of the gut as if a band had been tied round it, the fibrous mass and the aperture in it feeling something Hke an os uteri. In other cases, the bowel is stenosed for some distance, and its surface more or less idcerated; whilst if due to pelvic celluhtis, it mav 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 1166 A MANUAL OF SURGERY stricture is smooth, £ind free from nodular irregularities and excres- cences; often, however, it is ulcerated and irregular, the examina- tion causing great pain. The gut above the contraction is hyper- trophied and distended, whilst if filled with retained faeces, the mucous membrane may show signs of inflannnation, or even stercoral ulcers. The gut below the stricture is usually dilated (ballooned), partly from paralysis of its walls, and partly by invagination of the mass fiom above. The Treatment in the early stages consists in keeping the bowels regular and the motions soft by means of paraffin and laxatives, such as castor oil oi salines, whilst the passage of the excreta is assisted by enemata. The diet is regulated, so that there is no un- necessary dcbiis. Locally, the stricture, if within reach, should be dilated by means of bougies passed in increasing size.-? eveiy two or three days, care being taken that the point of the instrument engages the stricture, and is not caught against folds of mucous membrane or turned backward-. The utmost gentleness must be used, in order to stretch the mucous membrane, and not tear it. Laminaria or compressed sponge-tents are of use in some cases, fol- lowed subsequently by bougies. When situated low down, the stricture may be notched posteriorly, or sHghtly nicked in several places with a blunt-ended bistoury, and bougie., then passed. As there is always a great tendency in these strictures to contract again, treatment is usually prolonged. If the stricture is out of reach, or signs of obstruction manifest themselves in spite of treat- ment, colostomy is the final resource. Tumours of the Rectum.^ — Polypus Recti occurs most frequently in children, and consists usually of an adenoma of Lieberkiihn's folli- cles, but occasionally of simple fibrous tissue covered with mucous membrane. They are commonly found within easy reach of the anus, and present an appearance something like a small cherry with a long pedicle, pendulous and freely mobile. The Symptoms caused are irritabihty of the bowel and the passage of blood by the anus, which latter when occurring in a child without symptoms of obstruc- tion 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 cau?ed by the partial extrusion of the polypus during defcecation. A natural cure can be effected by rupture of the atten- uated pedicle, which is at fiist attended by a certain amount of hemorrhage. 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 gives rise to haemor- rhage from and irritability of the bowel, or, if large, even to obstruc- tion. This condition is not always limited to the rectum, but may extend through the greater portion of the intestine, and then proves fatal from haemorrhage. Treatment consists in removal by ligature or wire snare, where practicable. Sarcoma is another uncommon disease in the rectum. It occurs AFFECTIONS OF THE RECTUM AND ANUS 1167 in the shape of a large fleshy tumour growing from the submucous tissue, and piojecting 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, when 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 by an operation somewhat similar to that for excision of the rectum. Cancer of the Rectum appears in the form of columnar carcinoma, consisting, as described elsewhere (p. 224), of an overgrowth of Lieberkuhn's follicles, not only into the lumen of the gut (centri- fugal or papillomatous type of growth), but also invading the deeper portions of the bowel wall, infiltrating the submucous and muscular layers (centripetal growth). A vascular fibro -cellular stroma is found between the glandular acini, and the physical characters of the tumour are largely dependent on the relative amount of these two elements. Thus, (a) if the stroma is abundant and fibro-cicatricial, the growth is comparatively slow; the tumour is hard and nodular; it usually starts on one side of the bowel as a mahgnant wart -like mass, but gradually encircles the gut, and is always Hkely to produce obstructive phenomena from its contraction; ulceration occurs after a while, {b) In the softer, more rapidly growing type, the stroma is less abundant, and merely fibro-cellular in character. The tumour projects into the bowel, and early involves the whole circumference; ulceration and bleeding are constant features, and the pain is usually considerable. There is always greater destruction of tissue, so that obstruction to the onward passage of faeces is much less likely to occur in it than in the former type, where cicatricial contraction is a marked feature. The ulcer which develops in the bowel is of the usual malignant type, with an excavated surface and raised, in- durated, and everted edges (Fig. 532, and Plate XII.) ; it bleeds readily, and its investigation is very painful. Colloid degeneration is occasionally seen in cancer of the rectum. As the disease progresses, it invades surrounding parts, and thus the tumour may become adherent either to the pelvic walls or to the bladder, vagina, or prostate; sometimes the ihac vessels or sciatic nerves are compressed, causing oedema or neuralgia respectively. Of course it must be understood that this invasion is in part inflam- matory, and due to absorption of bacteria, etc., from the ulcerated surface, and this is always a grave addition to the case. Peri-rectal abscesses and fistulse sometimes form, opening externally in the ischio-rectal fossae, or perhaps internally into the bladder or vagina, and then the tumour begins to develop"^ along the line of the fistula, and may actuallv form a mass of some size in the bladder. The glands in the meso -rectum and the lumbar glands become ii68 A MANUAL OF SURGERY enlarged, but for a time this may be merely inflammatory in type, though later on they become cancerous. Anal cancer, of course, leads to involvement of the inguinal glands. Secondary deposits may also be found in the liver, but this is more common when the cancer is higher up the bowel; the disease may even be disseminated throughout the body, though this is decidedly rare. The Symptoms of the disease are often so slight, and the onset so insidious as to raise no suspicions of the existence of any growth until it has attained considerable size. The patient is usually an adult, and more often male than female. At first there may be -*,=»5^*^« FiG. 532. — Carcinoma of the Rectum. (King's College Hospital Museum.) I, Anus, split open posteriorly; 2, 2, margins of the ulcerated growth. merely some slight constipation, requiring an increased amount of opening medicine. Then may come more definite attacks of con- stipation, alternating with diarrhoea, and the discharge of large quantities of mucub, often blood-stained. A sense of weight or dragging pain is noticed in the rectum, and the patient after defaeca- tion feels as if there is still something to be passed. This sensation increases until true tenesmus and straining at stool are present, together with constant pain, which may radiate up the back and down the legs, causing sitting on any hard substance to be painful. At first a blood-stained discharge may be seen on the faeces, which become flattened and pipe-like, if stenosis is present, but later it PLATE XII. Malignant disease of Rectum, The growth was an ulcerated columnar carcinoma on the posterior wall, situated about 3 inches from the anus, and had extended nearly round the whole circumference ; it caused much irritability and diarrhoea, and was removed by Kraske's method, without interfering with the anal canal. [ To face page 1 1 68. AFFECTIONS OF THE RECTUM AND ANUS 1169 passes indep.'ndently of the motions. On examination, an ulcer- ating, crateriform mass is met with, wliich may be limited to one segment of the gut wall, and is then usually firm, and perhaps associated with stenosis ; or it may surround the bowel, and feel soft and spongy, readily breaking down under the finger, and bleeding freely. The bowel below the growth is usually ' ballooned.' 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. When the anterior wall is involved, the bladder is often fixed to the mass, and micturition becomes painful ; moreover, every time the bladder is emptied a discharge may occur from the bowel, and this may continue even after colostomy- has been performed. Marked cachexia supervenes, the digestion becomes impaired, any meal causing pain and flatulent distension; natural sleep is impossible, and if a recto-vesical fistula forms, the patient's troubles are further aggravated by the passage of fsaces 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 occurs in about 30 per cent, of the cases, being more marked in the chronic forms, and in those where the disease starts high up the bowel, on account of the peristalsis causing invagination of the mass and occlusion of the tube; whilst if ulceration is excessive, or the disease situated low down, obstruction is less common, invagination being here impossible, and peristalsis being expended on the onward passage of the faeces. Exhaustion from haemorrhage, pain, sleeplessness, or toxic absorption, accounts for most of the fatal results, whilst septic peritonitis following the perforation of stercoral ulcers above the growth occurs in a few instances. The Treatment of cancer of the rectum consists in the radical measure of excision of the mass, or in the palliative operation of colostomy. Excision of the Rectum, or proctectomy, is only applicable to cases in which there is a reasonable prospect of the whole disease being removed. This depends not so much on the upward extent of the growth as on the question of fixation to surrounding parts. When the mass is not fixed anteriorly so as to endanger other viscera^^.g., the prostate or bladder), the case is a favourable one for excision. Fixation of the mass laterally or behind is not so important, although it will prevent removal, if extensive. Enlargement of glands in the meso-rectum does not necessarily contra-indicate operation, as they may be included in the scope of the high operation. When the lumbar glands are involved, or the liver, excision is obviously useless and should not be undertaken. Formerly it was considered of vital importance to avoid opening the peritoneum ; but at the present day this is frequently done, and with no untoward result, if due pre- cautions are taken; so that, although the growth may be situated high up, if it is freely moveable, and there is no evidence of * British Medical Joumcil, 1889, ii., p. 407. 74 II70 A MANUAL OF SURGERY secondary deposits, an attempt should be made to take it away. It must be remembered that in the male the peritoneum is reached on the anterior aspect of the gut about 2 J inches from the anus with an undistended bladder, whilst it may be pushed up another inch when that viscus is full ; in the female the peritoneum is situated about 4 inches from the anus, being reflected to the posterior aspect of the cervix uteri. Posteriorly, the lower 4 or 5 inches of the bowel are uncovered by serous membrane in both sexes. Excision of the rectum must include in its scope not only the removal of the growth, but also of a considerable margin of ap- parently healthy intestinal wall, both above and below, together with the lymphatic vessels and glands draining this area and lying in the hollow of the sacrum. This removal can be effected in several ways, and the choice of operation depends chiefly on the character, position, and extent of the growth, but also to some degree upon the condition of the patient. The actual operations are known as (i) the perineal or Langenbeck's operation; (2) the trans-sacral or Kraske's method; (3) the abdominal; and (4) the combined abdomino-perineal procedure, where the growth is attacked both from above and below. I. Perineal Proctectomy, or Langenbeck's Operation, is a satisfac- tory procedure in cases of early cancer of the lower part of the rectum when the glands in the hollow of the sacrum are not obviously involved. In most cases preliminar\' colostomy is a desirable pro- cedure, especially if the whole circumference of the bowel for a distance of 3 inches or more has to be removed, and the more so if the anus has to be sacrificed. The passage of fseces over and through the raw surface of the wound is not only a source of septic con- tamination, but also causes extreme pain, whilst the ultimate issue of the operation is an opening which is almost certain to become unduly patulous or too much contracted, and there is always a total loss of control. An effective anus in the left iliac region obviates all these difficulties, whilst the preliminarv opening of the abdomen gives the surgeon an opportunity of investigating the con- dition of the lumbar and sacral glands, and of ascertaining the extent of the growth up the bowel, and whether or not secondary deposits are present in the liver. The Operation itself is conducted as follows : The rectiun having been thoroughly washed out and emptied, and the patient placed in the lithotomy position, the perineum is shaved and purified, and the posterior wall of the rectum and anus slit open in the middle line as far as the tip of 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, commencing posteriorly, where this is readily effected, di\nding the levator ani on each side, and working gradually upwards and to the front, where great care must be taken to protect the vagina, prostate, or AFFECTIONS OF THE RECTUM AND ANUS 1171 membrani)us urethra. In the male, a bougie or catheter may be passed into the urethra with advantage. Bleeding-points can be secured during this process by pressure-forceps. The upper attach- ments of the gut are divided either by scissors, ecraseur, or clamp and cautery. Haemorrhage, which is generally very free, is arrested by ligature or cautery, and the gaping wound powdered with iodo- form, and packed 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 ; granula- tions gradually cover the surface, and, as cicatrization progresses, the mucous membrane is b}^ degrees approximated to the skin margin, . and the patulous cavity diminished in size until healing is complete. 2. The Trans-sacral or Kraske's Operation consists in the removal of the growth after a portion of the coccyx or sacrum has been cut away. It may be undertaken in cases where the growth extends upwards from the lower into the upper parts of the rectum, but is more especially suitable to cases in which the anal canal is not involved, and the lower edge of the growth is situated 3 or 4 inches up the bowel. The question of a preliminary colostomy has again to be con- sidered. In this operation it is desirable that the surgeon should aim at a restoration of the canal, so that the patient shall afterwards pass faeces normally. Whilst admitting that this is not the usual ter- mination of the case, yet it is sometimes obtained, and therefore a colostomv is prima facie undesirable. It can always be established at a later date if a sacral anus or fsecal fistula in the sacral region persists and is troublesome. If, however, the patient is previously suftering from obstructive phenomena, and probably has a collection of hard faecal matter above the growth, a colostomj^ is essential in order to clear the bowel ; it is advisable, however, to make it in such a way that it may be subsequently closed. 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 ligament and gluteus maximus are de- tached from the left side of the 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 above the fourth posterior sacral foramen to the under border of the third, and then to the left border of the bone at that level (Fig. 533, a b). The loose cellular tissue behind the rectum is thus exposed, and the gut, together with the tumour and the enlarged glands in the hollow of the sacrum, is freed from its connections, and amputated from the sound gut abo^•e, the peritoneum being usualty encroached on in this stage of the proceedings. A strip of sterile gauze is packed in to protect the ca\-ity from infection, and the opening is subsequently 1 1 72 A MANUAL OF SURGERY sutured. If the growth extends to the anus, the whole length of the rectum below is excised, and then the upper segment is drawn down after being mobinzed by division of the peritoneum on either side of the meso-rectum, and sutured to the skin. If the sphincter and lower inch or two are free from disease, they are left in situ, and carefully sutured to the lower end of the upper segment, although it is very probable that complete union \\ ill not occur. The wound is carefully washed out, and stuffed with gauze sprinkled with iodo- form ; even if the peritoneal sac has been opened, no harm will usually come of it. The results which have followed this severe operation are, on the whole, encouraging. Should partial union of the upper and lower segments occur, and merely a fistula be left, it may be possible to clo^e this by a secondary operation. Various modifications of Kraske's proceeding have been suggested, one of the best being that performed by Bardenheuer. The sacrum Fig. 533.— Pelvis seen from Behind to indicate the Lines of Section OF THE Sacrum and Coccyx in Kraske's Operation. a b, Kraske's original operation; a c, Bardenheuer's modification. is exposed, sawn across just below the thiid foramina (Fig. 533, 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. In all such procedures the importance of preserving the third sacial neives which supply the bladder must be kept in mind. 3. The Abdominal Operation is only possible when the lower 3 or 4 inches of the bowel are free from disease. Its object is to remove the upper segment of the rectum, part of the pelvic colon, and of the attached mesentery with its lymphatic glands and cellular tissue, and to restore the continuity of the bowel by suturing the ends together from above. The operation is conducted in the Trendelenburg position, and the rectum must be previously thoroughly irrigated with lysol or some other antiseptic. The abdomen is opened in the middle line, and the intestines drawn down out of the way and pro- tected A full examination of the parts is then feasible, and a final AFFECTIONS OF THE RECTUM AND ANUS ii73 determination reached as to the character of the operation required. The rectum immediately below the disease is carefully clamped and cut across; the lower segment is temporarily guarded. The peri- toneum on either side of the upper segment is now divided, and the tissue.-, of the meso-rectum freed therefrom. A portion of the sigmoid suitable for approximation to the lower end is selected, and by dividing the peritoneum of the nieso sigmoid on its outer side the loop is freely mobihzed. The guc is clamped above, and the diseased segment removed, the vessels supplying it being secured by hgatures, and this may even include the main branches of the inferior mesenteric artery. The upper and lower segments are then united by sutures, either within the pelvis or by invaginating the two through the anus and performing the anastomosis outside, with subsequent reposition. An effort is made to restore the continuity of the peritoneum by suturing, and it may be wise to insert a large drainage-tube through the anus so as to reach above the line of suture and allow flatus to pass. In weakly patients it is sometimes undesirable to prolong the operation by attempting the restoration of the canal, and in stout patients it may be impossible to effect this owing to the amount of fat present. Under such circumstances it is wise to complete the operation by the formation of a terminal artificial anus in the left iliac fossa, and by closing completely the anal segment of the bowel. 4. The combined Abdomino-perineal Operation is chiefly used as an alternative to the perineal or to Kraske's method, and has the great advantage of permitting a wider removal of lymphatic vessels and glands. The abdomen is opened usually through the left rectus, with the patient in the Trendelenburg position. After due examma- tion, the bowel above the growth is divided in a suitable position; the lower end is completely closed, whilst the upper has a Paul's tube tied into it, and i.^ fixed in the wound so as to form a permanent colostomy. The peritoneum of the mesentery of the distal segment is then divided on each side close to its parietal attachment, and the bowel with all the tissues behind it lying in the hollow of the sacrum is peeled downwards to the pelvic floor, care being taken to guard the ureters and main iliac vessels. The peritoneum of Douglas's pouch is then incised transversely, and the separated bowel and the tissues connected with it are pushed down below it, and covered over by suturing together the divided segments of peritoneum. The abdomen may then be closed, and the rest of the operation is con- ducted in the left lateral position as in the perineal procedure. After the bowel has been removed, the perineal wound may be entirely closed, special care being directed to securing together the divided segments of the levator ani. Whenever possible, it is desirable that this operation should be conducted by two surgeons working together, one from the abdomen, and one from the perineum; much time is thereby saved, and shock is minimized. Occasionally it is possible to avoid the formation of a colostomy by carrying the lower end of the divided sigmoid flexure downwards, and fixing the lower end in the perineum. £174 A MANUAL OF SURGF.RY The mortality after all these operations is high, reaching at least to 26 per cent. ; this is largely due to the grave risks of infection, and in a less degree to the severity of the i)rocediire. Perhaps the abdominal methods which include the formation of an artihcial anus have some advantage by reducing the chances of f cecal contamina- tion. The tendency to recurrence is also considerable, but even should this occur the recurrence is often less painful than the primary disease owing to the previous removal of the nerve terminals. Excision of the rectum is only practicable in a small percentage ot the cases of cancer which come under observation; usually the disease has progressed too far by the time that the patient is first seen by the surgeon. Practitioners and students ahke must be warned emphatically of the importance of making a thorough examination of the rectum in all cases where haemorrhage or dis- charge occurs, or persistent discomfort is complained of. As already stated, if the radical operation is not feasible, Colostomy is sometimes justifiable as a means of relief to the patient's symp- toms. Cases where excision cannot be attempted may be divided into two groups according to the character of the s\miptom3 — i.e., whether obstructive or irritative phenomena predominate. 1. When the main trouble arises from difficulty to the onward passage of the bowel contents, much benefit will be derived from an early colostomy, {a) It allows the patient to indulge in solid food, and thus assists in maintaining the general health; (b) it frees him from the pain arising from the passage of faeces over the ulcerated surface, but not from that due to the growth and traction of the tumour upon surroimding nerves; [c) it may possibly retard the growth of the disease b\^ eliminating the irritating action of the faeces; {d) it removes all chance of intestinal obstruction from the growth itself; and (e) it diminishes the absolute risk of the opeiation by undertaking it when the patient is comparatively well and hearty, and when there is no urgency. Formerly, when performed for ob- struction alone, the death-rate was about 30 or 40 per cent.; in an early iliac operation it is now practically nil, or at most 3 or 4 per cent. 2. In the ulceyalive type, where there is but little tendency to stenosis, colostomy will do but little good, as, although it may pre- vent faeces from irritating the surface of the growth, yet the dis- charge of muco-pus and blood will continue unchecked, causing tenesmus and constant calls to empty the bowel below the artificial opening. The additional attention required by the colostomy wound may make the patient's Hfe a burden to him. For details as to colostomy, see p. 1034. Should the patient refuse colostomy, or should it be contra- indicated, treatment consists in limiting the diet to such materials as strong broths, arrowroot, etc., with some stimulant, so as to 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 moiphia. CHAPTER XXXIX. SURGICAL AFFECTIONS OF THE KIDNEYS. The kidneys are placed on either side of the middle line, and extend from the eleventh rib above to midway between the last rib and the iliac chest below, the right kidney being somewhat lower than the left, owing to the presence of the liver. The hilum is situated opposite the spinous process of the first lumbar vertebra, and the upper ends of the organs are nearer to the spine than the lower. The kidnej^s may be exposed by two chief routes, viz., the lumbar and the abdominal. The Lumbar incision (Fig. 534, B) commences at a point corre- sponding to the outer border of the erector spinae, and ^ inch below the last rib, extending downwards and outwards in the direction of the fibres of the external oblique towards the anterior superior iliac spine. The posterior portions of the abdominal muscles and the fascia lumborum are divided seriatim, and the fatty tissue surrounding the kidney is thus easily reached and opened. Variations of the incision must be made to suit the particular requirements of the case. In the Abdominal operation the kidney is exposed from the front, either through the linea semilunaris or some other suitable incision ; the peritoneal cavity is opened or not, as may be thought necessary. If the peritoneum is opened, the colon is displaced inwards and held aside, as also the other intestines, by cloths soaked in warm salt solution ; the peritoneum covering the posterior abdominal wall is incised to the outer side of the colon, and the organ thus exposed. When, however, the kidney is enlarged, it is often unnecessary to Fig. 534. — Diagram to Lumbar Incisions ILLUSTRATE A, For lumbar colotomy; B, for expos- ing the kidney. 1 1 76 A MANUAL OF SURGERY open tlie peritoneal cavity, the colon and other peritoneal contents being displaced inwards. Examinationof the Kidney and its Function. — i. Manual examina- tion of tile kidney is mack' with the jiatient (ni the back, with the legs raised, the head supported by a pillow, and the mouth open. The surgeon, kneeling or standing at the side of the couch, places one hand under the loin and presses it upwards, whilst the other is gently but firmly pressed backwards in the lumbar region, especially during expiratory movements. Unnatural mobihty, enlargement, or dis- placement downwards of the organ, will be thereby detected, as also irregularities in outline or modification of tension. An enlarged kidney is recognised by the following general char- acters: A swelling is noticed in the loin, which is shaped more or less like the kidney, a notch being occasionally, though rarely, felt on the inner border, and the outer margin being rounded. The flank is always dull on percussion, the note remaining unaltered whatever the patient's position, and intestine never finding its way behind the tumour. The passage of the colon in front of the kidney not unfrequently gives rise to a band of resonance over its anterior surface; the bowel, however, soon gets pushed aside inwards by the growth of the tumour. On the right side it is not unusual for the renal dulness to be continuous with that due to the liver; there is always distinct resonance below and to the inner side of the mass towards the pelvis, thereby distinguishing it from a pelvic swelling. The mass moves slightly on respiration, though less distinctly than the liver or spleen. On the left side it has to be distinguished from an enlarged spleen ; the latter viscus hugs the anterior abdominal wall, and has no gut in front of it, whilst the loin is usually resonant. 2. The Existence and Functional Utility of a second kidney must be carefully investigated in any case where the removal of a diseased kidney is being considered, {a) The only safe test lies in securing a satisfactory specimen of the urine from the second kidney. This can best be effected by catheterization of the ureters, which has practically displaced all other methods. The bladder is carefully washed out and disinfected, and after putting lo ounces of clear water in it, a suitable cystoscope is introduced, with a catheter ready for insertion. Considerable practice is necessary in order to effect this quickly and satisfactorily, but it is a most valuable proceeding. (5) Separators of various types were employed before ureteral catheterism became common, and of these Luys' instru- ment (Fig. 535) was the most satisfactory. The bladder is first thoroughly irrigated, and the instrument introduced. The india- rubber septum is then drawn into place, and the urine collected from the two sides as it enters the bladder. To act effectively the curved end must be pressed well backwards against the posterior vesical wall, and the patient must be in the sitting position, (c) A small injection of methylene blue {vide infra) is given, and the passage of the discoloured urine from the ureter into the bladder watched SURGICAL AFFECTIOXS OF THE KIDXEYS 1177 by means of the cystoscope. {d) It is sometimes necessary to remove a kidney during an operation when a previous thorough examina- tion has not been practicable. In such a case the only safe pro- ceeding is to open the peritoneal cavity and pass the hand across and palpate the opposite organ, not only noticing its size and shape, but also the condition of the pelvis and the renal vessels. Although the organ may be defectiv^e in function, the surgeon by observing such a precaution will be preserved from the tragedy of removing the onl}- available kidney. 3. The Activity of the Renal Function for both kidneys or for each separatel}- can be estimated by a number of methods, of which, however, one can only give the briefest notice here.* (i.) Ihe Fig. 535. -LuYs' Segregator in Position for Collecting Separately THE Urine escaping from the Two Ureters. The indiarubber septum can be seen stretching across the bladder cavity, and the curved beak fits down firmly into the ' bas fond ' of the bladder, so that the urine will at once pass into the openings on either side of the septum, and so up to the collecting glasses. The screw-head of the instru- ment controls the septum, which is, of course, only stretched into position after the introduction of the instrument. Methylene-hliie test is based on the fact that when a solution of this substance is injected into a muscle, it is absorbed into the blood as a colourless product, but is eliminated both in the bile and urine. In the latter, part of it appears as a blue or bluish-green colouring matter, part as a colourless product (chromogen), which can be made apparent by boiling with acetic acid. If 5 minims of a 10 per cent, solution is injected into a healthy person, chromogen appears in fifteen minutes, and the blue colour in the excretion is at its maximum in four or five hours, remains stationary for a few hours, and then gradually decreases; about half of the methylene blue is ehminated in twenty-four hours, but it is often five or seven days before it disappears entirely. In disease of the kidney's involving * For fuller details, see Thomson Walker's Hunterian Lectures on ' The Renal Function in Health and Disease,' Lancet, March 16 and 23, 1907. 117^ A MANUAL OP SURGlUiV defective function the elimination of this substance is kite in appear- ing and prolonged beyond the normal period. This, of course, can be estimated for each kidney separately by catheterism of the ureters, (ii.) The Phloridzin test. If lo' minims of a solution of phlorid/in (i in 200) are injected beneath the skin, sugar appears in the urine of a healthy person in fifteen to twenty minutes, and the glycosuria lasts for two to three hours, the total output of sugar being between i and 2 '50 grammes. Where the function of the kidney's is defective, the amount eliminated is much diminished, or it may be entirely absent. Diminution in or loss of the functional activity of the kidneys results in an accumulation of toxic products of varying characters in the blood, which leads sooner or later to the development of a condition of Uraemia, which ma}' have a gradual or sudden onset, and be represented by a multiplicity of varying symptoms. Head- ache, vomiting and convulsions, are probably the most characteristic features, but there are many other suggestive manifestations, such as delirium, vai'lous paralyses, asthmatic attacks, etc. In con- sidering the advisability of operating on man}? renal conditions, the possibility of the development of an acutely fatal attack of uraemia as the result of the anaesthetic must be kept in mind, and a careful examination of the urine made. In every renal case the daily output of urine and its specific gravity should always he noted ; a persistent low specific gravity (loio) and a defective urea-content are always danger-signals. The amount of urine passed apart from a know- ledge of its specific gravity is no guarantee of the efficiency of the renal secretion. 4. A thorough Examination of the Urine, chemical, microscopical, and bacteriological, is essential in all conditions aftecting the urinary organs, and particularly in affections of the kidney. In the majority of cases the chemical test limits itself to ascertaining whether or not albumen or sugar is present. Albuminuria, or the escape of some of the albuminous contents of the blood with the urine, is a condition of such frequent occurrence, and so important in its results, that the precaution should always be adopted of testing the urine of every patient before undertaking any operative proceedings ; and this is the more essential because it is well known that this condition often exists t]uite vmexpectedly and entirely apart from symptoms. Tests. — Many different methods have been adopted for detecting the presence of albuminuria. The following are, however, the chief: (i) On simply boiling the urine a milky white deposit forms similar to that which is caused by an excess of phosphates ; the latter, however, disappears entirely on the addition of a single drop of dilute acetic acid, whilst the former persists or increases. (2) Nitric acid gives a white cloud or light brown flocculent precipitate. The urine should first be boiled and the acid added, but not in excess, as the deposit may be re-dissolved. A more delicate test consists in pour- ing the cold urine into a test-tube, and cprefully adding the acid so SURGICAL .lI'/'/'CTfOMS OF I'lli: KIDMF.YS ii;9 as to form a stratum below t\\v urine; at the line of junction of the two. a white film is formed, if albumen is present. (3) With picric acid a yoUowish-white precipitate is thrown down, increased by boihn^t^. If the urine is neutral or alkaline, it must first be rendered shglitly acid by the addition of a few drops of acetic acid. \\'hen()nce the existence of albumen in the urine has been ascer- tamed, its source and its significance must be investigated. A careuil microscopical examination of the sediment is made, so as to determine whether casts or pus cells are present The condition of the peripheral bloodvessels in the limbs and the character of the pulse should be noted, as also the previous history of the patient. Albuminuria arises from a variety of sources, and its significance necessarily turns on the origin of the affection, (i) When it is associated with long-stanchng suppuration, as in diseases of bones or joints, it is probably due to lardaceous change in the kidneys. If the urine is of low specific gravity, and light in colour, and with but few casts, only an early stage of the condition is present, and conservative measures directed to the treatment of the primary lesion will probably suffice; if, however, the urine is scanty and of high specific gravity with much albumen and many casts, the affection has probably progressed, some way, and radical treatment, such as amputation, should be undertaken to save the patient's life. The surgeon must be careful to prevent any undue absorption of carbolic acid in the operation, as thereby acute nephritis may be lighted up, and even a fatal issue determined. (2) Albuminuria may be inter- mittent (cyclical) , and is then due to some temporary "functional disturbance ; this can only be ascertained by testing the urine from time to time. In such cases operation is not contra-indicated, the albumen usually disappearing with rest and careful diet. (3) When caused by chronic Bright 's disease, the concurrent phenomena of that affection will also be present in the shape of thickened arteries and high pulse tension, whilst possibly a certain amount of anasarca may be noted, or the history of such at an earlier date. If there is but little albumen, and a fair amount of urea is being passed, it is possible by rest and suitable diet so to diminish it as to warrant the performance of slight operations ; but where the condition is at all advanced, all opemtions de complaisance are absolutely contra- indicated, and only the chief surgical emergencies should 'be know- ingly dealt with, viz., haemorrhage, asphyxia, grave intraperi- toneal lesions, and retention of urine. In severe injuries, amputa- tion is generally indicated under circumstances where in a healthy individual conservative measures would be adopted. Operation for malignant disease may be undertaken at the request of the patient if the increased risks have been explained to him. The risk depends on the facts that such patients tolerate an anesthetic badlv, that the tissues are in a condition of lowered vitality, and hence the process of repair is hindered ; infective inflammations and erysipelas are very prone to develop, whilst secondary hsemorrhage is predis- posed to by the high pulse tension. Again, boils and carbuncle^ ii8o A MANUAL OF SURGERY are very common in these patients, and where such conditions are met with, and especially if they recur, the urine should always be examined. (4) Albuminuria may arise by extension of inflamma- tion to the kidneys from surgical affections of the lower urinary organs, and a fatal result from shock or suppression of urine may follow an operation under these conditions. (5) It is sometimes the result of cardiac disease, owing to valvular incompetence and regurgitation into the systemic veins, and it is then advisable to delay all operative measures until suitable treatment has relieved the urgent s^-mptoms. Glycosuria and Diabetes are alike characterized by the presence in the urine of sugar (glucose), but whilst the former may be tem- porary and of comparatively little significance, the latter is generally permanent and due to disease of the pancreas. The mere existence of sugar in the urine is not nowadays looked on as an absolute contra- indication to operative treatment, as was the case formerly, and yet the urine of all patients requiring operation should always be examined as a routine preliminary in order to ascertain whether or not it is present. The chief tests employed are as follows: (i) Equal parts of liquor potassae and solution of copper sulphate are boiled together, and then a few drops of the suspected urine added; if sugar is present, a yellowish-red precipitate forms by the reduction of the cupric salt to cuprous oxide. (2) The same result follows the use of Fehling's solution. It is better to keep the copper solution separate from the potash; equal parts of them are boiled together, and a few drops of the urine added; if sugar is present, a red deposit occurs. (3) Picric acid and liquor potassae are mixed and boiled, and the urine added; the presence of sugar is indicated by the solution turning to a dark, blackish-red colour. The admix- ture of 2 grains of sugar to the ounce is sufficient to determine this discoloration to such an extent as to render the fluid quite opaque. Simple Glycosuria arises from many different conditions, included amongst which may be mentioned an excess of carbohvdrates and of fatty or sweet things in the dietary, the liver being unable to store them away, hepatic disturbances of various types, and injuries or diseases of the medulla or upper part of the cord. An interesting form of glycosuria occurs in some infective conditions of the t37pe of cellulitis (boils, carbuncles, etc.), where the presence of glucose in the urine appears to be secondary, and disappearance quicklv follows effective operative treatment. The explanation of this condition is not at all obvious. True diabetes is now generally considered to be due to lesions of the pancreas . Experimentally, total removal of the gland in animals is followed by diabetes, and in man clinical research has demon- strated that certain types of chronic pancreatitis, in which degenera- tion or destruction occurs of the curious cellular bodies known as the Islands of Langerhans, are associated with diabetic phenomena. These islands are supposed to form the internal secretion of the gland, a ferment upon the activity of which the glycogenic function SURGICAL AFFECTIONS OF THE KIDNEYS 1181 of the liver depends. In the vast majority of the accredited cases of diabetes lesions of the pancreas are demonstrable, and the con- dition is often improved by hydrotherapy and measures directed to relieving hepatic engorgement. It is quite reasonable to consider seriously, in all cases of diabetes, the question of exploring the bihary and pancreatic passages with a view to remove calculi, or relieve congestion by temporary drainage. Although the condition may not be absolutely cured, yet great benetit has frequently resulted. In simple glycosuria limitation of diet for a few days and rest in bed, with some attention to the activity of the Hver and of the bowels, will frequently cause a diminution in the excretion of sugar, and under such circumstances a surgeon need not hesitate to perform ordinary operations. But if the sugar persists in spite of such treatment, and there is reason to suspect that the case is one of true pancreatic diabetes, operations must be undertaken very cautiously. The tissues are always in a condition of lowered vitality, so that infection readily occurs, as indicated by the frequency of such con- ditions as boils, carbuncles, and infective gangrene of the extremities. In old-standing cases, peripheral neuritis and sclerosis of the smaller vessels are induced, and gangrene is not an uncommon sequela (p. 117). It is therefore obvious that operative proceedings should not be resorted to unless they are absolutely necessary ; but, unless the case has progressed very'' far, there is no reason why necessary operations should not be performed, granted that the most rigid care is taken as to the maintenance of asepsis. Thus several cases have been reported 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. One of the chief dangers of neglected or serious diabetes is the supervention of Diabetic Coma, which may develop without apparent reason, or be lighted up by some septic compHcation, or the operative treatment required for the same, especially if a general anaesthetic is given. The patient becomes apathetic, and finally dies in a condi- tion of coma ; his breath smells of acetone, and the blood is defective in its alkalinity. The explanation of this is as follows : in diabetes there is always an excessive production of acid in the body^mainly i8-oxybutyric acid — which in health is either not formed, or is oxidized to CO2 and HgO. In this disease it is excreted in com- bination with alkalies, mainly with the ammonium which is normally formed into and removed from the body as urea. The sodium and potassium of the blood are also called on to neutralize it, and even calcium or magnesium mav be dissolved from the bones. The blood therefore suffers in its alkahnity; the carbonic acid is no longer carried to the lungs, and consequently dyspnoea, with or without cyanosis, mav result. Diacetic acid is also formed, especially just before coma "occurs. It arises by oxidation of the /3-oxybutyric acid, and breaks up in its turn into acetone and carbolic acid. Its presence can be demonstrated in the urine by the addition of ferric chloride, when a claret colour appears ; if the urine is subsequently 1 1 82 A MANUAL OF SURGERY boiled, this discoloration disappears (p. 1346). Naturally the presence of this acid in the urine of a diabetic patient is a danger signal, warning the surgeon that coma is not far distant, and that general anaesthetics must be avoided. Large doses of sodium bi- carbonate given by mouth or rectum, or even by intravenous infusion, may be of use in checking the progress of this condition. For the influence of diabetes and albuminuria in the choice of an anaesthetic, see pp. 1345 and 1354. Hsematuria, or the admixture of blood with the urine, is a frequent symptom in diseases of any part of the urinary track, and it is some- times a little difficult to ascertain the exact source from which the blood is derived. ((?) Renal hxma.tnna results from acute inflammation, congestion, calculus, tumours, or injuries of the kidney. The urine is sometimes deeply coloured with the blood, and may be as dark as porter. Blood-casts of the renal tubules are often observed, and even long sinuous clots, corresponding to the shape of the ureter. {b) Vesical hsematuria is due to injury, calculus, tumours, ulcera- tion, simple congestion of the bladder with varicosity of the vesical veins, or the presence of the Bilharzia hcematohia.^ The blood is intimately mixed with the urine, but is more abundant at the end of micturition, and clots are often present. The Bilharzia is a parasite which inhabits some of the rivers and pools of South Africa. It is taken into the system by the mouth, and may develop either in the urinary track, or sometimes in the k)wer bowel (p. 1148). The adult worms are found in the body inhabiting the radicals of the portal and vesical veins, and discharge their ova through the mucous membrane of the bowel or bladder, giving rise to haemorrhage. By an extension to the kidney, pyone- phrosis may be induced. No specific treatment has at present been discovered, but in most cases the disease after a time disappears spontaneously. Microscopic examination reveals the presence in the urine of the characteristic ova — ovoid bodies with a terminal spike. (c) Prostatic hematuria may be caused bv congestion, calculus, ulceration, or malignant disease, or especially by the passage of a catheter or bougie used in the diagnosis or treatment of any of these conditions. The blood may pass back into the bladder, and hence the phenomena simulate the vesical condition, but frequently it escapes from the urethra, particularly if due to traumatism. Ex- amination of the prostate from tfle rectimi may, however, give a clue to the source of the mischief: ' {d) Urethral haematuria arises. from acute gonorrhoea, laceration, or instrumentation. The blood often flows from the urethra inde- pendently of micturition, whilst the first few drops of the stream are also coloured. [e) Haematuria is occasionally oi constitutional origin, arising from purpura, scurvy, or haemophilia; other manifestations of these diseases will be observed, and render the diagnosis evident. SURGICAL AFFECTIONS OF THE KIDNEYS 1183 lAIicroscopical examination of the urine should always be made to ascertain whether or not blood-corpuscles are present, since the condition may be simulated by that known as ' paroxysmal hamo- globnuiria,' in which corpuscles are absent. The latter condition is supposed to be due to vaso-motor spasm of the renal arterioles, and is not uncommonly associated with Raynaud's disease. The only certain test for the presence of blood is by spectrum analysis ; but that most usually relied on consists in mixing together equal parts of tincture of guaiacum and ozonic ether. The sus- pected urine is subsequently added, and sinks to the bottom of the test-glass; a copious precipitate forms at the hue of junction of the two fluids, which on standing becomes a bright blue colour if blood is present. The investigation of a case of hsematuria in order to ascertain its origin should be conducted in the following way: [a] The history of the patient and of his urinary trouble should be taken, {b) The character of the urine should be investigated, noting its colour, and whether or not the blood is intimately mixed with it. (c) The relation of the passage of the blood to the act of micturition should be noted by making the patient pass the first and last portions of the urine into separate vessels from that in which he passes the bulk; if the urine in all three vessels is equally discoloured, the haemorrhage usually comes from the kidneys ; if most of the blood is in the first vessel, it comes from the urethra or prostate, whilst if the bulk of it is contained in the last vessel, it is probably derived from the bladder. (d) Microscopical examination of the urine may lead to the discovery of shreds of tumour, epitheHal cells, or blood-casts, which could be alone derived from some special part of the urinarv track. By these means the source of the haemorrhage, whether from kidney, bladder, prostate, or urethra, may be detected, and an opinion formed as to the nature of the disease. Pyuria is the term appHed to the admixture of pus or muco-pus with the urine. It always results from inflammatory affections of the mucous membrane lining the urinary passages, and may be renal, vesical, prostatic, or urethral in origin; the methods of investigation, in order to ascertain its exact source, are the same as for hagmaturia. Pus in urine is mainly recognised by the microscope, whilst- on the addition of liquor potassse it becomes ropy. Chyluria arises from distension or rupture of the lymphatic vessels in the \-esical mucous membrane, and is usually due to the presence of the Filaria sanguinis hominis (p. 361). The urine is milky in colour, and on microscopical examination this is found to be due to the presence of an emulsion of fat. Urinary Deposits of various kinds are of frequent occurrence, and require for their investigation both chemical and microscopic examination. Uric or lithic acid is eliminated in the form of ' cayenne-pepper ' granules, usually known as gravel. On micro- scopic examination, the granules are found to consist of flat rhom- boidal, lozenge-shaped plates, or masses of acicular crystals 1 1 84 A MANUAL OF SURGERY (Fig. 536). They are of a dusky brownish-red colour, due to the absorption of urobilin, the normal pigment of the urine. The secre- tion in these cases is always acid, and usually of high specific gravity. The deposit is not soluble in boiling water, but readily so in alkaline fluids; and on re-acidulating such a solution, the uric acid is precipitated in the shape of white needle-shaped crystals. Urates or lithates of potassium, sodium, or ammonium are of fre- quent occurrence in the urine, appearing as a deposit of amorphous granules of variable colour, according to the amount of urinary pig- ment present, and this is often known as a ' lateritious,' or brick-dust sediment. The ammonium salt is sometimes found in the shape of spiculated globular bodies (Fig. 537). Urates always occur in acid urine of high specific gravity, and are freely soluble in boiling water; on the addition of dilute hydrochloric acid the uric acid is precipi- tated. The murexide test may be applied for either uric acid or its salts; it consists in mixing the substance to be tested with a little Fig. 536. — Uric Acid Crystals. Fig. 537. — Urate of Ammonium IN Amorphous Granules and Hedgehog-shaped Bodies. nitric acid, and evaporating to dryness, when an orange-red dis- colouration is produced, which on the addition of liquor ammoniae 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 a pheno- menon constantly recurring and due to too great an indulgence in nitrogenous food, too little fresh air and exercise, or imperfect diges- tion, the result of some hepatic disturbance. It is also noted in con- ditions where great tissue change is occurring, as after violent exer- cise 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 present, the patient is said to be suffering from Lithiasis or Lithsemia. Should the material thus formed not be eliminated, an attack of gout is hkely to super- vene, 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 is to be prevented. The Treatment of lithaemia or lithiasis consists mainly in attention SURGICAL AFFECTIONS OF THE KIDNEYS 1185 to the personal hygiene. The patient's diet is regulated, all sweets, pastry, and alcoholic stimulants (with the exception, perhaps, of a little whisky well diluted with lithia or potash water) being avoided. Fish and poultry are permitted, but butcher's meat is forbidden. Regular habits are enforced, and plenty of outdoor exercise recom- mended. The hepatic secretion is stimulated, and the bowels regu- lated by the administration of saline purgatives, especially natural mineral waters [e.g., Friedrichshall, Carlsbad, or Hunyadi Janos), whilst an occasional dose of blue pill or podophyllin is advisable. Lithia salts and piperazine have also been employed with advantage. A course of treatment at a recognised spa is most useful in these cases. Oxalate of lime usually occurs in the urine of dyspeptic and hypo- chondriacal patients, who are pale, nervous, and irritable. It is "sup- posed to arise from the incomplete oxidation of carbohydrate foods. The urine is of low specific gravity, pale and abundant in quantity, and slightly acid in reaction; an excess of mucus is usually present, causing the crystals to adhere to any irregularities in a test-glass. Fig. 537A. — Oxalate OF Lime IN Octahedral Crystals and Dumb-bell-shaped Masses. Fig. 53S. — Crystals of Triple Phos- phate IN Urine. On microscopic examination they are found to be regular octahedra, or in|the shape of dumb-bells (Fig. 537 a). The treatment of oxaluria consists in regulation of the diet, which must be light and nourishing, all heavy food being avoided, as also rhubarb, which contains large quantities of oxalates, and the patient is directed to drink only boiled or distilled water. Tonics, such as mineral acids, iron, and quinine, ma}' be ordered, but the best treatment consists in change of air and removal, if possible, from causes of anxiety- and worr\'. Phospkatic deposits in the urine occur in three forms : (i.) The triple, or ammonio-magnesic, phosphate is found in alkaline or decom- posing urine, and is alwaj's vesical in origin. It exists in the form of hexagonal prisms, three of the sides, however, being very narrow; the ends also are bevelled off, so that the appearance of a ' knife-rest ' is produced (Fig. 538). (ii.) The amorphous phosphate of lime is exceedingly common, forming the main mass of any phosphatic sediment. It is always present in chronic cystitis, and is not unfre- quently met with a few hours after a meal, constituting what is known as the ' alkaline tide. ' This condition is often observed about twelve o'clock in the morning, especially if ari alkaline saline purga- 75 1 1 86 A MANUAL. OF SURGERY tive lias been taken before breakfast, llie plios])hatic material is voided at the end of the act of micturition, and may give rise to considerable anxiety 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. \\'hichever form is present, the deposit becomes more evident on boiling, disappearing, however, on the addition of a few drops of acetic acid. The treatment of phosphaturia is always directed to the vesical condition, except in those unusual cases where it is due to some constitutional error. A bacteriological examination of the urine has often to be made in order to make sure of the diagnosis of a case. Bacteria may find their way into the urinary passages through the kidneys, or gain an entrance to the bladder per urethram, and thence spread up the ureters, or may obtain a foothold in some part of the walls of the urinary track and thence become disseminated. Sometimes they are present in great abundance, and render the urine opalescent to the naked eye (bacilluria), but have little or no effect upon the lining walls. Care in diagnosis must be taken to ensure that the sample examined has not been contaminated by passage through the external organs ; this is especially needful in women, and, indeed, no bacteriological examination of the urine of a woman is of any value which has not been secured by aseptic catheterism. Bacilluria is a condition of frequent occurrence in women, and the Bacillus coli is the organism most often present. In some conditions the number of bacteria present is so small that they can only be found on a careful search after straining the centrifugahzed deposit from the urine — e.g., the B. tuberculosis in various tuberculous affections of the kidney or bladder; it is sometimes impossible to find them microscopically, and then inoculation experiments with the deposit must be under- taken. 5. Finally, a radiographic examination of the kidnej^s and ureters is often necessary in order to ascertain whether anything in the form of a calculus is present. The use of a soft tube will often enable the lower pole of a normal kidney to be detected ; still more obvious does the same part of an abnormally enlarged organ appear, especially if the seat of chronic inflammatory trouble or of a malignant tumour. There is now not much difficulty in making certain of the presence or absence of a stone in the kidney or ureter, although the per- meability to the rays of a pure uric acid calculus still renders mistakes possible. A large stone of this character held in the hand in front of the screen cast no shadow deeper than the muscles of the thenar eminence. Oxalate calculi, or those formed of phosphates, cystine, or of a mixed composition, ought in all cases to be demonstrable, and their number, site, and position ascertainable. The differential diagnosis of the shadows of calculi from those produced by other conditions which may appear on the plates has been rendered easier by the more perfect detail which can now be SURGICAL AFFECTIONS OF THE KIDNEYS 1187 obtained in the radiogram. In most cases it is possible to show the outhne of the kidney, as well as the stones contained in it (Fig. 542), and one can thus eliminate the shadows produced by calcified mesenteric glands, bowel contents, or appendicular concretions (Fig. 495). Gall-stones as a rule cast no shadow, but occasionally some abnormal change in the gall-stone makes it visible, and this may lead to a mistake in diagnosis. The positi\'e diagnosis of ureteral calculi (Fig. 543) is sometimes more difficult, as they have to be distinguished from phleboliths, calcified pelvic glands, appendicular concretions, bowel contents, calcified appendices epiploicse, and calcified uterine fibroids, whether pedunculated or sessile. It may be necessary to pass an opaque bougie up the ureter and repeat the examination before a diagnosis can be made. Pel\-ic glands are nearly always circular and frequently multiple, although it is not uncommon to find a single calcified gland opposite and internal to the ilio-pectineal eminence on one or both sides. Calcified inguinal glands are easily recognised by their superficial position on stereoscopic examination. Bowel contents are excluded by repeating the examination after effective purgation, and, indeed, this is a course which should always be followed except in cases which are absolutely characteristic. Calcified fibroids simu- lating ureteral or vesical calculi can generally be detected on clinical examination. The details of radiographic methods for ensuring good results cannot be entered into here, as they are too specifically technical; but one may note that the first essential to success is the effective preparation of the patient, and the second complete immobilization of the area of examination. A general ^^ew, including both loins and the upper ureteral regions, should first be taken, and sub- sequently the affected side should be more carefully examined through some form of diaphragm to limit the diffusion of the rays. The preparation of the patient for the examination is of great importance, especially in one of heav}' build. The intestine must be empty in order to get good results, and the patient should, if possible, be kept on light diet for some days previously. A course of purgation for two or three days, followed by a long-tube enema on the morning of the examination before the patient has had any food, is the ideal preparation. In addition to calculi, the X-rays are capable of demonstrating the existence of calcified caseous deposits in old-standing tuberculous kidneys, and by injecting some 10 per cent, collargol up the ureter through an ureteral catheter, and subsequently X-raying the side, it is possible to demonstrate the size and shape of the pelvis of the kidney. Congenital Affections of the Kidney.- — Many different malforma- tions and displacements are met with affecting this organ. The chief Malformations are as follows: (i) Complete absence of one organ, a very rare condition. (2) Congenital atrophy of one kidney; it being represented by a mass of fatty tissue. In both [1 88 A MANUAL OF SURGERY cases the other kidney is correspondingly enlarged and hypertro- phied. (3) The kidneys may be fused together, either forming one large organ in the median line and more or Kss normal in shape, or sometimes constituting the so-called horseshoe kidney, the con- vexity being directed downwards. The latter condition is not very uncommon, being present once in about 1,100 bodies examined; it is usually associated with an increased number of ureters or renal vessels. (4) Deep lobulation of the kidney, as in some animals, is occasionally seen, especially if the organ is displaced; this may be carried to such an extent as to divide it into two or more portions. (5) The ureter and pelvis may be double, this malformation affecting the pelvis alone, or extending as far as the bladder. (6) 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 some 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 light of the middle hue. 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 turn be described below. Floating and Moveable Kidney. — The normal kidney is not a fixed organ, but moves up and down on respiration, although usually this movement cannot be detected on palpation. It is therefore neces- sary to define as precisely as possible what is meant clinically by the terms ' moveable ' and ' floating ' kidney. Three stages of abnormal mobility may be described: (i.) A palpable kidney is one the lower half or more of which can be definitely felt on deep inspiration, (ii.) A moveable kidney is one in which the examining hand can define the upper end of the organ, and can restrain it from returning to its old position during expiration, (iii.) A floating kidney is one which can be moved freely about the abdomen in all directions, and even across the middle line in some cases. Formerly this last term was applied to a supposed congenital lesion, in which the kidney was attached to the posterior abdominal wall by means of a mesentery; it is more than doubtful whether such a condition exists. In the earlier stages the movements occur within the fatty capsule which surrounds the organ, but later on mild attacks of inflammation attach the fatty to the fibrous capsule, and the kidney with its associated fatty envelope moves behind the peritoneum. Two forms of movement are possible: (i.) An up-and-dowai or in-and-out move- ment in one plane {cinder-sifting movement), the kidney merely swinging on its pedicle; or (ii.) a movement of torsion may accom- pany this, either round a transverse axis when the lower end of SURGICAL AFFECTIONS OF THE KIDNEYS 1189 the kidney becomes prominent, or round a vertical axis when the outer convex border swings forwards. In the latter case kinking of the ureter or renal vessels is very likely to ensue. Mo\-eable kidney occurs more frequently in women than in men (10 to i), and more often on the right than on the left side (12 or 13 to i), partly because the renal vessels are longer on this side than on the other, and parth" because the descending colon is more fixed than the ascending. Causes. — -The kidney is placed between the layers of the peri- nephric fascia, which in turn are derived from a splitting of the fascia transversalis. In children this perinephric capsule is attached closely to the kidney front and back without any intervening fat; but as development proceeds, fat is packed in around the kidney in increasing amount, and hence in stout subjects the perinephric capsule is considerably distended, and the kidney is firmly supported. In addition to this, however, the tension of the peritoneimi, the main- tenance of the intra-abdominal pressure, and the support of the muscular abdominal parietes, have much to do in keeping it in place. Anj-thing that seriously modifies these three factors may lead to displacement and mobihty" of the organ. Parturition accounts for some cases; firstty, because of the sudden diminution of the intra-abdominal pressure, and, secondly, owing to the resulting pendulous and relaxed state of the abdominal muscles, especially if the patient too early resumes the erect posture, or undertakes physical work without efficient external support; hence it is more frequent among the poor than amongst the rich. It may also follow the removal of large abdominal tumours which stretch the abdominal w^alls, or rapid emaciation, whereby the perinephric fat is absorbed, whilst tight-lacing or traumatic influences may be responsible for some cases. It is frequently associated with that form of displace- ment downwards of the abdominal viscera w^hich is known as Glenard's disease, or enteroptosis (p. 1028). Constipation is an im- portant element in the production of moveable kidney, and probably acts by the loaded csecum dragging upon the anterior layers of the perinephric fascia, and thus displacing it forwards. Symptoms. — A moveable kidney is often discovered by accident, and may be entirely free from s\aTiptoms. In some cases the patient comes under observation because she has observed a moveable lump in the abdomen, which on handling is painful, the pain being often associated with nausea and vomiting. In other cases, pain and vomiting bring the patient under observation, the doctor discovering the moveable kidney. The pain is referred to the back, or perhaps shoots along the ureter to the groin, testis, or labium, majus. Vomiting is a significant sign, and the surgeon should never omit to examine the loins in cases of obstinate vomiting with no apparent cause. Periodical exacerbations of these symptoms, with a tem- porary diminution in the amount of urine, result from kinking of the ureter {Dietl's crises) ; sudden relief, followed by an increased flow of urine, possibly containing some muco-pus, indicates that the organ 1 1 go A MANUAL OF SURGERY has returned to its normal situation. Repeated attacks of this type may result in pyelitis and hydronephrosis. On examining the abdomen, a moveable tumour can often be observed with ease if the abdominal parietes are not loaded with fat, and on manipulation pain and vomiting may be induced. The adoption of the genu- pectoral position will sometimes enable a moveable kidney tr be more certainly felt, whilst a distinct loss of resistance is noticed external to the erector spiucC on the affected side. The patient is usually of a neurotic t^^pe, but possibly this may result in part from the mobility of the organ which necessarily involves a certain amount of traction upon the sympathetic centres in the abdomen. Evidence of the displacement of other abdominal viscera is often found, so that the detection of a moveable kidney does not necessarily explain the whole case, or indicate operation. After many an operation for moveable kidney, the symptoms (pain, vomiting, etc.) have persisted, even though the organ remained anchored to the abdominal wall. Treatment. — In the great majority of cases of moveable kidney operation is not required, and, indeed, it is usually unwise to tell the patient that such a condition is present. If it is associated with marked debility, bodily or nervous, and perhaps with general enteroptosis, a rest-cure in bed for six weeks, with abdominal and general massage and an abundance of milk and fatty foods, will do much to steady the kidney and improve the general condition. The application of a carefully-fitted kidney support will then suffice to keep her comfortable. This may consist of an abdominal truss, with an end shaped like a cup to fit over the kidney, or of an air- cushion fitted into an abdominal belt. The cushion should be triangular in shape, its sides corresponding to the costal border, Poupart's ligament, and the linea semilunaris; it is put on in the recumbent posture, and for choice with the pelvis raised. The indications for operation are — (i) Extreme mobility, so that the organ cannot be fixed by a support; (2) extreme tenderness, so that a support cannot be tolerated ; (3) the recurrence of acute attacks of pain and vomiting (Dietl's crises) ; (4) persistent discomfort in the loin, combined with dyspeptic symptoms, vomiting, and a great variety of neurasthenic manifestations : as a rule a kidney sufficiently mobile to produce such symptoms is tender to the touch, and examination causes pain and nausea; and (5) the supervention of hydronephrosis or pyelitis. Nephrorrhaphy 01 Nephropexy is the name applied to the operation for fixing the kidney. It is obvious that a rounded body like the kidney with a smooth fibrous capsule is not easily fixed, and the more so since the renal parenchyma has great absorbent power, so that sutures, even of silk, passed through its substance are readily disintegrated and absorbed; hence, although the kidney may seem to be efficiently immobilized at the completion of the operation, it readily becomes loose again. There are only two certain methods of fixing the organ, (i.) The wound down to the kidney is left open SURGICAL AFFECTIONS OF THE KIDNEYS 1191 and jxickeid with gauze, so that heahng occurs by granulation; the cure is certain, but tedious, and a lumbar hernia may follow, (ii.) The plan now usually adopted is to expose the organ through the loin. The fatty covering is opened, and as much of it as possible removed. A portion of the true fibrous capsule is now dissected up and fixed to the abdominal parietes so as to expose the raw and slightly bleeding cortex. Many methods of dealing with the capsule have been suggested, but it matters little which is employed. The follow- ing plan suggested by Mr. W. Billington, of Birmingham,* has been extensively tested, and gives excellent results. A lateral incision is employed, extending from just above the last rib almost vertically down to the crista ilii; the muscles are divided; the last dorsal nerve is retracted and protected; and the kidney in its fatty capsule ex- posed and cleared. The upper half of the fibrous capsule is then dissected up from the posterior surface and carried round the last rib to serve as a sling to the kidney; the apex of this flap is secured to its own base. Two silkworm-gut stitches are passed under the capsule of the lower half of the organ in a semicircular fashion, and carried through the muscles and skin at the upper angle of the incision, being finally tied over a pad of gauze and retained in situ for three weeks. The wound is then closed in the usual way, and dressed, special care being taken to exercise pressure over the right iliac fossa below the kidney by a suitable pad of sterilized wool. The organ is thus firmly fixed, but it is wise to keep the patient in bed for four or five weeks subsequently, to allow of consolidation, and afterwards a binder or belt should be worn for a time. Injuries of the Kidney are usually due to crushes of the body, as between the buffers of railway cars, or when a cart passes over the abdomen, or from blows or falls. Considerable haemorrhage follows, both into the substance of the kidney or its pelvis, and into the peri- nephric fatty tissue, and this even when the capsule has not been torn. The integrity of this structure is a point of great impoi"tance, since it limits to some extent the bleeding and prevents urinary extravasation; the kidney may be crushed to a pulp without any external hsemorrhage, and under these circumstances clots are likely to pass down the ureter, and may obstruct it and lead to its subse- quent occlusion. When the anterior portion of the capsule is torn, the peritoneum may also be involved, especially in children, and then evidences of intraperitoneal bleeding may manifest themselves, and, indeed, if the kidney is extensively lacerated, fatal haemorrhage may result, though this is unusual. Rupture of the posterior surface of the kidney opens up the perinephric cellular tissue, which becomes infiltrated 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. Not unfrequently other severe injuries are present, such as fracture of the pelvis, spine, or skull, bruising or tearing of intestine or liver, and from these associated lesions serious phenomena may arise. * British Medical Journal, November 30, 1907. 1 192 A MANUAL OF SURGERY The Symptoms consist in severe shock, followed by nausea, vomit- ing, pain in the loin, shooting down into the testis or thigh, localized tenderness and perhaps swelling over the injured organ, and haema- turia. The amount of blood lost in this way varies considerably ; in the slighter cases the haematuria 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 secre- tion on the affected side. The bladder may in some cases become greatly distended with clots, the blood coagulating after it has entered the viscus. Haemorrhage into the perinephric tissues is indicated by the formation of a swelling in the loin, and laceration of the peri- toneum is followed by distension of the abdomen, increasing anaemia from persisting haemorrhage, and the onset of peritonitis. The development of a perinephritic abscess is recognised by fever, rigors, increased pain in the loin, and the usual phenomena of deep sup- puration (p. 1200). The Treatment usually required is to keep the patient quiet in bed, with an icebag or Leiter's tubes applied to the loin; pain may be relieved by strapping the side or by applying a firm bandage. Per- sistent 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, the sutures being passed deeply through the glandular tissue. Some- times the blood does not escape externally, and then the rapid de- velopment of a swelling in the loin, with increasing anaemia and rapidity of pulse-rate, would indicate that operation is desirable. Distension 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 its condition. Rupture of the Ureter is a rare accident, usually due to direct violence, but occasional^ happening during pelvic operations, such as removal of the uterus. When the result of a subcutaneous injury, it cannot be recognised at once, but extravasation of urine takes place, leading to 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 undertaken the better. In a few favourable cases it has been possible to suture the rent in the ureter by the following plan: The lower end of the divided ureter is closed, the exposed mucous membrane being tucked in by sutures passing through the muscular coat ; the upper end is then implanted SURGICAL AFFECTIONS OF THE KIDNEYS ii93 into a longitudinal opening made in the side of the lower segment, and accurately stitched in position. Two cases probably of this natui'e came under treatment at hospital. Both occurred in young boys, and both were due to cab accidents. In the first, alter the preliminary shock had passed off, nothing special was noted for about ten days, when on sitting up sharp pain was experienced in the side, and this was followed by a retroperitoneal collection of fluid, together with some amount of fever. On incision a large quantity of limpid urine escaped, with but very little pus — an interesting illustration of the fact that healthy urine does com- paratively little damage to tissues into which it is extravasated . The finger introduced into the wound passed beyond the middle line, and the ureter could be felt traversing the cavity; but the rent could not be found. Drainage was provided, and for a time a urinary fistula persisted; finally, the wound healed completely. In the second case the inflammatory phenomena were more marked, but an incision was not made until the twelfth day; here also the lesion could not be found, and drainage was resorted to, but without avail, nephrec- tomy being subsequently required. Both children recovered. Hydronephrosis is a condition characterized by distension of the pelvis and calyces with urine, as a result of some obstruction to its exit. Causes. — (i.) It may be congenital in origin. It must be borne in mind that the body of the kidney is developed from the metanephros, and that the ureter unites subsequently with it to form its excretory duct; such union is occasionally defective at the upper end, well- marked obstruction occurring at the junction of the ureter with the infundibulum of the pelvis. Similar trouble sometimes arises from the ureter becoming kinked over an abnormally-placed renal artery. It is, however, more frequently due to an impervious condition of the urethra, or to the existence of a membranous septum therein ; both kidneys are then necessarily affected. The amount of distension in some of these cases is such as to interfere seriously with parturition until the abdomen has been tapped. The infants are often born dead, or succumb shortly after birth, (ii.) Acquired forms of obstruction are by no means uncommon, and may be arranged under the follow- ing heading: (a) Blocks within the urinary passages from the presence of stones, parasites, foreign bodies, or even blood-clot; (6) changes of structure affecting the walls of the urinary passages — e.g., inflammatory swelling of the mucosa, cicatrices, stenosis, or tumours; (c) kinking of the ureter in cases of floating kidney; and {d) the pressure of extrinsic tumours or cicatrices, as after pelvic cellulitis, or from uterine or rectal cancer. Hydronephrosis may be unilateral or bilateral; in the former case the obstruction arises within the ureter, or from some vesical condition involving its entrance into the bladder; in the latter case the cause is generally to be looked for below this spot. It must be clearly understood that a sudden and absolute block never leads to hydronephrosis. Should it occur as the result of im- paction of a calculus in one of the ureters or of ligature of the ureter, as has occurred in hysterectomy, the secretion on that side is totally suppressed as soon as the tension within the pelvis and calyces is sufficiently high. Atrophy of the renal epithelium follows after a 1194 A MANUAL OP SURGERV time, but if the obstruction is relieved within six weeks of its inci- dence, the secretion of urine will probably be re-established. Should, however, the obstruction be intermittent or incomplete, so that some of the urine escapes, thereby relieving the pressure, hydronephrosis develops. Sudden and complete occlusion of the urethra Hkewise results in dilatation of the bladder and rupture either of that viscus or of the urethra, whilst a gradually increasing obstruction is always likely to lead to hydronephrosis. Pathological History.— The earliest result of obstruction to the flow of urine consists in dilatation of the ureter and pelvis, which is soon followed by expansion of the calyces. Ihe pyramids are flattened, and the cortex expanded and thinned, so that the whole kidney looks larger than usual (Fig. 539). A certain amount of inter- stitial infiltration of the cortex is always present ; the urine secreted in the early stages is usually abundant and of low specific gravity. If the obstruction continues, the renal tissue becomes more and more atrophied, until finally it dis- appears entirely, the kidney being represented by a thin - walled multilocular cyst. At any stage septic phenomena may supervene, giving rise to pyonephrosis {vide infra) . The Clinical History varies con- siderably with the method of onset and the cause of the trouble. Fre- quently all that happens is a pain- FiG. 539.-HYDRONEPHROSIS. (From ^^ss enlargement of the affected Specimen in Bristol Hospital organ; if both kidneys are in- MusEUM.) volved, there may be at first some increase in the amount of urine secreted, which is pale, limpid, and of a low specific gravity ; after a time the quantity diminishes, and finally anuria and uramia follow, especially if septic changes supervene, as is so commonly the case. When only one kidney is affected, the excretion may remain normal in quantity and quality, owing to compensatory hypertrophy of its fellow. An elastic swelhng, fluctuant if of considerable size, is produced by hydronephrosis ; it presents all the physical signs of a renal tumour (p. 1176), and its formation maybe associated with pain, vomiting, and increased frequency of micturition. Finally, a perinephritic abscess may develop, owing to ulceration of the pelvis or ureter, and if this bursts externally, the cyst may eventually discharge through the loin. Occasionally the size of the tumour varies considerably from time to time, as a result of the obstruction being temporarily overcome by the pressure of retained urine behind it. SURGICAL AFFECTIONS OF THE KIDNEYS 1195 When due to a congenital stricture of the upper cud of the ureter or to a kink over a branch of the renal artery, there is usually a history of occasional attacks of painful swelling on the affected side, which has disappeared when the patient rested. Urinary symptoms may accompany this, but it is often supposed to be a bilious attack, or a mild appendicitis. Some pyelitis may follow, but sooner or later an acute attack supervenes, which does not improve, and, if left, sup- puration and perforation will follow. Such cases are by no means uncommon. The Treatment of hydronephrosis should in the first place be directed to removal of the cause, if practicable, and where the obstruction exists in the prostate or urethra, no other treatment is feasible. In some cases of congenital hydronephrosis due to mal- formation of the upper end of the ureter, it is possible to transplant it and thereby relieve the obstruction ; or the pinhole orifice of the ureter may be exposed within the pelvis, and divided longitudinally, with subsequent stitching open of the margins. This type of uretero- plasty is sometimes very successful. In the later stages, where sup- puration is threatening or present, nephrectomy will probably be required. Acquired unilateral hydronephrosis may be dealt with by aspiration as a temporary measure ; but this is rarely satisfactory, and usually needs to be followed by an exploratory incision (nephrotomy), by means of which it may be possible in a few cases to reach and deal with the obstruction. Inthe majority, however, the block is situated so low down that it cannot be reached, and the condition is often so aggravated that nephrectomy is the only reasonable treatment. Nephritis, or inflammation of the kidney, is an affection which occurs in many dift'erent conditions, and is suitably discussed in medical text-books. The presence of albuminuria is of considerable significance to surgeons, and in all cases demanding surgical inter- ference the urine should be carefully tested. It has been already discussed at p. 1179. In addition, we must note that surgical interference has been utilized in cases of chronic Bright's disease. Edebohl* of New York and others have completely removed the capsule of both kidneys in some of these patients. The technique is simple, and needs no special description, but the operation is often difficult in fat oedema- tous subjects. It is claimed that this operation, or, perhaps better, nephrostomy (p. 1199), is most suitable to young people with post- scarlatinal chronic nephritis, and may save life when suppression of urine follows catheterism or exposure to cold. The further history of these procedures will be watched with much interest. Pyogenic Infections of the Kidney and Ureter may develop from manv distinct sources, and give rise to several allied, though distin- guishable, chnical conditions. Thus, (i.) the infective material may reach the kidney from the blood in the shape of emboli, as in pyaemia, causing a diffuse inflammation of the renal substance with a develop ment of many scattered abscesses [acute suppumtive interstitial * Medical Record. March 28, 1903. II96 A MANUAL OF SURGERY nephritis), or of one larger abscess. Sometimes a focus of disease pre- exists in the kidney {e.g., stone, tubercle, or cancer), and the super- added infection adds much to the gravity of the symptoms, (ii.) When once the kidney substance is involved, the trouble is only too likely to spread to the pelvis, causing a suppurative pyelitis (or, inasmuch as the renal parenchyma is already invaded, a suppurative pyelo- nephritis) ; and thence the mischief spreads down the ureter, and may perhaps infect the lower urinary passages, constituting a condition of descending pyelonephritis. (iii.) A common method of origin consists in pyogenic organisms spreading upwards from the bladder to the ureter and kidney. This may arise from a primary cystitis, but is seen most frequently in the affection which used to be termed ' surgical kidney,' and follows in the train of many diseases accom- panied by cystitis — e.g., stricture of the urethra, enlarged prostate, stone in the bladder, etc. It will be remembered that the ureter passes through the bladder in an oblique direction, and is guarded by strong sphincteric muscular fibres, and thereby the spread of infection upwards is rendered more difficult. It is probable, how- ever, that the mucous membrane lining the orifice becomes itself inflamed, and a small plug of mucus develops wathin it, through which the germs are able to pass upwards. In other cases they certainly find their way via the lymphatics of the mucous membrane, which are continuous in the ureter and bladder. When the phe- nomena caused by this infection from below are hmited to a sup- purative condition, it is known as an ascending pyelonephritis ; but if to them is added an element of distension, due to the cause being of an obstructive type, then the distended suppurating kidney is known as a pyonephrosis, (iv.) Sometimes the infection reaches the urinary passages from neighbouring organs, as in disease of the rectum or even of the appendix ; in the former the bacteria are dis- seminated by the lymphatics ; in appendicitis an abscess may open into the kidney or ureter, or the latter structure may be involved in the inflammatory deposit. In the female infection may easily spread along the short urethra from the vulva. The organisms usually present are staphylococci, streptococci, or the B. coli, which, as will be seen later, is constantly associated with inflammation of the bladder. I. Pyelitis is the term applied to an inflammation involving the pelvis of the kidney, the calyces, and perhaps the ureter. The chief causes from which it arises are: [a] The presence of a calculus, or the passage of uric acid crystals in gouty individuals; {b) tuberculous disease, either starting primarily in the kidney, or extending upwards from the bladder; (c) extension of septic inflammation from the bladder and urethra; [d] malignant disease of the kidney; [e) occa- sionally in floating or moveable kidney ; (/) the ingestion of irritating drugs — e.g., cantharides, turpentine, and even cubebs or copaiba; (g) the presence of foreign bodies, such as needles, bullets, and para- sites — e.g., the Bilharzia hcematobia or the Strongylns gigas ; {h) a pyaemic embolus ; and (i) possibly cold. In the milder cases and in SURGICAL AFFECTIONS OF THE KIDNEYS 1197 the early stages it may be a simple catarrhal inflammation, but it is almost certain to become purulent if it lasts long. \Miate\-er the cause, the pathological phenomena are the same, consisting in the lining membrane becoming congested and thick- ened, and secreting a muco-purulent, or even purulent, discharge. Owing to the swelling of the mucous membrane, the entrance to the ureter is encroached on, and a certain amount of distension of the pelvis and calyces (hydronephrosis) follows. Where micro-organ- isms are present, as in cases due to distension from the bladder, the kidnev is likely to be involved in the process (pyelonephritis) , or the condition may be followed by a urinary abscess in the loin or sup- purative perinephritis. The Symptoms of pyelitis consist of pain and tenderness over the affected kidney, increased frequency of micturition, and the inter- mittent discharge of pus in acid urine. The intermissions are due to the inflammatory swelling of the mucous membrane, which tem- porarity blocks the upper entrance to the ureter, and necessitates a certain degree of pressure of the urine and pus accumulated in the pelvis of the kidney in order to overcome the obstruction. Neces- sarily, where pyelitis follows chronic cystitis, the acid reaction is neutralized if the urine in the bladder has become alkaline ; in such cases a nocturnal elevation of temperature is usually noted. The Treatment of pyelitis is mainly directed to the cause. Where this is removeable [e.g., calculus or foreign bodies), an operation is advisable. In the ascending type, which originates in the bladder, treatment should be first directed towards the latter viscus. In the simple catarrhal variety the patient is kept warm, and his diet restricted to bland fluids ; urotropine, alkalies, and sedatives are pre- scribed. If these measures fail and the condition becomes painful and purulent, the affected kidney should be explored, as a stone may pos- sibly be present, and the pelvis drained temporarily (nephrostomy). 2'. Pyelonephritis, or inflammation of the pelvis of the kidney together with the renal parenchyma, is almost invariably suppura- tive in type, and either due to extension upwards from the lower urinarv organs, or to a local lesion of pelvis or kidney, such as calcu- lous or tuberculous disease. In almost all cases of pyelitis a certain degree of renal congestion is present; but when the condition becomes confirmed, and especi- ally when infective matter is present in the calyces, it is certain to hght up a subacute interstitial nephritis. In the latter stages bacteria invade the pyramids and travel upwards along the lym- phatics or renal tubules, gi\dng 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 instances it is possible for many of these minute foci of pus to run together and form a large collection, which in time becomes recognis- able from outside ; but more usually the patient dies of toxaemia or uraemia before that stage is reached. When the affection ascends from the bladder, it may commence suddenly and with acute symptoms. 1 1 98 A MANUAL OF SURGERY and then probul:)h' r suits from some surgical operation or sim])ly 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 ; the walls of the ureters may in such cases be studded with miliary abscesses. Clinical History. — In acute cases the symptoms probably com- mence with a severe rigor, associated with pain in the loins or back, headache, vomiting, great thirst, and probably some amount of drowsiness, perhaps passing into a condition of coma. The rigor may be repeated, or the fever may remain high without exacerba- tions, but if uraemia is present or threatening, the temperature may be subnormal. The kichieys are felt to be enlarged and tender, and the urine is usually diminished in amount, and, indeed, may be sup- prtssed entirely; if any passes, it is high-coloured and contains albumen and perhaps blood, with some amount of pus, which is probably derived largely from the lower portion of the urinary track. The prognosis of the worst cases, which supervene on old bladder trouble, is nearly hopeless, the patient being almost certain to die of uraemia, especially as both kidneys are generally affected. In less acute cases, occurring perhaps in young people, secondary to a bacillary cystitis, the symptoms often improve in a few days and quiet down; but the urine is swarming with bacilH, and recurrence of the trouble is not uncommon. Abscess may sometimes supervene. In the more chronic cases, the symptoms are those of pyrexia, at first only slight, but gradually increasing and taking on the hectic type. The kidney is slightly enlarged and tender ; the urine contains epithelial cells from the pelvis or renal casts, and may be acid in the early stages, but is usually alkaline in the late. As the condition progresses, the temperature rises ; the patient wastes ; appetite and digestive functions flag; slight delirium supervenes at night; and unless the cause can be removed or dealt with effectively, death from uraemia is hkely to follow. If, however, effective treatment of the cause is possible, recovery may follow, but the kidney is, of course, permanently damaged, and some degree of sclerosis is certain to ensue. Treatment. — In the chronic variety, the cause must first be dealt with, but the surgeon must not forget that an acute attack may be easily lighted up by injudicious instrumentation or operations. Hence it is often desirable to drain and wash out the bladder first, as by a perineal cystotomy, rather than to dilate or divide a stricture of the urethra. An enlarged prostate or calculus must be removed, but it may be desirable to wash out or drain the bladder for a few days before undertaking such operations, so as to diminish the risks of infection. At the same time the patient is kept in bed, and encouraged to drink plenty of bland fluids. If the urine is swarming with the B. coli, an autogenous vaccine of that organism is desirable, and must be continued for some time in gradually increasing doses. In the acute form the patient is kept warm in bed, and plenty of fluid, such as milk or barley-water, is given ; stimulants are avoided, as also SURGICAL AFFECTIONS OF THE KIDNEYS 1199 opium. Hot-air baths, wet packs, and the hypodermic injection of pilocarpine, will suffice to get the skin to act well, and watery pur- gatives, such as jalap and scammony, are needed for the bowels. The loins are fomented or cupped, but if the urinary secretion is not re-established, or if it is suppressed, or if the phenomena of suppuration supervene, incision of the kidney and drainage of the pelvis (nephrostomy) are essential. It is sometimes remarkable to observe how rapidly the symptoms improve after such a procedure, and how quickly the urinary secretion is re-established. 3. Pyonephrosis is the term applied to indicate the association of a chronic pyelonephritis with distension of the pelvis and ureter, as a result of obstruction to the passage of urine. When unilateral, it is commonly due to the presence of a calculus, or of tuberculous disease, the obstruction being caused by the swelling of the ureteral mucous membrane; if the affection is secondary to obstruction in the lower urinary passages, it is usually bilateral. The lining membrane of the pelvis is inflamed, thickened, and perhaps ulcerated; decom- posing urine and pus collect in the dilated pelvis and calyces, and a soft, friable, phosphatic calculus may develop, even in cases where the originating cause is not of a calculous nature. Obstruction to the outlet may lead to such an accumulation of pus as to constitute an abscess of the kidney, whilst a certain amount of perinephritis is always present. The Clinical Signs are very similar to those of pyelonephritis, but to them are added those of an enlarged, tender, and painful kidney, and a more or less abundant pyuria, usually intermittent. The temperature is somewhat raised, especially at night, from the ab- sorption of toxic products; the patient steadily loses ground, and becomes emaciated ; the tongue is dry, the appetite diminished, and nausea and vomiting are sometimes present. The urine is generally scanty in amoimt, and if both kidneys are involved, the excretion gradually diminishes, leading to a fatal issue from uraemia, unless the patient dies previously from toxsemia or pyemia. Treatment. — -Where both kidneys are involved as a result of some urethral or prostatic affection, no special treatment directed to the kidneys is feasible; but if the condition is unilateral, and not secondarv to disease of the lower urinary organs, nephrotomy should be undertaken, and any removeable cause dealt with. Failing this, the cavity may be drained, or even nephrectomy performed. 4. Abscess of the Kidney may follow any of the conditions already alluded to, in which bacteria gain access to the organ from below, the pus then collecting in the pelvis and dilated calyces. It also occurs in connection with pysemia, and sometimes develops after the general infective fevers. In acute interstitial nephritis the abscesses are multiple and at first small, being located between the tubules or sometimes \\athin them; the pyramids then have a streaky -white appearance due to their infiltration 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 pyaemia the 1200 A MANUAL OF SURGERY abscesses are preceded by infarcts, which appear immediately beneath the capsule as wedge-shaped areas of a chocolate colour, which turns a yellowish- white as suppuration occurs. The kidney becomes enlarged and tender, and can usually be felt from outside, but fluctuation is rarely to be detected. The abscess may buist into the pelvis and discharge through the ureter, but when due to an ascending pyelonephritis from obstruction this is not likely to be the case. The inflammation is more liable to spread outwards through the kidney substance, and give rise to a suppurative perinephritis. The general symptoms produced are similar to those present in acute pyelonephritis. Treatment of an abscess of the kidney consists in nephrostomy 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 being the lumbar swelling, whilst pyuria is not necessarily present, owing to the ureter becoming blocked. 5. Perinephritis cannot be recognised unless suppurative in nature ; it results either from infected wounds or from ulceration involving the walls of the pelvis and calyces, or from the transmission of micro-organisms from the interior of a suppurating kidney or pelvis without any breach of surface. A perinephritic abscess may also arise from inflammation spreading from the intestine, appendix, pleural cavity, spine, ribs, or elsewhere. The Symptoms may be acute or chronic in nature. In acute peri- nephritis, signs of deep suppuration in the loin are produced — viz., an indurated painful swelling, associated with fever, and perhaps pre- ceded by rigors. The body is held stiff and rigid, wath an inclination towards the affected side. Fluctuation may sometimes be detected when pus has formed, but the abscess is often so deeply placed that it is difficult to recognise at first ; it is likely to point at the side of the erector spinae, or may burrow forwards between the abdominal muscles, and find an exit on the anterior abdominal wall. Occasion- ally it bursts into the peritoneal or pleural cavities, or into the intes- tine. If it comes to the surface, it is preceded by congestion and oedema of the skin. Chronic perinephritis gives rise to no character- istic symptoms until an abscess forms which is large enough to be felt. Sometimes it is of a simple type, and does not suppurate; but the kidney becomes adherent to surrounding parts, and to such an extent as to render nephrectomy difficult and dangerous. Treatment in the suppurating variety consists in giving exit to the pus through an incision at the outer border of the erector spinas ; the cavity is then carefully examined, and the cause of the suppuration, if possible, determined, and treated according to the requisites of the case. Tuberculous Disease of the Kidney occurs in one of three forms. [a] It may arise in the course of acute general tuberculosis, when miliary tubercles are found studding the organs, but giving rise to no special S3'mptoms. The patient is usually a child. Treatment, of course, is impracticable. SURGICAL AFFECTIONS OF THE KIDNEYS {b) It may extend upwards from a similar affection of the bladder, and then almost invariably involves both kidneys. The mucous membrane of the ureter becomes thickened and transformed mto cedematous granulation tissue containing tubercles, and that of the pelvis and calyces is similarly affected; finally, the renal parenchyma itself becomes infiltrated with tuberculous tissue spreadmg from the pyramids. The patients are usually young adult males, and this fact is explained by their Habihty to genital tuberculosis. Clinically, enlargement of both kidneys is noticed, aris- ing partly from the deposit of tubercle within the organ and partly from obstruction within the ureter. The symptoms caused by the renal mischief cannot at first be distinguished from those due to the vesical trouble. Perinephritic abscess occa- sionally follows, and the patient dies from exhaus- tion, toxic absorption, or uraemia. Treatment in these cases is of no avail. (c) Primary Tuberculosis of the kidney is generally unilateral, and commences as a deposit of tubercle in the cortex or at the base of one of the pyramids. It may early involve the pelvis, and give rise to an ulcerative pyelitis, or may invade the renal parenchyma more par- ticularly, replacing it by caseous masses, which in chronic cases may become calcified, and even cast a shadow on the radiographic screen. In the former case a tuberculous pyonephrosis follows, and the process spreads for some distance down the ureter, and even infects the bladder (Fig. 540) . A tuberculous ureter is always thickened and hard, due to the infiltration of the mucous membrane; obstruction to the flow of urine and to the escape of discharge ensues, and in old-standing cases the ureter contracts and drags upon its outlet in the bladder, which can be seen to be retracted. Suppuration of a chronic type sometimes occurs in the kidney, and large quantities of pus may be dammed back behind the thickened ureter. Suppurative perinephritis may also supervene, and give rise to an abscess which bursts externally. The Symptoms are at first indefinite. The patient is usually a 76 Fig. 540. — Tuberculous Kidney, show- ing Thickening of Mucous Membrane OF Pelvis and Ureter. (From Speci- men IN College of Surgeons' Museum.) I202 A MANUAL OF SURGERY young adult, and rather more frequently a male than a female. He complains of increased frequency of micturition, and unilateral pain in the loin, neither of which conditions is improved by rest, remaining the same at night as in the day, and, indeed, sometimes being worse. The pain is generally of an aching character, and more or less constant, although exacerbations may occur, taking on the type of mild renal colic, in consequence of the passage of fragments of disintegrated mucous membrane, or of caseous material. The urine is acid, and usually contains a certain proportion of pus, in which on examination the B. tuberculosis can sometimes be detected. More frequently they are not detected, unless the urine is centrifugalized, and cultivation or inoculation of the deposit may then demonstrate the presence of the bacilli. Hematuria is not marked, even if present at all. In the earliest stages albuminuria is sometimes present without any evidence of pus. On examination the kidney may be found to be slightly enlarged, but is not tender, except in the later stages, when it constitutes a tumour of considerable size, which may contain a large quantity of pus and even a phosphatic con- cretion. Loss of flesh, night sweats, and a nocturnal rise of tempera- ture, are present in the later stages. The Diagnosis of primary renal tuberculosis is usually a matter of doubt, if the presence of bacilli in the urine cannot be demonstrated, since the symptoms are very similar to those of renal calculus. The age of the patient and his personal and family history may be of importance, and he should be carefully examined for evidences of tuberculous disease elsewhere, especially in the genital organs. A bacteriological examination of the urine will often decide the case. The chief points of distinction clinically are that the symptoms are less influenced by exercise or rest, and there is less hsematuria or renal colic than when a calculus is present, whilst the kidney is usually not so tender on manipulation; of course the condition is much less common than that of stone. Radiography will determine the presence or absence of a stone, but also of calcified caseous deposits. Cystoscopy may reveal the existence of tuberculous ulcers in the bladder close to the ureteral orifice in the earlier stages, or of a retracted ureter, when the latter has become transformed into a sohd cord. In cases of doubt the final distinction is made by exploring the organ through an incision in the loin. In calculus the surface is uniformly even and dark red, and if any areas of softening are present, they are of a bluish-red colour; the pelvis and upper end of the ureter are usually lax and distended. The tuberculous kidney is generally mottled in colour and pallid-looking, whilst hard, scattered, caseous nodules may be felt, which become fluid on pressure, or on incision give exit to caseous pus. The condition of the ureter is also diagnostic ; in calculus, if altered at all, it is thin and dilated; in tubercle it is thickened and indurated, and this con- dition may sometimes be detected on rectal or vaginal examination. Treatment. — In the earliest stages the routine anti-tuberculous treatment (p. 184) maybe employed, creosote (lT\.xv. or n\ xx., t.d.s.) SURGICAL AFFECTIONS OF THE KIDNEYS being perhaps useful as a drug, and tuberculin in small doses being valuable. Operation must not be delayed too long, however, owing to the grave results that may follow from extension of the mischief. If on exploration of the kidney the disease is found to be strictly limited and the pelvis unaffected, it may be possible to cut or scrape away the diseased tissues, carefully purifving the cavity by liquefied carbolic acid, and packing the wound thus formed with gauze. In other cases it may be possible to excise wedge-shaped areas of the renal cortex, securing the wounds by sutures. In the majority of instances, however, the disease will have spread much too extensively through the ureter, pelvis, and calyces for such conservative treat- ment, or the kidney may consist of a series of cysts filled with offensive pus. If the surgeon is tolerably certain that the other kidney is healthy, ne- should be .ie<^'^ ""-w^P*^:,^.^ X phrectomv performed, care being taken to divide the ureter below the farthest limit of the disease, the in- cision being suitably pro- longed (p. 1209). The occurrence of a peri- nephritic abscess neces- sitates an incision in the loin, and through this opening the kidney can be explored and, if neces- sary, removed. Renal Calculus. — Renal Calculi are usually met with in individuals suffering from lithiasis, as indicated by the pass- age of sand or gravel in the urine. The general causes of this condition have been detailed elsewhere (p. 11S4). All renal concretions are primarily excreted in a crystalline form from the renal tubules, but under ordmary circumstances are sufficientlv small to find their way into the peMs of the kidney, and thence along the ureter to the bladder. If, however, they are obstructed in their onward course, either on account of their size or shape, or some narrowing of the tubules, they may become lodged in the kidney substance or in one of the caljxes, and by the gradual deposit of the same material increase m s]ze until large enough to give rise to sjonptoms. Renal calculi are usually not of great bulk; occasionally, however, the whole of the pelvis, and some of the calyces, may be occupied by a concre- tion, which takes the shape of the cavity in which it lies (Plate XIII., Fig. I). When many calcuh are present in the pelvis of a kidney, they are usually faceted (Fig. 3). Chemically thev consist Fig. 541. — Calculous Kidney. OF Surgeons' Museum.) (College I204 A MANUAL OF SURGERY either of uric acid or urate of ammonium; sometimes, however, they are com])()secl of oxalate or acid phosphate of hme. The Pathological Phenomena connected witli renal calculi vary with their_ size, shape, number, and position. If situated in the substance of the renal parenchyma, they may give rise to but little trouble, being more or less encapsuled in a cavity lined by granula- tion tissue and surrounded by a dense fibrous capsule. Sometimes, however, ulceration of the wall and suppurative perinephritis may follow; the calculus may even find its way into the abscess cavity, and be discharged spontaneously or removed through the loin, a urinary fistula perhaps resulting. If the calculus is held in place in one of the calyces by its branched shape, thereby limiting its mobility. Fig. 542. — Radiogram of Multiple Renal Calculi. (Dr. Knox.) a suppurative pyelonephritis follows (Fig. 541), by which the kidney substance is seriously damaged, the pelvis may become dilated, and possibly perinephritis ensues, with or without suppuration, and the formation of a urinary fistula. When occupying the pelvis of the kidney, calculi set up a suppurative pyelitis, and from the obstruction to the flow of urine, caused partly by the thickening of the mucous membrane, and partly by the calculus engaging the orilice of the ureter, produce dilatation of the pelvis of the kidney, and the phe- nomena of hydro- or pyo-nephrosis. If the calculus passes down the ureter, it gives rise to the s^miptoms 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. FLA'l'E Xlll. Renal Stones. Fig. I. — Large branched calculus, firmly held in the calyces of the pelvis. Fig. 2. — Oxalate of lime stone. Fig. 3. — Two facetted stones of uric acid. The patient passed two of this collection per urethram ; six were removed by nephro-lithotomy. [To face page 1204. SURGICAL AFFECTIONS OF THE KIDNEYS 1205 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 in time by disorganization. If the kidney thus affected is the only one available for excretory purposes, or if both ureters are similarly obstructed, 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 retnj- peritoneal urinary abscess, or possibly to suppurative peritonitis. If the ureter is only partially obstructed by the calculus, the changes which take place in the kidney are more gradual, and result in hydro- or pyo-nephrosis. The tvpical Symptoms arising from renal calculus are as follows : The patient complains of pain in the loin, more or less persistent, and often paroxysmal in nature, which is, however, always increased on exercise or jolting; it is frequently referred to distant regions, but most commonlv follows the course of the genito-crural nerve, giving rise to pain in front of the thigh, accompanied by retraction of the testicle; in the female it is also experienced in the labium majus; sometimes it extends down the back of the thigh. It is almost invariably associated with haematuria, and often with p5'uria, the amoimt of blood or pus being increased on exertion. Frequency of micturition is a prominent symptom, whilst if the pelvis is enlarged the kidney may be tender and distinctly palpable. 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 onty gain relief by lying on the affected side, and on manual examination the kidney, though some- what 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 that at night the patient lies on the sound side, since the organ is both enlarged and tender. On the other hand, it is an undoubted fact that stones even of large size may exist for years in the kidney without giving rise to any symptoms whatever. The pa,ssage of a calculus down the ureter is accompanied by the symptoms known as Renal Colic. They consist of excruciating pain of a paroxysmal nature, which comes on suddenty, and is referred both to the loin and along the course of the genito-crural nerve. It is always associated vnth vomiting and severe shock, the patient often lying on the floor writhing in agony, vnt\\ cold perspiration standing in beads on his forehead. The temperature is subnormal, and the pulse weak and rapid. Strangury is usually present, the patient suffering from frequent paroxysmal efforts to pass water, but only succeeding in passing a small amount, and that generally blood-stained. After lasting for a variable period, the pain suddenly ceases, as a residt of the passage of the calculus into the bladder, or of its slipping back into the pel\4s of the kidney. I206 A MANUAL OF SURGERY Impaction in the Ureter may occur eitlicr 2 inches below the pelvis of the kidney, or near the brim of the pelvis, or near the vesical orifice, sometimes even protruding through it. There is usually only one stone, but occasionally more ; the size is rarely greater than a coffee-bean, and the shape is usually somewhat elongated, like a date-stone.* In thin persons it has been detected on palpation through the abdominal wall, and when low down has been felt on rectal or vaginal examina- tion. Persistent pain and hasmaturia extending over days or weeks should cer- tainly suggest the presence of a ureteral calculus, and the more so if with each suc- ceeding attack the pain and tenderness are located lower down. The result may be that the stone will ulcerate through into the retroperi- toneal tissue, and be dis- charged in an abscess; or more frequently the kidney is disorganized, and perhaps the patient's life destroyed through the resulting renal incompetence. Occasionally the function of both kidneys is brought to an end — on the one side by the back pressure of urine due to the impaction of a small calculus ; on the sound side, by reflex suppression of urine. In a case of this character recently operated on all the symptoms were on the left sound side, and in the unavoidable absence of a radiograph the kidney and ureter on this side were first explored and found normal ; the peritoneum was then opened, and an impacted stone detected in the right ureter, and through a second incision this was removed. The urinary secretion was at once recommenced. Should the ureter of a solitary kidney be blocked by a stone, grave * Sometimes a calculus will remain in the ureter for a considerable period, acting as a ball-valve, and permitting a certain amount of urine to pass. It may increase in size, and reach considerable dimensions. The author recorded a case {Proceedings, Royal Society of Medicine, vol. iii., No. 3, Clinical Section, p. 63) in which he had removed a stone from the lower end of the ureter weighing 803 grains. The ureter above it was dilated like a coil of intestine, and filled with pus. 1 10 ^m^mt ^^^^^H Fig. 543. — Radiogram of Stone in the Pelvic Portion of the Ureter. The actual stone is seen in the inset against a centimetre scale ; it was removed by a retro-peritoneal operation. SURGICAL AFFECTIONS OF THE KIDNEYS 1207 symptoms of calculous anuria, or suppression, will arise. The condition is ushered in by pain in the loin of the usual character, which often passes away in two or three da3's. The anuria is rarely complete at first, a few ounces of pale limpid urine being passed at intervals, whilst occasionally distinct polyuria is present. Sooner or later definite uremic 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 persistent vomiting,' a slow, full pulse becoming irregular, contraction of the pupils, and muscular tremors. Coma and convulsions are rarely seen, and there is no dyspnrea; the temperature is subnormal. 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 cohc. It is most likely to be mistaken for tuberculous disease; the differential diagnosis between the two conditions has already been considered (p. 1302). The final determination of the presence or not of a renal or ureteral calculus is now usually made by radiography, which has made such advances that it may be relied on with almost absolute certainty, except perhaps in the case of small pure uric acid calculi. Reference has already been made (p. 1187) to some of the con- .ditions which must be observed if a reliable result is to be obtained. It is a good rule to follow that a second confirmatory examination should be made after an interval of two or three days in all cases where the diagnosis has not been established beyond all shadow of doubt. If a small stone has been located in the kidney, and opera- tion has for some reason or other been deferred, it is always advisable that a confirmatory radiogram be taken immediately before the operation. Cases have been known where a stone had, during an interval, shifted its position from the kidney to within an inch or two of the lower end of the ureter without any symptom which could suggest the change of position. Treatment.— In the early stages treatment is directed to the cure of hthiasis (p. 1185). The patient's diet and general habits of hfe must be suitably regulated, and he is instructed to make use of alkaline waters, such as those derived from Contrexeville or Vichy, or citrate of Hthia and sulphate of soda may be administered in a mixture. Plenty of bland fluid should be ordered, such as boiled or distilled water, in the hope of softening the stone or assisting its onward passage to the bladder. Sometimes it may become encysted if the patient is kept absolutely at rest; the sj/mptoms will" then gradually improve, and finally disappear. Attacks of renal colic are treated by the use of hot hip-baths, warm drinks, and hypodermic injections of morphia and atropine; in the more severe cases chloroform must be administered. In former days, when the presence of a calculus could only be suspected from the history or symptoms, the question of operation and when to undertake it was a subject of much discussion. Even i2o8 A MANUAL OF SURGERY at that time Sir Henry Morris wrote that an ' unsuspected renal calculus is a source of very real danger; and when its presence is disclosed, whether by accident or by the systematic examination of the urine, we should recommend its immediate removal, regardless of the fact that it is not causing pain, unless the general condition of the patient contra-indicates an operation.' At the present day, when radiography has placed in our hands a means of almost certain diagnosis, the same advice holds good^whenever a stone is found, remove it, unless special contra-indications exist. Especially is this the case when a considerable amount of blood or pus is being passed in the urine, and the patient's temperature is raised. Pain in both kidneys is no contra-indication to operation, since there is no objection to exposing and even removing calculi from both organs. The constant passage of gravel, moreover, need not deter one from operating, for 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. Nephro-lithotomy is alwaj^s undertaken through the loin. When exposed, the kidney is carefully freed from its connections, and drawn up into the wound; in the majority of patients it can be brought out on the loin, and this is certainl}' a desirable manoeuvre. The whole gland is then carefully palpated, as also the pelvis and upper part of the ureter, so as to locate, if possible, the stone. Should it be distinctly felt within the kidney substance, an incision is made over it through the renal parenchyma; free haemorrhage follows, but this is readily controlled by inserting the finger into the wound, or b}^ grasping the vessels in the hilum. Should the stone not be palpable, an incision is made through the convex border of the kidne}^ substance, a little posterior to the mesial plane of the organ and at the junction of its inferior and middle thirds. One of the lower catyces is opened by this means, and the interior of the pelvis is carefully and fully explored by finger and probe. Some- times the incision in the kidney has to be considerably enlarged, and the discovery of a small calculus may be a task of some difficulty. When the pelvis is much distended and the patient has previously passed a good deal of pus, careful precautions must be taken to pro- tect the surrounding tissues from infection. Sterile gauze is packed into the angles and hollows of the wound, and the assistant must press up the abdominal wall. The incision is usually made through the cortex in preference to opening directly into the pelvis ; but the objection often stated that a pelvic incision heals with difficulty, and is liable to leave a fistula, is not true, and most surgeons now deliberately open the pelvis in order to extract stones if it is more convenient to get at them in this way. Accurate suturing with catgut is generally successful in securing immediate healing, but the sutures must not encroach on the mucous membrane. Stones are removed by dressing-forceps, or scoop, and care must be exercised to prevent any from falling backwards into the ureter. Large branched calculi are often held very tightly, and require an extensive incision SURGICAL AFFECTIONS OF THE KIDNEYS 1209 and careful peeling off of the kidne}' substance. The pelvic cavity need not be irrigated under ordinary circumstances, but when dilated and suppurating it is well to do so with a hot solution of sublimate or of Condy's fluid. Before closing the wound in the kidney the ureter should be thoroughly examined; it is sometimes possible to introduce a ureteral sound through the open wound, but this is by no means easy, and it is often wiser to make a tiny opening through the pelvic infundibulum, through which the sound is passed, and which is subsequently closed by a Lembert's suture. Bleeding is usually controlled without difficulty by stitches passed through the kidney substance, to which in bad cases may be superadded pressure b}^ sponge or a gauze plug in the wound. It is useless to attempt to place a ligature on a vessel divided in the renal parenchyma. Should bleeding persist, sutures of the mattress type should be intro- duced and tied firmly. It is often wise to insert a drainage-tube down to the sutured wound in the kidney, after it has been replaced. The abdominal parietes may then be closed in the usual way. To explore and expose the ureter the incision should be prolonged downwards and forwards in a direction parallel with Poupart's liga- ment towards the inguinal canal (the lumbo-ilio-inguinal incision of Sir Henry Morris). The peritoneum and its contents are pushed bodily inwards, and the ureter attached to the posterior peritoneal wall can be followed down to within a few inches of the bladder. For a stone impacted near the lower end of the ureter, uretero- lithotomy is performed with the patient in the Trendelenburg position. The operation may be trans- or retro-peritoneal. 1. The trans-peritoneal operation is conducted through an incision in the middle line. The stone is located, and, if possible, coaxed by the finger out of the depths of the pelvis to a more accessible position. It is then cut down on through the peritoneum, and the stone removed. The incision is closed by a Lembert suture or two. 2. The retro-peritoneal operation requires an incision similar to that for tying the common iliac artery. The peritoneum and its contents are displaced inwards, and the ureter is easily found running down on its posterior aspect. The stone is, if possible, dis- placed up from the pelvis, and removed. Cases seem to do equally well whether the ureter is sutured or not, granting that the stone is small. For large calculi, where much pus is present, it may be wise to drain the ureter for a day or two. The uncertainty of the local condition, which may be disclosed on operation, leads the author to favour the retroperitoneal operation as the safer of the two pro- cedures. A calculus impacted close to the bladder has been removed through the rectum or vagina, or by a trans - sacral operation. When the kidney 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 dis- integrating calculous material may occupy the pelvis, which is sur- A MANUAL OF SURGERY rounded by a mass of dense libro-cicatricial tissue, the ri'nioval of which is impracticable and even dangerous. All that should be attempted locally is the extraction of the stone and the purihcation of the cavity. If the inconvenience arising from the clischarge of pus and perhaps urine in the loin is too great, it may be possible to check it in large measure by the plan suggested and practised by Colonel Holt, D.S.O. — viz., ligature of the renal artery.* Tumours of the Kidney.^ — -The different forms of tumour which originate in the kidney may be classified as the simple and the malignant. Several cystic conditions also occur. The general features of an enlarged kidney have been already described (p. 1176). The simple tumours of the kidney are: 1. Diffuse Cystic Disease (or, as it has been termed, adenoma of the kidney), which may be congenital or acquired. It is not un- frequently bilateral, especially when congenital. The kidney is enlarged and occupied by cysts, varying in size, but rarely ex- ceeding that of a cherry; they are lined with epithelium, which is generally flattened, and filled with a limpid fluid containing urea and perhaps cholesterine. The cysts are often very numer- ous, and may project from the surface of the kidney as nodular elastic outgrowths. The pelvis remains unaffected until the later stages of the disease (Fig. 544) . Generally the whole kidney is involved, and may attain enormous dimensions, constituting large swellings which can be easily felt, and with a distinctly nodulated surface; occasionally the growth is limited to one portion of the organ. The origin of this condition is uncertain, but it is supposed to be due to the persistence of the mesonephros (or Wolffian body) in the sub- stance of the true kidney (or metanephros), and its development into cysts. In the early stages no symptoms are produced, except, perhaps, a sense of dragging weight in the loins from the size of the tumours ; but later on the secretion of urine is interfered with to such an extent as to produce renal incompetency and finally uraemia. The tendency of this affection to affect both kidneys prevents any hope of benefit from operation. 2. Papilloma of the renal pelvis is a rare condition, characterized by the development within its cavity of a villous mass, identical in structure with that met with in the bladder. It has usually been * Trans. Royal Med. Chir. Soc, 1907. Fig. 544. — Cystic Disease of Kidney. (King's College Hospital Museum.) SURGICAL AFFECTIONS OF THE KIDNEYS izii observed in elderly people, and the chief, if not the only, symptom is excessive haematuria. It cannot be diagnosed with certainty, but if discovered in an exploratory operation, it can be removed with success. Malignant tumours of the kidney may be divided into : 1. The Sarcomata of Infants, which are often congenital, but may be acquired within the tirst few years of life. They are encapsuled, the kidney substance being spread over them, and consist of round or spindle cells, the latter often showing a cross-striation, resembhng that of muscular fibres (myo-sarcomata). They grow to a great size, and may affect both organs, but pain and haematuria are absent. Death results from general dissemination or from exhaustion, or may follow mechanical obstruction to the circulation, as by the detach- ment of a sarcomatous embolus, which travels upwards and blocks the pulmonary vessels. Treatment by nephrectomy has given most unsatisfactory results, the operative mortahty having been high and recurrence almost invariable within a short period. The operation itself is not particularly di^cult, but a large incision is required, and care must be taken to avoid displaced structures, such as the mferior vena cava. When both kidneys are affected nothing can be done. 2. The Sarcomata of Adults occur between the thirtieth and fiftieth years of hfe, and are of the spindle-celled variety, often originating from the capsule. Only one kidney is generally involved, giving rise to a rapidly-growing swelHng, associated with haematuria and perhaps pain. CalcuH are often found in the pelvis of such organs, and may be causative or consecutive. Secondary deposits form in the viscera ; extension through and beyond the capsule is not uncommon, and death is usually due to exhaustion. The results of nephrectomy have not been very encouraging. 3. Primary Carcinoma is an uncommon form of tumour in the kidney. It presents the same cHnical features as a sarcoma, except that there is rather more pain, and can only be recognised on micro- scopic examination. One symptom, however, requires special mention, since it is extremely suggestive of the presence of cancer — viz., the development of a varicocele. It is due to the pressure of enlarged and cancerous lymphatic glands upon the root of the spermatic vein, and hence, whenever an elderly person develops a varicocele, a careful examination of the kidney on the affected side should always be instituted. 4. The commonest tumours of the kidney, however, are the so- called Hypernephromata (75 to 80 per cent, of all renal tumours). They are looked on as growing from accessory and misplaced adrenals {adrenal rests), and develop primarily in the cortex as localized growths, gradually increasing in size and encroaching on the pelvis. They are of firm consistence, but show areas of necrosis and soften- ing, and some deep red patches due to haemorrhage (Fig. 545) ; the section is more or less mottled, and some bright yellow areas are very evident. On microscopic examination their appearance closely A MANUAL OF SURGERY resembles the zona fasciculata of the adrenal bodies, but this theory as to their origin is not universally accepted. They are malignant in type, being disseminated by the bloodvessels, and secondary growths are found in the lungs, liver, or bones. H\7)ernephromata usually occur in adults between fifty and seventy years of age, and are of comparatively slow growth. They give rise to haematuria, but it is late in appearance, and less persistent than in other malignant growths of the kidney. Pain is often well marked and referred to the loin ; it has two main t}''pes — a persistent ach- ing pain, which may be very severe and wear- ing, and a colicky pain, due to the passage of clots down the ureter. The renal enlargement is usually characteristic, but outgrowths from diffusion beyond the capsule may render the swelling of irregular shape. Treatment con- sists in removal, if there is no evidence of second- ary deposits in the lungs or elsewhere. The opera- tion is by no means simple in cases that are at all advanced, as serious adhesions in various directions may be present, and the bleeding may be severe. Various Cystic Condi- tions of the kidney must be noted in addition to the general cystic dis- ease, alreadv described. {a) Hydatid Disease affects the kidney, as it may involve any other organ in the body. It starts either beneath the capsule or in the glandular substance. In the former case it is likely to form a rounded projection, which maybe detected on palpation of the loin; in the latter it expands, or even destroys, the whole of the glandular tissue, and may burst into the renal pelvis, the cysts being passed along the ureter, accompanied by more or less colic. Suppuration may com- plicate matters, but, unless the cyst has ruptured into the renal Fig. 545. — HYPEKxtpHKoMA. (King's College Hospital Museum.) SURGICAL AFFECTIONS OF THE KIDNEYS 1213 pelvis, diagnosis is scarcely feasible apart from an exploratory in- cision. Treatment consists in cutting down on the kidney, and enucleating the mass, if possible. Failing this, drainage may be undertaken, but in bad cases nephrectomy is necessary. {b) Dermoid Cysts have also been found. (c) Serous Cysts are occasionally met with, arising possibly as a result of obstruction to some of the ducts, or due to lymphatic obstruction. Rounded swellings, simple or multiple, are produced, growing outwards from the cortex, and containing a thin fluid, with a small amount of albumen and saline substances in solution. They give rise to no symptoms except from their size, and rarely require treatment other than simple aspiration or drainage. If discovered at an operation, and of considerable size, they should be incised, and either dissected out, or the outer wall cut away, and the inner left continuous with the renal capsule. [d) Not unfrequently a number of small cysts develop in con- nection with chronic granular nephritis, but they are of no clinical importance. Nephrectomy, or total removal of the kidney, is performed for the following conditions : (a) For tuberculous disease, when conservative measures have failed or are impracticable, or when the pelvis and ureter are extensively involved; (6) for calculous pyonephrosis, when the renal parenchyma is disintegrated; (c) for hydronephrosis, when palliative measures or drainage have failed to give relief; {d) for malignant disease; {e) for traumatic lesions, such as disintegration or rupture, especially if complicated by laceration of the peritoneum; and (/) for some cases of ruptured ureter. Before undertaking the excision of any kidney, however diseased, it is essential that the surgeon should satisfy himself as to the exist- ence of another, and also, if possible, ascertain that it is capable of undertaking the increased duties which will subsequently fall upon it. Many different plans of doing this have been already alluded to (p. 1176). Nephrectomy may be undertaken through the abdomen or through the loin; but sundry combinations or modifications of these opera- tions have been recommended by various authorities. The A hdominal Operation is chiefly utilized when the organ is much enlarged, on account of the readier access obtained, especially to the pedicle. The peritoneum is likely to be opened, and may be exposed to septic contamination, when the pelvis and the upper part of the ureter are distended with decomposing pus, as is frequently the case ; but this is easily prevented. Drainage is obtained for the cavity left after the removal of the organ by a counter-opening made through the loin. One great advantage, as before stated, is that the other kidney can be first examined, if required, and its condition ascertained. As to the technique : there is frequently no necessity to open the peri- toneal cavity, since the kidney is almost always enlarged, but an opening is often made, intentionally or accidentally. The colon and I2I4 A MANUAL OF SURGERY peritoneum are peeled off the organ and displaced inwards; it is then freed from its adhesion to surrounding tissues, the surgeon endeavour- ing to keep outside its true capsule, but inside the layer of condensed perinephric tissue. Special precautions must be adopted in dealing with the deep 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. '1 he ureter is dealt with in the same way, small pieces of gauze being 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 kidney thus freed is removed, and the wound in the abdominal parietes closed in the usual way, provision for drainage having been previously made either through the loin or from the front. Considerable shock is often ex- perienced from this operation, and the death-rate is somewhat high. Occasionally the perinephric adhesions are so firm and extensive that the only practicable plan of removing the organ is to enucleate it from within the capsule as far as the hilum; the capsule is then torn or cut through so as to expose the pelvis and renal vessels, which are secured. The Lumbar Method can be employed when the kidney is not too greatly enlarged. The organ is exposed by the incision already described, enucleated from its surroundings, and the pedicle dealt with as in the abdominal operation. If the condition of the opposite organ has not previously been ascertained, the peritoneiun should be incised at the outer margin of the wound, so as to enable the hand to be inserted across the middle line, and thus allow an exploration of the opposite loin. Should it be desirable to include the ureter in the scope of the operation, the incision may be prolonged into the groin in the direction of the fibres of the external oblique, and the peritoneum and its contents pushed forwards ; by this means it can be traced down almost to the bladder. CHAPTER XL. BLADDER AND PROSTATE. Methods of Examining the Bladder. — When a patient presents himself com- plaining of increased frequency of micturition and other evidences suggestive of chronic disease of the bladder, a systematic examination of the individual and his urinary passages must always be instituted. The history of the case, the character of the symptoms, and the condition of the urine, are carefully gone into. An examination of the bladder should then be made, (i) The patient is laid on a couch, and the lower part of the abdomen uncovered. The hypogastrium is then examined by inspection, palpation, and percussion, so as to ascertain whether or not the bladder is distended, or if any abnormal resistance can be felt, either from thickening of the wall or the presence of a tumour. (2) A sound is then passed according to the method described at p. 1233, and the interior of the viscus explored; by this means a calculus may be detected, and even sometimes a tumour, as also a rough and irregular condition of the mucous membrane. (3) The finger is inserted into the rectum, or, in the female, into the vagina, before the sound is withdrawn, so as to enable the condition of the posterior vesical wall to be investigated between the point of the finger and the sound. Enlargement of the prostate or of the vesiculae seminales can also be detected in this way. (4) The patient may then be asked to void urine, after which a rubber catheter may be introduced, and the amount, if any, of residual urine estimated. (5) As mentioned else- where, Bigelow's evacuator is useful, not only to wash out the bladder, but also to detect the presence of very small calculi which the sound may have missed. (6) Of recent years a new means of examining the interior of the bladder has been introduced in the shape of the cystoscope. This consists of a straight tube with a short end bent at an angle, in which an electric lamp is placed, the wires leading to it being carried within the tube. A small window covered with glass is situated close to the angle, and a prism is here inserted in such a manner that, when the surgeon looks through an eye- piece placed at the end of the instrument, he is able to see the portion of the vesical wall illuminated by the electric lamp. To use it the bladder must be previously washed out, if necessary, and the patient anaesthetized, if thought desirable. About ten or twelve ounces of boric acid lotion or clear water should be present in the bladder, so as to prevent the vesical wall from being injured by the instrument, which always becomes hot after the lamp has been used for some time. Considerable practice is needed for any useful informa- tion to be gained by the aid of this instrument, but in skilled hands much may be learnt as to the condition of the mucous membrane. (See Plate XIV.) Slight modifications of the instrument permit of the passage of a solid bougie or small catheter, which can be passed into the ureteral orifice and up the ureter (Plate XIV., Fig. i). (7) Finally, in cases where great irritability of the bladder exists in spite of treatment, and its presence cannot be explained, an exploratory cystotomy, either suprapubic or perineal, is justifiable. A distended bladder constitutes a rounded swelling, which projects above the symphysis pubis, and naay even reach to the umbilicus in some cases. 1215 I2l6 A MANUAL OF SURGERY The swelling may be visible to the naked eye, and is dull on percussion, the dulness rising directly above the symphysis; it is quite immoveable, and therein differs from many ovarian and uterine tumours. Bimanual examina- tion per vaginam or per rectum should at once indicate its nature ; and when at all doubtful, a catheter should be introduced. Congenital Affections oJ the Bladder. — i. Ectopia Vesicae, or Extroversion of the Bladder, is the term employed to denote total absence of the anterior wall of the bladder and of the lower portion of the abdominal parietes, as a result of which the mucous membrane of the posterior vesical wall is exposed and rendered somewhat pro- minent by the pressure from behind of the abdominal contents (Fig. 546, I). This sur- face is usually not much more than an inch in diameter in an infant, and is often irregular, and covered with papil- liform processes ; the orifices of the ureters are easily recognised below, urine being occasionally emitted from them in forcible j ets. The condi- tion is necessarily one of the greatest discom- fort, not only from the constant dribbling of urine causing excoria- tion and eczema of the thighs and surrounding parts, but also from the pain and irritation due to friction of the clothes against the exposed mucous membrane. The s^onphysis pubis is always absent, and the horizontal ramus of the pubic arch terminates on either side in the inguinal region (4). The innominate bones are usually rotated out- wards, and the sacrum is convex anteriorly from side to side instead of being concave. In consequence of this pelvic malformation, the patient's gait and powers of progression are considerably impaired. The penis (2) is cleft, and in a condition of complete epispadias ; it is drawn upwards and backwards over the trigone, so that it requires pulling down to expose the ureteral orifices. The testes are often found in the inguinal canal, or, if in the scrotum, are accompanied by congenital hernise. No umbilicus is present. The condition is due to impaired development of the anterior wall of the allantois and the lower segment of the abdominal parietes. At birth the lower Fig. 546. — Ectopia Vesicae. I, Exposed mucous membrane of posterior wall of bladder; 2, glans penis drawn up to cover lower part of vesical mucosa and orifices of the ureters; 3, scrotum; 4, projection of pubic ramus. PLA'l'E XTV. Cystoscopic appearance of the Bladder in various conditions. Fig^ I.— Passage of ureteral catheter through a somewlmt congested right ureteral "''VJ^' 2.— Tuberculous bladder and kidney. The left ureteral orifice is thickened and pouting ; a small tubercle is seen on the outer side of it ; a spurt ot pus is being ejected from it. Towards the middle line is seen a more diftuse tuberculous inhltra- tion of the vesical nniscosa. Fig. 3. — Stone in Bladder. Pig^ 4. — Papilloma of Bladder. [To face page 12 16. BLADDER AND PROSTATE 121 7 portion of the umbilical cord is expanded over the raw surface, con- stituting the anterior vesical wall. When the cord separates, the posterior vesical wall is necessarily exposed. The Treatment of this distressing malformation is most unsatis- factory, and hence in the majority of the cases the appHcation of a urinal has been recommended, although the instriunents hitherto devised are not particularly efficient. Various operative measures have also been practised, {a) Trendelenburg's operation consists in division of the sacro-iliac ligaments from behind so as to enable the lateral halves of the pelvis to be compressed together. By this means the posterior vesical wall is thrown backwards and- its tendency to protrude lessened. The wounds are allowed to granu- late, and, if successful, the bladder wall finally hes at the bottom of the srdcus, which can usually be covered over by a plastic operation without much difficulty. The main objections to this method are that it involves a very severe operation, and also leads to a further weakening of the pelvic arch, the integrity of which is already much impaired by the absence of the pubic symphysis, {h) Plastic opera- tions without interfering with the pelvis were introduced and prac- tised by the late Professor John Wood, Thiersch, and others. For full details, we must refer to larger text-books. Suffice it here to state that a skin flap is turned down from the anterior abdominal wall above the breach of surface, and sutured on either side to the margins of the defect. The cutaneous surface of this flap constitutes the anterior wall of the newly-formed bladder, if such it can be called, whilst its raw outer surface is covered in eithsr by flaps derived from either side, or by undercutting the neighbouring skin and shding it inwards to the middle fine, where it is united by sutures, as suggested and successfully carried out by Mr. Boyce Barrow. The after-treatment is always prolonged and tedious, and the patients are likely to experience much subsequent inconvenience owing to the growth from the under surface of the abdominal flap of hairs, which become encrusted with phosphates, (c) More recently various methods of implanting the ureters into the rectum have been practised, and it is claimed that the urine is easily re- tained for some hours, and voided independently of the fseces. This is much the best procedure, although the patient runs the risk of an ascending infection of his urinary track. 2. An Umbilical Urinary Fistula is sometimes met with as a result of imperfect closure of the urachus. 3. Occasionally in cases of malformation of the rectum the Primitive Cloaeal Condition may in part persist (see p. ii45)- Traumatic Affections of the Bladder.— -Rupture may be produced in several ways: (i) It may be due to direct violence appHed to the lower part of the abdomen, especially when the viscus is distended. (2) It may comphcate a fracture of the pelvis, either as a direct result of the violence, or from penetration of a spicule of bone from the OS pubis. (3) The bladder may be opened by a penetrating wound. (4) Apart from traumatic lesions, rupture may occur from 77 1 21 8 A MANUAL OF SURGERY simple over-distension, especialh^ if destructive ulceration of its walls is present; or it may follow ulceration of a saccule if it contains a ])h()sphatic concretion. Rupture of the bladder is divided into two main classes, according to whether or not the peritoneal cavity is opened. The peritoneum covers the upper and back part of the viscus, being reflected anteriorly along the urachus, laterally along the obliterated hypo- gastric arteries, and posteriorly on to the rectum. Intraperitoneal Rupture involves the posterior or superior portions of the viscus, and is the variety most frequently met mth. The symptoms produced are severe shock, associated with hypogastric pain of a burning nature. The patient experiences a constant desire to micturate, but, as a rule, nothing is passed, except perhaps a little blood. Peritonitis soon follows, running a rapidly fatal course, especially if efficient treatment is not adopted. On passing a catheter the bladder is usually found empty, or possibly a little blood-stained urine may be withdrawn ; if, however, the instrument happens to be insinuated through the rupture into the peritoneal cavity, a considerable quantity of blood-stained urine can be drawn off, and the point of the catheter may be felt under the anterior abdominal wall. A useful diagnostic sign consists in injecting a measured amount of boric acid lotion into the bladder, and noting how much of it returns; when a rupture exists, some considerable discrepancy will probably be noted between the two quantities ; this test cannot, however, always be relied on. The Treatment of these cases consists in immediate laparotomy; the fluid within the peritoneal sac is removed by swabs, and the wound in the bladder clearly demonstrated, preferably with the patient in the Trendelenburg position (p. 960), which must not, however, be adopted until the urine and inflammatory' effusion have been removed. The rent is carefully closed by means of a row of Lembert sutures, not involving the mucous membrane, which should always extend a little beyond each extremit}^ of the wound. Possibly a drainage-wick or a Keith's tube may need to be inserted for a few hours, so as to remove any exudation. The abdominal wall is then closed in the usual way, and the patient put back to bed. The urine is either drawn off at regular intervals, or a catheter may be tied in the bladder, the urine being syphoned by an attached rubber tube into a vessel placed beneath the bed. Extraperitoneal Rupture of the bladder involves its anterior wall or base. The urine finds its way into the pelvic cellidar tissue, and if unhealthy at once gives rise to a most virulent fonn of suppurative pelvic cellulitis, which is usually fatal from toxaemia or pyaemia. Abscesses generalh* point either above the pelvic brim or in the perineum. The treatment consists in free incisions through the perineum, or above the brim of the pelvis. In the latter case it may be possible to reach the rent in the bladder and suture it ; otherwise it may be possible to introduce into the bladder a large tube, through \\'hich the urine can escape freel}- for a time. As soon as the tissues BLADDER AND PROSTATE 1219- are sealed off by the development of granulations, the tube may be withdrawn. The prognosis largely depends on the condition of the urine, whrthcr healthy or contaminated wath bacteria, and on the length of time it was allowed to remain in contact with the tissues. Foreign Bodies introduced into the bladder from without are of various natures, such as portions of catheters or bougies, pins, etc. They give rise to symptoms of chronic C3'stitis, and usually become encased with phosphatic deposit. They should be removed as early as possible with a lithotrite, but if of large size or thickly covered with phosphates, must be treated by perineal or suprapubic cyst- otom5^ In the female, digital dilatation of the urethra is the best means of gaining access to the interior of the viscus. Cystitis ma}- be due to a great variety of causes, but is always in essence of bacterial origin. Many different forms of bacteria may be found, but those most usually present are the ordinary pyogenic cocci, especially the Staphylococcus aureus, which, together with the Diplococcus uvecB liquefaciens, has the power of decomposing urea and setting free ammonia, whilst the B. coli is also commonly found in these cases. This latter organism has no power of rendering the urine alkaline, and, indeed, develops badly in alkaline media, and hence if present in a pure infection the urine remains acid, though stale and offensive to the smell. The methods of invasion of the bladder are diverse: (i) Bacteria may reach the viscus from above, either owing to a suppurative lesion of the kidney or its pelvis, or escaping into the urine from the blood. (2) They may travel up the urethra. This is a matter of no difficulty in the short and comparatively large urethra of a woman, and hence cystitis is frequentty associated with vulvitis or is seen after labour. In girls a pure bacillary c^'stitis with acid urine is not uncommon, and is probably secondarv to a vulvo -vaginitis, which arises from con- tamination of the vulva with the faeces where cleanliness is neglected. In the male sex, infection from the urethra is unusual unless urethri- tis has previousl}' existed or some irritation, due to the passage of instruments. Even if they are carefully sterilized, mucus is liable to form and cling about the urethral wall, and along this bacteria can find their way. Naturally the introduction of an unsterilized dirty instrument may suffice to cause cystitis. (3) Bacteria can invade the bladder from surrounding organs, being transmitted by lymphatic dissemination. Thus an injury of the rectum may easily lead to cystitis. ' The mere presence of bacteria in the bladder is, however, not sufficient as a rule to determine an attack of c^^stitis. Large quanti- ties of pus are frequently discharged from the kidney through the bladder, and that over lengthy periods, and yet no inflammatory reaction follows. Some local predisposing factor must be added in order to excite their acti\dty, and amongst the most favourable are the following: (i.) Congestion of the mucous membrane, determined bj' exposure to cold; this is peculiarh^ liable to occur in gouty indi\iduals, and, indeed, there are people who ' take cold ' in. their I2 20 A MANUAL OF SURGERY bladders instead of developing a nasal or bronchial catarrh, (ii.) In- jury, as by the presence of a foreign body, a calculus, or rough handling during an operation, may serve to render bacteria active and virulent, (iii.) One of the most important causes is retention of urine, from whatever cause it is due — e.g., enlarged prostate, stricture, etc. The bacteria develop and decompose the urine, rendering it offensive and ammoniacal, and the toxins and irritating bodies thereby produced affect the vesical mucosa, (iv.) The j)resence of irritants in the urine may determine cystitis, as also pyelitis — e.g., after the absorption of cantharides. Other drugs may light up bacterial activity m some predisposed individuals — e.g., copaiba or cubebs. (v.) Loss of nervous control is a most important predisposing factor, and comes prominently into play in spinal injuries. The greatest difficulty is experienced in protecting such patients, and even effective purification of penis, hands, and catheter and the application of a sterilized dressing to the organ after the catheter has been used, may not suffice to prevent an outbreak of cystitis, which is due to infection from the kidney or rectum. In these patients the disease always runs a virulent course, and is likely to kill the patient by extension up the ureter. Pathological Anatomy. — In acute cases the mucous membrane of the bladder becomes congested and thickened; the epithelium is shed; mucus is excreted, and is soon transformed into muco-pus, which may be extremely viscid, and develops in large quantities. Ulceration of the bladder wall may occur, or even sloughing ; in the worst cases the whole of the mucous lining may necrose, and be cast off as a slough. Sometimes a membranous form of inflamma- tion occurs, the patient frequently passing flakes of some size, which on examination are found to be chiefly composed of fibrin. In chronic cases the mucous membrane is thickened and con- gested, the superficial veins dilated and even varicose, whilst ulceration is not uncommon. The continued repetition of the act of micturition leads to hypertrophy of the bladder wall, which becomes thickened and fasciculated; this effect is of course most marked when the cystitis is associated with obstruction to the out- flow of urine. The mucous membrane may protrude outwards between the muscular fasciculi, giving rise to pouch-like saccules, in which phosphatic concretions are sometimes formed, and the re- tained urine undergoes decomposition. Perforative ulceration occa- sionally follows, originating a fatal peritonitis or pelvic celluHtis from extravasation of urine. The contracted state of the bladder and the overgrowth of its muscular substance lead to compression of the openings of the ureters, hydronephrosis being thus induced. A plug of viscid mucus often finds its way into the ureteral orifice, and by becoming infected with bacteria causes an extension of the infective mischief to the kidney. The Symptoms of Acute Cystitis consist in pain referred to the perineum and hypogastrium, together with tenderness on pressure over the symphysis pubis. This is accompanied by extreme irrita- li LADDER AND PROSTATE 1221 bility of the bladder, frequent efforts of a painful and spasmodic nature being made to pass water (strangury) ; but little urine is voided at a time, for as soon as any amount has collected it is ejected forcibly. It generally contains blood and pus, soon becoming alkaline, and teeming with bacteria. Some amount of fever is generally noted, as also vomiting, whilst tenesmus may be induced as a result of the proximity of the rectum to the inflamed bladder. The usual termination of the case is in resolution, but sometimes chronic irritability may persist. In rare instances the inflammation is of such a virulent nature as to cause death. The urine in these cases is often exceedingly foul, and the fatal issue is due to ex- haustion, peritonitis, suppurative pyonephrosis, or even acute toxaemia. In some patients, however, when the inflammation is concentrated at the neck of the bladder, retention, distension, and atony may ensue. Treatment. — The patient should be kept in a warm atmosphere, and preferably in bed, and fomentations applied to the lower part of the abdomen ; hot hip-baths twice daily, maintained for some time, are very advantageous. The diet should be restricted to fluid, and the patient encouraged to partake freely of barley-water and other bland liquids. Alkalies and henbane may be administered, and morphia and belladonna suppositories are useful to allay the pain and irritability. x\s a rule, no instrument should be passed during the acute stage, unless retention is present; but if the urine becomes very foul, the bladder may be gently washed out, or even drainage of the bladder through the perineum may be necessary (see Perineal Cystotomy, p. 1223). Urinarj^ antiseptics, such as urotropine (5 to 10 grains three or four times a day), salol (10 to 20 grains,) and boric acid (15 to 20 grains), together with acid phosphate of soda, adminis- tered by the mouth, may do good. Chronic Cystitis is much more common than the acute variety, and is usualh^ associated with some irritation of the walls of the viscus, as from calculi, tumours, foreign bodies, tuberculous ulceration, or retention and decomposition of urine, especially if associated with obstruction to the outflow, as by a stricture or enlarged prostate. It may also follow acute cystitis. The Symptoms are those of irritability of the bladder, the patient constantly desiring to pass water, and having to rise at night, perhaps several times, for this purpose. The urine becomes turbid, and, on standing, deposits a variable amount of mucus or muco-pus, mixed with epithelial cells, crystals of triple phosphate, and a granular sediment of phosphate of lime. It is usually alkaline (unless due to a pure infection with the B. coli), perhaps foul-smelling and ammoniacal, containing an abundance of micro-organisms. There is often but little pain, though when a calculus exists, or the neck of the bladder is ulcerated, this may become a prominent s}Tnptom. The patient's general health is not at first affected; but if the symptoms persist it soon becomes impaired — partly from the absorption of septic products from the bladder, and partty from the 1222 A MANUAL OF SURGERY want of rest and sleep arising from nocturnal disturbance — and this may be so marked as to lead to fatal exhaustion. In other cases the inflammation may spread from the bladder along the ureters to the kidneys, and the phenomena of septic pyelonephritis manifest themselves (p. 1197). The Diagnosis of chronic cystitis is readily made from the charac- teristic symptoms of irritation of the bladder and the condition of the urine; but considerable difficulty may be experienced in determining its cause. In investigating a case, not only must the character of its onset be considered, but also the general history of the patient; whilst a thorough examination of the lower urinary passages must be instituted, and the urine examined microscopically and bacterio- logically. The passage of a catheter or sound will generally detect any obstruction located in the urethra, whilst the bladder is also examined by the cystoscope and other methods described at p. 1215. The Treatment of chronic cystitis is naturally directed towards its cause, if such can be discovered ; thus, calculi or foreign bodies should be removed, and a stricture dilated. In most cases, even where the cause is not apparent, great benefit will be derived from washing out the bladder. The bladder is best irrigated by passing a soft rubber instrument to the end of which is attached a portion of drainage-tube, about 3 feet long, and beyond this a glass funnel, into which the material employed is poured. By raising the funnel the fluid runs into the bladder, whilst on depressing it below the bed or couch the fluid returns on the syphon principle. The patient's sensations must guide the surgeon as to how much fluid can be borne in any particular case. Various solutions are employed for this purpose, but perhaps the most useful are weak Condy's fluid, sanitas (i in 10), boric acid (20 grains to i ounce), perchloride of mercury (i in 5,000), a neutral solution of quinine (2 grains to i ounce), or nitrate of silver (J grain to I ounce), and they may be used alternately with advantage. The frequency with which the injections are made must vary with the severity of the symptoms ; it is not often necessary to perform the operation more than once or twice a day. Of course the most stringent precautions must be taken as to sterilization of the patient's penis, of the surgeon's hands, and of the instruments employed. At the same time that this local treatment is being adopted, the patient's general habits of life must be regulated. The diet should be bland and unstimulating ; alcohol is better avoided, but if essential for other reasons, well-diluted gin or whisky may be given. Tea and coffee should be prohibited, whilst milk should be given freely, together with barley-water and some mild alkaline water — -such as that derived from Contrexeville. As to medicines, there are none which can alter the reaction of the urine from alkaline to acid, but perhaps salol, boric acid, or benzoic acid maybe of some assistance. Urotropine is useful, acting by setting free formahn in the bladder. Hot infusions of buchu, uva ursi, and triticum repens act as mild diuretics, and as alteratives to the vesical mucous membrane; full BLADDER AND PROSTATE 1223 doses, however, such as a pint or a pint and a half in the course of the day, are needed. Where much muco-pus is excreted, copaiba, cubebs, turpentine, or sandal-wood oil may be given, wliilst injec- tions of dilute astringents have been advised, but must be used with caution. Vaccine treatment should be employed if the B. coli is the active organism; but in such cases the results are often very disappointing, possibly because the vaccine is in the blood and the bacteria in the urine. The patient may remain apparently well, and yet the urine teems with bacteria, and occasional bouts of cystitis occur, which must be treated by alkaline drugs and by washing out the bladder either with Condy's fluid or with a very dilute solution of nitrate of silver. In cases which do not improve, and if the patient is becoming exhausted from the constant interference with his rest, etc., the only Fig. 547. — Perineal Cystotomy (Fergusson.) means of treatment left is that of opening the bladder through a perineal incision. Perineal Cystotomy is undertaken not only for draining a chronically inflamed bladder, but also to explore the mucous lining of the viscus to remove growths and foreign bodies, as also sometimes to deal with prostatic enlargements and calculi. The bladder is first thoroughly washed out, a few ounces of antiseptic solution being left within it. After anaesthesia has been induced, a staff with a median groove is passed into the bladder, and then the patient is placed in the lithotomy position, and the perineum shaved. An incision is made in the middle line of the perineum, from a point 2| inches in front of the anus to about i inch from that opening. The knife divides the deeper structures of the perineum, and, guided by the left index finger in the wound (Fig. 547), is made to enter the groove in the staff at a point corresponding to the membranous portion of the urethra. It is then carried upwards and backwards along the groove, incising the prostate and entering the bladder. 12 2^ A MANUAL OF SURGERY The knitc is carefully withdrawn, the linger gently inserted into the cavity, and the staff removed. After digital exploration of the bladder, a full-sized gum-elastic catheter (No. i6 or i8) is passed in through the wound and fixed, a long piece of rubber tubing being attached to allow of the constant escape of the urine, as well as to permit of occasional ii ligation. 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 w^eek ; in severer cases a permanent opening nia\' haxe to be maintained. Complications and Dangers of Perineal Cystotomy.— (i) llcemorrhage may arise from the superlicial arteries of the perineum, tlie deep branches of the pudic (especially that which passes to the bulb), ami the veins of the prostatic plexus. The first of these are divided in the superlicial incision, and may be readily secured by forceps. If the artery to the bulb or its branches in the bulb are cut. free haemorrhage follows, which is usually stopped without difficulty b\- opening up the wound and seizing the bleeding pomts with forceps, or by packing around a catheter. \'enous haemorrhage from the prostate is more serious, and is especially prone to occur in elderh- persons. Venous blood wells up from the depths of the wound, or passes back into the bladder, which becomes distended with clot, considerable pain being thereby induced. 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- elastic catheter, the deep portion of which is surrounded by an indiarubber bag, which can be inflated with air through a small tube fitted with a stop-cock, to which a force-pump can be attached. The petticoated tube is used when the former 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 then passed into the bladder, and the space between the petticoat and the tube packed with gauze. If the 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 Rectum may be caused by carrying the incision too far backwards, or by not maintain- ing the point of the knife strictly in the groove; it is more liable to happen, however, whilst withdrawing the knife, the point being swept backwards, thus opening the bowel. It is often not recognised until flatus and faeces are passed through the wound at a later date. If of small size and situated low down, it will probably close b^- cicatrization without special treatment; but when high up and more extensive, a rccto-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 cystotomy wound into one cavity, the communication being sometimes closed by the contraction of the granulation 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) Pelvic Cellulitis is caused by cutting beyond the limits of the prostate, and thus opening up the recto-vesical fascia, or by bruising and over-distension of the neck of the bladder by dragging through it too large a stone. In either case urinary extravasation and diffuse septic inflammation are likely to follow, resulting in grave constitutional disturbance of a septic nature, and possibly in the death of the patient. The treatment suggested is to support the general health by suitable diet and stimulants, whilst local tension is relieved by extending the wound backwards even into the rectum. (4) An acute ascending pyelo- nephritis is occasionally lighted up, in .spite of all precautions, and cannot be prevented. For symptoms, etc., see p. 119S. Tuberculous Disease of the Bladder may be primary or secondary, the latter being the more usual, and extending from 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 BLADDER AND PROSTATE 1225 in the submucous tissue as a deposit of miliary tubercle (Plate XI\'., Fig. 2), which caseates and suppurates, breaking down, and giving rise to ulcers with undermined edges ; these are rarely of large size at hrst. are usually multiple, and situated in or near the trigone. The Symptoms are those of chronic cystitis and hematuria, the irrita- bility of the viscus being very marked. The diagnosis is made by demonstrating the bacillus of tubercle in the urine, and by the cysto- scope. The course of the case is unfavourable, the ulcers increasing in size, and death resulting from exhaustion, general infection, phthisis, or extension to the kidne3'-s. Treatment. — The case is usually"^ treated for some time as one of chronic cystitis before its nature as a tuberculous affection is ascer- tained. In the milder cases it will suffice to attend to the general health and hygiene of the individual, and to wash out the bladder \v\t\\ 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. Injections of tuberculin (p. 184) have been found decidedly valuable in this condition. In more advanced cases cystotomy' has been undertaken bv the suprapubic method, and the ulcerated surfaces scraped and disinfected by applying the galvano- cautery or pure carbolic acid. To effect this the patient should be placed in the Trendelenburg position, and a suitable speculum used as a caisson through which to work. It is doubtful, however, whether such practice is of much ultimate value. When the primary lesion in kidney or testis is efficiently treated, a secondary bladder trouble often improves. _ \^ery 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 tngone, gi^dng rise to great irritabihty of the viscus and hematuria, ■ 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 a stone. Treat- ment consists in washing out the bladder with lactic acid (i to 3 per cent.), or in scraping and cauterizing the base of the sore through a suprapubic incision. Tumours of the Bladder. — New growths from the vesical wall are not very uncommon ; they may be simple or malignant. Simple Tumours occur in 'the form of fibroma, myoma, and myxoma ; but that most often seen is the Papillomatous or Villous Tumour, which appears as a soft fiocculent mass, usually situated near the trigone, and close to the opening of one of the ureters (Fig. 548 and Plate XIV., Fig. 4). The floating tufts or villous processes consist of an extremely dehcate connective tissue, covered with a layer or two of epithelium similar to that lining the bladder, and traversed by bloodvessels. Occasionally the grov/ths have a narrow base, and are pedunculated, but more frequently are sessile. They may be single, or may multiply rapidly, and spread all over the bladder by infection from the primary growth. 1226 A MANUAL OF SURGERY The Symptoms are those of recurrent h;einorrhagc, the ])loi)d being of a bright red colour, followed later on by irritaliility of the bladder. At first the haemorrhage is intermittent, considerable intervals oc- curring between the attacks; but subsequently it becomes more continuous. The irritability of the bladder is generally induced by chronic cystitis, and when the urine has undergone alkaline changes, there is a copious exudation of ropy mucus, which, mixing with the urine, causes considerable difficulty in micturition, leading in some cases to strangury. The urine may also contain portions of the i^ f*^^ h v^^' Fig. 548. — Villous Tumour of the Bladder. (From King's College Hospital Museum.) tmnour which have been set free, and occasionally, if situated near the neck of the bladder, some of the fimbriated ends may be swept into the urethral orifice, and interfere with micturition. In the same way the opening of one or both ureters may be encroached upon, leading to hydro-nephrosis. On examination of the bladder with a sound, nothing definite can be detected, unless the surface of the growth becomes encrusted with phosphates, and no abnormality is noticed on rectal examination. Occasionally a small portion of the growth may be caught in the eye of a catheter. The Prognosis of the case is unsatisfactory in the absence of effec- BLADDER AND PROSTATE 11-2.'] tive operative treatment, sinee, although the tumour is not malig- nant, it may give rise to multiple growths by tissue implantation, and then their removal is almost an impossibility, and the patients are likely to bleed to death. True malignant disease is said some- times to supervene, but this is very doubtful. The after-result of operations for a single mass is usually satisfactorj'. Sarcoma of the bladder is an uncommon disease, more often seen - in children than in adults. In the former it gives rise to multiple polvpoid growths; in the latter it is often single and sessile. The tumour grows rapidly, and may attain considerable dimensions, Fig. 549. — Cancer of the Bladder. (From Royal College of Surgeons' Museum.) spreading outside the bladder, and even invading the pelvic bones. Lymphatic glands may be implicated at an early date. Cancer of the bladder may originate in that viscus, or may spread to it from the rectum or neighbouring organs. In the former case, the growth is generally a squamous epithelioma; in the latter, its nature is, of course, similar to that of the primary disease; thus, when secondary to rectal cancer, the tumour is of a columnar type. Most frequently the affection commences in the posterior wall above the trigone, extending forwards to the neck of the bladder. The growth is sometimes superficial, projecting into the vesical cavity as a soft spongy mass, which does not ulcerate early, or invade the muscular walls till late; but more frequentty the neoplasm ex- tends into and infiltrates the walls, whilst marked ulceration is also 1228 A MANUAL OF SURGERY present (Fig. 549), the raw surface often becoming coated in places with a phosphatic deposit. A cancerous growth in the bladder is always more or less likely to become papillated. The disease is much more common in men than in women. The Symptoms vary somewhat in these two forms, although the conspicuous features of each are haematuria and irritability of the bladder. In the slowly-growing superficial variety, the tumour often attains a considerable size before causing any trouble, beyond possibly some slight irritability of the bladder. A severe attack of haematuria, unaccompanied by pain, is usually the first symptom of importance, and may be induced by some injury which causes a crack or fissure in the growth. This painless haematuria closely simulates the early symptoms of a simple villous tumour, but is more persistent, and yields less readily to treatment. After one or more of such prolonged attacks, cystitis follows, and the subsequent history resembles that of the harder and more rapidly growdng infiltrating tumours. In such, the symptoms of vesical irritability precede those of haematuria. Dysuria and severe pain referred to the bladder and perineum are complained of, and the urine early becomes alkaline and putrescent; shreds of the growth may also be found in the urine on microscopic examination. If the tmnour involves the internal meatus, micturition may be considerably im- paired; whilst if the orifices of the ureters are obstructed, hydro- nephrosis results. On passing a sound, the tumour can be detected as an irregular mass projecting into the bladder, whilst the posterior vesical wall may be felt pey rectum to be hard and resistant ; its ulcerated surface may also be seen with the cystoscopy The course of the case is similar to that of a somewhat rapidly growing carcinoma, leading to early and marked cachexia, increased by the sleeplessness resulting from the vesical irritation; secondary deposits are found in the \ascera and lumbar glands, whilst perfora- tion of the wall may occasionally follow, causing urinarv extravasa- tion, septic celluHtis, and death. Another most distressing com- pHcation is the estabhshment of a recto-vesical fistula, through which the urine makes its way into the rectum, thus intensif^-ing the sufferings of the patient. The Diagnosis of a vesical tmnour can only be made with certainty by the cystoscopy or by discovering fragments of its substance in the urine, though in the female it is easy to dilate the urethra, and explore the bladder with the finger. Whenever haemorrhage is associated with marked vesical irritabihty, and cannot otherwise be explained, a tumour of the bladder may be suspected, and cysto- scopy must be undertaken. In this viscus, as in others,' the only hope of curing malignant disease lies in early operation, and if the practitioner waits until the diagnosis is assured by the symp- toms, the patient's case is probabl}^ hopeless. Early cystoscopy is all-important. In simple papilloma and the superficial type of epithelioma, haemorrhage precedes the irritability; but whilst it is usually im- BLADDER AND PROSTATE 1229 possible to detect the villous growth either by examination with the sound, or from the rectum, a f ungating malignant growth may some- times be recognised by the sound. In the infiltrating type of malig- nant disease, on the other hand, pain and dysuria always precede the bleeding for a considerable interval ; whilst definite evidence of the existence of the growth can usually be made out, both by the sound and on rectal examination. A worn and exhausted appear- ance must not be 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 o£ the Bladder. — ^In the early stages, when the diagnosis of a tumour has not been confirmed, the hEematuria may be treated with ordinary haemostatic remedies, such as a mix- ture containing dilute sulphuric acid and ergot, or turpentine ad- ministered in capsules (10 minims three times a day). When once a diagnosis has been established, removal by opera- tion is the only plan which holds out any hope to the patient, and this can only be undertaken with any prospect of success in benign growths, or in the very earliest stages of malignant disease. The suprapubic operation is alwaj^s employed. The bladder is first washed out, and the patient placed in the Trendelenburg position. After opening the bladder and exploring it with the finger, a specu- lum is introduced and its interior illuminated by an electric lamp fitted to the surgeon's head. If more room is required, one of the rectus muscles may be cut across about ih inches above its inser- tion, and the viscus can then be freely opened. Papillomata and other simple tumours are removed, together with the mucous membrane from which they grow, by cutting round them with the knife or scissors. The base is ligatured and the growth removed, or a cautery knife may be used for this purpose. The fingers of an assistant in the rectum will suffice to press up the posterior wall and to give support. If possible, the incision in the mucous membrane should be closed by catgut stitches. Where the papillomata are large or multiple, this may involve an extensive operation, but with careful after-treatment there is a good prospect of recovery. For malignant disease of the bladder, partial or complete cystec- tomy may be possible. Partial Cystectomy consists in removal of the whole thickness of the vesical wall involved by the growth, and according to its location this may involve opening the peritoneal cavity or not. The bladder is exposed as described above, and the peritoneum is detached up to and beyond the growth, which is cut away, the solution of continuity in the wall being made good by careful suturing with catgut. Complete Cystectomy has been under- taken for extensive malignant disease, and may include removal of the prostate and seminal vesicles, the scope of the operation ex- tending nearly to th; membranous urethra. Necessarily, pre- liminary arrangements have to be made as to the ureters. Three plans are feasible; (i) They are implanted into the rectum, and the I230 A MANUAL OF SURGERY patient must run the chance of an ascending pyelonephritis ; (2) the ureters are brought out of incisions in the loin and drained; or (3) a double nephrostomy is performed, and the pelvis drained on either side, the patient then experiencing the discomfort of a double urinary fistula. The subsequent operation of removing the bladder is not one of extreme difficultv, but requires care to protect the patient from haemorrhage and from infection of the peritoneal cavity. When removal is impracticable, it only remains to ease the patient's sufferings by means of morphia, the bladder also being occasionally washed out; but if the irritabihty is very great, a permanent suprapubic or perineal opening may be established. Stone in the Bladder. Varieties. — A vesical calculus may be formed of almost any of the urinary deposits commonlv met with, and each has its own special characteristics. [a] The uric acid calculus (Plate XV., i and 2) is usually an oval, flattened body of considerable density, with a smooth or slightly nodular surface, and of a nut-brown colour. On section it is distinctly laminated, and it may be surrounded by a crust of phosphatic material. [h] The urate of ammonium calculus is of very similar structure, but of a lighter colour, and the lamination is less distinct. (c) The oxalate of lime or mulberr\- calculus (Plate XVI.) is a rough, irregular body, sometimes evenly nodular, but not imfre- quently tuberculated, or even spiculated. It is extremely hard and dense, laminated, and of a dark red-brown colour, or sometimes black, owdng to admixture uath blood. It is rarely of great size, oh account of the irritation caused b}' its presence, and its slowness of growth. [d] A pure phosphatic calculus (Plate XV., 4 and 5) is ver}- im- common, but any stone or foreign bodv is certain to become coated with a phosphatic deposit when chronic cystitis has resulted in alkaline decomposition of the urine. Occasionallv concretions of a similar nature form spontaneouslv in saccules of the bladder ; such bodies are white and chalk\- in appearance, friable in consistency, with no evidence, or but little, of lamination, and on removal are exceedingly offensive. These concretions consist of a mixture of the triple phosphate and phosphate of lime. Less commonly an excess of the triple phosphate is present ; if in the proportion of two parts of the latter to one of phosphate of lime, a laminated and somewhat denser calculus is produced, which is sometimes termed di fusible calculus, owing to the fact that it fuses to a bead imder the blowpipe flame. Occasionally a phosphate of hme calculus occurs in the upper urinary passages {e.g., the pelvis of the kidney), and has a crystalline appearance on drying. [e) Cystine forms the basis of a rare calculus which is of a yellowish-green colour and waxy appearance. PLATE XV. Stones from the Bladder. Figs. I afid2. — Uric acid Calculus - on section and outer surface. Fig. 3. — Encysted Calculus of uric acid. The lower segment was held firmly in a saccule near the trigone ; the larger portion projected into the bladder. A certain amount of phosphatic deposit covers the exterior. It was successfully removed by a suprapubic operation. Figs. 4 and 5. — Phosphatic Calculus. \_To face page 1230. PLATE XVI. Oxalate of Lime Calculus. Fig. I. — From the exterior. Fig. 2. — On section. \_To face page 1230 BLADDER AND PROSTATE 1231 (/) Xanthine, or xantliic oxide, occurs very exceptionally as a calculus of a reddish colour. An encysted calculus is one which develops in a pocket or pouch connected with the bladder wall. It may consist of any of the above substances, and is due to a small stone hnding its way into a sac- cule and being arrested there. It grows by gradual accretion of new calculous material, and after a time projects into the vesical cavity. A typical illustration is shown in Plate XV., 3, where the large'intravesical portion is separated from the encysted part by a narrow neck. Occasionally this condition is due to the decomposi- tion of stagnant urine in a pouch, and the calculus is then phos- phatic in composition ; it is not unlikely to lead to ulceration of the sac wall and extravasation of urine. Structure of a Calculus. — A calculus usually consists of the fol- lowing parts: i. The nucleus, which may be formed by a portion of blood-clot, inspissated mucus, a renal calculus, or some foreign substance introduced from without. 2. The body, which consists of superposed layers of uric acid or oxalate of Hme, or of whatever substance the stone is composed ; not unfrequently the composition of adjacent laminaa differs, leading to what is known as an alternat- ing calculus. Each lamina consists of myriads of minute crystals, held together by vesical mucus, with which a certain amount of phosphatic material is often mixed, whilst layers of pure phosphatic deposit may be interposed. 3. The crust consists of a variable amount of soft, friable phosphatic material, the quantity of which is the measure of the degree of chronic cystitis originated by the calculus; in some cases it is entirely absent. The Number of calculi present in a bladder varies greatly. Some- times there is only one ; occasionally a considerable number, counted perhaps by hundreds, may exist; in such circumstances they are never of great size. Multiple calculi are not unfrequently faceted as a result of mutual friction. The Causes of vesical calculus must be looked for in some of those constitutional conditions already described as predisposing to lithiasis or oxaluria. They are very common in children during the first decade of life, especially amongst the lower classes, the children of the rich rarely suffering from stone. It diminishes in frequency from childhood to the age of twenty-five, and then gradually increases until it is relatively common in elderly men. The condition is comparatively rare in women, o\^dng to the fact that the shortness and large size of the urethra allow small calculi to be much more readily passed. Possibly the character of the drinking-water, or the amount imbibed, is a matter of importance, as indicated by the fact that the occurrence of calculus is very unequally distributed in different parts of the country; thus, it is most frequently met with in the Eastern Counties. It is also very common in India and Arabia, a fact which may possibly be ex- plained bv the large amount of fluid withdrawn "from the body by perspiration. 12 32 A MANUAL OF SURGERY Symptoms. — The effects produced by vesical calculi vary in different individuals, according to the shape of the stone, and the tolerance of the mucous membrane. In children and young adults, where the parts are very sensitive, even a smooth calculus gives rise to severe sjonptoms, whilst old men often tolerate a large stone without much inconvenience; cceteris paribus, an oxalate of lime calculius 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 having passed ' gravel ' for a long time, or by an attack of renal colic, on the cessation of which the calculous s^TTiptoms commenced. Sometimes the vesical symptoms do not appear for some time after the passage of a stone into the bladder, presumably in consequence of its small size. They consist of pain in the perineum and neck of the bladder, which radiates to the back and down the thighs, but is especially noticed at the end of the penis immediately after micturition. The stone is then pressed down against the sensitive neck of the bladder by the contraction of its muscular walls. Increased frequency of micturition is also present, and perhaps hematuria of a vesical type, though this is not a prominent feature. All these phenomena are increased in severity by jolting, jmnping, or any form of exercise, and hence are more marked during the day than at night. Occasionally the patient complains that the flow of urine suddenly ceases before the bladder has been completely emptied, and that some change in the position of the body is needed in order to allow him to complete the act. In addition to these characteristic symptoms, he may suffer from various phenomena secondary to the irritability of the bladder, and dependent on the straining induced by the calculus. Thus, tenes- mus, followed by piles or prolapsus ani, may be produced by sympa- thetic irritability of the rectum, especially in children ; whilst a hernia may also be caused, and not unfrequently 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 circumcision for phimosis. The actual Diagnosis of vesical calculus can be made by radio- graph}^ or sounding. X-ray examination is conducted in the usual fashion, care being taken to see that the rectum is empty. The lamp is placed over the patient's abdomen, with the rays directed downwards and backwards, and the plate is behind. The calculus usually appears as a shadow immediatel}^ above the pubic rami (Fig. 550). In order to examine a patient by sounding, he is laid on a couch with the head low, and the buttocks raised on a pillow placed beneath them. The bladder should always contain a few oimces of fluid, so as to obliterate any folds produced by laxity of the mucous membrane, as well as to facilitate the introduction of BLADDER AND PROSTATE 1233 the instrument; the usual antiseptic precautions as to surgeon's hands, patient's penis, instrument, and lubricating material, are of course rigidly enforced. A sterilized sound of suitable size, warmed and lubricated by some antiseptic preparation, is then gently passed along the urethra, and the handle depressed between the separated legs so as to enable the point to enter the bladder. The handle, which should be cylindrical in shape and fluted, with the maker's name or some mark to indicate the direction of the beak, is then lightly grasped between the index-finger and thumb, and rotated from side to side, whilst at the same time the whole instru- ment is drawn forwards or backwards in the urethra. Each side of Fig. 550. — Radiogram of Vesical Calculus in a Boy. the bladder is thus carefully investigated, and, finally, if no stone is detected, the beak is turned directly downwards, so as to examine the pouch which often forms behind a slightly enlarged prostate. The presence of a stone is recognised by a metallic click, which can be felt and even heard, when the end of the instrument taps it. The character of the click is some guide to the size and density of the stone. The presence of two or more calculi is indicated by the surgeon being able to touch them on rotating the instrument alter- nately to each side of the middle line, or by seizing one stone with a lithotrite, and using it as a sound for the other. In doubtful cases, a still more delicate test than the sound is obtained by passing a 78 1234 A MANUAL OF SURGERY medium-sized tube of a Bigelow's evacuator, and washing out the bladder. The calcuH may by this means be sucked out even from saccuh, and be felt to rattle against the end of the instrument when the pressure upon the indiarubber bulb is relaxed. When the calculi are multiple and of small size, they may be even removed in this way by an examination which was only intended to be diagnostic in character. The surgeon must not forget that a hypertrophied bladder with projecting fasciculi may somewhat resemble a calculus, espe- cially when coated with phosphatic material. In some rare instances a calculus may be so completely hidden in one of the saccules as to render its detection impossible by these means. An encysted cal- culus which projects into the bladder is recognised by being always found at the same place. Course of the Case. — A patient suffering from vesical calculus is certain, sooner or later, to develop symptoms of chronic c\^stitis, and septic changes in the urine are equally sure to follow — possibly as a natural sequence, but often as the result of the introduction of dirty instruments. The bladder is hypertrophied, and if the stone is not removed, the mucous membrane becomes ulcerated, and the inflammation extends to the kidneys; the patient's life is thus destroyed, partly by exhaustion, and partly by septic or ursemic poisoning. The Treatment of vesical calculus is a matter which has exercised the judgment and manipulative dexterity of surgeons for many centuries. A large number of operations have been made use of. but at the present day only three are employed — viz., lithotrity, suprapubic c^'stotomy, and very uncommonly perineal cystotomy. Lithotrity was formerly- conducted in several stages, the stone being crushed, and the patient allowed to pass the debris subse- quently ; this process was repeated at intervals of a few days, 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 Bigelow's evacuator completely revolutionized this operation, and enables it to be completed at one sitting, con- stituting the proceeding sometimes termed Litholapaxy. Operation. — The patient is carefully prepared by keeping him under observation for a few days, regulating the bowels, and, if possible, 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 sHghtly to raise the pelvis. The bladder is carefully washed out A\ath some bland antiseptic, such as a solution of boric acid, and about 6 ounces of lotion are left within it, in order not only to obhterate all folds of mucous membrane, but also to facilitate the seizure of the stone, and to prevent injury of the walls during the operation. BLADDER AND PROSTATE 1235 The lithotrite (Fig. 551) is then introduced. The male blade slides easily up and down a groove in the stem of the female blade, and after the stone has been seized the blades are forcibly pressed together by a screw action, brought into play by the mechanism in the handle, which can be put in and out of gear at will. It is absolutely essential that the instrimient should be made of well-tempered steel, so as to prevent any risk of breaking during the operation. To introduce it some skill is needed, since the curved end is short, and consequently the handle must be well depressed between the legs, in order that the beak may pass under the pubic arch. The posi- tion of the stone is next ascertained by rotating the instrument, and using it as a sound; the blades are opened, and the stone caused to roll between them by a sHght jerk of the handle. This is better than attempting to pick up the calculus by inverting the blades, and is less likely to injure the mucous membrane. If fairly grasped, the blades when screwed up crush it into several fragments, each of which is sub- sequently dealt with in a similar fashion. If only the margin of the stone is gripped, the application of screw pressure may cause it to slip awa\^ and the manceuvre must then be care- fully repeated, ^^'hen the surgeon is satisfied that the fragments are sufficiently small, the largest evacuator-tube that can be safely intro- duced 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 the bladder thoroughly washed out by alternate pres- sure upon, and relaxation of, the rubber bottle (Fig- 55-)- By this means the fragments of the stone are collected in the glass receptacle which forms part of the apparatus. The washing is continued imtil 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; the old practice of withdra\\ing small fragments mthin the grasp of a lithotrite is to be condemned. 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, however, considerable bleeding follow, the H 1236 A MANUAL OF SURGERY bladder is likely to become subsequently distended \\ith clots, necessitating the use of a large-eyed catheter for their removal. After-Treatment. — The patient is placed in bed as soon as the operation is completed, and kept warm and quiet, and suitable measures must be taken to combat shock. The diet is restricted to fluids for a few days, whilst pain, if complained of, may be reUeved by a little morphia. If all goes well, he may be allowed to get up at the end of the week. Various Sequelae may follow this operation. Cystitis results partly from mechanical causes, but more frequently from imperfect asepsis. The s^-mptoms are usually subacute in character, and may pass away after a few days ; but if of a serious ty^e, considerable constitutional disturbance arises, and a large amount of viscid muco-pus is excreted, whilst the urine becomes alkahne and ammoniacal. In such a case it is absolutely essential to wash out the bladder once or twice a day, Fig. -EVACUATOR IN POSITION IN THE BLADDER. 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 pyelone- phritis. Atony of the bladder is occasionally induced, either by the operation or by a consequent cystitis, and is especially common in elderly individuals. It must be treated by regular and aseptic catheterism. When the patient's kidneys are already affected prior to the operation, an acute ascending pyelonephritis (p. 1198) may be originated by it, perhaps leading to suppression of urine and death from unemia. Suprapubic Lithotomy was formerly looked on as a serious pro- cedure with a high mortality; at the present time increasing ex- perience has shown that the dangers were preventable, and that it may be considered a very successful procedure. The bladder is washed out, and 8 or 10 ounces of lotion left within it; the patient is then placed in the Trendelenburg position, with the pelvis raised, the intestines being thus allowed to gravitate to the postero-superior BLADDER AND PROSTATE 1237 part of the abdomen; as soon as the abdominal parietes are opened, air finds its way into the connective tissue behind the symphysis (ca\-um Retzii), and the peritoneum is thus pressed back. Operation. — The pubes having been previously shaved, and the hypogastrium purified, an incision is made in the median line reacliing from the top of the symphysis upwards for about 2 or 3 inches ; the lower part of the linea alba is divided, and the retro- pubic cellular tissue opened up. The tense rounded outHne of the bladder can now be readily detected with the finger, and a couple of lateral silk sutures or shngs are passed through its walls so as to steady it and prevent its subsequent retraction. An opening is then made into it in the middle line from below upwards, through which the index-finger is passed and the stone examined. Suitably curved hthotomy forceps are introduced, and the stone grasped and with- drawn. A careful examination of the interior of the bladder is made, to ascertain whether any further calculi are present, as also to investigate the condition of the prostate, which may sometimes be advisably removed at the same time. The after-treatment of the wound differs with the condition of the bladder ; if it is infected, a good-sized drainage-tube is introduced, and the urine syphoned off, healing occurring by granulation in three to six weeks (see After-Treatment of Prostatectomy, p. 1251). If the bladder is healthy and free from infection, it may be closed by sutures, which only pass through the muscular and submucous coats, and thus when tied do not project into its cavity. 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 leak into the wound. The urine is either drawn off by a catheter at regular intervals, certainly not less than three or four times daily, or the bladder is drained by tying in a catheter. Perineal Lithotomy is seldom required at the present day; the procedure described as perineal cystotomy (p. 1223) would be adopted. The finger is passed into the bladder, and the stone located. It is removed by suitable stone forceps, or by a scoop and the finger. Care must be exercised not to damage the structures at the neck of the bladder, or pelvic cellulitis may ensue; but this danger is little likely to arise, as the operation ought never to be undertaken when the stone is of large size. Formerly much importance was attached to the operation of lateral lithotomy, in which the stone was removed through a perineal incision which included the left lateral lobe of the prostate. This procedure is now entirely superseded, and need no longer be de- scribed. Choice of Operation for Vesical Calculus. — At the present day lithotrity has been brought to such a standard of excellence that there is no doubt as to the general rule which should be followed — viz., that unless some contra-indi cation is present, all cases of vesical calculus should he treated by lithotrity. 1238 A MANUAL OF SURGERY The Contra-indications to Lithotrity are as follows: (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 that no lithotrite can crush them. Phosphatic concretions, on the other hand, are so soft that a lithotrite becomes clogged, and crushing is impracticable. An encvsted stone will also preclude lithotrity on account of its fixed 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 evacuator. (2) Conditions of the Urethra. The existence of an organic stricture, or an enlarged prostate, may render lithotrity impracticable from the impossibility of passing large enough instruments, whilst false passages may make it exceedingly dilhcult. Excessive irritability of the urethra, as evidenced by the occurrence of severe rigors after instrumentation, may also render the operation unadvisable. (3) Conditions of the Bladder. The existence of severe cystitis or the presence of sacculi, as indicated by the cystoscope, will usually suggest the performance of lith- otomy; whilst a contracted bladder, which will only hold a few ounces of urine, materially increases the dangers and difficulties of lithotrity. Suprapubic Lithotomy should be undertaken under the following 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, and it is often feasible to remove the prostate at the same time. Suprapubic cystotomy is only absolutely contra-indicated by two conditions — ^\iz., severe septic cystitis and contraction of the bladder. Indications for Perineal Lithotomy. — (i) When serious cystitis and great irritability of the bladder are present, the incision facilitating the process of draining and washing it out ; (2) a contracted and hypertrophied condition of the bladder; (3) when a calculus is impacted in the neck of the bladder. Calculus in Boys is a common occurrence. It must be remembered that the bladder is rather an abdominal than a pelvic organ in children, and hence suprapubic lithotomy is particularly indicated, except in the hands of skilled lithotritists. It has been shown, how- ever, that lithotrity can be safely practised, and many surgeons in the East, where stone is so common, employ it as a routine procedure, granting that a No. 6 catheter can be passed, and that the stone is not too large for a lithotrite to grasp. Special hthotrites and evacuators are constructed for the purpose. Calculus in the Female. — As already mentioned, vesical calculus is very rare amongst women, owing to the shortness and greater size of the urethra, so that small stones passing downwards from the kidneys are easily voided. Phosphatic concretions are not un- common, and are then formed around a foreign body usually intro- duced by the patient. Many of the symptoms are very similar to BLADDER AND PROSTATE 1239 those in the male. Treatment. — If the calculus does not exceed i to f inch in diameter, it can usually be extracted by dilating the urethra with the linger, the sphincter being also nicked in two or three places if necessary. It is never wise to divide the sphincter totally, as incontinence is almost certain to follow. For a somewhat larger stone lithotrity can be undertaken, whilst for those of really large size suprapubic cystotomy is the best procedure. It has been recommended to open the bladder through the anterior vaginal wall, and thus remove a stone; but this is scarcely desirable, for fear of the persistence of a vesico-vaginal fistula. Functional Derangements of the Bladder. The act of micturition is a complicated proceeding, which for its effective performance requires the due co-ordination of several factors. When urine collects in the bladder, it is prevented from escaping at once by the tonic contraction of the sphincter vesicae; in infants this is but little developed, and hence is readily overcome by the relatively strong detrusor in response to but slight intravesical pressure. As the child grows, the sphincter becomes better de- veloped, and is under more effective control ; whilst at puberty the growth of the prostate adds to this, and therefore micturition loses its reflex character, and becomes entirely voluntary. Three chief elements enter into the act of urination — -viz., (i) an apprecia- tion of the stimuli set up in the bladder by its increasing distension, which depends on the sensory nerves having a free communication with the sensorium; (2) as a result of this stimulus, the sphincter vesicse is voluntarily inhibited; and (3) the detrusor muscle is con- tracted, expulsion of the urins necessarily following. A volimtary contraction of the abdominal muscles is often employed to assist in this expulsive effort. Each of these muscular elements has its own centre in the lumbar enlargement of the spinal cord, and it is possible for one or both of them to be destroyed or weakened. Should the sphincteric control become weak, the activity of the detrusor may be relatively increased, and the bladder contents are expelled too frequently (active incontinence). Should the sphinc- teric control be relatively increased, the expulsive efforts of the detrusor will be hindered, and retention results. Necessarily other causes than nervous enter into the production of these two con- ditions, and hence they must be considered separately. Incontinence of Urine. — A patient is said to be suffering from incontinence when the urine escapes involuntarily, dribbling away either constantly or intermittently from the urethra. I. Active Incontinence (Enuresis) is often present in young children, mostly boys, in whom, as already indicated, sphincteric control is not too well developed. It results from some condition of increased excitability of the urinary apparatus, and is looked on bv some as of a choreic nature. The chief sources of irritation are phimosis, ascarides in the rectum, a rectal polypus, or urine of high I240 A MANUAL OF SURGFUY specilic gravity, containing uric acid crystals in suspension. The affection is most obvious at night, and, indeed, may only occur during sleep; it usually disappears when adult life is reached, if not cured before, but has been known to persist later. Treatment of the nocturnal incontinence consists in the removal of all sources of irritation — such as a tight foreskin ; whilst the child is waked from sleep at regular intervals in order to pass water, so as to break him from the bad habit. Tonics — e.g., iron, arsenic, and quinine — may be administered, and tincture of belladonna should also be given in full doses. He must not be allowed to lie on his back, or to eat or drink late at night, but must be kept warm. All excitement of the sexual senses must also be avoided. 2. Passive Incontinence is said to be present when the neck of the bladder is relaxed, so that as soon as any urine is secreted, it flows out of the urethra — the bladder in this way never becoming dis- tended. It arises mainly from two causes: (a) Paralysis of the sphincter vesicae, as a result of some injury or disease of the spinal cord, which may impair its function either temporarily or perma- nently. Thus, in severe shock, the bladder is unconsciously evacu- ated from relaxation of the sphincter ; but if the Imnbar cord is not compressed or destroyed, the function is soon regained. Any lesion involving the centre for the sphincter necessarily destroys its future utility, and results in permanent incontinence. It is quite possible for the detrusor centre to be damaged without injury to the sphincter, and in such a case distension of the bladder with subsequent over- flow supervenes. Paralytic incontinence occasionally follows over- distension of the female urethra for the removal of a calculus. Nothing can be done for either of these conditions, if permanent, beyond the application of a suitable urinal, {b) Mechanical Incon- tinence sometimes results from the impaction of a calculus in the internal meatus, or from its dilatation by a pedunculated growth from the prostate. 3. False Incontinence, or Distension with Overflow, may be the outcome of an attack of retention, naturally relieved, or is due to any condition in which the outflow of urine is impeded to such an extent as to lead to a certain quantity being left in the bladder after every act of micturition, although the patient, imagines that the organ has been completely emptied. This so-called residual urine gradually increases in amount until the bladder becomes filled, and then some of it dribbles away involuntarily so as to wet the patient's clothes. In old-standing cases the bladder can be de- tected as a tense, rounded swelling in the hypogastrium. This condition is usually met with in patients with' neglected stricture or enlargement of the prostate, and in the latter case the bladder may be so distended as to contain many pints of urine. Very much the same state of things obtains in paralysis due to spinal mischief. Treatment must be directed to keeping the bladder emptied by the regular use of a catheter, but it often remains in an atonic state for some time. BLADDER AND PROSTATE 1241 Retention of Urine. — When a person is unable to expel the con- tents of his bladder, so that it becomes distended, retention is said to be present. It results from a variety of conditions, which may be classified as follows: I. Mechanical obstruction which may involve any part of the urethra or the neck of the bladder, the actual cause varying some- what with the age and condition of the patient. Thus, in infants the commonest cause of retention is the narrowed orifice of a tight phimosis; in children, an impacted calculus in the urethra or a ligature tied round the penis ; in young men, gonorrhoea or one of its comphcations ; in young women, foreign bodies in the urethra or bladder; in adult men, stricture; in adult women, uterine fibroids or some uterine condition compressing the bladder or urethra ; and in old men, hypertrophy of the prostate. 2. Nervous lesions may be responsible for some cases. Anything that excites the sphincteric energy or diminishes the activity of the detrusor muscle may determine retention, and thus it may be brought about in many ways : (a) Spasm of the sphincter may result irom mental perturbation or excitement, a person being unable to micturate in the presence of others; possibly this is more evident in those who have been guilty of masturbation, [h] Neurosis is a common cause, as in hysteria or shock ; whilst a reflex neurosis is responsible for retention after injuries or operations, especially when the latter are somewhere in the neighbourhood of the genital organs, as for piles, hernia, varicocele, etc. (c) Organic disease of the nervous system produces retention, as in tabes, disseminated sclerosis, traumatic and neoplastic conditions of the cord, etc. 3. Inflammatory diseases of the bladder may be followed by difficulty in micturition or even retention, probably as the result of an interstitial fibrosis of the vesical wall, and may, perhaps, occur most frequently after gonorrhoeal cystitis, or that due to the B. coli. 4. Retention is sometimes the outcome of habit or circumstances, as in clerks or school teachers, and then when the opportunity to micturate occurs the act cannot be completed. If left unreHeved, the urine accumulates and the bladder becomes distended, as described at p. 12 15, giving rise to much pain and dis- comfort. One of two conditions is certain to follow: [a) In cases of retention from stricture, or when a calculus is impacted in the urethra, the dilated urethra behind the seat of obstruction gives way, resulting in perineal extravasation of urine. If, however, the vesical bladder wall has been weakened as the result of ulceration, or if it be sacculated, rupture of that viscus may occur, and pelvic extravasation may follow, [h) When the retention is not due to complete obstruction of the passages, the distention is in time fol- lowed by unconscious overflow, and rehef is thereby obtained, al- though the bladder wall passes into a condition of atony. The treatment of retention necessarily varies with the cause, as it is but a S3^mptom. 1242 A MANUAL OF SURGERY Atony of the Bladder is the term applied to a condition in which the patient is unable to expel the contents, not on account of any true paralysis, but simply from loss of tone of the muscular wall. The causes are as for retention, and the condition may be determined by a single act of over-distension, or be the outcome of a more chronic type of retention. Thus, owing to the oversight of a house- surgeon, it occurred in a patient who had been operated on for varicocele, and left unrelieved for twenty-four hours. More com- monly, however, it is met with in old people who are suffering from retention due to enlargement of the prostate, or in men who are the subjects of stricture of the urethra. In the slighter cases all that is noticed is some hesitation or diffi- culty in commencing the act of micturition, whilst the flow itself is weak, the urine escaping with no force, and often dribbling away after the act is apparently completed. In bad cases a considerable amount of residual urine may be left in the bladder, the decomposi- tion of which may lead to chronic cystitis. The Treatment should be directed to removing any source of obstruction which exists, whilst regular catheterism two or three times a day will prevent any dis- tension of the bladder, and the administration of strychnine, phos- phoric acid, and other tonics, will improve the expulsive power of the viscus. The passage of a constant current of electricity may also be employed two or three times a week, to stimulate the mus- cular fibres ; one electrode is inserted into the bladder, and the other placed over the hypogastrium. Affections of the Prostate. Acute Prostatitis arises most usually as a sequela of gonorrhoea, either in its acute or chronic stage, by direct extension backwards of the inflammatory process; it is also occasionally met with as a result of stricture arising from the irritation of retained and decom- posing urine, or from the passage of instruments. It is said to be induced by the application of cold or damp to the perineum, as by sitting on cold stones or damp grass, but probably this has been preceded by bacterial invasion of the posterior part of the urethra. Suppuration follows in not a few cases, being due to the infection of the prostatic folhcles with pyogenic organisms. Sometimes merely one or two superficial follicles are affected, causing what is termed a follicular abscess ; occasionally the mischief extends much more widely, involving the whole of one lobe, or perhaps the whole organ, and constituting a parenchymatous abscess. The Symptoms consist of deep-seated pain referred to the neck of the bladder, with perhaps a sense of weight and fulness about the perineum, and pain referred to the end of the penis. Micturition becomes frequent and painful, and defaecation may cause consider- able distress. As the organ increases in size, the pain becomes more and more severe, and all movements of the body, as also the act of sitting, are increasingly difficult. On rectal examination the BLADDER AND PROSTATE 1243 organ can be felt enlarged, hot, and tender. Suppuration is likely to follow, and retention of urine may be thereby induced. A fol- licular abscess bursts into the urethra spontaneously, or is ruptured by the passage of a catheter for the relief of retention ; the opening, however, is sometimes 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 through the perineum. In either of the latter conditions a rectal or perineal fistula is liable to result. Considerable constitutional dis- turbance, and perhaps a good deal of fever, are usually associated with this affection, whether suppuration occurs or not. The forma- tion of a parenchymatous abscess is always attended with much more acute symptoms, both general and local. The organ is larger and produces more rectal irritation ; a considerable quantity of pus may form, and suppuration may extend beyond the capsule into surrounding parts. Treatment. — The patient should be kept in bed on a restricted diet, and the bowels freely opened by saline purges, combined with 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 the 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 off, 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 gonorrhoea is also present, suitable treatment must be adopted in order to check the discharge. When the abscess is pointing in the rectum, it may be wise to open it from that cavity ; but every effort must be made to avoid this contingency, as a recto- urethral fistula may result. Chronic Prostatitis is perhaps one of the most common causes of chronic gleet after gonorrhoea. It is sometimes left as a sequela of an acute attack, or may arise as a result of stricture. The Symptoms produced by it are a sense of weight and fulness about the perineum, combined with irritability of the bladder, and pain referred to the extremity of the penis at the end of micturition, owing to the bladder contracting upon the hypersemic and sensitive organ. A glairy discharge of viscid material, similar in appearance to uncooked white of egg {prostatorrhoea), is often present, whilst fine threads of mucus are usually seen floating in the urine, being due to the formation of mucous casts of the prostatic ducts. On examination through the recttun, the organ can be felt enlarged 1244 A MANUAL OF SURGERY and tender, and the vesicuke are usually in the same condition. Chronic suppuration may follow, the abscess bursting into the urethra or rectum, or pointing in the perineum. The Diagnosis from tuberculous disease can usually be made by careful attention to the history and physical signs. Treatment consists in counter-irritation of the surface of the perineum, as by blisters or iodine paint, care being taken that the reagent employed does not extend either to the anus or scrotum. Belladonna 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 no suspicion of suppura- tion, a cure may occasionally be brought about by the administra- tion of iodide of potassium, or of the liq. ferri perchloridi (H^xv. or more, t.d.s.), combined with sulphate of magnesia. The local ap- plication of a solution of nitrate of silver by a porte-caustique is also sometimes recommended, but probably the best treatment con- sists in forcible dilatation of the prostatic urethra, as suggested by Oberlander, the follicles being thereby emptied of their secretion; massage of the prostate per rectum 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 vesicles 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 ulceration, 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 perinemn. Haematuria is occasionally produced, whilst pyuria is almost con- stant. The urine is feebly acid or neutral, and, on examination of the pus which is deposited on standing, the tubercle bacillus may be detected. Rectal examination will demonstrate an irregular enlargement of the organ, whilst if the vesiculae are invaded they can also be felt. Treatment consists in attending to the general health, and the administration of tonics ; vaccination with tuberculin may prove of some value. Possibly, if the disease is not too extensiv^e, benefit may be derived from scraping away the tuberculous tissue through a perineal incision. Prostatic Calculi are of unfrequent occurrence, being usually met with in cases of chronic prostatitis, especially that resulting from stricture of the urethra or previous attacks of gonorrhoea. They are generally multiple, and of small size, consisting mainly of carbonate of lime, i hey develop primarily in the glandular crypts, and may remain embedded in the organ, giving rise to but little inconvenience. When large and protruding from the gland into the BLADDER AND PROSTATE 1245 urethra, symptoms of obstruction to the flow 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. Diagnosis can be effected in some instances by radiography, the calculi casting shadows usually a little below the brim of the; pelvis. It is in some instances possible to remove the calculi through the urethra, but more frequently a perineal incision is required. Enlargement of the Prostate (or, as it used to be termed, senile hypertrophy) is a condition rarely seen under fifty years of age, characterized by a chronic persistent overgrowth of the organ, which results in interference with the act of micturition, and may finally destroy life by inducing secondary changes in the bladder and kidneys by prolonged backward pressure. As to causation, but little is known ; it is not apparently attributable to excessive sexual indul- gence. It may attain a considerable size, perhaps constituting a tumour as large as one's fist and weighing 200 grammes, the average normal weight of the prostate being about 18 grammes. It may be of hard or soft consistence, and in the latter case is extremely vascular. The vascularity varies from time to time, and the patient is liable to sudden attacks of congestion, which aggravate the symptoms. On section the organ may appear to be homogeneous and of the same texture throughout, but most commonly it consists of a nrnnber of firm rounded masses, sharply defined, and held to- gether by a certain amount of connective tissue. Outside these is an ill-defined layer of stretched (and sometimes atrophied) muscular tissue, containing a few glandular elements, but continuous with the stroma, and constituting the true capsule of the organ. Still further out is the extrinsic sheath, derived from the pelvic fascia (mainly recto-vesical) ; it consists of two layers, between which are the veins of the prostatic plexus. Histologically, an enlarged prostate consists of an overgrowth of the glandular tissue, sometimes diffuse, more frequently in the form of multiple adenomata, set in a connective-tissue basis developed from the prostatic stroma of muscle fibres. Cystic changes are not unusually observed in these adenomata. Occasionally a few fibro- myomata may develop, but they are decidedly uncommon. The changes induced in connection with an enlarged prostate are numerous and important.* 1. The prostatic sheath of pelvic fascia becomes thickened and condensed, thereby preventing any downward expansion of the organ, and directing its enlargement upwards. 2. The close connection between the capsule and the sheath, which is so marked a feature in the normal anatomy of the organ, is profoundly modified, so that it becomes easy to enucleate the gland in its entirety from its surroundings. * Vide ' The Surgical Anatomy of the Normal and Enlarged Prostate,' by J. W. Thompson Walker, Med.-Chir. Trans., vol. Ixxxvii. 1246 A MANUAL OF SURGERY 3. The relations to the bladder wall are also much altered. Normally, the sphincter (Fig. 553, S.V.) is interposed between the prostate and the vesical mucosa. As the gland enlarges, this rela- tion may persist (Fig. 554), and although the bladder base is raised up, the growth is extravesical, and the sphincter muscle covers over the enlargement. More frequently, however, the gland, as it en- larges, insinuates itself between the sphincter and internal meatus, constituting an intravesical enlargement (Fig. 555). This is gener- ally most marked in the middle line behind, constituting the so- called 'middle lobe'* (Fig. 556); but it may involve the whole gland, which projects into the bladder as a collar-like enlargement around the meatus, whilst sometimes one or both of the lateral lobes are chiefly affected in this manner. The gland also pushes backwards between the seminal vesicles, which in time are dis- FiG. 553 Fig. 554- Fig. 555. P'iGS. 553-555. ^Diagrams to illustrate Relation of the Prostate to THE Sphincter Vesica (S.V.). In Fig. 553 the prostate is supposed to be of normal size, and the sphincter hes above it; in Fig. 554 the prostate is enlarged, but has no intravesical pro- jection or ' middle lobe,' and hence the sphincter retains its normal rela- tion; in Fig. 555, the most common type of prostatic enlargement, a well- marked intravesical projection or middle lobe exists, the sphincter being displaced backwards by this development. placed from their connection with the back of the bladder, and con- stitute a posterior relation with the enlarged organ. It is interest- ing to note that this overgrowth involves mainly, if not entirely, the upper part of the gland, and that the portion below the veru- montanum is rarely affected, so that the openings of the ejaculatory ducts are not displaced backwards. 4. The changes produced in the prostatic urethra and neck of the bladder vary considerably in different cases. The length of the urethra is always increased, perhaps by 2 or 3 inches, or even more. Some amount of obstruction to the outflow of urine is universal. In rare instances it may be due to an adenoma becoming pedunculated, and projecting downwards into the urethra as a polypus. Occa- sionally the base of the middle lobe becomes narrowed, probably as the result of constriction by a band of longitudinal muscle fibres * Students must remember that in the normal pi estate there is no middle lobe, and that the structure thus named is caused by an abnormal overgrowth or projection from one of the lateral lobes. BLADDER AND PROSTATE 1247 passing down on either side from the ureteral orifice to the meatus; the middle lobe thereby becomes more or less pedunculated, and may be moveable, constituting a ball-valve which determines re- tention, or else wedging open the internal meatus and causing incon- tinence. As a rule the outflow of urine is hindered by the ' prostatic bar,' caused by the projection of the middle lobe, which also hinders the entrance of a catheter. When both lateral lobes are enlarged symmetrically, the lumen of the urethra is diminished from side to side, being narrow or chink-like instead of triangular, but its ver- tical measurements are increased. Asymmetrical enlargement, of course, displaces the urethra to one or other side. 5. The effect of an en- larged prostate on the bladder is important. The obstruction to the outflow of urine leads to increased expulsive ef- forts on its part, and consequently the wall becomes thickened and hypertrophied. This in- volves the muscular fibres, which stand out prominently as rounded fasciculi, and the mucous membrane may project outwards between them as hernial protrusions, constituting saccules in which urine may stag- nate and decompose, and even phosphatic p^^ ^^g — Enlarged Prostate with a Large concretions form. Intravesical Portion. (From College of In almost every case Surgeons' Museum.) the enlarged prostate projects more or less into the vesical cavity, either as a collar-like mass around the internal meatus, or as one or more rounded out- growths. This is necessarily associated with a pouching backwards of the lowest part of the bladder {prostatic pouch), which, being below the level of the meatus, does not become emptied during the natural process of micturition, and in which residual urine is there- fore able to collect and remain. Cystitis is very likely to follow, either by infection from within or from the use of unsterilized instruments, and then the bladder wall becomes inflamed; ammoniacal decomposition of the urine follows, and renal complications may ensue (either hydronephrosis or pyo- nephrosis), which will determine a fatal issue. A MANUAL OF SURGERY The Symptoms \'ary somewhat with the nature and position of the enlargement. The patient at hr^t iinds some difficulty in mic- turition, 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. Gradually irrita- bility 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 subsequent!}' induced by the straining. Intermittent attacks of increased pain and diffi- culty in micturition occur from time to time, being generally induced by exposure to cold and wet, and pre- simiably due to conges- tion of the prostate. After lasting for a few days the more acute symptoms slowly dis- appear, if judiciously treated. -^°- As the obstruction increases, a certain amount of residual urine remains within the bladder after each act of micturition, the vesi- cal muscles in time los- ing power and becoming atonic. Well-marked distension and atony of the bladder ensue at length in neglected cases, the urine drib- bling away and wetting the clothes, whilst de- composition of the retained fluid follows, and causes cystitis \\ath in- creasing vesical irritation and muscular spasm. The urine becomes alkahne after a time, containing muco-pus and phosphates, the result of chronic cystitis. This, if untreated, is certain to lead to hvdro- nephrosis and pyelonephritis. The general health of the patient is slowly undermined by the constant irritation produced by this process, as also by toxic absorption, and the final chapter may be ushered in by sx-mptoms of uraemia from the mischief inflicted on the kidnej^s. Occasionally the early symptoms may pass unnoticed for a con- siderable time, the patient imagining that the frequent calls to pass Fig. 557. — Enlarged Prostate after Re- moval BY Suprapubic Operation. The catheter has been placed in the urethra. I, The so-called middle lobe, or intravesical projection behind the internal meatus; 2 and 2fl, the lateral lobes; 3, indicates the nodular adenomatous masses which constitute the bulk of the swelling. BLADDER AND PROSTATE ^^^ 1249 tte bhridfr °^ ''^f '^*''''' *"" evidences of disease. In such cases pete^^^SS^Z^fblTrf *'"'''''■ ^"^ "^^ <=ond.tion uns: ! fu^7.s?„?i^v9^^^^^ condition anS the effect of thl"*P'?K '" *°'"?*™« a troublesome senous a„dlei^^!„t^*el*'l\"c s'^f-^^oT^^ ^^ -^^ tio^':f?re*f,^';ttTSaS:?r^'^r?""- of the ureth^rnd «ctr,P'"T^^ age'of the' mlien''t'?h'"""'""*'™ irritability of the bladdpr h„ „,vi,t^ j j patient, the increasing hinders i/ther than M™ til ^ 1 ""^ '^''^- **= '^"^^ *=»* straining a finger in the rectum r^nn^' *^^^. ^^^ size, as recognised by rectum, the obstrtti^l^t^rteS!' XcSf^Sr^cti Fig. 558.— Catheter Coude and Bicoude. blrri:?'at't"necrSVhe'Sfa':,7 '"'= ''T°5'^- '"-"-'> - '^^ times with difficulty oasserf '''^'^'^e'- is easily detected, and some- prostate, see rrisl^ *''" diagnosis from cancer of the ord'^frTTOVhe'bMdTfrot h'"'"'' " ^^^"'" catheterism, in this the /atient may otnt tau"htt°d"7fr Wmslf X^'*' ^"^ and bars the onward DrXJfff^^'-P?^""*' '"=™=^=' *e urethra, shape. The sweon ihoflH tT, f '"strument of the ordinary bicoude liZ -/li I, T^ therefore use a catheter coude or tt ustf^fenfh Lpe ' ae'rd'ol fv r-'\^'™ght instrument o an angle, hke an el^?w so as to enlbleV'to '"1* °' '^""ij'j' l'™* ^^^ tion; or he may emnlov an F^Jn T \ '".""^e over the obstruc- of which istown out a httfe foS?™"'''''''^"^*'=ter, utilize the silye™rostati catheter ^Cr^i^'T '*' '"T' " "^^ "^'^ than usual, denrLim? it well K.f ' }: "* [""^er and more curved pubic arch. \?Sc?er me hod Ts"adop?ed 'fo' f "" ''^"'"^ the Since with a little slHll fh^^^ ? 5 adopted, no force is requ red the obstruetio "and nter tL Sadder "Ff""^"* ^""- P^^"°>»